HomeMy WebLinkAbout08-04-15 REV-1500 EX 101-10' 1505610140
OFFICIAL USE ONLY
Department of Revenue
Bureau of Individual Taxes CountyCode Year File Number
BuINHERITANCE TAX RETURN
Po aox 2sosol
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 2 1 1 5 0 2 0 2
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 1 0 8 2 0 1 5 0 1 1 3 1 9 4 7
Decedent's Last Name Suffix Decedent's First Name MI
R E A M W E N D E L L R
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
0 1.Original Return 2.Supplemental Return F1 3.Remainder Return(date of death
prior to 12-13-82)
❑ 4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12-12-82)
6.Decedent Died Testate 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9.Litigation Proceeds Received 10.Spousal Poverty Credit(date of death El 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
M A T T H E W A M c K N I G H T 7 1 7 2 4 9 2 3 5 3
REGISTER OF WILLS USE ONLY
ry
First line of address
(z) rr,
I R W I N & M c K N I G H T P C �'' 0 ` C
Second line of address r t o
6 0 W E S T P 0 M F R E TS T R E E T c{:> 0 '- Z-_7
City or Post Office State ZIP Code '&ATE:FIIFEQ "I --n
_ _n
C A R L I S L E P A 1 7 0 1 3
Correspondents e-mail address:
cn I
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.
S T EEE SIBLE FOR FILING RETURN DATE
� .�G�s�-tom..
ADDRESS
1145 PHEASANT DRIVE N. CARLISLE PA 17013
SIGNAT J PAREFFOTHER THAN REPRESENTATIVE M-6 f
ADDRESS
60 WEST POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: W E N D E L L R. REAM
RECAPITULATION
1. Real Estate(Schedule A) ......... ........ ........ . ... ........ ... .. . 1 1 9 4 0 0 0 . 0 0
2. Stocks and Bonds(Schedule B) .. ... ...... . .. ... ... . ... .. . ... . .. .... . 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. . . . 3.
4. Mortgages and Notes Receivable(Schedule D) ...... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. ... 5. 6 3 7 . 8 3
6. Jointly Owned Property(Schedule F) FISeparate Billing Requested .. .. .. . 6.
7, Inter-Vivos Transfers&Miscellaneous N Probate Property
(Schedule G) Separate Billing Requested .. .... . 7.
8. Total Gross Assets(total Lines I through 7) ........................... 8. 1 9 4 6 3 7. 8 3
9. Funeral Expenses and Administrative Costs(Schedule H) ... ............... 9. 1 2 0 8 0 . 0 4
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. . .. ... ..... 10. 2 7 6 9 7 . 9 8
11. Total Deductions(total Lines 9 and 10) .... .. . ........ ... . .. ... .... . . 11. 3 9 7 7 8 . 0 2
12. Net Value of Estate(Line 8 minus Line 11) ....... .. .. . . ... .. .. . .. ... .. 12. 1 5 4 8 5 9 . 8 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ............... ... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ..... ................. 14. 1 5 4 8 5 9 . 8 1
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(12)X.0 _ 0 . 11 11 15. 0 . 11 11
16. Amount of Line 14 taxable
at lineal rate X.0- 0 - 0 0 16. 0 . 11 0
17. Amount of Line 14 taxable
at sibling rate X.12 1 5 4 8 5 9 . 8 1 17. 1 8 5 8 3 . 1 8
18. Amount of Line 14 taxable
at collateral rate X,15 0 - 0 0 18, 0 . 11 a
19. TAX DUE ........ ...... ............... ........ ....... 19. 1 8 5 8 3- 1 8
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240 1505610240
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 15 0202
DECEDENTS NAME
WENDELL R. REAM
STREET ADDRESS
1000 CLAREMONT ROAD
CITY STATE ZIP
CARLISLE PA 117013
Tax Payments and Credits:
1• Tax Due(Page 2,Line 19) (1) 18 583,18
2. Credits/Payments
A.Prior Payments
B.Discount
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.
Fill in oval on Page 2,tine 20 to request a refund. (4) 0,00
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 18 583.18
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; ...................................................................... ❑ n
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑
c. retain a reversionary interestIZI
;or ................................................................................................ ❑
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 0
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ n
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ Q
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑ 0
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 stepparent 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(1.2)(72 P.S.§9116(x)(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.
