The URL can be used to link to this page

Home My WebLink About06-03-15 (2) f 1505614134 c EX(03-14)(FI) REV-1 500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 4 4 5 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 3 2 2 2 0 1 4 1 1 1 3 1 9 1 6 Decedent's Last Name Suffix Decedent's First Name MI G 0 U S E E L I Z A B E T H A (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.Agriculture Exemption ❑ 5.Future Interest Compromise(date of ❑ 6. Federal Estate Tax Return Required (date of death on or after 7-1-2012) death after 12-12-82) ❑X 7. Decedent Died Testate ❑ 8. Decedent Maintained a Living Trust 0 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 ❑ 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 D A V I D H S T O N E E S Q U I R E ? 1 ? ? ? 4 ? 4 3 5 First Line of Address 4 1 4 B R I D G E S T R E E T Second Line of Address City or Post Office State ZIP Code rn_ N E W C U M B E R L A N D P A 1 ? 0 ? 0 o C-) C:3 -0 Correspondent's e-mail address: D S T O N E a@ S T O N E L A W • NET _ REGISTER dF WILLS USE ONLYQ, REGISTER OF WILLS USE ONLY ! ) CD .r DATE FILED MMDDYYYY m i, f CD. fV _T1. DATE FILED STAMP PLEASE USE ORIGINAL FORM ONLY Side 1 I IIIIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII 1505614134 1505614134 V� 1505614234 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: ELIZABETH A - GOUSE RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 0 0 0 0 . 0 0 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. 2 2 7 9 1 . 0 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 2 6 3 8 . 2 9 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . . . . 7. w 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 1 4 5 4 2 9 . 2 9 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 7 0 6 8 2 . 7 2 10. Debts of Decedent, Mortgage Liabilities, and Liens(Schedule 1) . . . . . . . . . . . . . 10. 1 8 3 4 6 5 . 4 5 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 5 4 1 4 8 . 1 7 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. - 1 0 8 7 1 8 . 8 8 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. - 1 0 8 7 1 8 • 8 8 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)x - 0 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate x • q_4 5 0 . 0 0 16. 0 . 0 0 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 0 • 0 0 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. SI ATURE OF PERSON RESPONSIBLE f OR FILING RETURN DAT ADDRESS BdIRW UNTAIN RD DILLSBURG PA 17019 SIG ER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN ATE �- DDRESS RID TREET NEW CUMBERLAND PA 17070 111111111111111111111111111111111111111 IN Side 2 1505614234 1505614234 J REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: 21 14 0445 DECEDENT'S NAME ELIZABETH A • LOUSE STREET ADDRESS 5225 WILSON LANE CITY STATE ZIP MECHANICSBURG � PA 117055- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0 . 00 2. Credits/Payments A.Prior Payments B.Discount (See instructions.) Total Credits(A+B) (2) 0 . 00 3. Interest (3) 0 . 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0 . 00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0 .00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer 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 ..................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 191 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 121 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ 191 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ FKI IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for 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 step-parent of the child is 0 percent[72 RS. §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-1502 EX+(12-12) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ELIZABETH A . GOUSE 21 14 0445 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 Property located at 520 Eutaw Ave New Cumberland 1201000 .00 Cumberland County, PA sold to Thomas E . Dixon and Mary Jean Dixon, husband and wife on April 1, 2015 TOTAL(Also enter on Line 1,Recapitulation.) $ 120,000 - 00 If more space is needed,use additional sheets of paper of the same size. REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: ELIZABETH A . GOUSE 21 14 0445 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 Avalon Insurance Company-refund on premium 85 .80 2 Capital Blue Cross-refund on prescriptions 660. 15 3 Com of PA-Owner/Rent rebate check received 750 . 00 4 Foremost Insurance-refund on premium 159 .75 5 Gingrich Memorials-Money held for headstone 4 ,000 . 00 prior to death 6 Leffler Energy-refund on service at property 254 . 00 7 Net proceeds of personal property sold at auction 808 . 20 by Newberry Peddlers Market in January 2015 8 Ohio Casualty-refund on cancellation 630 . 00 9 SecurChoice-Account held for funeral expenses 15,417 . 74 prior to death as per funeral home 10 Susquehanna Bancshares Inc-Checking Acct 25 . 36 #10008203415 Princ $25. 36 TOTAL(Also enter on Line 5,Recapitulation) $ 22 ,791 - 00 If more space is needed,use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ELIZABETH A . GOUSE 21 14 0445 If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. MILTON S GOUSE JR 429 CHESTNUT GROVE ROAD SON DILLSBURG, PA 17019 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1 - A - 4-30-07 Metro Bank-Checking Acct #513032441 joi.it276 . 