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Home My WebLink About06-04-15 Ipennsylvania 1505614105 DERARTMENTOFREVENUE EX(03-14)(FI) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 280601 INHERITANCE TAX RETURN l�___., ___.. Harrisburg, PA 17128-0601 RESIDENT DECEDENTV_I I ( I� _J ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 170-30-8236 09062014 09271912 Decedent's Last Name Suffix Decedent's First Name MI [Green L-_-_ Be LA] 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 cD 1. Original Return O 2. Supplemental Return O 3. Remainder Return(date of death prior to 12-13-82) O 4.Agriculture Exemption(date of O 5. Future Interest Compromise(date of O 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) OD 7. Decedent Died Testate O 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) O 10. Litigation Proceeds Received O 11. Non-Probate Transferee Return O 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) O 13. Business Assets C=:) 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 Marvin Beshore, Esquire i(717) 236-0781 1 First Line of Address _ 130 State Street Second Line of Address City_ or Post Office State ZIP Code Harrisburg PA 1117101 Correspondent's email address: mbeshore@beshorelaw.com REGISTER OF1N)LLS USEgZkNLY �> j, REGISTER OF WILLS USE 0N LY �.I DATE FILED MMDDYYYY - CJ DATE FILED STAMO' r. 1`71 G') C N PLEASE USE ORIGINAL FORM ONLY Side 1 i 111111 11111 11111 11111�ii�iiiii 11111 11111 11111 11111 ilii ilii 15 614105 1505614105 1505614205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Bertha A. Green F170-30-8236 RECAPITULATION 1. Real Estate(Schedule A). . . ... . . .. . ...... ... .. . ......... ..... .. .... .. 1. 0-0-0 2. Stocks and Bonds(Schedule B) . . ..... ... .... ... .. .. ....... .. ... ...... 2. ()_0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ... .. 3. JI -0-0- 4. _ 0-04. Mortgages and Notes Receivable(Schedule D) . ... .... . .. . .... ... . . ... ... 4. 0:-0.0 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)... .... 5. 3, 182. 54 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ..... 6. 4F523. 75 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... ... .. 7. 0-A-0 8. Total Gross Assets(total Lines 1 through 7).... .... ....... .. ..... .... .. . 8. 7, 706. 29 9. Funeral Expenses and Administrative Costs(Schedule H)..... .... .... ... ... 9. 29, 693. 7 3 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). ...... .... .. .. 10. 0 _0.0 11. Total Deductions(total Lines 9 and 10). .. . .... .. .... . ... .... .... ... .. . . 11. 29,693:73 12. Net Value of Estate(Line 8 minus Line 11) . .. . .... .... ... .. ......... .. .. 12. 13. Charitable and Governmental Bequests/Sec.9113 Trusts for which - 9.8�.4 4 2� _ an election to tax has not been made Schedule J 13. ( ) .. .... ... ....... .... .. . . _ 0_.0,0 14. Net Value Subject to Tax Line 12 minus Line 13 14. -21 , 987. 44 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- 15. 16. Amount of Line 14 taxable w at lineal rate X.0_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE . .... ... .. ... .. .. . ..... .. . ... ... ...... .... .... .. .. ... .... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT o 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. SIGNATU OF PERSON RESPONSIBLVFOR FILING RETURN ATE ( "W/ &Z,J.b 5-- - ADDRE 112 Fineview Broad Camp Hill PA 17011 SIGN OFF PREPARER R TH PERS N RESPONSIBLE FOR FILING THE RETURN DA ADDRESS 130 State Street0 Harri Ghtirg1., PA 1 71f11 11111111111111111111 �i1l111t1111�11111111111111111111111 Side J 6 4 0 1505614205 REV-15pb EX (FI) Page 3 File Number "Decedent's Complete Address: DECEDENT'S NAME Bertha A. Green STREETADDRESS 112 Fineview Road CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount (See instructions.) Total Credits(A+B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 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 .......