HomeMy WebLinkAbout07-21-14 � 15056101�5
REV-1500 EX�02_��>�F�> .
OFFIGAI USE ONLY
PA Department of Revenue pennsylvania
Bureau of Individual Taxes ' ` County Code Year File Number
PO BoX28o6oi INHERITANCE TAX RETURN � /�, �� �/-�
Harrisburg,PA 1�1�8-0601 RESIDENT DECEDENT [J
ENTER�ECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
! 5 l 2� � 20 I 2 b� � i�� i �I�-b
DecedenYs Last Name Suffix DecedenYs First Name MI
��h 1�lXln _ _ ��1_I � � _ �� '
(If Appiicabie)Enter Surviving Spouse's information Below �
Spouse's�ast Name Suffix Spouse's First Name MI
��Q�Yi�,m �o hC�I�1 �
Spouse's Social Security Number
THIS RETURN MUST BE FIIED IN DUPLICATE WITH THE
�„��' ZQQ�' I�OI� ; REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
i 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 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 BE DIRECTED T0:
Name Daytime Telephone Number
__ _ _ _ __ __ . . _ _ _
l`�,'Pc�l �`GWII�bK�� �Iht� __ ��'f�l 23L1��'�32� _ '
REGISTER OF WILLS USE ONLY
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First Line of Address �� �H. ,�
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CorrespondenYs e-mail address: �M�U�1J�`�-� �- 'P�SMR2���.t,A. Co.�..
� 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.
P R ON ESPO IBLE FOR FILING RETURN DATE
ADDRESS � I � � VIII � � �I � �
SIG RE RE TH AN REPRESENTATIVE DATE
�' b�'
AD RESS
�5�3 n1 �av�r. ���cs,�s�, PA l�t�o
PLEASE US ORIGINAL FORM ONLY
Side 1
� 15D56107,05 1505610105 � ,
�
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� 15�5610205
REV-1500 EX(FI)
DecedenYs Social Security Number
�ecedent•s Name: Shit'ley J. Graham
RECAPITULATION
1. Real Estate(Schedule A). ............................................ L '
2. Stocks and Bonds(Schedule B) ....................................... 2.
3. Closely Heid 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)....... 5. 149,355.65
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... .... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets total Lines 1 throu h 7 $. 149,355.65
� 9 ).............................
9. Funeral Expenses and Administrative Costs(Schedule H).............. ... .. 9. 3,33Fi.75 '
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). ...... ........ 10. 30,786.18
11. Total Deductions(total Lines 9 and 10)....... .. ... .... ................. 11. 34,122.93 '
12. Net Value of Estate(Line 8 minus Line 11) .... ....................... ... 12. 1 15,232.72 '
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........ ... ............. 13. 0.00 '
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 115,232.72 '
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0 0 15. ', 0.00 ,
16. Amount of Line 14 taxable ' '
at lineal rate X.0_ 16. ' '
17. Amount of Line 14 taxable '
at sibling rate X.12 ' 17. '
18. Amount of Line 14 taxable
at collateral rate X.15 �$.
19. TAX DUE ................... ....... ........... .. ... ...... ... ...... 19. ' U.UO '
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
� 15056102�5 15056102�5 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Shirley J. Graham
STREETADDRESS
1822 Walnut Bottom Road
CITY - —- STATE j.ZIP
Newville PA I 17241
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
Total Cretlits(A+B) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
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.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ■
c. retain a reversionary interest.............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
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 imposetl 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 tax,and the statutory requirements for disclosure of assets and
filing a tax return are still appiicable 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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 atloption.
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POWER OF ATTORNEY AND
FEE AGREEMENT
I, Ronald Graham, have asked R.J. Marzella& Associates, P.C. to represent me in
connection with:
The probating of the Estate of Shirley Graham.
We, R.J. Marzella& Associates, P.C., accept this engagement on the terms set forth
below:
1. You understand that in no event does our role in undertaking this engagement
include transferring any aspect of this matter to any federal court, or appealing any aspect
of this matter to any appellate court.
2. We will endeavor to keep you informed by sending you copies of significant
papers we prepare or receive in connection with this matter. In addition, we will be
available to you by telephone or in person for consultation. If no one is available when
you telephone, your call will be returned within a reasonable time under the
circumstances.
3. Our hourly fee for this engagement is at a rate of$150.00 per hour, to be due
on a monthly basis.
4. You understand that a one and one-half percent per month service charge will
be assessed by our firtn on any bill balance that remains unpaid for more than thirty(30)
days after the date the bill has been sent. We expect and require prompt payment of the
bills our firm sends you, and we reserve the right to terminate the attorney/client
relationship if you should fail to pay those bills on time. We also reserve the right to
terminate the relationship if you insist upon pursuing or ask us to help you pursue an
objective or engage in a course of conduct that we consider repugnant or imprudent or
with which we have a fundamental disagreement. You, as the client,may terminate the
attorney/client relationship with us at any time, of course,but if you wish to do so,please
do so in writing. In the event of a termination,whether by client or by attorneys, client
agrees to, upon request, promptly sign a Praecipe for the attorneys to withdraw their
appearance in any litigation and/or Praecipe for the client to represent himself/herself,pro
se, in any litigation. In event of a termination of our services while money is still
owed,you understand that you are responsible to pay our fees incurred to the date
of termination and you will so inform any future attorney that you still owe us fees.