57 50 - 2,638 . 29 joint w/Milton S . Gouse on 4-30-07 Princ $5,276 . 47, Int $ - 10 _ $5,276 . 47 TOTAL(Also enter on Line 6,Recapitulation) $ 2,638 - 29 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ELIZABETH A . LOUSE 21 14 0445 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Gingrich Memorials-headstone and engraving 4 ,000 . 00 Parthemore Funeral Home-funeral expenses 12,720 . 52 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) D a w n n E T r o s t 1 e 7,139 - 00 Street Address 120 Blair Mountain Rd city Di11sburg State PA Zip 17019 Year(s)Commission Paid: 2015 2 . AttomeyFees: David H Stone, Esquire 7,271 . 00 3, Family Exemption:(If decedent's address is not the same as claimants,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4 • Probate Fees: See 018 below 5 . Accountant Fees: 6 • Tax Return Preparer Fees: 7 • Metro Bank-check order charge 25 . 60 2 Metro Bank-bank charge 30 . 00 3 Metro Bank-service charge from Jan-April B $18 72 . 00 4 Foremost Insurance-homeowners insurance 178 . 45 5 Foremost Insurance-homeowners insurance 178 . 45 6 Foremost Insurance-homeowners insurance 178 . 45 7 Foremost Insurance-homeowners insurance 187 . 05 8 Foremost Insurance-homeowners insurance 178 . 45 9 Foremost Insurance-homeowners insurance 178 . 45 10 Foremost Insurance-homeowners insurance 178 . 45 11 Randy Gross-services for cleaning house for sale 800 . 00 12 Randy Gross-bal due on cleaning and hauling items 800 . 00 TOTAL(Also enter on Line 9,Recapitulation) $ 70,682 - 72 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent ELIZABETH A. GOUSE 21 14 0445 Decedent's Name Page 1 File Number Schedule H - Funeral Expenses &Administrative Costs- 67. ITEM NUMBER DESCRIPTION AMOUNT 13 Leffler Energy-service at property 254 .00 14 Mark Heckman-appraisal fee on property 450 .00 15 Leffler Energy-sevice at property 573 .72 16 Hamilton & Musser-income tax prep fee 40 . 00 17 Checks written by decedent before death 780 . 95 18 Dawnn Trostle-Reimb for probate fees 328 . 50 19 Dawnn Trostle-Reimb for filing Inh tax ret and Inv 30. 00 20 Attorney Hatch-service rendered 42 . 00 21 Stone LaFaver & Shekletski-Reimb for adv letters 265 . 54 22 Peerless Insurance Co-homeowners insurance 825 . 00 23 Robin Gasperetti-real estate taxes on property 2 ,142 . 31 24 Selling costs ($31,232 . 91) less reimb ($909 . 77) 30,323 . 14 25 PPL Electric-service at property 50 . 54 26 PPL Electric-service at property 39 . 43 27 PPL Electric-service at property 37 . 60 28 PPL Electric-service at property 19 . 04 29 PPL Electric-service at property 21 . 40 30 PPL Electric-service at property 17 . 06 31 PPL Electric-service at property 30 . 39 32 PPL Electric-service at property 23 . 57 33 PPL Electric-service at property 40 . 33 34 PPL Electric-service at property 38 . 36 35 PPL Electric-service at property 41 . 05 36 PPL Electric-service at property 52 . 92 37 Reserve for closing expenses 100 .00 SUBTOTAL SCHEDULE H-137 36,566 - 85 REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ELIZABETH A . LOUSE 21 14 0445 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 • Bethany Village-living expenses 1,463 . 98 2 Dept of Public Welfare-claim 182,001 . 47 TOTAL(Also enter on Line 10,Recapitulation) $ 183,465 - 45 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES RIES INHERITANCE TAX RETURN DGI�IGr I1R G�7 RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ELIZABETH A . GOUSE 21 14 0445 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 DAWNN E TROSTLE Lineal 0 . 00 120 BLAIR MOUNTAIN ROAD DILLSBURG PA 17019- 2 MILTON S LOUSE III Lineal 0 . 00 429 CHESTNUT GROVE ROAD DILLSBURG PA 17019- 3 MILTON S GOUSE JR Lineal 0 .00 429 CHESTNUT GROVE ROAD DILLSBURG PA 17019- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 • TOTAL OF PART 11 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. ep\wi11s\G0USE,ELIZABETH 1 t , LAST WILL AND TESTAMENT OF ELIZABETH A. GOUSE I, ELIZABETH A. GOUSE, of the Borough of New Cumberland, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me . ITEM I : I direct that my Executor hereinafter named. shall pay all my just debts and funeral expenses as soon as conveniently may be done after my decease from the residue of my estate . ITEM II : I devise and bequeath all the rest, residue and remainder of my estate of every nature and wherever situate as follows : A. One-third (1/3) to my son, MILTON S . GOUSE, JR. B. One-third (1/3) to my grandson, MILTON S . GOUSE, III. C. One-third (1/3) to my granddaughter, DAWNN E . TROSTLE . ITEM IV: I appoint my granddaughter, DAWNN E . TROSTLE, Executrix of this my last will . Should my granddaughter, DAWNN E . TROSTLE, fail to qualify or cease to act as Executrix, I appoint my great- granddaughter, STEPHANIE D. PONTIUS, Executrix of this my last will. Page 1 of 4 L ITEM V: No fiduciary acting hereunder shall be required to post bond or enter security for the faithful performance of his or her duties in any jurisdiction . IN WITNESS WHEREOF, I, ELIZABETH A. GOUSE, .have hereunto set my hand and seal this day of2006 . ELIZABETH A. LOUSE Page 2 of 4 SIGNED, SEALED, PUBLISHED