HomeMy WebLinkAbout08-12-15 J pennsy�vania 15 0 5 61814 8
DEPARTMENTOF REVENUE EX(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po aox 2sosoi INHERITANCE TAX RETURN � �1
Harrisburg,PA 17128-0601 RESIDENT DECEDENT �� l 7 ���� �`
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
DecedenYs Last Name Suffix DecedenYs First Name MI
COULSON MARGARET N
(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 BOXES BELOW
x0 1. Original Return Q 2. Supplemental Return Q 3 Remainder Return(date of death
priorto 12-13-82)
Q 4. Agriculture Exemption(date of Q 5. Future Interest Compromise(date of Q 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
Q 7. Decedent Died Testate Q 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 Q 11. Non-Probate Transferee Return Q 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
� 13. Business Assets Q 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
STEPHEN D . TILEY 717-243*5838
First Line ofAddress
5 SOUTH HANOVER STREET
Second Line ofAddress
City or Post Office State ZIP Code
,-.�
CARLISLE PA 17�13 c� � =� rn
Correspondent's email address: S T I L E Y a F R E Y T I L E Y . C 0 M � Q � `� �'
c-� � �
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REGISTER:CS�VyilL$�1SE thNLY !"i m
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REGISTER OF WILLS USE ONLY ��� ��."` ` :;�;;� ��
DATE FILED MMDDYYYY ����, �� � "ZJ ""��'��t �T�
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DATE�FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
I���I���������������������������(I��������������������������
� 1505618148 1505618148 �
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� 1505618155
REV-1500 EX
DecedenYs Social Security Number
Decedenrsr,ame: MARGARET N COULSON
RECAPITULATION
1. RealEstate(Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. � . �0
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 0. ��
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. `J 1`I 4 . 8 5
6. Jointly Owned Property(Schedule F) �Separate Billing Requested. . . . . . . . 6 � . ��
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) �Separate Billing Requested. . . . . . . . 7. 0. ��
8. Total Gross Assets(total Lines 1 through 7). . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 8. 919 4 . 8 5
9. Funerai Expenses andAdministrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . . . g, 2660 . 48
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I) . . . . . . . . . . . . . . . . 10. 216160 . 66
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11. 218821. 14
12. Net Value of Estate(Line 8 minus Line 11). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. �2 D 9 6 2 6 . 2 9
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. -2 0 9 6 2 6 . 2 9
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 O 15. O . �0
16.Amount of Line 14 taxable
at Iineal rate x.0 4 5 16. 0 . 0 0
�7. Amount of Line 14
taxable at sibling rate X . 12 17. D . 0 0
18. Amount of Line 14 taxable
at collateral rate X . 15 18. 0 . 0 0
19. TAX DUE. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 19. � . ��
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0
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.
SI T�U\R OF P�SON RE PS�NSIBLE FOR FI N RETURN D T /
ADDRESS
LINDA ANN KAMOWSKI 2206 DOUGLAS DRIVE CARLISLE PA 17013
SIGNAT E PR AN PERSON}�ESPONSIBLE FOR FILING THE RETURN DATE
c_ /L
�� l<2 6-'
ADDR S
STEPHEN D . TILEY, 5 SOUTH HANOVER STREET, CARLISLE, PA 17�13
I���������������I��������������������I����I���I�I��I��I����� Side 2
L 1505618155 1505618155 �
REV-1500 EX Page 3 File Number 172-14-0462
Decedent's Complete Address: 21-14-0462
DECEDENT'S NAME
MARGARET N COULSON
STREETADDRESS
700 WALNUT BOTTOM ROAD
CITY STATE ZIP
CARLISLE PA 17013
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) 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 box on Page 2,Line 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) 0.00
Make check payable to: REGISTER OF WIL�S, 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............................................................................... ❑ ❑X
b. retain the right to designate who shall use the property transferred or its income................................. � Q
c. retain a reversionary interest.................................................................................................................. ❑ Q
d. receive the promise for life of either payments,benefits or care?.......................................................... ❑ XQ
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.