In the event that the Client(s) seek(s) legal representation elsewhere regarding the
incident described herein and after the instant Fee Agreement is executed, Client(s)
agrees to immediately reimburse Attorney for all expenses incurred to date. Moreover,
for the work performed by the Attorney up to the date of separation of Attorney and
Client(s), Client(s) agree(s)that, in the event of an ultimate monetary recovery, Attorney
is entitled to reasonable compensation (quantum merit) from any verdict or settlement.
5. You agree to bring to our attention any questions you have about any bills our
firm sends you within thirty (30) days of the date of those bills. You will not be charged
for any time we spend with you on the telephone or in person discussing our firm's bills
to you. Further, you agree that any monies we may receive on your behalf as a result of
settlement, court order, or otherwise, may be used by us to pay any amount you owe us at
that time.
6. In the event of any disagreement concerning this attorney/client relationship,
this fee agreement, and/or for the client to bring any action against the attorneys for
negligence or any other kind of action, both parties agree that any unresolved disputes or
issues arising out of the Firm's representation of the Client(s) in this matter will be
submitted to mandatory, binding arbitration with a certified Christian conciliator. If a
dispute arises,the Firm will provide the names of the arbitrators. The Client will select
one who will act as the sole arbitrator. Judgment upon an arbitration decision may be
entered in any court otherwise having jurisdiction. The parties understand that these
methods shall be the sole remedy for any controversy or claim arising out of this
agreement and expressly waive the right to file a lawsuit in any civil court against one
another for such disputes, except to enforce an arbitration decision.
7. The foregoing should not be construed to prevent the attorneys from suing the
client to collect any undisputed fee or portion thereof.
8. You understand that you are engaging this law firm and that a firm attorney
other than the attorney who initially met with you or who was initially assigned to work
on your case may appear at hearings or perform work for you on your case.
This agreement shall become effective and our representation will commence
upon our receipt of a signed copy of this letter and $0 retainer. Please execute a copy of
this Agreement where indicated below and return it to us with payment of our fee and we
will then commence working on the case. You understand that until you have signed this
Agreement and paid us the fee, we have not been hired and we will do no work on your
case. Of course, if you have any questions on this agreement, please ask us before you
sign and return it to us.
2
I, RONALD GRAHAM, HAVE READ TAE ABOVE AGREEMENT AND UNDERSTAND AND
AGREE TO ITS TERMS. THERE ARE NO OTHER AGREEMENTS BETWEEN THE PARTIES
HERETO PERTAINING TO THIS MATTER. THIS AGREEMENT IS ENTERED INTO THIS
9TH DAY OF MAY 2014.
o �-- ,���� �, 2a C�
RONALD GRAHAM DATE
���� �
KARI E.MELLINGER,ESQUIRE
R.J.MARZELLA&ASSOCIATES,P.C.
3
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Patrick Doane,Production Director, of The Sentinel, of the County and State aforesaid,
being duly sworn, deposes and says that THE SENTINEL, a newspaper of general
circulation in the Borough of Carlisle,County and State aforesaid,was established
December 13�, 1881, since which date THE SENTINEL has been regularly issued in said
County, and that the printed notice or publication attached hereto is exactly the same as
was printed and published in the regular editions and issues of
THE SENTINEL on the following day(s):
May 15, 2014 and May 22,2014 and May 29,2014.
COPY OF NOTICE OF PUBLICATION
� �°� �� a r EBTAF��IOTICE - � a ;
E`aSTRT�t7��� `���'`"�.' wY� g�{IREk''��l�4HAlIM��^� �.��� `
� ..�gkt�� �'�,��� � � �.v"'�.t , r",�'aFa^t�rc. �`+€�^;�'� t '� �t
�aT�a� .� ������wr,a�r����„��s��a�,�€�a�rh�� Affiant further deposes that he/she is not
�t�i���� t��,,.�� � '� y�� ��"__,����'������trt"; interested in the subject matter of the
�~ �
�x�c�`����' ' `�`f `�� � ata����`�,� �����; aforesaid notice or advertisement,and that
����� ��p�a�����. ��war����������.�� ,j ; all allegations in the foregoing statement as
���
��� �. �- ; ��--�, �
�'� � �`�-��_� ,� �.����*t��s � ���� � '� to time,place and character of publication
�,.
��,���.��:���_�������
"� ss��ia� �s g����`����;��; are true.
- - �#lainsburg PA fi2116 ' >� ��' (�/
� .. , '.a= . ,r . �i �
��— ` �—�
Sworn to and subscribed before me this
3d� a� �a �t .