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WENDELL R. REAM 21 15 0202
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1. 1162 MYERSTOWN ROAD, GARDNERS, PENNSYLVANIA 194,000.00
SETTLEMENT STATEMENT ATTACHED
TOTAL(Also enter on Line 1,Recapitulation.) $ 194 000.00
If more space is needed,use additional sheets of paper of the same size.
REV-1508 EJC+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE . CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
WENDELL R. REAM 21 15 0202
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. MEMBERS 1 ST FEDERAL CREDIT UNION-SAVINGS ACCOUNT#152635-00 536.77
2. MEMBERS.1 ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT#152635-05 0.60
3. MEMBERS 1ST FEDERAL CREDIT UNION-CHECKING ACCOUNT#152635-11 100.46
TOTAL(Also'enter on Line 5,Recapitulation) $ 637.83
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WENDELL R. REAM 21 15 0202
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Names)of Personal Representative(s)
Street Address
City State ZIP
Years)Commission Paid:
2. Attorney Fees: IRWIN &McKNIGHT, P.C. 9,500.00
3. Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 350.50
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. CLOSING COSTS FROM SALE OF REAL ESTATE 1,960.00
8. THE SENTINEL-ESTATE NOTICE 189.54
9. CUMBERLAND LAW JOURNAL-ESTATE NOTICE 75.00
10. REGISTER OF WILLS-SHORT CERTIFICATE 5.00
TOTAL(Also enter on Line 9,Recapitulation) $ 12,080.04
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WENDELL R. REAM 21 15 0202
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 PUBLIC WELFARE-CLAIM 26,103.19
2, PSERS-REIMBURSEMENT OF PENSION 1,069.26
3. CENTRAL PENN MANAGEMENT GROUP-MEDICAL 10.00
4. CAROLYN R. McQUILLEN, TAX COLLECTOR-TAXES 515.53
TOTAL(Also enter on Line 10,Recapitulation) $ 27,697.98
If more space is needed,insert additional sheets of the same size.
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WENDELL R. REAM 21 15 0202
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Tnistee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).)
1. RONALD K. REAM Sibling 38,714.96
1145 PHEASANT DRIVE N. 1/4TH REMAINDER
CARLISLE, PA 17013
2. KENNETH E. REAM Sibling 38,714.95
932 MYERSTOWN ROAD 1/4TH REMAINDER
GARDNERS, PA 17324
3. LORRIE HENNEMAN Sibling 38,714.95
156 CREEK ROAD 1/4TH REMAINDER
NEWVILLE, PA 17241
4. VERNON J. REAM Sibling 38,714.95
7942E 50ON ROAD 1/4TH REMAINDER
ST. ANNE, IL 60965
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
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 H-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.
A. 'Settlement statement U.S.Department of Housing and Urban Development
B.Type of Loan OMB Approval No.2502-0265
1. ❑FHA 2, ❑FmHA 3, ❑Conv.Unins. 6,File Number :7.Loan Number 8.Mortgage Insurance Case Number
4. VA 5. ❑Conv.Ins. 1 15.113
C.Note: he paid
e s eam the closing;
seit ;theey aemeshn owcono hem
ee mfoorun moi o an e se erne gnre
et
a s TitiBExpress Settlement System
MEMOow3ngtir makfalse statements the United Statsthis or ttr similar form.Penalties upas
convtaiarrcon Include m sae:TitleUCodes.----btreSection
foto. Printed 07/02/2015 at 13:55 SOD
D.NAME OF BORROWER: Lisa L.Rowe
ADDRESS: 1267 Goodyear Road Gardners PA 17324
E.NAME OF SELLER: Estate of Wendell Ream
ADDRESS:
F.NAME OF LENDER:
ADDRESS:
G.PROPERTY ADDRESS: 1162 Myerstown Road,Gardners,PA 17324
Dickinson Township
H.SETTLEMENT AGENT: The Law Office of Andrew H.Shaw,PC
PLACE OF SETTLEMENT: 200 S.Spring Garden Street Suite 11 Carlisle PA 17013
1.SETTLEMENT DATE: 0710212015
I SUMMARY OF BORROWER'S TRANSACTION: K.SUMMARY OF SELLER'S TRANSACTION:
100.GROSS AMOUNT DUE FROM BORROWER 400.GROSS AMOUNT DUE TO SELLER
101. Contract sales price 194 000.00 401. Contract sales prim 194 000.00
102. Personal property 402. Personal property
103. Settlement charges to borrower line 1400 3,631,00 403.
104. 404.
