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Home My WebLink About05-12-15 DECEDENT'S ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Ray K. Forney , DECEASED No. 21-14-0005 M PETITION FOR ADJUDICATION/ STATEMENT OF PROPOSED DISTRIBUTION , , T - ,_• fni. PURSUANT TO Pa. O.C. Rule 6.9 ' ry F C` M. This form may be used in all cases involving the Audit of the Account of a Decedent's Estgk.. IP `. space is insufficient, riders may be attached. Attach the spouse's election, if any; .the papers required under items 8-19 inclusive; and any instrument pertinent to the adjudication. INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: David L. Forney, Esq. Supreme Court I;D. No.: 43795 Name of Law Firm: K&L Gates, LLP Address: 1601 K Street NW, Washington, D.C. 20006 Telephone: (202) 778-9497 Fax: (202) 778-9100 Fornt OC-01 rev.10.13.06 Page 1 of 10 Estate of Ray K. Forney , Deceased . 1. Name(s) and address(es) of Petitioner(s): Name. .David L.Forney Address: 1601 K Street NW Washington;DC 20006 Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: Is this the first accounting by this fiduciary? . . . . . . . . . . . . . . . . . . . . . M Yes 0 No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2. Decedent died on December 18,2013 Letters Testamentary or FLJ Letters of Administration were granted to Petitioner(s)-on January 3,2014 Date of Will (if applicable): March 24, 2005 Date(s) of Codicil(s) (f applicable): Date of probate (if different from date Letters granted): Was a bond required? Oyes 0 No If yes, state amount: Are proofs of advertising of the grant of Letters attached? : . . . . . . . Yes 0 No Dates of advertising of the grant of Letters: patriot-News 1-21, 1-28, 2-04, 2014 Cumberland Law Journal 1-24, 1-31, 2-7, 2014 Form OC-01 rev.10.13.06 Page 2 of 10 I Estate of Ray K. Forney , Deceased 3. Was decedent survived by a spouse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OYes 0 No If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? . . . . . . . . . . . . . Yes No (See Section 2201 et sem. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, so state): 6. Did decedent marry after execution of Will or Codicil(s)? . . . . . . . . . . . Yes No Were any children born to decedent after execution of Will or Codicil(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, give names and dates of birth: Name: Date of Birth: 7. If required by the Medical Assistance Estate Recovery Act, 62.P.S. § 1412, was a request for a statement of claim sent to the Department of Public Welfare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Form OC-01 rev.10.13.06 Page 3 of 10 Estate of Ray K. Forney Deceased 8. Written notice of the Audit as required by Pa.O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa.O.C.Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs if there is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Name and Address of Each Parly in Interest I.Relationship and Comments i an I Interest SEE SCHEDULE 9A ATTACHED Form OC-01 rev.10.13.06 Page 4 of 10 Page 4, No. 8 The attached notice is being mailed to: Steven Keath Forney 40 West 22nd Street Apt. 7C New York, NY 10010 David Lloyd Forney 1601 K Street NW Washington DC, 20006 Susan Marie Forney 5 Old Hunt Road Northfield, IL 60093 Paul Francis Forney 3 Locust Lane Leola, PA 17540 Mary Grace Stauffer 712 Aspen Lane Lebanon, PA 17042 Peter Ignatious Forney 475 Main Street Hingham, MA 02043 Lynda Heckenberger-Doane 998 Prospect Road Columbia, PA 17512 Pamela J. Radle 120 Wilson Court Harrisburg, PA 17112 e K&L GATE S K&L GATES LLP 1601 K STREET,N.W. WASHINGTON,DC 20006 T+1202 778 9000 F+1202 778 9100 klgates.com David L.Forney 202.778.9497 Fax: 202.778.9100 david.forney@klgates.com May 4, 2015 The Interested Parties of the Estate of Ray K. Forney Re: Petition for Audit, Court Accounting and Schedule of Proposed Distribution for the Estate of Ray K. Forney This is to advise you that David L. Forney, executor of the estate of Ray K. Forney, has filed the Petition for Audit, Final Account and Proposed Schedule of Distribution with the Clerk for Audit. Note that the Executor is requesting