HomeMy WebLinkAbout06-12-14 J 15056101401
REV-1500 EX (02-11)(FI)
PA Department of Revenue OFFICIAL USE ONL•
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 2 9 3
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 1 1 7 2 0 1 3 0 6 1 9 1 9 1 9
Decedent's Last Name Suffix Decedent's First Name MI
M O W E R Y PAUL I N E C
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
FXJ 1. Original Return 2.Supplemental Return E:] 3. Remainder Return(Date of Death
Prior to 12-13-82)
4. Limited Estate 4a. Future Interest Compromise(date of 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 6. Decedent Died Testate E:] 7. Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
9. Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death E:] 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O).
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD-LE DIRI_6T4�TO:
Name Daytime Tele.�h?ab NumbeF. m C _
47
J I L L M WI N E K A E S Q U I RE 7 1 7 cr ,2�n4 1 �7
�10 n r— H—' r.1m
REGIShi !ILLS M ONOW
T. r0
n O T
First Line of Address
f✓
1 7 1 9 NORTH F RONT ST R E E T
Second Line of Address � p
City or Post Office State ZIP Code DATE FILED
H A R R I S B U R G P A 1 7 1 0 2
Correspondent's e-mail address: jvvinekaCcDpkh.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F PERSON RESPONS FOR FILING RETURN /JDATE
!O
ADDRESS ((�/
Grace M. Reese, 1814 Tuscarora Court Frederick MD 21702
51 A U OFPAR RO EREPRESENTATIVE �D PATE
ADD SS /'/I1 y / /4.'
Jill . Wineka 1719 North Front Street Harrisburg PA 17102
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J'
J 1505610240
REV-1500 EX(FI) Decedent's Social Security Number
DecedenrsName: PAULINE C. MOWERY
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . .. .. . . . ... . 1
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. . . 3.
4. Mortgages and Notes Receivable(Schedule D) . .. . . . . . . . . . . .. . . . . . . . . . . . 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. . . . . S. 3 8 7 5 • 6 5
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . ... . 6. 1 5 7 . 1 4
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested . . . .. . . 7.
8. Total Gross Assets(total Lines 1 through 7) . . . .. . . . . . . . . . . . . . . . . . . . . . . 8. 4 0 3 2 • 7 9
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . .. . . . . .. . 9. 1 4 0 0 . 4 5
10. Debts of Decedent, Mortgage Liabilities,and Liens Schedule 10. 9 9 9 4 7 • 1 2
11, Total Deductions(total Lines 9 and 10) . . .. .. .. . . . .. . . . . . .. . . . . . . . . .. . 11. 1 0 1 3 4 7 . 5 7
12. Net Value of Estate(Line 8 minus Line 11) . . . . .. . . . . . . . . . . . .. .. . .. ... . 12. - 9 7 3 1 4 . 7 8
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . .. . . . . . . . . .. . . . ... . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . .. . . . . . . . .. . . 14. - 9 7 3 1 4 . 7 8
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(t.z)X 0 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.045 1 5 7 . 1 4 16, 7 . 0 7
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . . . . . . . . . . . . . .. . . . . . . . . . ... . . .. . . . . . . . . .. . . . . . . . . . . . . . 19. 7 . 0 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
.'2EV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 14 0293
DECEDENTS NAME
PAULINE C. MOWERY
STREETADDRESS
121 WALNUT BOTTOM ROAD
CITY STATE ZIP
SHIPPENSBURG PA 17257
Tax Payments and Credits:
1. Tax Due(Page 2,Une 19) (1) 7.07
2. Credits/Payments
A.Prior Payments 0.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Une 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Une 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 7.07
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ...................................................................... ❑ X❑
b. retain the right to designate who shall use the property transferred or its income ............................... ❑ ❑X
c. retain a reversionary interest ..................................................................................................... ❑ ❑X
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ ❑X
3. Did decedent own an'in trust for or payable-upon-death bank account or security at his or her death? ......... ❑ JC❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from lax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in V2 P.S.§9116(a)(1)).
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
PAULINE C. MOWERY 21 14 0293
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Balance in the Decedent's Personal Care Account at the Shippensburg Health 3,875.65
Care Center.
(See attached Check No. 004208 dated 1/7/14 from Shippensburg Health Care Center
to the Estate of Pauline Mowery.)
