HomeMy WebLinkAbout09-05-14 (2) J 1505610143
REV-1500 EX(02.11) Is OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania ngy County Ogle Veer File Number
Bureau of Individual Taxes
PO 60x.280601 INHERITANCE TAX RETURN 21 14 0121
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
01 16 2014 09 15 1922
Decedent's Last Name Suffix Decedent's First Name MI
BOYER ELVA 14
(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 ❑ 2. Supplemental Return ❑ 3. RRremmai d2 Return of Death
to 4. Limited Estate 4a.Fu a Inlefe8l Ica 5. Federal Estate Tax Return Required
❑ (dateoF=,Iher &72-92) ❑
® g, paeedenl Died Teetere ❑ T M Malrant��Iryn�d a Living Trutt 0 6. Total Number of Safe De Boxes
(Aaetlt COpyMwill) A Copy of" POWt
❑ 9. Utigation Proceeds Received ❑ to. IPM?TVjg1%rD-Ih El i i.Election
ach Schedule under Sec.9113(A)
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 OF WILLS USBANLY I
n o
First Line of Address rn
555 GETTYSBURG PIKE m x c� v !
Second Line of Address rn Cr'1 Ynn 71
STE C100 _
City or Post Office state ZIP Code OWD T]
MECHANICSBURG PA 17055 N rn
N "IT
Correspondent's 9-mall address: JessicBPkeYatoneelderlaw.eom
2!!, ,P!cor ect�eA%ry � �of p pa� ' i psebve n Information f iGif aede belief,erother9t�BIncluding per l reeenrie l based all statements, best of any roMg
31G TORE Of P SO RESPONSIl FOR FILING RETURN eDq
Ann M Omer 2
—ADDRESS
1199 W.Trindle Road Mechaniesburia, PA 17055
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATA
Q pn Cry" �j\ Q f�� Jessica F. Greene Esq. q 31 l q
AD ss
555 Gettysburg Pike,Mechanicsburg, PA
1505610143 Side 1 1505610143 \�
V i�
1 1505610243
-1 REV-1500 EX
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
1 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. 5 , 862 . 14
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous N u Probate Property
(Schedule G) Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 5 , 862 . 14
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 3, 697 . 06
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 197 . 01
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 3, 894 . 07
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 1, 968 . 07
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. 1, 968 . 07
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 1 , 968 . 07 16. 88 . 56
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. 88 . 56
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-14-0121
Decedent's Complete Address:
DECEDENTS NAME
Boyer, Elva M.
STREET ADDRESS
1199 W.Trindle Road
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 88.56
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 88,56
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;.................................. z
c. retain a reversionary interest;or............................................................................................................... x
d. receive the promise for life of either payments,benefits or care?............................................................ z
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ ❑z
3. Did decedent own an'in trust for or payable upon death bank account or security at his or her death?....... ❑ ❑z
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 January 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 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)).
• 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 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-1500 EX.(11-10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Boyer, Elva M. 21-14-0121
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property)ohmly�owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Diamond Pharmacy-Refund of overpayment 20.83
2 Ecumenical Retirement Community Refund 1,185.84
3 Metro Bank,personal acct#xxxxx1443 4,159.47
4 United States Treasury Income Tax Refund 496.00
TOTAL(Also enter on Line 5,Recapitulation) 5,862.14
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-1511 EX-(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE DECEDENT ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Boyer, Elva M. 21-14-0121
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. - FUNERAL EXPENSES:
See continuation schedule(s)attached 187.20
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid Waived
2. Attorney's Fees Keystone Elder Law P.C. 2,665.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationshio of Claimant to Decedent
4. Probate Fees 143.50
5. Accountant's Fees
6. Tax Return Preparers Fees
7. Other Administrative Costs 701.36
See continuation schedule(s)attached
TOTAL(Also enter on line 9, Recapitulation) 3,697.06
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
Boyer, Elva M. 21-14-0121
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Hershey Cemetery Company-Grass maker Foundation 187.20
H-A 187.20
Other Administrative Costs
2 Cumberland County Law Journal Estate Notice 75.00
3 Harland Clarke for Estate Account Checks 25.60
4 State Employees Retirement System Pension Overpayment(withdraw from account) 420.84
5 The Sentinel -Estate Notice 179.92
1-1-137 701.36
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-0512 EX.(12 48)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Boyer Elva M. 21-14-0121
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 Community Life Team Transportation Bill 52.60
2 Diamond Pharmacy final medical bill 135.55
3 Genesis Rehabilitation Services 8.86
TOTAL(Also enter on Line 10, Recapitulation) 197.01
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Boyer, Elva M. 21-14-0121
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)1
Ginger Keffer Daughter 984.04
370 Fresno Drive
Harrisburg, PA 17112
Joseph A. Kirwan Grandson 492.02
7624 FT McCord Road
Chambersburg, PA 17202
Ann M.Orner(Kirwan) Granddaughter 492.02
1199 West Trindle Road
Mechanicsburg,PA 17055
Total 1,968.08
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropr iate.
