HomeMy WebLinkAbout12-02-14 J1505610105
REV-1500 Ex(02-11)tFI?, .
PA Department of Revenue P ennsytvania INSOLVENT OFFICIAL USE ONLY
Bureau of Individual.Taxes County Code Year File Number
PO BOX 28o6o1 Ur INHERITANCE TAX RETURN
I �� ��
Harrisburg,PA 17128-o6oi RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
............._.... . , ..., . ... ..
12/03/2011 02/26/1926
Decedent's Last Name Suffix Decedent's First Name MI
,KUNKLE MILDRED C
(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
CaD 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate p 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
OID 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JANE M. ALEXANDER, ESQ (717)432-4514 0
......... .... _
...._ .............. c7 •-.
M
REGIST_ OVILLS USFeJLY C>
Q r-ri d
Fn S n Q
First Line of Address > r—
I--
148 S. BALTIMORE STREETS N o
Second Line of Address <> G7
P. O. BOX 421 = ►--► c7
... ........... _ .. .. .... .... - DATEJFILED O MCity or Post Office State ZIP Code p
...........
DILLSBURG PA 17019
Correspondent's e-mail address:jmalexander.148@comcast.net
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true, rrect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer gas any kn wledge.
SIGNAV4E OF PERSON RE ON IBLE (LING UR ZATE
-1)411
ADD S
6 ountain Road,Yo Springs, PA 1 372
IGN UREOF PREPAIRER OTHER THAN REPRESENTAI IVE DATE
AbDIRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
J 1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name:
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 and Notes Receivable(Schedule D)..................... ...... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 14,911.25
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. ... ... 7.
8. Total Gross Assets(total Lines 1 through 7). ... ........... ... ... ........ 8. 14,911.25 '
9. Funeral Expenses and Administrative Costs(Schedule H)................ ... 9. 1,937.87
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............... 10. 41,611.69
11. Total Deductions(total Lines 9 and 10)....... . ............... ....... ... 11. 43,549.56
12. Net Value of Estate(Line 8 minus Line 11) ........................... ... 12. -28,638.31
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. ; 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 00 15.
16. Amount of Line 14 taxable _ .._._,.,,,_ _ ....... ....r_ __......_..._., _.
at lineal rate X.0 45 0.00 16.; 0.00
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
19. TAX DUE ............................................ ............. 19..; 0.00
........................................................................................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Mildred C. Kunkle
STREETADDRESS
One Longdorf Way
CITY STATE ZIP
Carlisle PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
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.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 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 transferred.......................................................................................... ❑ N
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N
c. retain a reversionary interest.............................................................................................................................. ❑ ■
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ E
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ E
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ N
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)(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
[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.
'rant will =Zr c eotammt
of
960red C. XunkCe
I,Mildred C.Kunkle of the Township of Warrington,County of York and Commonwealth of
Pennsylvania,being of sound mind,memory and understanding,do hereby publish and declare this to
be my Last Will and Testament,hereby revoking and declaring null and void any and all Wills and
Codicils heretofore written by me.
ITEM I. I direct that all my just debts and funeral expenses be paid as soon after my demise as
may be convenient to the proper administration of my estate.
ITEM II. I then give,devise and bequeath my entire estate after payment of debts and
funeral expenses to my husband,J.Donald Kunkle,if he be living at the time of my death and
survives me for a period of thirty(30)days.
ITEM ID. If my husband should predecease me or fail to survive me for a period of thirty
(30)days I then order and direct my hereinafter-named Executrix to convert my entire estate into cash
at either public or private sale,whenever in her discretion it may be most expedient for the proper
administration of my estate. In the event of such conversion,I authorize my said Executrix to execute
a good and sufficient Warranty Deed to the purchase of any real estate of which I may die seized,in
the same manner and capacity as I could if living.
ITEM IV. I direct that all inheritance and estate taxes be paid on the proceeds of the above
conversion and on all the rest,residue and remainder of my estate from the residue of my estate prior
to further distribution.
ITEM V. I direct that my hereinafter named Executrix distribute all the rest,residue and
remainder of my estate,including the proceeds of the above-mentioned conversion,in equal shares to
my two(2)children:Penny S.Lee and J.Donald Kunkle,Jr.,per stirpes and not per capita.
ITEM VI. I nominate,constitute and appoint my husband,J.Donald Kunkle,as Executor of
this my Last Will and Testament. Should he predecease me or be unable or unwilling to serve,I then
nominate,constitute and appoint Jane M.Alexander,as Executrix in his place and stead. I direct that
my Executor/Executrix shall not be required to post bond other than his/her personal assurance for
his/her duties as Executor/Executrix.
