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Home My WebLink About02-03-15 � REV-1500 E"`02-t1, 1505610143 PA De artment of Revenue � OFFICIAL USE ONLY P pennsylvania co�nry coae Year File Number Bureau of Individual Taxes DEPARTMENTOFftEVENUE Po aox.28o601 INHERITANCE TAX RETURN � / / ( f �� ' Harrisburg,PA 17128-0601 RESIDENT DECEDENT � / % ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 12 19 2014 08 26 1916 DecedenYs Last Name Suffix DecedenYs First Name MI KEYSER RUTH I (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. Original Return ❑ 2. Supplemental Return � 3, Remainder Return(Date of Death Pnorto 12-13-82) � 4. Limited Estate � 4a.Future Inferest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-82) � 6 Decedent Died Testate � � Decedent Maintained a�iving Trust , 8. Total Numbe�of Safe Deposit BOxes (Attach Copy of Wilq (Attach Copy of Trust) --- � 9. Litigation Proceeds Received � 10.Spousal Poverty Credit(Date of Death � ��,Election to tax under Sec.9113(A) between 12-31-91 and t-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAT,IQ�I SHOULD BE DIRECTED TO: Name D�time Telephone Nu[�e� GREGORY R REED ESQ 2;3'� 238-Os43r47 c-� r_� =� r--, __�. �;�� r. � _�.. I�EGIS�R OF WILLS�15E;ONLY ; C.J ; c � First Line of Address � � � • � � � � 'T�7 ,b -��7 �, i ---i .,_._ ...7 3120 PARKVIEW LANE - . ...., f�..' . ' 4.�J � Second Line of Address , r _ 6�`� t�.� Li <`� i,X� '�7 Ci or Post Office DATE FILED tY State ZIP Code HARRISBURG PA 1711 CorrespondenYs e-maii address: I awoff i c e@ reed p a I aw.c o m Under penalties of peryury,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,corre t and complete.Declaration of preparer other than the personal representatrve is based on all information of which preparer has any knowledge. SIGNATURE ERSON RES�ONS�I FO,�R F�ILING RETURN DATE t1,�� y '�� . Frank A. Keyser i"��d�/s^ ,«� ADDRESS 207 Delmont Avenue , Middletown, PA 17057 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE Gregory R Reed Esq ADDRESS Gregory R. Reed Attorney At Law 3120 Parkview Lane, Harrisburq, PA 1711 Side 1 � 1505610143 1505610143 1 � � 1505610243 REV-1500 EX DecedenYs Social Security Number oeoede�t�5 Name: K E Y S E R� R U T H I 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. 6 , 1 1 8 . 0 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. g. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 6 , 1 1 8 . 0 0 _ ___ _ __ _ ._-- ---____ 9. Funeral Expenses and Administrative Costs(Schedule H)........ ........................ 9. 2 , 9 4 6 . 5 0 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................. 10. 6 7 , 4$ 9 . 1 9 11. Total Deductions(total Lines 9 and 10).................................................................. ��. 7 O , 4 3 5 . 6 9 12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. - 6 4 , 3 1 7 . 6 9 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. - 6 4 , 3 1 7 . 6 9 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 .�2 ��• 18. Amount of Line 14 taxable at collateral rate X .15 �$• 19. TAX DUE................................................................................................................... 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 � 1505610243 1505610243 J REV-1500 EX Page 3 File Number Decedent's Complete Address: D N ' Keyser, Ruth I STREET ADDRESS _ __._— ---_ - - _ . _----. _---- --— -- __ --_ CITY , STATE ZIP 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 +g) (2) 0.00 3. Interest (3) 0.0 0 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) �.�0 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:.................................................................................. ' rx_�i b. retain the right to designate who shall use the property transferred or its income:.................................... _ ' L'� c. retain a reversionary interest;or.................................................................................................................. �x'� �-_: . r d. receive the promise for life of either payments,benefits or care?.............................................................. . i i_x_, 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?....................................................................................................................... ir.