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Home My WebLink About12-22-14 � 15056101�5 REV-1500 EX(o2-ii)(FI) � enns lvania OFFICIAL USE ONLY PA Department of Revenue PEppq,ME Y County Code Year File Number Bureau of Individual Taxes pINHERITANCE TAX RETURN PO BOX z8o6oi � I � --y � ( �� I Harrisburg,PA i�128-0601 RESIDENT DECEDENT �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10/08/2012 03/10/1910 DecedenYs Last Name Suffix DecedenYs First Name MI Myers Dorothy E (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 FILI IN APPROPRIATE OVALS BELOW � 1.Original Return O 2.Supplementai Return O 3. Remainder Return(Date of Death Prior to 12-13-82) p 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) � 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust _ 8. Totai 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 T0: Name Daytime Telephone Number William S. Daniels, Esqui (717)243-3831 REGISTER OF WILLS USE ONLY r-V C� First Line of Address n � � One West High Street � � � � � -n c� c,r� � Second Line ofAddress « � � •-� Suite 205 i�� n N 4'"� �� T ATE-FFLED_. `'`, � City or Post Office State ZIP Code � ' �� . G"J � -v-y Carlisle PA 17013 `�' `"' �� "` � - :, C.� .�... c� ;;.:7 S r- rn . r ,_:7 � �, £n � CorrespondenYs e-maii address: ��` G.J Under penalties of perjury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief, it is tr rr � and compiete.Declaration f preparer than the personal representative is based on all information of which preparer has any knowledge. OF ON RESPONSIB G RETURN DATE � � f Z1 � �� DD ESS Holbert G. Myers, 18 alnut Botto oad, Newville, PA 17241 SIGNATURE OF PR R OTH R THAN REPRESENTATIVE DATE �liam . Daniels, squire, One West High Street, Carlisle, PA 17013 ��j'�� ,��"� `.q- PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 15�5610105 J �`�y , � sJ � 15�5610205 REV-1500 EX(FI) DecedenYs Social Security Number oecedenrs Name: Myers, DorOthy E. RECAPITULATION 1. Real Estate(Schedule A). . . . .. ..... . ... ... ..... ..... . ............... . 1. 2. Stocks and Bonds(Schedule B) . ... ................. . . . . ........... . . . 2. 500.00 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. 4,212.28 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. 4,712.28 9. Funeral Expenses and Administrative Costs(Schedule H). . . ... . . . . . . . . . . . . . 9. 4,212.82 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I).. . . . . .. . . . .... 10. 51,218.49 11. Total Deductions(total Lines 9 and 10).. . ... .............. . . ..... .. .. . . 11. 55,431.31 12. Net Value of Estate(Line 8 minus Line 11) ........ ..... . . ..... .......... 12. -50,719.03 13. Charitable and Govemmental 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. -50,719.03 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_ 15. 16. Amount of Line 14 taxable at lineal rate X.0_ 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. 0.00 19. TAX OUE . . . . . . . ........... .. . . . . . . . . . . . . . . . . . ......... . . . . . . ..... 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 :/) 1 � %j L; ( + �1 Decedent's Complete Address: DECEDENI"S NAME Dorothy E. Myers STREETADDRESS Chapel Pointe at Carlisle 770 South Hanover Street CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments 0.00 B.Discount Total Credits(A+g) (2) 0.00 3. Interest (3) 0.00 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) 0.00 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 antl: Yes No a. retain the use or income of the property transferretl.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec.12,1982,tlid decedent transfer property within one year of tleath without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-tleath bank account or security at his or her tleath?