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Home My WebLink About06-19-15 iuu � � ii � . � � JE��' pennsylvania 15 0 5 618 4 0 3 ��e DEPARTMENTOFREVEN�X(03-14) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburq PA 17128-0601 RESIDENT DECEDENT 21 0 9 1118 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 11 29 2009 01 18 1926 DecedenYs Last Name Suffix DecedenYs First Name M� POTTER BARBARA 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 a1. 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) � 7. Decedent Died Testate � 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 � 14. Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number JEFFREY R BOSWELL ESQUIRE 717 236 9377 First Line of Address 315 N FRONT STREET Second Line of Address P 0 BOX 741 City or Post Office State ZIP Code HARRISBURG PA 171080741 CorrespondenYs email address: Jboswell(a�btpalaw.com REGISTER OF WILLS USE ONLY r7 �., REGISTER OF WILLS USE ONLY C �=.,� ^"' � `�-.+ _ � DATE FILED MMDDYYYY ^ ' C::7 _U C� I', ('+� ":7 f-.._ ,,� C'� TI S.�:'` � �,'.� *~ +l , P''1 � .`.�f .. ��',,,, ;. � C� ,�.,, ...,.i DATE F1L�D�TAMP -' > � l �� - . , �_. _..,r ('� . ;:i _':'.�. ,`..._ !_.,..� C�.ti) i:,'� �'.7 Side 1 � `rl � I I��III I��I�I I III� II II I I� ��I I�III'�II II�I I I II�I 1505618403 1505618403 � � in � � ii � PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Potter, Barbara Ann 21-09-1118 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements,and to the best of my knowledge and belief,it is true,correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. � Signature#2 Name Brett Guy Holmes Address1 1040 West Foxcroft Drive Address2 City, State,Zip Camp Hill PA 17011 Date � �� i uu � � i� � � 1505618411 REV-1500 EX DecedenYs Social Security Number DecedenYs Name: POtt@C, Barbara Ann 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(Schedufe D).................................................... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 19 ,6 0 8 • 6 5 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. 19 ,6�8 - 6 5 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 8 , 416 • 5 7 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 14 2 ,4 6 7 • 6 3 11. Total Deductions(total Lines 9 and 10)................................................................ ��. 15 O ,8 8 4 • 2 0 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -131 ,2 7 5 • 5 5 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. -131 ,2 7 5 • 5 5 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 15. 0 - 0 0 16. Amount of Line 14 taxable at lineal rate X .045 ❑ • 0 0 16. ❑ • ❑0 17. Amount of Line 14 taxable at sibling rate X .12 0 - 0 0 17. 0 • 0 0 18. Amount of�ine 14 taxable at collateral rate X.15 0 - 0 0 18. 0 • 0� 19. TAX DUE................................................................................................................ 19. 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. SIGNATURE OF PERSOf;�F�SPOf� IB�FOR II,ING RETURN Charles P. Holmes n DATE - �.�u/.�ii�-u- (/� �I�1V'�i YLL�t �i C.�/�� ADDRESS Greenwood Lake, NY 10925 SIGNATURE �P� OTH�RTHAN REPRESENTATIVE Jeffrey R. Boswell, Esquire � QATE� ZO I.7 ��S ADDRESS 315 N. Front Street, Harrisburg, PA 17108-0741 � I II II IIII II I I�II II I�I I� II)IIIII'III III'I IIII IIII Side 2 1505618411 1505618411 � i u � � i� � REV-1500 EX Page 3 File Number 21-09-1118 Decedent's Complete Address: DECEDENT'S NAME Potter, Barbara Ann STREET ADDRESS 46 Erford Road - _ CITY � STATE �ZIP Camp Hill PA j 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� Make Check Payable to: REGISTER OF WILLS, AGENT. --- __-- ---�i NI�� 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:............................................................................... [_� � b. retain the right to designate who shall use the property transferred or its income:.................................. � �� c. retain a reversionary interest;or............................................................................................................... x 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?.................................................................................................................... �_� �� 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... �li �X I 4. Did decedent own an individual retirement account, annuity,or other non-probate property which I l � contains a beneficiary designation?.................................................................................................................. I—I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. � I�,� 