TOTAL(Also enter on Line 5,Recapitulation) $ 3,875.65
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX-(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
PAULINE C. MOWERY 21 14 0293
If an asset was made jointly owned within one year of the decedenits date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. Grace M. Reese 1814 Tuscarora Court Daughter
Frederick, MD 21702
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
REM FORJOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND RANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLYMELD REAL ESTATE. VALUEOFASSET INTEREST DECEDENT'SINTEREST
1. A. 9/27/02 M&T Bank Checking Acct. No. 951022942 314.28 50. 157.14
(See attached M&T Bank letter dated 4/16/14 documeting
date of death balance and joint ownership.)
TOTAL(Also enter on Line 6,Recapitulation) $ 157.14
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PAULINE C. MOWERY 21 14 0293
Decedents debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) Grace M. Reese 193.78
SfreelAddress 1814 Tuscarora Court
City Frederick State MD ZIP 21702
Years)Commission Paid: not yet paid
2. Attorney Fees: Purcell, Krug & Haller 1,000.00
3. Family Exemption:(If decedents address B not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: RegisterofWills 30.00
5. Accountant Fees:
6. Tax Return Preparer Fees:
7. Register of Wills-fee to file Will; Short Certificate; JCS fee; Automation fee; fee to file
Inventory; fee to file Inheritance Tax Return; fee to file Renunciation 88.50
8. Grace M. Reese-mileage reimbursement(132 miles @$.54/mile) 71.28
9. Grace M. Reese-reimbursement for postage 1.40
10. Purcell, Krug & Haller- reimbursment for postage 15.49
TOTAL(Also enter on Une 9,Recapitulation) E 1,400.45
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PAULINE C. MOWERY 21 14 0293
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,Including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PA Department of Public Welfare-Class 3 claim for medical services 22,994.11
2. PA Department of Public Welfare-Class 5.1 claim for medical services 76,953.01
(See attached 4/14/14 PA Dept. of Public Welfare letter documenting the amount and
priority of both classes of claims against the Estate.)
TOTAL(Also enter on Line 10,Recapitulation) $ 99,947.12
If more space is needed,insert additional sheets of the same size.
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
PAULINE C. MOWERY 21 14 0293
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distnbutions and transfers under
Sec.9116(a)(1.2).]
1. Samuel A. Mowery Lineal
200 East Stephens St., Apt. 702 1/7 of residuary estate
Martinsburg, WV 25401 minus $8,141.00
2. Mary C- Mason Lineal
1421 Philadelphia Ave., Apt. 230 1/7 of residuary estate
Chambersburg, PA 17201
3. Charles B. Mowery Lineal
645 Wild Horse Lane 1/7 of residuary estate
Fairbanks, AK 99709
4. Norman G. Mowery Lineal
3850 Rio Road, #1 1/7 of residuary estate
Carmel, CA 93923
5. Joy M. McGuire f/n/a Joy M. Mowery Lineal
218 West Ridge Street 1/7 of residuary estate
Carlisle, PA 17013 minus $3,000.00
6. Grace M. Reese Lineal
1814 Tuscarora Court 1/7 of residuary estate
Frederick, MD 21702
7. Eva Jane Tutch Lineal
8250 East Sage Drive 1/7 of residuary estate
Scottsdale, AZ 85240
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
IN RE: IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
ESTATE OF PAULINE C. MOWERY, ORPHANS' COURT DIVISION
DECEASED NO. 2114-0293
TABLE OF CONTENTS
1. Last Will and Testament of Pauline C. Mowery dated November 3, 2004.
2. Copy of Check No. 004208 dated 1/17/14 regarding balance in Decedent's Personal
Care Account.
3. Letter dated April 16, 2014 from M&T Bank documenting joint ownership and date of
death value in Decedent's Checking Account No. 951022942.
4. Letter dated 4/14/14 from the PA Department of Public Welfare documenting the
amounts of both Classes of claims for medical services provided to the Decedent.
i
f
LAST WILL AND TESTAMENT
or,
PAULINE C. MOWERY
I,PAULINE C.MOWERY, of 101 North Prince Street, Shippensburg Post Office,
Cumberland County,Pennsylvania, revoke any prior Wills and Codicils and declare this to be
my will.
