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Home My WebLink About08-21-14 REV-1500 EX(02-11) 1605610143 OFFICIAL USE ONLY PA Department of Revenue penns Ivania Bureau of individuat Taxesa*+r cournT coax Tour Flld Numeor PO BOx.280601 INHERITANCE TAX RETURN 21 Harrisburg,PA 1712MSOI RESIDENT DECEDENT I 0095 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date Of Birth 11 21 2013 05 02 1950 Decedent's Last Name Suffix Decedent's First Name MI WAY MARGARET G (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 X 1, Original Return El 2. Supplemental Return 3. Remainder Retum(Date of Death Prior to 12.13-s2) 4. Limited Estate 4a.FMrae imerasl corm�lcmtu S. Federal Estate Tax Retum Required ff (dale of 1anM 21282) L 8. ( cC oy ofwo)a 7 Ag , MyaViZdf living Trust 0 8, Total Number of Safe Deposit awes 9.Litigation Proceeds Received O 10,ba 1 P1 1%1 aM IDa9IN Death 1 i Xiecgon telex under Sec.9113(A) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JESSICA F GREENE ESQ 717 697 3223 REGISTER Oe8li USE OVtY ? C7 a1�o G First Line of Address -L C-) c Q CM cTa:L7 ?� N I'll tL� r1 555 GETTXSBURG FIRE s'r c Second Line of Address �- O n s.+. -•T i STE C100 w City or Post Office OATEtfjtCEO •• ti7 State ZIP Code -� MECHANICSBURG FA 17055 M1T Correspondent's e-mail address: JessicaRkeystoneelderlaw.com Under penalties of perjury.I declare that I have examined this return,Including Socon IwIIg schedules and statements,and to the best of my knowladppe and belief, it is true,conect and complete.Declaration of preparer other than the personal represent3five Is based wall Information of which preps er has any krxNAedge. SIGNATURE SPOt1SIB RETT9! DATE��r/ .� Richard F Way �y�`- ADD�RE 4 ��"TI " r 67 Painter Avenue West Haven CT 06516 SIGNATURE OF PREPARER OTHER THAN R EEPIRREESENTATNE DATE [I + OV HA S . �1 (lQ gQ Jessica F. Greene Esq. � to 0 555 Gettysburg Pike,Mechanicsburg,PA Side 1 L, 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number Dec enl'sName, Way, Margaret G. 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&Notes Receivable(Schedule D).. - - .. ...-.............................. 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 3,200 . 55 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous I�oD;Probate Property (Schedule G) LJ Separate Billing Requested............ 7. 8. Total Gross Assets(total Lines 1 through 7).. - .......... .. - . ..... 8. 3 ,200 . 55 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 1,478 . 42 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I).....................-..... 10. 93 , 483 . 72 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 94 , 962 . 14 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -91, 7 61 . 59 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. -91, 761 . 59 TAX COMPUTATION-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.00 15. 0 . 00 16. Amount of Line 14 taxable 0 . 00 16. 0 . 00 at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X.12 0 . 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 0 . 00 19. TAX DUE................................................................................................................ 19. 0 . 00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21-14-0085 Decedent's Complete Address: DECEDENT'S NAME Way, Margaret G. STREETADDRESS 940 Walnut Bottom Road CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments S. Discount 0.00 Total Credits(A +B) (2) 0.00 3. Interest (3) q, If Line 2 Is greater than Line 1 +Line 3,enter the difference, This is the OVERPAYMENT. (q) Check box on Page 2,Line 20 to request a refund 5. if line 1 +Line 3 is greater than Una 2,enter the difference. This is the TAX DUE. (5) 0,00 Make Check Payable to: REGISTER OF WILLS AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" IN THE APPROPRIATE BLOCKS I, 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;or.........................___............................................................................... x d. receive the promise for life of either payments,benefits or care?............................................................ N x 2, If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate c onsideration?......................_....._..._._._._....._................_.