and DECLARED by ELIZABETH A. LOUSE, the Testatrix above named, as and for her Last Will and Testament, and in the presence of us, who at her request, in her presence and in the PL e of e ch , ther, have subscribed our names as witnesses . '� 414 Bridge St . , New Cumberland, PA Witn s Address 414 Bridge St . , New Cumberland, PA Witness Address COMMONWEALTH OF PENNSYLVANIA: . SS . COUNTY OF CUMBERLAND I, ELIZABETH A. GOUSE, the Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law do hereby acknowledge that I signed and executed this instru- ment as my last will; that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein contained. ELIZABETH A. GOUSE Sworn to or affirmed to and acknowledged before me by ELIZABETH A. GOUSE, the Testatrix, this 2.Q� day of 2006. COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL DANIEL M. HARTMAN, Notary Public New Curnberland Boro.,Cumberland Co. Notary Public My Commission Expires Jan. 21,2009 Page 3 of 4 COMMONWEALTH OF PENNSYLVANIA SS : COUNTY OF CUMBERLAND We, a n d the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw Testatrix sign and execute the instrument as her last will; that Testatrix signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; that to the best of our knowledge, the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence L Wit ss Witness Sworn to or affirmed to and acknodged before me by J�� and witnesses, this QA'Iay of 2006 . COMMONWEALTH OF PENNSYLVANIA Notary Public NOTARIAL SEAL DANIEL M. HARTMAN, Notary Public Naw Cumberland Bora.,Cumberland Co. LMY Commission Expires Jan. 21,2009 Page 4 of 4 STONE LAFAVER & SHEKLETSKI ATTORNEYS AT LAW 414 BRIDGE STREET DAVID H.STONE POST OFFICE BOX E OF COUNSEL GERALD J. SHEKLETSKI NEW CUMBERLAND. PA 17070 CHARLES H.STONE www.stonelaw.net JON F.L.AFAVER TELEPHONE(717)774-7435 December 12, 2014 FACSIMILE (717)774-3869 PA Department of Revenue Bureau of Individual Taxes Inheritance Tax Division-Ext PO Box 280601 Harrisburg, PA 17128-0601 RE: Estate of Elizabeth A. Gouse Cumberland County File No. 21-14-0445 DOD: March 22, 2014 To Whom It May Concern: I represent the Estate of Elizabeth A. Gouse in which Dawnn E. Trostle is Executrix. Please be informed that I am requesting an extension of six months on the filing of the Inheritance Tax Return and Inventory for the following reason: The real estate situate at 520 Eutaw Avenue, New Cumberland, Cumberland County, Pennsylvania has not been sold as of this date and we anticipate it being sold in the next several months. Please note that no prepayment of tax was made because the expenses exceed the assets, one being the Department of Public Welfare with a claim against the estate of$182,001.47. The amount of assets total approximately $130,000 which includes the real estate assessed at $123,675.00. Your attention and cooperation to this request is greatly appreciated and should you have any questions, please do not hesitate to contact me. Very truly yours, ST V & SHEKLETSKI David H. DHS/tmb cc: Dawwn E. Trostle, Executrix - CQ(DPy 7_:\RE\DED\Gouse.E1izabeth—520 Eutaw Avenue(buyer-Dixon) Tax Parcel#:25-24-0811-186 Address:520 Eutaw Avenue New Cumberland,PA 17070 DEED THIS-INDENTURE made the�'� day of eft , in the year 2015, between DAWNN E. TROSTLE, Executrix of the Last Will and Testament of ELIZABETH A. GOUSE, late of New Cumberland Borough, County of Cumberland, and Commonwealth of Pennsylvania, of the first part; hereinafter called the Grantor, - AND - THOMAS E. DIXON and MARY JEAN DIXON, husband and wife, of the second part, hereinafter called the Grantees: WHEREAS, the said ELIZABETH A. GOUSE became in her lifetime seised, as of fee, of and in a certain tract of land, together with the improvements thereon erected, situate in New Cumberland Borough, County of Cumberland, and Commonwealth of Pennsylvania, and more particularly described hereinafter; and being so thereof seised, died on March 22, 2014, having first made her Last Will and Testament in writing dated January 20, 2006, duly probated and registered in the Office of the Register of Wills of Cumberland County on May 7, 2014, wherein and whereby she appointed as Executrix, the said DAWNN E. TROSTLE, to whom Letters Testamentary were duly issued by said Register of Wills on May 7, 2014, wherein and whereby said premises hereinafter described were not specifically devised, all as in and by said Will and the records of said Register of Wills, recourse thereunto being had, appears: NOW THIS INDENTURE WITNESSETH, that the said Grantor, for and in consideration of the sum of ONE HUNDRED TWENTY THOUSAND and NO/100------($120,000.00)------Dollars, which has been paid to her by the said Grantees at or before the sealing and delivery hereof_ receipt whereof is hereby acknowledged, has granted, bargained, sold, aliened, released and confirmed, and by these presents does grant, bargain, sell, alien, release and confirm unto the said Grantees, ALL THAT CERTAIN piece or parcel of land situate in the Borough of New Cumberland, County of Cumberland, Commonwealth of Pennsylvania, more particularly bounded and described as follows, to wit: BEGINNING at a point on the western side of Eutaw Avenue, one hundred ninety-nine and thirty-eight