HomeMy WebLinkAbout02-17-15 J 1505610105
REV-1500 EX�02_��,�Ft, .
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
�_o��. .a�,E��E
Bureau of Individual Taxes INHERITANCE TAX RETURN (}! /� ���J
PO BOX z8o6o1 RESIDENT DECEDENT L �
Narrisburg PA i�i28-o6oi
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
424- '07/19/2014 ;05/08/1921
DecedenYs Last Name Suffix DecedenYs First Name M�
Grubic _ Mary L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name M�
Spouse's social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
' REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Originai Return O 2.Supplemental 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. Federai Estate Tax Return Required
death after 12-12-82)
� 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Randall K. Miller,Esq (717)361-8524
REGISTER OF WILLS USE ONLY
First Line of Address -"
. � '.�
�._� —
1255 South Market St � o "�' ,�`� �
Second Line of Address � � � � �`�
� � -
.. ._. .. . _ ... ...i -. r-�y �;.� "�:[7
. . . . . . ... ...... _.,. �
- - �,:1
Suite 102 ' }"� � r
...,
_ i
City or Post Office
State ZIP Code �P�TE FILEII� , s
PA '17022 . _�
Elizabethtown , .=.� ` •�i
_ .: ��
� C.J :.. F�i
CorrespondenYs e-mail address:rkmandjmm gmail Com ' ' _�,, ;.,', �-�
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my�wledge an21rt}elief,
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
SIGNATUR O; REPARE�TH�AN REPRESENTATIVE DATE y/'
�� � �� ���7
A•DRESS
1255 S. Market Street, Suite 102, Elizabethtown, PA 17022
PLEASE USE ORIGINAI FORM ONLY
Side 1 �
� 1505610105 150561�1�5 � �
��
� 15�5610205
REV-1500 EX(FI) DecedenYs Social Security Number
�ecedent's Name: M8ry L. GrublC 424-24-8044
RECAPITULATION
1. Real Estate(Schedule A). .............. ...... ......... ....... ...... .. 1. 0.00 '
2. Stocks and Bonds(Schedule B) 2. 0.00
................ ............ ....... ....
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mort a es and Notes Receivabie Schedule D 4. 0.00
9 9 t ) ..................... . ... . .
5. Cash,Bank Deposits and Miscellaneous Perso�al Property(Schedule E)..... .. 5. 11,413.16
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. ...... 7. ' 0.00
8. Total Gross Assets total Lines 1 throu h 7 ...... ... . ... 8. ' 11,413.16
( 9 )............ ....
9. Funeral Expenses and Administrative Costs(Schedule H).. . ... .. . ... .... ... 9. ' 2,923.94 '
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. 'iiii! 187,463.33
11. Total Deductions(total Lines 9 and 10)...... ......... .... ............. . 11. 19�,387.27 '
12. Net Value of Estate(Line 8 minus Line 11) ....... ... ...... .... ... ....... 12. ' -178,974.11 '
13. Charitabie and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........... ... . ... ...... 13. 0.00
14. Net Value Sub'ect to Tax Line 12 minus Line 13 ... .... ...... 14. '; 0.00
J � ) ..... ......
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of�ine 14 taxabie
at the spousal tax rate,or __
transfers under Sec.9116 0.00 ' 15 0.00 '
ta)(1.2)X.0 0
16. Amount of Line 14 taxable
at lineal rate X.0 45 0.00 �g, 0.00
17. Amount of Line 14 taxabie 0.00
at sibling rate X.12 0.00 , 17.
18. Amount of Line 14 taxable 0.00 0.00 ;
at collateral rate X.15 ' �$� ' -
19. TAX DUE . . ........ . .... . .... ........... ... .... ..... ..
. .... ... ... 19. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT a
$Ide 2
� 1505610205 ],505610205 ,J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
OECEDENT'S NAME
Mary L. Grubic
STREETADDRESS
Manor Care Health Services
1700 Market Street
CITY STATE ZIP
Camp Hi�l PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,l.ine 19) (1) 0.00
2. CreditslPayments
A.Prior Payments __.