Name: KUNKLE,MILDRED Account Type:Non-Transferring Account#: 403402164
Tax ID: Allowonce:$0.00 Direct Deposit#: 20000165961370216
Res ID: 20630411 Date Opened: 03/29/11 Current Balance: $0.00
Status: Closed 02/17/12 Restroints: No Transactions At All Status Reason: Deceased 12/03/11
Statement Date: 02/29/12
Account Disbursing
Date Description Debit Credit Reject Balance Batch Record Seq Credited Check
01/29/12 OPENING BALANCE 1225.18
02/01/12 INTEREST PAID 0.06 1225.24 40201 0
02/17/12 CLOSING INTEREST 0.03 1225.27 102164 0
02/17/12 TO CLOSE ACCOUNT 1225.27 0.00 102164 0 2000016596140
..............
CUMBERLAND CROSSINGS
..... .......
RFMS PET .
TY CASH ACCOUNT
1 LONGSDORF WAY 001 Gnn
? CARLISLE, PA. 17013 699
PAY (C 66.76o
TO THE DATE ft✓� Zt �C r y 560
ORDER OF E `� CJt C--
n'►�U?�� �IVKL>
WACHOVIA BANK nn,
DOLLARS U `°
FOR F g G
II'00 1699u' I-
5 1400 54 91: 20000 16 S CI C3 .40118
.-
I. L'44
Page: I
DIAKON L UTHERAN SOCIAL MINISTRIES
66212 ESTATE OF MILDRED KUNKLE 8737 07/18/12
INVOICE NUMBER INVOICE DATE INVOICE DESCRIPTION GROSS AMOUNT DISCOUNT NET AMOUNT
6888 06/30/12 3858 10.64 0.00 10 . 64
10 . 64 0 .00 10 . 64
DIAKON LUTHERAN SOCIAL MINISTRIES
66212 ESTATE OF MILDRED KUNKLE 8737 07/18/12
INVOICE NUMBER INVOICE DATE INVOICE DESCRIPTION GROSS AMOUNT DISCOUNT NET AMOUNT
6888 06/30/12 3858 10. 64 0.00 10 . 64
10 . 64 0 .00 10 . 64
—.____.._._.__a.uswaw.w.wY..awsauwasrs�ue
X .• �;'.' dX.•ir �( r` :. ,� h- THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER • "•• _ - •' -'''
DIAKON LUTHERAN SOCIAL MINISTRIES M&T BANK
960 CENTURY DRI YE York So Queen st
York PA 17403 60-295 �
MECHANICSBURG PA 17055 313
DATE CHECK NO. AMOUNT
07/18/12 8737 *10.64*
TENAND 64/100---------------------------------------------------------
Void after 180 days
PAY ESTATE OF MILDRED KUNKLE 66212
TO THE C/O JANE ALEXNADER, ATTNY r�r,
ORDER 148 SOUTH BALTIMORE STREET
OF
DILLSBURG PA 17019
2nd Signature required over$20,000.00
+ i;:.•. '�X� ..•i1.? !' .:•! THE BACK OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATERMARK—HOLD AT AN ANGLE TO VIEW -. e
00008 ? 3 ?11• 1:03L3029551A984899619611'
Life Claims Division
�r.,l.Croup P.O. BOX 6100
SCRANTON, PA 18505-6100 MetLife"
STATEMENT OF CLAIM
INSURED: KUNKLE,DONALD J CLAIM NUMBER: 21109010837
PAYEE: ESTATE OF MILDRED KUNKLE GROUP/SUB/PAY POINT: 0121920 0001 0001
ADDRESS: JANE M ALEXANDER EXTRX FACE VALUE: $ 12455.00
C/O JANE M ALEXANDER ESO INTEREST AMOUNT: $ 182.73
DILLSBURG PA 17019 AMOUNT PAID: $ 12637,73
The
The interest portion of this payment is taxable income and should be included on your federal and state income tax returns. It
interest paid is $200 or more, it will be reported to the IRS, and you will receive Form 1099-INT at year end. Therefore,
i res
please notify the claims office listed above of any address changes.
__s_,."_,
M.S"S.SM0310s)
METROPOLITAN UEE M COMPANY
pa BDX 6100 99997
SCRANTON. EA 18505-6100
etlillaifd
M528
POLICY HOLDER: CATERPILLAR INC. 50-937/213
imohdPIOLITAN LIFE INS.CO.