�
Notary P lic
My commission expires:
coMMOn,w�a�r�a���rVN�Y�,V,�NtA
NoWrlal Seal
Bethany M.Holtry,Notary PubIIC
Carlisle Boro,Cumberland County
My Commisslon Fxp(res Scpt,26,2tl15
MEMBER,PENNSYtVA;V:rS.y5S()CTA:TTCJN O�NCl`PAI�Y�S
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA :
. ss.
COUNTY OF CUMBERLAND .
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
May 23 MaY30 and June 6, 2014
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
� �
isa Marie Coyne, Ed' or
SWORN TO AND SUBSCRIBED before me this
6 day of June, 2014
� `
Notary ,
Graham,Shirley, dec'd.
Late of Penn Township.
Executor: Ronald Graham, 1822
Walnut Bottom Road,Newville,PA COMMONWEAITH OF PENN&YLVMNA
17241.
Attorneys: Kari E. Mellinger, Es- NOTARIAL SEAL
quire,R.J.Marzella&Associates, DEBORAH A COILINS
3513 North Front Street, Harris- Notaty Public
burg, PA 17110. CARIISLE BOAO„CUMBERlANO CNTY
My Commisslon Expires Apr 28,2018
, i�f',.',� � ��i`;'1 �,�'_);� �''� �'i:.i�1,`l ,., `�, j �' ���a ;� ;tli `1° �;�,°i'���'i�'�� ! -_
7 f'!�
�����;;�-T°�� rJ�' �i�;�v��"�k,��,�i� �-: �'
��, .�����;. �'�
..� ° c�
�� � : �
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;
1lJ -�T �:�
^T ,s.i i' fl1
�,�M'�L�r:>4'm•s{,y°�,g .,1 �/"l�i '�y�'S'��
A'./�."�� �'� _� ��..�.��;`�'
�-
=, GLENDA F,�R/VcR STR.a SB�UGF� _
�e�iscer ror the Proba�e or ti�Ti�1s and G-r�:�t?r�
Lette-rs of �drr?nistration in and for
C'L�l�IBERLAI�TD Coun ty, do here.b_y cer�i fy tha t on
the 6th day of November, Two Thousand and
Twe1 ve,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
es ta te of SHIRLEY J GRAHAM , 1 a te of PENN TOWNSHIP
/First,Middle,LasU�
in said county, deceased, to RONALD G GRAHAM
lFrrst,Middle,Lastl
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal o.f said office at CARLISLE, PENNSYLVANIA, this 6th day of November
Two Thousand and Twel ve.
Fi l e No. 2012- 01170
PA File No. 21- 12- 1170
Date of Death 5/27/2092
S. S. #
�
� .�
< ''�! 1 C�r � /1;L'' ',� 4�/ ,'�:�'.1 C(..11t�''�' ' `-
� - Register f Wills
� �•( �• � ! f� ` ( ,�/
� �, ;���; �%� c. f `2� �t._._
Deputy �
�
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL '
_ _ _ -
AEV-i5o8 EX+(o8-�z)
� pennsylvania SCNEDULE E
��� DEPAPTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX REfURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Shirley J. Graham 2012-01170
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
�. Survival Benefits/Claim 149,355.65
TOTAL(Also enter on Line 5, Recapitulation) $ 149,355.65 -;
If more space is needed,use additional sheets of paper of the same size.
�` _ � �f2�j���
' ' �
R.J. MARZELLA&ASSOCIATES, P.C.
BY:Charles W. Marsar,Jr., Esq.
PA SUPREME COURT I.D.I+TO.86072
35�3 North Front Street Attorney for Ronald Graham,
Harrisburg, PA�7��o Individually,and as Executor of
Telephone: (7�7) z34-78z8 The Estate of Shirley Graham
Facsimile: (7�7) 234-6883
IN THE COURT OF COMMON PLEAS ..
CUMBERLAND COUNTY, PENNSYLVANIA u ✓ � �(� � `v/�
RONALD GRAHAM,INDIVIDUALLY AND AS . DOCKET NO. � t �
EXECUTOR OF THE ESTATE OF SHIRLEY .
GRAHAM :
PLAINTIFF, . PROFESSIONALMEDICAL
. NEGLIGENCE
V. .
TIMOTHY HORSKY,D.O.; :
WEATHERBY LOCUMS,INC.; :
DONALD CHAPMAN,M.D.; : `- ' "�'
�
NICOLAU DACOSTA-NETO,M.D.; : --�,� _. -.
TODD LUPOLD,PA-C; ; �r� ��== '-`'-
JOEY WISNER,PA-C; : �i= � r
APOLLOMD,Irrc.; . �x �'° �
��. - -
RUCHI DASH,M.D.; : L,_ ��: - -,
JULIUSZ NITECKI,M:D.; ; =��a� �-' -
HOSPITALISTS OF CENTRAL : 7r�° " --
PENNSYLVANIA,P.C.; : -� ---
LATOYA MONTFORT,R.N: :
MEDICAL STAFFING NETWORK :
HEALTHCARE,LLC; :
BERNADETTE BRAZE,D.O.; :
CARLISLE HMA PHYSICIAN :
MANAGEMENT,LLC,T/D/B/A MIDSTATE :
EAR,NOSE AND THROAT CENTER; :
CARLISLE HMA LLC,T/DB/A :
CARLISLE REGIONAL MEDICAL CENTER; :
Dorlrr PoLSOrr,RN; :
z�
KATHY STUART,EMT-P;AND :
HERSHEY MEDICAL CENTER :
DEFErv�arvTS . JURYTRIAL DEMANDED
ORDER
AND NOW, this�day o 014, upon consideration of the attached Petition
for Court Approval of Settlement of Survival Action and Apportionment of Settlement
with Wrongful Death Action,
IT IS HEREBY ORDERED THAT:
1) Settlement of this matter in accordance with the terms of the Petition is hereby
approved.