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 fling 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 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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 decedenPs 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. iuu � � i� � Rev-1508 EX+�OS-12) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENTOFREVENUE pERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF I FILE NUMBER Potter, Barbara Ann 21-09-1118 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 Personal injury/motorvehicle accident claim-Estate of Barbara A. Potter v.Johnson-CCCP 15,940.07 08-6157-net settlement proceeds($25,000-$9,059.93 attorney fees and litigation costs) 2 PNC Bank-BAP Regular Checking Account No.5004145752 3,440.65 3 AmeriGas -customer refund 225.94 4 PNC-overdraft litigation settlement 1.99 TOTAL(Also enter on Line 5, Recapitulation) 19,608.65 (If more space is needed,additional pages of the same size) Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 08-12) I IIIR II I�IIIII 1 REV-1511 EX+(OS-13) pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND RESIDENTDECEDENTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Potter, Barbara Ann 21-09-1118 DecedenYs debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER q, FUNERAL EXPENSES: See continuation schedule(s) attached 3,691.32 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Charles P. Holmes Brett Guy Holmes StreetAddress 1040 West Foxcroft Drive City Camp Hill State PA Zio 17011 Year(s)Commission Paid Waived 2. Attorney's Fees Boswell,Tintner& Piccola 2,000.00 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 98.00 5. AccountanYs Fees 6. Tax Return Preparer's Fees 500.00 7. Other Administrative Costs 2,127.25 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 8,416.57 Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13) i uu � � i� i Y SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Potter, Barbara Ann 21-09-1118 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex ep nses 1 Charles P. Holmes-funeral dinner for immediate family 170.54 2 Maye's Memorials-memorial marker 700.00 3 Parthemore Funeral Home-funeral 2,820•7$ H-A 3,691.32 Other Administrative Costs 4 Boswell, Tintner&Piccola-disbursements 71.21 5 Charles P. Holmes -reimbursement for family funeral costs 708.39 6 Charles P. Holmes-reimbursement for travel expenses,estate administration 915.20 7 Closing Costs 150.00 8 Cumberland Law Journal -legal advertising 75.00 9 Journal Publications-legal advertising 151.00 10 Sovereign Bank-estate check fee 31.45 11 Sovereign Bank-bank fees 25.00 H-B7 2,127.25 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) iuo � � i� � Rev-1512 EX+(12-12) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF IFILE NUMBER Potter, Barbara Ann 21-09-1118 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 Benefits Coordination&Recovery Center-Center for Medicare and Medicaid Services 15,940.07 (subrogation claim/,motor vehicle accident) 2 Golden Living Center-room charges 208.75 3 Highmark Retirement Plan-return of pension payment 230.76 4 PA Department of Public Welfare-medical assistance reimbursement: $17,150.45(Class 3 17,150.45 claim)-see attached 5 PA Department of Public Welfare-medical assistance reimbursement: $108,937.60(Class 5.1 108,937.60 claim)-see attached TOTAL(Also enter on Line 10, Recapitulation) 142,467.63 (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) i ua � � i� � FCEV-1573 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OFREVENUE INHERITANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Potter, Barbara Ann 21-09-1118 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$) o Not List T stee s TAXABLE DISTRIBUTIONS [include outright spousal I• distnbuUons,and transfers under Sec.9116 a 1.2 Brett Guy Holmes Son 50%of residuary 1040 West Foxcroft Drive estate Camp Hill, PA 17011 Charles P. Holmes Son 50% of residuary P.O. Box 623 estate Greenwood Lake, NY 10925 Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. 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 OF BARBIIRA ANN POTTER n� C-) r_-3 c�� _ CT� ..ci _4 �:lJ ��7 - �U� � � '_ � , --. �� i ��— �� '^ � ' , , � i -_�,7�� ' � _ti`_'t�1 -.--�.T. ` 1 i_ �� _- �, _ .- _._ ..