_ ..':�.��"��th��,'.z"'�,.;.N�.�.,� ,.�.....� .n., .>�`«.�. . . .n,a, ..a., . .. . -, x 3 .�,�;.zs .� . . .. . � ,.r , . .,. .,,.*.. ,.,„?«.�. . ..«o,. .�z',� ,.xs. . . '`.a...... .
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 decedenPs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)J.
• 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+(02-15) SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENTOFREVENUE PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret N Coulson 21-14-0462
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. M&T Bank Classic Checking Acct. No.: 9863518594 (See Exhibit"B") 289.31
Accrued Interest to DOD 0.00
2. M&T Bank Select Checking No. 1063715 (See Exhibit"C") 8,265.52
Accrued Interest to DOD (Included interest through 5/16/14) 0.06
3. Refund- Ewing Brother Funeral Home 9.96
4. VA Death Benefit 630.00
TOTAL(Also enter on Line 5, Recapitulation) $ 9,194.85
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(02-15)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
RESIDENTDEC DENTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Margaret N Coulson 21-14-0462
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Note: Funeral Expenses Were Pre-Paid
2. Funeral Luncheon to Carlisle VFW 287.98
3. Grave Marker 499.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 750.00
Name(s)of Personal Representative(s) Linda Ann Kamowski
StreetAddress 2206 Douglas Drive
c�ty Carlisle State PA ziP 17013
Year(s)Commission Paid: 2015
2. Attorney Fees: 1,0��.��
3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 123.50
5. Accouncanc Fees: Incl. in Atty. Fee
6. Tax Return Preparer Fees: InCI. In Atty. F28
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 2,660.48
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(02-15)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN DEBTS OF DECEDENT�
RESIDENT DECEDENT MORTGAGE LIABILITIES 8� LIENS
ESTATE OF FILE NUMBER
Margaret N Coulson 21-14-0462
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.
Checks Cleared After Death-M&T Bank Select Checking No.: 1063715 946.36
2. Pennsyivania Department of Public Welfare-Estate Recovery Program 215,214.30
(See Exhibit"A")
TOTAL(Also enter on Line 10, Recapitulation) $ 216,160.66
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(02-15)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mar aret N Coulson 21-14-0462
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).]
Linda Ann Kamowski
�� 2206 Douglas Drive, Carlisle, PA 17013 Daughter 50%
Cynthia K. Bouder
2� 69 East Willow Street, Carlisle, PA 17013 Daughter 50%
ENTER DO�LAR 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. $ O.00
If more space is needed,use additional sheets of paper of the same size.
LAST VVILL AND TESTAMENT
I,MARGARET N.COULSON,now residing in North Middleton Township,
Cumberland County,Commonwealth of Pennsylvania,being of sound and disposing mind and
memory,do hereby make,publish and declare this to be my Last Wiii and Testament.
FIRST:I hereby revoke any and all other Wills and Codicils made by me at any time.
SECOND:I direct that all of my debts and my funeral and testamentary expenses be paid
from my estate as soon after my decease as they may conveniently be paid.
THIRD:I further direct that all estate,inheritance,transfer or succession taxes upon or
with respect to any property required to be included in my gross taxable estate under the pro-
visions of the laws of the United States or of any state thereof,or of any taxing authority,
whether or noi disposed of by or passing under this Will,be chazged upon and.paid out of my
residuary estate by my Personal Representative and Executrix or Executor,as the case may be,
without apportionment,and that no taxes or any portion thereof so paid shall be collected from or
paid by any other person,persons,or corporation by way of reimbursement,proration,
apportionment,or otherwise.
� � C FOURTH:All the rest,residue and remainder of my property and estate,whether real,
personal,or mixed,of whatsoever the same may consist and wheresoever situate at the time of
my decease,and of which I may die seized or possessed,or to which I may be entitled,or over
which I may have a power of testamentary disposition or appointrnent,I give,devise,and
bequeath in equal shares unto my daughters LINDA ANN KAMOWSHI and CI'NTIiIA K.