2) The distribution of the $500,000 settlement shall be allocated as follows: `
Wron�fiil Death Claim Survival Claim
Gross-$2,50,000.00 Gross- $250,000.00
Atty fees- $100,000 Atty fees- $100,000
Ex�enses- $644.35 Expenses- $644.35
HighMark lien-$25,683.84
Medicare lien-$5,102.34
Net = $149,355.65 Net = $ 118,569.47
3) Petitioner is authorized to execute all necessary relea
Date: � Cornm n P e s Jud e
9
J.
TFtUE COp�! FROM ��CORD
In Testimony Whereof,I here ui�to set my hand
and the se ( f sao Co rt� at Ca!'�i��20�
This �/t� -
Prothon N
�. �
��
_
1
a �
Distribution Sheet:
Charles W. Marsar, Jr., Esq.
R.J. Marzella&Associates Shaun Mumford, Esq.
3513 N. Front Street Stevens & Lee
Harrisburg, PA 17110 51 South Duke Street
Lancaster, PA 17602
MARC LEVIN,ESQ.
WEBER GALLAGHER Peter Samson, Esq.
FULTON BANK BUILDING Cipriani & Werner
2OO NORTH 3RD STREET 450 Sentry Parkway, Suite 200
Su�TE 9A Blue Bell, PA 19422
HARRISBURG,PA 17101
John Stepanian, Esq.
Stuart T. O'Neal, Esq. McQuaide Blasko
Burns White 1249 Cocoa Avenue
100 Four Falls, Suite 515 Suite 210
1001 Conshohocken, PA 19428 Hershey, PA 17033
4 �
Cindy Ellis, Esq. Naomi Plakins �
Foulkrod Ellis Plakins &Associates,P.C.
4000 Market Street 140 East State Street
Camp Hill, PA 17011 Doylestown, PA 18901
� I
aev-�si1 exk (o�-��)
�=� � p pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
� INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shirley J. Graham 2012-01170
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Egger Funeral Home, Inc.Expenses 2,420.42
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
510.00
2. Attorney Fees:
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4, Probate Fees: 406.33
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 3,336.75
If more space is needed,use additional sheets of paper of the same size.
10:08 AM R.J.MARZELLA, ESQUIRE AND ASSOCIATES, P.C.
07/17/14 Account QuickReport
nccn,ai easis All Transactions
Type Date Num Name Memo Split Amount Balance
Ciient Prepaids
CWM'S
Graham, Est.Shirley
�
Check /23/2012 20103 Reqister of Wills VOID: Bank(M&� ... . 79.50
* - -
Check 11/15/2012 20292 Healthport 0117909693 Bank(M&l) ... 125.04 264.37
Check 11/30/2012 20317 Healthport 0118454584 Bank(M&� ... 253.59 517.96
Check 06/16/2014 21669 Lehman Mediatio... Bank(M&� ... 360.00 877.96
�
�
Check 06/20/2014 21675 Charles W. Marsar Parking Bank(M&� ... 40. 1,184.96
Check 06/20/2014 21679 Cumberland Cou... Bank(M&� ... 103.75 1,288.71
Deposit 07/10l2014 Ronald G. Graham Deposit Bank(M&T) ... -1,288.71 0.00
Total Graham, Est. Shirley 0.00 0.00
Total CWM'S 0.00 0.00
Total Client Prepaids 0.00 0.00
TOTAL 0.00 0.00
.� c f v� . 33
Page 1
Hourlv Billing for the Estate of Shirlev Graham
02.14.13 KEM Notices to Beneficiaries .3 (18)
02.14.13 KEM Certificate of Notice .2 (12)
5.1.14 KEM LT Dept of Rev re: 50/50 split .6 (36)
5.06.14 KEM TC w/client re: probate agreem. .2 (12)
05.06.14 KEM Status Report .1 (6)
5.9.14 KEM Advertising .3 (18)
7.10.14 KEM Mtg with client re: distribution .3 (18)
7.14.14 NLM ROW letter&Filing Inheritance Tax 1.3 (78)
Pending NLM Final Status Report/ROW .1 (6)
TOTAL: 3.4 hrs @ $150/hr= $510.00
Jul 16 2014 3: 26PM Egger Funeral Home 7177764589 p. z
� � L%���G�. ��?�!'-
c����� 15 8ig Spring Avenue
NEWVILLE, PENNSYLVANIA 17241
F CHARLES EGGER, Superv�sor 717-776-3414 FRANK C. EGGER, Funeral Directc
July 16, 2014
Funeral bill for Shirley Jean Graham
Date of death May 27, 1940
Professional services $1,955.00
10 Death Certificates $6.OU a piece $60.40
Va11ey Times Star Obituary 450.00
Sentinel Obituary $9�.43
Urn $265.4�
Total $2,420.42
J�/
Funeral Paid In Full June 28, 2012 �
�
,
REV-1512 EX+(12-12)
� pennsylvania SCHEDULE I
�;�y DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
INHERITANCE TAX REfURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shirley J. Graham 2012-01170
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• High Mark Lien 25,683.84
2. Medicare Lien 5,102.34
TOTAL(Also enter on Line 10, Recapitulation) $ 30,786.18 '
If more space is needed,insert additionai sheets of the same size.