one-hundredths (199.38) feet south of the southwest corner of Eutaw Avenue and Beacon Road, at the division line between Lots Nos. 10 and 11 on the hereinafter mentioned Plan of Lots; thence along said last mentioned line, South forty-four degrees fifteen minutes West (S 44° 15' W) one hundred fifty (150) feet to a point at the division line between Lots Nos. 4 and 10 on said Plan: thence along said last mentioned line and along the division line between Lots Nos. 5, 6 and 10 on said Plan, North forty-five degrees forty-five minutes West (N 45°45' W) sixty (60) feet to a point at the division line between Lots Nos. 9 and 10 on said Plan; thence along said last mentioned line, North forty-four degrees fifteen minutes East (N 44' 15' E) one hundred fifty (150) feet to a point on the western side of Eutaw Avenue; thence along the western side of Eutaw Avenue, South forty-five degrees forty-five minutes East(S 45* 45' E) sixty (60) feet to a point, the Place of BEGINNING. BEING Lot No. 10 on the Plan of Lots of Hillside Manor, which Plan is recorded in the Office of the Recorder of Deeds in and for Cumberland County, Pennsylvania in Plan Book 11, Page 21. HAVING thereon erected premises known and numbered as 520 Eutaw Avenue, New Cumberland, Pennsylvania. BEING the same premises which William L. Allen and Jacquelyn S. Allen, his wife, by Deed dated July 17, 1972, and recorded July 17, 1972, in the Office of the Recorder of Deeds of Cumberland County in Deed Book 24, Volume "S", Page 397, granted and conveyed unto Milton S. Gouse, Sr. and Elizabeth Gouse, his wife. Milton S. Gouse, Sr. died on June 10, 1995, thus by operation of law vesting title in Elizabeth Gouse, deceased. TOGETHER with all and singular the buildings, improvements, ways, streets, alleys, passages, waters, water-courses, rights, liberties, privileges, hereditaments and appurtenances whatsoever, thereunto,belonging or in any wise appertaining and the reversions and remainders, rents, issues and profits thereof, and all the estate, right, title, interest, property, claim and demand whatsoever of her, the said ELIZABETH A. GOUSE, at and immediately before the time of her decease, in law, equity, or otherwise howsoever, of, in, to or out of the same. TO HAVE AND TO HOLD the said lot or piece of ground above described, with the buildings and improvements thereon erected, hereditaments and premises hereby granted or mentioned, and intended so to be, with the appurtenances unto the said Grantees, to and for the only proper use and behoof of the said Grantees, forever. AND the said Grantor, for herself and her respective heirs, executors and administritors, does covenant, promise and agree to and with the said Grantees, their heirs and assigns, that she, the said Grantor, has not heretofore done or committed any act, matter or thing whatsoever whereby the premises hereby granted, or any part thereof, is, are, shall or may be impeached, charged, or encumbered in title, charge, estate or otherwise howsoever. WITNESS WHEREOF, the said Grantor has hereunto set her hand and seal the and ye first above written. WITNESS "' d 3ye first above v f S1 aled,4andd livered crit P e eo (SEAL) Witness DAWNN E. TROTLE, Executrix of the Last Will and Testament of ELIZABETH A. GOUSE -2- COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF On this, the (Cbr day of 2015, before me a Notary Public, the undersigned officer, personally appeared DAWNN E. TROSTLE, Executrix of the Last Will and Testament of ELIZABETH A. GOUSE, known to me or satisfactorily proven to be the person whose name is subscribed to the within instniment, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereto set my hand and notarial seal. COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL y 1J�ary Public In b Judy A.Palm,Notary Public Bora, be [Camp Hill Soro,Cumberland County MLycomm 5 Expires 'as .25 My Commission Expires Nov.15,2018 PENNSYLVANIA PENNSYLVANIA ASSOCIATION OF NOT-ARIES NOTARIAL SEAL J--;dy A.Palm,Notary Public Camp!!:`.i Foro,Cumberland County 'expires Nov.15,2018 MEMSE , 'YK&SYLVA;-0,A ASSOCIATION OF NOTARIES I hereby certify that the precise address of the Grantees is DATE: Attorney for -3- Susquehanna �,, June 6,2014 Susquehanna Bancshares,Inc. 26 North Cedar Street P.O. Box 1000 Lititz,PA 17543-7000 Tel 1.800.311.3182 STONE LAFAVER& SHEKLETSKI Fax 717.625.4478 1414 BRIDGE STREET PO BOX E NEW CUMBERLAND PA 17070 RE: Elizaabeth Ann Gouse Estate DOD: March 22, 2014 SS#: Tracking# 373163 To Whom It May Concern: In response to your letter of May 30, 2014,here is the above customer account information as of March 22, 2014. Account#1 Account#2 Account#3 • Account Title: Elizabeth A Gouse Milton S Gouse Jr POA • Account Type/# Checking 10008203415 • Date Opened /Maturity 06/11/2010 • interest Rate: 0.00% • Account Balance*: $25.36 • Accrued interest: $0.00 « YTD Interest: $0.00 *Account balance does not include accrued interest. ® There is no safe deposit box in the name of the decedent. [� There is a safe deposit box# 0 in the name of the decedent located at the branch name. If I can be of further assistance, please feel free to call. Dawn M Berrier Susquehanna Bank Deposit Research - Reporting Department