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HomeMy WebLinkAbout09-08-14 . _ _ _ _ IN RE: : ORPHANS COURT DIVISION ESTATE OF BETTY L. ADAMS, : COURT OF COMMON PLEAS OF �" : CUMBERLAND COUNTY,�, � � m : PENNSYLVANIA � o � `�", Q LATE OF TOWNSHIP OF MIDDLESEX : WILL NO. 2014-00065 m -�v � -�'v r�� � : ADMIN. NO. 21-14-0065 � � r� �.� �� I" ,.:_ Fr' (� r a C7 �^`� " -� CJ . _ , '-� -r7 �1 � ,__, � � PETITION FOR SETTLEMENT OF A SMALL ESTATE' ' ` 3 �..�. �-, PURSUANT TO 20 Pa.C.S.A. SECTION 3102 � �:� ~' ,-"�- � -c � _,,.� _ � TO: THE HONORABLE JUDGES OF SAID COURT: The Petition of Richard L. Adams, Jr. respectfully represents as follows: 1. Decedent, Betty L. Adams, died on January 10, 2013, a resident of Middlesex Township, Cumberland County, Pennsylvania. 2. Petitioner, Richard L. Adams, Jr., is an adult individual whose address is 916 Gobin Drive, Carlisle, Pennsylvania, 17013. 3. Petitioner, who is the son of the Decedent, filed a Petition far Grant of Letters Testamentary and was named Executor of the Decedent's estate on January 21, 2014, a copy of said Letters being attached hereto and incorporated herein as Exhibit"A". 4. At the time of Decedent's death, Decedent was seized of the following probate assets with the following values: (A) Claremont Nursing and Rehabilitation Center 546.24 Personal-Care Account � � (B) Highmark Blue Shield medical insurance 724.76 payment Total $ 1,271.00 5. Subsequent to Decedent's death, Petitioner secured a Federal Income Tax Refund from the filing of Decedent's 2013 Personal income tax return, in Decedent's name, which was distributed to the estate, in the amount of$500.00. 6. At the time of Decedent's death, there existed a non-probate asset, being a checking account at Citizens Bank, held jointly with your Petitioner, with a total value of $1,550.00, half of which value was attributable to the estate for inheritance tax purposes, but none of which was distributed to the estate. 7. Subsequent to Decedent's death, Petitioner has paid the following items associated with the Decedent's death and the administration of the estate from the limited estate assets and from Petitioner's personal funds: (A) Hoffman Roth Funeral Home Crematory, Inc. $ 883.87 (B) Griffie & Associates, P.C. (legal services) 1,500.00 (C) Probate Fees 143.50 (D) Cumberland Law Journal (Advertising) 75.00 (E) The Sentinel (Advertising) 169.30 (F) Cumberland Goodwill Fire Rescue EMS, Inc. 89.80 Total $ 2,861.47 8. At the time of her death, Decedent also had an outstanding obligation to the _ . Pennsylvania Department of Public Welfare totaling $48,984.82, pursuant to the claim as set forth in correspondence from the Department dated January 25, 2014, a copy of said correspondence being attached hereto and incorparated herein by reference as Exhibit"B". 9. As such, Petitioner has paid all known debts associated with the Decedent's death and the processing of matters related to the Decedent's estate. 10. Petitioner has given notice of the insolvency of the estate to the Department of Public Welfare, Bureau of Program Integrity, Division of Third Party Liability, Recovery Section, P.O. Box 8486, Harrisburg, Pennsylvania, 17105-8486, and the Department has responded by correspondence of June 11, 2014, recognizing the insolvency of the estate, said correspondence being attached hereto and incorporated herein by reference as Exhibit "C". 1 L There are no additional probate assets of which Petitioner is aware which could be included in decedent's estate. 12. Any and all assets in which Decedent had an interest have been included in the estate to pay estate debts associated with the Decedent's passing, or have passed to joint owners by operation of law. 13. The Decedent's immediate heir is her only son, your Petitioner herein, Richard J. Adams, Jr. 14. There are no probate assets from which to pay the Decedent's additional debt to the Department of Public Welfare, Cumberland Goodwill Fire Rescue EMS Inc., and Commercial Acceptance Company, nor the cost of processing this estate, nor the fees and costs associated with Decedent's death, and, thus, there are no probate assets to distribute to the Decedent's beneficiaries. 15. The passing of any non-probate assets has no affect upon Decedent's estate as those assets passed directly to any named joint owners. 16. As this is an insolvent estate, there is no inheritance tax due to the Commonwealth of Pennsylvania for any probate or non-probate assets, as confirmed by the Notice of Appraisement received from the Commonwealth of Pennsylvania, Department of Revenue, said Notice being attached hereto and incorporated herein by reference as Exhibit"D". 17. To Petitioner's knowledge, there are no other parties to whom benefits from the within estate would be due. 18. To Petitioner's knowledge, there are no individuals entitled to receive distribution or payment of any items referenced in Section 3101 of the P.E.F. Code, nor have any individuals received such benefits or assets referenced therein. 