��',� �
. _ ��
Py�LAKINS �� . �� .
�
� A S S � C. July 3,2oY4 .
ACtorneys-aC-law
A Professionat Corporatian �A���ICiHT��Q,
Ricarda Rich,Esquire
Neo�a a.Ptekins Gibson&Sharps,Attorneys at Law
n�ekina�p/ektns/aw.cam 9390 Bunsen Parkway
Ava M.Ptektos"O �.01113Vlll8�KY 40232-2080
ap/ektns�p/aklns/ew.com
3areh M. ee��t RE: Event Number 7905930-79066�2
atrek�pla�Hns/ew.com Our File No.180-I17
Eileen F. Solamon
eso/omon�plek�ns/ew.com D�Att�,gich:
* AlsomsmbarConnaecicue8s� I snclose herewith Sedgwick CMS�ru tale�]n Lii�fiQiCll ajrjQU]'Zt �f
t Also member New Jersay Bar
O AlsomembarNawYh�tBer �25,683•$4 made payable to Trover Solutions, in fiill and final
satisfaction of your lien interests with respect to Shiriey Graham,as per
"The John Barcley House-1844• the letter of Shannon Harris of your office, which I attach for your
14D EasE Stete Street reference.
A0.8ox 1287
Doytestown, I would much appreciate yowr sending to me a Satisfaction of
B„�,��,,,,,�, Lien at your earliest convenience, or other written confirmation that
�MB,m��,aso, your lien interests have been satisfied and that the debt has been
(215)345-0801 discharged. Thank you.
r-sx:c��s�aao-ss3o �
rz��aa6-eea� VerY YY �,
Website:www.plekinslawcom
AO A.PLAKINS
NAP:cc
EnclosureS
1SQ 117�RtCIi.I1T.
{w�ith enclosures)
cc: Charles Marsar,Esquire
Julianne Sais, c/o Sedgwick CMS
. • �� �
Sedgwick CMS Inc. On 9ehalf Of DATE CHECK AMT CHECK NO.
�Southwest Physicians RRG, Inc. o7/a�/2o�a 2s,sea.sa 1012004344
Professionai Liabitity Account
P.O. Box 1447$ EB AX ID
Lexington, KY 40512-4bj8 7ROVER SaLUTiaNS
SCMS UNIT PAGE
219 SWPRRG - PL Dututh Office 001
►OOOOf6 101200r344 00002 OF OOG02 OqA /40701 f208
PLAKINS AND ASSOCIATES PC
140 E STATE STR�ET
DOYLESTOWN, PA 18901
Loss Date C ' Number S3
FACIlITY: HM-SWPRRG
ACCOUNT NUMBER:
Graham. Shirtey J 05/25/2012 2012329662
Amt Paid: 25683.84 Description: Indemnity Miscettaneous
Amt Bitied: 25683.84 Invoice:
ICN:
Dates: - Comment: Shir7ey Graham N7905830-7906672
B1991.1+RM(07�98-0:
t� 'k M R e � _ I T � K 0 ' 3 55 "6.
�s. �Ph c' a �o ./. :o � -
r B o # c :
xingtor� 0 . . :� ��� _ , ,.-
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d P�rY �:�. .<.�'YJ�1!I�FI�,� �t�OUS�D����,y;FJl1�ILQRED:�iEI�H�<� :�`.MR��°�z. �`:�x :w�,`:` ,.....�' :!r�".�t ,
�; �:
:., , *AN�"i84 -10�'`UO�I.AI�S*.; ��' �:�` .�� ; r<. _ .:; . � i .�
�: < - • $25683.84
TO THE ORDER OF B ��:
TROVER SOLUTIONS
Y.:.;�".5.�', ,.m
`N:�a-�r6n0.. ..2•ky� y��p .
ia�;,,.CdLt'ry ''!� 'Ln\ K'F�w�F a;bn"�'M:r?'Fp!r. ba"'�
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t; :��'.�: � _ � '� a
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P.0.Box 34060
Lou�sville,KY 40232-4060
June 27, 2014
NAOMI PLAKINS, ESQ.