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 SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Forth PA-1500 Schedule J(Rev.01-10)
LAST WILL AND TESTAMENOrO
M
CA s, .
F n =pia
ELVA M. BONE R
_ M
{- C)
n
I, LLVA M. BOYER, currently residing. at, 3300 Union Deposit Road, Apt. G206,
Harrisburg, Dauphin County, Pennsylvania, 17109, do hereby declare this to be my Last Will
and Testament,revoking all other Wills and Codicils heretofore made by me.
I declare that I am widowed and that I have the folloxdng two (2) children born to me, 10
Ellen Kirwan and Cringer Keffer,and that•all references to my children are to theirs.
ITEM ONE: I direct that all my valid'debts and,the expenses of my last illness and
funeral be paid from my estate as soon as practicable after my death.
ITEM TWO: I give and bequeath all of my- tangible personal property to my
residuary heirs under Item Three,below as follows:
A. ,Ali items of tangible personal property shall be ,inventoried and valued at a fair
market value,
B. I. may leave a Memorandum listing some of the items of my tangible personal.
property which I wish certain persons to have and request that my wishes as set forth
in the memorandum be observed by nay Personal Representative. Any items of
tangible personal property not so designated shall be divided and distributed among
my residuary heirs as follows:
I. Each of my heirs may select one item,in rotation, in order determined by lot,until
such time at which the items chosen by each heir teach such heir's proportionate
share of the total value of my estate, or until such time as each heir wishes to
make no further selections,
1
2. Any items not selected shall be sold and the net proceeds added to the residue of
MY estate.
3. To the extent my heirs are unable to agree,the decision as to what may constitute
"one item" for purposes of this selection shall be made by my Personal
Representative(s).
4. Any disputes concerning this method of allocation shall be resolved by my
Personal Representative in my Personal Representative's sole discretion.
5. To the extent my Personal Representative is unable to resolve a dispute among
two or more of my heirs concerning the in-kind distribution of any of my personal
property,I direct my Personal Representative to sell the disputed property and the
net proceeds there from be added to the residue of my estate.
ITEM THREE: I give,bequeath and devise all the residue of my estate, of whatsoever
nature and wheresoever situate, to my daughters, JO ELLEN KIRWAN and GINGER KEFFER,
in equal shares, per stirpes. In determining the value of a beneficiary's share of my residuary
estate, I direct that the value of my residuary estate be augmented by the value of any personal
property distributed in-kind under Item Two,above.
ITEM FOUR: Should any beneficiary of mine be under the age of twenty-five (25)
years,my Personal Representative shall hold such beneficiary's share of my estate,as Trustee, IN
TRUST and shall invest, reinvest and distribute the principal and net income of such
beneficiary s share as follows:
A. Until such beneficiary attains the age of twenty-five (25) years, my Trustee, in my
Trustee's sole but reasonable discretion, may pay or apply the income and any or all of
the principal of such beneficiary's share for the health, maintenance, support and
education of such beneficiary considering all other sources of income available to such
beneficiary and known to my Trustee. Upon such beneficiary attaining the age of
twenty-five (25) years, my Trustee shall distribute the balance of the principal and
accumulated income,if any,of each such beneficiary's share to such beneficiary.
