Loading...
HomeMy WebLinkAbout08-11-14 ORIGINAL J REV-1500 (maol u�tv. 1505610101 Ex "L►1, Bu Department of ReVPnuP Pennsylvania OFFICIAL USE ONLY PO BOX 28060idual Taxes INHERITANCE TAX RETURN County Code Year File Number Harrisbur f,PA 1 128-06o1 RESIDENT DECEDENT Z1 L+ ENTER DECEDENT INFORMATION BELOW J Social Security Number Date of Death MMDDYYry. Date of Birth MMDDYYYY 09/23/2013 02/09/1952 Decedent's Last Name Lichty Suffix Decedent's First Name MI (If Applicable)Enter Surviving Spouse's Information Belo Gary W w Spouse's Last Name Lichty Suffix Spouse's First Name MI Spouse's Social Security Number Jill M 170-44-0596 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ' FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS C111D 1.Original Return O 2.Supplemental Return O 3. Remainder Return(date of death O 4.Limited Estate O 4a. Future Interest Compromise(date of prior l0 12-13-82)state death after 12-12-82) O 5. Federal Estate lax Return Required -� 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 (Attach Copy of Will) (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death between 12-31-91 antl 1-1-95) O 11. Election to tax under Sec.9713(A) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Gary J. Ifrlblurn, Esquire Daytime Telephone Number h) n REGISTER OF -USE ONLY' First line Of address -D Cri CD 4615 Derry Street M .^Second line of address C)0 �`r .T 0(__ _ City or Post Office ti tV ; T Harrisburg State ZIP Code DATE�ED �O PA 17111 Correspondent's a-,all address: a .Ifl'IbIURI irnblumlaw.coDT Untler penalties of perjury.I declare that I have examined this return,including accompanying schedules and statements,and to the boss of my knowledge and ballot, it is true,correct and complete.Declaration of preparer other than the personal represontetive is based on ell inlormation of 10 the preparf has any knowledge. —SIG E OF PERSON RESPON IBLE FOR FILING RETURN ADDRESS DATE 101D.S -.�•� I 11-% SIGNATURE OF PREPARER OTH R ATIV �1 ADDRESS L`lDSb DATE Gl ,fi` 'f2 Y111�T IfA�Z2i38L 2� A9 / 7/!/ PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number oecedenl's Name: Ga William Lich RECAPITULATION I. Real Estate(Schedule A). ............................................ 1. 0.00 2. Stocks and Bonds(Schedule B) ....................................... 2. _ 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable(Schedule D)........................... 4. 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. _ 8,860.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 0.00 (Schedule G) C=:) Separate Billing Requested........ 7. 0.00 8. Total Gross Assets(total Lines 1 through 7)............................. s. . 8,860.00 9. Funeral Expenses and Administrative Costs(Schedule H)...... s' 20,913.90 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .............. 10. 0.00 - - -- -' - 11. Total Deductions(total lines 9 and 10)................................. 11. 20,913.90 12. Net Value of Estate(Line 8 minus Line 11) .......... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 0.00 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. 0.00 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_ 0.00 15. 0.00 16. Amount of Line 14 taxable - --- "' - -- - - -- - _ _ _ at lineal rate X.0 45 0.00 17. Amount of Line 14 taxable - ' " - - - i6. 