19. This estate has assets, exclusive of real estate, totaling less than $50,000.00 and, therefore, may be resolved pursuant to 20 Pa.C.S. Section 3102 through the filing of the within Petition for Settlement of a Small Estate. WHEREFORE, Petitioner requests your Honorable Court to issue a Rule upon the Pennsylvania Department of Public Welfare, Cumberland Goodwill Fire Rescue EMS Inc. and Commercial Acceptance Company, to show cause, if any they have, as to why the claims should not be extinguished, voided and vacated, thereby terminating all collection activities relative to said debts. Respectfully submitted, B i f , squire o y for Petitioner Supreme Court ID No. 34349 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 � (800) 347-5552 I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. DATE: j -���,.�1/�' /�c���n„�1���C�r�jnrot,,�L, Richard L. Adams, Jr. IN RE: : ORPHANS COURT DIVISION ESTATE OF BETTY L. ADAMS, : COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY : PENNSYLVANIA LATE OF TOWNSHIP OF MIDDLESEX : WILL NO. 2014-00065 : ADMIN. NO. 21-14-0065 CERTIFICATE OF SERVICE I, Bradley L. Griffie, Esquire hereby certify that I did, the d day of September, 2014, cause a copy of the within Petition for Settlement of a Small Estate Pursuant to 20 Pa.C.S.A. Section 3102 to be served upon Respondent PA Department of Public Welfare by certified mail, return receipt requested, and to Cumberland Goodwill Fire Rescue EMS Inc. and Commercial Acceptance Company by first class mail, postage prepaid, at the following addresses: (A) PA Department of Public Welfare Bureau of Program Integrity Division of Third Party Liability Recovery Section PO Box 8486 Harrisburg, PA 17105-8486 Attn: Tina M. Wise (B) Cumberland Goodwill Fire Rescue EMS Inc. PO Box 726 New Cumberland, PA 17070-0726 (C) Commercial Acceptance Company PO Box 3268 Shiremanstown, PA 17011 DaTE: � y = r ' ie, Esquire Attorney for Petitioner �� � �--� --------- --- REGISTER OF WILLS CERTIFICATE CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA i ; ..� No. 2014- 00065 PA No. 21- 14- 0065 Es ta te Of: BETTY L ADAMS fFirst Middle,Lastl � La te Of: MIDDLESEX TOWNSHIP CUMBERLAND COUNTY Deceased Social Securi ty No: 498- WHEREAS, on the 21st day of January 2014 an instrument dated January 25th 2002 was admitted to probate as . the last wi11 of BETTY L ADAMS lFirst,Middle,LasU late of M/DDLESEX TOWNSH/P, CUMBERLAND County, who died on the lOth day of January 2014 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, L/SA M. GRAYSON, ESQ. , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certi fy tha t I have thi s day gran ted Le t ters TESTAMENTARY to: RICHARD L ADAMS JR who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 2�st day of January 20�4. � Re ister of Will �, • eput Exhibit "A" **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) �� pennsyLvania _ -- : . � .► . : . . : DEPARTMENT OF PUBLIC WELFAflE January 25, 2014 • • • � GRIFFIE & ASSOCIATES BRADLEY L GRIFFIE ESQUIRE 200 N HANOVER ST CARLISLE PA 17013 Re: Betty A�ams CIS #: 620343119 SSN: ###-##-9926 Date of Death: 01/10/2014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Mr. Griffie: 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 Department's claim against the estate of the above referenced individual and explains the obligations of executors, administrators, and persons receiving estate property. Aithough 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. Siacemeni oi c.iaim iwmounr The Department maintains a claim in the amount of�48,984.82 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 �27,438.44, 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 $21.546.38, 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 � Divlsion of Thfrd Party Liability � Recovery Section EX�'11�J1t ��B�� PO Box 8486 � Harrisburg,Pennsylvanfa 17105-8486 �� pennsylvania ;�' • . DEPAflTMENT 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 ali estate recovery claims and therefore we require documentation to substantiate ull deductions from the gruss estate. The reg�latEons 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 � Divlsion of Thlyd Party Llabiltty � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 �! pennsyLvania ;�• • . DEPARTMENT OF PUBLIC WELFARE r� ' �� . Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in fuli, 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 qreater of 6% of the esta*_e assets or $1,000. Contingent fees for estatn 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, �� `����-�Q.