HomeMy WebLinkAbout12-03-14 p �EV 1500 1505610143
J EX(02-11)
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''� OFFICIAL USE ONLY .
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes �EPARTMENTOFREVENUE
PO BOX.280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 2 1 14 � °,�jC��
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ENTER DECEDENT INFORMATION BELOW
Sociai Security Number Date of Death Date of Birth
03 10 2014 O1 10 1918
Decedent's Last Name Suffix DecedenYs First Name MI
GALINAS DOLORES H
(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
� 1. Originai Keturn j] 2. Supp{emeriial R•�tur�� n� ? Remainder Return(Date of Death
Priorto 12-i3-a2)
� 4. Limited Estate � 4a. Future Interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
6 Decedent Died Testate � � Decedent Maintained a Living Trust � g, Total Numbe�of Safe Deposit Boxes
� (Attach Copy of Will) (Attach Copy of Trust)
� 9. Litigation Proceeds Received � 10.Spousal Poverty Credit(Date of Death � �1.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 GONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO�
Name Daytime Telephone Number
DEBRA K WALLET 717 737 1300
REGISTER OF WILLS USE ONLY
First Line of Address �
n � �
24 NORTH 32ND STREET c� � � �
Second Line of Address � � � c a t.n
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TOA�k�ED �''� ��
City or Post Office State ZIP Code ._. . „. , �_-�
CAMP HILL PA 17011 _`f � � � �`�, -�r�
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Correspondent'se-mailaddress: walletdeb@aoI.00111
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Under penalties of perjury,i declare that I have examined tnis return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIQNATURE OF PERSQ RESPON i. LE FOR FILING RETURN DATE ��
;.� Y � ' �� , ,��-�,,r Elaine G. Encimer 1/�-�, ��' —��"
AD R SS
597 Locust Lane, Mechanicsburg, PA 17055
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
����. ��,�,r Debra K Wallet �� ��Y(iy
ADDRESS
Law Offices of Debra K.Wallet
24 North 32nd Street, Camp Hill, PA 17011
Side '�
� 1505610143 1505610143 � '� `
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: GALINAS, DOLORES H 186 24 5212
RECAPITULATION
1. Real Estate(Schedule A)..............................................................................:........... 1.
2. Stocks and Bonds(Schedule B)............................................................................... 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5• Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 831 . 60
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 4 , 186 . 69
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 51 018 . 29
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 544 . 48
10. .Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 146 , 735 . 59
11. Total Deductions(total Lines 9 and 10).................................................................. 11. 14 7 , 2 8 0 . 07
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. - 3.42 , 261 . 78
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. -142 , 261 . 78
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.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
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. ❑
Side 2
1505610243 1505610243
--� � enns Ivania �
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DEPARTMENTOFREVENUE ��5� ��NK DEPO�I 1 S AND �Ia7ls.
INHERITANCE TAX RETURN . � p
RESIDENTDECEDENT I� PE�SONAL P�OPEfITY
FILE NUMBER
ESTATE OF Galinas, Dolores H 21 - 14
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Blue Cross refund 831.60
TOTAL(Also enter on Line 5, Recapitulation) 831.60
REV-1509 EX+(01-10) �
-� t pennsylvania �CFiEDULE F
=y�.
DEPARTMENT OF REVENUE i
INHERITANCETAXRETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT I
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ESTATE OF Galinas, Dolores H FILE NUMBER
21 - 14
If an asset was made joint within one year of the decedenYs date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Elaine G. Encimer 597 Locust Lane Daughter
q Mechanicsburg, PA 17055
JOINTLY OWNED PROPERTY:
' LETTER � DATE L�F�SCRIPTIO�J O.F PRO�ERTY %OF � oATe oF oEnTH
ITEM I Inciude name o inancial ins itution an bank account numbe DATE OF DEATH I va,�ue oF
NUMBER ;FOR JOINT! MADE or similar identifying numbec Attach deed for jointly-held reai VALUE OF ASSET DECD'S � oeceoENrs wreResT
i TENANT ! JOINT estate. INTERESTI
1 ' A , 01/29/2004 Members 1st FCU Savings Acct. 4,184.13 50%�, 2,092.07
' #240389 '
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2 , A j 01/29/2004 Members 1st FCU Checking Acct. a,189.23 50%�I 2,094.62
' #240389 ;
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TOTAL(Also enter on line 6, Recapitulation) 4,186.69
REV-1511 EX+(10-OS)
�=:� :�r pennsy6vania �����
b �' FU9V�AL EXPENSES AND
��i DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN AIy1A'I�II�+TflArnE WS`�`
RESIDENT DECEDENT f�16�JIYl l�lh7 1 fW
- FILE NUMBER
ESTATE OF Galinas, Dolores H 21 - 14
DecedenYs debts must be reported on Schedule I.