2
B. Should the principal of the Trust Estate,in the sole opinion of my Trustee,be or become
too small to warrant placing or continuing of such fund in trust or should its
administration be or become impractical for any other reason, my Trustee, in the
exercise of their sole discretion, may pay such share absolutely to the person maintain-
ing such beneficiary or may place such shares in the beneficiary's name in an interest-
bearing deposit in any bank,bank and trust company or national banking association of
his choosing, payable to the beneficiary at majority, or if said beneficiary has reached
his or her majority,then to him or her directly.
C. All shares of principal and income hereby given shall be free from anticipation,
assignment, pledge or obligation of my beneficiary(s), and shall not be subject to any
execution or attachment.
ITEM FIVE: I appoint, my grandson, MICHAEL T. KEFFER, Personal
Representative of this my Will. In the event my grandson is unable or unwilling to act or
continue to act as my Personal Representative, I appoint my granddaughter, ANN M. KIRWAN,
my Personal Representative.
ITEM SIX: I appoint my duly appointed Personal Representative as Trustee of any
Trust(s)created pursuant to Item Four,above.
ITEM SEVEN: No bond shall be required of any fiduciary hereunder in any jurisdiction.
No fiduciary hereunder shall have any liability for any mistake or error of judgment made in good
faith.
ITEM EIGHT: I authorize my Personal Representative(s)and Trustee(s)to exercise the
following powers in addition to those given by law,to be exercised in their sole discretion:
A. To retain any or all of the assets of my estate,without regard to any principle of
diversification,risk or productivity;
B. To invest in all forms of property without restriction to investments authorized for any
type of fiduciary;
C. To compromise any claim or controversy;
3
D. To loan money to or buy property from my estate;
E. To borrow money from any person,including any Executor or Trustee, and to mortgage
or pledge any real or personal property;
F. To sell at public or private sale,to exchange or to lease for any period of time, any real
or personal property, and to give options for sales, exchanges or leases, all for such
prices and upon such terms and conditions as they deem proper;
G. To allocate receipts and expenses to principal or income or partly to each as they deem
proper;
H. To repair,alter or improve any real or personal property;
I. To distribute in cash or in kind or partly in.each at valuations fixed by them;
I To keep reasonable amounts of cash in a bank uninvested if deemed advisable for the
protection of the principal;
K. To subscribe for or to exercise options for stocks, bonds or other investments;to join in
any plan of lease,mortgage, merger,consolidation,reorganization,foreclosure or voting
trust and to deposit securities thereunder, and to generally exercise all the rights of
security holders or employees of any corporation;
L. To register securities in the name of a nominee or in such manner that title shall pass by
delivery;
M. To add to the principal of any trust created by this instrument any real or personal
property received from any person by Deed,Will or in any other manner;
N. To exercise all power, authority and discretion given by this instrument after the
termination of any trust created herein until the same is fully distributed;
O. To use their sole discretion in deciding whether stock dividends on stock they hold in
trust should be apportioned to principal or income, except stock dividends of regulated
investment companies which shall be added to principal;
P. To commingle the assets of any trust estate created by this Will in any one or more
common funds for greater convenience and flexibility;
Q. To employ agents, accountants, engineers and such other persons, professional or
otherwise,as may be necessary for the proper administration of this estate or trust and to
pay their compensation from such funds;and
R To disclaim all or any interest in a property passing tome or my estate.