ITEM 1. I give my automobiles,household and personal effects and other tangible
personalty of like nature(not including cash and securities),together with any existing insurance
thereon,in as nearly equal shares as practicable,to my children, SAMUEL A. MOWERY,
MARY C. MASON, CHARLES B.MOWERY,NORMAN G. MOWERY,JOY M. MOWERY,
GRACE M.REESE, and EVA JANE TUTCH. The gifts in this Item 1 of my Will are subject to
the deductions set forth in Item 2 regarding gifts to JOY M. MOWERY and SAMUEL A.
MOWERY.
ITEM 2. 1 give all the rest,residue, and remainder of my estate in equal shares to
my children, SAMUEL A.MOWERY,MARY C.MASON, CHARLES B. MOWERY,
NORMAN G.MOWERY, JOY M. MOWERY, GRACE M.REESE, and EVA JANE TUTCH,
each to receive his or her share upon surviving me by thirty days. Notwithstanding this bequest,
however,with this bequest and the bequests of Item 1 of this Will,I direct that there be deducted
from the share of JOY M.MOWERY the total sum of Three Thousand Dollars($3,000),which I
313755-1
had previously extended to her as a loan. I also deduct from the share of SAMUEL A.
MOWERY the total sum of Eight Thousand One Hundred Forty-One Dollars($8,141). These
deducted sums shall be given instead in equal shares to my other children or their issue per i
stirpes.
i
ITEM 3. If any child is not living on the thirty-first day after my death,I give his or
her share to his or her issue per stapes who survive me by thirty days. If any child is not living
on the thirty-first day after my death and leaves no issue who are living on the thirty-first day
after my death,that child's share shall lapse and be given instead to my other beneficiaries in
proportion as they take shares of my estate. I'
II
i
ITEM 4. I direct that all my just debts and the expenses of my illness and burial, I�
including my grave marker,shall be paid from my residuary estate as soon as practicable after f
my death as part of the expense of the administration of my estate.
ITEM 5. In addition to the powers granted by law or by other parts of this Will,my
Executrices and Trustee shall have the following powers:.
(a) To retain any and all assets of my estate and trust,real,personal,or
mixed, without regard to any principle of diversification,risk, or productivity, except as
may be otherwise expressly provided herein;
(b) To sell at public or private sale,to exchange,to lease,to pledge,to j
mortgage,to transfer,to convert, or otherwise dispose of,and to grant options with
I
respect to, any and all property,real,personal,or mixed, at any time forming part of my
313755-1
estate or trust estate in such manner, at such time or times, for such purposes,for such
price or prices and upon such terms, credits, and conditions as may be deemed advisable;
(c) To invest and reinvest the estate and trust property in stocks,
bonds,mortgages,notes, insurance policies, annuities, common trust fund participation,
or other property of any kind,real,personal, or mixed, irrespective of any statute, case,
rule, or custom limiting the investment of trust funds,except as expressly provided
otherwise herein;
(d) To settle, compromise, contest,prosecute, or abandon claims in
favor of or against my estate or any trust as may be deemed advisable;
6
(e) To allocate receipts and disbursements to principal or income or
f
partly to both and to ascertain principal or income in accordance with the laws of the
Commonwealth of Pennsylvania; j
(f) To make distribution or division of the trust or estate in cash,in
i
kind, or partly in both, to postpone distribution by agreement with a beneficiary and to
distribute articles of tangible property to a minor or to any person to hold for a minor
within the limits authorized by statute or rule of law; and
(g) To exercise any law-given option to treat administration expenses
either as income tax or estate tax deductions,without regard to whether the expenses it
were paid from principal or income, and without requiring reimbursement.
1
ITEM 6. Notwithstanding any other provision of this Will,I direct that if any
beneficiary of mine is under twenty(20)years of age,my Trustee shall retain whatever share
such beneficiary otherwise would have received hereunder and apply so much of such share or
313755-1 '
i
i
the income thereof as my Trustee considers advisable for the beneficiary's support,education,
and maintenance, accumulating any income not needed for these purposes. It is my wish that
such beneficiary have an education beyond high school,if desired, and funds may be used for
such education if the beneficiary so desires,including vocational and business school,college,
graduate, and post-graduate school. When a beneficiary attains the age of twenty(20) years, the
Trustee shall distribute to such beneficiary the then remaining principal and income of his or her
share, discharged of the trust, or shall be paid to such beneficiaries of the estate in the event of 1
death prior to that tine.