B.Discount
Total Credits(A+B) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. l4)
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.
.. �.. y����� tm �i�i �' P� �—�.,�'��i .rwa5�—a,-�p�,ilc��"Jtl � '==�dvli,� � �rrl(�`�`. , .�i'�w�'��, �`w,��"i� ,' �ni.a� ,i "a
i �: ��„ w�F : 't� . u ;�a. k:.'' � 7 . 4 ':�u... r;� ,v '� � -, . .
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ �
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 death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Ditl decedent own an intlividual retirement account,annuity or other non-probate property,which
containsa beneficiary designation? ........................................................................................................................ ❑ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
�4 - kk i IIU a7 '�#—iJd..L7 9��2' : 3''�tl'r"'�a �'. �4a ��� d,mku`�i�. .;i4 .
� . . ..1� � �� 'Ae1'u„r�— r'S-x . - v r. .... �'£���b�.Th � .,s=ti� . "�'t��.� o-ai�':�fi� ;� �T94.}. . . �
,. . r.. , << . A � .. _ ..�t
For dates of tleath on or after July 1, 1994,antl 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)j.
For tlates of death on or after Jan. 1, 1995, the tax rate imposetl 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 antl
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For tlates 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 tlecedenYs 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 intlividual who has at least one parent in common with the decedent,whether by blood or atloption.
REV-1508 EX+(6-98) �,
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS� Ot MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary L. Grubic 21-14-0977
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. 1.HCR ManorCare($1,254.53+$612.18) 1,866.71 1,866.71
2. 2.PNC Bank 5140261475($782.52)+5113317592($7,686.37) 8,468.89
3. 3.Highmark refund of premium 577.56
4. 4.Revenue rebate 500.00
TOTAL(Also enter on line 5; Recapitulation) a 11,413.16
(If more space is needed,insert additional sheets of the same size)
REV-1511 EX+ (10-09}
� pennsylvania SCHEDULE H
DEPAFTMENT OFPEVENUE F U N E RAL EXP E N S ES AN D
� INHERITANCE TAX RETURN AD M I N ISTRATIV E COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary L. Grubic 21-14-0977
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1' Romberger Memorials stone inscription 220.00
2. Funeral meal 498.44
B, ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 500.00
Name(s)of Personal Representative(s) Michael T. Grubic
Street Address 2119 Mount Pleasant Road
c�ty Mount Joy __ _ state PA zIP 17552 _ _
Year(s)Commission Paid: 2015
1,500.00
2. Attorney Fees
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: 205.50
5. Accounkant Fees:
6. Tax Return Preparer Fees.
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 2,923.94
If more space is needed,use additional sheets of paper of the same size.
REv-isrz ex+ t12-os)
�� SCHEDULE I
`� � pennsylvania
� DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITAN�E TAx RET�RN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary L. Grubic 36-14-0977
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� PA Department of Revenue Estate recovery claim 187,463.33
TOTAL(Also enter on Line 10, Recapitulation) $ 187,463.33
If more space is needed,insert additional sheets of the same size.
Rev-lsis ex+ t�i-oa)
� pennsylvania SCHEDULE �
� �EPARTMENT OF flEVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary L. Grubic -21-14-097
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 Michael T.Grubic,2119 Mt.Pleasant Rd.,Mt.Joy,PA 17552 Son 33.3%
2. Thomas F.Grubic,9 Clairford Ct.,Halethorpe,MD 21227-3835 Son 33.3%
3. Judith Lee Bedard,6680 Springford Terrace,Harrisburg,PA 17111-6986 Daughter 33.3°/a
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 I5 NOT TAKEN
B. CHARITAB�E AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,insert additional sheets of the same size,
�: � ; ,. � I.�':���z��C�'��
. �
�r�.�� `�'��I� �z���t �-
C �
OF
' MARY L. GRUBIC
I� �Y L._ GgUgIC, of the Township of Aampden, County of
Cumberland and State of Pennsylvania, being of sourid and
disposing mind, memory and understanding,
do make, publish and
dec'lare this my Last Will and Testament, ,hereby revoking and
making void any and all prior Wills by me at any time heretofore .
made.