ITEM NINE: I realize that Personal Representatives are given discretion by law to
make various elections which affect the income and estate taxes payable by estates and
beneficiaries, as well as the relative shares of beneficiaries, such as taking administration
expenses as deductions for either estate or income tax purposes, selecting options for the
payment of employee death benefits,electing to take a qualified terminable interest as part of the
marital deduction, selecting alternate valuation dates, postponing the payment of taxes, filing
joint income tax or gift tax returns and redeeming corporate stock. The decisions made by my
fiduciaries in any of these matters shall be binding upon, and not subject to question by, any
4
affected persons. I rely upon my fiduciaries to take into consideration the total income and estate
taxes payable by reason of their decisions including those payable by my survivors, and they are
authorized in their discretion, but not required, to make adjustments between income and
principal as a result thereof.
ITEM TEN: I direct that all estate,inheritance and other taxes in the nature thereof,
together with any interest and penalties thereon, becoming payable because of my death with
respect to the property constituting my gross estate for death tax purposes, whether or not such
property passes under this my Last Will and Testament, shall be paid from the principal of my
residuary estate, and no person receiving or having a beneficial interest in any such property,
whether under this my Last Will and Testament or otherwise, shall at any time be required to
contribute to or refund any part thereof; PROVIDED,however, that this direction shall not apply
to the taxes on any property included in my estate solely because of a power of appointment
thereover which I possess but have not exercised or on any qualified terminable interest or to any
generation-skipping transfer taxes.
ITEM ELEVEN: No gift or beneficial interest shall be subject to anticipation,
assignment, pledge, obligation, or alienation of my beneficiary(s), whether voluntary or
involuntary, and the income and principal thereof shall not be subject to any execution or
attachment.
ITEM TWELVE: If any beneficiary, person or entity in any manner, directly or
indirectly, contests or attacks this Will or any of its provisions,or objects to the accounts or actions
of my fiduciaries, without probable cause, such beneficiary, person or entity shall pay all costs,
including but not limited to attorneys' fees, arising in connection with such contest, attack or
objection incurred by my estate, such trust or such fiduciary personally. In the event that such
beneficiary, person or entity does not prevail in such action, any share or interest in my estate or
such trust which would otherwise pass to such beneficiary, person, entity or remainderman under
this Will shall be revoked and the property consisting of such share shall be disposed of in the
5
manner provided herein as if that contesting person or entity had predeceased be without surviving
issue.
ITEM THIRTEEN: Should any of the provisions of my Will be for any reason
declared invalid, such invalidity shall not affect any of the other provisions of this Will and all
invalid provisions shall be wholly disregarded in interpreting this Will.
ITEM FOURTEEN: This Will shall be construed, regulated and governed by and in
accordance with the laws of the Commonwealth of Pennsylvania.
IN WITNESS WHEREOF, I have at Mechanicsburg, Pennsylvania, on March 17, 2011,
set my hand and seal to this my Last Will and Testament consisting of six (6) pages plus any
witness,acknowledgement,affidavit and certification pages.
/"�" '* (SEAL)
ELVA M.BOYER
SIGNED, SEALED,PUBLISHED AND DECLARED BY ELVA M. BOYER,the above named
Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request and
in her presence, and in the presence of each other, have hereunto subscribed our names as
witnesses.
Witness Witn s
Address Address
6
SELF-PROVING AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
:SS:.
COUNTY OF CUMBERLAND
We;ELVA M. BOYER,• /O''e(_
and ZrttSS- ) .{islrj the.Testatnx and the witnesses
respectively, whose'names are signed-to he attached or foregoing'instrument being fast duly sworn, do hereby declare to.the undersigned authority that the.Testatrix signed,and executed the
;instrument'as her Last Will and Testament that-she had signed willingly—(or willingly-directed
Another to sign for her), and that she;executed'it
as -free and voluntary act-for the.purposes
therein expressed, and that eacli.of the witnesses, in the presence and healing of the Testatrix,
signed the Will as witness'and that to'the best of their knowledge the Testatrix was at that time
eighteen years of age or older,of sound•mind,and under no constraints or undue influence.
ELVA M.BOYER�
WITNESS
.
WITNESS
Subscribed, swom to and acknowledged before me by ELVA M. BOYER, the
Testatrix and the witnesses,on March 17,2011.
