HomeMy WebLinkAbout07-31-15 COURT OF COMMON PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA ORPHANS' COURT DIVISION
IN RE: DAVID DEMLER JR. ,AN INCAPACITATED PERSON
FILE NO: 21-14-0442
ANNUAL REPORT OF THE GUARDIAN OF THE ESTATE
1. INTRODUCTION
Pennsylvania Guardianship Association / Brian D. Brooks was apRginted the
Limited, X Plenary Guardian of the Estate by Decree of o c M r;'
T. Placey , Judie Dated: 7/03/2014M �, v X ,
�_ rn rn
(A) This is the Annual Report for the period from c, o
X (B) This is the Final Report for the period from 7/03/14=`to--7/28/1 ; i rn i
and is filed for the following reason:
1
1
1. The death of the incapacitated person, Date of Death 4/21/15
2. The guardianship was terminated by the Court by Decree of
, Judge, Dated
2. Summary
A. State the value of the Estate reported on the inventory$ 5,708.17
B. State the value(s) of the principle assets at the beginning of the report period.
(Same as the inventory if this is the first report, otherwise,balance from last report)
$ 5,708.17.
C. What is the total amount of income earned during the report period?
$ 9,574.81
D. What is the total amount of income and principle spent for all purposes during the
report period?
$ 15,282.98
E. What are the balances remaining at the end of the report period?
1. Principle $
2. Income $
3. Total principle and income $ 00.00
ALL REMAINING FUNDS SENT TO THE ESTATE RECOVERY PROGRAM DPW/DHS
THE ESTATE OF: DAVID DEMLER JR.
3. ADDITIONAL INFORMATION
(If more space is needed, please attach additional pages.)
A. Principle
1. How is the principle balance listed above currently invested? (Specify)
2. Have there been any expenditures from principle during the report period?
X Yes No
If yes:
a. Have all expenditures from principle been for the sole benefit of the
Incapacitated Person X Yes No
b. List the purpose and amounts of expenditures:
SEE ATTACHED ALL TRANSACTION REPORT
c. Was court approval received prior to expending priciple?
Yes X No
3. Were additional principle assets received during this report period that were not
included in the initial inventory or any prior report filed for the estate.
Yes X No
If yes:
a. Was court approval requested prior to receiving additional principle?
Yes No
b. State the sources of income received during the report period:
B. INCOME
1. State the sources of income received during the report period:
1. SOCIAL SECURITY
2. ANNUITY
Total income received during the report period $ 9,574.81
2. How is the income currently invested?
{
THE ESTATE OF: DAVID DEMLER JR.
C. Expenses for care and maintenance:
(Specify what expenditures were made from the principle and income for the care and
maintenance of the incapacitated person)
SEE ATTACHED ALL TRANSACTION REPORT
D. Other expenditures: (Specify any other expenditures not previously reported)
E. Guardians Commissions:
(List the amount of compensation paid as guardian's commission and state how amount
was determined):
Amount Method of Determination Court Approval Obtained
$ 1,845.00 (Yes) No
INITIAL FE 500.00 9 MONTHS AT 100.00 1 MONTH AT 275.00 2 HOURS AT 85.00
F. Counsel Fee
(List amounts paid as counsel fee, and indicate whether Court approval was obtained.)
I verify that the foregoing information is true and correct to the best of my
knowledge, information and belief, and that this Verification is subject to the
penalties in 18 PA. C.S.A S/S 4904.
Date: k /s—
Bri . Brooks
Pennsylvania Guardianship Association
PO Box 7295
Lancaster, PA 17604
717-299-4568
Itemized Categories - Earliest To Date
7/28/2015 7/15/2014 through 7/28/2015(Cash Basis)
Date Account Num Description Memo Tag CIr Amount Page 2
7/28/2015 PAGA 2014 32722 ...RIVERSOU... ANNUITY ...'REFUND -96.73
.............. ...... ANNUITY ... REFUND -96.73
ANNUITY REFUND.. ... -------—
7/28/2015 96,73
PAGA 2014 32724 ...PAGA GENE...4/15 4/16 SERVIC... -275.00
2 HOURS... SERVIC— -170.00
�AdWiO-6'4'-
5 32725 ESTATE RE... DAVID'bif.'.—.