a reserve of$1,500 to pay additional fees and expenses in order to conclude the administration of the Estate. The account will be presented for audit and confirmation at the Office of Registration of Wills, Cumberland County Courthouse, Carlisle, Pennsylvania on June 16, 2015 at 9:00 a.m. Any objections to the Account and Proposed Schedule.of Distribution shall be filed no later than 9:00 a.m. on June 16, 2015. Thank you for your attention. Sincere y, " Y l David L. Forney Attachment Schedule 9A Page 4, No. 9 Name and Address of Interested Parties Relationship Interest Steven Keath Forney 40 West 22nd Street One-Seventh Apt. 7C Son (1/7) of Residuary New York, NY 10010 Estate David Lloyd Forney One-Seventh 1601 K Street NW Son (1/7) of Residuary Washington DC, 20006 Estate Susan Marie Forney 5 Old Hunt Road One-Seventh Northfield, IL 60093 Daughter (1/7) of Residuary Estate Paul Francis Forney 3 Locust Lane One-Seventh Leola, PA 17540 Son (1/7) of Residuary Estate Mary Grace Stauffer One-Seventh 712 Aspen Lane Lebanon, PA 17042 Daughter (1/7) of Residuary Estate Peter Ignatious Forney 475 Main Street One-Seventh Hingham, MA 02043 Son (1/7) of Residuary Estate Lynda Heckenberger-Doane One-Seventh 998 Prospect Road Daughter (1/7) of Residuary Columbia, PA 17512 Estate Pamela J. Radle 120 Wilson Court Friend None - Claim Harrisburg, PA 17112 Denied Estate of Ray K. Forney , Deceased Name and Address of Each Party in Interest Relationship and Comments,ifany Interest B. Identify each party who is not sui juris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each. C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O.C. Rule 12.4). D. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. Form OC-01 rev.10.13.06 Page 5 of 10 Estate of Ray K. Forney , Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paid In Full? Pamela J. Radle SEE ' E]Yes O Yes 120 Wilson Court SCHEDULE ONo ONo Harrisburg, PA 17112 10A ATTACHED 0Yes O Yes ONo No Yes El Yes ONo No E]Yes Yes E]No No If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OYes ONo Was family exemption allowed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Yes E3No Family exemption claimant's name and relationship: Name: Relationship: Form OC-01 rev.10.13.06 Page 6 of 10 SCHEDULE 10A Attachment to Petition for Adjudication Page 6,No 10 Pamela 1.Radle Claim Informal Claim: In an email dated February 18,2014 to the Executor,Pamela J. Radle of 120 Wilson Court,Harrisburg,Pennsylvania 1.711.2("Radle"),claimed that, weeks before his death,the Decedent transferred to Radle title of certain Armani figurines and other items of household personal property. Denial of Claim: The claim by Radle is denied and will not be paid. After a thorough investigation of the facts,including interviews with various family members,the Executor discovered that Radle's claim was unsupported and extremely suspect. The Executor asserts that the Decedent did not transfer title to the claimed items to Radle during his lifetime. Rather,near the end of his life he was merely contemplating making a gift to Radle of the claimed items,but had not completed that review. He was at the same time actively considering selling the items to help cover his medical expenses. Two weeks before the Decedent's death, Radle threatened that she had spoken to an attorney, and the Decedent responded angrily and immediately revoked all intentions of such gift. There was no document transferring title, no contract, no completed gift, no delivery, no promise to include the items in his will,no witnesses, and no consideration, only Radle's claim that she had a deal with a deceased man witnessed only by herself. On the other hand, (i) numerous witnesses heard the Decedent state on several occasions before his death that he did not want Radle to have the claimed items, (ii) he expressly refused to allow Radle to take the requested items from his house (after Radle's treat of an attorney), and(iii) he barred her from his house two weeks before his death. This entire escapade took place under extremely troubling circumstances involving questionable behavior of Radle from November 