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa beneficiary tlesignation? ........................................................................................................................ ❑ � 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 disciosure 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 imposetl 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 tlecetlenYs 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. � � �>_- o— ��z�Y. �i11 �.n� C�I�e��.m�nx I , DOROTHY E. MYERS, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my last will and revoke all wills and codicils which I have previously made . I . I direct my executrix hereinafter named to pay all of my just debts , funeral and administrative expenses and all estate , transfer , inheritance and succession taxes whether payable by reason of property passing under this will of otherwise, as soon after my decease as may be convenient . II . I give and bequeath the sum of Five Thousand and no/100 ($5 , 000 . 00 ) Dollars to the Dickinson Presbyterian Church of Cumminstown , Pennsylvania, ( 12 Church Road, Carlisle , Pennsylvania 17013) to be used as the Board of Trustees may � �: determine . ,� �� III . I give an�d bequeath to my niece, MARY LEE BURY, the sum ��_�� . ,� of Five Thousand and no/100 ($5 , 000 . 00 ) Dollars ; to my niece , E. ' � JEAN BIXLER, the sum of Five Thousand and no/100 ($5 , 000 . 00 ) �•.',j Dollars ; to my nephew, JOHN K. BIXLER, JR. , the sum of Five ��—, \.�� Thousand and no/10,0 (55 , 000 . 00 ) Dollars ; to my nephew, HOLBERT G. �.�� . ; � MYERS, the sum of Five Thousand and no/100 ($5 , 000 . 00) Dollars ; � and to such � person or persons as in the judgement of my personal representative shall have taken care of ine during the final portion of my life, and if there be more than one such person, to � D � __ �_ . ...��._ _ti�.._ _ �. ._ .�...�w�.. _.. __ _ ___..__ be divided between or among them in such proportion as my executor may deem appropriate, the sum of Five Thousand and no/100 ($5 , 000 . 00 ) Dollars , and if there be no such person, then to lapse . IV . I give and bequeath to my sister , OLIVE L. MYERS, such articles of tangible personal property having sentimental , family or heirloom significance . V . I give and bequeath the residue of my estate as follows : 1 . 33 1/3� to my sister , OLIVE L . MYERS; 2 . 33 1/3� to my sister , ELVA M. BIXLER, and if she shall predecease me , then in equal shares to her two children, JOHN R. BIXLER, JR. and E. JEAN BIXLER; 3 . 33 1/3$ to my nephew, HOLBERT G. MYERS, if living , and if deceased, in equal shares to his two children, A. RYLE MYERS and ALLISON E. MYERS. If the beneficiary or beneficiaries of any of the foregoing share or shares shall have predeceased me , said legacy shall '; � lapse and be added to the share or shares of the beneficiaries ti. -� . living at the time of my death. �� VI . I appoint my sister , OLIVE L. MYERS, as Executrix of r�', this will , and if for any reason she shall fail to qualify� or J__, .; cease to act as s�ch during the administration of my estate , I �� ' :, appoint my nephew, HOLBERT G. MYERS, as substituted Executor of � �.� this my last will . Should both my sister , OLIVE L . MYERS, and my T �� nephew, HOLBERT G . MYERS , fail to qualify or cease to act as executors , I appoint WILLIAM S. DANIELS as Executor of this my _._. .....�,.:.e,,,,�l,,.»..�,„.�,,,�,..,. - ______._�_______...._ __ . ...:�� . ......�:-� .�,,;.,:,,.�.�,�:�.,,..�.�...�.�.�,� . last will . VII . I direct that neither my executrix nor her successors shall be required to give bond for the faithful performance of their duties in any jurisdiction . IN WITNESS WHEREOF, I have hereunto set my hand this ! �'�� < day of � tz >z-cc ��' � C — , 1991 . � r � r , 'ci,��L,C. ��,'�) �.c' :�.�,i DOROTHY ' MYERS ; The preceding instrument , consisting of this and two other typewritten pages identified by the signature of the testatrix , DOROTHY E . MYERS, was on the day and date thereof signed , published and declared by DOROTHY E . MYERS, the testatrix therein named, as and for her last will , in the presence of us , who at her request , in her presence, and in the presence of each other have subscribed o ames as witnesses hereto . � � . .