-.................-.._..............-.... ❑ Q 1 Did decedent own an"in trust for^ or payable upon death bank account or security at his or her death?....... ❑ Q 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?........................_............_......................................__................................ ❑ 0 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)(1)]. For dates of death on or after January 1,1995,the lax 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)(il)]. 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 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)1. • 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[72 P.S.§9116(a)(1)]. • The tax rate In 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. R".1 SOS Ex.(11-10) SCHEDULE E Pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT T REVENUE PERSONAL PROPERTY INHERITANCE RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Way,Margaret G. 21-14-0085 ttx3uCa tho ptoceeesol rr atian artl u»dotomapaceeeswme.eceived bWy d,a estato. All property jointlyowned with me right of auMvorship must be disetosodon achadote F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 PNC Bank personal checking xxxxxx6499 3.200.55 TOTAL(Also enter on Line 6,Recapitulation) 3.20055 (tf more space is needed,additional pages of the same size) Copyright(c)2010 forth software only The Lackner Group,Inc. Forrn PA-1500 Schedule E(Rev. 11-10) REV-1611 IX.IMM) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Way, Margaret G. 21-14-0085 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zia Year(s)Commission Paid 2. Attorneys Fees Keystone Elder Law P.C. 1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City Stale Zia Relationshio of Claimant to Decedent a. Probate Fees 123.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs _ 354.92 See continuation schedules)attached TOTAL(Also enter on line 9,Recapitulation) 1,478.42 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Way, Margaret G. 2144-0085 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Cumberland County Law Journal Estate Publication Notice 75.00 2 Gunn Mowery Fiduciary Bond Fee 100.00 3 Sentinel Estate Publication Notice 179.92 H-B7 354.92 Copyright(c)2002 form software only The Lackner Croup,Inc. Faint PA-1500 Schedule H(Rev.698) Rev-0512 E%.(12-0) SCHEDULE i Pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Way,Margaret G. 21-14-0085 Report debts Incurred by the decedent pdcr to death that remained unpaid at the date of death,Includinp unmlmbumed medical expenaea. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Commercial Acceptance Co:Ambulance/medical bill incurred within 6 months of death- 10100 Debt collector for East Pennsboro Ambulance Company 2 Department of Public Welfare Estate Recovery Claim for Medicaid paid within 6 months of 27,613.35 death 3 Department of Public Welfare Estate Recovery Claim for Medicaid paid longer than 6 months 61,468.40 of death(remaining balance) 4 Hospice of Central Pennsylvania-for medical services incurred within 6 months of death- 3.000.00 Medical bill 5 Pinnacle Health Hospital-medical bill for services incurred within 6 months of death - 1,184.00 medical bill 6 Pinnacle Health Medical Group-medical bill for services incurred within 6 months of death - 114.97 medical bill TOTAL(Also enter on Line 10,Recapitulation) 93,483.72 (If Tram space Is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1600 Schedule 1(Rev. 12.08) REV-0610 EX•jai-to) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE - INHERITANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT - ESTATE OF FILE NUMBER Way, Margaret G. 21-14-0085 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSONS)RECEIVING PROPERTY DECEDENT (Words) ($$$) I• TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9176 a 1.2 Richard F.Way Brother 67 Painter Avenue West Haven,CT 06516 Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as approD riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Copyright(c)2010 form software only The Lackner Group, Inc. - Form PA-1500 Schedule J(Rev.01-10) May. 21.. 