Notary Public or PA Attorney'
NOTARIAL SEAL
:.PAULA N WHITE ..
Notary Public
UPPER ALLEN TWP.,CUMBERLAND COUNTY
My Commisslon Expires Apr 5,21112- — -
7
Z A PHARMACY SERVICES
r} 645 KOLTER DRIVE • COMMERCE PARK • INDIANA, PA 15701-3570
\ PHONE: 724.349.1111 FAX: 888.284.3784
NURSING FACILITY DIVISION
March 25, 2014
Estate of Elva Boyer
1199 West Trindle Road
Mechanicsburg PA 17055
Re: Elva Boyer - Refund Check
To Whom It May Concern
Please find enclosed a refund check in the amount of $20.83 for Elva Boyer, a former
resident of Ecumenical.
Should you have any questions or comments, please feel free to contact our billing
department at our toll-free telephone number: 1-800-882-6337 ext. 1301,
Sincerely,
DIAMOND DRUGS, INC. 1648-
REFERENCE NO. DESCRIPTION INVOICE DATE INVOICE AMOUNT DISCOUNT TAKEN AMOUNT PAID
RY000286- 3/5/2014 20.8 0.00 20.83
CHECK DATE CHECK NO PAYEE DISCOUNTS TAKEN CHECK AMOUNT
4/10/2014 16489 46100 BOYER,ELVA 20.83 0.00 20.83
oMMU Retirement STATEMENT
3525 Canby Street Statement Date: 02/01/2014
Harrisburg, PA 17109
Telephone: (717) 561-2590
Amount EndosecJ.*'-
Amount pLe: $ -1,185.84
Account #: 1788,
RE: Elva M Boyer
Ann Omer
1199 West Trindle Road —
Mechanicsburg, PA 17055 's i P
Please detach and return top portion with payment.
Oate ,
. panents
- h
Balance 8/1- 2,822.32
01/15/14 BOYER,ELVA M 177.32
01/15/14 BOYER, ELVA M 2,645.00
12/30/13 Beauty Shop 1 27.00 27.00
01/01J14-01/31/1 L Private Small Studio 31 -2,645,00
01/01/14 -01/10/14 AL Private Small Studio 10 869.59
01/11/14-01/15114 L Private Small Studio 5 434.79
01/16/14 AL Private Small Studio 1 55.66
01/03/14 2 Guests Christmas Dinner 2 10.00 20.00
01/05/14 Incontinence Pull-Up 1 42.12 42.12
01/28/14 Laundry 1 10.00 10,00
Current 31-60 Days 61-90 Days Over 90 Days Amount Due
99.12 -1,284.96 .00 .00 1r185.84,: .
"******************Information Statement********************
Funds will be directly withdrawn from your account on the 15th of the
month.Please direct any billing questions to the Billing Department- Statement Date: 02/01/2014
717-561-2590
Thank you for choosing Ecumenical Retirement Community!
Elva M Boyer -Account #: 1788
3525 Canby Street
Harrisburg, PA 17109
Telephone: (717) 561-2590
ME o
BANK Harrisburg PAr17111 maymet obank.com
February 22, 2014
To whom it may concern:
This letter is written per your request for the information regarding the assets held in Metro
Bank in the name of Elva M. Boyer. An estate account has been opened with Ann M. Orner named as the
executrix. Ms. Boyer did not hold a safe deposit box with our institution, and the only account she held
was her personal checking account.
Upon the date of her passing, the balance of this account was$4,159.47.The account currently
holds a balance of$6192.68, and these funds will be transferred to the estate account once processing
is complete. '
If you need any other information, please feel free to contact me by phone or email with the
information provided below.