� Tina M. Wise TPL Program Investigator 717-214-1204 717-772-6553 FAX Enclosure Bureau of Program Integrity � Divisfon of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg,Pennsylvania 17105-8486 , COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 � • January 24,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of ADAMS,BETTY ID 620 343 119 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 27,438.44 21,546.38 48,984.82 DRUG .00 .00 .00 REIMBURSEMENT TO DPW 27,438.44 21,546.38 48,984.82 _ - — _ - --- -- - --------- --- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23=6003113 Page 1 of 3 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 24,2014 STATEMENT OF CLAIM NAME ADAMS,BETTY ID 620 343 119 CUMBERLAND CO COMMRS 1000 CLAREMONT RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/01/13 - OZ/28/13 03/25/13 20130604203480001 20130604203480001 5,766.88 3,896.78 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 03/01/13 - 03/31/13 04/22/13 20130914138460001 20130914138460001 6,384.76 4,515.38 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 04/01/13 - 04/30/13 05/27/13 20131214229700001 20131214229700001 6,178.80 4,309.42 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 05101/73 - 05/31/13 06/24/13 20131544249410001 20131544249410001 6,384.76 4,515.38 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 06/01/13 - 06/30/13 07/22/13 20131824139380001 20131824139380001 6,178.80 4,309.42 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 07/01/13 - 07/31/13 01/13/14 55140074057040001 55140074057040001 6,384.76 4,643.10 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 08/01/13 - 08/31/13 01/13/14 55140074058950001 55140074058950001 6,512.48 4,643.10 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 09/01/13 - 09/30113 �01/13/14 55140074061000001 55140074061000001 6,302.40 4,433.02 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 Page 2 of 3 � COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE January 24,2014 . STATEMENT OF CWIM NAME ADAMS,BETTY ID 620 343 119 CUMBERLAND CO COMMRS 1000 CLAREMONT RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10/01/13 - 10/31/13 07/20/14 55140154327650001 55140154327650001 6,512.48 4,643.10 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 11/01/13 - 11/30/13 01/20/14 55140154329690001 55140154329690001 6,302.40 4,433.02 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 12/01/13 - 12/31/13 01/16/14 55140154331790001 55140154331790001 6,512.48 4,643.10 DIAGNOSIS 1 : V5789 REHABILITATION PROC NEC DIAGNOSIS 2: 2851 AC POSTHEMORRHAG ANEMIA PROC CODE: 0000000 PROVIDER SUB TOTAL CUMBERLAND CO COMMRS 69,421.00 48,984.82 03 100007309 0009 Page 3 of 3 -��' pennsylvania :�' �_ . DEPARTMENT OF PUBLIC WELFARE June 11, 2014 � . � GRIFFIE & ASSOCIATES BRADLEY L GRIFFIE ESQUIRE 200 N HANOVER ST CARLISLE PA 17013 Re: Betty Adams CIS #: 620343119 SSN: ###-##-9926 Date of Death: 01/10/2014 Dear Mr. Griffie: Pursuant to your correspondence dated April 18, 2014, regarding the above-referenced estate, the Department recognizes the estate to be insolvent. Please notify us of any change in circumstances which may affect the insolvency of the estate. Thank you for your cooperation in this matter. If you have any questions, please contact me. Sincerely, �'� `t'1�..��-t� Tina M. Wise TPL Program Investigator 717-214-1204 717-772-6553 FAX Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvanfa 17105-8486 EX�liblt '�C�� NOTICE OF INHERITANCE TAX r�"�� pennsylvania BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE � �tyt DEPARTMENTOFREVENUE INHERITANCE TAX DIVISION O F D E D U C T I O N S A N D A S S E S S M E N T O F TAX � REV-1547 DC AFP (08-13) PO BOX 260601 HARRISBURG PA 17128-0601 DATE 08-18-2014 ESTATE OF ADAMS BETTY L DATE OF DEATH 01-10-2014 FILE NUMBER 21 14-0065 COUNTY CUMBERLAND GRIFFIE BRADLEY L ACN 101 200 N HANOVER ST APPEAL DATE: 10-17-2014 CARL I SL E PA 17 013-2423 (See reve►•se side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE --! RETAIN LOWER PORTION FOR YOUR RECORDS F- REV-1547 EX AFP C08-13� NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: ADAMS BETTY LFILE N0. :21 14-0065 ACN: 101 DATE: 08-18-2014 TAX RETURN WAS: C X) ACCEPTED AS FILED ( ) CHANGED APPRAISED VALUE DF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) �1� .00 NOTE: To ensure proper 2. Stocks and Bonds CSchedule B) �2� .00 credit to your account, .00 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) C3) of this form with your 4. Mortgages/Notes Receivable CSchedule D) (4) •0� tax payment. 5. Cash/Bank Deposits/Misc. Personal Property CSchedule E) (5) 1,771.00 6. Jointly Owned Property CSchedule F) C6) 775•28 7. Transfers (Schedule G) ��� .00 8. Total Assets (8) 2.546.28 APPROVED DEDUCTIONS AND EXEMPTIONS: 4. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9� 2.771.67 10. Debts/Mortgage Liabilities/Liens CSchedule I) �lp�_ 4 9.074.62 11. Total Deductions C11� 51�846.29 12. Net Value of Tax Return � �lZ� 49,300.01- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13� .00 14. Net Value of Estate Subject to Tax �ly� 49,300.01- NOTE: If an assessment was issued previously, Lines 14, 15, 16, 17, 18 and/or 19 will reflect figures that include the total of all returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at spousal raie C15) •00 X OG - .00 16. Amount of Line 14 taxable at lineal rate (16) -�� x 045 = .00 17. Amount of Line 14 at sibling rate (17) .00 X 12 = .00 18. Amount of Line 14 taxable at collateral rate C18� .00 X 15 = .00 19. Principal Tax Due C19)= .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 EXhi.bit "D" TDTAL DUE .00 � IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A CREDIT CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE FOR INSTRUCTIONS.