-1: � , �... TI -CJ-� � � `-- ' � l�1 � Jeffrey R. Boswell, Esquire Boswell, Tintner, Piccola & Wickersham 315 North Front Street Hamsburg, Pennsylvania 17101 (717) 236-9377 i uu � ■ i� . LAST WILL AND TESTAMENT OF BARBARA ANNPOTTER Introductory Clause. I,BARBARA ANNPOTTER, a resident of and domiciled in the Borough of Wormleysburg, County of Cumberland and Commonwealth of Pennsylvania, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils at any time heretofore made by me. I have two living children: CHARLES P. HOLMES and BRETT GUYHOLMES. ITEM I Direction to Pay Debts. I direct that all my legally enforceable debts, secured and unsecured, be paid as soon as practicable after my death. ITEM II Direction to Pay All Taxes from Residuary Estate. I direct that all estate, inheritance, succession, death or similar taxes (except generation-skipping transfer taxes) assessed with respect to my estate herein disposed of, or any part thereof, or on any bequest or devise contained in this my Last Will (which term wherever used herein shall include any Codicil hereto), or on any insurance upon my life or on any property held jointly by me with another or on any transfer made by me during my lifetime or on any other property or interests in property included in my estate for such tax purposes be paid out of my residuary estate and shall not be charged to or against any recipient, beneficiary, transferee or owner of any such property or interests in property included in my estate for such tax purposes. ITENT III General Bequest of Personal and Household Effects With a Precatory Memorandum. I give and bequeath all my personal and household effects of every kind including but not limited to furniture, appliances, furnishings, pictures, silverware, china, glass, books,jewelry, wearing apparel, boats, automobiles, and other vehicles, and all policies of fire, burglary, property damage, and other insurance on ar in connection with the use of this property, to my children surviving me in approximately equal shares; provided, however, the issue of a deceased child surviving me shall take per stirpes the share their parent would have taken had he or she survived me. If my issue do not agree to the division of the property among themselves, my Executor shall make such division among them, the decision of my Executor to be in all Last Will and Testarnent o(BARBARA ANN POTTER Page t respects binding upon my issue. I request that my Executor and my issue abide by any memorandum by me directing the disposition of this property or any part thereof. This request is precatory and not mandatory. If any beneficiary hereunder is a minor, my Executor may distribute such minor's share to such minor or for such minor's use to any person with whom such minor is residing or who has the care or control of such minor without further responsibility and the receipt of the person to whom it is distributed shall be a complete discharge of my Executor. The cost of packing and shipping such property shall be charged against my estate as an expense of administration. ITEM IV Outright Gift of All Property to Children, Contingent Gift to Named Beneficiary. I give, devise and bequeath all the rest, residue and remainder of my property of every kind and description (including lapsed legacies and devises) wherever situate and whether acquired before or after the execution of this Will, absolutely in fee simple to my surviving children in equal shares, provided, however, the then living issue of a deceased child of mine shall take per stirpes the share their parent would have taken had he or she survived me. ITEM V Naming the Executor, Executor Succession, Executor's Fees and Other Matters. The provisions for naming the Executor, Executor succession, Executor's fees and other matters are set forth below: (1) Naming Individuals as Executor. I hereby nominate, constitute and appoint as Executors of this my Last Will and Testament CHARLES P. HOLMES and BRETT GUY HOLMES and direct that they shall serve without bond. (2) Individual Executors Succession. If any individual Executor should fail to qualify as Executor hereunder, or for any reason should cease to act in such capacity, the remaining individual Executors shall continue to serve without a successor or substitute. (3) Fee Schedule for Individual Executor. For its services as Executor, the individual Executor shall receive reasonable compensation for the services rendered and reimbursement for reasonable expenses. (4) Executor Voting Rights. If there is more than one Executor serving, then the vote of the Executors for any action hereunder must be by unanimous vote of the Executors. ITEM VI Definition of Executor. Whenever the word "Executor" or any modifying or substituted pronoun therefor is used in this my Will, such words and respective pronouns shall include both the singular and the plural, the masculine, feminine and neuter gender tliereof, and shall apply Last Will and Tatarnent of BARBARA