HomeMy WebLinkAbout07-15-15 i i i i ai■ �
'��'+ pennsYIvania 1505618403
�iii �OMTMENTOFREVEN�X(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po sox 280601 INHERITANCE TAX RETURN /� ��/'
Harrisbur4,PA 17128-0601 RESIDENT DECEDENT 21 / �T
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMD�YYYY Date of Birth MMDDYYYY
159 24 8234 01 15 2015 05 29 1913
DecedenYs Last Name Suffix DecedenYs First Name MI
ROSHER MAXINE M
(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
� 1. Original Return � 2. Supplemental Retum � 3. Remainder Return(date of death
❑ priorto 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
JENNIFER B HIPP 717 737 8761
First Line of Address
1 WEST MAIN STREET
Second Line of Address
City or Post Office State ZIP Code
SHIREMANSTOWN PA 17011 r�,
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� � � rn
CorrespondenYs email address: ��AP@bogarlaw.com C�_., ��� c">
R I �R�9f WI LS US _ I�fj
REGISTER OF WILLS USE ONLY � ''�_,,, � ~ - ��
�- ,� (T' (Jl :�r; C7
DATE FILED MMDDYYYY '.'� �;) -= r_, �
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,�DATE FILED MP� -r7
Side 1
� (I��I�I II'll IIIII III�I�IIII�II�I IIIII I�III IIIII�II�I IIII IIII 15 0 5 618 4 0 3 �
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� 15U5618411
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: Rosher, Maxine M. 15 9 2 4 8 2 3 4
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D).................................................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 4 ,6 2 6 - 0 6
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. 4 ,6 2 6 - 0 6
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 6 0 6 • 4 9
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 1 p. 10 8 ,2 2 3 • 6 8
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 1 U 8 ,8 3 0 • 17
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -1 O 4 ,2 0 4 • 11
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. -10 4 ,2�4 • 11
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 0 16. 0 • 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 • 0 U 17. 0 • 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 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 peryury,I declare I have examined this retum,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 PERSON RESPONSIBLE FOR FILING RETURN S�/IVIB.J. F�'�/ DATE
,��-�� / �� 7 1 r
ADDRESS
325 Wesley Drive,Apt. 3301, Mechanicsburg, PA 17055
SIGNATURE OF PREPARE T AN REPRESENTATIVE Jennifer B. Hipp DATE
, '�
ADDRESS
1 West Main Stree Shiremanstown, PA
� I I�II�I II��I�IIII I�III�III�IIIII II��I IIIII�I��I II'�I II�I II�I Side 2 1505618 411 �
REV-1500 EX Page 3 File Number 21
Decedent's Complete Address:
DECEDENT'S NAME
Rosher, Maxine M.
STREET ADDRESS
100 Mt.Allen Drive
CITY STATE ZIP
Mechanicsburg PA 17055
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 +g) (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 Pa�rable to REGISTER OF WILLS, AGENT
,. . . . � . �::r . � y����' " ,a �-'�'� �dy� Ss`",+ ,�"� ,,F� . �, �'�,"1f," . # ..�����'.�� �.'�?>`:�ra:; ,�.��..��.;', 3 ., ..
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:.................................. ❑ �
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?.................................................................................................................... ❑ ❑X
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which ❑ ❑
contains a beneficiary designation?.................................................................................................................. X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
� �' r, x
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,or a 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 decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1508 EX+(08-12�
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OFREVENUE pE RSONAL P RO PE RTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rosher, Maxine M. 21
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Belco Community Credit Union-Savings Account No.8260. Principal balance at date of 129.00
death$128.99;accrued interest$0.01
2 Belco Community Credit Union-Checking Account No.8260. Principal balance at date of 3,679.47
death$3,679.46;accrued interest$0.01
3 Highmark-Refund 337.49
4 Highmark-Refund 220.10
5 Highmark-Refund 260.00
TOTAL(Also enter on Line 5, Recapitulation) 4,626.06
(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)
_.
_ �
ELCO
COMMUNITY CREDIT UNION
.