1. . �
I direct the payn►ent of all my just debts and funeral
ex enses as soon after my decease as the same can conveniently be
P
done.
2.
All the rest, residue and remainder of my estate, real,
P
ersonal and mixed, of whatsoever nature and wheresoever situate,
I give, devise and bequeath to my husband, Edwin F. Grubic,
absolutely and in fee simple.
_ 1 -
3.
In the event my husband should predecease me or should die
within thirty (30) days from the date of my death, I give, devise
and bequeath my entire estate to my children in equal shares.
4.
I nominate, constitute and appoint my husband, Edwin F.
Grubic, to be the Executor of this my La�t Will and Testament,
and in the event he should predecease me or for any reason be
unwilling. or unable to act as such, then I nominate, constitute
and appoint my three (3) children, Thomas F. Grubic, Michael T.
Grubic,� and Judith Lee Bedard, to be the Executors of this my
Last Will and Testament in his place and stead. .
IN WITNESS WHEREOF, I have hereunto set my hand and seal I
this �D'�j daY of March, 1993 . �
,
` � r �... (SEAL)
� Mary L. Grubic
Signed, sealed, published and declared by the above named
MARY L. GRUBIC, as and for her Last Will and Testament, in the
P
resence of us who have subscribed our names hereto as witnesses,
at the request of said testatrix, in her presence and in the
presence of each other. �
. „�,,,;,.
; .
�
- 2 -
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" -001363
P1 '16Q7074
theck Date: 09-03-2014 Gheck No. 0006325576
Invoice Number lnvoice Date `Voucher ID Gross Amount Discount Availabie Paid Amount
2145 07-19-2014 "'MCHS-Camp Hill 3254.53 .00 `1254,53
Patient Refund-Invoice: :2195*
� endo Number ' Name ' t tal i�c unts '
OOQQ590365 Michaek Grubic ;�
Check Number Date Totat Amount �iscounts'Taker► � To[al Paid Amount
0006325576 09-03-2014 1254.53 7254.53
First Name ' last Name Referente Number #`i StarE;DaCe End Date
Mary Grubic 2i45. - '�7-/1-9/14
Reference # 2
REMOVE DOCUMENT ALONG THIS PERFORATION
.. . . . .- .. . - . :-�
p ' anorC;ar�� 0006325576 4,,,?
MCHS-Cam Hiii HCR � �o. ��
333 N. Summit Street 4
TOI@CIO OH 43699-00$C '' �dID AFTER 60 DAYS i "
DATE 09-03-2014 AMOUNT
PAY One Thousand Two Hundred Fifty-Four and 53/100 Dollars $"""`"""'*`1,254.53
T� Michael Grubic
THE 2119 Mt. Pleasant Rd.
ORDER
OF '.�--"'
Mt Joy PA 17552 ' �
The Huntington National Bank Authori:ed Signpturo "
Westerville,Ohio
u'0006 3 25 576n■ �:044LL5L26�: OL472LL7614u'
EFORM100472-0900 �
�PNCBANK Your account was DEBITED for the following reason:
❑ Check# posted on encoding error_posted to incorrect account '
� Closed accountsi4o25i4�s
❑ Branch adjustment(branch name) �o � , . � � � `
❑ Service charge error :� � ` �� � ,,. � ,�', ,
�- � z ::,, . � � �
_.� �. .
❑ Other.