3, 2013 (the date the Decedent's spouse died) and December 18, 2013 (the date the Decedent's died). During that time, the Decedent was in critical end-of-life care at Hershey Medical Center and discharged to Manor Care because a bed at a hospice was not available, and then discharged to home under family care where he was preparing to move to his son's house to die. Radle is not a beneficiary in the Decedent's will. The Executor responded to Radle in a letter dated February 20, 2014 and again immediately before this filing denying her email claim and has not heard from Radle since February, 201.4. Radle has not filed a formal Notice of Claim. If she does, the Executor is committed to honoring the Decedent's dying wishes that Radle receive nothing and is prepared to enter into the court record the Executor's entire findings and present testimony of at least four of the Decedent's children repudiating Radle's claim and litigate the matter if necessary. Estate of Ray K. Forney , Deceased 12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate Tax paid, the date(s)of payment(s), and the interest(s)upon which paid, are as follows: Date Payment Interest March 11,2014 $2,200.00 August 8, 2014 $2,047.49 December 14, 2014 $337.50 13. On the date of death,was the decedent a fiduciary (personal representative,trustee,guardian,agent under power of attorney) or surety on the bond of a fiduciary? . . . . . . . . . . . . . . . . . . . Yes 0 No If yes,provide the name of the estate, indicate whether an account has been filed and confirmed absolutely and all awards performed, or, in the alternative, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s)as to each question: B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? . . . . . . . . . . . . . . . . . . Yes 0 No 15. If Petitioner(s)has/have knowledge that a share has been assigned,renounced,disclaimed or attached,provide a copy of the assignment, renunciation, disclaimer or attachment, together with any relevant supporting documentation. Form OC-01 rev.10.13.06 Page 7 of 10 Estate of Ray K. Forney , Deceased 16. Had the decedent been adjudicated an incapacitated person? . . . . . . . . . . Yes ® No If yes, attach a copy of the Order if available; otherwise state the Court, term,number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? . . . . . . . . . . . . . Yes 0 No 18. If a reserve is requested, state amount and purpose. Amount: $1,500 P"Po": Costs and fees payable to David L. Forney, Esquire,in order to complete the administration of the estate. If a reserve is requested for counsel fees,has notice of the amount of fees to be paid from the reserve been given to the parties in interest? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OYes M No If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? . . . . . . . . . . . . . . . . . . . . . . . . . . MYes El No As to real estate only? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M.Yes ONo Form OC-01 rev.10.13.06 Page 8 of 10 Estate of Ray K. Forney ,Deceased Wherefore,your Petitioner(s)ask(s)that distribution be awarded to the parties entitled and suggest(s)that the distributive shares of income and principal (residuary shares being stated in proportions,not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/Proportion See Schedule 9 A Attached B. Principal: Proposed Distributee(s) Amount/Proportion See Schedule 9 B Attached Submitted By: (All petitioners must sign. Add additional lines if necessary): A Name of Petitioner:David L.Forney Name of Petitioner: Form OC-01 rev. 10.13.06 Page 9 of 10 ' Page 9, A Proposed Distribution of Income Steven Keath Forney 4OWest 22ndStreet Apt. 7C New York, NY1OO1O � 32.64 David Lloyd Forney 16D1KStreet, NW Washington, DC3OOOO 22.64 8usany4aMeRJrney 5Old Hunt Road Northfield, IL 60093 22.64 Paul Francis Forney ' 3-Locust Lane . Leola, PA 17540 ' ` 32.64 Mary Grace Stauffer 712Aspen Lane Lebanon, PA 17042 22.64 Peter Ignatious Forney 475Main Street Hingham, MA 02043 22.04 LvndaHeckenbenger-[}oane 9g8Prospect Road Columbia, PA17512 22.64 lota| 158.46 Page 9, B Proposed Distribution of Principal Steven Keath Forney 40 West 