5,682.51
OVERALL TOTAL 0.00
^
Itemized Categories - Earliest To Date
^
7/28/2015 7/15/2014
through7/28/2U15(Cash Basis)
Page
Date Account Num Description
|NCOK0G
0.00
DE88LER' D"D 0.00
9/3/2014 PAGA2U14 30285 ...PAGAGENE...7'Q/14 |N|T'SERV|O- R -800.00
8/3/2014 PAGA20i4 R3648 DEPOSIT BANK TRA`' BANK l[' R 6,000l0
9/3/2014 PAQA2014 R3649 DEPOSIT ANNUITY ANNUITY R 96.73
10/1/2014 PAGA2O14 30442 ...PAQAGENE...1O/14 SERV|C... R 400.00
108/2014 PAQA2014 R1351 DEPOSIT SGD| GSD| EFT R 984.80
1D/7/�O1� RAQA2�14 R1�37 DEP6S1T
ANNUITYn --------------
u//r *mmuY e 96.73
1089/2014 RAGA2014 30557 MANOR CA... DAVID DE... COST 0... R '868.84
1D/Q/2O14
PAQA2014--30574 SEE-RIGHT...DAVID DE... MEDICAL R -48.97
-
-
1021/2014 PAGA2014 R8618 DEPOSIT PENSION PENSION R 96.73
11/3/2014 PA8A2O14 30882 ...PAGAGENE...11/14 E;DNFEE R '100.00
01,i7 1,016.03*
110/2014 PA8A2D14 R8647 DEPOSIT PENSION PENSION R 96.73
11/3/2014 RAGA2014 R8848 DEPOSIT PENSION PENSION R 96.73
-- 11----14 ------ ----014 R8725 DEPOSIT SSDI---- ----| EFT--- ----8G4--
.00
11/18/2014 PA8A2O14 38799 MANOR CA... DAVID DE COSTO... R -888.84
11/18/2014 PA��2O14 R1��� 96.73DEPO�|T ANNUITY PAYOUT R Q� �
'
/12/^:0/4 r*u*zo1w 30851 CAPITAL uL...DAVID uE... |muu*m... e -283.80
12C3/3014 PAGA3O14 R1478 DEPOSIT SSD| SSO| EFT R 964.00
12/4/2014 PAQA2D14 30907 ...PAQAGENE...12/14 8ERV|C... R '100.00
12/12/2014 PAG82O14 31000 CAPITAL BL..DAVID DE... |NSURA... R -133.80
12/17/2014 PAGA2O14 R8058 DEPOSIT AK4ER|Pg|SEANNU|TY R 0873
- i----5 ---' ---- �����D��-'l�nn----- O�����'' '-���| -'---D| E�f�--�- '---' QB[.bd
10/2015 PAGA 2014 R6396 DEPOSIT PENSION PENSION R 9673
1/8/2015 PAGA2U14 R6398 DEPOSIT PENSION PENSION R 06.73
1/14/2015 PAQA2014 81117 ...PAGAGENE...1/15 SERV|C- R 400.00
1/16/2015 PAGA2O14 R8052 DEPOSIT ANER|PR|SEANNU|T... R 86.73
1/30/2015 PAGA2O14 31380 ...PAGAGENE ..2/15 SERV|O... R '180.00
2/3/2015 PAGA2014 R8200 DEPOSIT GGD| Q8D| EFT R 981.00
'-- 2/17/��5-' ---- 'P-kdA2O _4_-�14 _-N1ANd-RcA- 64v-ib�DE- ---TO.--k- '-- '826.�f2-
2/102O15 PAGA2014 31531 CAPITAL BL...DAVID DE... |NSURA... R '133.80
2/102015 PAGA2O14 R8287 DEPOSIT
PENSION AKER|P��� R 96.73
*2�_D1_4 RO-O����D�EPOG|T 8SO| _8GD| EFT R�- �Q�8�-1.-0-0-
3/4/2015
0��
3/4/2016
PAGA2O14 31613 ...9AGAGENE...3/15 GDN FEE R '100.00
3/9/2016 RA8A2O14 31680 MANOR CA... DAVID DE... COST O..� R '806.13
A �L
3/12/2U15 PA@A�O14 3177U CAP!TL .b4V|��DF_--- --
3/18/2015 PAGA2D14 R4470 DEPOSIT AMER|PR|S ANNUITY R 96.73
4/3/2015 PAGA2O14 R1696 DEPOSIT S8D| 88D| EFT R 981.00
4n3/2015 PAQA2814 31871 MANOR CA... DAVID DE... COSTO... R -799.13
4/18/2015 PAQA2014 R1737 DEPOSIT PENSION 9EN8|O... R 9873
