HomeMy WebLinkAbout07-24-14 O.C. Form I
Petition for Settlement of Small Estate
(Rev. 10104)
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
Estate of Stephen L. Miller
Late of Middlesex Township
Cumberland County, Pennsylvania, deceased No. 2 - U� 2
Petition for Settlement of Small Estate
Pursuant to section 3102 of the Probate, Estates and Fiduciaries Code, the
undersigned petitioner respectfully represents that:
1. The name and address of the petitioner are: n ?;
30 Maizefield Drive z _
Shippensburg, PA 17257 93 G')C)xis;; Z:j
N r '
2. The relationship f the petitioner to the decedent is: v�-' r-
P P
son
3. The decedent died on: y
October 17, 2011 -_j �'
4. The decedent was domiciled at time of death in Cumberland County,
Pennsylvania, with a last family or principal residence at:
The Claremont Nursing & Rehabilitation Center, but prior thereto lived
and was domiciled at 167 Amy Drive, Carlisle, PA 17013
5. The decedent's social security number is: 165-38-0358
6. The death certificate is attached hereto.
7. The decedent died:
® (a) intestate
❑ (b) testate
If the decedent died testate:
❑ (i) the will has been probated, and a copy is attached
hereto. Letters have been issued to:
1
❑ (ii) the will has not been probated and the original will
is attached hereto. [If not attached, explain.] The
personal representative(s) named therein is (are):
8. The name(s), relationship(s), and interest(s) of all parties beneficially
interested in the estate are:
Name Relationship Interest Sui Juris
Estate of Theresa P. Miller spouse (now deceased) 100% Yes
[Petitioner is the sole heir of the Estate of Theresa P. Miller]
9. A spouse's elective share:
® (a) has not been claimed (Spouse died on 02/22/14)
❑ (b) has been claimed. [Give details.]
10. If the decedent died testate, the decedent:
❑ (a) was not married or divorced after the date of execution of
the will
❑ (b) was married or divorced after the date of execution of the
will. [Give details.]
11. If the decedent died testate, the decedent:
❑ (a) did not have a child or children born or adopted after the
date of execution of the will
❑ (b) had a child or children born or adopted after the date of the
execution of the will. [Give the name and date of birth or
adoption of each such child.]
12. The decedent died owning property (exclusive of real property and property
payable under section 3101 of the Probate, Estates and Fiduciaries Code) of a gross value not
exceeding $50,000, which is itemized below. [Include account numbers and registration
numbers, etc. If bequest is adeemed, explain.]
2
Item Amount
Wells Fargo Bank Checking Account 41010187826390 $10,115.99
Wells Fargo Bank Savings Account 41010187826400 247.22
Total $10,363.21
13. An itemized statement of all claims against the estate is set forth below:
(a) The following person(s) claim(s) the family exemption under
section 3121 of the Probate, Estates and Fiduciaries Code by virtue
of being a member of the same household as the decedent:
Name Relationship Amount or Items Claimed
NONE
(b) The following persons claim reimbursement for debts, expenses,
and other claims (including inheritance tax, if applicable) they
have paid with their own funds:
Nature of
Person Claiming Date of Debt or
Reimbursement Payment Payee Expense Amount
NONE
(c) The following claims remain unpaid:
Claimant Nature of Claim Amount
NONE
14. ® (a) All claims are undisputed.
❑ (b) The following claims are disputed:
[Give details]
15. The petitioner has paid or will cause to be paid all Pennsylvania inheritance
tax due on all property to be awarded under this petition.
16. All parties beneficially interested in the estate, other than the petitioner,
including all holders of claims that are denied, or, in the case of an insolvent estate, all holders of
claims who will not be paid in full, have: N/A
3
❑ _ (a) signed the joinder in this petition which is hereto attached;
or
❑ (b) been mailed at least ten (10) days written notice of the date,
time, and place of the Orphans' Court audit session at
which the petition will be ruled upon by the Court, a copy
of which notice is attached hereto.
17. Your petitioner proposes:
(a) that the family exemption, if any, be paid or satisfied as follows:
N/A
(b) that the following claims be paid: [Refer to section 3392 of the
Probate, Estates and Fiduciaries Code to establish Priority among
claims, ifnecessary.]
Claimant Nature of Claim Amount
NONE
(c) the balance, if any, be distributed as follows:
Item Amount
NONE
18. Attached Exhibits are as follows:
A. Death Certificate of Stephen L. Miller
B. Death Certificate of Theresa P. Miller
C. Letter from Department of Public Welfare indicating no Medical
Assistance reimbursement due to the State of Pennsylvania
ure o etitioner
Typed Name: Keith R. Miller
Signature of Attor ey for Petitioner
Typed Name: Michael J. Connor, Esquire
Supreme Court I.D. No.: 75927
Office Address: 247 Lincoln Way East
Chambersburg, PA 17201
Telephone Number: 717-262-2185
4
Verification
The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa.
C.S.A. §4904 (relating to unsworn falsification to authorities), that the facts set forth in the
foregoing petition which are within his (her) knowledge are true, and, as to the facts based on
information received, after diligent inquiry, he (she) believes them to be true.
Date:
nature of Petitioner: Keith R. Miller
Joinder
I (we), the undersigned, being parties other than the petitioner beneficially
interested in the estate of the foregoing decedent, do hereby certify that I (we) have read the
foregoing petition and join in the prayer thereof.
None
5
' LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
'ee for this certificate, $6.00 „nr" This is to certify that the information here given is
a�Ep��d�F,pEdy=_ correctly copied from an original Certificate of Death
dr'`pZ` _�_�-* , t• rrg duly filed with me as Local Registrar:The original
certificate will be forwarded to the State Vital
€v t b Records Office for permanent filing.
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P 17726978
Certification Number """""j0 Local Registrar Date issued
nm+ortu iwaoe COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
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CERTIFICATE OF DEATH
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Stephen L. Miller Male 165 — 38 —0358 10/17/2011
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Theresa P. Miller 167 Amy Drive, Carlisle, PA 17013
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
:e for this certificate. $6.00 This is to certify that the information here given is
yi��Ep1tH'OF pf��y_ correctly copied from an original Certificate of Death
duly filed with me as Local Registrar, The original
certificate will be forwarded to the State Vital
;t m°1 f x na Records Office for permanent filing,
3 i-
P 20506727
Certification Number jffNfJUpm°'
.,.c Registrar Date Issued
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#.wm.mm•nD N s EXHIBIT
olaperltlm w+mn Ne Y01166a
pennsyLvania
DEPARTMENT OF PUBLIC WELFARE
July 16, 2014
WALKER CONNOR & SPANG LLC
JULIA M METZ ESTATE PARALEGAL
247 LINCOLN WAY E
CHAMBERSBURG PA 17201
Re: Stephen Miller
SSN: ###-##-0358
Dear Ms. Metz:
Pursuant to your letter dated July 07, 2014, the Department's, Estate Recovery
Program, has reviewed the information you provided regarding the above-referenced
individual.
It has been determined that this individual did not receive any type of assistance
during the questioned period.
Therefore, according to the information you provided, the Department's Estate
Recovery Program will not seek any recovery from this estate. If your client applied for
Medical Assistance and had an application and/or hearing pending at the time of death,
please advise us and provide any additional information that may affect a recovery by our
Department.
Thank you for your cooperation in this matter. If you have any questions, please
contact me.
Sincerely
eWl
Vince A. Porter
Recovery Section Manager
(717)772-6604
EXHIBIT
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17106-8486