PLAKINS&ASSOCIATES, PC
14Q EAST STATE STREET
DOY�ESTOWN PA 18901-
RE: Member: SHIRLEY GRAHAM
Health Plan: HIGHMARK SENtOR PRODUCTS
Date of(njury: 5/25/2012
EveM Number: 790593Q-7906672
�ear :
Trover Solutions pravides recovery senrices (through subrogation, reimbursement, or otherwise) for the
a6ove-referenced Health PEan.
Please atlow this letter to serve as written confirmation that Ricarda Rich with Gibson and Sharps has
made an agreement on behatf of Trover Solutions and the above referenced to ac�ept $25,683.84 as
satisfaction of the plan's right to be reimbursed from your client's recovery.
You may make the check payable to Trover Solutions, 1nc., and include our tax identifica�ion # 61-
1141758, and evenf number on the face of the check. Should you have any questions, please da not
hesitate to contact me.
If you have any questions, please eontact me at the toll-free number below.
Sincerely,
.�•.n.._..�`�
Shannon Harris
(8fJ0) 889-3923
7905930-7908872/OPRGH
�
PLAK11�1S �c,..
.
� A► S S � C. Juiy�,2oz4
�eorneys.ea-t.�w C +�TTFIED MAIL
A Professional Corporation
RETURN RECETPT REQ,UE.STED
Naoml A.Plakins
npleb(na($Tplek/na/ew,00m Medicare
Ava N1,p�ak►ns*° NGHP
�8�,�,8�..�, P.O.Box Y38832
Sarah M. 8akert Oklahoma City,OK 73i�3
abeker+�p/sk/ne/aw.aom
Eltean F. Solomon �: Senefici.ary Name: Gratiam, Shirley J.
�a°"�°'�'�'8�"y°'°"' Medicare No.: x9532O983A
Case ID No.: 2o�2g 46090 o�i.4a
• Also msmber ConneaEloue Bar Our File No. �t8o-11�
--'--t�AItO�neAnbeC'NeW.Ner[kyB6P ' - - --- • --_...- ''-----'------�'
'_"''__'_•' '_' _' "
a Also msmher New lbrk Ber
Dear Sir or Madam:
'The John Berctey Houae-1874'
140 East SteCe Street �th reference to fihe above matter, on behalf of Sedgwick CMS,
Po. ���2a� Inc., I herewith submait to you a check in the total amount of$5,io2.34
E,,�eB�w�, made payable to Medicare with reference ta a "Final lien letter"
Bic1��� (attached)in fu11 and final satisfaction of any and all Medicare liens with
��,�we�� �eso, �'�Pe�to the above ciaimant.
[216)346-0801
Fax:(215)340-883D I would much appreciate your sending ta the undersigned,at the
r��6��.se22 above address, a proof of satisfaction of this claim, in Medicare's.Finai
web�,�:www plaktr�sbw cam Lien letter,
Tf you have any questions whatsoever,please free fio contact me.
Thank you. �
Very your
N MI LAKINS
NAP:cc -�
�
Enclosures
1 SO-117�M2(I tCQ I'Q.l h'..
(with enclosures}
cc: Charles Marsar,Esquire
Julianne Sais,c/o Sedgwick CMS
Sedgw i ck CMS I nc. f}n Beha 1 f Of DAT'E CHECK AMT CHECK NO.
Southwest Physicians RRG, Inc. 0�/o2/2oia s.i02.34 1Q1200A345
Professionai Liability Account
� P.O. Box ik478 AY T I
Lexington, KY 4oslz-�+�+78 MEDICARE SECONDARY PAYER REGOVERY
CONTRACTOR
SCMS UNIT ' AAGE
219 SWPRRG - PL Duluth Office pp�
•OOOOt7 10120p4J�15 00001 OF OOOpi OCM 1,0702 121/
PlAKINS AND ASSOCIATES PC
140 E STATE STREE7
QOYLESTOWN, PA 18901
Lo Date Cia�m Number
FACILITY: FiM-SWPRRG
ACCOUNl' PtUMBER:
Graham, Shiriey J 05/25/2012 2012329662
Amt Paid: 5102.34 Description: Indemnity Mfscettaneous
Amt BiT1ed: 5l02.34 Invoice:
ICN:
�$'�es� - Comment: HICN �+ 195320983A
E1991.PRM(q2-2&O)
. . .' • • • ,
Cl � �C M 111� : ; T� . • T K•��,�2 . �� > � .:� gg: r`a
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:� �"' }�� � ���,�?. •�' '� , �}' � � � -
i, P1AY f'.�'�',� *;Fr�f��^�{1i0U .N,�ON�':;HU�ID�ED '�I�Qs AN� ��t/��JQ,. O� �� y:£ � {'( �r }��" �
. . . . y', ��V . +�: t:.3 'vr ?R::\ J.� . '4� �:}:.��A� � ::A Y:y {�+� F'Y`._'.�� N'2�' •
. . . . . . • ., - '`� s�' $5102.34
TO THE ORDER OF � " ' � " •� e ��
MEDICARE SECONDARY- PAYER RECOVERY CONTRACTOR �
�FOR:,THE, B,ENEF IT OF_,...,�- . . �
'� �SH IRl'�Y�J GRAHAM F��fCN �9532d'g83�A CASE' � � - � � �
�;2,01234�b09001142 NGHP ,�; a.. ��,��,� f :{�:� � .,�,y,.:�.�; � k
:- ,��'- � - �;.�-r:r
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Y �
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Nt i, L :;. . .,�,#'�• -qk�;€' .�
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n' i0120D4345�i' �: 266086554�: 32D0602489ii'
_ __ _ _
� � ����
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BaiNNa and RKerory
� � May 20,2014
� 1459 I MB 4.435
, �'**AUTU�'"1bi1XED AADC 720$:I459 T:13 P:t6 PC:�4 F:386301
�STATE OF SHIR[,EY J GRAHAM
. � ' 1822 WAL,Nt3T$OTTQM RD
tVLWVILI.E,PA 17241-9510 •
ilii�ut�'1���'�I�f'�t�telu1l't��Il1�Ne��t�h�i�ni����,f�lh1�
RE: Beneficiar}i 1Vame: GRAHAM,SHIRLEY J
a � Medicare Number: 19S32U9�3A.