� .L -�� ,�'�/J7 Lc-�L- �"'� ��L/�' �7<,�rd'l'��v �� , ,� � � ''_ ' - � �i�2/7��-�S �� Z� '� � ' ^__ ,�' _ �O S�D �L ,�-.��--�,.-,-.. �� i�s�-�•� �/�- / � ,`3 ,.z..�/ , REV-1503 EX+(8-iz) � pennsylvania SCHEDULE B � DEPARTMENT OP REVENUE INHERITANCETAXRETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy E. Myers 21 12 0113 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1� U.S.Savings Bond 500.00 TOTAL(Also enter on Line 2, Recapitulation) $ 500.00 If more space is needed,insert additional sheets of the same size � �� ,;�-��; . ., . „ .., . ,_ . . ,��r�,,�..x.� ; � � � � � _� �; � � _ � S�`�o� � o� fYl ��,,,�- � � � � _ � �,_ , `� •��'�' � ar, � ac o� ca � �``.,.� � (', � �. .►� _ � .� � 00 � `��; , Q �^ u. ao �� i�n ...0 �" p � 2� . N '� a, T ;;� �� v N* .�.� � �,,,► (�l ,�; ; w �: Z Z � � .- �:, �"" ' � � X ---+ ",� (n `= Q,i ►"1 rr� o W � a ,;`� ,�,-... t� - �',Z G. r�*� � � .,+.� — T o . qC A �'. �� 3 r�;� o;,- - - � .� ,°� e� �C M � �� r,,,, p" "'rT ■ x M N� ,.:� w N'/ w r ��.�,\. �� m ¢ ("� : � r�,t a � % �r; N M � Q .S : �,� '�i ~�, ;:.w, M N w ` �� cD r�� :~,, `f'.: V. LL �' �„�, �; I� Q � o , rf� �� " r- p ° o ' .-a � ��1 ��i a �� O u �n � Y 1-LJ Z o ; O :� J N , � l. ,(' � ' V1 O 2 O : I�M � ^, � Z � �� ^�� o �, � Z o O `�" W ^, o � ii�`„�' � a � ' W ��. � m �.�. •.� • `I.%,. 2 ,..�. 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C O� f,^ ►� _ d O C?� � � �+�'��i. � .�r �., a o� - r�� , k._�... . h',�,��, � �� - ^i(% �,_..y._ ,- y' �., . �� <� , ,,: . � ,ry i_� � _ � �'� ' - 11�1 � � ,� z i--n+�-_,; = ��,1 �.r° � ` O C �:; � 1 1 F ' �� ,� : .i ',� a ,_ ��'a, �_ � � .� ��, . �.� /� _.+ `"'��'dll� ;yf' � ,+. �� r==x� x�, ' .. � „:, r,. � ,1`\ �F� �,'I' - , � � . .... . tlll�lta,�.... . �+u�111�L�L�1tsLau:i2Sitil.�rux4.�Yk.i' -�vS:i.i�fA'�'.��1�tit;nv"AQ�`.P...YVOf'uav Q�v.(hv�•y, REV-15o8 EX+(o8-lz) � pennsylvania SCNEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dorothy E. Myers 211201131 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Chapel Pointe at Carlisle 3,712.28 770 South Hanover Street,Carlisle,PA 17013 TOTAL(Also enter on Line 5, Recapitulation) $ 3,712.28 If more space is needed,use additional sheets of paper of the same size. j . � I I ' � I � � ' v� �OYD� F, /� GrS � � �� Ge��' .- � Zb Z �vr � b'�,,,,�,L /1/, /oCo ��o �"i�/ = 3(o�7lnlo�5 �' __ o ~ � � � � / ��.35 - --___ _ i ,� O/Z�S G�GOSr>rC OT YG C�K G� isf� �� Z �iz_ _ l--- , , eG� �� s�-►� ' './o �i i2- �6�dS � �o,3 — _- - , , ✓ D o i� i' S. _.._ l/5 i _--.-_ � � PD '��S�iv t�w��S�k o7� �Sy� - �7�'. ` � � J .� ,�! � _ � �� .Z ..� � b Z �c_ 5/ _ �+ --, I, PD�6�I v ��GL�GCG �G� 0�1 ��'�l,C j n 1`Crivlc� 7�Q._Q.�j r.�GRt��+ � C?!"GL�Li / (NO/'�S �tG� �� i ---� -� . � ��y I� �SG�-i 6� 7`a0� 57'�NL _::. — �l` .D d � \ __-- - -{-�fj.-p3� . 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Trust Fund Quarterl,y Statement Chapel Polnte aj�Q,Ilsle Statement Date: 12/31/2012 • Reporting Period: 10/O1/2012 To 12/31/2012 770 SOUTH HANOVER STREET,CARLISLE,PA 17013-4105 MYERS, AOROTHY E ID: 12581 HOLBERT G MYERS . 1804 WALNUT BOTTOM RD " NEWVILLE, PA 17241 � Trans. Date Description/ Comment Reference peposit Withdrawal Vendor Fund: RTF Resident Trust Fund 10/O1/2012 Beginning Balance 1,365.45 10/03/2012 Deposit-Soc. Sec. Check 1,305.00 10/03/2012 Deposit-Pension Check 2,140.73 10/16/2012 Funds To Private Pa,y -3,400.73 Funds to Private-Patient Pa,y ' 10/16%2012 Funds To Private Pa,y -0.10 Funds to Private-Pat Pa,y Int � 10/24/2012 Miscellaneous 0300001221 -1,410.35 Estate of Dorothy Myei•s close PCA ' Totals - Number of Transactions 5 3,445.73 -4,811.18 12/31/2012 Ending Balance 0.00 Decedent's Assets Itemization Form Item Information � Present Value of Property Property/Real Estate nddress: Owned by the Decedent /�J A Owners�s listcd on Dced: $ Check onc: "Tcnants in Common" _'7oint Tenants wrlh RigM of Survivorship" _"Tenunts by the Entirely" D�te of Dccd: � If you answer Yes to any of the following Value at Death Value Now questions,fill in the dollar amount(s) in the far right columns. 