Regards
Greg Archi
Customer Service Representative
NMLS Registration: 1102073
Metro Bank—Simpson Ferry Rd 717-766-6800
�{ r o0o P 500, 552 , 736
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a 03�fig 14 20090800 KANSAS CITY,-AM 0 4034 -:1262334:0
" ' f�0�fV19260706'6 403:.4 1262Z;340 +I" ,0:0002011407008'1
I�r�l��l,j,lll'JIIvII, I,II��l�if
J94, W TRIN.D'LE nRD s d - $**k**496*00
MEWHANSCSBUR%G PA x17055 45.08 5 ='
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ELDER I W RC.
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i/A Omer,Personal RePreseatati've
1199 w*Trindle Road:
MecharuESburg,;P;A, 17055:
INVOICE
FeesFnrProAkOhMal'Services Rendered°•
Estate Adni tiistration',for Elva Boyers
Hours Rate TOTAL,
Jessica-F.Greene, Esq., 7,90 $25.0. $1,9700
1 .eoki:L: Starr; ega3 Asst, 3;5 $150' $690.00
\ t Subtotal: $2,665:00'
Retainer-.[2eceiveek — SOOtOa
BAIAKE DU i $2,165.00
Kit
ELVA'MS6YEit.._.....o2a4 --- '104 .
ESTATE 0F.ELVA.M BOYER
ltse w,.mwnREaD ea,eanls
MECHhNtGSBClRt3,RAt7066. � �;`j.:�..LI)-�'
PAYjq THE;
ORDER QF .�.�
P yR
- ZYR
BANK
�:OQk84.6�: 28438?2'99iu� :0.3t];4
b Cseftysbw Prke Yufe L 100 Meielianiesburg,PA 17;055 • Phone: 717:697.3223 Fax: 717691,809
HERSHEY =Box445 No. 1458
100 MANSION ROAD EAST•HERSHEY, PENNSYIN.4N
TO: Ann Omer DATE: 4/16/2014
1199 W.Trindle Road
Mechanicsburg, PA 17055 Due upon receipt
Phone No. 717-520-1110
Description
1 Grassmarker Foundation -24"x 12"-Elva M. Boyer $187.20
Section D, North 1/2 Lot 372
ti,✓'
Foundations are scheduled to be poured May 16,2014
^v
Total Amount Due $187.20
i
s-FShy,�.rey�r
�RSSOCV�'�°
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tole: (717)249-3166 Fax:(717)249-2663
April 4, 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: Elva M. Boyer 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:
March 21, March 28, and April 4, 2014
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 75.00
Total Amount Due $ 0.00
Becky H. Morgenthal, Executive Director
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM IN
HARRISBURG REGIONAL COUNSELING CENTER
30 NORTH THIRD STREET,ROOM 319
HARRISBURG,PA 17101
'* TELEPHONE:(717)783-9065
FAX:(717)783-9599
TOLLFREE: 1-800-633.5461
w .sers.state.pa.us
February 26, 2014
Estate of Elva Boyer Invoice # 29790
C/O Ann Omer
1199 W Trindle Rd
Mechanisburg PA 17055
RE: Elva Boyer
SS#: XXX-XX-7474
Dear Ms. Omer:
We have been informed of the death of Elva Boyer, a retired member of this System. We wish to
extend our condolences to you at this time.
Since Ms. Boyer died 1/16/14 and the January check was not returned to our office, this account
has been overpaid in the amount of$420.84 for the period from 1/17/14— 1/30/14. It will
jtherefore be necessary for our office to be reimbursed for$420.84 to liquidate this overpayment.
The reimbursement should be made payable to The State Employees' Retirement System,and
mailed with the enclosed copy of this letter to the address shown above.
If you have not already done so,we will need a certified copy or an original death certificate
for our file. If you cannot permanently spare the originals, please submit them with a note to ask
us to return them. We will return the originals to you within 5 working days.
Upon receipt of the reimbursement,this account will be closed. There are no further benefits to
be paid from this System.
Should you have any questions concerning this matter, please do not hesitate to contact me at the
above address or by telephone at(717) 783-9065 or 1-800-633-5461.
Thank you for your cooperation.
Sincerely,
1Ui Ut.