22nd Street Apt. 7C New York, NY 10010 10,017.94 David Lloyd Forney 1601 K Street, NW Washington, DC 20006 10,017.94 Susan Marie Forney 5 Old Hunt Road Northfield, IL 60093 10,017.94 Paul Francis Forney 3 Locust Lane Leola, PA 17540 10,017.94 Mary Grace Stauffer 712 Aspen Lane Lebanon, PA 17042 10,017.94 Peter Ignatious Forney 475 Main Street Hingham, MA 02043 10,017.94 Lynda Heckenberger-Doane 998 Prospect Road Columbia, PA 17512 10,017.94 Total $ 70,125.59 Total income and Principal Available for Distribution 70,284.05 Estate of Ray K. Forney , Deceased Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that helshe is title of the above-named name of corporation and] that the facts set forth in the foregoing Petition for Adjudication/ Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities). Signature of Petitioner *Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. J Signature of Counsel for P iti Ar Form OC-01 rev.10.13.06 Page 10 of 10 IN RE:ESTATE OF RAY.K.FORNEY, : IN THE COURT OF COMMON PLEAS Deceased : CUMBERLAND COUNTY,PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-14-0005 RULE 6.3 CERTIFICATION I,David L. Forney,Esquire, do hereby certify that the requirements of Rule 6.3 regarding notice have been met in the above captioned matter. Dated: May 4,2015 DA D L.FORAY The Patriot-News Co. 2020 Technology Pkwy cot atnotAwNews Suite 300 Mechanicsburg, PA 17050 NOW you know Inquiries - 717-255-8213 DAVID L. FORNEY ESQUIRE 1601 K STREET NW WASHINGTON' DC 20006 THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin) ss Marianne Miller, being duly sworn according to law, deposes and says: That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the Township of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 1900 Patriot.Drive, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/Community Weekly editions which appeared on the date(s) indicated below. That neither she nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by.the. stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book"M", Volume 14, Page 317. PUBLICATION COPY This ad# 0002287313 ran on the dates shown below: January 21,2014 January 28,2014 e tte'sl'oYeS'tamen i1YYyveti en t� February 04, 2014 ?anted Infhe"ESTA T E'0EAAYjK. .ORNEY�lafe of 1801 Wtir e"nStreet, eWCumberlandPA 17070 who died . . . . . . . ecemberjl8,".20731�0 DavldL For."ey, zecutoY;1601J,K'Street'N ashlnpt6n bG20006. All persons°indebted t0 t Syl a toe Sworn re�requlredtomakYJp strand Q and ubscribed before m is 07 day of February, 014 A.D. oseha0�ne,clolms�orade'monds•to resent the spnle5nilthouftlelgvao�the 5S'�cG��r'��o'y�'h(s,ctfojney n6cne belpw: gme3f atforney � 4avltlrL�F�d1r�teb�Esq. Aildres�`ofatf�-ney 160 KS eetNW, Astilnefan` bC.20006 a ublic hone'um er"bf attorheY 202.77&94 7 COMMONWEALTH OF pFNNSYLV Notarialseal ANIq Holly Lynn Warfel,N01ary Ptfblic Washington ommi�lonwp.�Dauphin County MY Comm Expires '"En79ER.PENN,SyLVANIA '12.2016 ATtON OF NnTA_ Q CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)2494166 Fax:(717)249-2663 February 7, 2014 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association-and-isdesignated by-the Court-'of common'T Pleas as the official-legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: David L. Forney, Esquire RE: Ray K. Forney Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: January 24, January 31, and February 7, 2014 Advertising Cost $ 75.00 Proof of-Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 ------------- Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director NOTICE OF INHERITANCE TAX pennsytvarna BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE 1'' .7 INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX ; DEPARTMENT OF REVENUE PO BOX 280601 REV-1547 E)( AFP (11-14) HARRISBURG PA 17128-0601 DATE 12-22-2014 ESTATE OF FORNEY RAY K DATE OF DEATH 12-18-2013 FILE NUMBER 21 14-0005 FORNEY DAVID L COUNTY CUMBERLAND 1601 K ST NW ACN 101 APPEAL DATE: 02-20-2015 WASHINGTON DC 20006-1682 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG-THIS-LINE - LINE ---- —•♦ RETAIN LOWER PORTION FOR YOUR RECORDS E-- _ --------- ---- ----- --------- ------------- REV-1547 