Account Number File ID
AMOUNT $ �s2 .5a
5140261475 040
PNC Ban]s, National Association
p MIKE GRUBIC FOR BANK USE ONLY
E 2119 MOiJNT PLEASANT RD Branch#/Dept. # Date
B MOUNT JOY, PA 17552-8522 0000032 08/07/2014
I
T Prepared By(PRINT Name) Authorized By
BARBA'RA ANN WEBER � � `
Customer' s Advice of Charge
B PNCBANK
PNC Bank,National Association
Cashier's Check No. 15610341
0
Date August 7, 2014
0
�
0
N�' , $ 782.52
Pay to the order of MIKE GRUBIC
�
° Seven Hundred Ei ht -two Dollars And Fift -two Cents
w
Non-Negotiable Customer Copy
5140261475
Remitter
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____�____._---------_�__� ________. � __ ---M�.�__._____�
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PNC Bank Nattonai Associafion j
Cashier's 'Check I�o. 15610341 �
�
_ _:. . _.. _
�
Date A:ugus�;7,2014 �
, $ !a � '
� N Pay to the order of MIKE GRUBIC $ 782.52 �
� �
� � _
' oSeven Hun c[re d �i�htv two {�a f tars An d Fi f ty-two �en ts ' !
PNC Bank Natcoual Assoc�at�qn �
� ' �� :: �
� 5140261475 - c`-h--' ''"--�-� �-'L'
� Remitter� � � � . �� �— � Signature . � �. j
+--------�__._.__�.__�-- ----------_____.__�____�— ._____�___ ____ __..__ ____�.. — __�._.___.___.�
_!
ii■ � 56 LO 34 1��' �:0 3 L 3 L 2 7 38�: 5000 �0064 5i�'
�_._._�_m_____.__v. -- _ ----- .— -""'.�"".`�"------ -' � � 601273/333
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@ PNC1��►.1'�IK
PNC Bank Na#�onai Assoc�atzon '
Cashier's Ch�ck ` No. lsssolll -
Date A:ugust l,2014
0
0. _> ,, .: _ <
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� Pay to the Order of MICHAEL T GRUBIC $ 7,686.37
� �
LL Seven Thousancl �tx Hundr�d Eighty-six Dollars And Thir��r �even Certts `
w pAIC B8n1c NaUonal Assoc�tzon :
1
�--
5113317592
. � . Remitter � � . � � � � � Signature .
�_.._.,._.._.a_.._._�_�__�:��:. �� � � �_e� _., _�_.__�._.�.._ � ...._. - ---
��■ 1 5 5 50 � L Lii' �:0 3 13 L 2 7 38�: 5000 L0064 5��'
_ _ __ _ _
. . . .- . : -. �
�� �,CITIZENS�3A�IR �"�;;�"����
� �������f���I�/� � �3605
;: .�;: ' ;
Dir�ct Pay Cex�,tral R�:g�.on '
Premlum ��."�LlI�,� DA7E A{viOUN�'>
< � 08 j19/�Q14 I �� � �77 .56 `
Voitl Pt not cash�tl yvithi�1 year
*FIU� .�UNDR�D` ��UE1�7'�'�-S�'ttEN AN1,� 5 6/�.Q O 130LLA."E2.S* :
PqY THE ESTATE' OF MA.RY L`GRUB3�
To'THE 17 0 0 MARKET ST ' '1
ORDER OF
CAMP HZLL ; PP: 17 Q 1? �����U�i�.,
���� l�UfHOPoZED 514NANRE
u■p467896ii' �:036076 L50�: 6 20 54 5 2 58 Li�'
__ _ _ _ _ _
� � • � • SZQ32t3
P1 16025Q3
Check Date: 2014Q826 �" Check No. 583000094
Batch No. Patient Name Descriptlon Net Ampunt
GflUB�G MARY TO CLOSE ACCOUNT $12.18
,
Payee Address ` Gross Amount
GRUBIC,MARY ' C!O MICHAEL Cf�UBIC MT.JOY PA 17552 '`612.18`
� Memo Facility Name Facility Phone Number
TO CLOSE ACCOUNT HCR Manor�are:
REMOVE DOCUMENT ALONG THIS PERFORATION
Y� i �-f • 0' i• � • � �'!..
HCR Manor Care H�R���r�.�i��'.� No. 5ss0000sa ;s�bo;,
333 N. Summit St. , , , ,' ?sao
Toledo, �hi0' ' VOId AFTER 60 DAYS .