4/21/2015 PAGA2O14 DOD DATE OF0... DATE OFD...DATEO��� R 8.00
4/21/2015 PAGA2O14 31980 AUER K4EK0- DAVID DF_ FUNERAL R� ---54.00
5/18/2015 PAGA2014 R1088 DEPOSIT PENSION PENS|O... o 98.73
8/17/2016 PAGA2O14 R3182 DEPOSIT PENSION PENG|O... 96.73
PAGA2012 7/28/15
Itemized Categories Report
6/15/12 Through 7/28/15
Page 1
Cat/Sub Date Num Description Memo CIr Amount
Odd
DEMLER,DAVID
8/11/14 30145 REGISTER OF WILLS DAVID DEMLER JR. 21-14-0442 R -15.00
8/19/14 30209 MANOR CARE CAMP HILL DAVID DEMLER 583-4357 R -2,994.75
TOTAL DEMLER, DAVID -3,009.75
TOTAL INCOME -3,009.75
TOTAL INCOME-.EXPENSES -3,009.75
Itemized Categories - Earliest To Date
7/15/2014 through 7/28/2015(Cash Basis)
7/28/2015 Page I
Date Account Num Description Memo Tag Cir Amount
INCOME 15,282.98
DEMLER,DAVID 15,282.98
9/3/2014 PAGA 2014 R3648 DEPOSIT BANK TRAN...BANK TR... R 6,000.00
9/3/2014 PAGA 2014 R3649 DEPOSIT ANNUITY ANNUITY R 96.73
10/3/2014 PAGA 2014 R1351 DEPOSIT SSDI SSDI EFT R 964.00
--f6/—i/- 201 i�--------PA—GA CP70—Slf ANNUITY ANNUITY
10/21/2014 PAGA 2014 R8618 DEPOSIT PENSION PENSION R 96.73
11/3/2014 PAGA 2014 R8631 DEPOSIT BANK TRAN...BANK TR... R 1,016.03
11/3/2014 PAGA 2014 88647 QEPOSIT PENSION PENSION R 96—J-3
11/3/2014 PAGA 2014 R8648 DEPOSIT PENSION PENSION R 96.73
11/3/2014 PAGA 2014 R8725 DEPOSIT SSDI SSDI EFT R 964.00
11/18/2014 mT PAGA 2014 R1366 dE--P6§fT--' ANNUITY PAYOUT... R 96.73
12/3/2014 PAGA 2014 R1478 DEPOSIT SSDI SSDI EFT R 964.00
12/17/2014 PAGA 2014 R8058 DEPOSIT AMERIPRISE ANNUITY R 96.73
1/2/2015 PAGA 2014 R6306 DEPOSIT SSDI SSDI EFT R 981.00
1/8/2015 PAGA 2014 R6396 DEPOSIT PENSION PENSION R 96.73
1/8/2015 PAGA 2014 R6398 DEPOSIT PENSION PENSION R 96.73
1/16/2015- -- PAGA 2014 8$052 DEPOSIT "ANff k—P—R1—Sff
2/3/2015 PAGA 2014 R8200 DEPOSIT SSDI SSDI EFT R 981.00
2/19/2015 PAGA 2014 R8287 DEPOSIT PENSION AMERIPR... R 96.73
3/3/2015 PAGA 2014 R2800 DEPOSIT SSDI SSDI EFT R 981.00
3/18/2015 PAGA 2014 R4470 DEPOSIT AMERIPRIS ANNUITY R 9633
4/3/2015 PAGA 2014 81696 DEPOSIT SSDI SSDI EFT R 981.00
4/16/2015 PAGA2014 81737 DEPOSIT PENSION PENSION... R 96.73
5/18/2015 PAGA 2014 R1969 DEPOSIT PENSION PENSION... c 96.73
6/17/2015 PAGA 2014 R3182 DEPOSIT PENSION PENSION... 96.73
OVERALL TOTAL 16,282.98
2c
'41
6 W,
Itemized Categories - Earliest To Date
7/15/2014 through 7/28/2015(Cash Basis)
7/28/2015 Page I
Date Account Num Description Memo Tag Cir Amount
INCOME -1,845.00
DEMLER, DAVID -1,845.00
9/3/2014 PAGA 2014 30285 S PAGA GENE... 7-9/14 INITI...SERVICE... R -800.00
10/1/2014 PAGA 2014 30442 S PAGA GENE... 10/14 SERVICE ... R -100.00
11/3/2014 PAGA 2014 30682 S PAGA GENE... 11114 GDN FEE R -100.00