BOUDER Should LINDA ANN I{AMOWSKI or CYNTHIA K BOUDER predecease me,
or if we should meet our deaths under such circumstances that it is difficult or impossible to
determine which of us survived the other,then,in that event I give,devise,and bequeath her
share to her issue,per stirpes,who survive me.
FIFTH:I hereby make,nominate,and appoint my daughter,LINDA ANN
KAMOWSHI to be my Personal Representative and Executrix of this,my Last Will and
Testament. ff she is unable,unwilling,fails to qualify,or ceases to serve in that capacity,then I
hereby make,nominate,and appoint her husband,ROBERT MARK KAMOWSKI,to be my
Personal Representative and Executor of this,my Last Will and Testament.
I direct that no bond or other form of security be required of her or him as Personai
1
Representative and Executrix or Executor,as the case may be,in this or any other jurisdiction.
SIXTH:I hereby specifically authorize and empower my Personal Representative and
Executrix or Executor,as the case may be,hereinbefore named,in her or his discretion and
without leave of court,with respect to any and all property,whether real,personal or mixed,of
which I am seized or possessed at the time of my death,or which shall,at the time,form a part of
my estate,without lunitation by reason of enumeration,and in addition to the powers conferred
by the Pennsylvania Probate,Estate,and Fiduciaries Code,Sections 3301,et seq,and by the laws
of the United States or of any state thereof:
A. To retain,for such time as they deem necessary,without liability for loss or
depreciation,any or all property owned by me at the time of my death,in the form in which it
then exists;acquire by purchase or otherwise and retain,temporarily or permanently,without
liability for loss or depreciation,any kind of personalty,without limitation,including but not
limited to stocks and unsecured obligations,undivided interest,interest in investment trusts,
mutual funds>legal and discretionary common trust funds,shares of investment companies,all
without diversification as to kind or amount,without being limited to investments authorized by
law for trust funds,and to deposit any monies at any time constituting a part of my estate or any
.� C,
�� trust fund held hereunder in one or more banks,savings or commercial,or savings and loan
associations,in such form of account as they shall deternune,having due regard for my
testamentary intent as reflected herein.
B. To sell,at public or private sale,to mortgage,lease or let for any term,or
exchange for any purpose,or otherwise dispose of any and all such property,without the
requirement of any court order,for such consideration,and at such time and upon such terms and
conditions,including terms of credit,as she may deem advisable,and in connection therewith,to
enter into contracts or agreements,and grant options>and to execute and deliver good and
sufficient bills of sale,deeds,mortgages,leases or other insttvments for the transfer or
conveyance thereof;and,whenever it shall become necessary,to make final distribution of any
property for the purpose of such distribution to sell and convert into money the whole or any
portion of such properly,whether real or personal.
C. In making distribution of any property to persons entided thereto hereunder,to
convey,transfer or pay over the same in kind or in money,or partly in kind and partly in money,
and for such purposes to transfer and assign undivided interests in any such property.
2
D. To adjust,settle,compromise and azbitrate claims or demands in favor of or
against my estate upon such terms as they shall deem advisable.
E. To pay all expenses,costs,fees and other charges incurred in connection with
the preservation,protection and delivery of all real and personal property.
F. To engage and retain,at estate expense,investment advisors or consultants,
accountants and attorneys as my Personal Representative and Executrix or Executor,as the case
may be,shall deem advisable in her or his sole and absolute discretion.
IN WITNESS WHEREOF,I ha�e hereunto set my hand and seal this�_day
of November,2001.
�j a.v� nf, Ce��j L.S.
-.y�, C� MARGARET A.CQLTLSON
.� .
WITNESSES:
The foregoing instrument,consisting of three(3)typewritten pages,including this
page,each identified by the initials of the Testatrix,was on this S day of November,2001,
signed,sealed,published and declared by the above name Testatrix,MARGARET A.