P_D_ B.01 6100 99997
SLRANIDN-, P_AL 18505-6100 ,.c,QQ25 785 14
um .e
Claim No. 6o%I� Niq�! [Namd.o(Insured NOT VALID BEFORE
2110901683 'D-121920 .0001 000 KUN.KLE 70ONALD J AUG 19 2014
_— V
Amount
Dollars Cents
..:pa to.the:Wder of:
'ESTATE OF MI L I R f U_N.K;L'E-
$**12637*73
T
4 AN E M ALEXAND'Ek., ::EX RX_
JOMorgan Chase Bank N.A. C/O JANE M ALEXANDER ESQ
6040 Tarbell Road DILLSBURG PA 17019AUTHORIZED SIG14ATURE
Syracuse,NY 13206
fin 0 0 2 S 7 13 S I L, 1:0 2 1, 3-0 q 3 7 91: 3 3 2 3 0 0 S 2.':
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF J. DONALD KUNKLE
LATE OF SOUTH MIDDLETON TOWNSHIP
FIRST AND FINAL ACCOUNT OF
JANE M. ALEXANDER
EXECUTRIX
Date of Death: September 13, 2011 File No.: 2114-0427
Social Security No.:
Letters Granted: May 2, 2014
'Date of Advertising Grant of Letters: None
Account stated to: October 9, 2014
SUMMARY AND INDEX
PRINCIPAL
Receipts $1,974.66
Disbursements $937.05
Balance before distribution $1,037.61
Distribution to beneficiaries $0.00
Total available after distribution $1,037.61
INCOME
Receipts $0.00
Disbursements $0.00
Balance before distribution $0.00
Distribution to beneficiaries $0.00
Income balance remaining $0.00
Combined balance remaining $1,037.61
PRINCIPAL RECEIPTS
The Accountant charges herself with the following:
Personal property as set forth in the Inheritance Tax Return filed in the Register
of Wills Office of Cumberland County, Pennsylvania on June 2, 2014 and
confirmed by Pennsylvania Department of Revenue October 6, 2014 $1,974.66
TOTAL PRINCIPAL RECEIPTS $1,974.66
PRINCIPAL DISBURSEMENTS
And ask credit for the following disbursements:
Cocklin Funeral Home - funeral expense $323.55
Baughman Memorial Works, Inc. - lettering $190.00
Diana M. Fetrow- witness fee $25.00
Narumol Alexander- witness fee $25.00
Register of Wills - Probate fee $63.50
Jane M. Alexander- executrix fee $100.00
Jane M. Alexander—attorney fee $140.00
Register of Wills - filing inheritance tax return and Inventory $30.00
Notary fees $35.00
Reserved for filing Release $5.00
TOTAL DISBURSEMENTS $937.05
TOTAL PRINCIPAL AVAILABLE $1,037.61
INCOME RECEIPTS
NONE $0.00
TOTAL INCOME RECEIPTS $0.00
INCOME DISBURSEMENTS
NONE
TOTAL INCOME DISBURSEMENTS $0.00
TOTAL INCOME AVAILABLE FOR DISTRIBUTION $0.00
RECAPITULATION
Total Principal Receipts $1,974.66
Total Principal Disbursements $937.05
Total Principal Available for Distribution $1,037.61
Total Income Receipts $0.00
Total Income Disbursements $0.00
Total Income Available for Distribution $0.00
COMBINED BALANCE AVAILABLE FOR DISTRIBUTION $1,037.61
DISTRIBUTION PRIOR TO FINAL ACCOUNTING
NONE
TOTAL DISTRIBUTION TO DATE OF ACCOUNTING $0.00
BALANCE AVAILABLE FOR DISTRIBUTION $1,037.61
Held as follows:
Citizens Bank - Law office escrow account $1,037.61
PROPOSED DISTRIBUTION
Estate of Mildred C. Kunkle $1,037.61
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
I, Jane M. Alexander, accountant in the foregoing Account, being duly sworn according to law,
depose and say that the above Account is just and true, both as to items of charge and discharge, and
that the grant of letters and the first complete advertisement thereof occurred more than six months prior
to the preparation of this Account.
i
e . Alexan er, ecutri
Sworn to and subscribed r
before me this day
Of Oc 2014
Notary Public
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Narumol Alexander, Notary Public
Dillsburg Boro, York County
My Commission Expires May 22, 2017
MEMBER,PENNSYLVANIA ASSOCIATION OF N01MU,
Cocklin Funeral Home, Inc.
30 N. Chestnut St.
Dillsburg, PA 17019
(717)432-5312
January 17, 2012
Mrs. Penny Sue Lee
832 S. Ridge Road
York Springs, PA 17372
The Funeral Service for Mildred C. Kunkle
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Services
Funeral Director&Staff 3,725.00
Total Professional Services 3,70
Merchandise
S48 Heirloom Pewter 2,565.00
Monticello 1,390.00
Total Merchandise Selected
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO
OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
Newspaper Notice-Harrisburg 301.76
Newspaper Notice-Carlisle 110.43
Certified Copies 30.00
Clergy Honorarium 75.00
Flowers 215.18
Tent Rental 175.00
Cemetery Opening 500.00
Total Cash Advances
SALES TAX 0.00
SUB-TOTAL 9,087.37
INITIAL PAYMENT/DISCOUNT/CREDITS 8,630.00
TOTAL AMOUNT DUE 457.37 �R e
The unpaid balance over 1 days is subjected to a 0%service charge per month-0%per annum.