Linda Dolan,Administrative Assistant
Harrisburg Regional Counseling Center
Enclosure
,.1 5�
The-Sentinel KEYSTONE ELDER LAW, P.C. AD NUMBER gSALESPERSON NO.
w w w-eewr.b,e r I I.k.c o m 555 GETTYSBURG PIKE 429011 f 1
MECHANICSBURG, PA 17055-8070
717-697-3223 BILL DATE C1lME 91rfEn45RAG MWCq.P11Y 03128114 lfc START DATE DATE 03/14/14 8/14
AD NUMBER I AD DESCRIPTION CLASS I LINES
429011 NOTICE LETTERS TESTAMENTARY ON THE 10 PUBLIC NOTICES 1 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 01PRF $7.00
3 MOBILE SITE MOB2 $3.00
Purchase order Est. Elva Boyer PAY THIS AMOUNT $179.92 $215.90•
'AFTER 04/22/14
Lee Enterprises no longer accepts credit card payments sent via e-mail.
Emails containing credit card numbers will be blocked. Please use the coupon
below to send credit card payment to our lockbox. E SENTINEL
You may also send the coupon to a secure fax at 319-291-4014. THE
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.
Retum this portion with your payment Legal
THE SENTINEL ❑ Check# ❑Credit Card Ad Number 429011
c/o LEE NEWSPAPERS ❑ tS ❑ v ❑ ❑ o Billing Date 03/28174
PO BOX 540
WATERLOO IA 50704-0540 Acct#: Amount Due $ 179.92
Exp.Date:m m _
Amount
Name on credit card EnCIOSa $ j lq q
Signature
Please make checks payable to: THESENTINEL
000140 THE SENTINEL
- KEYSTONE ELDER LAW'
AW, P.C. c/o LEE NEWSPAPERS
555 GETTYSBURG PIKE PO BOX 742548
MECHANICSBURG, PA 17055-8070 CINCINNATI OH 45274-2548
21540200000004290110000000000000002159000000179922
RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date : 2/10/2014
Cumberland County - Register Of Wills Receipt Time : 09 : 26 : 41
One Courthouse Square Receipt No . : 1076951
Carlisle, PA 17Q13
BOYER ELVA M
Estate File No. : 2014-00121
Paid By Remarks : KEYSTONE ELDER LAW
CJ
------------------------ Receipt Distribution ------- - - -- ------ - --- ---
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN
Check# 1788 $128 . 50
Total Received. . . . . . . . . $128 . 50
CDrnih'�r�ity�zLlf�7e�m�lne�,l r° �' S S°C�'
13-136770 5/2/2013 $52.60
'r:. PO Sox726 :',-,— ..:- ..
New Cumberland, PA '17670-0726
QUESTIONS ABOUT THIS 8IL17 Phone: 877-214-6018 EsPatt101: 866-724-4114 Fax: 717-214-6020 Email: infott lambulancebillingoffice.com
Date of Service: 3/2512013 17:55 Please visit our ..ebsfte ta-provide•insurance or make payment, and
Patient Name: BOYER,ELVA for addition>_'.`xyment options and frequently asked,questions:,
From COMMUNITY GENERAL OSTEOPATHIC N ww.ambulancebillirtgoffice.cam JZ
To: ECUMENICAL COMMUNITY
IMPORTANT,
"Frfti7/NatiCe*!,IJwe'tio`not.receivepayment.x�rftirn10`i9ays; youraccormtn:cn:bereferredYo collection`%ContacC out Owce
•.:.: .to make"payment atrmCg`etnenis:=fifes service:s tro7 covered by most anSurance Crnz:ers:
r
3125/13 Wheelchair Van Trans-One Wa; AO130-- :-1.0_ 45.00 45.00
3/25/13 Mileage(loaded) 50204 3.6. 2.66 7.60
Total 52.60 0.00 0.00
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
+tatemerslWaW:.. 01122114 /0, --^"�� 1 1 } Diamond Pharmacy
:ustomer Number: 46100 J U /I 645 Koster Drive
Indiana, PA 15701
acility ID: CMECi (800)882-6337 phone
.'ustomer Group. P135
(724)349-1311 toll-free
Balance Forward
5190.09
�a tnents
Check Data Check Number Amount
12123113 969 ($57.67)
01115114 970 {$132.22}
VewActivity
Date 121(No Drug Name City Price Ins.Pay Amt. Pat.Pay Amt.