105. 405,
Adjustments for items paid by seller in advance Adjustments for Items paid by seller in advance
106. Ci (town taxes 406. Cityltown taxes
107. County taxes 07102115to12131115 258,47 407. County taxes 07/02J15to12131115 258.47
108. School taxes 408. School taxes
109. 409.
110, 410.
111. 411.
112. 412,
120.GROSS AMOUNT DUE FROM BORROWER 1 197 889.47 420.GROSS AMOUNT DUE TO SELLER 194 258.47
200.AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500.REDUCTIONS IN AMOUNT DUE TO SELLER
201. Deposit or earnest money 501. Excess DB osit see instructions
202. Princi ai amount of new loans 502. Settlement charges to seller line 1400 35 578.19
203, Existing loans taken subject to 503, Existing loans taken subject to
204. 504. Payoff of First Mortgaae Loan
205. 505. Payoff of second mortgage loan
206. 506.
207, 507.'
208. 508,
209. 509.
Adjustments for items unpaid by seller Adjustments for items un aid bv seller
210. Ci /town taxes 510. Ci /town taxes
211. County taxes 511. County taxes
212. School taxes 07101115to07102H5 7.31 512, School taxes 07101115to07102115 7.31
213. 513.
214. 514.
215. 515.
216, 516.
217. 517.
218, 518.
219. 519.
220,TOTAL PAID BWFOR BORROWER 7.31 520.TOTAL REDUCTION AMOUNT DUE SELLER 35 585.50
300.CASH AT SETTLEMENT FROM OR TO BORROWER 600.CASH AT SETTLEMENT TO OR FROM SELLER
301. Gross amount due from borrower line 120 197 889.47 601. Gross amount due to seller line 420 194,258.i7-
1
302. Less amounts paid by/for borrower line 220 7.31 602. Less reduction amount due seller line 520 35 585.50
303,CASH FROM BORROWER 197 882.16 1 603.CASH TO SELLER 158 672.97
SUBSTITUTE FORM 1099 SELLER STATEMENT:The information contained herein is important tax information and is being furnished to ins internal Ranieri Service.N you ora required to fire a return,
negagance penalty or other sanction will be imposed an you g this Item is required to be reported and the IRS determines that it has not been reported.The contract Sales Price described on
line 4D1 soove constitutes the Gross Procseds of this transaction.
You are required by law to provide the statement agent(Fed,Tax ID No:261544555)with your conics taxpayer identification number.If you do not provide your correct taxpayer Identification
number,you maybe subject to civil or criminal penalties Imposed by taw.Under penalties of perjury,I-,Cry met the number shown an this statement is my correct taxpayer identification number.
TIN: ,,,,,__ 7 -- SELLER(S)SIGNATURE(S): f
SELLER(S)NEW MAILING ADDRESS:
SELLER($)PHONE NUMBERS: (H) (W)
rnuct
SETTLEMENT STATEMENT TitleEx rens Settlement System Printed 07/02/2015 at 13:55 SOD
L. SETTLEMENT CHARGES PAID FROM PAID FROM
700.TOTAL SALES/BROKER'S COMMISSION based on price s194,000.00= BORROWER'S SELLER'S
Division of commission fine 700 as follows: FUNDS AT FUNDS AT
701. t0 SETTLEMENT SETTLEMENT
702. to
703: Commission oaid at Settlement
B00.ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Origination Fee %
802. Loan Discount %
803. Appraisal Fee
804. Credit Report
805. Tax service
806. Flood certification
807.
808.
809.
810.
811.
900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to Ida
902. Mortgage Insurance Premium for 0 Mont to
903. Hazard Insurance Premium for years to
904.
905.
1000.RESERVES DEPOSITED WITH LENDER FOR
1001.Hazard Insurance mo. /mo
1002.Mortgage Insurance mo. Imo
1003.City Property Tax mo. hno
1004.County Prow*Tax mo. ho
1005.School taxes mo. /mo
1009.Agamate Analysis Ad'ustment 0.001 0.00
1100.TITLE CHARGES
1101.Settlement or Closing Fee
1102.Abstract or Title Search
1103.Title Examination
1104.Title Insurance Binder
1105.Document Preparation to The Law Office of Andrew H.Shaw PC 100.00
1106,Notary Fees to Sarah Dieckman 5.00 10.00
1107.Attome's fees
includes above items No:
1108.Title Insurance to AHSWLTIC 1507.00
includes above items No:
1109.Lender's Poiley
1110.Owner's Policy 194 000.00 -1507.00
1111.Tax Certification to The Law Office of Andrew H.Shaw PC 10.00
1112.