Page
Price
Memorial Works,Inc.
23-25 South Main Street • Dover, PA 17315
Telephone (717) 292-2621 • Fax (717) 292-7936
E-mail info@baughmanmemorials.com
Total Price �L a
Please design and build the following memorial I
(� Date
For A 00 1113)
Address
Design No.
Material
Die
Base /
Markers
Posts
Vases
Price Tax
Deposit
Balance Due
Style of Letters
Foundation to be furnished by
Material to be best selected monumental grade and to be free from imperfections and first class in every way.Work to be finished in a workmanlike
manner.
This memorial to be erected in Cemetery in or near
during the month of unless unavoidably delayed by labor
troubles and other contingencies beyond our control and then as soon as possible.Additional lettering and other work on this memorial in the future is
not included in the Contract Price.
Title and right of possession and removal of said stone,monument or appurtenances shall remain for all purposes in Baughman Memorial Works,
Inc.until work and materials ordered are fully paid by purchaser or purchasers. In consideration of the acceptance by Baughman Memorial Works,Inc.
of this order,the undersigned(hereinafter known as the purchaser)agrees to pay Baughman Memorial Works,Inc.
Dollars on or before the 15th day following
the billing of the work or job upon completion thereof by Baughman Memorial Works,Inc.Thirty(30)days from date of invoice a 1-1/2%finance charge
will be added to the unpaid balance. Said billing to be notice of completion thereof, this order shall become a contract between the purchaser and
Baughman Memorial Works,Inc.upon acceptance thereof in the space below by a duly authorized representative of said Baughman Memorial Works,
Inc.It being understood that this instrument upon such acceptance covers all of the agreement between the purchaser and Baughman Memorial Works,
Inc. and that no agent or representative of Baughman Memorial Works, Inc. has made any statements or agreements, verbal or written, modified or
adding to the terms and conditions herein set forth.
It is further understood that upon the acceptance of this order the contract so made cannot be cancelled,altered,or modified by the purchaser or
by any agent of Baughman Memorial Works,Inc.in any manner except by agreement in writing between the purchaser and Baughman Memorial Works,
Inc.and it is hereby understood and agreed by all parties involved that in case of default by purchaser or purchasers,twenty-five per cent of the total
original cost of the work or work and materials ordered,as the case may be,shall be a specified correct sum as liquidated damages which purchaser
shall owe Baughman Memorial Works,Inc.less any payment on account made prior to such default,this specification of damages to be due regardless
of removal and taking possession of stone, monument or materials from purchaser or purchasers by Baughman Memorial Works, Inc. upon following
such default.
(SEAL)
i\ I 20 (SEAL)
Baughman 3emorial Works, Inc.Approval By (SEAL)
White:Office Copy;Canary:Customer Copy;Pink:Salesman Copy;Gold: Deposit Copy
•• pennsyLvania
DEPARTMENT OF PUBLIC WELFARE
February 14, 2012
JANE M ALEXANDER ESQUIRE
148 S BALTIMORE ST
DILLSBURG PA 17019
Re: Mildred Kunkle
CIS #: 520260970
SSN: ###-##-
Date of Death: 12/03/2011
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Alexander:
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.
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 $41,611.69 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 $12,129.84, 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 $29,481.85, is to be entered as a priority Class 5.1 claim against the estate.
_._You.should-refer to.Secti.on_3.392_for a more complete expla.natio.n_of-th.e_pr_iority_ru.les..r -- _
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 i Division of Third Party Liability i Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
_
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DEPARTMENT opPUBLIC 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 acopy.
The Department audits all estate recovery claims and therefore we require
documentation tosubstantiate all deductions from the gross estate. The regulations
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 |avv 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 current appraisal, if available
2. Copy ofthe funera|biU
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 ina nursing home
5' Copies of original and updated |ifg insurance policy forms naming beneficiaries
S. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
0. Copies of signature cards or other proof ofwhen accounts were made joint
Q' A list of any gifts or other transfers for |eya than fair market value made by the
decedent (personally or under power of attorney)
Your Responsibilities to the Department
Under State |ovv, executors oradministrators may be personally liable to pay the
Department's estate recovery dalrn 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 |iab|e. 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 mnaklrfg'distributinn of ass-ets t6h6|rs�----'
Bureau mProgram Integrity | Division of Third Party Liability | Recovery Section
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DEPARTMENT opPUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor oradministrator has duty to act in the best interest ofcreditors when
administering the estate. If you must spend the estate's rnnmey 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
greate[ of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not beapproved. Ifyou donot obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
. .
Jennifer Hartman ^
TPL Program Investigator
717-772-6962
717-772-6553 FAX
Enclosure '
Bureau of Program Integrity Division of Third Party Liability Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
'