ANN POTTER Page 2 equally to the Executor named herein and to any successor or substitute Executor acting hereunder, and such successor or substitute Executor shall possess all the rights, powers and duties, authority and responsibility conferred upon the Executor originally named herein. ITEM VII Powers for Executor. By way of illustration and not of limitation and in addition to any inherent, implied or statutory powers granted to Executors generally, my Executor is specifically authorized and empowered with respect to any property, real or personal, at any time held under any provision of this my Will: to allot, allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, contract with respect to, continue any business of mine, convey, convert, deal with, dispose of, enter into, exchange, hold, improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise options with respect to, take possession of, pledge, receive, release, repair, sell, sue for, to make distributions or divisions in cash or in kind or partly in each without regard to the income tax basis of such asset, and in general, to exercise all the powers in the management of my Estate which any individual could exercise in the management of similar property owned in his or her own right, upon such terms and CGriCIltivilS as to riiy�xecutor rnay seem best, and to execuie and deiiver any anci all instruments and to do all acts which my Executor may deem proper or necessary to carry out the purposes of this my Will, without being limited in any way by the specific grants of power made, and without the necessity of a court order. ITEM VIII Provision for Executor to Act as Trustee for Beneficiary Under Age Twenty-One. If any share or property hereunder becomes distributable to a beneficiary��ho has not attained the age of Twenty-one (21) years or if any real property shall be devised to a person who has not attained the age of Twenty-one (21) years at the date of my death, then such share or property shall immediately vest in the beneficiary, but notwithstanding the provisions herein, my Executor acting as Trustee shall retain possession of the share or property in trust for the beneficiary until the beneficiary attains the age of Twenty-one (21), using so much of the net income and principal of the share or property as my Executor deems necessary to provide for the medical care, education, support and maintenance in reasonable comfort of the beneficiary, taking into consideration to the extent my Executor deems advisable any other incoine or resources of the beneficiary or his or her parents known to my Executor. Any income not so paid or applied shall be accumulated and added to principal. The beneficiary's share or property shall be paid over, distributed and conveyed to the beneficiary upon attaining age Twetity-one (21), or if he or she shall sooner die, to his or her executors or administrators. Whenever my Executor determines it appropriate to pay any money for the benefit of a beneficiary for whom a trust is created hereunder, then the amounts shall be paid out by my Executor in such of the following ways as my Executor deems best: (1) directly to the beneficiary; (2) to the legally appointed guardian of the beneficiary; (3) to some relative or friend for the care, support and education of the beneficiary; (4) by my Executor using such amounts directly for the beneficiary's care, support and education; (5) to a custodian for the beneficiary under the Uniform Gifts or Transfers to I,ast Will and Testarr�ent of BARBARA ANN P07"CER Page 3 Minors Act. My Executor as trustee shall have with respect to each share or property so retained all the powers and discretions conferred upon it as Executor. ITEM IX Discretion Granted to Executor in Reference to Tax Matters. My Executor as the fiduciary of my estate shall have the discretion, but shall not be required when allocating receipts of my estate between income and principal, to make adjustments in the 1-ights of any beneficiaries, or among the principal and income accounts to compensate for the consequences of any tax decision or election, or of any investment or administrative decision, that my Executor believes has had the effect, directly or indirectly, of preferring one beneficiary or group of beneficiaries over others; provided, however, my Executor shall not exercise its discretion in a manner which would cause the loss or reduction of the marital deduction as may be herein provided. In determining the state or federal estate and income tax lial�ilities of my estate, my Executor shall have discretion to select the valuation date and to