13ank Accounts in gank Account(s) Is this a joint account? Decedent's name Checking ' Yes No $ $ i 1� Savings Yes No $ $ �� If you answer Yes for either account, please submit a copy of the bank stateme.nt at the time of death and a copy of the original signature card. Nursing Home Personal l.es No $ ,��pa,ry3 $ U Care Account Decedent's Burial gurial Account(s) Prepaid Fu eral Aceounts yes�No Yes�No $ �33�. � $ G� ��AOJ•-'��i� Yes No Yes No $ $ Stocks/Bonds/Other �. U.'j� N �� jp�� oD $ �-� $ �-OD in Decedent's name -� �, -�� g�x�� ' g $ P�S �j'�y� Insurance Policy(s) Beneficiary Living �,%rJ�t�' Yes� No Yes No� $ 7bZ.l'/ $ ��2:�/ Beneticiary Name Life Insurance Policies Yes No Yes No $ $ Beneficiary Name $ $ Yes No Yes No Beneficiary Name i ACKNOWLEDCE THAT THE INFORMATION I HAVE SUPPLIED ON THI FORM IS SUBJECT TO THE PENALTIES SE'T FORTH IN 18 PA C.S.4904.(relating to nswo `cation to auth t' f�� G 1�'l �2� `� �� 3 Name (Please print clearly) Signature (Please sign ink) Date _� — 77� — -1�� . Phone Number (Please include Area code) REV-1511 EX+ (08-13) � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXREfURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy E. Myers 211201131 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1� Eby Granite Works/Monuments 119.00 111 Carlisle Road, Newville,PA 17241 Inscribe Foot Stone 2. Hoffman Roth Funeral Home 305.32 219 North Hanover Street,Carlisle,PA 17013 Opening of Grave B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 1,000.00 Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: Z• Attorney Fees: 1,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 83.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 285.00 �• Advertising,Cumberland Law Journal 75.00 s. Advertising,The Sentinel 300.00 s. Register of Wills, Filing 45.00 io. Reserve for Settling Estate 500.00 TOTAL(Also enter on Line 9, Recapitulation) $ 4,212.82 If more space is needed, use additional sheets of paper of the same size. i � � � i � �ord� �; �-s � :.� � , ,� ��- - ¢ 2o�Z ��,-s ,� __ � �. /o� ��o �"i�l % 3(��7(01�0�5 �' — -- o � � .. � / �o.3S � __- ; ,� O ZBS G�6dSvr� OT- f G� C,�t GI hf� !� Z ��z�_ , I � ; � _---_ _-- C��.� -�,;s,�-r ---- - - �!, !.�0 3� i2- z�o� � !o,3 _ _ �- , � ✓ i o o .' �' S -- r�s � ,�-i - � i � '�45 ►y vGY�'s,k o 7� �c s f�"e.- - 1 7'�'• a - � � J f � � �� , / ✓ ' DD Z.. f�a�m a-�r — ��i, �M.a9� i�� -- '�3d S 3 z- � :'_— ' OP�I v �6Q.�G CG �G� D/�l �Cs�ic l�L //J�C�'�'I� _ Q..�3� f � � � / �+.s�� ✓ �� ' � �r�� cr�c-s �i� �' , - --_ '�i . �� _____�✓ /' i �� ' iPD ��SJI�/ �-ytSG-id�G 7�0� ST�N� � l`9.Dd ,�t�Dii �`; �: �5 —' fg3,so �" � /' �o ._, C 5z7,53 n s�l i�- �va,Kc� Y� . � �.' � ---- � � / d Z --_ �! 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RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date : 10/19/2012 Cumberland County - Register Of Wills Receipt Time : 11 :25 :49 One Courthouse S quare Receipt No. : 1071789 Carlisle, PA 17613 MYERS DOROTHY E Estate File No. : 2012-01131 Paid By Remarks : HOLBERT G MYERS DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20 . 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 ---------------- Check# 1402 $83 . 50 Total Received. . . . . . . . . $83 . 50 REV-1512 EX+ (12-1Z) � pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF PILE NUMBER Dorothy E. Myers 211201131 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� Pennsylvania Department of Public Welfare,Bureau of Program Integrity,Division of Third Party 51,218.49 Liability,Recovery Station P.O. Box 8486,Harrisburg,PA 17105-8486 TOTAL(Also enter on Line 10, Recapitulation) $ 51,218.49 If more space is needed,insert additional sheets of the same size. � ~ �_ C�� #'� nn lvania � / k pe sy � DEPARTMENT OF PUBLIC WELFARE 1 � � `%%''�� January 16, 2014 HUMER & DANIELS LAW OFFICES WILLIAM S DANIELS ESQUIRE FARMERS TRUST BLDG STE 205 ONE W HIGH ST CARLISLE PA 17013 Re: Dorothy Myers CIS #: 950285092 SSN: ###-##-8112 Date of Death: 