__.'� LXJI 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... � ', �x', 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?...................................................................................................................... �--�I i X� IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: •The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. •The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in [72 P.S.§9116(a)(1)]. •The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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,wfiether by bloo or adoption. -� pennsylvania SCHEDULE E � DEPARTMENTOFREVENUE CASH BANK DEPOSITS AND MISC. �� INHERITANCE TAX RETURN � RESIDENT DECEDENT '��..., PERSONAL PROPERTY ------- _.____ ._ .�__ _._- - - ---_-.---.__-_ __._- --- �- --_. _- ---. .___- . . ---____ ... _ _. .. - - ..____ -__ ...._-- �,FILE NUMBER ESTATE OF Keyser, fZUth � 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 Wells Fargo Checking Account#1773643307 - See copy of Wells Fargo account statement 5,104.84 attached hereto marked Exhibit"A"and incorporated herein by reference 2 PSERS payment 440.25 3 Cash, furniture, etc. 572.91 __--- TOTAL(Also enter on Line 5, Recapitulation) 6,118.00 REV-1511 EX+(10-09� --�: pennsylvania ''�, ��H �� DEPARTMENT OF REVENUE � rIJNC(\F1L G/�rGYJW MIYD ��, INHERITANCE TAX RETURN I, wry�A�w,�T�pA�� '� RESIDENT DECEDENT I - fW1Y11Y 1 IW ,. - .__.. ____-------------------___ I__.-___ __.__ _____ .._ .. . _-- _.. ____. .._. . .__....._------- -----______ FILE NUMBER ESTATE OF Keyser, Ruth i , - ---- _____- - - ---- -- _-___-_- ----_ _ _- _ __- - - ------------ ---_ __ _ DecedenYs debts must be reported on Schedule I. ITEM ! - ---------- -- - --- ___ _--- NUMBER DESCRIPTION AMOUNT FUNERAL EXPENSES: I _ _ _ _ __ � ___ _ _ _ _ __ _ __ . _ __ _ - -------- _ A. 1 Matinchek and Daughter Funeral Home 633.00 B. I ADMINISTRATNE COSTS: �I �. Personal Representative's Commissions Name of Personal Representative(s) Frank A. Keyser 1,000.00 Street Address 207 Delmont Avenue, City Middletown State PA Zip 17057 ', Year(s)Commission Paid 2015 ', 2. ', Attorney'sFees GregoryR. Reed II 1,000.00 3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant I Street Address '� City State Zip ' Relationship of Claimant to Decedent I a. i Probate Fees Register of Wills 113.50 s. , AccountanYs Fees Boreman and Babbs, CPA II 200.00 6. Tax Return Preparer's Fees 7. Other Administrative Costs ' 8 I I--.---._ ____ ___ - -------- — ( __-_ __ p- --_)- --� __ _-- --- -- TOTAL Also enter on line 9, Reca itulation � 2,946.50 �� pennsylvania � SCHEDULE I I DEPARTMENTOFREVENUE DEBTS OF DECEDENT MORTGAGE INHERITANCE TAX RETURN f RESIDENTDECEDENT LIABILITIES & LIENS � -- ----- -----___ ._... __----L_---_ ____ _ ___ _..._. _.___- _ __._--I------ - ----__ . . _. _ .._.- -- ..._. _.- -r:-- ::�.-___c- .._---------_ . ._ ___.-_- -._ _._--. - _ _--- I FILE NUMBER ESTATE OF Keyser, Ruth I Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. __ __ ____---- __. _. _ __---- _-- -- - -------- ITEM NUMBER DESCRIPTION AMOUNT --- ------ __--- --____ ___ ____ ___ _ _ _--- — _ __-- - - — __ 1 DPW lien - See DPW letter attached hereto marked Exhibit"B" and incorporated herein by 67,489.19 reference _. —___ _ _._ . _------- TOTAL(Also enter on Line 10, Recapitulation) 67,489.19 REV-1513 EX+(01-10) -� pennsylvania l �� DEPARTMENT OFREVENUE SCHEDULEJ INHERITANCE TAX RETURN BENEFICIARIES , RESIDENT DECEDENT � — --_.�___ _._ _._... — -- -._ . .---- __._. ._.. --- .__.. -__ — ._.__ ESTATE OF FILE NUMBER Keyser, Ruth I - _ _ - RECEIVING PROPERTY --- __. __ . __ ._ ____- ----- _ _--- — NAME AND ADDRESS OF PERSON S RELATIONSHIP TO I SHARE OF ESTATE AMOUNT OF ESTATE NUMBER ' ( ) -- � DECEDENT (Words) � ($$$) � Do Not List Trustee�s) I - .._.._- ------- ------. ...____-- --. _ _ .I.-_ . __. . ._..