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N c. retain a reversionary interest .............................................................................................................................. ❑ N d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 0 3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ E 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 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. ' WILL(Single Sheet Publiebed=d Sold by The Plankenhom Co.,Wmiamsaort,Pa.17701 33e it Rtmembrreb That I, Bertha A. Green ,of Irvona in the County oj Clearfield and State of Pennsylvania,being of sound mind, memory and understanding, and considering the uncertainty of life, do hereby make,publish and declare this my last 'd HI and Uestament, hereby revoking and making void any and all former Wills by me at any time heretofore made. FIRST: I direct that all my just debts and funeral expenses be paid by my Execut ors hereinafter named,as soon after my decease as may be convenient. SECOND: I give,devise and bequeath to my beloved husband, Charles Leroy Green, All my Estate, Real, Personal and/or Mixed of which I may be possessed at the time of my demise or wherever situate at the time of my demise, for his use for the remainder--of his natural lifetime. The rest and residue of my Estate remaining unused at the time of his demise, shall be equally divided among my children, namely: John L. Green, Janet A. Sayre, and Gwen D. Daigle. AND LASTLY.—Ido make, constitute and appoint John L. Green and Janet A. Sayre to be Fxecutors of this my last Will and Testament. without bond Sit 19ft oo 35jrmd, I have hereunto subscribed my name, and affixed my seal, the Fourth day of June in the year one thousand nine hundred and Seventy-f our. Signed,sealed,published and declared by BerthaA. Green ..-............................................................................................ --the testatrix above named, as and for her last Will and Testament,in the Presence of us, who have at her request, ` subscribed our names in her presence,and h` `... in the presence of each other, as witnesses Bertha A. Green her o. .ah.c�....... .. ...................................... REV-15o8 EX+(o8-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: 'Bertha A. Green 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. Highmark(premium refund) 197.20 2. PSERS(death benefit) 299.80 3. Diamond Drugs(refund) 31.64 4. Parthemore Funeral Home&Cremation Services(refund) 2,653.90 TOTAL(Also enter on Line 5, Recapitulation) $ 3,182.54 If more space is needed,use additional sheets of paper of the same size. May 0515 09:59a Janet Green Sayre 717-737-9490 p•5 000002 0001 0001 000 543928-002-0 H MARK 120 Fifth Ave. Pittsburgh PA 15222-3499 cm ID JANET SAYRE 112 FINEV€EW ROAD g CAMP HILL,PA 17011 Premium Refund � 04/27/2015 . Check-numker`0095815:1 rp(aces: :.Check Number 0000935649 dates!09/23/2014• Check Date ".. .: ... .04/2712015 Product Name Direct Pay Western Region, Gross payment.amount $1"97.20 Net payment amount $197.24 Highmark Blue Shield Is an independent licensee of the Blue cross and Blue shield Association CAMP HILL PA 17011-8446 N THEN DETACH CAREFULLY • • III FAA If Rol • - - • ■ • s - • r - • r. _ .... v Y, :0l RAA �- 92 ♦, a ... .a, w. a x7 x p ti. e, 4, -- ol - I� .:,,....,..,....r.- r .. LA:PI4IDEL?-iA p : : • : : .•. 4S1'2f2oVE I I ATIU A\AILAi.R ,pyFPYPk TECTED I lie b, �.� . DATE:'. S CTS '1GID AFTER 180 DAY ..ATO THE ORDER OF 5 _ JANET G SAYRE 112 FI NEVIEW RD CAMP HILL PA 17011-8446 04 brfsst_opher I :Graig _ _. _. ._.'.. I I.: �. �I h �.I I Ill .I• E,',A-�•.CI�F�''•��R'Q;Fyi�,.E•.:N N S:�Y c�::V•�•J4y N l:'A�� .. II' ? 000 3 6 9 20 ?II' 1:0 3 1 100 2 2 51: 80 1 700 2 3801I' L'd 06t 6-L£L-L �L ejAeS uaaaE) jauer d6£:Z� 9t 9� Ae[N DIAMOND DRUGS, INC. 20381 REFERENCE NO. DESCRIPTION INVOICE DATE INVOICE AMOUNT DISCOUNT TAKEN AMOUNT PAID CN000105440 5/31/2014 31.64 0.00 31.64 CHECK DATE CHECK NO. PAYEE DISCOUNTS TAKEN CHECK AMOUNT 9/25/2014 20381 47748 GREEN,BERTHA 31.64 0.00 31.64 Feb 1015 04:03p Janet Green Sayre 717-737-9490 p.2 ' � ✓".. .r f„�,!