EX AFP (11-14) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR _ DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: FORNEY RAY KFILE NO. :21 14-0005 ACN: 101 DATE: 12-22-2014 TAX RETURN WAS: C X) ACCEPTED AS FILED ( ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate CSchedule A) (1) 195,000.00 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) 00 of this form with your C4) tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 84,851 18 6. Jointly Owned Property (Schedule F) (6) 00 7. Transfers (Schedule G-) (7) 25,437.53 8. Total Assets (8) 305,288 71 4 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)_ 44,448 10 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10)_- 164,000.87 11. Total Deductions (11) 208,448.97 12. Net Value of Tax Return (12) 96,839.74 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) .0 0 14. Net Value of Estate Subject to Tax C13) C14) 96,839.74 NOTE: If an assessment was issued previously, Lines 14, 15, 16, 17, 18 and/or 19 will reflect figures that include the total of all returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at spousal rate C15) 00 •X 00 - .0a 16. Amount of Line 14 taxable at lineal rate (16) 96.R39 7 • X 045 = 4,357.79 17. Amount of Line 14 at sibling rate (17) onn X 12 = 00 18. Amount of Line 14 taxable at collateral rate (18) 00 X 15 = 0 0 19. Principal Tax Due (19)= 4,357.79 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 03-11-2014 CD018884 115.79 2,200.00 08-11-2014 CDO19521 .00 2,047.79 TOTAL TAX PAYMENT 4,363.58 BALANCE OF TAX DUE 5.79CR INTEREST AND PEN. .00 TOTAL DUE 5.79CR * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A CREDIT CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE FOR INSTRUCTIONS. pennsylvania PO . DEPARTMENT OF HUMAN SERVICES April 13, 2015 DAVID L FORNEY, ESQ., EXECUTOR 1601 K STREET NW WASHINGTON DC 20006 Re: Ray K Forney SSN: ###-##-5933 Dear Attorney Forney: Pursuant to your letter dated April 09, 2015, the Department's, Estate Recovery Program, has reviewed the information you provided regarding the above-referenced individual. It has been determined that this individual did not receive any type of assistance during the questioned period. Therefore, according to the information you provided, the Department's Estate Recovery Program will not seek any recovery from this estate. If your client applied for Medical Assistance and had an application and/or hearing pending at the time of death, please advise us and provide any additional information that may affect a recovery by our Department. Thank you for your cooperation in this matter. If you have any questions, please contact me. Sincerely (X- K�, Vince A. Porter Recovery Section Manager (717)772-6604 Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA ORPHANS' COURT DIVISION File No. 21-14-0005 FIRST AND FINAL ACCOUNTING OF DAVID L. FORNEY, Executor For RAY K. FORNEY ESTATE Date of Death: December 18, 2013 Date of Incapacity, if any: None Date of Appointment: January 3, 2014 Date of First Complete Advertisement: January 21, 2014 Accounting for the Period: December 1.8, 2013 to May 4, 2015 Purpose of Account: The above fiduciary offers this account to acquaint interested parties with the transactions that occurred during his administration. It is important that the account be carefully examined. Requests for additional information, or questions, or objections, can be discussed with: K&L GATES, LLP 1601 K. STREET,NW WASHINGTON, DC 20006 DAVID L. FORNEY, ESQUIRE (202) 778-9497 Supreme Court I.D. No. 43795 rn � Signatures: ® -MI David L. Forney, Exec or ry Ray K. Forney Estate Summary of Account Pages Principal Receipts 3 $ 295,670.84 Net Gain on Sales or Disposition 4 (1,980.67) Less Disbursements: Debts 5 $ 170,359.64 Funeral Expenses 6 3,611.00 Administrative Expenses 7 40,692.91 Family Exemption 0 Federal, State and Local Taxes 0 Fees & Commissions 8 8,901.03 Subtotal (223,564.58) Balance Before Distribution 70,125.59 Less Distributions to Beneficiaries 0 Total Principal on Hand 70,125.59 For Information: Exhibit A - Sale of Residence and Auction of Personal Property 