HomeMy WebLinkAbout03-05-15 J pennsylvania 1505618403
DEPARTMENT OF REVEN
ZX(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 14 09924
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
09 05 2014 08 14 1926
Decedent's Last Name Suffix Decedent's First Name MI
FORTINI MARIO R
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
❑X 1. Original Return 2. Supplemental Return ❑ 3. Remainder Return(date of death
prior to 12-13-82)
4. Agricultural Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82) EJ
❑X 7. Decedent Died Testate R 8. Decedent Maintained a Living Trust 9, Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
13. Business Assets FJ 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
WAYNE M PECHT ESQ 717 691 9808
First Line of Address
650 NORTH TWELFTH ST SU
Second Line of Address
City or Post Office State ZIP Code
LEMOYNE PA 17043
Correspondent's email address: wpecht(aD-pechtlaw.com
REGISTER OF WILLS USE ONLY
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY z
4 `r-I s 7
DATE-`FILED STAMP
r1
C"3
Side 1
IIIIIII VIII VIII VIII VIIIA II VIII VIII IIID VIII IIII IIII
1505618403 1505618403 j
J1505618411
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Fortini, Mario R.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D)......'.............................................. 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 29,086 - 35
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 291086 - 35
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 81542 - 3?
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 61 ,168 - 98
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 69 ,711 - 35
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -40-o625 • 00
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. -40 ,625 - 00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 0 . 00 15. 11 - 00
16. Amount of Line 14 taxable
at lineal rate X .045 0 . 00 16. 11 - 00
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGN ERSO� IBLE FOR FILING RETURN Anthony Fortini 3 3 DA/S
ADDRESS
12 Golfview Road,Camp Hill, PA 17011
SIGNA F PREPA OT TH ENTATIVE Wayne M Pecht Esq.
DATE
ADDRESS
650 North Twelfth St., Suite 100, Lemoyne, PA 17043
111111111111111111111111111111111111111 Side 2
1505618411 1505618411
REV-1500 EX Page 3 File Number 21-14-0924
Decedent's Complete Address:
DECEDENT'S NAME
Fortini, Mario R.
STREET ADDRESS
Golden Living Center
CITY STATE ZIP
Camp Hill PA _] 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (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) 0.00
Make Check Pa able 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;............................................................................... ❑x
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑x
c. retain a reversionary interest;or............................................................................................................... ❑
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ ❑x
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?.................................................................................................................. 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 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.
Rev-1508 EX+(08-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fortini, Mario R. 21-14-0924
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Allianz 2,087.28
2 RRB Treasury 1,584.94
3 Santander Bank#xxx0536-checking account 17,308.20
4 Golden Living Center-refund unused nursing home care 8,105.93
TOTAL(Also enter on Line 5, Recapitulation) 29,086.35
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12)
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE RESIDENT DEC ENT�R" ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Fortin!, Mario R. 21-14-0924
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s)attached 3,988.59
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees Pecht&Associates, PC 2,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationshio of Claimant to Decedent
4. Probate Fees 468.84
See continuation schedule(s) attached
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 1,584.94
See continuation schedule(s)attached
TOTAL(Also enter on line 9, Recapitulation) 8,542.37
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Fortini, Mario R. 21-14-0924
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
nses
1 Malpezzi Funeral Home-funeral services 3,988.59
H-A 3,988.59
Probate Fees
2 Cumberland Law Journal-legal advertisement 75.00
3 Patriot News-legal advertisement 208.34
4 Register of Wills-probate fees 155.50
5 Register of Wills-additional probate fees 30.00
H-134 468.84
Other Administrative Costs
6 RRB Treasury-refund overpayment 1,584.94
1-1-67 1.584.94
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12.12)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OFMORTGAGE LIABILITIES AND LIENS
RET
INHERITANCE TAXAXRETURRNN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fortini, Mario R. 21-14-0924
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 Dr. Edward Lamarque-medical bill 93.06
2 PA Department of Welfare-lien 61,075.92
TOTAL(Also enter on Line 10, Recapitulation) 61,168.98
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-12)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Fortini, Mario R. 21-14-0924
NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER
PERSON(S)RECEIVING PROPERTY (Words) ($$$)
Do Not List Trustee(sl
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Anthony Fortini Son one-fourth of
12 Golfview Road residue
Camp Hill, PA 17011
Richard Fortini Son one-fourth of
1012 East Coover Street residue
Mechanicsburg, PA 17050
Pamela Ann Tarrell Daughter one-fourth of
2204 Morning Glory Drive residue
Richardson,TX 75082
Mary Ellen Wotring Daughter one-fourth of
304 Wertz Avenue residue
Mechanicsburg, PA 17055
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
Last Will and Testament
OF
MARIO R. FORTINI
I, MARIO R. FORTINI, of Mechanicsburg, Cumberland County, Pennsylvania, do make,
publish and declare this to be my Last Will and Testament,hereby revoking all Wills and Codicils by
me heretofore made.