ITEM 7. No interest of any beneficiary under this Will or any trust established
hereunder or any codicil hereto shall be subjected to anticipation.
ITEM 8. No bond shall be required by my Executrices and Trustee,but if bond is
nevertheless required,it shall be without surety.
ITEM 9. I appoint my daughters, GRACE M.REESE and EVA JANE TUTCH,
Executrices. If either of my daughters fail to qualify or cease to act,the remaining daughter shall i
i
serve as Executrix.
ITEM 10_ I appoint MANUFACTURERS AND TRADERS TRUST COMPANY,
(M&T BANK),successor to Allfirst Bank,Trustee. I1; however, this Bank declines to serve as
Trustee of�ny trust, I appoint my Executrices, or the survivor of them,as Trustee(s).
I
i
r.
3!3755-!
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ITEM 11. I note to my Executrices that I have retained the services of Jered L. Hock,
Esquire, and the firm of Metzger,Wickersham,Knauss&Erb,P.C.,in connection with the
writing of this Will.
Executed this_,�day of Nouem\ner 2004.
Pauline C. Mowery
Signed, sealed, and published and declared by the above-named Testatrix, PAULINE C.
MOWERY, as and for her Last Will and Testament,in the presence of us,who,at her request,in
her sight and presence, and in the sight and presence of each other,have hereunto subscribed our
names as witnesses.
Address �i..r L°. . �i.�..�rai✓
Address
I
I
is
313755-1 .I
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i
Commonwealth of Pennsylvania
ss
County of bcwpW,n
We,PAULINE C.MOWERY, and I env d 14. mn c-k;neau and
reel L 11r ,the Testatrix and the witnesses,respectively,whose
names are signed to the attached or foregoing instrument,being first duly swom,do hereby declare
to the undersigned authority that the Testatrix signed and executed the instrument as her last Will
and that she had signed willingly(or willingly directed another to sign for her), and that she
executed it as her free and voluntary act for the purposes therein expressed, and that each of the
witnesses,in the presence and hearing of the Testatrix,signed the Will as witness and that to the
best of our lmowledge the Testatrix was at that time eighteen years of age or older, of sound mind
and under no constraint or undue influence.
l01 6)
Testatrix
Witness
Witness
SWORN to or affirmed and acknowledged before me by the above named Testatrix and
witnesses this, day of p)n,»M Lse�- 2004.
Notary Public
My Commission Expires:
(SEAL) Notarial Sent
ngela M Mier,Notary Public
Lmcyljl y of Harrisburg, Dauuhm County
Commission Expires Lkt. 15, 2006
3/3755-1
PERINI SVCS/SOUTHAMPTON MANOR 00420$
LP TJA SHIPPENSBURIG HLTH CC
RFMS PETTY CASH ACCOUNT 6671 YB
121 WALNUT BOTTOM RD z4sa
SHIPP04SBURG,pA:7725711 OATS D1`O��IT•
PAY aS J' `�1/✓//1 r
oapeA OF / li d 1 Y liYi.// $ 3 75. to
� JJ 8 5.
=6 " . LA RS
CAPITAL ONE fIANK
FOR - led:
M.
0.00004208n' 1: .25507.1.9811:093 43 76743n'
M&TBank
499 Mitchell Road,Millsboro,DE 19966 Records Management
Phone 888-502-4349
F ax (302)934-2955
April 16,2014
Law Offices
Purcell,Krug& Haller
1719 North Front Street
Harrisburg, PA 17102-2392
Re: Estate of Pauline c.Mowery
Social Security:
Date of Death: November 17,2013
Dear Sir or Madam:
Per your inquiry on April 10, 2014, please be advised that at the time of death,the above-named decedent had
on deposit with this bank the following:
1. Type ofAccount Checking Account
Account Number 951022942
Ownership(Names oj) Pauline C Mowery
Grace M Reese
Opening Date 0912712002
Balance on Date of Death $ 314.28
Accruedlnterest $ .00
Total -------- -- ----- -- -- --
$314.28
For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds,
please call the Walnut Bottom at 717-537-2414.