0.00 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 O I_ Side 2 1505610105 1505610105 J REV-15x0 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Gary William Lichty STREETADDRESS 5665 Chariton Way qTV — ~-�- i STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments 0.00 S.Discount 0.00 3, Interest Total Credits{A+B) (2) 0.00 4. If Line 2 is greater than Line t+Line 3,enter the difference. This is the OVERPAYMENT. (3) 0.00 Fill in ovat on Page 2,Line 20 to request a refund. (4) 0.00 S. If Line 1+Line 3 is greater than Line 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 1. Did decedent make a transfer and: Yes No a. retain the use or Income of the property transf ined:.......................................................................................... ❑ E b. retain the right to designate who shall use the property transferred or its Income;_...................................... ❑ 0 c. retain a reversionary interest;or.......................................................................................................................... ❑ El d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 0 1 Dirt 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 containsa beneficiary designation? ........................................................................................................................ ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent 172 P.S.§9116(a)(1.1)(it)).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(11)[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 172 P.S.§9116(a)(1,3)).A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1508 EX.(698) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE-0F Gary William Lichty FILE NUMBER 2014-579 ITEM Include the proceeds of litigation and the dale the proceeds were received by the estate. All property)olndyowned with right of survivorship must be disclosed on Schedule F. NUMBER DESCRIPTION 7VALUE 1 199616'Catalina Cap ri Sailboat with Trailer(stated value is purchase price of 6/212011) 0 2 200313'Boston Whaler Fiberglass Boat vrith Trailer(stated value is as per NADA) 0 TOTAL(Also enter on line 5,Recapitulation) $ 8,860.00 (II more space is needed,Insert add'cional sheets o1 the same sae) REVIIS10 EX+ (08-09) ji pennsy(vania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND ERE DECEDENT INHERITANCE RETURN RESIDE NT DE TM MISC. NON-PROBATE PROPERTY ENT RT ESTATE OF Gary William Lichty FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-15500 is yes. s. REM DESCRIFFION OF PROPERTY NUMBER ENDNDE THE NAME OF iRaRSrFREE.THEIR ROATIONSNEPTO DECEDENT TAD DATE OF DEATH 460E DECD'S EXCLUSION THE wTEaTRaxSPER anaa A�o�r of THE DEED roR REAI ESraTE. TAXABLE VALUE OF ASSET INTEREST IF APTU VALUE 1 Federal Government Pension-Beneficiary was wife,Jill Lichty. Benefit received in monthly payment amounts. 100 0.00 TOTAL(Also enter on Line 7, Recapitulation) $ 0.00 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10.09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE DECEDENT ADMINISTRATIVE ADMINISTRATIVE L`AS'TS' RESIDENT DECEDENT ESTATE OF Gary William Lichty FILE NUMBER R 2014-579 EM ce Dedent's debts must be reported on Schedule I. NUMBER DESCRIPTION A. FUNERAL EXPENSES: AMOUNT 1' Stradling Funeral Homes Inc Grave Marker 12,183.00 5,870.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State_ZIP Year(s)Commission Paid: Z• Attorney Fees: 1,333.18 3• Family Exemption:(If decedent's address is not the same as daimant's,attach explanation.) Claimant Street Address city State_ZIP Relationship of Claimant to Decedent 4. Probate Fees: 148.