1113,
1200.GOVERNMENT RECORDING AND TRANSFER CHARGES
1201.Recording Fees Deed$79.00 *Mortgage$ •Release$ 79.00
1202.City/County taWstam s Deed 1940.00 Mort a e 1,940.00
1203.State Tax/stamps Deed$1,940.00 Mon a e$ 1940.00
1204. Deed$ Mortgage
1205.Dead •Mortgage Release
1300.ADDITIONAL SETTLEMENT CHARGES
1303.Estate Recovery Lien to Department of Human Services 26103.19
1304.Inheritance Tax t0 Re ister of Wills A ent 7,515.00
1400.TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 3,631.001 35 578.19
HUD CERTIFICATION OF BUYER AND SELLER
1 have Carefully reVioMd the HUD-1 SettlementStatement and to the bast of my ImoWleege and belief,itis a two ane accurate statement of all receipts and disbursements made on my account
a by rna inn tthhiis/s nsaeion,t further c�ortiry Matt I have rretsiivvedd a copy of the MUD-1 Settlement Statement
iso
eam
WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Statement wtf lneve preparetlisa tl rata aCWunt of this
UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON CONVICTION transaction,i have causetl orvria the Eo bed u In once WIN this statement.
CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:
U.S.CODE SECTION 1001 AND SECTION 1010. J,� �,.,
SETTLEMENT AGENT: '✓'-'- DATE:7-,7 /�
A
MEMBERS 1St
FEDERAL CREDIT UNION RECEIVED j I '`
MAIR 16 2015
1gw1N&1WW164
LAIN OFFICES
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 152635-00
Date Account Established 07/08/1995
Principal Balance at Date of Death $536.76
Accrued Interest to Date of Death $0.01
Total Principal and Accrued Interest $536.77
Name of Joint Owner None
INVESTMENT SAVINGS ACCOUNT:
Account Number/Suffix 152635-05
Date Account Established 01/31/2008
Principal Balance at Date of Death $0.60
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $0.60
Name of Joint Owner None
CHECKING ACCOUNT:
Account Number/Suffix 152635-11
Date Account Established 07/08/1995
Principal Balance at Date of Death $100.46
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $100.46
Name of Joint Owner None
MEMBERS 1ST FEDERAL CREDIT UNION
Tessa L Klugh
Lending Insurance Support Specialist
March 12, 2015
Estate of: WENDELL R REAM
Date of Death: 01/08/2015
Social Security Number: 180-38-9865
5000 Louise Drive - P.O. Box 40 - Mechanicsburg,Pennsylvania 17055 - (800) 283-2328 - www.memberslst.org
RECEIPT_FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date : 2/23/2015
Cumberland County - Register Of Wills Receipt Time : 14 : 55 :59
One Courthouse Square Receipt No. : 1080566
Carlisle, PA 17613
REAM WENDELL R
Estate File No. : 2015-00202
Paid By Remarks : IRWIN & MCKNIGHT
DMB
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 260 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 8699 $350 . 50
Total Received. . . . . . . . . $350. 50
RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date: 7/23/2015
Cumberland County - Register Of Wills Receipt Time : 15 :25 :28
One Courthouse Square Receipt No. : 1082057
Carlisle, PA 17613
REAM WENDELL R
Estate File No. : 2015-00202
Paid By Remarks : REAM
DMB
------------------------- Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 037146 $5 . 00
Total Received. . . . . . . . . $5 . 00
.. ,pennsyivan�a
�.
fJ�P.ARTMENT OF.PUBL'1G 1N�ELFi4R!E � ��
March 17, 2015
IRWIN & MCKNIGHT PC
MATTHEW A MCKNIGHT ESQUIRE
W POMFRET PROFESSIONAL BLDG
60 W POMFRET ST
CARLISLE PA 17013-3222
Re: Wendell Ream
CIS #: 730367560
SSN: ###-##-9865
Date of Death: 01/08/2015
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney McKnight:
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$26.103.19 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 $26.103.19, 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 .00, 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 Uabillty i Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
N^
COMMONWEALTH OF PENNSYLVANIA
PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM
PS S Toll-free: 1.888.773.7748(1.888.PSERS4U)
5 5th Street Local. 717.787.8540
Harrisburg PA 17101-1905 www.psers.state.pa.us
February 9, 2015
KENNETH REAM
932 MYERSTOWN RD
GARDNERS, PA 17324
RE: Wendell Ream
SSN: XXX-XX-9865
Dear Mr. Ream:
The Public School Employees' Retirement System (PSERS) is processing the benefit of
Wendell Ream. Please accept our condolences for your loss.