Lead 1-717-625-6546 DMBfkmc METRO BANK 3801 Paxton Street 888.937.0004 Harrisburg, PA 17111 mymetrobank.com 6/3/14 David H. Stone, Esquire Stone LaFaver& Shekletski Attorneys at Law 414 Bridge St. P.O. Box E New Cumberland, PA 17070 RE: Estate of: Elizabeth Ann Gouse Tax Identification Number: 172-01-7240 Date of Death: March 22, 2014 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type:CK Account Number: 513032441 Date Opened: 04/01/1999 Date Became Joint: 04/30/2007 Date Closed: 05/07/2014 Primary Owner: Elizabeth A. Gouse Secondary Owner: Milton S. Gouse Jr. Accrued interest: '*$0.10 Date of Death Balance: $5,276.47 Please note: The accrued interest will not be paid if the account is closed prior to the date the interest is scheduled to post. Please feel free to contact us at 1-888-937-0004 if we may be of further assistance. Sincerely, Jennifer Jacobs Research Associate Metro Bank OMB NO.2502-0265 A. B. TYPE OF LOAN: 1.[]FHA 2.[]FmHA 3.[]CONV.LININS. 4.E]VA I.[]CONV,INS. U.S.DEPARTMENT OF HOUSING&URBAN DEVELOPMENT 6. FILE NUMBER: T LOAN NUMBER: SETTLEMENT STATEMENT DIX64-15 8. MORTGAGE INS CASE NUMBER: C. NOTE; This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked'IPOCI'were paid outside the closing;they are shown here for informational purposes and are not included In the totals. 10 3*0 (DIX64-15RFDOX64-15118) D. NAME AND ADDRESS OF BUYER: E. NAME AND ADDRESS OF SELLER: F. NAMEAND ADDRESS OF LENDER: THOMAS E.DIXON and ESTATE OF ELIZABETH GOUSE CASH MARY JEAN DIXON 520 EUTAW AVENUE 833 TAMANINI WAY NEW CUMBERLAND,PA 17070 MECHANICSBURG,PA 17055 G. PROPERTY LOCATION: H. SETTLEMENT AGENT. 25-1619811 I. SETTLEMENT DATE: 520 EUTAW AVENUE TRI-COUNTY ABSTRACT SERVICE NEW CUMBERLAND,PA 17070 April 2,2013 CUMBERLAND County,Pennsylvania PLACE OF SETTLEMENT 841 TAMANINI WAY MECHANICSBURG,PA 17055 J.SUMMARY OF BUYER'S TRANSACTION K.SUMMARY OF SELLERS TRANSACTION 100. GROSS AMOUNT DUE FROM BUYER: 400. GROSS AMOUNT DUE TO SELLER 101, Contract Sales Price 120 000.00 401, Contract Sales Price 120,000.01 102. Personal Property 402. Personal Property 103. Settlement Charges to Buyer(Line 1400) 2,284.00 403, 104. 404. 105. 405. Adjustments For Items Paid By Setter in advance Adjustments For Items Paid By Seller in advance 70-6-CitytTown Taxes to 406.Ci frown Taxes to 107, County Taxes 04/02115 to 01/01116 585.11 407, County Taxes 04/02/15 to 01101/16 585.11 108. SCHOOL TAX 0410211115 to 07/01115 284,11 40& SCHOOL TAX 04/02/15 to 07/01/16 284,11 109. TRASH APRIL-JUNE 04/02115 to 07/01115 40.55 409. TRASH APRIL-JUNE 04/02/15 to 0710IM5 40.5! 110. 410. ill. 411. 112. 412. f20. GROSS AMOUNT DUE FROM BUYER 123.193.77 420. GROSS AMOUNT DUE TO SELLER 120,909.7', 200. AMOUNTS PAID BY OR IN BEHALF OF BUYER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. Deposit or earnest money 5,000-00 501. Excess Deposit(See Instructions) 202. Principal Amount of New Loan(s) 502. Settlement Charges to Seller(Line 1400) 11,23ZO-, 203. Existing loan(s)taken subject to 503. Existing loan)taken subject to 204. 504. Pa%of first Mortgage 205. 505. Payoff of second Mortgage 2D6. 506. 207, 507. (Deposit disb.as proceeds) 208. 508. 209. CREDIT FOR REPAIRS 20,000.00 509. CREDIT FOR REPAIRS 000.00 - Adjustments For Items Unpaid By Seller Adjustments For Items Unpaid By Seller 210. Cf frown Taxes to 510,Ci frown Taxes to 211. County,Taxes to 511. County Taxes to 212. SCHOOL TAX to 512. SCHOOLTAX to 213. SEWER APRIL-JUNE 04/01/15 to 04102JI5 0.84 513. SEWER APRIL-JUNE 04/01/15 to 04102/15 0.84 214, 514. 215, 515. 216. 518. 217. 517. NET PROCEEDS to STONE LAFAVER&SHEKLETSKI A. 89,676.86 218. 518. 219. 519. 220. TOTAL PAID BY/FOR BUYER 25,000.84 520. TOrAl.REDUCTION AMOUNT DUE SELLER 120,909.77 300. CASH AT SETTLEMENT FROM/TO BUYER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 301. Gross Amount Due From Buyer(Line 120) 123 193.77 601. Gross Amount Due To Seller(Una 420) 120.9E0917 7 302. Less Amount P 90,J Paid BylFor Buyer(Line 220) 25!000.84) 602. Less Reductions Due Seller(Line 520) 120.9093. 303. CASH(XFROM)( TO)BUYER 98,192.93 603. CASH( TO)( FROM)SELLER 0.00 The undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement&any attachments referred to herein. I HAVE CAREFULLY REVIEWED THE HUD-1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELIEF,IT IS A TRUE AND ACCURATE STATEMENT OF ALL RECEIPTS AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY MEIN THIS T CTION. I FURTHER CERTIFY THAT I HAVE RECEIVED ACO LEMENT STATEMENT Buys PY OF THE HUE Seller ES I DOUSE r MARY JION TO THE BEST OF MYKNOWLtz' THE HUD-1 S4TLEMENT STATEMENT WHICH I HAVE PREPARED IS A TRUE AND ACCURATE ACCOUNT OF THE FUNDS WHICH WERE JECEIVECZ�ND HAVE BEEN OXW161-BkOISBURSED BY THE UNDERSIGNED AS PART OF THE SETTLEMENT OF THIS TRANSACTION T.- RI-COUNTY ABSTRACT SERVICE Settlement Agent WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN iNCLUDEA FINE AND IMPRISONMENT, FOR DETAILS SEE: TITLE 18 U.S.CODE SECTION 1001&SECTION 1010. i pa L.SETTLEMENT CHARGES 700.TOTAL COMMISSION Based on Price S 120 000.00 @ 7=000% 8,400.00 AUD FROM AUDFROM Division of Commis Ion line 700 as Follows: BUYER'S SFLLER'S TO-Is. 4,800.00 to RE/MAX REALTY ASSOCIATES INC. FUNDSAT FUNDS a 702.