ITEM 1: Family Information. I am married to Eleanor B.Fortini,and all references to
my wife in this Will are to her. I have four children: Pamela Ann Tarell(born September 19, 1953);
Anthony Fortin (born September 30, 1955); Mary Ellen Wotring (born August 3, 1964); and
Richard Fortini(born October 9, 1967).My children are referred to in this Will as my children or as
- -children of mine. Any person born to or adopted by a child of mine is referenced in this Will as my
issue. Provided,however,no adopted person shall benefit under this Will unless the order or decree
of adoption is entered before the adopted person attains the age of twenty-one (21)years.
ITEM 11: Death Taxes. I direct that all inheritance and estate taxes becoming due by
reason of my death,whether payable by my estate or by any recipient of any property, shall be paid
by the Executor out of the residue of my estate, as an expense and cost of administration of my
estate, except that no taxes shall be charged against any gift qualifying for the marital or charitable
deduction in my estate. The Executor shall have no duty or obligation to obtain reimbursement for
any such tax so paid,even though on proceeds of insurance or other property not passing under this
Will.
ITEM III: Debts and Final Expenses. I direct the Executor to pay the expenses of my last
illness and funeral expenses from the residue of my estate as an expense and cost of administration
of my estate.
Initials
ITEM IV: Tangible Personal Property. If I die before my wife,Eleanor B.Fortini,I give
to her all my tangible personal property, including but not limited to,all of my household furniture
and furnishings, books, pictures,jewelry, silverware, automobiles, wearing apparel and all other
articles of household or personal use or adornment and all policies of insurance thereon. If I do not
die before my wife, I may leave a written list in my safe deposit box or elsewhere disposing of
certain items of my tangible personal property. The Executor shall dispose of items of my tangible
personal property as specified in the written list. If no written list is found in my safe deposit box or
elsewhere and properly identified by the Executor within thirty (30) days after the probate of my
Will, it shall be presumed that there is no other statement or list. Any subsequently discovered list
shall be ignored. If I survive my wife,I give any property of the type described in this Item and not
set forth in a written list to my children,to be divided among them as they shall agree. Should there
be no agreement, the Executor shall divide this property among them in equal shares, as the
Executor,in his discretion,deems appropriate,having due regard to the personal preferences of my
children..---
ITEM V: Residue. I give the residue of my estate, not disposed of in the preceding
portions of this Will, to my wife, Eleanor B. Fotini. If my wife does not survive me, I give the
residue of my estate,not disposed of in the preceding portions of this Will,to my children,Pamela
Ann Tarell,Anthony Fortini,Mary Ellen Wotring,and Richard Fortini,in equal shares,per stirpes.
If any of my said children shall predecease me,leaving no issue,such deceased person's share shall
be distributed to those of any children who survive me, in equal shares,per stirpes.