PSERS issued the following monthly retirement benefit(s) prior to processing the death benefit:
Check Month Check Amount
January, 2015 $1,618.39
Wendell Ream was entitled to a prorated amount of$549.13 for the month of January.
Therefore, please reimburse PSERS $1,069.26, which represents the total of the monthly
.benefit payments and debts(if applicable) listed above, minus the prorated amount. Please
make your check or money order payable to Public School Employees Retirement
System and remit payment by March 11, 2015.
Please retain this information for preparation of the member's final tax return.
If you have any questions, please contact the PSERS Member Service Center by calling
toll-free 1-888-773-7748 (1-888-PSERS4U). Harrisburg local callers, please use
717-787-8540. To contact PSERS by email, use the following address:
ContactPSERS@pa.gov. For your convenience, the Member Service Center is staffed each
business day from 8:00 a.m. to 5:00 p.m. For more general information, you may visit PSERS
online at www.psers.state.pa.us.
Sincerely,
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;. Date � pescnption Amount
Insurance Patient Lme Item
Balance :Balance Balance
X2111/14 ENCOUNTER 194927 FOR WEN DELL WITy.`.' ..
SACHELARIE MD, IRINA
12/1.1/14 99294 OFFICE OUTPATIENT VISIT
01!13/15 Payriaent LB Medicare(PR2::(Comsurance 87
Amount)
01/13/15 Ad�us ent Medicare(RR2(Coinsurance $66 60
•' unt))
Payment LB Commerdial(P.3(Copayment =$5 53
.' Amount)) •.::.. .:. ` . .
ENCOUNTER TOTAL $1Q:00.':. $0.00 $10:00. . $10.00
Message--
:F'or.Billing lnquities Please Call 717-519=1550. Please contact:the.office.at the.number indicated on TOTAL ACCOUNT
this staternent if you would-like to make a.credit card,payment: BALANCE
$10:00 . .
PAYMENT DUE UPON RECEIPT-THANK YOU
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3eorder TSS Software 443.321 5600:. TS-04 .," ..t;� -77;77'
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TAX PAYER'S COPY :'f_ of _THf ,P RTI{)fV°V,. R YOUR RECORDS
1 a • a a a •• a i •
Payable To: CAROLYN R MCQUILLEN,f TAX CbLI O i A -APR MON 6:9PM TUES 9-12 NOON
1044 PINE ROAD
CARLISLE,PA 17015-9 9-14-AM 8 6-8PM;MAY-JUNE MON 6.9PM
3 ''•`
NOV-FEB BY APP LY NO SATAUN OR HOLIDAYS
,t. , < Bill No: 1853
PHONE(717)486-5907 �rtis;a zL a/ t Bill Date: 3/1/15
MAP NO: 08-15-0199.047. Control No: 08001468
Desc: 1162 MYERSTOWN ROAD s- (;� u IMProverrient:173,400 Total:217,200
MICHAUX MEADOWS ' D'snt Face Penalty
LOT 26 PH 11 PB 72 PG 5 r','. ��•
Acres 1.19 Deed 0027301470 �-%4i '3 21 $476.75 $524.43
'k tai6lnEy ?brt:r''f':0:14 A4 $31.06 $34.17
1111111 VIII IIIIIIIIINIIII VIII VIII INIi 1181111 Fire Protc 0.084 $17.88 $18.24 $20.06
Tax Payer:
REAM,WENDELL R
1162 MYERSTOWN RD TAX AMOUNT DUE $515.53 $526.05 $578.66
GARDNERS PA 17324-9040 If Date Of Payment is on 3/111 0/15 511/15 thru 6/30/15 7/1/18 or Later
To review the assessment data for this property,go to:
www.courthouseonline.con1>AssessmentOffice>Cumberiand>PropertyRecords.
Then enter Control# 08001468 and password CUFFGABY