COULSON,as and for her Last Will and Testament,in the presence of us and each of us,who
thereupon,at her request and in her presence,and in the presence of each other,subscribed our
names as witnesses thereto,and we do at like request hereunder sign and write our names and
opposite thereto our respective places of residence.
/ l�1'1��...—L--3'
1�nar� � l�otle 1�c� residingat 3� �an�oa � ,�r� • �r�uEe, �
� no�
� �, 7 L.S.
:,r/;��//� �f t�it�
��� u f� GUII'�d_4 l � residing at�� 4'�.•�- l.otJ�2r 5� �}c7�.1�
Co-rl�st�e, PYa- 17U�3
3
�F'FIF3A��IT O�'ATTESTING�'ITI�TESSES
At Execution
COMMONWEALTH OF PENNSYLVANIA )
)ss.
CUMBERLAND COUNTY )
Each of the undersigned,individually and severally being duly sworn,deposes and says:
The within will was subscribed in our presence and sight at tl�..end thereof by
MARGARET A.COULSON,t e wi�in nam�testa 'x n the `a day of November,
�,� — Pennsylvania.
2001,at O.Z v
Said testatrix at the time of making such subscription declared the instrument so
subscribed to be her last will and testament
Each of the undersigned thereupon signed his or her name as a witness at the end of said
will at the request of said testatrix and in her presence and sight and in the presence and sight of
each other.
Said testatrix was,at the time of so executing said will over the age of 18 years and,in
the respective opinions of the undersigned,of sound tnind,memory and understanding and not
under any restraint or in any respect incompetent to make a will.
The testatrix,in the respective opinions of the undersigned,could converse in the English
language and was suffering from no defect of sight,hearing or speech,or from any other
physical or mental impairment which would affect her capacity to make a valid will.The will
was executed as a single original instrument and was not executed in counterparts•
• Each of the undersigned was acquainted with said testatrix at such time and makes this
a�davit at her request.
'The within will was shown to the undersigned at the time this affidavit was made,and
was examined by each of them as to the signature of said testatrix and of the undersigned.
The foregoing instrument was executed by the testatrix and wituessed by each of the
undersigned affiants under the supervision of DOUGLAS C.LOVELACE,JR•,an attorney-at-
law. �
Severally swom to before me �e of ant)
�S 5 m day of November,2001. �
Notary Public (I.l�ne of Affiant)
Notariai Seal
Fiora M.Vogt,Pdotary Public
Gari'vie Bo�n.Curt�e� 21 2005
My Commissi�n F�cAires Y
aAe�r�ber.PelmsY��oQNOta�"�S
NOTE: ATTESTING WITNESS SHOULD READ CAREFULLY BEFORE SIGNING
THIS AFFIDAVIT.
NOTARY SHOULD NOT BE A PARTY OR WITNESS.
4
r
�
of
b S 2001
MARGARET N. COULSON, Dated �����p� e r �
DOUGLAS C. LOVELACE, TR.
ATTORNEI'AND COUNSELLOR AT LAW
36 DONEGAL DRIVE,CARLISLE,PENNSYLVANIA 17013
�� pennsyLvania
;� DEPARTMENT OF PUBLIC WELFARE
May 28, 2014
FREY &TILEY
STEPHEN D TILEY ESQUIRE
FIVE SOUTH HANOVER ST
CARLISLE PA 17013
Re: Margaret Coulson
CIS #: 110197125
SSN: ###-##-8389
Date of Death: 04/21/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Mr. Tiley:
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 $215.214.30 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 $22,822.05, 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 $192.392.25, 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.
eureau of Program Integrity � Division of Third Party Liability � Recovery Section
„ n..__, —,�:��*
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 �_ „_„ , t,-:.