12/4/2014 2014 —Rd§07 S-PAGA—GENE... 12/14 SERVICE... R -100.00
1/14/2015 PAGA 2014 31117 S PAGA GENE... 1/15 SERVICE... R -100.00
1/30/2015 PAGA 2014 31380 SPAGA GENE... 2/15 SERVICE... R -100.00
3/41266 PAGA 2014 31613 S PAGA GENE... 3/15 GDN FEE R -100.00
7/28/2015 PAGA 2014 32724 S PAGA GENE... 4/15 SERVICE... -275.00
2 HOURS A... SERVICE... -170.00
OVERALL TOTAL -1,845.00
Pennsylvania Guardianship Association
PO Box 7295 Lancaster, PA 17604
Ph. (717)-299-4568 / Cell (717)-940-7599 / Fax (717)-299-5540
e-mail pagabrooks@veizon.net
July 28, 2015
Commonwealth of Pennsylvania
DPW/Division of Third Party Liability
Estate Recovery Program
PO Box 8486
Harrisburg, PA 17105
Attention: Tammey Hughes
Re: David Demler Jr.
Record#: 21 /0183461
SSA#: 200-26-8030
Date of Death: 4/21/2015
Greetings,
I am writing to notify you of the death of the person named above. I had been serving as the
Court Appointed Guardian or as the Agent under a Power of Attorney for thiXerson. My
authority to act on behalf of this estate ended at the time of death.
At the time of death this person was living in a long term care facility receiving Medical
Assistance Long Term Care benefits. I realize the DPW may have a claim under the Medicaid
Estate Recovery Program for any remaining assets of this person.
I am aware of liquid assets in this persons name consisting of 5,682.21 These funds were
held PA Guardianships' Custodial Account.
I send you PA Guardianship Association Custodial Account check No: 32724 In the amount of
$ 5,682.51 This represents the total amount of assets in our custodial account or the deceased.
To the best of my knowledge, no Will has been probated and no Estate has been opened for this
person. This is an unadministered estate.
Thank You, Sincerely,
4riD. Brooks
Pennsylvania Guardianship Association
Jefe4
PENNSYLVANIA GUARDIANSHIP ASSOCIATION webs Fargo,N.A.
CUSTODIAL ACCOUNT
P.O.BOX 7295 3-50-310
LANCASTER,PA 17604
PH,717-299-4568 7/28/2015
0
PAY TO THE
ORDER OF ESTATE RECOVERY PROGRAM $ **5,682.51
m
Five Thousand Six Hundred Eighty-Two and 51/100****** DOLLARS t
COMMONWEALTH OF PA/DPW
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105
MEMO A D SIGNATURE
VID DEMLER JR
111032724112 1:0 3 1000 50 31: 20000 380 L 50 3 6ii'
PENNSYLVANIA GUARDIANSHIP ASSOCIATION
32724
ESTATE RECOVERY PROGRAM 7/28/2015
DEMLER, DAVID/CLOSE ACCOUNT 5,682.51
�i
PAGA 2014 DAVID DEMLER JR 15,682.51
PENNSYLVANIA GUARDIANSHIP ASSOCIATION
32724
ESTATE RECOVERY PROGRAM 7/28/2015
DEMLER, DAVID/CLOSE ACCOUNT 5,682.51
r
PAGA 2014 DAVID DEMLER JR 5,682.51
PRODUCT SSLT104 USE WITH 91663 ENVELOPE