detennine whether any or all of the allowable administration expenses in my estate shall be used as state or federal estate tax deductions or as state or federal income tax deductions. ITEM X - Definition of Children. For purposes of this Will, "children" means the lawful blood descendants in the first degree of the parent designated; and "issue" and "descendants" mean the lawful blood descendants in any degree of the ancestor designated; provided, however, that if a person has been adopted, that person shall be considered a child of such adopting parent and such adopted child and his or her issue shall be considered as issue of the adapting parent or parents and of anyone who is by blood or adoption an ancestor of the adopting parent or either of the adopting parents. The terms "child," "children," "issue," "descendant" a�id "descendants" or those terms preceded by the terms "living" or "then living" shall include the lawful blood descendant in the first degree of the parent designated even though such descendant is born after the death of such parent. The term "per stirpes" as used herein has the identical meaning as the term "taking by representation" as defined in the Pennsylvania Probate Code. Testimonium Cla se. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal this��ay of April, 2002. ��__��Z�E�-) BARBARA ANN POTTER I.azt Will and Testament of BARBARA ANN POTTER Page 4 Attestation Clause. The foregoing Will bearing on the margin the signature of the Testatrix, was this�day of April, 2002, signed, sealed, published and declared by the Testatrix as and for her Last Will and Testament in our presence, and we, at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses on the above date. . of �.,�`L� � ,�.,"--��(�.�,— — --,--. . ,, - - � / �j�/f � � ��1' s ? Of �._��"t1j/Lt-%i,�"1GL?._C r:f't �/�� ,� . v.: Last Will and Testament of BARBARA ANN POTTER Page 5 � u � ■ i� . PROOF OF WII,L COMMONWEALTH OF PENNSYLVANIA : : Self-Provi�ng Affidavit COUNTY OF DAUPHIN � We,BARBARA ANNPOTTER, and Jeffrey R. Boswell _and Diane E. Grissinge�the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last `�Jill and that she had signed willingly(or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and tliat each of the witnesses, in the presence and hearing of the Testatrix, and in the presence of each other, signed the Will as �V1ii1eSS S17U' iu iriE uESt O�t'iL11"i{iiGW�2�gE tri2 Tes�atrix �as at i�lui ti�i�� i�ii�e�il `y'�?,S C��e �; older, of sound mind, and under no constraint or undue influence. -✓ �,.-,t,� ��r�-� BARBARA ANNPOTTER f Witrie �� , - /I(.'��r-n� % l��-�-f '`��t-' =�-U� Witness ��— Subscribed, sworn to, and acknowledged hefare me by BAR�ARA AN1V POTTEdZ, the Testatrix and subscribed and sworn to before me by Jeffrey x. Boswell and Diane E. Grissinger , witnesses, this 18ttrlay of April, 2002. l ._____ fr; .�� : �_ . �,�t� e�:l} No ary Public for Pennsylvania Notariat Seal My Commission Expires: ►,ie� Ha��V.Nota� Pub�ic Ha►risburg,Dauphin�nty My Commisslon Expires Feb.10,2003 Iast Will and Testament of BARBARA ANN P07"CER Page 6 I I111' I� I�lul • ,BPNCBANK PNC Bank,National Association Cashier's Check No. 03571231 Date January 26, 2010 a 0 � 0 o Pay to the order of ESTATE OF BARBARlA A POTTER _ $ 3,440.65 � � Three Thousand Four Hundred Forty Dollars And Sixtv-five Cents w Non-Negotiable Customer Copy 5004145752 Remitter • � , Il i , t !; . e . � ua � ■ i� . �y�o`t (?'`73 :..T,:.,47 � .. 4 —��"r l],� ��,.. ..�.. ' "�# \ � � �� `¢� � 7' ! � VOID IF NOT PRESENTED WITHIN 6 MONTHS AFTER DATE OF ISSUis' ate ssue rea O E' 1'3 56-389 o icy nsure Number 480019211 4�z 47932066 -002 JOHNSON, CHARLES 10/29/2013 165 Claim # Claimant Date of Loss State Code Office Issued At PAC 060 1 1 1 820 POTTER,BARBARA 10/20/2006 PA PA-PALLC-REG- Dollars $*****25,000.00 Pay TWENTY FNE THOUSAND AND 00/100 In Payment Of FULL AND FINAL SETTLEMENT OF ALL CLAIMS AND DEMANDS CODE 12PCL Payable throngh PNC Bank� �./�+ O■ O Ashland, Ohio 1-877-448-9544 Progressive Specialty Insurance Company Pay CHARLES P. HOMES AND BRETT GUY HOLMES, AS EXECUTORS OF THE TO ESTATE OF BARBARA POTTER, AND THEII2 ATTORNEY ************* BOSWELL, TINTNER&PICCOLA, ONLY ************************* The 315 NORTH FRONT ST. - Order HARRISBURG PA 17108-0741 - Of By � Authorized si nature ii■4800 L9 2 L Lii' �:04 L 203895�: 4 239694508►i' ��` enns lvania � +2��3`'�'3 � P Y DEPARTMENT OF PUBLIC WELFARE December 17, 2013 BOSWELL TINTNER PICCOLA & ALFORD JEFFREY R BOSWELL ESQUIRE 315 N FRONT ST HARRISBURG PA 17101 Re: Barbara Potter CIS #: 880187583 SSN: ###-##-1176 Date of Death: 11/29/2009 ESTATE RECOVERY