$ 3,600.00 to TAMANINI REALTY SETTLEMENT SkTrtEMEM 703.Commission Palo at Settlement 8'400 704.BROKER FEE t0 REAW REALTY ASSOCIATES INC. 495 800.ITEMS PAYABLE IN CONNECTION WITH LOAN 801.Loan Origination Fee % to 802.Loan Discount % to 803.Appraisal Fee to 804.Credit Report to 805. Lender's Inspection Fee to 806. Mart a e Ins.App.Fee to 807. Assumption Fee to $08. 809. 810. 811. 944.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901.interest From to $ /day da e!%) 902. MIP Totins.for LifeOfLoan for months to 903.Hazard Insurance Premium for 1.0 years to 904. 905. 1000.RESERVES DEPOSITED WITH LENDER 1001.Hazard Insurance months $ per month 1002.Mortgage Insurance months $ per month 1003.CI !Town Taxes months $ per month 1004.County Taxes months $ per month 1005. SCHOOL TAX months $ per month 1006. months @ $ per month 1007. months a $ per month 1008.AGGREGATE ESCROW ADJUSTMEI months 0 $ per month 1100.TITLE CHARGES 1101. Settlement 4r Closing Fee to 1102. CLOSING PROTECTION LETTER to FIRST AMERICAN TITLE INSURANCE COMPANY 1103. Title Examination to 1104. Reimbursement for Tax Cert to TRI-COUNTY ABSTRACT SERVICE 10•0c 1105. Document Preparation to STONE LAFAVER&SHEKLETSKI DEED 225,00 1106. Notary Fees to CASH 5.00 1107. NOTARY FEE to JUDY PALM 5.00 Includes above Item numbers: 1108. Title Insurance to TRI-CO N ASST A T$ERVICE/AGENT SERVICE/AGENTFOR IST ERICAI 1,000=1 includes above Item numbers5011442.0141556e 1109.Lender's Coverage $ 1110.Owner's Coverage $ 120,000.00 1,000.00 1 1111. ENDORSEMENTS 1112. 1113. 1200.GOVERNMENT RECORDING AND TRANSFER CHARGES I 1201.Recording Fees: Deed $ 79,00:Mortgage S Releases $ 79.00 I 1202.City/County City/CountyTax/Slam s: Deed 1,200.00*Mortgage 1 1,2 0.00 1203.State Tax/Stamps: Revenue Stamps 1,200.00:Mortgage 1,200.001 1204. 1205. 1300.ADDITIONAL SETTLEMENT CHARGES 1301. Survey to 1302. Pest Inspection to 1303.2015 COUNTYITOWNSHtP TAXES to ROBIN GASPERETTI TAX COLLECTOR BILL#999 779.43 1304.TRASH APRIL-JUNE to NEW CUMBERLAND BOROUGH 41.00 1305. SEWER JAN-MARCH to NEW CUMBERLAND BOROUGH 76.64 1400.TOTAL SETTLEMENT CHARGES Enter on Lines 103 Section J and 502,Section K 2,2a4,00l 11.232.07 By signing page f at this statement the signatories aw"ledge foostpt of a completed mpy of page 2 of this dao page statement . ... 3 TRI-COUNTY ABSTRACT SERVIMCECE Settlement Agent Certified to be a true copy. S cele O rv'C ahs 120000 Costs 1.3a.�! Le t i, cn_ 1109 f-7 Z li:xv,rs a-h-Gsi. �/� IDix84.15f01cs4•15f1el J p ihnsyWania. DEP ARTMEN,Ti'O;F-'P'UBLI.0.,WELFAR9 June 25, 2014 DAVID H STONE ESQUIRE 414 BRIDGE ST NEW CUMBERLAND PA 17070 Re: Elizabeth Gouse CIS #: 018832323 SSN: ###-##- Date of Death: 03/22/2014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Stone: 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$182.001.47 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 $18.741.15, 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 $163,260.32, 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 i Recovery Section PD Box 8486 1 Harrisburg, Pennsylvania 17105-8486 ~ ` , n�~ �� r _ DEPARTMENT op�pooucwccpAnE ' 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 beexpected. When the estate accounting is complete, please provide acopy. The Department audits all estatb recovery claims and therefore we require documentation hosubstantiate 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 |avv libraries. In order to document computation of the amount due the Department, the following items should be submitted tothe address below: 1' For real estate: a. Copy of the deed b. Copy ofthe latest tax assessment c. Copy of 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 |nanursing home 5' Copies oforiginal and updated life insurance policy forms naming beneficiaries 6.�Copiesofany and all stocks and bonds 7. Copies of bank statements showing balances onthe date mfdeath 8. Copies of signature cards or other proof of when accounts were made joint 9' /\ list of any gifts orother transfers for lass than fair market value made by the decedent (personally mrunder apower ofattorney) 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 tothe estate may also bepersonally liable. The responsibilities of the primary next of kin/ad min istnytor/execubor, 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, issent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau mProgram Integrity | Division mThird Party Liability | Recovery Section poBox u4oa 1 *am,uunu, Pennsylvania 17105'8*86 pennsytVania. 