��► pennsylvania
DEPARTMENT OF PUBLIC WELFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate all deductions from the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to document computation of the amount due the Department, the following
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
DepartmenYs 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 -��-� �� `�
,+�i pennsytvania
'I� DEPARTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater 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,
t;+��!'��'�r-�..�-�t,�t...
v
Jessica L. Frederick
TPL Program Investigator
717-772-6238
717-772-6553 FAX
Enclosure
Bureau of Program Inte9rity � Division of Third Party Liability � Recovery Section "'ea; s�
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 �-�"'� '��
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FOR INQUIRIES CALL: (800)724-2440
ACCOUNTTYPE
M&T CLAS5IC CHECKING W/INTEREST
00 0 04344M NM 017
ACCOUNT NUMBER STATEMENT PERIOD
000006228 FIDS1549D01705161405 OS 010000 P 9863518594 APR.19-MAY.16,2014
t '�•
• MARGARET N COULSON BEGINNING BALANCE $2gg.3�
` LINDA A KAMOWSKI, LEGAL CUSTODIAN DEPOSITS&CREDITS 720.00
2206 DOUGLAS DR LESS CHECKS&DEBITS 0.00
CARLISLE PA 17013 INTEREST 0.01
LLSS SERYI�E�HARGES' 0.00
�N[3lhIG'BAl,RMi�� $1�OOs.32
INTEREST EARNED FOR STATEMENT PERIOD $0.00 SPRING GARDEN
INTERESl�PAID YEAR TO DATE $0.01
ACCOUNT SUMMARY
BEGINNING DEPOSITS&OTHEH
BALANCE CREDITS + CHECKS PAID OTHER DEBITS(-) CURRENT ENDING
NO. AMOUNT NO. AMOUNT NO. AMOUNT �NTEREST PD BALANCE
$289.31 2 $720.00 p
$0.00 0 $0.00 $0.01
�
$1,009.32
; ACCOUNT ACTIViTY
; POSTING DEPOSITS&OTHER WITHDRAWALS& DAILY
� DATE TRANSACTION DESCRIPTION
;`- CREDITS + OTHER DEBITS - BALANCE
Q�1,�19/2014 BEGlt�iJifvGSn�;aPJ�E �'��� �a
a�89.31
; 04/28/2014 US TREASURY 310 XXVA BENEF $630.00
919.31
05/01/2014 US TREASURY 310 XXVA BENEF 90.00
1,009.31
05/16/2014 INTEREST PAYMENT 0.01
1,009.32
ENDING BAIJaNCE
� 1 009.32
ANNUAL PERCENTAGE YIELD EARNED=0.00%
YOU HAVE THE FREEDOM TO USE YOUR M&T DEBIT CARD THE WAY YOU WANT AT THE
REGISTER-CHOOSING EITHER"CREDIT'OR"DEBIT'-AND YOU WILL NOT BE CHARGED ANY
M&T TRANSACTION FEES'ON YOUR PURCHASES IN THE U.S.,EVEN WHEN YOU GET CASH
BACK!*M&T DOES NOT CI-(ARGE FEES FOR USINU YOUR M&T DEBIT CARD FOR PURCHASES IN
THE U.S.;HOWEVER, FEES WILL APPLY IF YOD USE YOUR CARD OUTSIDE THE U.S.,
INCLUDING ONLINE PURCHASES WITH A MERCHANT LOCATED OUTSIDE OF THE U.S.IN
ADDITION,OTHER FEES,INCLUDING INSUFFICIENT FUNDS AND OVERDRAFT FEES,MAY APPLY
TO YOUR DEPOSIT ACCOUNT ACCORDI�TO THE TERMS OF YOUR ACCOUNT.MEMBER FDIC.