� ;;_ ,'" � {„iyti.� ...:�IiNj�_ _ '.. '�.1:v°;i:�L:t��.tli PARTHEMORE Funeral Home & Cremation Services, Inc. 1303 Bridge.Street . P.O.Box 431 September 22, 2014 New Cumberland,PA 17070 PH:(717)774-7721 Janet Green Sayre FX:(717)774-5546 112 Fineview Road www.parthemore.com Camp Hill,PA 17011 Re: The funeral-service for Bertha A. Green Dear Janet; Gilbert W.Parthemore We.sincerely appreciate the confidence you have placed in tis and will continue Founder to assist you in every way we can. Please feel free to contact us if you have any questions in regards to this statement. Gilbert J.Parthemore Supervisor The following items were either not funded or not guaranteed in the pre- arrangements for Mrs.Green: Stephen K.Parthernore President,CFSP Cash Advance Items Actual Cost As Funded Bruce R Parthemore Certified Death Certificates $ 42.00 $ 42.00 Pre-Need Coordinator,CPC Hairdresser 45.00 45.00 Tent&Cemetery Equipment 275.00 275.00 Transportation Miles 290.00 290.00 -- Clergy Honorarium 200.00 200.00 Casket Spray Flowers 265.00 265.00 2 Matching Maches of Flowers ($79.50 ea) 159.00 165.00 Professional h4emberships: Grave Opening 450.00 1,000.00 Cemetery Admin Fee 100.00 0 Cemetery Chapel Fee 100.00 0 - Obituary 100.10 400.00 14 Additional Laminates ($3.00 ea) 42.00 0 r Pennsylvania Funeral Directors Association Subtotals: $ 2,068.10 $2,682.00 Al P Al 8 V K . Order of me Difference: ($ 613.90) Golden Rule ate' ' Feb 1015 04:03p Janet Green Sayre 717-737-9490 p.3 � l i PA,.RT'HEMOR.E Funeral Home & Cremation "Services, Inc. 1303 Bridge Street P.O.Box 431 New Cumberland,PA 17070 The following items were changed from the pre-arrangements for Mrs.Green: PIS: (717)7747721 FX:(717)774-5546 www,parthemore.com Services &Merchandise Items Actual Cost As Funded Traditional Service Grouping&Merchandise $9,080.00 $111,120.00 Vs. Graveside Service Grouping Difference: ($ 2,040.00) GllbertW Parthemore Total,Refund Due: ($21653.90) Founder Gilbert I Parthemore 5uper:risor Please call if you have any questions. Thank you. Stephen K.Parthemore President,CFSP Bruce R.Parthemore Pre-Need Coordinator,CPC Professional Memberships: Pennsylvania Rmeral Directors Association X1 c N1 it eR QrdCr?f the Golden Rule REV-1509 EX+ (02-15) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE 30INTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Bertha A. Green If an asset became 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.Janet Green Sayre 112 Fineview Road Daughter Camp Hill, PA 17011 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 DECEDENTS VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR IOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 09117101 Northwest Savings Bank(checking xxxxxx9969) 9,047.50 50 4,523.75 TOTAL(Also enter on Line 6, Recapitulation) $ 4,523.75 If more space is needed,use additional sheets of paper of the same size. BUREAU OF INDIVIDUAL TAXESPenns Ivania Inheritance Tax pennsyLvanla PO•BOX 280601 Y HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE REV-1543 EX DocEXEL (08-12) And Taxpayer Response FILE N0.21 ACN 14152729 DATE 09-23-2014 Type of Account Estate of BERTHA A GREEN Savings / SSN X Checking Date of Death 09-06-2014 Trust JANET G SAYRE County CUMBERLAND Certificate 112 FINEVIEW RD CAMP HILL PA 17011-8446 NORTHWEST SAVINGS BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.2856019969 Remit Payment and Forms to: Date Established 09-17-2001 REGISTER OF WILLS Account Balance $9,047.50 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $4,523.75 Tax Rate X 0.120 Potential Tax Due $542.85 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A ❑No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. B [_�The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C JXThe tax rate is incorrect. 