nvoice-)N00041680
BOYER,ELVA
12702113 445790 OTC-ACETAMINOPHEN 500MG CAPLET 60 $1,25 $000 $1,25
12WI3 463431 OTC--STIMLAXAT TAB 5LAGEC o0 51.25 50 Cq". 5125
IZVW'13 457524 RX-#ZGESTRr;,AC BUS:.Y2' 'L 24C 5?7..22 59 0
R1'FSFY3 45950 RX-C'1Pk^5 e:'V 3'cZ;c 526+' 5L 1
t t3tt3 19( tk'W-fr ct c , GCE -
SN56rF3 7MG"€ABi.c'-T : E3 - - : $1.25 VCa ' -
�t7/1 fiI13 .387563 ki -OLAiNAPtNE TA875MG 50 56.84 56.18 - copay 52.66
Nor
17116113 - 387975 RX"-AMPiallin 250MG CAPS 30 $5.29 $4.53 copay $0.76
12/16/13 467005 OTC-VITAMIN D31000UNIT TAB 60 $1.25 $0.00 $1.25
1283113 476748 RX-NYSTATITRIAM CRE 60 $182.83 $159.98 copay $22.85
12124113 -. 15965551 RX-MEGESTROL AC SUB 40MGIML ""240 $17.22 $9.46 repay $7,74
12127113 479292 RX-EXELON DIS 4.6MG124 30 $321.37 $258.62 copay 362.55
12130/13 372166 RX-NITROSTAT SUB0.4MG 25 $11.23 $9.05 copay $2.18
416807 Totals
_ Total Legend-IN00D416807 $566.87 M $459.65 $107.22
Total OTC-IN000416807 $7.50 $0.00 $7,50
Total-IN000416807 $574.37 $459.65 $114,72
5tatemem Totals '1` ucvso=mccsma
Total Legend-Statement $566.07 $459.65 $107.22
�Y.
ll-7otal OTC-Statement $7.50 50.00 $7.50
T 1- tatement� $574.37 $459.65 $114.72
Page 1 Balance Due: $114.72
1.30 Days 0111w 31-600 ays orDue 61.90 Days O0-w ^:a Cars O_'.p
Si 14.72 $p,
Payment
STATEMENT Of ACCOUNT Territory 2
i Boyer, Elva M
PLEASE SEND CHECK OR MONEY ORDER TO: ACCOUNT 62 51690
Genesis Rehabilitation Services
P.O,Box 7247&524 ��— ^]
Philadelphia,PA 19170-6524 �rAT M Nt DATE: 05ti0f2D k3
11AMO JNSENSI.OSEn
MAKE CHECK PAYABLE TO;
Genesis Rehabilitation
FOR MORE INFORMATION.TELEPHONE
IF ADDRESS INFORMA'T'ION IS INCORRECT.PLEASE MAKE ADDRESS CHANGE ON BACK 566-671-6046
DETACH AND FETUR14 TOP PORTION MT14YDUR PAYMENT
SERVICE DATE RANGE •'
Boyer,Elva 01/04/2013-01/04/2013 PT
Me4loare Highmark -17.96
M6410are Hignmark -12.14
BCBS PA Transfer
SCSS PA Payment -39.94
Boyar,Elva Transfer 6.66
r
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i,
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1t
I
BALANCE DUE a 6.66 i
BALANCE DUE UPON RECEIPT I
i
ACCOUNT NUMBER STATEMENT DATE
Boyer,Elva M 51690 05/10/2013
624 Wilhelm Road
Harrisburg,PA 17111
Territory 2
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