June 19,2015
James D. Bogar
Attn: Jennifer Hipp
One West Main Street
Shiremanstown,PA 17011
Dear Jennifer,
My name is Katelyn Thompson and I am the Compliance Specialist here at Belco Community Credit
Union. I have received your date of death balance request for Maxine M. Rosher.
Enclosed you will find a date of death valuation.
Please let me lrnow if there is anything else that I can help you with.
Sincerely,
Katelyn Thompson, CUCE,BSACS
Belco Community Credit Union
Compliance Specialist
717-720-6270
thompsonk@belco.org
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ELCO
CONLMUNITY CREDIT UNION
. - _ __ __ _ _ _ . - --- ___-_ --- _. � l � ' :-- _ ��- _ ._ `.�-_-=-_- _-= '- - =:_
Decedent Account Information(On Date of Death)
Belco Community Credit Union
l. Name(s) in which the account was held: Maxine M. Rosher
2. Account Number: 8260
3. Total Account Balance as of Date of Death: $3808.45 �
Balance Accrued Dividends Date Opened
Regular Savings $128.99 $0.01 (O1/O1/2015-01/15/2015) OS/Ol/2008
Holiday Club $
IRA $
Money Market $
Checking $3679.46 $0.01 (O1/O1/2015-01/15/2015) O1/11/1999
Money Market $
Certificates:
Certificate Number Balance Accrued Dividends Date Opened
$
$
$
$
$
$
4. Name(s)in which Safe Deposit Box was held: None
5. Date the box was initially rented: �
6. Branch address at which the box is located:
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ELCO
� COMMUNITY CREDIT UNION
.
. _ ___ __ _ __ _ _ -----__ _ __ _ - _ _ � ._ _.-:_ -R-_;_ --__- `_W=-= `_- - _'-=-�---=
7. Loan Information:
Balance Interest Rate Date Opened
Line of Credit $
Visa $
Home Equity Fixed $
Auto Loan $
HELOC $
Home Equity $
Misc.Loan $
8. Miscellaneous:
� g_
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REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OFREVENUE F U N E RAL EXP E N S ES AN D
RESIDENNDEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Rosher, Maxine M. 21
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N MBER
q, FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2, Attorney's Fees Bogar and Hipp Law Offices 600.00
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
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 6.49
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 606.49
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Rosher, Maxine M. 21
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
1 US Postal Service-certified mail to MetLife 6.49
H-B7 6.49
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+��y�72)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rosher, Maxine M. 2�
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 Department of Human Services-Claim for restitution of inedical assistance per attached 104,199.38
letter
2 Messiah Lifeways 4,024.30
TOTAL(Also enter on Line 10, Recapitulation) 108,223.68
(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)
..''� pennsylvania
DEPARTMEt�T OF HUMAN SERVICES
April 3, 2015
JAMES D BOGAR ATTORNEY AT LAW
ONE W MAIN ST
SHIREMANSTOWN PA 17011
Re: Maxine Rosher
CIS #: 350318196
SSN: -,�##-##-8234
Date of Death: 01/15/2015
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Bogar:
Under State and Federal law, the Department of Human Services (the Department) is
required to recover medical assistance (MA) reimbursement fram 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 $104.199.38 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 cfaim.
A portion of this medical expense, namely $24.251.12, 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. 339Z(3). The balance of the
claim, namely $79,948.26, is to be entered as a priority Class 5.1 claim against the estate.
You should refer to Section 3392 for a more complete explanatican 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
y�''� pennsylvania
DEPARTMENT OF HUMAN 5ERVICES
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,
pfease 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. ThPse regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to accurately compute the amount due the Department, the following items
should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
`b . �..-�,-�v--.�-�.�� (c�� (2�e �rn.
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
�''� pennsylvania
DEPARTMENT OF HUMAN SERVICES
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are nat 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 �ut of your own pocket.