2014 2:40PM PNC Bank No. 3347 P. 1 • a IN May 21,2014 Keystone Elder Law PC 555 Gettysburg Pk Mechanicsburg PA 17055 RE: Margaret G Way SSN: 04046-4146 DOD: 11-2i-2013 Dear Sir/Madam: In response to your.requuest for Date of Death(DOD)balances for the customer noted above,our records show the following: Checking Account Account#15004496499 Established:01-29-2005 MARGARET G WAY DOD balance: $ 31200.55 +0.00 accrued interest Please note that this office provides date oideath balances for deposit accounts(MAs,CDs,Cbecking and Savings). We do not process any financial transactions or provide statements. If you need assistance with any of these items,please call 1.888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank,N.A. Member FDIC This message is intended for the use of the individual or entity to which it is addressed and may " contain information that is privileged confidential and exempr from disclosure under applicable law: If the reader of this message is not the Intended recipient or the employee or agent responsible for 'deli'vering-this message 07 the 4ritended reel ient;you are hereo notified that'an" diss"e"mination; " distribution or copying of this communications is strictly prohibited If you have received this communication in error,please notify the immediately by reply or by telephone at 800-762-1775 and immediately destroy this faxed document. Pagel of l `'-,MYq ON tl A�MT ro! ELDER LAIN P.C. www.keystoneelderlaw.com August 14, 2014 Margaret G. Way Estate C/o Richard Way,Personal Representative 67 Painter Avenue West Haven, CT 06516 INVOICE Fees For Professions!Services Rendered Estate Administration for Mazgaret G. Way Estate $1.000.00 Reimbursement of Cumberland County bond filing fee paid on 3/13/2014 $15.00 BALANCE DUE: 51,015.00 B PN CBATK NO. PNC Bank,N.A 040- ` -/ Central PA - _LY ./5 X12731313 ' DATE b PAY TO THE ORDER:OF- - /&� DOLLARS ESTATE.OFQlll�R.� FOR jOL6t/� og!!��S5irn Jicxr 1 tG y _ wl — —' FEPREESSEH0171VE 1:03131 27381: 5GOb440444u' 555 Gettysburg Pike,Suite C-100 • Mechanicsburg,PA 17055 Phone: 717.697.3223 Fax: 717.691.8070 'y� RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 1/24/2014 Cumberland County - Register Of Wills Receipt Time : 13 : 11 : 35 One Courthouse Mare Receipt No. : 1076834 Carlisle, PA 17613 WAY MARGARET G Estate File No. : 2014-00085 --- Paid By Remarks : KEYSTONE ELDER LAW WZ ------------- ----------- Receipt Distribution ------ ------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 30 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1785 $108 . 50 Total Received. . . . . . . . . $108 . 50 A KEYSTONE ELDER LAW P.C. 1 785 � S � � NNN TO REORDER PL SE LALL CHEOKOM nC(BIv7]!1-]WSTOLL FREE 8MS55 74 RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 3/13/2014 Cumberland County - Register Of Wills Receipt Time : 13 : 13 :42 One Courthouse Square Receipt No. : 1077294 Carlisle, PA 17613 WAY MARGARET G Estate File No. : 2014-00085 - -- Paid By Remarks : JESSICA F GREENE DMB --- - -- --- ---- ----------- Receipt Distribution ----- ---- -- ----- -------- Fee/Tax Description Payment Amount Payee Name BOND 15_00 CUMBERLAND COUNTY GENERAL FUN Check# 295 $15 . 00 Total Received. . . . . . . . . $15 . 00 @2ptssoCNnO .CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)24M166 Fax:(717)249-2883 June 13, 2014 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Jessica F Greene; Esquire RE: Margaret G. Way Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: `r May 30, June 6, and June 13, 2014 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 CCCJJJ�� Payment received $ 75.00 ------------- Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director 6 February 12, 2014 Jessica Fisher Greene, Esquire Keystone Elder Law 555 Gettysburg Pike, Suite C-100 Mechanicsburg, PA 17055 R.E.: Executor Bond Principal-Richard F. Way Estate of Margaret G. Way, Deceased Dear Jessica, Enclosed herewith you will find the $7,800 Executor Bond that you requested, on behalf of your client, Richard F. Way. A billing invoice will follow, under separate cover. The bond premium is $100 annually. Thank you for the business. Bgst" gards, Gam//f.r.,- David T. Rousche Bond Manager GUNN MOWERY the upside of insurance 650 N.Twelfth Street,Lemoyne, PA 17043 P.O.Box 900,Camp Hill,PA 17001 P (717)761-4600 • (800)840-1243 F (717)761-6159 www.gunnmowery.com The ntinel KEYSTONE ELDER LAW,P.C. FAD NUMBER PAGE NO. 555 GETTYSBURG PIKE 430751 1 Oft MECHANICSBURG, PA 17055-8070 717-697-3223 LL DATE SALESPERSON cARM .umsrrasmc amcou 6/01/14 wolfc RT DATE STOP DATE 5/17/14 05131114 AD DESCRIPTION ' 430751 NOTICE LETTERS TESTAMENTARY ON THE CLASS LINES 10 PUBLIC NOTICES 32 ` 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL-LEGAL 3 LGL $169.92 TOTAL AD CHARGE $169.92 3 PROOF OF PUBLICATION 3 MOBILE SITE 01PRF $7.00 MOB2 $3.00 V O� Purchase Order Est.MargarelWay PAY THIS AMOUNT $179.92 $215.90• Lee Enterprises no longer accepts credit card payments sent via e-mail. 