STATEMENT OF CI..AIM Dear Attorney Boswell: Under State and Federal law, the Department of Pubiic 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 $126,088.05 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 $17,150.45, was incurred during the last six months of the decedent's life; therefore, it is a Ctass 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 �108,937.60, is to be entered as a priority Class 5.1 claim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. �., Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 JZ l3 ��' pennsyLvania DEPARTMENT OF PUBIIC 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 document computation of 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 taw, 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 � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 ��f pennsylvania � 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 qreater 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, n J�� ,! ,+d� � rJ �� /��r�. (,.c4.,,��t�/'�+.+�-. +...•C�L.ir G Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-£3486 COMMONWEA�TH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 December 4,2013 STATEMENT OF CLAIM SUMMARY `NAME' Estate of POTTER,BARBARA ID 880 187 583 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 11.50 11.50 LONG TERM CARE 17,130.37 108,761.17 125,891.54 DRUG 20.08 164.93 185.01 REIMBURSEMENTTO DPW 17,150.45 108,937.60 126,088.05 - --- ---_ — . --- --_ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE E W- 23-6003113' Page 1 of 11 COMMONWEALTH OF PENNSYLVANIA [ DEPARTMENT OF PUBLIC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 PHILHAVEN HOSPITAL 283 S BUTLER RD MOUNT GRETNA PA 17064 DATE OF SERVICE PAYMENT DATE `ORIGINAL CRN ` ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 01/08/09 - 01/08/09 02/16/09 27090441000820001 27090441000820001 80.00 11.50 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA,UNCOMPLICATED PROC CODE: 99302 EVALUATION AND MANAGEMENT OF A NEW OR ES PROVIDER SUB TOTAL PHILHAVEN HOSPITAL 80.00 11.50 01 100772000 0016 Page 2 of 11 `COMMONWEALTH OF PENNSYLVANIA �_ DEPARTMENT OF PUBLIC WELFARE _ _ _ December 4,2013 STATEMENT OF CLAIM NAME ' POTTER,BARBARA ID 880 187 583 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/13/07 - 02/28/07 09/17/07 20072354021310001 20072354021310001 2,579.52 1,611.17 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 03/01/07 - 03/31/07 09/17/07 20072354021330001 20072354021330001 4,997.82 4,002.47 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 04/01/07 - 04/30/07 09/17/07 20072354021350001 20072354021350001 4,929.60 3,934.25 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 05/01l07 - 05/31/07 09/17/07 20072354021360001 20072354021360001 3,286.38 2,291.05 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2 : 00245 PROC CODE : 0000000 07/01l07 - 07/31/07 10I22/07 55072904705720001 55072904705720001 3,122.08 2,218.94 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 08/01/07 - O8/31/07 10/22/07 55072904706080001 55072904706080001 5,093.92 4,245.86 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 09/01/07 - 09/30/07 10/29/07 55072904706580001 55072904706580001 4,929.60 4,076.95 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 10/01/07 - 10I31/07 11/26/07 20073054231120001 20073054231120001 5,285.81 4,295.46 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 Page 3 of i l � Y COMMONWEALTH OF PENNSYLVANIA_— DEPARTMENT OF PUBLIC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN 'ADJUSTED GRN. USUAL CHARGES AMOUNT APPROVED 11/01/07 - 11/30/07 12/31/07 20073404110380001 20073404110380001 5,001.63 4,011.28 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 12/01/O7 - 12/31/07 01/28/08 20080034146620001 20080034146620001 5,285.81 4,295.46 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 01/01/08 - 01/31/08 02/25/08 20080324081760001 20080324081760001 5,236.21 4,245.86 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 02/01/08 - 02/29/08 03/31/08 20080664144760001 20080664144760001 4,898.39 3,908.04 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 03/01/08 - 03/31/08 05/26/08 69081194020790001 69081194020790001 5,236.21 4,235.41 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2 : 00245 PROC CODE : 0000000 04/01/08 - 04/30/08 OS/26/08 20081224235220001 20081224235220001 4,947.90 3,947.10 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 05/01/08 - 05/31/08 06/30/08 20081574127000001 20081574127000061 5,112.83 4,112.03 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 06/01/08 - 06/30/08 07/28/08 20081854157610001 20081854157610001 