-- -----._ .. ._._---- — --. ____ .. _.. _. __._ _ �- 1 I� TAXABLE DISTRIBUTIONS[include outright spousal distributions,and transfers I ' j ', under Sec.9116(a)(1.2)] I 1 I Frank A Keyser ' Son '� Zero 0.00 207 Delmont Ave. Middletown, PA 17057 , �, II � II �I Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. ' II. I�NON-TAXABLE DISTRIBUTIONS: I A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN IB.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I ITOTAL OF PART II-ENTE - - R TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET I 0.00 _ _____ -- _ --__— _ . _---------_ ---- — -- _— -i_ _ ��r�y� �J�''el�s Fargo �ombined Statement of Accounts Primary account number:7000645574754 ■ December 10,2013-)anuary 9,2014 0 Page 1 of 4 � � • DCDP11 DTM7 013216 Questions? I1�1��1�11�1�1��11'�I��I�Ill�ll��l��l��l��l�ti��l��ll �'°"°"�i RUTH I KEYSER Available by pnone 24 l�uurs a day,'l days a week: ETHEL KENDREW POA 1-80U-70-WELLS (1-800-869-3557) a00 W PINE ST m: i-soo-an-as33 MOUNT HOLLY SPRINGS PA 17065-1126 En espanol: 1-877-727-2932 �p 1-800-288-2288(6 am to 7 pm PT,M-F) Online:wellsfargo.com Write: Wells Fargo Bank,N.A.(345) P.O.Box 6995 'ru�iiend,0it 97"t�8-o9y5 0 (� 0 � 0 � � V You and Wells Fargo Account options � W Getting ready for tax season can be a challenge!Creating a checklist,and A ctieck mark in the box indicates you have these � preparing in advance will set you up for a successful meeting with your tax convenient:ervices with youraccount. Go to z preparer.Remember to bring your deposit routing and account number when wellsfargo.corr,orcull the numberobove ifyou have Z preparing your taxes and you may be able to take advantage of using direct que:tions orifyou woule'like to add ne�vse�vices. Z deposit for your tax refund into one of your Welis Fargo checking or savings Online Bariking [] Direct Deposit �✓ z aCCounts. Ornine Bill Pay n AutoTransfer/Payment[� Z Onlme Statements � Overdraft Protection � Z Mobile Banking � Debit Card Z My Spending Report ✓Q Overdraft Service � g 0 0 N W A N O Summary of accounts � W 0 Checking/Prepaid and Savings � � Fn<iir;r�h�;l�rce Fndi�n hnl�nr_e m m Accaunt Page Accountnumber laststa[ement thissratement f Crown Account Regular 2 1000645574754 8,983.44 5,545.09 Wells Fargo•Regular Savings 3 3065950012591 0.01 0.01 Total deposit accounts S8,983.45 55,545.10 Primary account number:7000645574754 ■ December 10,2013-January 9,2014 ■ Page 2 of 4 ' ` ' • Crown Account Regular ACt1Vlt�/S11111111a1'y/ Account number: 1000645574754 Beginning balance on 72/70 58,983.44 RUTH I KEYSER Deposits/Additions 440.25 ETNEL KENDREW POA Withdrawals/Subtractions - 3,878.60 Pennsylvania account teims ond conditions apply For Direct Deposit and Automatic Payments use Ending balan<e on 1/9 55,545.09 Routing Number(RTN): 031000503 Overdraft Protection This account is not currentiy covered by Overdraft Protection. If you would like more information regarding Overdraft Protection and eligibiliry requirements please call the number listed on your statement or visit your Wells Fargo store. Transaction history Check Deposits/ Withdrawals/ Ending daily Date Number Description Additions Subtractions balance 12/13 3778 Check 1478.60 7,504.84 .. _ .,,, ..,....,..�,�,.,�,...�..._.�.,....�_ . ..,.._,.,._....,.,.,....�..�.....,.�..,.�.�,._....,_...�....._V,_.�..�..._._..�_�.._._.._.,.�.. ..�.... 12/18 3780 Cashed Check �� ................._.._.._........_......._ .................. ............,__.., _. .. 12/18 . . .. 3781. Cashed Check . . 1,400.00 5 104 84 , _.__,....,,.�. .,�.�.�.w..._.._...,.�...�.....�,...,.�._.,. ..�__.___..,�._,�.._.._ .,...,.,,._....�,,....,..�,,._..,_..�..�.,�__._.�..,. ,.. 12/31 PA Treasu De t Annuitant 131231 xxxxx5162 Ruth I Keyser 440 25 _ W.w.�.._. µ _._.,_µ,_. _y 5 545 09 .. ..... .... ......_.,...,... .,,. .._..__,._�...�..�.........�...,.,............_...,._..W..._.,..,_......,.._... __._...._._._ ,,�...._._...,...,.. ........ ..... Ending balance on 1/9 5,545.09 Totals 5440.25 53,875.60 The Ending Daily Balance does not reflect any pending withdrawals or holds on deposited funds that may have been outstanGing on your account when your transactions posted. If you had insu�cient available funds when a transaction posted,fees may have been assessed. Summary of checks written(checks listed are also displayed in the preceding Transaction history) 0 � Number pote Amount Number Date Amount Number Date Amount � 3778 12/13 1,478.60 3780" 12/18 1,000.00 3781 12/18 1,400.00 A "Gap in check sequence. Monthly service fee summary For a comple[e list of fees and detailed account information,please see the Welis Fargo Fee and Information Schedule and Account Agreement applicable to your account or talk to a banker.Go to welisfargo.com/feefaq to find answers to common questions about the monthly service fee on your account. Fee period 12/10/2013-Ol/09/2014 Standard monthly service fee$12.00 You paid$0.00 How to avoid the monthly service fee Minimum required This fee period Have any ONE of the following account requirements • Average daily balance $1,500.00 $6,009.00 [✓( • Monthly automatic loan payment to a Wells Fargo mortgage 1 0 ❑ '?'�r,fi • Combined balances in linked accounts,which may include 52,500.00 56,024.78 Q '� - Average daily balances in checking and savings accounts • Combined balances in linked accounts,which may include 55,000.00 50.00 ❑ - Average daily balances in time accounts and fDIC-insured retirement accounts • Combined balances i�linked a�counts,which may include $5,000.00 $0.00 ❑ - Outstanding balances in consumer installment loans - Li�e amount in credit cards and consumer lines of credit Priniary at count number:1000645574754 ■ December 10,2013-January 9,2014 ■ Page 3 of 4 . � Monthly service fee summary(continued) ,�,� � Did you kno�v that you can review your safe deposit box information through Wells Fargo Online Banking?Siyn on to online banking and go to your account summary page.Check it out today. � IMPORTANT ACCOUNT INFORMATION We want to let you know about an important upcoming change. CffCCIIVC A�/II:,2^ut•.,ti,e iee ior deposired i3.S.or foreign currency denominated international items,including dra(ts,will be$5.00 0 � per item. � If you have questions,please contact your local banker,or call the phone number listed at the top of your statement. � � 0 _ � N Wells Fargo ExpressSendm transfer fees will be changing effective April 7,2014.Please visit the ExpressSend Remittance Cost Estimator m at wellsfargo.com/costestimator or talk with a Banker beginning April 7 to get information on the new fees. Z z z Wells Fargo� Regular Savings z Z Z Z Account number. 3065950012591 Z Activity summary Z Beginning balance on 72/10 $0.01 RUTH 1 KEYSER z ETHEL KENDREW POA � Deposits/Additions 0.00 ^' Withdrawals/Subtractions -p,pp Pennsylvania occount terms and conditions apply o For Direct Deposit and Automatic Payments use p Ending balance on 1/9 50.01 Routing Number(RTN): 031000503 "� rn � m o, 0 Interest summary '' � Interest paid this statement So.Oo °' m Average collected balance 50.01 , Annual percentage yield earned O.00g'o Interest earned this statement period $�•� Interest paid this year $0.� Total interest paid in 2013 50.00 ii Priirary account number:7000645574754 ■ December 10,2013-January 9,2014 ■ Page 4 of 4 • • Worksheet to balance your account General statement policies for Wells Fargo Bank Follow the steps below to reconcile your statement balance with your � To dispute or report inaccuraciQs in information we have furnished to a account register balance. Be sure that your register shows any interest Consumer Reporting Agency about your accounts. You have the right to paid into your account and any service charges,automatic payments or dispute the accurecy of information that Welis Fargo Bank,N.A.has ATM transactions withdrawn from your account during this statement furnished to a consumer reporting agency by writing to us at Wells Fargo period. Servici�g,P.O.Box 1441 S,Des Moines,IA 50306-341 S. Piease describe the QA Enter the ending balance on this statement. $ � specific informa[ion that is inaccurete or in dispute and the basis for the dispute along with supporting doaimentation. If you believe the ❑B List outstanding deposits and other information furnished is the result of identity theft,please provide us