We were unable to locate any safe deposit box for the above-mentioned decedent
This letter does not include any amounts in which the deceased may ban been listed as Power of Attorney,Custodian of Uniform Transfers,
Representative Payee,or Trustee under a Written Agreement
Sincerely,
Valarie Mercer
Records Management
San, pennsylvania
NMI DEPARTMENT OF PUBLIC WELFARE
April 14, 2014
PURCELL KRUG & HALLER LAW OFFICES
JILL M WINEKA ESQUIRE
1719 N FRONT ST
HARRISBURG PA 17102
Re: Pauline Mowery
CIS #: 670207431
SSN: ###-##-
Date of Death: 11/17/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear JILL M WINEKA:.
Under State and Federal law„ the,Department of Public Welfare (the.Department) is
required_to recover medical assistance _(MA).reimbursement from the probate-estates of
deceased individuals who were over age 55 when such assistance was received.. 42, U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This lettersets forth the,amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our_claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of$99,947.12 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $22,994.11, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $76,953.01, is to be entered as a priority.Class 5-.1:claim against the estate.
You 'should refer to Section 3392 for a•more complete explanation of the priority rules.
If a lawsuit is-filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity I Division of Third Party Uabllity I Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvanla 17105-8486
S ol pennsyLvania
- DEPARTMENT OF PUBLIC WELFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate all deductions from the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to document computation of the amount due the Department, the following
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
Bureau of Program Integrity I Olvlslon of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
•• pennsylvania
•.
DEPARTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely, 1 '
Marianne Meckley
TPL Program Investigator
717-772-6246
717-772-6553 FAX
Enclosure
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
' BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8488
HARRISBURG,PA 171054 B8
April 8,2014
STATEMENT OF CLAIM SUMMARY
NAME Estate Of MOWERY,PAULINE
ID 570 207 481
MEDICAL - CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
.OUTPATIENT .00 119.00 119.00
LONG TERM CARE 22,994.11 76,822.79 99,816.90
DRUG .00 1122 11.22
REIMBURSEMENT TO DPW 22,99,4.11 76,953.01 99,947.12
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
- ID 670 207 481
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 17257
DATE OF SERVICE, PAYMENT DATE ORIGINALCRN ADJUSTED CRN USUALCHARGES AMOUNTAPPROVED
12/01111 - 12/31111 06/18/12 55121654510790001 55121654510720001 5,824.28 4,494.52
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
01/01112 - 01131112 01121113 69130174020480001 69130174020480001 5,624.28 4,702.66
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
02101112 - 02/29112 01/21113 69130174020490001 69130174020490001 5,448.52 4,330.94
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
03101112 - 03/31112 01121/13 69130174020500001 69130174020500001 5,824.28 4,702.66
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
04/01112 - 04/30112 01/21113 69130174020520001 69130174020520001 5,277.00 4,218.00
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
05101112 - 05/31/12 01/21/13 69130174020540001 69130174020540001 5,452.90 4,393.90
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
06/01/12 - 06/30/12 01/21113 69130174020570001 69130174020570001 5,722.00 4,218.00
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000 -
07/01/12 - 07/31112 01/28/13 55130244330870001 55130244330870001 5,452.90 3,927.04
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
Page 2 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670 207 481
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 17257
DATE OF SERVICE I PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
08101/12 - 08/31/12 01/28/13 55130244330880001 55130244330880001 5,452.90 3,927.04
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE : 0000000
09101/12 - 09/30/12 01/28/13 55130244330890001 55130244330890001 5,277.00 3,766.20
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2 : 0
PROC CODE: 0000000
10/01/12 - 10131112 02118/13 55130444031540001 55130444031540001 5,335.63 4,115.87
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
11101/12 - 11130/12 02118113 55130444031550001 55130444031550001 5,277.00 4,059.00
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2 ' 0
PROC CODE: 0000000
12101112 - 12131112 02118113 55130444031560001 55130444031560001 5,452.90 4,229.60