4.5% 1 am a lineal beneficiary(parent, child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part F—] 12% 1 am a sibling of the deceased. 3 on reverse.) 15% All other relationships (including none). D ❑Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART 2 Debts and Deductions Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"intrust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners =25%,etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state Official Use Only ❑AAF your relationship to the decedent: PA Department Of Revenue 1. Date Established 1 2. Account Balance 2 $ PAD 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 8. Tax Due 8 $ 8 9. With 5% Discount(Tax x .95) 9 X Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work Home Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 REV-]511 EX+(02-15) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Bertha A. Green Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Prepaid 0.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 750.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. Cumberland County Register of Wills(filing fees) 30.00 8. Pennsylvania Department of Human Services(DPW claim) 28,212.23 9. Highmark(insurance premium) 246.50 10. RJL Properties(storage unit rental) 455.00 TOTAL(Also enter on Line 9, Recapitulation) $ 29,693.73 If more space is needed,use additional sheets of paper of the same size. pennsylvania DEPARTMENT OF PUBLIC WELFARE j MAR 2G 2015 i March 13, 2015 MILSPAW & BESHORE ATTY AT LAW MARVIN BESHORE ESQUIRE 130 STATE STREET PO BOX 946 HARRISBURG PA 17108-0946 Re: Bertha Green CIS #: 270349941 SSN: ###-##•- Date of Death: 09/06/2014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Beshore: 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 $28,212.23 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 $21,452.80, 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 $6,759.43, is to be entered as a priority Class 5.1 claim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486 REV-1513 EX+(02-15) Qpennsytvania SCHEDULEDEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Bertha A. Green 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. Janet G.Sayre, 112 Fineview Road,Camp Hill,PA Daughter 1/3 2. John L.Green,750 Follette Run Road,Warren,PA Son 1/3 3. Gwen D.Daigle, 1054 Brigman Highway,Eunice,LA Daughter 1/3 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: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II— 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. LAW OFFICE OF MARVIN BESHORE 130 State Street Harrisburg, PA 17101 Telephone:*(717)236-0781 Marvin Beshore Facsimile: (717)236-0791 Mbeshore@beshorelaw.com June 3, 2015 Lisa Grayson, Register of Wills .,o rn Court of Common Pleas of Cumberland County cn; One Courthouse Square ;c? Carlisle PA 17013-3387 .:t Re: Estate of Bertha A. Green `'- :3 Dear Ms. Grayson: , 0 e>:: ' ry ;_191- Enclosed please find two originals and two (2) copies of the REV-1500 (Resident .. Decedent- Inheritance Tax Return)to be filed in your office in relation to the above-referenced matter. Please note that an estate has not been opened for this Decedent; therefore, you will need to assign an estate number at this time. Kindly file the originals,time-stamp the copies and return same to me in the enclosed self-addressed, stamped envelope. A check in the amount of$15.00 is also enclosed to cover the filing fee. Thank you. Very tri ly yours, jtoM .. SZeshore, ARTZ Paraln Esquire Enclosures =•may E 1� i ! r fUi�'Y gEtY7fE 02 IP "RE JSSTER fir- Wfla:S 0000606508 EMAILE-DFROmvpcoos.17101 2015 JUN 4 ?M 1 43 ter FI.RST CLASS MAIL. law MARVIN BESHORE ATTORNEY AT LAW + - 130 STATF $TP,FFT , HARRISBURG. PENNSYLVANIA 17101 _ 'Aw- TO: Lisa Grayson, Register of Wills `_ Y Court of Common Pleas of Cumberland County One Courthouse Square Carlisle, PA 17013-3387