ITEM VI: Administrative Powers. In addition to the powers granted at law,the Executor
and the Trustee shall possess the following powers, each of which shall be construed broadly and
may be exercised without court approval,but in a fiduciary capacity only:
A. To retain any investments I have at my death, including specifically
those consisting of stock of any bank even if I have named that bank as the Executor.
'10 R 2
Initlals
B. To vary investments, to make loans, and to invest in bonds, stocks,
notes,real estate mortgages or other securities or in other property,real or personal,
without being restricted to so-called"legal investments",and without being limited
by any statute or rule of law regarding investments by fiduciaries.
C. The Executor is authorized to divide and distribute personal property
and real property, partly or wholly in kind, and to allocate specific assets among
beneficiaries so long as the total market value of each share is not affected by the
division,distribution or allocation in kind. The Executor is authorized to make,join
in and consummate partitions of lands,voluntarily or involuntarily,including giving
of mutual deeds,or other obligations,with as wide powers as an individual owner in
fee simple.
D. To sell either at public or private sale real and personal property
severally or in conjunction with other persons,and to consummate sale(s)by deed(s)
-- - - - -or other instrument(s)to the purchaser(s),conveying a fee simple title. No purchaser
shall be obligated to see to the application of the purchase money or to make inquiry
into the validity of any sale(s). The Executor is authorized to execute,acknowledge
and deliver deeds,assignments,options or other writings as necessary or convenient
to any of the power conferred upon the Executor.
E. To mortgage real estate, and to make leases of real estate.
F. To borrow money from any person, including the Executor, to pay
indebtedness of mine or of my estate, expenses of administration or inheritance,
legacy, estate and other taxes, and to assign and pledge assets of my estate
established by this Will.
G. To pay all costs, taxes,expenses and charges in connection with the
administration of my estate established under this Will.
H. To make distributions of income and of principal to the proper
beneficiaries,during the administration of my estate,with or without court order,in
such manner and in such amounts as the Executor deems prudent and appropriate.
I. To vote shares of stock which form a part of my estate established
under this Will, and to exercise all the powers incident to the ownership of stock.
9, 3
Initials
J. To unite with other owners of property similar to property in my estate
to carry out plans for the reorganization of any company whose securities form a part
of my estate.
K. To disclaim any interest in property which would devolve to me or my
estate by whatever means, including but not limited to the following means: as
beneficiary under a will, .as an appointee under the exercise of a power of
appointment, as a person entitled to take by intestacy, as a donee of an inter vivos
transfer, and as a donee under a third-party beneficiary contract.
L. To prepare, execute and file tax returns of any type required by
applicable law,including but not limited to filing a joint tax return with my surviving
spouse, and to make all tax elections authorized by law.
M. To employ custodians of property, investment or business advisors,
accountants and attorneys as the Executor deems appropriate, and to compensate
- -- - these persons from assets-of my estate or trust,without affecting the compensation to
which the Executor is entitled.
N. To allocate administrative expenses to income or to principal, as the
Executor deems appropriate. However,no allocation to income shall be made if the
effect of the allocation is to cause a reduction in the amount of any estate tax marital
deduction or estate tax charitable deduction.
O. To make any adjustment to basis authorized by law,including,but not
limited to increasing the basis of any property included in my estate,whether or not
passing under this Will, by allocating any amount by which the bases of assets may
be increased. The Executor shall be under no duty and shall not be required to
allocate basis increase exclusively,primarily,or at all to assets which pass as part of
my probate estate as opposed to other property for which a basis adjustment is
allowable. The Executor shall allocate basis increase equitably among those
beneficiaries receiving property as a result of my death,but shall not be liable to any
person, nor subject to removal or surcharge, for any reasonable allocation of basis
increase.
,,
P. To compromise claims.
—7-hh gT. 4
Initials
To do all other acts in his or her judgment necessary or desirable for the proper and
advantageous management, investment and distribution of the estate established under this Will.