The Department's approvaf is required if you expect the legal fees to exceed more than the
preater 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,
�-z �
Karen H. Peterson
Claims Investigation Agent
717-772-6615
717-772-6553 FAX
Enclosure
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX&486
HARRISBURG,PA 17105-8486
April 1,2015
STATEMENT OF CLAIM SUMMARY
NAME Estate of ROSHER,MAXINE
ID 350 318 196
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 24,244.04 79,948.26 104,192.30
DRUG 7.08 .00 7.08
REIMBURSEMENTTO DPW 24,251.12 79,948.26 104,199.38
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 7
COMMONWEALTH OF PENNSYLVAiJIA
DEPARTMENT OF PUBLIC WELFARE
April 1,2015
STATEMENT OF CLAIM
NAME ROSHER,MAXINE
ID 350 318 196
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
100 MOUNT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/01/12 - 07/31N2 01/14/13 5�130094343600001 55130094343600U01 5,571.32 3,548.36
DIAGNOSIS 1 : 2449
HYPOTHYROIDISM NOS
PROC CODE: 000000
08/01/12 - 08/31/12 01/14/13 55130094343610001 55130094343610001 5,571.32 3,548.36
DIAGNOSIS 1 : 2449
HYPOTHYROIDISM NOS
PROC CODE: 000000
09/01/12 - 09/30N2 01/14/13 55130094343620001 55130094343620001 5,391.60 3,369.93
DIAGNOSIS 1 : 2449
HYPOTHYROIDISM NOS
PROC CODE: 000000
10/01N2 - 10/31/12 01/28/13 55130244104630001 55130244104630001 5,391.60 3,508.06
DIAGNOSIS 1 : 2449
HYPOTHYROIDISM NOS
PROC CODE: 000000
11/01/12 - 11/30/12 01/28N3 55130244104970001 55130244104970001 5,391.60 3,330.93
DIAGNOSIS 1 : 2449
HYPOTHYROIDISM NOS
PROC CODE: 000000
12/01/12 - 12/31/12 02111/13 55130244105420001 55130244105420001 5,571.32 3,508.06
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
01/01/13 - 01/31/13 03/11/13 27130464023580001 27130464023580001 5,491.03 3,418.26
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
Page 2 of 7
COMMONWEALTH OF PENNSYLVANIA i
DEPARTMENT OF PUBLIC WELFARE I
April 1,2015
STATEMENT OF CLAIM
NAME ROSHER,MAXINE
ID 350 318 196
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
100 MOUNT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAt CRN ADJUSTED CRN USllAL CHARGES AMOUNT APPROVED
02l01113 - 02/28N3 Q4/08/13 27130744022240001 2713074402224U001 4,886.84 2,894.67
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
03/01/13 - 03/31/13 05/13/13 27131064024400001 27131064024400001 5,410.43 3,418.26
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
04/01/13 - 04/30/13 O6/10/13 27131364023860001 27131364023860001 5,655.50 3,663.43
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
OS/01/13 - 05/31N3 07N5/13 27131694022590001 27131694022590001 5,844.12 3,851.95
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
06/01/73 - O6/30/13 08/12/13 27131974021310001 27131974021310001 5,655.60 3,663.43
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
09/01/13 - 09/30/13 04N4/14 27140774022610001 27140774022610001 5,655.60 3,547.19
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
10/01/13 - 10/31/13 04/14/14 27140774022630001 27140774022630001 5,844.12 3,937.06
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
Page 3 of 7
COMMONWEALTH OF PENNSYLVANIA � �
DEPARTMENT OF PUBLIC WELFARE
April 1,2015
STATEMENT OF CLAIM
NAME ROSHER,MAXINE
ID 350 318 196
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
100 MOUNT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
11/01/13 - 11/30/13 04/14/14 27140774022650001 27140774022650001 5,655.60 3,745.79
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
12/01/13 - 12/31/13 04/14/14 27140774022670001 27140774022670001 5,844.12 3,937.06
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
01/01/14 - 01/31/14 04/14/74 69140774023020001 69140774023020001 5,765.38 3,751.07
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
02/01/14 - 02/28/14 12/15/14 69143244024620001 69143244024620001 5,207.44 3,193.13