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. Camp Hill Emergency Physicians B Holy 6.25 y Spirit Hospital a Medical Expense(Claim No.20606873299) 555.47 10 _ 826.00 Medical Expense 11 Legal Advertising 100.00 75.00 TOTAL(Also enter on Line 9, Recapitulation) $ 20,913.90 If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF GAILY WILLIAM LICHTY I, GARY WILLIAM LICHTY, of 37 Victoria Way, Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind, hereby make, publish and declare this my Last Will and Testament,hereby revoking and making void all prior Wills and other testamentary,writings at any time heretofore made by me. I. I direct my Executrix or successor Executrix, hereinafter named, to pay all of my just debts, funeral and testamentary expenses as soon as conveniently can be done after my demise. H. I give, devise and bequeath my entire estate of whatsoever kind and wheresoever situate, unto my wife, JILL MIGONETTE LICHTY. M. Should the said JILL MIGONETTE LICHTY, predecease me, or should she survive me by a period of less than two(2)months or should she die simultaneously with me, or in a common disaster, it being my direction and intent that in the event of such simultaneous death or common disaster no Uniform Act regarding such event shalt apply and only the above stated provision of this Will shall apply, then and only then, I give, devise and bequeath the following, i I A. I give, devise and bequeath all of my wife's jewelry to her niece, JAMIE DELONG, of Bath, Pennsylvania; i B. I give,devise and bequeath all the rest,residue and remainder of my estate, of whatsoever kind and wheresoever situate to be divided equally between my sister, SANDY MELLINGER and my sister-in-taw,DAWN DeLONG. C. If the said SANDY MELLINGER faits to survive me, her share shall be divided equally among her three children: MICHAEL MELLINGER, of Ephrata, Pennsylvania, SCOTT MELLINGER, of Pittsburgh, Pennsylvania and DR. TRACI MELLINGER-KOHL, per stirpes. D. If the said DAWN DeLONG should fail to survive me,her share shall pass to my wife's niece,JAMIE DeLONG,'per stirpes. IV. Should there be any property of whatsoever Idnd and wheresoever situate of which I have the right to dispose at the time of my death, including but not limited to any special or general power Of appointment or both, I hereby appoint the same to my legatees set forth in Paragraphs II and III hereof. V. I nominate,constitute and appoint JILL MIGONETTE LICHTY as Executrix of this,my Last Will and Testament and further direct that she shall serve without bond. i VI. If the said JILL MIGONETTE LICITLY is for any reason unable or unwilling to serve as Executrix of this, my Last Will and Testament,then I nominate, constitute and appoint my sister, SANDY MELLINGER, as successor Executrix. She, too,shall serve without bond._ 2 VII. Said Executrix or successor Executrix shall have the power to discharge all the debts, liens and encumbrances upon my estate, as well as any taxes thereon, to pay for the cost of the final disposition of my remains and final illness, if any, to receive any and all commissions and other compensation for services rendered by me during my lifetime and to perform any and all fiduciary duties authorized by statute. Further, I direct my Executrix or successor Executrix to preserve my estate and any instructions pertaining to the distribution of the same from any attachment or anticipation whine in the hands of my said personal representative, it being my express intent that all legacies shall be free from any attachment or anticipation while