9 Income Receipts 10 158.46 Net Gains on Sales or other Dispositions 0 Less Disbursements: 0 Balance Before Distribution 158.46 Less Distributions to Beneficiaries 0 Total Total Income on Hand $ 158.46 Combined Balance on Hand $ 70,284.05 Verification 11 Page 2 Ray K. Forney Estate Receipts of Principal Inventory Value Receipts of Principal (date of receipt) 12/18/13 Real Estate Residence (12/18/13) 1801 Warren Street New Cumberland, PA (Exhibit A) $ 195,000.00 Household Household Auction Lot (Keller Bros.) (12/18/13) (See Exhibit A) 17,989.06 Statue Collection Auction Lot (Keller Bros.) (12/18/13) (See Exhibit A) 7,399.65 Jewelry Auction Lot (Keller Bros.) (12/18/13) (See Exhibit A) 6,587.57 Miscellaneous Auction Lot (Keller Bros.) (12/18/13) (See Exhibit A) 4,857.95 Property to Grandaughter (Keller Bros.) (12/18/13) (See Exhibit A) 2,074.00 Cash and Cash Equivalents PNC Bank checking account.(12/18/13) 2,078.22 Members First Bank checking and savings (12/18/13) 16,031.41 Cash in Possession of Decedent (12/18/13) 8,020.00 Coins in Possession of Decedent (12/18/13) 160.00 Investments AXA Account (12/18/13) 1,472.16 T. Rowe Price (1/22/14) 11.71 T. Rowe Price (1/22/14) 5.07 T. Rowe Price (1/22/14) 5,435.96 T. Rowe Price (1/22/14) 2,717.86 TIAA CREF (3/24/14) 2,802.46 Subsequent Receipts Members First intransit deposit (12/18/13) 323.77 Prudential Life Insurance (1/21/14) 9,660.16 Prudential Life Insurance (2/4/14) 5,000.00 PA Employee Retirement Benefits (2/4/14) 197.12 Milton Hershey Medical Center Benefit (2/6/14) 45.27 Penn State Medical Center Refund (5/6/14) 10.00 2013 Joint Income Tax Return Refund (5/6/14) 2,128.00 House Insurance refund (6/6/14) 73.00 Reimbursement of estimated HUD-1 closing costs (6/6/14) 1,389.44 Spouse Estate Exemption (DOD 11/2/13) (6/30/14) 3,500.00 2014 Estate Tax Return Refund 5/4/15, 701.00 Total $ 295,670.84 Page 3 Ray K. Forney Estate Net Gain on Sale or Disposition Gain/Loss - Property Given to Spouse's Grandauahter Certain sentimental items formerly owned in part by Decedent's spouse were given to her grandaughter (S. Waros) at her request in exchange for a complete Release and the Inheritance Tax on the value of the items given. S. Waros was not a beneficary under the Decedent's will. Grandaughter Items (Keller Bros. valuation) (3/3.1/14) $ 2,074.00 Tax Reimburement (3/14/14) (93.33) Total $ (1,980.67) Page 4 Ray K. Forney Estate Debts (date paid) 12/18/13 Members First Visa Balance online transfer $ 1,981.35 01/16/14 Lederer Attorneys Fees check #7003 1,192.50 01/16/14 Lederer Attorneys Fees check #7004 224.50 01/16/14 Lederer Attorneys Fees check #7005 175.00 01/17/14 Gutter Guys check #7007 500.00 RMS Reverse Mortgage payoff on sale 05/15/14 of Residence (Exhibit A) HUD-1 166,286.29 Total $ 170,359.64 Page 5 Ray K. Forney Estate Funeral Expenses (date paid) 01/13/14 Snyder Funeral Home check #3041 $ 3,041.00 09/30/14 Gingrich memorial check #116 225.00 10/14/14 Longnecker Cemetary check #119 120.00 12/15/14 Gingrich memorial check #118 225.00 Total $ 3,611.00 Page 6 Ray K. Forney Estate Administrative Exoenses (date paid) 12/18/1.3 PP&L electricity Residence online transfer $ 102.74 12/18/13 Miscellaneous DOD payment in transit bank charge 100.00 01/10/14 Wire transfer fee online transfer 15.00 01/17/14 Parthmore Funeral Horne - spouse funeral expense check # 7002 4,704.08• 06/30/14 Reimburement of spouse funeral expenses from spouse's estate (4,704.00) 01/21/14 PNC transfer charge online transfer 41.60 02/03/14 PP&L Electric - Residence online transfer 32.24 02/12/14 PNC - Check printing fees bank charge 18.45 02/19/14 Culligan Water - Residence check #0 (temp check) 52.95 02/21/14 New Cumberland Borough Sewer/Trash - Residence check #101 162.15 03/04/14 PP&L Electric - Residence online transfer 72.83 03/10/14 Shipley Heating Company - Residence check #104 820.26 03/11/14 Cumberland County Real Estate Taxes - Residence check #106 1,512.41 03/14/14 Erie Insurance - Residence online transfer 181.00 03/31/14 Keller Bros. - Household Auction Lot Setoff against proceeds Sales Commissions Exhibit A 6,296.67 03/31/14 Keller Bros.. - Statue