with credits to your account that do not appear on an identity theft report. this statement. Enter the total in the column � In case of errors or questions about your electronic transfers, to the right. telephone us at the number printed on the front of this statement or write Description Amount us at Wells Fargo Bank,P.O.Box 6995,Portland,OR 97228-6995 as soon as you can,if you think your statement or receipt is wrong or if you need more information about a transfer on the statement or receipt. We must hear from you no later than 60 days after we sent you the FIRST statement on which the error or problem appeared. —. 1.Tell us your name and account number(if anyl. 2.Describe the error or the transfer you are unsure about,and explain as Total S � + S � clearly as you can why you believe it is an error or why you need more information. 3.Tell us the dollar amount of the suspected error. Q AddO and Q to calculate the subtotal. = s � We will investigate your complaint and will correct any error promptly. If QD List outstanding<hecks,withdrawals,and we take more than 10 business days to do this,we will credit your account other debits to your account that do not appear for the amount you think is in error,so that you will have the use of the on this statement. Enter the total in the column money during the time it takes us to complete our investigation. to the right. � In case of errors or questions about your Direct Deposit Advance• sQrvice NumberlDescription Amount If you think your bill is wrong,or if you need more information about a transaction on your bill,write us at Wells Fargo Bank,P.O.Box 6995, Portland,OR 97228-6995 as suon as possible.We must heai from you no late�than 60 days after we sent you the first bill on which the error or problem appeared.You can telephone us,but doing so will not preserve your rights. In your letter,give us the following information: 1.Your name and account number 0 2.The dollar amount of the suspected error o 3.Desc�ibe the error and explain,if you can,why you believe there is an m error.If you need more information,describe the item you are unsure about. You do not have to pay any amount in question while we are investigating, but you are still obligated to pay the parts of your bill that are not in question.While we investigate your questiun,we cannot reportyouu as delinquent or take any action to collect the amount you question. wv i sC .` '� Total $ � . S I �E Subtract QD fron►❑C to calculate the adjusted ending balance.This amount should be the same as the current balance shown in your Q register. _ � � KQO70 Wells Fargo Bank,N.A All righ!s reserved.NMlSH ID 399801 Member FDIC.�i�oie ,�� pennsylvania ��II� DEPARTMENT OF PUBLIC WELFARE November 4, 2014 FRANK KEYSER 207 DELMONT AVE MIDDLETOWN PA 17057 Re: Ruth Keyser CIS #: 770239611 SSN: ###-##-5904 Date of Death: 12/19/2013 Dear Mr Keyser: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. 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. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of�67,489.19 against the above-mentioned estate. This claim is for restitution of inedical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $18,165.19, 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 $49.324.00, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise when payment may be expected. We are in receipt of the Decedent's Assets Itemization Form that you completed. If the estate does not have sufficient funds to pay this lien in its entirety please provide the Department with copies of the following, if applicable—funeral invoice, proof of burial account, proof of personal care account or refund from nursing home, life insurance policy forms naming beneficiaries, proof of any and all stocks and bonds, date of death bank statements, all pages, and if bank account(s) was(were) held jointly with the decedent by a person other than a spouse you are required to provide copies of the original signature cards or proof from the banking institution showing ownership of any and all bank accounts on the date they were made joint. Proof of all real estate owned either individually by the decedent or jointly with another person; please provide copies of the deed, the latest tax assessment, and a current appraisal if available. If real estate owned by the decedent was sold prior to or after their death please provide the HUD1 document for that sale. Also provide the Inheritance Tax Return with all schedules and supporting documentation. Please remember to provide only copies of these documents, not originals. �� Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrlsburg, Pennsylvanla 17105-8486 •� pennsyLvania ►� DEPARTMENT OF PUBLIC WEIFARE Sincerely, � �" �� V E. Jane Cleland Claims Investigation Agent 717-772-6232 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 DEPARTMENT OF PUBUC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 MANORCARE HEALTH SERVICES-CAMP HIL 1700 MARKET ST CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 03/06/12 - 03/31/12 O6/25/12 55121654863900001 55121654863900001 4,171.44 2,750.02 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 04/01/12 - 04/30/12 06/25/12 20121514021040001 20121514021040001 4,813.20 3,324.70 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 05/01/12 - 05/31/12 06/25/12 20121534266600001 20121534266600001 4,973.64 3,487.74 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 06/01/12 - O6/30/12 07/23/12 20121844028840001 20121844028840001 4,891.20 3,324.70 DIAGNOSIS 1 : 4019 HYPfRTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 07/01/12 - 07/31/12 01/14/13 55130104254550001 55130104254550001 5,054.24 3,352.27 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 08/01/12 - 08/31/12 01/14/13 55130104255070001 55130104255070001 4,347.74 2,664.70 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 53081 ESOPHAGEAL REFLUX PROC CODE: 000000 09/21/12 - 09/30/12 01/14/13 55130104255910001 55130104255910001 1,630.40 20.20 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 10/01N2 - 10/31/72 01/28113 55130244824460001 55130244824460001 5,054.24 3,386.99 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 Page 2 of 10 �' ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 MANORCARE HEALTH SERVICES-CAMP HILI 1700 MARKET ST CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11/01/12 - 11/30/12 01/28N3 55130244825080001 55130244825080001 4,891.20 3,227.20 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 12/01/12 - 12/31/12 01/28/13 55130244825720001 55130244825720001 5,054_24 3,386.99 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 01/01N3 - 01/31/13 02/25/13 20130324279220001 20130324279220001 4,918.77 3,440.17 DIAGNOSIS 1 : 78039 OTHfR CONVULSIONS DIAGNOSIS 2: 311 DEPFtESSIVE DISORDER NEC PROC CODE: 000000 02/01113 - 02/28/13 03/25/13 20130604265090001 20130604265090001 4,442.76 2,964.16 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 03/01/13 - 03/31/13 04/22/13 20130914246400001 20130914246400001 4,918.77 3,440.17 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 04/01/13 - 04/30/13 05/27/13 20131214253620001 20131214253620001 4,887.60 3,409.00 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPI:ESSIVE DISORDER NEC PROC CODE: 000000 05/01/13 - 05/31/13 06/24/13 20131534060420001 20131534060420001 5,050.52 3,571.92 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 06/01/13 - 06/30/13 07/22/13 20131824275640001 20131824275640001 4,887.60 3,409.00 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 Page 3 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 MANORCARE HEALTH SERVICES-CAMP HIL 1700 MARKET ST CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ` ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 07/01/13 - 07/31/13 02/10l14 55140364155710001 55140364155710001 5,050.52 3,373.21 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 08/01/13 - 08/31/13 02/10/14 55140364156200001 55140364156200001 5,050.52 3,373.21 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 09/01/13 - 09/30/13 02/10/14 55140364156790001 55140364156790001 4,887.60 3,216.70 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 10/01/13 - 10/31/13 03/10/14 55140644170530001 55140644170530001 5,050.52 3,478.61 