� Case Identi�cation Namber: 20J.23 46Q90 01142
� Date of LZCidant May 27,2012
� D�mandAmoanf: $S,1Q2,34
3 I?ear Estate AHAAq;
PleASe note th�at if we I�ow tha#you have an attorne ar ot�er indivi.dual re resentin
f � �Y�u
it� this matter, we are sending him/t�er s copy oP thie Ietter. If you have aa attoxney or
other representative for tl�is matter ttnd hislher caame Is reot sho��n as� "cc" at tbe end vP
this letter(indicating that he/she is receiving a copy),p[ease contact i�s immediately. If you
have any quesNons regarc�ing this �ett�r szncI �u•e represe.�ted by an attoraiey ar other
i�adividua! in this matter,you may wish ta talk to your repxesentative And ma[ce sure t�st
helshe has received a copy of#��is�etter hetore cantactiug us.
We a�e wriling to you becanse we learued that y�u �iave made a liability claiin ralating to an
accident,illness,injury,or ineident occurring an or�bouC Ms�y 27,2Q12 and obtaiued a recvvery.
We have determinect that you�ue required to repay the Medzcare progt�m$5,]02.34 f'or the cost
of inedica! care it paid relaking to your Iiability�z�ecovery. (The term "re�overy" includes a
settlenient,judgment,award,ar any other ty�e of recov�ry.)
� Please read thzs entire letter,as it contai�ts impartRnt information,fncluding:
o An exp�a��ation oF why you need to repay Meclicare and the way w etermined the
' , ount you are required ta repay(Parts T annd II);
• TnstrucCions for re�aying Mediaare if yau agree that thare has been an overpayment and
uccept the amount we h�ve ctetermi�ed you owe. (Part III);
NGAP.YU BOX 138832•OK�AHOMA CT�'Y,OK 73113 5GLDBLNGI�lP
Pa$c L of 6
' ��� ����
c.�neraH�awcuro,uwsanas �-"'� coadm�6onor
, 90n�fii Hid Aetew7
� addition�l money frarn ttiis liability recvvery,or any ather liubility recavery,yau nnust let as knnw.
III.If I accept ihis deter�n�nataon,how da I repay Mecticare wuat I owe?
As stated, Medicare has calculated an overpayment af $5,102.34, with repayruent �equestecJ
within sixty{60} days af tite dace of.this letter, M�ty 20,. 2014. Please sencE a check or money
order for$5;I42.34,made payable to Medicare,to us at the address listed at the end of this letter.
ease m inc u e your name an_ 'care n.um,e�on e ea, or money� er an
inctude a copy of this letter with your payment.
�,►
The urtaunt reqaested in this letter may not incIade payments received prior to the issuance af
this dzmand Ietter dated May 2�, 2014. Upon issuing a check,please deduct previous payments
made to the Hene�tts Coordination&Recovery Center{BCRC)for the above referenced debt.
a
� Please continue reading fc�r information ragarding your rights with re;spect to this overpayment
� and what happens if you do not repay Medicare timeIy(including the accrual and assessment of
� interest).
� IV.What rights do I have if I disagree with the amaunt this istter says I owe or think Ehat I
' should not have to repay Medicare for so�ne ofher reason?
�{isht to Reauest a Wafve,�--You hava the right to request that ihe Medicare pragram waive
recovery of fhe amount you owe in ftill or in part. Your right io request a wtuver is separate from
your xight to appeal our determination,and you may request both a waiver and an appasl at the
same time. The Medieare pro�razn may waive recovery of the amount you nwe if you can show
� that yoa meet bottt of the foltowing conditions:
1. This overpayment {for gurposes of reques�ing waiver of recoyery, the Amount you
owe is coztsidere@ sn overpaymeat) was not your fautt,because the infvrrnadon you
gave us with yoi�r claims for Medicare benefits was correat�nd caznplete as fAr as you
knew; and when the Madicare paynient�was made, you thoogh� that it w�s the right
�ayment;
ANI�
2. Paying back this money would c:ause i'inancial hardship or tyauld be uni'air fnr s�me
atlier i�easoii.