in the hands of the accountant for my estate. IN WITNESS WHEREOF, I have to this,my Last Will and Testament,typewritten on three (3) pages of paper, set my hand and seal at the end thereof this ZO day of _ , 2002. IM/14k/l &A (SEAL) GARY JkLLIAM LICHT SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testator, GARY WILLIAM LICHTY, as and for his Last Will and Testament in the presence of us who, at his request, in his presence and in the presence of each other, all being=AQ, have hereunto set our hands as witnesses. _ (SEAL) f 3 ����.� COMMONWEALTH OF PENNSYLVANIA :SS: COUNTY OF DAUPHIN I,GARY WILLIAM LICHTY,Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament;that I signed it willingly;and that I signed it as my free and voluntary act for the purposes therein expressed. GARY ftaw LICHTf Sworn to and subscribed before me this day of 2002. {SEAL) Notary Public My Co Sep Cardv,shay,isor�yi�bAc aNt)t ham.�#�tbr+�Y bbgmmi OW Fea.26.zoos COMMONWEALTH OF PENNSYLVANIA : :SS: COUNTY OF DAUPHIN WE, 0" -T ) P4 � and ��0/If� �• Kot�r� , the witnesses whose names are signed to the attached or foregoing instrument, being qualified according to law, do depose and say that we were present and saw GARY WILLIAM LICHTY, Testator, sign and execute the instrument as his Last Will and Testament;that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witness,and that to the best of our knowledge,the Testator was at that time 18 or more years of age, of sound mind and under no constraint o due influence, Sworn to and subscribed before me this �(t_' -,day of 2002. Y i _ j) _,p -- t AA d, V . �� f (SEAL) Notary Public . . . My Commission Expires: aouWSeW Caemi Y.9W Not"Ptdto CA'ON ftfturg,i'lauptin Ckuky .. oxmisom eo es Feb.2B,zoos �rcM�aASm�G, Nomrtes ws AUTOS CLASSIC CARS MOINCYLLES EATS M MMUFACTUREONOMES PRODUCTSTORE IN A Gn.'Ne Manuwaww+CMNa Yaaa LkeasCtwnpeamant>CM1Mae AOpant>Wkea � . 2996 Capri Sailboats .: ,,,, CAPRI 16 R �`�+Nta rlmat Values � Spechnatiom Specmi NOtoa V+Nao Values ca ®� Suggested LOW Average ' List Price Retail Retail ease Mae N/A $3,110 $3,550 Options:01W ' Trailer.Ssaaasst 1496 Single 17 Peet $270 $305 TOTAL PRICE: NITA 53[380 $3,855 Oonl ntekaa p,R55MSbkp Boat Insurance Boat History Report , ISM hm midi Imm YOU Can sava WWI a 1.eaengto0w-. FREE Quote w a 19%Capa Sailboats Ch"the NOW ASt ' subrt% Enter ltTN Or GO sutumt Boat Buying&Selling Services , alas hoM MaM'et gat app"I row $d Yww Wa at BOenMna _ fM WNS ra Selek Yb+arM NeoOe"W"Jtwet" arya opal aRaalaae � NeRC=60tttfiCatinnt - � Vali•+T1ew aalinabm Sa9aa LW-we nave Udww maat(atlwa'i WR mwI MtA@wI ea(MW)mam ak fow4 p,WA."am mpwur d aessds,TTv mw k ae m ,fwwet aaaa owwws Wma t gm;na a few CAM M ft us A.Mn MataL tter+.lte M6PP6fumaMatry fM mawAaalwaa W aIIaWlabtl ere anana0 mtgoSay.UrtYit . iM4ted aK HSTmdxt MI Inau0e 0.LMAaoa aRrRr9et.aeTke wtvp,#Mew 1ota1+2xaA ikenu teaaw kMaVe. L Rams value—AT aYdaea bnm Ma now 4»Gta x wtWta(pet rnsmaafaal eaaw nitlSMi[eey. 11%Goat mat a mryn Wka 09 waa.The WM ran etRea k t k mamk vvw nraU+awO crab.tow 2W�mssatu Vf e2 as food asaneevYt kt.LW ReMUa aadeia vabe. ArOn RNgYawn—Mettiabe rtaY vaatl boa t!ku#oe'n g000twg6on Mat n0'rb4R 0a'�a0e aatl4tt. TMs Wet wntMwnkaaeteweat aM lea as MR MMtWM+rmanp aakaaa 110 may Mal w Im kWe' mW mimafk a mNraN¢tware. IndmIry Rafp Toofa company ne.aex Rra eanya rro ,tWww Faariww Y�t3(I LmamUa comeww Mtiwa% Rrva PW ttee�RPan eeaway Qiae�mAr PrWWuw ikre' COWI)M .Hb ! AUTOS CLASSIC CARS MOTORCYCLES BOATS M MANUFACTURED HOMES PRODUCT S70RE XFINITY- SPEM 911M TV iW AND INTERNET s Ctanpn Man uoixM>ernange Year a Model>CNege Options>Charge Addaro>Vaues 2003 Boston Whaler Inc SPORT 130fRB(*) Values Specifications Special Notes .... . . ..... ... . .. .. . ...._ .... .. .... .. .. _,....._.... Yaluns Values 62&MI ^,PAOGNLWIVAF Suggested Low Average -g&TAE FREE BDAT Ust Price Retail Retafi i':?