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
03/01/14 - 03/31/14 05/12/14 27141074020670001 27141074020670001 5,765.38 3,773.04
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
04/01/14 - 04/30/14 06/09/14 27141344024360001 27141344024360001 5,554.20 3,634.36
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
OS/01/14 - 05/31/74 07/07/14 27141644020650001 27141644020650001 5,765.38 5,143.00
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
Page 4 of 7
�� ������,_Q,�_ Q
COMMONWEALTH OF PENNSYLVANIA �
DEPARTMENT OF PUBLIC WELFARE
April 1,2015
STATEMENT OF CLAIM
T1AME ROSHER,MAXINE
ID 350 318 196
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
100 MOUNT ALLEN DR
MECHANICSBURG PA 77055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
06/01/14 - 06130l14 92/15/14 6J143244024680001 69143244024680001 5,554.20 3,562.86
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
07/01/14 - 07/31N4 09/08/14 27142264020930001 27142264020930001 5,869.23 4,777.89
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
08/01/14 - 08/31/14 09/29/14 27142554020850001 27142554020850001 5,869.23 3,877.89
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
09/01/14 - 09/30N4 10/27/14 27142874022850001 27142874022850001 5,679.90 3,688.56
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
10/01/14 - 10/31N4 12/08/14 27143164023010001 27143164023010001 5,664.63 3,673.29
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
11/01N4 - 11/30/14 01I05/15 27143444022660001 27143444022660001 5,481.90 3,490.56
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
12/01/14 - 12/31/14 02/09/15 69150144023570001 69150144023570001 5,664.63 3,673.29
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
Page 5 of 7
�, ,��� �,.�.,,.. ,
COMMONWEAIT#i OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
April 1,2075
STATEMENT OF CLAIM
NAME ROSHER,MAXINE
ID 350 318 196
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
100 MOUNT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAI CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
01/01/15 - 01N5/15 03/09/55 27i50424022160001 27150424022160001 3,075.52 1,062.56
DIAGNOSIS 1 : 7837
ADULT FAILURE TO THRIVE
PROC CODE: 000000
PROVIDER 5UB TOTAL MESSIAH LIFEWAYS AT MESSIAH VILIAGE 159,748.74 104,192.30
03 100002572 0004
Page 6 of 7
,,�, �������_.,� R
COMMONWEALTH OF PENNSYIVANIA
DEPARTMENT OF PUBLIC WELFARE
April 1,2015
STATEMENT OF CLAIM
NAME ROSHER,MAXINE
ID 350 318 196
ALERT PHARMACY SERVICES INC
219 N BALTIMORE AVE
MOUNT HOLLY SPRING PA 17065
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/09/14 - 11/09N4 12/08/14 25143145229690001 25143145229690001 17.18 2.36
DIAGNOSIS 1 :
NDC CODE: 0060301793 FERROUS SULFATE 325 MG TABLET - HEMATINICS&BLOOD CELL STIMULATORS
12/09/14 - 12/09/14 01/OS/15 25143435406880001 25143435406880001 17.18 2.36
DIAGNOSIS 1 :
NDC CODE: 0060301793 FERROUS SULFATE 325 MG TABLET - HEMATINICS&BLOOD CELL STIMULATORS
01/08/15 - 01/08/15 02/02/15 25150085429390001 25150085429390001 17.18 2.36
DIAGNOSIS 1 :
NDC CODE : 0060301793 FERROUS SULFATE 325 MG TABLET - HEMATINICS 8�BLOOD CELL STIMULATORS
PROVIDER SUB TOTAL ALERT PHARMACY SERVICES INC 51.54 7.08
24 100738546 0005
Page 7 of 7
REV-1573 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rosher, Maxine M. 21
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDEN e (Words) ($$$)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Sylvia J. Fry Daughter Rest,residue
325 Wesley Drive,Apt.3301 and remainder of
Mechanicsburg, PA 17055 estate
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 AND TESTAMENT
OF
MAXINE M. ROSHER
I, MAXINE M. ROSHER, of Camp Hill, Cumberland County,
Pennsylvania, make, publish and declare this as and for my Last
Will and Testament, hereby revok_ing all oth�r ?�lills and Cvd���ls
heretofore made by me.