If you bet�evethat both of these coa�ditions apply to you, you should send us a letter that explains
w�iy you think you should receive a waiver of recovery af tl�e amount you owe. If you request a
IYG�P+�PQ 130X 13883Z •OKr.AHOMA CIx'X,OK 73113 SCiLDBLNGNP
Page 3 ciF b
. • .....-:----- , ��
��� ����
mausw.wo�iw..rwu.�sanau . e.,e�.,.rawowrr
� successftll in nppeaiittg our c�ecision, Medicare wilI refund any excess amounts you have paid.
Medicare wil]not initiate a�iy recovery actian while your requesx for�vxiver or ap�eal is pending.
: If yau can't repay Medieare in one payment,you may ask us to eonsider whether to aliow you to
, pay in regular installinents. Tf you make install�nent payments,you should be flw�re that yow•
payments witl be apptied to any interest due�rst and then ta the ouistand'tng principai amoun#.
The pravisions nf. the Debt.Cotleeti�n_ Improvement Act of 1996 appty io Medicare debt.
Recovery actions may include co2lectzan by Treasu.ry offset a�sinst any monies otherwise�Sayahle
to the ciebtor by any agettcy of the United Siates (for example, tax r�fun�s or �etieral benefits),
�among other cvileetion methods. Zf Medicare intends to take colleetion actian(iac:ludin�refenal
to Treasury), you will be�mvided with �ppropriate notice. This notice will incIude informatian
concerning Rpprapriate steps to avoid such actions.
i �
� VI.Who shonld I eontact if I have questions about this letter?
:
� If you have any questions concerning this maaer, please call tiae BCRC at 1-855-798-2627
� ('1"CY/TllD: 1-$55-797-2b27 far the hearing and s�eeeh impraired) or you may contact ux in .
3 wri�ing at the address betow. If you contact ns in wridug, please be sure to inclucle the
' benefieiary'sname, Medicare. Health Insurance Claim Nitmber (this is the uumber focmd on the
beneficiary's xed, white and blue Medicare card)t and the date of the incident. l.�roviding us witt�
this information will help us respond moz�e quickiy to any questions you may have.
1VGHP
PO BOX 13$832
OKLAI�UMA CITY,OK 73113
Sirtcerely,
BCRC
CC: RJ MAZELLA&ASSOCIA'TES
Enclosure:Paymenl Summary Farm
NCrHP•PO BQX 13$832�OKLA.HOMA G1TY,UK 73113 SGt,DI3J�tG1•If'
Page 5 of 6
3513 NORTH FROM SIREET, HARRISBURG, PEN�SYLVANIA 17110
717.234.7828 866.625.Z590 717.234.6883 F�x
ARZELLA
1
� ASSOCIATES
Attorneys � Counselors At Law
July�7, zoi4
r..,
Cumberland County Register of Wilis cQ x _�;.�
�_T.,�
� Courthouse Square �-�, � r;=�'�-�
��.,; t_" , TJ
Suite�oz �--.. �, '
; ; � ' �
Carlisle, PAi7oi3 ��� " �
�� ., , _
c��::: � _ �;
Re: Estate of Shiriey J Graham ��.; c,, r� rri
File Number: zo�z-o��70 � -- ���
r�
To Whom It May Concern:
Enclosed please find the original and three copies of the REV-�5oo for the
above-referenced estate. Please return any additional time-stamped copies in the
envelope provided.
Should you have any questions or concerns, please do not hesitate to contact
our office. Thank you for your attention to this matter.
Very truly yours,
R.�.MARZELLA&ASSOCIATES�P.C.
BY: !
Nico eyer, Paralegal Int n
Kari E. Mellinger, Esquire
NM/
Enclosures �
Cc: Ronald Graham
1822 Walnut Bottom Road
Newville, PA 17241
f'1_���r�'_,lf'D f�i`' ; t
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PRIORITY MAIL 1 -DAYTM i
Robin Marzella, Esquire ���5 �
3513 North Front Street
Harrisburg, PA 17110 I
I
I
I
I
SHIP Cumberland County Register Of Wills ,
To: 1 Court House Sq Rm 102
Carlisle PA 17013-3�22
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3513 NORTH FRONT STREET, HARRISBURG, PENNSYLVANIA 17110
717.234.7828 866.625.2590 717.234.6883 Fnx
ARZELLA
1
�' ASSOCIATES
Attorneys d�' Counselors At Law
July z4, zo�4
Cumberland County Register of Wiils
Attention: Heidi
� Courthouse Square
Suite �oz
Carlisle, PA�70�3
Re: Estate of Shirley J Graham
File Number: 2012-011�0
Dear Heidi:
Enclosed please find the check for the filing of the Inheritance Tax Return and
additional probate for the above-referenced estate.
Should you have any questions or concerns, please do not hesitate to contact
our office. Thank you for your attention to this matter.
Very truly yours,
R.�.MARZELLA&ASSOCIATES�P.C.
BY:
Nic e Meyer, Parale I tern To
Kari E. Mellinger, Esquire
NM
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