�tNSIfRANCE NOW! - ease Price $9,149 $4,160 $4,750 ;'- options,am Trailer,rp iarrus 2002 Single 15 Feet - $225 .$255 - TOTAL PRICE: $9,149 $4,385 #s,005 point make a$5,805 01102ke,net a Reat Nlatdv Rapp,OHe wort AM Boat Insurance Boat History Report See how much molly You Can save with a looking W buy— FREE quote on a 2003 Boston Whaler Ine Check the history first Submit' Enter MTN or press GO Submit - Boat Buying&Selling Services New beat BnandAR?Get approved now See Year coat in Bbatrnr n FIW boats in,sal in Yw ari Need A puck to hate your boat Ow a boat prlar grMe Next-Specifications ValueMqagpefini SugpeslM ttst-wehava uWuded manuract roes suggesW ratio pfty(MSM to assist in the nranratg,insurtbg and appMNing of sesseh.The MSRP is the mdMdedn2f5 and7ord&bQxAo's highest aggested retain pvxe in nil I.I.S.A.when the unit was row.The NSRP Is famished by she mawni Mm VWw dsinbxnp end are assumed to be annect.unless Indicated,da MSRP dots rot hxaee deselaWn Barges,deal"vrtu srate b incal tam,license togs n kauMtoe. Law Retail value—A ksw retail vaha d beat will sloweMessive ieeol and tan etmn cosn"MO,and/or nec arkary, This boat may or may rot be N running order.Tie bean on epees,to invest at Cosoetit anWor nethankai wok.tow MW weeseis usually Are riot round on a dealer's W.Low Renate is not a bededn"Vim " Average Retell value—An average retail ranted boat should be in good oo doin wan no v19Ge damage or dee0a. This beet Ma show moderate wear and tear ell will be In sound nxmhg ianppon.The Wear may need to 4aest in elmp minor ownedc or mechanical work FUNERAL HOMES,we October 10,2013 a JillLichty 5665 Charleton Way , Mechanicsburg,PA 17050 RE: Funeral Expenses for Gary Lichty Dame of Death:9/23/2013 1. Funeral Services $5,340.00 1I.Merchandise $5,275.00 II. Charges made by others that we advanced on your behalf 20 Certified Copies®$6.00 each $120.00 Cemetery/Tent $265.00 Newspaper $308.00 Clergy $100.00 Pianist $100.00 Sound $50.00 Custodian $50.00 Clergy(Walter Carter} $100.00 i PU Roo 92 1-522 1 Grave opening $750.00 Phone:(717)7M472 I Total of Above Items $1,843.00 5%discount on casket and vault n$275.00 Banrilv Business Total Balance $12,183.00 Payment received. X12,1$3.00 Balance: $0.00 PAID IN FULL. THANK YOU! Websee.www.Wadttogfunerathome.com • Email.s&adjk@ptd.net Phone.(717)859-1230 Akron • (717) 733-2472 Ephrata • Fax:(717) 738-3549 + t - 5 v I y. f 'p1a 4 �� vS• L�"� � .. 1 - J C!L x. wey..t"'ut�y�� �'�•f _ _ _ it " sk.�� a - +r. - .t�' '°F�" b ��t_..1. 4 ''•�`s•r �1 'F".v�' ""-t'+'�.� ++a�'���p �� C �"sh'� < {d_-.�l:i ,�r+ to '1 h f 6 •tii4x F ,'�_ t �'7- Y" :.cc'�•�fi. c 54 sw,. a ' 'S` `}i3*:i i. -.'� '. vT' •r• �'2 i� � S . -41 y �•+ >: ,Ei., xrg,ors "3�y+y Y�" �y` �' .F1Y r Y�" �^"a .r ism OW LY ,Rl + } 1 a �, }::_o� ;, mido Explanation of Benefits y.w.. ...,� -e,; 5765 :, . °yexrogram THIS IS NOT A BILL .Pamrylvaafa 790p1 hm FEDERAL EMPLOYEE PROGRAM PO 80% 890035 CAMP HILL PA 17089.0035 MEDICAL QUESTIONS CALL 1-800.779 4945, DENTAL QUESTIONS CALL 1-800-746-5687, Try QUESTIONS CALL 1-800-345-3848 GARY N LICHTy 5665 CHARLTON RAY MECHANICSBURG PA 17050-6617 ( EXPLANATION OF BENEFITS AT A GLANCE I i [We Sent Check To, fa$Mp KILL EMERGENCY PHYSICIANS j ID Number" 850019905 1 ( Claim Number: 20006900620 (patient Name: ,GARY LICHTY ( Claim Paid On: 10/16/2013 1 i C"Im Received On, '10/09/2013 )Dates of service, 09/23/2013 - 09123/2013 I Claim Processed on-. 