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, 4 -Barbara E. Witmer Claims Investigation Agent 717-772-6611 717-772-6553 FAX Enclosure Bureau of Program Integrity Division of Third Party Liability 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 June 10,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of DOUSE,ELIZABETH ID 018 832 323 MEDICAL CLASS 3 CLASS 5.1 TOTAL . INPATIENT .00 .00 .00 OUTPATIENT 80.00 .00 80.00 LONG TERM CARE 18,661.15 162,536.89 181,198.04 DRUG .00 723.43 723.43 REIMBURSEMENT TO DPW 18,741.15 163,260.32 182,001.47 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME LOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5.225 WILSON LN MECHANICSBURG PA 17065 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 04120110 - 04/30/10 12/13/10 55103425230900001 55103425230900001 1,675.00 434.82 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01110 - 05131110 12/13/10 65103425230840001 55103425230840001 429.94 443.92 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 06101/10 - 06/30/10 12/13110 56103426230910001 55103425230910001 4,838.87 3,669.07 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 09114110 - 09/30110 10117/11 55112854626370001 55112854526370001 2,415.73 1,065.23 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 10/01/10 - 10/31110 10124/11 66112924697180001 55112924697180001 4,896.68 3,694.20 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 11/01/10 - 11/30110 10124111 55112924697000001 56112924697000001 5,707.50 4,401.87 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 12/01110 - 12/31110 10/24/11 56112924697250001 55112924697260001 6,515.34 4,208.87 DIAGNOSIS I : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01/11 - 01/31111 10131111 55112994682620001 65112994682620001 6,897.75 4,529.62 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 2 of 20 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME GOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 DATE OF SERVICE I PAYMENT DATE ORIGINAL CRN ADJUSTED CRN 5SUALCHARGES JAMOUNTAPPROVED 02/01111 - 02/28/11 10/31/11 55112994682740001 55112994682740001 6,327.00 3,969.17 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 03101/11 - 03/31111 10/31111 55112994682820001 55112994682820001 5,897.76 4,529.62 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 04/01/11 - 04/30/11 11/07/11 56113054597280001 65113064597280001 5,327.01 4,119.06 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01/11 - 05131111 11107111 55113054597350001 55113064597350001 5,897.75 4,706.63 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 06/01/11 - 06/30/11 11/07/11 551130 W 97500001 55113054597500001 5,897.75 4,510.77 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 07/01111 - 07/31111 05/07/12 55121244027300001 55121244027300001 5,897.76 4,733.91 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 08/01111 - 08/31/11 05/07112 55121244027370001 55121244027370001 5,897.75 4,733.91 DIAGNOSIS I : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 09101111 - 09/30111 05/07/12 55121244027440001 56121244027440001 5,707.50 4,537.17 DIAGNOSIS I : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 3 of 10 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF PUBLIC WELFARE71 ` June 10,2014 STATEMENT OF CLAIM NAME LOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 DATE.OF SERVICE PAYMENT DATE ORIGINAL CRN"' ADJUSTED CRN USUAL CNARGES AMOUNT APPROVED 10/01/11 - 10/31/11 06/18/12 55121654428710001 55121654429710001 6,071.66 4,481.57 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 11/01/11 - 11/30/11 06118/12 55121654429810001 55121654429810001 5,875.80 4,292.97 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 12/01/11 - 12/31/11 06/18/12 55121664430010001 55121654430010001 6,071.66 4,481.57 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01/12 - 01/31/12 07/16/12 65121944289860001 56121944289860001 6,071.66 4,430.96 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 02/01/12 - 02/29112 07/16/12 55121944289870001 55121944289870001 5,679.94 4,059.36 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000' 03/01/12 - 03/31/12 07/16/12 56121944289910001 55121944289910001 6,071.66 4,430.96 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 04/01/12 - 04/30112 05/28/12 20121234027970001 20121234027970001 9,990.00 4,852.06 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01/12 - 05/31/12 07/02/12 20121604020160001 20121604020160001 6,386.93 5,058.09 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 4 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME LOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17065 IUSUAL DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN T I S AMOUNTAPPROVED 06/01/12 - 06/30/12 07/30112 20121874035650001 20121874035650001 4,120.61 2,791.76 DIAGNOSIS 1 : 2449 HYPOTHYROIDISM NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 08/01112 - 08131/12 01114/13 55130104568330001 55130104568330001 4,326.63 3,028.03 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 09/01112 - 09/30/12 01114/13 55130104568460001 56130104568460001 6,180.90 4,895.26 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 10101/12 - 10131/12 01/28113 55130245508750001 55130246508760001 6,386.93 4,712.75 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 11/01112 - 11/30/12 01/28/13 55130245508900001 55130245508900001 6,180.90 4,517.86 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 12101112 - 12131112 01/28113 55130245509190001 55130245509190001 6,041.59 4,712.76 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01/13 - 01/31/13 04122/13 69130884020630001 69130884020530001 6,084.99 4,746.76 DIAGNOSIS I : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 02101113 - 02/28/13 04/29113 69130924022770001 69130924022770001 5,496.12 4,157.89 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 5 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME GOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVEIJ 03/01/13 - 03/31/13 04/29/13 27130924021370001 27130924021370001 6,084.99 4,746.76 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 04/01/13 - 04/30113 05127113 20131214084310001 20131214084310001 10,380.00 4,793.17 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01/13 - 05/31/13 07/01/13 20131554024450001 20131554024450001 6,335.78 4,997.55 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 06/01113 - 06/30113 07/29/13 20131834027950001 20131834027950001 6,131.40 4,793.17 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 07/01/13 - 07/31/13 01/13/14 55140074399190001 55140074399190001 6,335.78 5,162.47 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 08/01113 - 08/31/13 01/13114 55140074399600001 55140074399600001 6,335.78 5,162.52 DIAGNOSIS i : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 09/01/13 - 09/30/13 01/13/14 55140074399610001 55140074399610001 6,131.40 4,952.82 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE : 0000000 10/01/13 - 10/31/13 01/20/14 55140154229640001 55140154229640001 6,335.78 5,119.43 DIAGNOSIS i : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 6 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME DOUSE,ELIZABETH ID 018 832 323 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 DATE OF SERVICE I PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11/01/13 - 11/30/13 01/20/14 55140164229830001 55140154229830001 6,131.40 4,911.12 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 12101113 - 12131/13 01127/14 55140164230100001 55140154230100001 6,335.78 5,119.43 DIAGNOSIS 1 : 78097 ALTERED MENTALSTATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01/14 - 01/31114 03/24/14 69140584026300001 69140584025300001 4,696.32 3,331.75 DIAGNOSIS 1 : 78097 ALTERED MENTAL STATUS DIAGNOSIS 2: 0 PROC CODE: 0000000 03114/14 - 03/22114 04/28114 27140924031790001 27140924031790001 1,544.00 179.42 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 0 PROC CODE: 0000000 PROVIDER SUB TOTAL BETHANY VILLAGE RETIREMENT CENTER 247,043.36 181,198.04 03 101750581 0003 Page 7 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME LOUSE,ELIZABETH 113 018 832 323 CONTINUING CARE RX 28 S,2ND,ST NEWPORT PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN T-ADJUSTED CRN USUAL CHARGES AMOUNTAPPRO.VED 04/24/10 - 04/24/10 06/21/10 25101465234490001 26101465234490001 223.11 24.23 DIAGNOSIS 1 : 0 NDC CODE: 63481068706 LIDODERM 5%PATCH - ANESTHETIC LOCAL TOPICAL 04128110 - 04/28110 06121110 25101465234500001 25101465234500001 6.61 4.43 DIAGNOSIS 1 : 0 NDC CODE: 00409610204 FUROSEMIDE 40 MG/4 ML VIAL - DIURETICS 06/04/10 - 06/04/10 07/06110 25101595367800001 25101695367800001 81.91 30.91 DIAGNOSIS 1 : 0 NDC CODE: 00071101368 LYRICA 50 MG CAPSULE - ANTICONVULSANTS 06/09/10 - 06/09110 07/05/10 25101605279900001 25101605279900001 223.11 203.16 DIAGNOSIS 1 : 0 NDC CODE: 63481068706 LIDODERM 6%PATCH - ANESTHETIC LOCAL TOPICAL 06/11/10 - 06/11110 07/05/10 26101626273860001 25101625273860001 12.53 5.14 DIAGNOSIS 1 : 0 - NDC CODE: 50111039803 HYDRALAZINE 10 MG TABLET - OTHER ANTIHYPERTENSIVES 06/100 - 06116/10 07112110 25101685567570001 25101686557570001 12.55 5.27 DIAGNOSIS 1 : 0 NDC CODE: 00378001805 METOPRbLOL TARTRATE 25 MG TAB - OTHER CARDIOVASCULAR PREPS 06116/10 - 06/16/10 07/12/10 2510685567850001 25101686567850001 9.78 5.01 DIAGNOSIS 1 : 0 NDC CODE: 00378020810 FUROSEMIDE 20 MG TABLET - DIURETICS 06/16/10 - 06/16/10 07/12/10 25101685658670001 25101685558670001 252.10 229.76 DIAGNOSIS 1 : 0 NDC CODE: 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS Page 8 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME GOUSE,ELIZABETH ID 018 832 323 CONTINUING CARE RX 28 S 2ND ST NEWPORT PA 17074 ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED DATE OF SERVICE I PAYMENT DATE 1 . ORIGINAL CRN 06116110 - 06116/10 07112/10 25101686558870001 25101685558870001 16.02 3.71 DIAGNOSIS 1 : 0 NDC CODE: 00378180510 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS 06116110 - 06/16110 07/12110 25101685559610001 25101685559610001 12.75 3.82 DIAGNOSIS 1 : 0 NDC CODE: 00591564310 ALLOPURINOL 100 MG TABLET ANTIARTHRITICS 06/16/10 - 06/16110 07/12/10 25101685560700001 25101685560700001 19.33 .79 DIAGNOSIS 1 : 0 NDC CODE: 00591079410 DICYCLOMINE 10 MG CAPSULE ANTISPASMODIC AND ANTICHOLINERGIC AGENTS 06/21110 - 06121/10 07119110 25101726345300001 25101725345300001 223.11 203.16 DIAGNOSIS 1 : 0 NDC CODE: 63481068706 LIDODERM 5%PATCH - ANESTHETIC LOCAL TOPICAL 10/21/10 - 10/21/10 11/15/10 25102945597140001 25102945597140001 4.59 4.04 DIAGNOSIS 1 : 0 NDC CODE: 00228206750 LORAZEPAM 0.6 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER SUBTOTAL CONTINUING CARE RX 1,097.50 723.43 24 100731447 0011 Page 9 of 10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 10,2014 STATEMENT OF CLAIM NAME LOUSE,ELIZABETH ID 018 832 323 WEST SHORE ADV LIFE SUP SVC 503 N 21 ST ST CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED] 01/24/14 - 01/24/14 03/17/14 27140596217790001 27140596217790001 994.54 80.00 DIAGNOSIS 1 : 78907 ABDOMINAL PAIN GENERALIZE PROC CODE: A0432 PARAMEDIC INTERCEPTRURAL AREA,TRANSPORT PROVIDER SUB TOTAL WEST SHORE ADV LIFE SUP SVC 994.64 80.00 26 001173277 0001 Page 10 of 10