� FIRST: I devise and bequeath all the rest, residue and
�,� remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment and
�j together with any insurance policies thereon, unto my daughter,
�
SYLVIA J. FRY, provided she survives me by sixty (60) days .
�.,�,� SECOND: Should by daughter, SYLVIA J. FRY, predecease
�� me or die on or before the sixty-first day (61st) day following
� my death, I devise and bequeath all the rest, residue and remain-
der of my estate of whatever nature and wherever situate, in
� equal shares, to my grandson, DONALD L. FRY, my grandson, CHRIS-
�
� TOPHER J. FRY and my great-grandson, CONOR P. FRY. Should DONALD
L. FRY, CHRISTOPHER J. FRY or CONOR P. FRY predecease me, I
direct that his share be divided evenly among the survivors
thereof .
THIRD: Should my great-grandson not have attained
the age of twenty-two (22) years at the time for distribution to
him, I give, devise and bequeath the share of such great-
grandson to my hereinafter named Trustee or Trustees, to hold,
manage, invest and reinvest the share so received, and to use and
apply from time to time such portion of income and principal for
the said great-grandson' s education (including college, trade
school or other similar training or education) , as my Trustee or
Trustees, in their sole discretion, deem advisable. The Trustee
or Trustees, in exercising their discretionary authority with
respect to the payment of income or principal of the within Trust
to my great-grandson, shall take into consideration any income or
other resources available to my great-grandson from sources
outside this Trust .
Any income or principal not so applied shall be distributed
to my great-grandson when he attains the age of twenty-two (22)
years . In the event my great-grandson dies prior to the termina-
tion of this Trust established herein for his benefit, the
interest of said great-grandson in said Trust shall cease.
FOURTH: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
`` ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
c
� options for sales, exchanges or leases, for such prices and upon
� such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it .
(� (B) To partition, subdivide, or improve real estate
and to er.ter into agreemen}s concerning the partition, subdivi-
sion, improvement, zoning or management of real estate and to
impose or extinguish restrictions on real estate.
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
2
..�. nrn-�i-ir rrr. . a
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments .
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws .
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
� to pay debts, taxes, or estate or trust administration expenses,
�
`-� to protect or improve any property held under my will, and for
investment purposes .
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
� stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
� any other rights which they may have under the plan, in whatever
manner they consider advisable.
FIFTH: I nominate and appoint DONALD L. FRY and CHRIS-
� TOPHER J. FRY, or the survivor as between the two of them, as Co-
Trustees of the hereinabove described Trust. In the event of the
death, resignation or inability to serve for any reason whatso-
ever of the said DONALD L. FRY and CHRISTOPHER J. FRY, I noir�inate
and appoint my granddaughter-in-law, VIVIAN L. FRY, as Trustee of
the hereinabove described Trust . I direct that my Trustees shall
serve without bond and shall receive fair and reasonable compen-
sation.
SIXTH: I direct that all inheritance, estate, trans-
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with respect
to property passing under this Will, shall be paid out of the
principal of my residuary estate.
3
..�„n nrn-rrr�arr �
SEVENTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any
beneficiary, and furthermore, shall not be subject to pledge,
assignment, conveyance or anticipation.
EIGHTH: I nominate and appoint my daughter, SYLVIA J.
FRY, Executrix of this, my Last will and Testament . In the event
of the death, resignation or inability to serve for any reason
whatsoever of the said SYLVIA J. FRY, I nominate and appoint my
grandson, DONALD L. FRY, Executor of this, my Last Will and
Testament . I direct that my Executor or Executrix, as the case
may be, and their successors, shall not be required to post
security or a bond for the performance of their duties in any
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this � �� day of
� G�, 200� .
� �y , �'��'" �%�J�
�i � � (SEAL)
MAXINE . ROSHER
Signed, sealed, published and declared �y the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her request, in her presence and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses .
t
Address ,
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a ... _
Address f` -
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4