10/10/2013 1 ( Patient Acct No, 46215083HYP IYo, Out¢ Provider, 626.25 f Provider, DUBIN Dates of Services 09/23/2013 - 09/23/2013 Type, PREFERRED PROVIDER Type of Service I submitted I Plan (Remark( Deduct)Coinsurance l Medicare/ I What IYou Owe the I Charges t Allowance I, CodesX 1 Or rdIyav [Other Ina. i We Paid i Provider TOTALRy ! , gn.ODI ',175.001 1 0,001 26.2,51 0.001 148.751 26.25 EXPLANATION OF REMARK CODES 610--THE SUBMITTED CHARGES EXCEED OUR ALLOWABLE CHANCES FOR THESE SERVICES. OUR ALLOWABLE CHARGES ARE THE SUBMITTED CHARGES LESS ANY NON-COVSREO CHARGES. BECAUSE THIS PROVIDER IS A PREFERRED OR PARTICIPATING NETWORK PROVIDER, YOU ARE NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE SUBMITTED CHARGES AND OUR ALLOWABLE CHARGES. ( Suemarv, of Out-of-pocket,Expenses for 2013 l ( Your Out-of-Pocket Expenses ) 1 I I Catastrophic Protection-1 i On This Claim ( ' lCaleadar Yearl Preferred I Nan-Preferred/ I lCaleadar Year Deductible $0.001 I I Deductible I Preferred Totail lPer Admission Copay $0.001 lVhat You Have Paid i I I I ICoineurance $26.2S1 I Individual 1 $350.001. Sol $D1' ICopayment $0.001 I Family 1 $698.181 $5241 $6241 lNon-covered Charges $o.0ol (Annual Maximum I I I I lPrecertification Penalty 50.001 I Individual 1 6350.001 SOI $01 1 1 1 Family I S700.00,1 65,0001 S7.0001 ITOTAL, S26.251 If you have questions, please call a customer service representative at your local Blue Cross and Blue Shield Plan. You may also request the diagnosis codes, the treatment codes, and the corresponding meanings of the codes for your claim. If you disagree with the decision on your claims or request for services, and wish to have the decision reconsidered, you must notify your Plan in writing within 6 months from the date of this decision, i.e. 04/16/2014. You may request copies, free of charge, of any relevant materials and Plan documents relating to your claim. Your Plan will not accept unauthorized reconsiderations from providers. See the Disputed Claims section of your Service Benefit Plan Brochure. 005639 00210841 B1ueCrosse Explanation of Benefits THIS IS NOT A BILL BlueShielde Fed rat pIoyee Program. { nv.fepblue.org CAPITAL BLUE CROSS HARRISBURG, P.A. 17177 (800) 344-5446 2638- 1 GARY W LICHTY 5665 CHARLTON NAY MECHANICSBURG PA 17050-6617 t EXPLANATION OF BENEFITS AT A UMM-i i t 11!le Sent Chock To: PROVIDER OF SERVICE 1 ID dumber: - - " RS001990S t i Claim Number: 132753066100 1patient Name: GARY LICHTY I Claim Paid On: 10/09/2013 I 1 Claim Received On: 10/02/2013 1Dates of Service: '0912312013 - 09/2312013 1 Claim Processed On: 10/07/2013 1 1 "IYou Owe the Provider: 0555.47 1 Provider: HOLY SPIRIT HOSPITAL Dates of Service: 09/23/2013 - 09/23/2013 Type: PREFERRED PROVIDER .. Type of Service I Submitted 1 Plan 1Remarki DeductlCoinsurancel Medicare/ 1 What IYou Owe the 1 Charges 1 Allowance 1 Codost i Or Popov iOtho Ins I We Paid 1 Prpvi4ar MEDICAL CARE 1 1,258.001 727.501 610 t 1 109.121 1 618.381 109.12 . MEDICAL AR 1,716,001 3 .3 51 1 *546,01 TOTALS• 1 2,974 00,1 1,719.861 1 350 007 20!i.471 0,001 1,164,391 555.47 EXPLANATION OF REMARK CODES 610--THE SUBMITTED CHARGES EXCEED OUR ALLOWABLE CHARGES FOR THESE SERVICES. OUR ALLOWABLE CHARGES