ITEM ' DESCRIPTION I AMOUNT
NUMBER I FUNERAL EXPENSES:
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A. 1 �!, Gabriellas Italian Restaurant (funeral luncheon) j 254.48
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g. ',ADMINISTRATIVE COSTS: �
�, I Personal Representative's Commissions
I Name of Personal Representative(s)
' Street Address
� City State Zip II
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i Year(s)Commission Paid �
2, ; Attorney's Fees Debra K. Wallet, Esq. 250.00
3. ; Family Exemption: Qf decedenYs address is not the same as claimanYs,attach explanation) �
, Claimant
I Street Address
City State Zip
�� Relationship of Ciaimant to Decedent �
4. I Probate Fees Inh. Tax Return filing fee 15.00
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5. ' AccountanYs Fees
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6. ' Tax Return Preparer's Fees '
7, Other Administrative Costs
� � Postage, copies, etc. ; 25.00
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TOTAL(Also enter on line 9, Recapitulation) 544.48
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:.-�. ; penn�ylvania � SCHEDULE I
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'1` DEPARTMENTOFREVENUE �����` OF DCCGDCIV� MO��l�h4'l��
INHERITANCE TAX RETURN �
RESIDENTDECEDENT LIA�ILITIES & LIENS
I
FILE NUMBER
ESTATE OF Galinas, Dolores H 21 - 14
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 PA Department of Revenue claim (see attached) 146,735.59
TOTAL(Also enter on Line 10, Recapitulation) 146,735.59
REV-1513 EX+(01•10) i
=� ;.; penr�sylva��ca SCHEDUL� J
� ��$�� DEPARTMENT OF REVENUE w� /� �+
� ������ INHERITANCETAXRETURN , B�IY�FICl/'1RI��7
RESIDENT DECEDENT I
ESTATE OF FILE NUMBER
Galinas, Dolores H 21 - 14
' RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER ',� NAME AND ADDRESS OF PERSON(S) � DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I. ',TAXABLE DISTRIBUTIONS[include outright spousal ' I
distributions,and transfers '
' under Sec.9116(a)(1.2)] ;
1 ', Elaine G. Encimer i Daughter 100% of residuary
; 597 Locust Lane � Estate
' Mechanicsburg, PA 17055 �
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�!Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
�I� NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
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�B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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TOTAL OF PART il-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET i 0.00
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;� LAST WILL AND TESTAMENT �
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DOLORES GALINAS
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�'� I, DOLORES GALINAS, of the City of Hazleton, County of Luzerne,i
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ICommonwealth of Pennsylvania, declare this to be my Last Will and ;
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ilTestament and revoke any and all wills previously made by me.
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'� FIRST I
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I direct that my funeral be conducted in a manner correspon- �
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jiding with my estate and situatiori in life and that a11 my l.egal �
�idebts and funeral expenses be fully paid and satisfied as soon as �
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i� possible after my decease. ;
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" � devise and bequeat'r, aii of my estate of every nature and '�
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�'� wherever situate to my daughter, Elaine G. Encimer. i
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j; Should my daughter, Elaine G. Encimer, predecease me, then I �i
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i� devise and bequeath the residue of my estate of every nature and '�
'jwherever situate, in equal one-half (%2) shares, to my grandchildren,
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;� James and Karen Encimer. ;
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I direct that all estate, inheritance, and succession taxes, �
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;iinterest, and penalties on property passing under this my Wil1, onI
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I� any codicil thereto, sha11 be paid out of the principal of my
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!! general estate to the same effect as if such taxes were expenses �
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jof administration an3 all legacies, devises and other gifts of
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ieither Yrincipal or income made by this my 69i11, on any codicil.