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 11l01/13 - 11/30/13 03/10N4 55140644171150001 55140644171150001 4,887.60 3,318.70 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 12/01/13 - 12/19/13 03/10/14 55140644171800001 55140644171800001 2,932.56 1,399.78 DIAGNOSIS 1 : 78039 OTHER CONVULSIONS DIAGNOSIS 2: 311 DEPF7ESSIVE DISORDER NEC PROC CODE: 000000 PROVIDER SUB TOTAL MANORCARE HEALTH SERVICES-CAMP HILL 101,846.88 67,320.14 03 102062927 0001 Page 4 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 78106 DATE OF SERVICE PAYMENT`DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 03/09/12 - 03/09/12 06/11/12 25121385326950001 25121385326950001 27.82 12.51 DIAGNOSIS 1 : 0 NDC CODE: 00245005810 KL04�-CON M20 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS 03/11/12 - 03/11/12 06/11/12 25121385326940001 25121385326940001 167.01 7.38 DIAGNOSIS 1 : 0 NDC CODE: 00378668910 PANTOPRAZOLE SOD DR 40 MG TAB - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 03/11/12 - 03/11/12 06/11/12 25121385326960001 25121385326960001 73.80 4.54 DIAGNOSIS 1 : 0 NDC CODE: 00172290780 FUROSEMIDE 40 MG TABLET - DIURETICS 03/13/12 - 03/13/12 06/11/12 25121385326970001 25121385326970001 80.20 4.86 DIAGNOSIS 1 : 0 NDC CODE: 00378521005 AMLUDIPINE BESYLATE 10 MG TAB - OTHER CARDIOVASCULAR PREPS 03/13M2 - 03/13112 06111/12 25121385326990001 25121385326990001 11.38 4.29 DIAGNOSIS 1 : 0 NDC CODE: 00603385632 HYDhOCHLOROTHIAZIDE 25 MG TAB - DIURETICS 03l19/12 - 03/19/12 O6/11/12 25121385326980001 25121385326980001 76.79 5.44 DIAGNOSIS 1 : 0 NDC CODE: 00093474150 CITAL.OPRAM HBR 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 04l10/12 - 04/10/12 06/11/12 25121385327000001 25121385327000001 167.01 7.38 DIAGNOSIS 1 : 0 NDC CODE: 00378668910 PANTOPRAZOLE SOD DR 40 MG TAB - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 04I10/12 - 04/10/12 06111/12 25121385327020001 25121385327020001 13.80 4.54 DIAGNOSIS 1 : 0 NDC CODE: 00172290780 FURdSEMIDE 40 MG TABLET - DIURETICS Page 5 of 10 ( COMMONWEALTH OF PENNSYIVANIA I DEPARTMENT OF PUBUC WELFARE I July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 18106 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ' ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 04/11/12 - 04/11/12 06/11/12 25121385327030001 25121385327030001 27.82 12.13 DIAGNOSIS 1 : 0 NDC CODE: 00245005810 KLOR-CON M20 TABLET - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 04/12/12 - 04/12/12 06/11/12 25121385327060001 25121385327060001 80.20 4.86 DIAGNOSIS 1 : 0 NDC CODE: 00378521005 AMLODIPINE BESYLATE 10 MG TAB - OTHER CARDIOVASCULAR PREPS 04/13/12 - 04/13/12 06/11/12 25121385327050001 25121385327050001 11.38 4.29 DIAGNOSIS 1 : 0 NDC CODE: 00603385632 HYDROCHLOROTHIAZIDE 25 MG TAB - DIURETICS 04/16/12 - 04M 6N 2 06/11/12 25121385327080001 25121385327080001 76.79 5.44 DIAGNOSIS 1 : 0 NDC CODE: 00093474150 CITALOPRAM HBR 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 05N0/12 - 05/10/12 06/11/12 25121385317190001 25121385317190001 13.80 4.54 DIAGNOSIS 1 : 0 NDC CODE: 00172290780 FUROSEMIDE 40 MG TABLET - DIURETICS 05/11/12 - 05/11/12 O6/11/12 25121385317180001 25121385317180001 11.38 4.29 DIAGNOSIS 1 : 0 NDC CODE: 00603385632 HYDROCHLOROTHIAZIDE 25 MG TAB - DIURETICS 05/15/12 - OS/15/12 06111/12 25121385317200001 25121385317200001 80.20 4.86 DIAGNOSIS 1 : 0 NDC CODE: 00378521005 AMLbDIPINE BESYLATE 10 MG TAB - OTHER CARDIOVASCULAR PREPS 05/16/12 - 05/16/12 06/11/72 25121385317210001 25121385317210001 76.79 5.44 DIAGNOSIS 1 : 0 NDC CODE: 00093474150 CITALOPRAM HBR 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS Page 6 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID"`` 770 239 611 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 18106 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 05/20/12 - 05/20/12 O6l18/12 25121415277570001 25121415277570001 167.01 7.38 DIAGNOSIS 1 : 0 NDC CODE: 00378668910 PANTOPRAZOLE SOD DR 40 MG TAB - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 05l30/12 - 05/30/12 06/25/12 25121515501170001 25121515501170001 28.86 4.86 DIAGNOSIS 1 : 0 NDC CODE: 00378232105 LORAZEPAM 0.5 MG TAB�ET - ATARACTICS-TRANQUILIZERS 06/08/12 - 06/08/12 07/02/12 25121605607880001 25121605607880001 28.29 .86 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS O6/25/12 - O6/25/12 07/23/12 25121775248430001 25121775248430001 18.65 2.52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LOREIZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS O7/04/12 - 07/04/12 10/O8/12 25122555257640001 25122555257640001 19.90 5.07 DIAGNOSIS 1 : 0 NDC CODE: 51672201602 TRIPL_E ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 07/09/12 - 07/09/12 10/08/12 25122555257670001 25122555257670001 18.65 .52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORA.ZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07123/12 - 07/23/12 10/08112 25122555257910001 25122555257910001 18.65 2.52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/06/12 - 08/06/12 10/08/12 25122555257980001 25122555257980001 18.65 .52 DIAGNOSIS 1 : 0 NDC CODE_ 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS Page 7 of 10 � . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE I July 75,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 18106 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 09/26/12 - 09/26/12 10/22/12 25122705455450001 25122705455450001 13.50 2.17 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/19/12 - 10/19/12 11/12/12 25122935336590001 25122935336590001 10_93 .07 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/23/12 - 10/23/12 11/19/12 25122975617250001 25122975617250001 22.51 2.52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/29/12 - 10/29/12 11l26/12 25123045259820001 25123045259820001 11.89 3.64 DIAGNOSIS 1 : 0 NDC CODE: 00904582460 VITAI4AIN D3 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 11/05/12 - 11/05/12 12/03/12 25123105787250001 25123105787250001 22.51 .52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 11l19/12 - 11/19l12 12/17/12 25123245760360001 25123245760360001 22.51 2.52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/02N 2 - 12/02/12 12/31/12 25123375234440001 25123375234440001 22.51 .52 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 72/03/12 - 12/03/12 12/31/12 25123385775920001 25123385775920001 19.90 5.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS Page 8 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 18106 DATE OF SERVICE PAYMENTDATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 12/04/12 - 12/04/12 12/31/12 25123395572580001 25123395572580001 28.29 .74 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/18/12 - 12/18/12 01/14/13 25123535237800001 25123535237800001 28.29 2.74 DIAGNOSIS 1 : 0 NDC CODE: 00591024001 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 02/08/13 - 02/08/13 03/04/13 25130395608330001 25130395608330001 11.89 3.64 DIAGNOSIS 1 : 0 NDC CODE: 00904582460 VITAIVIIN D3 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 09/11l13 - 09N1/13 10/07/13 25132545278580001 25132545278580001 19.90 4.98 DIAGNOSIS 1 : 0 NDC CODE: 51672201602 TRIPI_E ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL HEARTLAND PHARMACY PA LLC 1,489.46 150.35 24 101710595 0001 Page 9 of 10 � : COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 15,2014 STATEMENT OF CLAIM NAME KEYSER,RUTH ID 770 239 611 ONSIGHT HEALTH CARE LLC 2593 WEXFORD-BAYNE RD A STE 105 SEWICKLEY PA 15143 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 02/04/13 - 02/04/13 04N 5/13 27130916209810001 27130916209810001 60.00 18.70 DIAGNOSIS 1 : 3804 IMPACTED CERUMEN PROC CODE: 69210 REMOVAL IMPACTED CERUMEN(SEPARATE PROCE PROVIDER SUB TOTAL ONSIGHT HEALTH CARE LLC 60.00 18.70 31 102372661 0005 Page 10 of 10 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROC>R,4M INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG.PA 17105-8486 July 15,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of KEYSER,RUTH ID ' 770 239 611 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIEN"f .00 18.70 18.70 LONG TERM CARE 18,160.21 49,159.93 67,320.14 DRUG 4.98 145.37 150.35 REIMBURSEMENTTObPW 18,165.19 49,324.00 67,489.19 COMMONWEALTH OFPENNSYLVANIA ' DEPARTMENT OF PUBLIC WELFARE EIN=':23-6003113 Page 1 of 10