10/08/2012 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Daniels: 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 �51,218.49 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 $12,341.39, 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 �38,877.10, 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 PUBIIC WELFARE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits 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 PUBIIC 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, �� Marie A. Trayer TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY • DIVISION OF THIRD PARTY LIABILITY � RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 January 10,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of MYERS,DOROTHY ID 950 285 092 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 12,320.83 38,860.62 51,181.45 DRUG 20.56 16.48 37.04 REIMBURSEMENT TO DPW 12,341.39 38,877.10 51,218.49 -- -- — _ --— COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE E W= 23-6003113 Page 1 of 7 • COMMONWEALTH OF PENNSYLVANIA � DEPARTMENT OF PUBUC WELFARE ' January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUA�CHARGES AMOUNT APPROVED 10/08/10 - 10/31/10 10/24/11 55112924029300001 55112924029300001 3,707.04 1,111.35 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 11/01/10 - 11/30/10 10/24/11 55112924029310001 55112924029310001 5,214.60 2,293.37 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 12/01/10 - 12/31/10 10/24/11 55112924029320001 55112924029320001 5,388.42 2,459.54 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01/11 - 01/31/11 10/31/11 55112994028760001 55112994028760001 5,388.42 2,208.90 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 02/01/11 - 02/28/11 10/31/11 55112994028770001 55112994028770001 4,866.96 1,779.71 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 03/01/11 - 03/31/11 10/31/11 55112994028950001 55112994028950001 5,388.42 2,208.90 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 04/01/11 - 04/30111 11/07/11 55113054028370001 55113054028370001 5,214.60 2,068.17 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 05/01/11 - 05/31/11 11/07111 55113054028660001 55113054028660001 5,388.42 2,249.20 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 Page 2 of 7 COMMONWEALTH OF PENNSYLVANIA �I DEPARTMENT OF PUBLIC WELFARE January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED O6/01N1 - O6l30/11 11/07/11 55113054028970001 55113054028970001 5,214.60 2,068.17 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 07/01/11 - 07/31/11 05/07/12 55121254120340001 55121254120340001 5,388.42 2,453.80 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 08/01/11 - 08/31/11 05/07/12 55121254120570001 55121254120570001 5,388.42 2,453.80 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 09/01/11 - 09/30/11 05/07/12 55121254120840001 55121254120840001 5,214.60 2,266.17 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 10/01/11 - 10/31/11 05/21/12 55121374554600001 55121374554600001 5,388.42 2,337.55 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 11/01/11 - 11/30/11 05/21/12 55121374554820001 55121374554820001 5,430.90 2,153.67 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 12/01/11 - 12/31N1 05/21/12 55121374555130001 55121374555130001 5,611.93 2,337.55 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 01/07/12 - 01/31/12 06/18/12 55121644398920001 55121644398920007 5,611.93 2,258.63 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 Page 3 of 7 COMMONWEALTH OF PENNSYLVANIA I DEPARTMENT OF PUBLIC WELFARE January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/01/12 - 02/29/12 06/18N2 55121644399160001 55121644399160001 5,249.87 1,893.51 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 03/01/12 - 03/31/12 O6/18/12 55121644399370001 55121644399370001 5,611.93 2,258.63 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 04/01/12 - 04/30/12 05/28/12 20121224187930001 20121224187930001 5,430.90 2,218.77 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 