ITEM VII: Distributions to or for Beneficiaries. The Executor is authorized to distribute
principal and/or income in any one or more of the following ways if the Executor considers the
beneficiary unable to apply distributions to the beneficiary's own best interests,or if the beneficiary
is under a legal disability:
A. Directly to the beneficiary;
B. To the legal guardian or conservator of such beneficiary;
C. To a Trustee,as custodian under the Pennsylvania Uniform Transfers
to Minors Act as to a beneficiary under the age of twenty-five (25) years;
D. To a relative of the beneficiary,to be expended by that relative for the
- --- --- benefit of the beneficiary; or -
E. By directly applying distributions for the benefit of the beneficiary.
ITEM VIII: Survival. Subject to item X,any person who has died within thirty(30)days
after my death, or under such circumstances that the order of our deaths cannot be established by
proof, shall be deemed to have predeceased me. Any person(other than myself)who has died at the
same time as any beneficiary under this Will,or in a common disaster with that beneficiary,or under
such circumstances that the order of deaths cannot be established by proof,shall be deemed to have
predeceased that beneficiary.
ITEM IX: Executors and Trustees. I make the following provisions with respect to my
Executors and Trustees:
A. I appoint my son Anthony Fortini to be the Executor of my Estate. In
the event that my son Anthony Fortini is unable or refuses to serve as Executor of
my estate, I appoint my son Richard Fortini to serve as Executor of my estate.
xr. 5
Initials
B. The Executor shall have the right to receive reasonable compensation
for services rendered and reimbursement for reasonable expenses.
C. No Executor shall be liable or accountable for any loss that may result
from the good faith exercise of the authority granted in this Will.
D. The Executor is specifically relieved from the duty of filing bond or
entering security.
ITEM X: Simultaneous Death. In the event that my spouse and I die simultaneously,or
that the order of our deaths is uncertain, she shall be deemed to have survived me.
IN WITNESS WHEREOF,I have set my hand and seal to this,my Last Will and Testament,
consisting of this and the preceding five (5)pages this 5th day of August 2011.
Mario R. Fortini
SIGNED, SEALED, PUBLISHED and DECLARED by Mario R. Fortini,the above named
Testator, as and for his Last Will and Testament, in the presence of us,who, at his request and in his
presence, and in the presence of each other,have hereunto subscribed our names as witnesses.
ResidenceI v,
Residence
Initials
ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
ss:
COUNTY OF CUMBERLAND :
We, Mario R. Fortin, . .c �_`..: .� "�` c._�•; and
Testator and witnesses, respectively, whose names are
signed to the attached and foregoing instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testator signed and executed the instrument as his last will and that he
had signed willingly, and that he executed it as his free and voluntary act for the purpose therein
expressed,and that each of the witnesses,in the presence and hearing of the Testator,signed the Will as
witnesses and that to the best of his/her knowledge the Testator was at that time eighteen years of age or
older, of sound mind and under no constraint or undue influence.
_-� a uy le
Mario R. Fortini
Testator
AlGtlli
Witness
Witn
Subscribed and sworn to and acknowledged before me by Mario R. Fortini,the Testator,and
subscribed and sworn to before me by _ "`t:. - �,. .:�', k c_ ,`g and
witnesses, on this 5th day of August 2011.