� thereto, shall be free and clear thereof.
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I SIXTH
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II I appoir.t my daughter; Elaine G. Encimer, to be Executrix of
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, this my Last Will. Should Elaine G, Encimer fail to qualify or
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i�cease to act as Executrix, then I appoint my granddaughter, Karen
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iiEncimer, as Executr.ix of this my Last Will.
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I direct that my Executrix shall not be required to give bond
i� for the faithful performance of her duties in any jurisdiction.
I IN WITIQESS 4dHEREOF, I, DOLORES GALINAS, have herunto subscriL�d
� and sealed and do publish and declare these presents as my Last
IWill� in the presence of the witnesses who are attesting below. at
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� my request, this "�� day of /���'1G , 1985.
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WITNESSES:
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��� COUNTY UF LUZERNE . I
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� I, DOLORES GALINAS, Testatrix, whose name is signed to the i
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,�: attached or foregoing instrument, having been duly qualified �
I� according to law, do hereby acknowledge that I signed and executed'i
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jjthe instrument as my Last Will; that I si.gned willingly; and that
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!� Sworn or af.firmed to and acknowledged before me, by Dolores I
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'� Galinas, the Testatrix, this ,��/ day of /��-�� C. , 1985. i
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�jwitnesses whose names are signed to the attached or foregoing �
iiinstrument, being duly quulified accorc�ing to 1aw, do depose and i
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�AY � 5 2�14
+• pennsylvania
;'•
DEPARTMENT OF PUBLIC WEIFARE
May 7, 2014
DEBRA K WALLET ESQUIRE
24 N 32ND STREET
CAMPHILL PA 17011-2917
Re: Dolores Galinas
CIS #: 027955508
SSN: ###-##-5212
Date of Death: 03/10/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Wallet:
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 considerabiy 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 $146,735.59 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 �22.787.25, 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 $123,948.34, is to be entered as a priority Class 5.1 claim against the
estate. You should refer to Section 3392 for a more complete explanation of the priority
rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
`* pennsylvania
,;��
DEPARTMENT OF PUBLIC WEIFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate 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 law libraries.
In order to document computation of the amount due the Department, the following
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
�+ pennsylvania
:�•
DEPARTMENT OF PUBLIC 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 or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
������� �. �����
� �
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 8ox 8486 � Harrisburg, Pennsylvania 17105-8486
. � -� --- COMMONWEALTH OF PENNSYLVANIA _ ..
BUREAU OF PROGRAM INTEGRITY .
- DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8486 �
HARRISBURG,PA 17105-8486
April 29,2014
STATEMENT OF CLAIM SUMMARY
NAME Estate of GALINAS,DOLORES
ID 027 955 508
MEDICAL CLASS 3 CLASS 5:1 TOTAL'
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 22,787.25 123,948.34 146,735.59
DRUG .00 .00 .00
REIMBURSEMENT TO DPW 22,787.25 123,948.34 146,735.59
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 6
COMMONWEALTH OF PENNSYLVANIA �
� ' DEPARTMENT OF PUBLIC WELFARE
�
April 29,2014
STATEMENT OF CLAIM
NAME GALINAS, DOLORES
ID 027 955 508
MANORCARE HEALTH SERVICES-CAMP HIL .
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL'CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/01/�1 - 01/31/11 10/31/11 55112994817020001 55112994817020001 4,881.88 3,945.18
DIAGNOSIS 1 : d019 HYPERTENSION NOS
DIAGNOSIS 2 : 0
PROC CODE: 0000000
02/01/11 - 02/28/11 10/31/11 55112994816740001 55112994816740001 4,409.44 3,463.86
DIAGNOSIS 1 : 40'19 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE : 0000000
03/01/11 - 03/31/11 10/31/11 55112994817360001 55112994817360001 4,881.88 3,945.18
. .[1�,..� 'a,ll �1 ` ,2i1�9 'r7y'��;�(rCli,i�!1ie!fh,nc � .__ ._ _.._ . ._.__.._.__.
nr� c��� . . ...- -- _.