05/01/12 - 05/31/12 06/25/12 20121564050590001 20121564050590001 5,677.65 2,276.92 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 O6/01/12 - O6/30/12 07/30/12 20121854022490001 20121854022490001 5,494.50 2,093.77 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 07/01/12 - 07/31/12 01/28/13 55130244659390001 55130244659390001 5,677.65 1,947.91 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 08/01/12 - 08/31/12 01/28/13 55130244659540001 55130244659540001 5,677.65 1,947.97 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 09/01/12 - 09/30/12 01/28/13 55130244659790001 55130244659790001 5,494.50 1,775.37 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 Page 4 of 7 i COMMONWEALTH OF PENNSYLVANIA ' i .i DEPARTMENT OF PUBLIC WELFARE - i January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10/01/12 - 10/08/12 02/18/13 55130444175610001 55130444175610001 1,159.95 60.18 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 2900 SENILE DEMENTIA UNCOMP PROC CODE: 0000000 PROVIDER SUB TOTAL CHAPEL POINTE AT CARLISLE 129,280.70 51,181.45 03 000745163 0001 Page 5 of 7 - COMMONWEALTH OF PENNSYIVANIA •I DEPARTMENT OF PUBLIC WELFARE January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10/31/10 - 10/31/10 02/28/11 25110325704010001 25110325704010001 2.78 2.78 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES&MISCELLANEOUS NUTRIENTS 11/30/10 - 11/30/10 02/28/11 25110325704760001 25110325704760001 2.69 2.69 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CA�CIUM-VIT D TAB - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 12/31/10 - 12/31/10 02/28/11 25110325706210001 25110325706210001 2.78 2.78 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES&MISCELLANEOUS NUTRIENTS 01/14/11 - 01/14/11 02/28/11 25110315815680001 25110315815680001 5.45 5.45 DIAGNOSIS 1 : 0 NDC CODE: 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 01127/11 - 01/27/11 02/28/11 25110325249280001 25110325249280001 2.78 2.78 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 07/23/12 - 07/23/12 08/20/12 25122055239620001 25122055239620001 5.25 4.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 07/30/12 - O7/30/12 08/27/12 25122125560030001 25122125560030001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 08/07/12 - 08/07/12 09/03/12 25122205443640001 25122205443640001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS Page 6 of 7 , COMMONWEALTH OF PENNSYLVANIA ' DEPARTMENT OF PUBUC WELFARE January 10,2014 STATEMENT OF CLAIM NAME MYERS,DOROTHY ID 950 285 092 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/12/12 - 08/12/12 09/10/12 25122255229600001 25122255229600001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 08/16N 2 - 08/16/12 09/10/12 25122295455360001 25122295455360007 5.25 4.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 08/21/12 - 08/21/12 09/17/12 25122345265960001 25122345265960001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 08/28/12 - 08/28/12 09/24/12 25122415620530001 25122415620530001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS 09/05/12 - 09/05/12 10/01/12 25122495321690001 25122495321690001 5.25 2.07 DIAGNOSIS 1 : 0 NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 58.48 37.04 24 001887261 0008 Page 7 of 7 REV-1513 EX+(01-10) � pennsylvania SCHEDULE � DEPARTMENT OFREVENUE INHERITANCE TAX RERIRN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dorothy E. Myers 211201131 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1• Holbert G.Myers Nephew $5,000.00 1804 Walnut Bottom Road,Newvilte,PA 17241 Residue1/2 2. Mary Lee(Myers)Bury Niece $5,000.00 P.O.Box 341,Machiasport,ME 04655-0341 3. E.Jean Bixler Niece $5,000.00 119 Race Street, P.O.Box 45,Boiling Springs,PA 17007 Residue1/2 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1, B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. Dickinson Presbyterian Church,Attention: Cierk of Session 5,000.00 12 Church Road,Carlisle,PA 17015 TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. �b � �