DATE 20140826 AMOUNT
PAY Six Hundred Twelve and 18/100 Dollars $"""""*"""'`612.18
TOTHE C/O MIC�IAELGRUBIC
��FER 2119 MT. PLEASANT ROAD
MT.JOY PA 17552 ..-----1�
'l
Memo:TO CLOSE ACCOUNT numonzed si9nature,°'
ii'0583000094u' �: 254070 L L6�: 0009 2503 340 5 2u■
ROMBE1tGER MEIV�ORIALS 1
2395 State Street, Penbrook, PA 17��3 PHONE
GRANITE Speciafizing in
MARBLE 232-1147
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� ` � Best Western Premier Social Banquet Event Order Contract
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HOTEL & CONFERENCE CENTER
Client/Organization Event Date Telephone Fax Event#
Grubic Bereavement Dinner 7/25/2014(Fri) (717)591-1056 ( ) - E23986
Address Booking Contact Site Contact Guests
6680 Springford Terrace, Harrisburg,PA 17111 Judith Bedard 25 (Pln)
Party Name Sales Rep Theme Booking Email
Grubic Bereavement Dinner Erica Biretz Dinner
In order to assign definite status to these arrangements,this document must be signed and returned with any requested deposits.
This must be received no later than two weeks from today's date. If function date is less than 30 days from today's date,these
documents must be received within 48 hours. Any deposits requested are non-refundable.
If all of the requested signed documents are not received by the above due date,the Central Hotel and Conference Center,
Harrisburg reserves the right to release all space being protected for your group. At that point all items within this contract will
be made available for sale to the general public.
Final guaranteed count must be received within 10 BUSINESS DAYS of the event. If a final count is not received,we reserve
the right to charge your estimated count.
The prices below reflect an estimated cost of your event. Prices may vary depending on meal choices and quantities.
Venue
Description Start End Banquet Room Setup Style
Dinner 4:00 pm 10:00 pm Harris Rounds
Setua Notes
Rounds of 8
Ivory Tablecloths
Black Napkins
Hotel Centerpieces
Group may go to the pub for drinks
Food&Beverage
Food/Service Items Price Qty Total
The American Buffet
(25) Chicken Corn Chowder 15.95 25 398.75
Tossed Salad Greens,Assorted
Toppings&Dressings
Pot Rast of Beef
Grilled Chicken Breast with
Herb Cream Sauce
Roasted Red Bliss Potatoes
Seasonal Fresh Vegetables
Pasta Salad
Apple Pie
Cheery Cobbler
Coffee,Decaf, Iced Tea,Hot
Tea,Water
7/22/2014-12:54:00 PM Page 1 of 4
Clients Initials D.O.S Initials
J
� ' E23986-Grubic Bereavement Dinner
Comments
Group is responsible for a food&beverage minimum of$300.00 prior to tax&service charge- if group does not hit the minimum it
will be charged as room rental
signed contract&final payment due 7/22/2014(non-refundable)
Subtotal 398.75 Paid 0.00 Pay Method Pay In Advance
Tax 23.93 Balance 498.44
Service Charge 75.76
Total Value 498.44 Signature
All reservations for banquet/meeting/convention functions are made upon and subject to the rules and regulations of
the Central Hotel and Conference Center and the following conditions described under Terms and Conditions. All
prices are subject to a 6%PA sales tax as well as an 19%service charge.
TERMS&CONDITIONS
Security Deposit Hotel may require a cash security deposit to cover reasonable costs of repair or replacement of hotel property
damaged due to misconduct or negligence of Customer or persons affiliated with customer's group or function.
Substitution of Facilities Hotel reserves the right to substitute similar or comparable rooms and facilities,such
substitution is considered full performance of hotels obligations under this agreement.The hotel guarantees meeting
space as it deems is sufficient for guaranteed participants at a given event.
Menu Selection All food and beverage consumed in banquet&meeting rooms shall be purchased from the hotel.
Final menu selection must be submitted no less than 3 weeks prior to the event. In the case of short term bookings of
less than 3 weeks final menu selection must be made at the time the event is booked.Any food that is left over may
not be taken from the hotel.