4,947.90 3,947.10 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 Page 4 of l i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE' December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 GOLDEN LIViNGCENTER-CAMP HIL� 46 ERFORD RD CAMP HILL PA 17011 bATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 07/01/08 - 07/31/08 03/02/09 55090574974180001 55090574974180001 5,617.51 4,637.79 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 08/01/08 - 08/31/08 03/02/09 55090574974690001 55090574974690001 5,617.51 4,637.79 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 09/01l08 - 09/30/08 03/02/09 55090574975240001 55090574975240001 5,436.30 4,455.90 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 10/01/08 - 10/31/08 03/23/09 55090784292690001 55090784292690001 5,617.51 4,562.46 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 11/01/O8 - 11/30/08 03/23/09 55090784293190001 55090784293190001 5,456.70 4,383.00 DIAGNOSIS 1 : 8209 FX NEGK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 12/01/08 - 12/31/OS 03/23/09 55090784293700001 55090784293700001 5,638.59 4,562.46 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 01/01/09 - 01/31/09 05/11/09 69091144021510001 69091144021510001 5,638.59 4,471.48 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 02/01/09 - 02/28/09 OS/11/09 69091144021520001 69091144021520001 5,092.92 3,940.36 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 Page 5 of 11 COMMONWFALTH OF PENNSYLVANIA � DEPARTAAENT OF-PUBLIC WELFARE ' ' December 4,2013 STATEMENT OF CLAIM NANIE POTTER,BARBARA ID - 880 187 583 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/01/09 - 03/31/09 OS/11/09 69091144021540001 69091144021540001 5,488.24 4,471.48 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 04/01/09 - 04/30/09 05/18/09 20091214110990001 20091214110990001 5,554.20 4,537.44 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 05/01/09 - OS/31/09 06/22/09 20091544188360001 20091544188360001 5,739.34 4,722.58 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 06/01/09 - 06/30/09 07/20/09 20091834140870001 20091834140870001 5,554.20 4,537.44 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 07/01/09 - 07/31/09 11/O8/10 55103074394290001 55103074394290001 5,739.34 4,759.47 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 O8/01/09 - 08/31/09 11/08/10 55103074394710001 55103074394710001 5,739.34 4,759.47 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE : 0000000 09/01/09 - 09/30/09 11/O8/10 55103074395190001 55103074395190001 3,394.19 2,399.29 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 Page 6 of 11 — --_ � COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11/01/09 - 11129/09 11/15/10 55103145102230001 55103145102230001 5,183.92 674.70 DIAGNOSIS 1 : 8209 FX NECK OF FEMUR NOS-OPN DIAGNOSIS 2: 00245 PROC CODE: 0000000 PROVIDER SUB TOTAL GOLDEN LIVINGCENTER-CAMP HILL 161,400.01 125,891.54 03 101553090 0001 Page 7 of 11 � COMMONWEALTH OF PENNSYLVANIA L DEPARTMENT OF PUBLIC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 PHARMERICA INC#22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE ' PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 07/18/07 - 07/18/07 12/31/07 25073385220740001 25073385220740001 7•82 7•78 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS O8/22/07 - 08/22/6� 12/31/07 25073385220760001 25073385220760001 7-82 7.78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 09/19/07 - 09/19l07 12/31/07 25073405564600001 25073405564600001 7.82 7•78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 10/22/07 - 10/22/07 12/31/07 25073385220770001 25073385220770001 7•82 7•78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 11/19/07 - 11/19/07 12/31/07 25073385220780001 25073385220780001 7•$2 7•7$ DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 12/21/07 - 12/21/07 01/14/08 25073555239540001 25073555239540001 7•$2 �•7$ DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 01/21/08 - 01/21/08 02/18/08 25080215568230001 25080215568230001 7•$2 �•78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 02/13/08 - 02/13/08 03/10/08 25080445230070001 25080445230070001 7•$2 3•�8 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS Page 8 of 11 GOMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE - December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 PHARMERICA INC#22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE PAYMENTDATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/10/08 - 03I10/08 04/07/08 25080705344880001 25080705344880001 7.82 7•78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 04/02/O8 - 04/02/08 