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FOR INQUIRIES CALL: (800)724-2440 p��j,�(��j'�'}(pg � 7
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M&T SELECT WITH INTEREST
00 0 04319M NM 117
$�� �L4 ',�����""����.� .�`�.�N� �qC��-�;
P 1063715 �� APR.17-MAY.16,2014
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000001321 FIDS1541G70105161405 03 010000
� MARGARET N COULSON ;BEGINNIN(�HEILANCE ' ° 58,265.52
9.96
� 2206 DOUGLAS DR 946.36
CARLISLE PA 17013
0.06
0.00
57,329.18
INTEREST EARNED FOR STATEMENT PERIOD $0.06 HIGH STREET-CARLISLE
INTEREST PAID YEAR TO DATE $0.35
ACCOUNi'SUMMARY
.`���E�I d1C� � �,�EE�51'�'�S$��QT';ER'���j' .�`�� ��l�i��� �„A� �,�� ���'I`F��M��?�Bl'�� -��k� ��€URy�yR(�F�f!R'� �,��`F ENDtC�t(� ��
�� � ���� �„�,. � � �� �
:�r:;�:� :�" �.�. Lrz'4 ..5�..:'�.� ..���'A.R3�f�.�^�e L.. ; �e!�. �'�T.'�ls�• .�33ius�"`.�..',�x.+��«���s:?_ ��?rc:.:F.^s��ffx#i'�. .�"�.. ".��.. .-�Ci�w � �::� �. -� �..
.. ...,r... .... . . ...... ....,,..u.. ..�v+�t'm.. .. . . _s.. _.. ... ..... v., ix .
NO. AMOUNT NO. AMOUNT NO. AM NT
$8,265.52 1 $9.96 1 $946.36 0 $0.00 $0.06 $7,329.18
� ACCOUNT ACTIVITY
g �m�0^.�TIN� ����x���:�.�M�"�A1�1SAC�01�����`�4"l�E�'1'l�7I�������'���� DEP�E�S�iffc03'HEE3:� VY�fF1QRAWALS&� ���a��;�D�t[L1F� �;
a .-�:� � ,�`�;::- -�:�.. _.�3-:�Ft b��l�' �`'' IaLi0. � �
,
I' ...� �,:3.:�..�.4.�.. k .�'#._ ..n�_.......n,... .ao�a'��'R._.. ..T,..._�.:. ..-r,�_...,.:.... ;,.:r ...,_..,.___ „ ����� �' �-m` � .,,�'k,
� � . .. . . .� .
� 04/17/26t4 BEGINNING BALANCE ' � � ` '��/ $8,265.52
� 04/22/2014 CHECK NUMBER 3576 $946.36 7,319.16
� 05/13/2014 DEPOSIT $9.96 7,329.12
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'� 05/i6/2014 INTEREST PAYMENT 0.06 7,329.18
N
� ENDING BALANCE 7 329.18
•
�
a CHECKS PAID SUMMARY
� -_ �HECK`1+�tl���<x�DA'f�"�����..: . �AMQUIIT'I' °��,:�kCE�IC`�I�J!���� t31�`�������'"`;� `<,�fA01�3MT.,� -`:�HEGI��IQ........DAT�°, �`��'��;sA . �J1MC�UN'F :;
0
' 3576 04/22/14 946.36
N
!1 ._._ .. . .._. . . ..
O . . ._. .. ..__ . .
ANNUAL PERCENTAGE'YIELD EARNED=0.00%
YOU HAVE THE FREEDOM TO USE YOUR M&T DEBIT CARD THE WAY YOU WANT AT THE
REGISTER—CHOOSING EITHER"CREDIT"OR"DEBIT"-AND YOU WILL NOT BE CHARGED ANY
M&T TRANSACTION FEES`ON YOUR PURCHASES IN THE U.S.,EVEN WHEN YOU GET CASH
BACKI'M&T DOES NOT CHARGE FEES FOR USING YOUR M&T DEBIT CARD FOR PURCHASES IN
THE U.S.;HOWEVER,FEES WILL APPLY IF YOD USE YOUR CARD OUTSIDE THE U.S.,
INCLUDING ONLINE PURCHASES WITH A MERCHANT LOCATED OUTSIDE OF THE U.S.IN
ADDITION,OTHER FEES,INCLUDING INSUFFICIENT FUNDS AND OVERDRAFT FEES,MAY APPLY
TO YOUR DEPOSIT ACCOUNT ACCORDING TO THE TERMS OF YOUR ACCOUNT.MEMBER FDIC.
N � ,,��� '�=3 PAGE 1 OF 2
LOOBACS(6/12)