Final Counts and Minimum guarantees Customer must provide the hotel with a final count for catered functions no
later than 7 business days prior to the event. If no count is received,the hotel reserves the right to use the original
estimated count. Charges for catered functions will be based on the Minimum Guaranteed Amount or the actual
number of attendees whichever is greater.
Prices All prices quoted are subject to change and may be increased to meet the cost of increases incurred by the hotel from their
providers.If beverage sales do not meet the required minimums,an additional bartender fee of$75.00 per bartender will be
charged.Any changes made on the day of the event may result in additional charges.
Disputed Charges Hotel will review all catering charges with customer prior to applying charges to Customers
master account. CUSTOMER MUST NOTIFY THE HOTEL OF ANY DISPUTED CHARGES WITHIN 3
BUSINESS DAYS AFTER CUSTOMERS RECIEPT OF FINAL BILLING OR ADJUSTMENTS SHALL BE
WAIVED.
Taxes,Service charges &Gratuities All catering and meeting prices are subject to applicable 6%PA State sales tax
and an 19%service charge.
Deposits&Payments All deposit&payments made are non-refundable. Payments.Payments are due no later then the date
(s)indicated under the comment section of the contract.Final payment must be made by cash,money order,certified check or
authorized credit card.
Tax Exemption Requests for tax exemption must be accompanied by appropriate state or federal exemption certificates and shall
be submitted to the hotel at least 72 hours prior to any function.
Cancellation All cancellation notices must be in writing and do not become effective until the date they are received by the
hotel. It is agreed that because actual damages due to cancellation can not be easily ascertained, the customer agrees to pay
liquidated damages,over and above the forfeited deposit,as shown if the event is canceled.
7/22/2014-12:54:00 PM Page 2 of 4
_._'_�_
Clients Initials D.O.S Initials
RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date : 10/14/2014
Cumberland County - Register Of Wills Receipt Time : 13 : 03 : 52
One Courthouse S quare Receipt No. : 1079413
Carlisle, PA 17613
GRUBIC MARY L
Estate File No. : 2014-00977
Paid By Remarks : RANDALL K MILLER
DBl
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D
SHORT CERTIFICATE 30 . 00 CUMBERLAND COUNTY GENERAL FUN
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 10 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 11595 $185 . 50
Total Received. . . . . . . . . $185 . 50
REGISTER OF WILLS
OF LANCASTER COUNTY
LANCASTER, PENNSYLVANIA 17608-3480
PHONE (717)299-8243
RECEIPT - PROBATE
Trans# 51358
File# : 36-MISC Date: 10/08/14
Decedent: TRANSACTION ONLY Date of Death:
Case Type: TRANSACTION ONLY
Received from: RANDALL K. MILLER
Total Charges: $20.00
For: 1 COMMISSIONS from Register of PA, execution of $20.00
PR-42
,
�'� pennsylvania
'i
DEPARTMENT OF PUB�IC WELFARE
October 1, 2014
RANDALL K MILLER ESQUIRE
JOANNE M MILLER
1255 S MARKET ST STE 102
ELIZABETHTOWN PA 17022
Re: Mary Grubic
CIS #: 870243143
SSN: ###-##-8044
Date of Death: 07/19/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Ms Mil�er:
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 $187,463.33 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 $20,013.24, 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 $167.450.09, 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
�,and�all�. .�VLilCer
Attorney at Law
1255 South Market Street, Suite 102
Elizabethtown, Pennsylvania 17022
(717)361-8524 -- F� (717)361-9071
February 12, 2015
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
RE: Estate of Mary L. Grubic
Dear Sir or Madam:
Enclosed herewith are the original and a copy of the Inheritance Tax Return for the
Estate of Mary L. Grubic, aka Mary Louise Grubic. Please file the return and send back the time-
stamped first page in the stamped return envelope. There are no taxes due with this return.
Thank you for your kind attention to this matter.
Very truly yours,
,
�
�
���- � �' ' �-
, , ,
Joanne M. Miller
Legal Assistant to
Randall K. Miller
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