'AFTER 06/26/14 Emails containing credit card numbers will be blocked. Please use the coupon below to send credit card payment to our lockbox. You may also send the coupon to a secure fax at 319-29113014. THE SENTINEL c/o LEE NEWSPAPERS Thank you for advertising with The Sentinel! Deadline for PO BOX 540 in-column legal ads is 4:00 p.m. two business days prior to WATERLOO IA 50704-0540 date of insertion. For questions, call (717)'240-7130. Return this portion with yourpayment Legal THE SENTINEL ❑ Check# ❑Credit Card Ad Number J430751 c/o LEE NEWSPAPERS ❑ ❑ M1 ❑ � ❑ Billing Date PO BOX 540 WATERLOO IA 50704-0540 Acct# Amount Due, 6y.Date: > Name on creoit card Amount — Enclosed' $ Signature Please make checks Payable to: THE SENTINEL PW214 THE SENTINEL • KEYSTONE ELDER LAW, P.C. c/o LEE NEWSPAPERS 555 GETTYSBURG PIKE PO BOX 742548 MECHANICSBURG, PA 17055-8070 CINCINNATI OH 45274-2546 21540200000004307 510000000000000002159000000179920 14 .4 Q -•--.e.�.•-'j—r'�--1��Camttaercial A,ceeptance Company - P.t3.Box'3268 Debt Recoveg Cansultant.Y Shiremanstown, PA 17011 Phone: (73 7)901-4557•(800)690-3857 Extension 217 $ March 29,2014 i14ARGARET'G.WAY Payment Amount: £102.00 67 Painter Ave Account Number: 999XM0 C/o Rick Way West Haven CT 06516-5829. C:LIENT,NAME AGENCY " CLIENT-t TOTAL-PAID SALAticr t. - EAST P--ENNSBOR0 AMBULANCE 999XM0, 13-00644 $:t)d $7x42.00 TOTAL; $•00 $742.00 The creditor listed above has assigned your account to our agency for collection. Your entire balance is to be paid directly to our office at the above address. If your account balance is not satisfied,further collection activity will result. You are hereby notified that your credit rating may be negatively affected if you fail to resolve your obligation. _ This communication is from a debt collecton'I'his is an attempt to collect a debt and any inforrnatiou obtained will be ' used for that purpose.There will he a$20.00(twenty dollar)fee for any check returned by your bank.The representative assigned to your file is: CHUCK BLACK at Extension 217. Unless you uotify this office within 30 days of receiving this notice that you dispute the validity of the debt or any Portion thereof, this office will assume the debt valid, If you notify this office in writing within 30 days of receiving this notice that you dispute the validity of this debt,this office will obtain verification of this debt or a copy of the judgment against you and mail you a copy of such judgment or verification. I f you request this7offiee in writing within 30 days after receiving this notice, this office will provide you with the name and address of the original creditor,if different from the current creditor. You may now pay your bill online at our secure site,tvst>tv.paycac.com. You will need to enter your agency number. i'or security reasons,credit card payments will not be.prncessed without the security code from the back of the card. 5Y-CMCOAC 10-001;01/10173 °".."._ e acTi'1+a'vier"i'i}rtton'And ftetvm'With isa°yment•�. "" - - `. '. . •` rnlerzalr1ei 1 j IF YOU WISH TO PAY BY CREDIT CARD.CIRCLS ONE AND FILLIN THE INFORMATION 8F00Y, P.O. Box 3268 G t3`i 1 '..•,; ` V►SA� D 7 Shiremanstown PA 1710111-3268 i RI-.TURN SERVICE REQUPSTPD CARD NUMBER EzP.oATe _ calm NOtoEaitn>,t��' - cvY . SiONAT AMOUNT PAID Payment Amount: $102.00 Account Number: 999X IO - 4 Brbuttttttuyfttt. u'title••tttH'I•ItlIttal.l.11.11i.{, W'avuxaWq,tW80r,euBStlsni96".1ar YllfaocTer Si .,t.