Auction Lot Sales Setoff against proceeds Commissions Exhibit A 2,589.97 03/31/14 Keller Bros. - Jewelry Auction Lot Sales Setoff against proceeds Commissions Exhibit A 2,305.96 03/31/14 Keller Bros. - Household Auction Setup Setoff against proceeds Expenses Exhibit A 1,080.00 03/31/14 RSR Realtors - House cleaning charges check #109 250.00 04/04/14 PP&L Electric - Residence online transfer 39.36 05/06/14 New Cumberland Borough Sewage and Water - Residence check #110 115.24 05/15/14 Residence sale closing costs - net (Exhibit A) HUD -1 23,004.59 05/19/14 PP&L Electric - Residence online transfer 49.13 05/21/14 Keller Bros. - Miscellaneous Auction Lot Setoff against proceeds Commissions Exhibit A 1,700.28 I 05/27/14 RSR Realtors - House carpet cleaning - Residence check #111 150.00 i Total $ 40,692.91 E I Page 7 I M Exhibit A Ray K. Forney Estate Information Sheet Sale of Residence and Auction of Personal Property Residence The Decedent's residence was sold on market terms on May 15, 2014. The outstanding mortgage was paid in full. 1801 Warren Street, New Cumberland, PA - Residence Sale Price (Closing on 5/15/14) HUD-1 $ 195,000.00 RMS Reverse Mortgage payoff on sale HUD-1 (166,286.29) Closing Costs (including $10,000 Seller assist) HUD-1 (23,004.59) Reimbursement of estimated HUD-1 costs (6/6/14) 1,389.44 Total net to estate $ 7,098.56 Personal Property Except for the transfer on Page 4, all of the Decedent's personal property was sold on an on-line auction conducted over several weeks commencing in February, 2014 followed by a physical auction on May 12, 2014 by Keller Brothers Auction Company. Household Auction Lot (Keller Bros.) (3/31/14) $ 17,989.06 Auction Commission (3/31/14) (6,296.67) 11,692.39 Statue Collection Auction Lot (Keller Bros.) (3/31/14) 7,399.65 Auction Commission (3/31/14) (2,589.97) 4,809.68 Jewelry Auction Lot (Keller Bros.) (3/31/14) 6,587.57 Auction Commission (3/31/14) (2,305.96) 4,281.61 Miscellaneous Auction Lot (Keller Bros.) (5/12/14) 4,857.95 Auction Commission (5/21/14) (1,700.28 3,157.67 Setup Expenses (Keller Bros.) (3/14/14) (1,080.00I Total net to estate $ 22,861.35 Page 9 Verification DAVID L. FORNEY, Executor of the Will of Ray K. Forney, Deceased, hereby declares under oath that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to his knowledge, there are no claims outstanding against the Estate; that all taxes presently due from the Estate have been paid; and that the grant of Letters Testamentary and the first complete advertisement thereof occurred more than four months before the filing of the foregoing First and Final Account. This statement is made subject to penalties of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. David L. Forney Dated: May 4, 2015 Page 11 K&L GATES K&L GATES LLP 1601 K STREET,N.W. WASHINGTON,DC 20006 T+1202 778 9000 F+1202 778 9100 klgates.com David L.Forney 202.778.9497 Pax: 202.778.9100 david.fbmey@klgates.com May 4, 2015 Cumberland County Orphans Court Courthouse 1 Courthouse Square Suite 102 Carlisle,PA 17103 Re: Petition for Adjudication/Statement of Proposed Distribution Pursuant to Rule 6.9; First And Final Accounting of Ray K. Forney;File No. 21-14-0005 Attached please find: (i) one original Petition for Adjudication/Statement of Proposed Distribution Pursuant to Rule 6.9 for the Estate of Ray K. Forney File No. 21-14-0005, (ii) one original and one copy of First and Final Accounting for the Estate of Ray K. Forney File No. 21-14-0005 (iii) a check payable to the Register of Wills of Cumberland County in the amount of $365.00. (iv) one postage paid return envelope. As follows is additional information relevant to the filings: Decedent's name: Ray K. Forney File No. 21-14-0005 Account type: Executor With Distribution Distribution amount is: $70,284.05 � I M Gross value of Estate is$305,288.71 o - � o First Complete Advertising Date was: January 21.,-2014. r zvi V y truly yo s, r• N t C> >— F m Davi omey, Exe for t �, Enclosures ! ss I � CCO 00 0 C6 ! i ! do vi 90 cn obi g a n ! U IW b ; 1 �a I m q� m, O AAtn I qkyr gti co _ CDCD �.. GD o =-=:CL apt c n Com,/ ri „! C� t m --.... OD ! p CD O I