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
04101l11 - 04/30/11 11/07/11 55113054728680001 55113054728680001 4,724.40 3,784.74
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2 : 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
05/01l11 - 05/31/11 11/07/11 55113054729420001 55113054729420001 4,881.88 3,945.18
DIAGNOSIS 1 : 40'19 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
06/01/11 - 06/30/11 11/07/11 55113054729800001 55113054729800001 4,724.40 3,784.74
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
07/01/11 - 07l31/11 05/07/12 55121244237650001 55121244237650001 4,881.88 3,928.44
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
08/01/11 - 08/31/11 05/07/12 55121244238160001 55121244238160001 4,881.88 3,928.44
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IROPd DEFIC AtJEMIA NOS
PROC CODE: 0000000
Page 2 of 6
- - �
i� COMMONWEALTH OF PENNSYLVANIA
` DEPARTMENT OF PUBLIC WELFARE
April 29,2014
STATEMENT OF CLAIM
NAME GALINAS,DOLORES
ID 027 955 508
MANORCARE HEALTH SERVICES-CAMP HIL
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
09/01/11 - 09/30/11 05/07/12 55121244238850001 55121244238850001 4,724.40 3,768.54
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
10/01/11 - 10/31/11 OS/21/12 55121374116420001 55121374116420001 4,973.64 4,117.85
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
11/01/11 - 11/30/11 05/21/12 55121374117330001 55121374117330001 4,813.20 3,951.84
_ - --- - -- -_- - --_
.�r,.�a�r-+:3`_i � 'ir�'� :3�3��.`'�.ia:.���ns>3;.�'�°�, , - _
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
12/01/11 - 12/31/11 05/21/12 55121374117690001 55121374117690001 4,973.64 4,117.85
DIAGNOSIS 1 : 8208 FX NECK OF FEMUR NOS-CL
DIAGNOSIS 2: 0
PROC CODE: 0000000
01/01/12 - 01/31/12 O6/18/12 55121654862070001 55121654862070001 4,973.64 4,118.16
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
02/01/12 - 02/29/12 06/18/12 55121654862680001 55121654862680001 4,652.76 3,773.89
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
_ 03/01/12 - 03/31/12 O6/18/12 55121654863330001 55121654863330001 4,973.64 4,095.16
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
04l01l12 - 04/30/12 02/04/13 69130144021520001 69130144021520001 4,891.20 3,850.51
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
Page 3 of 6
� COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 29,2014
STATEMENT OF CLAIM
NAME GALINAS, DOLORES
ID 027 955 508
MANORCARE HEALTH SERVICES-CAMP HIL
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
05/01/12 - 05/31l12 02I04/13 69130144021790001 69130144021790001 5,054.24 4,013.55
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2 : 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
O6/01/12 - 06/30/12 02/04/13 6913014402175000� 69130144021750001 4,891.20 3,850.51
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
07/01/12 - 07/31/12 02/04/13 69130144021740001 69130144021740001 5,054.24 3,878.08
„ � � . - - . .
-- - --
--- -- -- -
. Rl�.;, P-�r cl�7� � ...._ t'a . ..,. . . r� .�_ _, '� - - --- — — � - - �
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
08/01/12 - 08/31/12 02/04/13 69130144021690001 69130144021690001 5,054.24 3,878.08
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PR�C CODE: 0000000
09/01/12 - 09/30/12 02/04/13 69130144021650001 69130144021650001 4,891.20 3,719.41
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
10/01/12 - 10/31/12 02/04/13 55�30244826070001 55130244826070001 5,054.24 3,912.80
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
11/01/12 - 11/30/12 02/04/13 55130244826060001 55130244826060001 4,891.20 3,753.01
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
12/01/12 - 12/31/12 04/08/13 69130714021390001 69130714021390001 5,054.24 3,913.30
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
Page 4 of 6
I COMMONWEALTH OF PENNSYLVANIA 1
DEPARTMENT OF PUBLIC WELFARE I
April 29,2014
STATEMENT OF CLAIM
NAME GALINAS, DOLORES
ID 027 955 508
MANORCARE HEALTH SERVICES-CAMP HIL
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/01/13 - 01/31/13 04/08/13 69130714021550001 69130714021550001 4,918.77 3,891.82
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2 : 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
02/01/13 - 02/28/13 03/25/13 20130604264670009 20130604264670001 4,442.76 3,403.81
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
03/01/13 - 03/31/13 04/22/13 20130914245340001 20130914245340001 4,918.77 3,879.82
.i�-r�A��r ic , . � - . -r � � ---- —- - -- � � --- �- - ...