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
FROG CODE: 0000000
01101/13 - 01/31/13 02104113 27130324040520001 27130324040520001 5,402.06 4,324.06
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
02/01/13 - 02/28113 03104113 27130604049430001 27130604049430001 4,879.28 3,801.28
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
03101113 - 03/31/13 04115113 69131014021810001 69131014021810001 5,402.06 4,451.06
DIAGNOSIS 1 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2 : 0
PROC CODE: 0000000
Page 3 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670 207 481
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 17257
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/01/13 - 04/30113 05/06/13 27131214042560001 27131214042560001 5,440.80 4,489,80
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
05/01/13 - 05131113 06/10/13 27131574024540001 27131574024540001 _ 5,622.16 4,671.16
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
06101113 - 06130113 07/08113 27131834031420001 27131834031420001 5,440.80 4,489.65
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
07101113 - 07/31113 02110/14 55140364219740001 55140364219740001 5,622.16 4,228.33
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
08/01/13 - 08/31/13 02/10114 55140364220520001 55140364220520001 5,622.16 4,228.33
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
09/01/13 - 09130/13 02/10/14 55140364221340001 55140364221340001 5,440.80 4,061.25
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2' 0
PROC CODE: 0000000
10101/13 - 10131/13 03110114 55140644056180001 55140644056180001 5,622.16 4,335.90
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
Page 4 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670 207 481
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 17257
DATE OF SERVICE PAYMENT DATE ORIGINALCRN ADJUSTED CRN USUALCHARGES AMOUNTAPPROVED
11101113 - 11117113 03110/14 55140644057370001 55140644057370001 2,901.76 1,650.65
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2: 0
PROC CODE: 0000000
PROVIDER SUB TOTAL SHIPPENSBURG HEALTH CARE CTR 129,017.79 99,816.90
03 001550908 0002
Page 5 Of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENTOF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670 207 481
TRINITY PHARMACY SERVICES
100 N 4TH ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
10124112 - 101247/2 11119112 25122985349350001 25122985349350001 12.60 6.20
DIAGNOSIS 1 : 0
NDC CODE: 00603052411 HEMORRHOIDAL SUPPOSITORIES - HEMORRHOIDAL PREPARATIONS
10124/12 - 10124/12 11/19/12 25122985430130001 25122985430130001 12.30 5.02
DIAGNOSIS 1 : 0
NDC CODE: 00536199553 SELENIUM SULFIDE 1%SHAMPOO - ALL OTHER DERMATOLOGICALS
PROVIDER SUB TOTAL TRINITY PHARMACY SERVICES 24.90 11.22
24 102420203 0002
Page 6 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670207481
WEST SHORE ADV LIFE SUP SVC
503 N 21ST ST
CAMP HILL PA 17011 '
DATE OF SERVICE PAYMENT DATE ORIGINAI.CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10122J12 - 10122112 11126112 27123146234450001 27123146234450001 984.62 80.00
DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS
PROC CODE: A0432 PARAMEDIC INTERCEPT RURALAREA,TRANSPORT
PROVIDER SUB TOTAL WEST SHORE ADV LIFE SUP SVC 984.62 80.00
26 001173277 0001
Page 7 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 8,2014
STATEMENT OF CLAIM
NAME MOWERY,PAULINE
ID 670 207 481^
SUMMIT PHYSICIAN SERVICES
601 NORLAND AVE
STE 201
CHAMBERSBURG PA 17201
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
01/27112 - 01/27112 03/12112 27120556197530001 27120556197530001 138.00 28.00
DIAGNOSIS 1 : 38910 SENSORNEUR HEAR LOSS NOS
PROC CODE: 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD EV AN
01/27/12 - 01127112 03/12/12 27120556197530002 27120556197530002 69.00 11A0
DIAGNOSIS 1 : 38910 SENSORNEUR HEAR LOSS NOS
PROC CODE: 92567 TYMPANOMETRY
PROVIDER SUB TOTAL SUMMIT PHYSICIAN SERVICES 207.00 39.00
31 100730726 0034
4t
Page 8 of 8
LAW OFFICES
Purcell, Krug & Haller
HOWARD B.KRUG 1719 NORTH FRONT STREET HERSHEY
LEON P.HALLER HARRISBURG, PENNSYLVANIA 17102-2392 (717) 533.3836
JOHN W.PURCELL JR. TELEPHONE (717) 234-4178
JILL M. WINEKA FAX (717) 783-4939 JOHN W. PURCELL(1924.2009)
LISA A.RYNARD
JOSEPH NISSLEY (1910.1982)
June 11, 2014
Register of Wills
Cumberland County Court House
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Pauline C. Mowery
No. 21-14-0293
Dear Register of Wills:
Enclosed for filing, please find two originals and two copies of the Pennsylvania Inheritance
Tax Return in the above-captioned matter. Please return two date-stamped copies of the Return in
the enclosed stamped, self-addressed envelope. Thank you.
Sincerely,
. "^.r
M. Wineka
JMWJbas
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