ARE THE SUBMITTED CHARGES LESS ANY NON-COVERED CHARGES: BECAUSE THIS PROVIDER IS A PREFERRED OR PARTICIPATING NETWORK PROVIDER, YOU ARE NOT RESPONSIBLE FOR IRE DIFFERENCE BETWEEN .THE SUBMITTED CHARGES AND OUR ALLOWABLE CHARGES*. . ' I Summary of Put-of-Pocket Exnensgs £or 2013 1 ' 1 Your Out-of-Packet Expenses i I - i Catastrophic Protection 11 On This Claim 1 I - [Calendar Yearl-- Preferred -"t-- Non-Preferred/- •1--- ICelendar Year-Oeductible - .4350.00t i 1 Deductible i I Preferred Tatalt IPer Admission Cepay 00.001 (What You Have Paid I I I I ICoinsuranco 0205.471 I Individual 1 6350.001 Sol 081 ICoPayment 60.001 1 Family 1 6698.181 65031 65031 [Non-covered Charges 60.001 lAnnual Maximum I. I i I IPrecertification Penalty 60.001 1 Individual 1 6350.001 601 601 I I I Family 1' 6700.001 05,0001 67.0001 ITOTAL: 655 .471 If you have questions, please call a customer service representative at your local Blue Cross and Blue "Shield Plan. You may also request the diagnosis codes, the treatment codes, and the corresponding meanings of the codes for Your claim. If you disagree with the decision on your claims or request for services, and wish to have the decision reconsidered. you must notify Your Plan in writing within 6 months from the date of this decision, i.e. 04/09/2014. You may request copies, free of charge, of any relevant materials and Plan documents relating to your claim. Your Plan will not accept unauthorized reconsiderations from Providers. See the Disputed Claims section of your Service Benefit Plan Brochure. CON0020CUTpn21 ,T � � Y � Fs F ,t .., � ;, •tr ��r rc ..il a j POW f ic T ��'• }s ' .tilt 1� � +�•��yr �' >, +` y wC4,,,. ymr �y�}��do �}M'�/W�2: 0* 0�R� ,pl y i �' lf^� ♦._ r�,�+p # tom•.. w✓ a w, .� � � 4 _ 'in - `�`� ?' s y Air v « y a 4 V ;, «,}�. �r ";1 7FT`� � ay{'p•s wt i"! J s �' +lfi �^r't — �. != s rty 477 _'. ) A r+ay1 ••�,,. .t +yty .0 S7 . . `• } r (} TT 444 � fl !M f •t ; s Lt4 ' j7 v �r •'�¢—f r� V �S+ �15f iv � �y � WWW �.P;Q Y'iyXa, a. Y F v • pp _ _� 4°1 ,�, � �'f.�} f*;.f. �. ��y "�'++7 T�' ��� •L�':2i °s�t t�.- {F "-�+ .?2� � .-s j'" .n. fr3 '� #"�r�r. �� � s� � �' �t ° - } yµ �7.e '3 Fry_ 1 '/{"�t,y�+vvy/3� 7' fa'j�{ty ♦�g� ii � IT- NY le � � f« _ty�s,•:� - ?�'i � .-..E.rx..s+.'.�Y R T'S S-i- � e-7't-+ � 9 � is �',� �� r _ - � •" ' �. .� 1! 615 �'�' r z Yi IMBLUM LAW OFFICES, P.C. Gary J.Imblum 4615 DERRY STREET Gettysburg Telephone Jeffrey L.Troutman(of counsel HARRISBURG,PA 17101 Telephone:717-238-525o 717-337-0797 Facsimile:717-558-8990 Lebanon Telephone email:&4a.imblu-@imblumlaw.com 717-270-6989 August 5, 2014 OFFICE OF REGISTER OF WILLS CUMBERLAND COUNTY ONE COURTHOUSE SQUARE CARLISLE PA 17013 Re: Estate of Gary W. Lichty No: 2014-579 Our File No. 7-14-0091 Ladies and Gentlemen: Enclosed please find an original and two (2) copies of the Inheritance Tax Return with respect to the above referenced estate. Please return one(1)time-stamped copy to the undersigned in the stamped, pre-addressed envelope provided for your convenience. Thank you for your attention to this matter. Very truly yours, LUM LAW FICE C. y J. Imb um, Esquire n �_7 gary.imbluly@ mblumlaW.c�° a GJI/cyJ1 enclosure(s) CA Q3 C -, v -n o` cc: JILL K LICHTY < T 5665 CHARLTON WAY MECHANICSBURG PA 17050 F:\USER\CANDY\ESTATES 6 FORMS\OPEN ESTATES\Lichty\Inheritance Tax Return\B-5-2019 letter to P,eg Of Wills with Inheritance Tax Return.wpd (�33 ©22 k/\ ° / \ % »}q %® 62 6 ® C.L. \/ AL, kC) �\ y / — /In � § ? _ 4L, » . 3 CC � � in ;,� /° ? 2 \ , )