;DMMOMVEALTH OF rRENWn(L�'ARfA
N [03TAR.IAL. TAL
Lori A.BackEnstaes Notay61ic
Notar 't �n
MY COMMISSI019 EXPIRES OCT.14,2011
7
Initials
pennsytvania
DEPARTMENT OF PUBLIC WELFARE
October 16, 2014
PECHT &ASSOCIATES PC
WAYNE M PECHT ESQUIRE
650 NORTH TWELFTH ST
SUITE 100
LEMOYNE PA 17043
Re: Mario Fortini
CIS #: 870295393
SSN: ###-##-0270
Date of Death: 09/05/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear
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 $61,075.92 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 $8,794.82, 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 $52,281.10, 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 I Division of Third Party Liability Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
pennsylvama
DEPARTMENT OF PUBLIC 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 accurately compute 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 i Division of Third Party Liability i Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
F� pennsylvama
DEPARTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
Marianne
Marianne Meckley J
TPL Program Investigator
717-772-6246
717-772-6553 FAX
Enclosure
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 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
October 15,2014
STATEMENT OF CLAIM SUMMARY
NAME Estate of FORTINI,MARIO
ID 870 295 393
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 8,794.82 52,281.10 61,075.92
DRUG .00 .00 .00
REIMBURSEMENT TO DPW 8,794.82 52,281.10 61,075.92
COMMONWEALTH OF PENNSYLVANIA
.DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 3
. COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 15,2014
STATEMENT OF CLAIM
NAMEFORTINI,MARIO
ID 870 295 393
GOLDEN LIVINGCENTER-WEST SHORE
770 POPLAR CHURCH RD
CAMP HILL PA 17011
DATE'OF SERVICE PAYMENT DATE.. ORIGINAL CRN ADJUSTED CRN USUAL CHARGES ,AMOUNT APPROVED
03/01/13 - 03/31/13 09/30/13 27132474026310001 27132474026310001 6,342.29 4,826.60
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
04/01/13 - 04/30/13 09/30/13 27132474026340001 27132474026340001 5,919.30 4,403.61
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
05/01/13 - 05/31/13 09/30/13 27132474026380001 27132474026380001 6,116.61 4,600.92
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
06/01/13 - 06/30/13 09/30/13 27132474026390001 27132474026390001 5,919.30 4,403.61
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
07/01/13 - 07/31/13 02/10/14 55140364179630001 55140364179630001 6,116.61 4,365.01
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
08/01/13 - 08/31/13 02/10/14 55140364179640001 55140364179640001 6,116.61 4,365.01
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
09/01113 - 09/30/13 02/10/14 55140364180360001 55140364180360001 5,919.30 4,175.31
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
10/01/13 - 10/31/13 03/10/14 55140644158560001 55140644158560001 6,116.61 4,406.55
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
Page 2 of 3
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 15,2014
STATEMENT OF CLAIM
NAME FORTINI,MARIO
ID 870 295 393
GOLDEN LIVINGCENTER-WEST SHORE
770 POPLAR CHURCH RD
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/01/13 - 11/30113 03/10/14 55140644159520001 55140644159520001 5,919.30 4,215.51
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP.
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
12/01/13 - 12/31/13 U3/10/14 55140644160560001 55140644160560001 6,116.61 4,406.55
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
01/01/14 - 01/31/14 04/07/14 69140764021970001 69140764021970001 5,922.24 4,340.76
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
02/01/14 - 02/28/14 04/07/14 69140764021950001 69140764021950001 5,349.12 3,771.66
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
03/01/14 - 03/31/14 04/28/14 20140944049100001 20140944049100001 5,880.70 4,340.76
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
04/01/14 - 04/30/14 05/26/14 20141254051370001 20141254051370001 5,994.00 4,454.06
DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 78097 ALTERED MENTAL STATUS
PROC CODE: 000000
PROVIDER SUBTOTAL GOLDEN LIVINGCENTER-WEST SHORE 83,748.60 61,075.92
03 101553152 0001
Page 3 of 3
UNITED STATES
X POS AL SERVICES C i', ' ��. C F k t CE 4Q�
USPS TRACKING # R E 1 =' ' L' ��M ?-,1,� US.r"DSTA6E
C=
f
c 1.2 �� W-3.15 p 0 5,15
"g' 5 p
cn, p
PA ftPosrAuaI00620
9114 9010 7574 2511 2741 34 d} {?
t ECHT 4r ASSOCIAT-ES, p.C.
650 N0vt1,7'wd tkStre,t
Suite,100
Lemoyte,pA 17043
Lisa Grayson
Register of Wills
Cumberland County Courthouse �o }
O- A
One Courthouse Square ` cOA
Carlisle, PA 17015FQ .S ?f?1,,�
t et 4S r sFR '
J�uaY-1008
1
2