% 999xtvtt}•AOt -51 6H1HHIM..III'lit:1 III,111,11411111111111111HIT1111111it t MARGARLA'U.WAY Remit Payment 10: 67 Painter Ave Commercial Acceptance Co. 0/o Rick Way P.O. Box 3268 West Haven CT 06516-5829 Shiremanstown PA 17011-3268 l T 2014 3:52PM NO, 5362- P. 2 — — *1 PeCinsYlVa nia aEMPIMBNy Of ftSLIC WtifABe July 22, 2014 KEYSTONE ELDER LAW PC 3ESSICA F GREENE, ESQUIRE STE 0.100 555 GETTYSBURG PIKE MECHANICSBURG PA 17055 Re: Margaret Way CIS #: 730161781 SSN: ###-##-4146 Date of Death: 11/1212013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Greene: 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 letter sets forth the amount of the Departments 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$89,082,75 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 X7,613.95, was incurred during the last six months of the decedents 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 561,469.40, 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"ram integrity i omsi*n of Third POKY t iaoirity I ReWVtry Section PO Box 8486 1 Harrisburg,Pennsylvania 17185.8486 Invoice i invoice dumber 3: J9 t ' V�l;iCe: ` iZ til: d invoice Date Fax: zst-' gar I10SPICe I' '39.'li _ Page: ❑� ilLVlk5t 1'LA� f IIILY ,L.v �•,� Payment Teams Due Date f -t Desch Orion Amount r t i 4 Please note our new office address -- 1320 Linglestown Road, Harrisbur PA 17110 Tota{ In%uicc Amoun ChechlCredit 'Nemo No Paymcm cmdit :Applicr TOTAL Thank you for choosing Hospice of Central Pennsylvania. r ONAMSYOI PO Box 1022 - Wxom Mt 403831022 { ADDRESS SERVICE REQUESTED 1 i May 21, 2014 111 Lancewood Road • Columbia, SC 29210 Phone:(717)221-1294 t Toll Free: (888)467-2563 80519490-1034 315817256 - t�i}rl;'}�lllllllr}pr11II}'r}}Itrtnritl}11}tl}Lr}litrlu}I}t}' t Margaret Way Date' May 21,2014 67 Painter Ave West Haven CT 06516-5829 Account 4: 340279 Total Due: $1184 00 i i You are rece,'ving this letter because of your failure to respond to our previous communication about your account vvitt, Pinnacle Health Hospitals with payment in full or an appropr,ate arrangement to pay. If you are unable to pay in full, representatives of your creditor are.available to help. it:s your responsibility to send E the balance or make the proper payment i Pinnace Health Hospitals PO Box 2353 Harrisburg. PA 17105 (717)221-1294 (888)467.2563 This is an attempt to collect a debt.Any information obtained will be used for that purpose. This communication is from a debt collector. i j i SEE REVERSE SIDE FOR BILLING DETAILS AND OTHER IMPORTANT INFORMATION ♦t0 ENSURE PROPER GREOS7 DETACH AND RETURN 1.4wER AQ[tTtON 14 TIC-,SNGIQw`b 7NJE1.E-'PC7 F7�FU51Y f'>•f7 pU3. YtAD T'kra.r'S Oi GAOF [,' g1 :r;4ay 24. 2014 ❑ice vu:{ CJ ' " � ,: Q 1 cn;dtwv Print+a'r;W"11th rioepnais kr;"Pt: 340279 Si iv:%DW0: 1?11403 SYIF $1184.00 211 p1putli I t 161AKE CHECK PAYABLE TO; a.Rw �x w,r..x era. Pinrt'6ei Hwaith Ho:pitnra Wrgaret Way PO Box 2353 67P War Ave H4rri:;btq PA 17105.2353 vvurtHcvtnCTM16-gs2s brrtibrdrrrliilrr drl r trtrJl,rl trrriL4i,Lr.ltrrlrlr! ' a� .• a t r. z Fs•, Full payment on your account balance is now due, If this bill does not reflect the f ^� correct insurance information please contact bltdica!Group our Office immediately to resolve the issue. For awmat information Please c ril (717) 231-8980 or(800) 585-$229 for Out of Area Calls. See details nn the back of this vtafernent. 61 PAiARER WAY it payment has been sent. pfea. desrcgard. t G7 PAtNi"ER AVE ( WE-St HAVEN CT 085165829 Respoosible Party. Marqaret Way Total Charges: 11 ,154.00 Account ID. 197515 Payments and Adjustments- $1 ,039.03- Bill Date 0311914 Bill Number- 8037400 Please Pay This Amt: 1114.97 1141-5 T-0 Y e mom MEdicaw B For questions, call Customer Service at 717-231-8c960 for total calls or 1-800-56S-8229 for Out of Area I Customer Service Hours. :X Mon-Wed-Fri 8.00 AM to 4 30 PM o Tues Thurs 8.00 AM to 8 00 PM m a .._-----»....r.__.. _ ---—--- - -- 8037400 - -- ---b�I1 �_ E. MARGARET WAY .1H itNbN:. LA X1'11 ••, ___.._ _ ___ i a Gm1 Ey Dae« ' -I MrY bnr itlnw a.fau..c .nlc.—ni.y � {� ! . AM1JXd 41wve nIMX XXnVXa gel bX4t ^ib 5«c,.,n fadr .iMe Est]C�g.tn cn xtx tract of mur c.«a2 aXa.W ro e s.yna u.e I Make Check Payahfe To PINNACLE riEA,i T H VECeiA,_ 00017440 002 0.72 Flay onnneathtlp5.;ib�i:E: yiirrapq:ehld.gim _^rg 1�� MARGARET WAY Please do not send cash through the mat 4 87 PAINTER AVE WEST HAVEN CT 08518-5829 PINNACLE HEALTH MEDICAL GROUP 1I PO BOX 1129 HARRISBURG PA 17108-1129 pOpf10Q00C f0Qppap374U0pp0fJ0p00QL97575p00C1001,14972pL4p3192