��, .�..__ ,��..�-..' .'r''_i''•. :�','. 'r�.��t_3�j'�rv`��if�^ ,. -- ._ --�-.�- _ . .� ... _ . .
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
04/01/13 - 04/30/13 05/27/13 20131214252820001 20131214252820001 4,887.60 3,848.65
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
05/01/13 - 05/31/13 06/24/13 20131534059630001 20131534059630001 5,050.52 4,011.57
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
06/01/13 - O6/30/13 07/22/13 20131824275340001 2013'1824275340001 4,887.60 3,848.65
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
07/01/13 - 07/31113 02/10/14 55140364155660001 55140364155660001 5,050.52 3,812.86
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE : 0000000
08/01/13 - 08/31/13 02/10/14 55140364156130001 55140364156130001 5,050.52 3,812.86
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
Page 5 of 6
� COMMONWEALTH OF PENNSYLVANIA �
i DEPARTMENT OF PUBLIC WELFARE
Aprii 29,2014
STATEMENT OF CLAIM
NAME GALINAS,DOLORES
ID 027 955 508
MANORCARE HEALTH SERVICES-CAMP HIL
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
09/01/13 - 09/30/13 02/10/14 55140364156720001 55140364156720001 4,887.60 3,656.35
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
10/01/13 - 10/31/13 03/10/14 55140644170460001 55140644170460001 5,050.52 3,918.26
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
11/01/13 - 11/30/13 03/10/14 55140644171070001 55140644171070001 4,887.60 3,758.35
-+'?. `�n�c,.1 : �i:1r� - W i�i��R�E'i .r�i� n�(.c _ _ _ - -- - _ - - -_ ---_.- -
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
12/01/13 - 12/31/13 03/10/14 55140644171720001 55140644171720001 5,050.52 3,918.26
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
01/01/14 - 01/31/14 02/24/14 20140344070620001 20140344070620001 4,851.81 3,818.14
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE : 0000000
02/01/14 - 02/28/14 03/24/14 20140624079010001 2014062407901000� 4,382.28 3,348.61
DIAGNOSIS 1 : 4019 HYPERTENSION N05
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
03/01/14 - 03/10/14 04/01/14 20140914246060001 20140914246060001 1,408.59 369.28
DIAGNOSIS 1 : 4019 HYPERTENSION NOS
DIAGNOSIS 2: 2809 IRON DEFIC ANEMIA NOS
PROC CODE: 0000000
PROVIDER SUB TOTAL MANORCARE HEALTH SERVICES-CAMP HILL 186,914.54 146,735.59
03 102062927 0001
Page 6 of 6
oLaw��icee of
DEBRA K.WALLET
24 N. 32nd STREET
CAMP HILL,PA 17011-2917
PHONE:(717)737-1300 E maiL•Walletdeb@aol.com FAX:(717)761-5319
December 1, 2014
N
c � � 'rn
� � t� cyo
Lisa M. Grayson, Register of Wills � � r-"- � -�-+ �
Cumberland County Courthouse s ��., � �~' � �
1 Courthouse Square �::, ,c; �, ��, -,-,
Carlisle, PA 17013 ��'� a � � :� �
, � �, � �
Re: Estate of Dolores H. Galinas �.� � � .�
1700 Market Street, Camp Hill, PA
Dear Ms. Grayson:
Enclosed are an original and one copy of the Pennsylvania lnheritance Tax Return for
Dolores H. Galinas (D.O.D. March 10, 2014), and a check in the amount of$15.00
representing the filing fees for the tax return.
There will be no need to open an Estate.
I have also enclosed two copies of the first page to be stamped in and returned to me in
the pre-addressed envelope provided.
Should you need any additional information, please contact me.
Sincerely yours,
�Io r�, '�c. (�.�,fd,,,l•
Debra K. Wallet
DKW/mm
� Enc.
cc: Elaine G. Encimer
.
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