04/28/08 25080935240110001 25080935240110001 7.82 3•78 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 05/22/08 - 05/22/08 06/16/08 25081435557300001 25081435557300001 7.82 7•78 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS O6/23/O8 - 06/23/08 07/21/08 25081755445810001 25081755445810001 7.82 6•99 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 07/16/08 - 07/16/08 08/11/08 25081985232670001 25081985232670001 7.82 2•99 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 08/20/08 - 08/20/08 09/15lOS 25082335590260001 25082335590260001 7-82 6•99 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 08123/OS - 08/23/08 09/22/08 2508236532745Q001 25082365327450001 5.50 5.40 DIAGNOSIS 1 : 0 NOC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/17/08 - 09/17/08 10/13/08 25082615471140001 25082615471140001 5.40 5.40 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS Page 9 of 11 � COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 PHARMERICA INC#22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10l13/08 - 10/13/08 11/10/08 25082875478420001 25082875478420001 5.40 5.40 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/27/08 - 10/27/08 11/24/08 25083015220160001 25083015220160001 5.49 5.49 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 11/12/08 - 11/12/08 12/08/08 25083175561320001 25083175561320001 5.40 5.40 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/02/08 - 12/02/O8 12/29/08 25083375781570001 25083375781570001 5.49 5.49 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 12/12/08 - 12/12/08 01/05/09 25083475639800001 25083475639800001 5.40 5.25 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUI�IZERS 01/06/09 - 01/O6/09 02/02/09 25090065421480001 25090065421480001 5.49 5.30 DIAGNOSIS 1 : 0 NDC CODE: 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 01/08/09 - 01/08/09 02/02/09 25090085675620001 25090085675620001 5.40 5.25 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/29I09 - 01/29/09 02/23/09 25090295593890001 25090295593890001 6.79 2.50 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS Page 10 of l i COMMONWEALTH OF PENNSYLVANIA � � DEPARTMENT OF PUBUC WELFARE December 4,2013 STATEMENT OF CLAIM NAME POTTER,BARBARA ID 880 187 583 PHARMER�CA iNC#22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/25/09 - 02/25/09 03/23/09 25090565695240001 25090565695240001 6.79 6.50 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 03/30/09 - 03/30/09 04/27/09 25090895810280001 25090895810280001 6.50 6.50 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 04/29/09 - 04/29/09 05/25/09 25091195642910001 25091195642910001 6.50 6.50 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 06/05/09 - 06/05/09 06/29/09 25091565627530001 25091565627530001 6.25 6.25 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/07/09 - 07/07/09 08/03/09 25091885588680001 250918855886800Q1 6.28 6.28 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/07/09 - 08/07/09 08/31/09 25092195620380001 25092195620380001 6.28 6.28 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/18/09 - 08/18/09 10/OS(Q� 25092535343330001 25092535343330001 5.02 1.27 DIAGNOSIS 1 : 0 NDC CODE: 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER SUB TOTAL PHARMERICA INC#22000 208.86 185.01 24 100751181 0013 Page l l of i l . . . . � N��t� coB� C�S � � Coordination of CENTE0.5 FOR MEDICACE&MfDIUID SERVI� Beneftts and Recovery May 5, 2015 1691 1 MB 0.435 ***AUTO**MIXED AADC 720 R:1691 T:14 P:20 PC:1 F:504101 � C OPY� BOSWELL TINTER&PICCOLA 315 N FRONT ST HARRISBURG,PA 17101-1203 For Information Only �I��I'I�I�II�"II'�'�I�'I�I�'I�II��I��III��I�� ' May 5, 2015 � ' 1691 1 MB 0.435 ***AUTO**MIXED AADC 720 R:1691 T:14 P:20 PC:1 F:504101 CHARLES HOLMES ' BARBARA A POTTER CHARLES HOLMES FOR PO BOX 623 GREEI�IWOOD LAKE, NY 10925-0623 Medicare Number. ' 146141176A Beneficiary's Name: POTTER, BARBARA A Date of Incident: October 20,`2006 Case Identification Number: 20133 58090 01343 Insurer Claim Number: 0120060111820 Insurer Policy Number: 47932066002 Dear CHARLES HOLMES, We have received check number 008172 in the amount of $15,940.07. This amount has been applied to the outstanding debt due to Medicare. The principal amount of the debt and interest(if applicable) has been reduced to zero and our file is being closed. If a refund is due it will be processed and forwarded to the appi-opriate party under separate cover. If the original check submitted to Medicare had multiple payees it will be the attorney NGHP • PO BOX 138832 •OKLAHOMA CITY,OK 73113 SGL900NGHP Page 1 of 2 c � F:':� `-+'�` t:FB.�� '�-_�/�� '�/^S � L �___----�-'�: