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Home My WebLink About10-13-05 \. F:\FILES\DAT AFlLE\ESTA TES\11566.! ,ffa IN RE: ESTATE OF MARGARET H. O'HARA, DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-05-0362 FIRST AND FINAL ACCOUNT OF DORIS H. HESS, ADMINISTRATRIX C.T.A. OF THE ESTATE OF, MARGARET H. O'HARA, LATE OF CARLISLE, CUMBERLAND COUNTY, PENNSYL VANIA Date of Death: Date of Administratrix's Appointment: Letters Advertised: Sentinel - Cumberland Law Journal - Accounting for the period: April 2, 2005 April 18, 2005 April 30, May 7, 14,2005 May 6, 13, 20, 2005 04/02/05-09/31/05 Purpose of the Account: Doris H. Hess, Administratrix c.t.a., offers this account to acquaint interested parties with the transactions that have occurred during the administration. [The account also indicates the proposed distribution of the estate to unpaid creditors.] It is important that the Account be carefully examined. Requests for additional information or questions or objections can be discussed with: Carl C. Risch, Esquire MARTSON DEARDORFF WILLIAMS & OTTO 10 East High Street Carlisle, P A 17013 (717) 243-3341 (,) " ..) (." SUMMARY OF ACCOUNT Page No. Current Value Proposed Payments to Unpaid Creditors: PRINCIPAL 4 Receipts Less Disbursements 2 3 Principal Balance on Hand INCOME Receipts Less Disbursements 3 4 Income Balance on Hand COMBINED BALANCE ON HAND RECEIPTS OF PRINCIPAL Assets Listed on inheritance Tax Return (Value on Date of Death) M&T Bank, checking account #1135457 Aetna, prescription drug benefit u.s. Treasury, VA benefit for October-December, 2004 U.S. Treasury, V A benefit for January-March, 2005 Receipts Subsequent to inheritance Tax Return (Value When Received) Aetna, prescription drug benefit TOTAL RECEIPTS OF PRINCIPAL -2- $ 1,774.85 Fiduciary Acquisition Value $ 1,774.85 5,874.56 -4.102.71 1,771.85 3.00 0.00 3.00 $ 1.774.85 Fiduciary Acquisition Value $ 3,129.12 659.02 1,498.00 90.00 498.42 $ 5,874.56 04/04/05 04/04/05 04/26/05 06/23/05 06/23/05 DISBURSEMENTS OF PRINCIPAL PA Dept. of Revenue, 2004 income tax Harold S. Fraker, Jr., preparation of2004 income tax return Hoffman-Roth Funeral Horne, balance due after payment from life insurance policy Register of Wills, filing fee, inheritance tax return Register of Wills, additional probate fee Reserved for Class 1 Creditors: Doris H. Hess, Administratrix commission MARTS ON DEARDORFF WILLIAMS & OTTO, discounted attorney fees MARTSON DEARDORFF WILLIAMS & OTTO, costs advanced: Probate fee Advertising Grant of Letters-Curnb. Law Journal Advertising Grant of Letters- The Sentinel Certified Mail/Postage Filing fee, First and Final Account 85.00 75.00 144.29 8.12 130.00 TOTAL DISBURSEMENTS OF PRINCIPAL PRINCIPAL BALANCE ON HAND Current Value [09/31/05] M&T Bank, estate checking account M&T Bank, estimated additional interest TOTAL $ 5,494.59 0.77 $ 5,495.36 RECEIPTS OF INCOME M&T Bank, estate checking account, interest through 9/21/05 M&T Bank, estimated additional interest on checking account TOTAL RECEIPTS OF INCOME -3- $ 443.00 35.00 352.20 15.00 15.00 300.00 2,500.00 442.51 $ 4,102.71 Fiduciary Acquisition Value $ 5,494.59 0.77 $ 5,495.36 $ 2.23 0.77 3.00 $ DISBURSEMENTS OF INCOME None $ $ 0.00 0.00 TOTAL DISBURSEMENTS OF INCOME SCHEDULE OF PROPOSED DISTRIBUTION TO UNPAID CREDITORS Claim Pro rata Prorated Class 3 Uno aid Creditors: Amount percentage Payment PA Department of Public Welfare, CIS $14,557.77 95% $ 1,686.11 #490169838, nursing care (Exhibit "B") Pharmerica (date-of-death balance), prescriptions 705.39 5% 88.74 Account No. 5704-01-06407 (Exhibit "e") Belvedere Medical Corporation, Patient #3534201, 68.85 0% 0.00 medical services (Exhibit "D") Philhaven, Account #161569, medical services 50.50 0% 0.00 (Exhibit "E") Total Proposed Payments to Unpaid Creditors $ 1,774.85 Class 6 Unpaid Creditors: United Church of Christ Homes, Thomwald Home, $ 7,002.50 0 $ 0.00 Account #563 (Exhibit "P") Darlene Moyer, Bill No. 6250, 2005 personal tax 10.00 0 0.00 (Exhibit "G") PA Dept. of Revenue, 174-05-0547,2004 estimated 11.63 0 0.00 tax penalty (Exhibit "H") -4- COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND ) Doris H. Hess, Administratrix c.t.a. of the Estate of Margaret H. O'Hara, deceased, hereby declares under oath that she has fully and faithfully discharged the duties of her office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been set forth in said accounting; that, to her knowledge, all taxes presently due from the estate have been paid. ~ XI' ;:ad"-) Doris H. Hess, Administratrix c.t.a. Sworn and subscribed to before me this JIM day of October, 2005. ~.~ . ... AA~ k1-C"~ Notary Public 0 NOTARIAL SEAL CORRINE L. MYERS, NOTARY PUBLIC CARLISLE BORO. COUNTY OF CUMBERLAND MY COMMISSION EXPIRES MAY 27, 2007 -5- LAST WILL AND TESTAMENT OF MARGARET H. O'HARA I, MARGARET H. O'HARA, of Carlisle, Cumberland County, Pennsylvania, make, publish and declare this to be my Last Will and Testament, hereby revoking any and all former \vills by me at any time heretofore made. 1. I direct the payment of my just debts and funeral expenses as soon after my death as will be convenient to my ExeclltoT, hereinafter named. 2. I give, devise and bequeath all my property, whether real, personal or mixed, and wheresoever situate at the time of my death unto my husband, Christian B. O'Hara. 3. Should my husband fail to survive me then I direct my Executor, hereinafter named, to sell all my property, either at public or private sale, and for the best price or prices that can be obtained for the same, and the proceeds thereoF distributed, share and share alike, unto my brothers and sisters. Should any of my brothers or sisters fail to survive me then the share to which that brother or sister would have been entitled shall be distributed to his or her children, share and share alike. 4. I nominate, constitute and appoint my h~sband, Christian B. O'Hara, to be the Executor of this, my Last Will and Testament. If my said husband shall fail to survive me, or shall for any other reason be unable or unwilling to fulfill the obligations of this trust, then I name Farmers Trust Company, of Carlisle, Pennsylvania, t)O be the Executor of my will. IN WITNESS MIEREOF, I have hereunto set my hand and seal this 31st day of May, A.D. 1967. l-)) 1 d iL ." ~;;;) -7- ,;~? ~;.. f/-r.Li'r:-r:.) (SEAL) Signed, sealed, published and deClared by the above named Testatrix as and for her Last Will and Testament, in the presence of us, who, in her presence, at her request and in the presence of each other have hereunto subscribed our names as witnesseSe (.Q ////j:-r "'-:'-/.-.'.!~",,-~:4/J~_ ~ j;....' ... ..,,)1 u-t:t,t"u. zf..- j L)-,.J-"l.A.j-L)'U'I.,I-..:e>f..J/'c_ E 'J-illh, f './'('/ *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY,PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 May 9, 2005 MARTS ON DEARDORFF WILLIAMS & OTTO CARL C RISCH ESQUIRE 10 EAST HIGH ST CARLISLE PA 17013 Re: MARGARET OHARA CIS #: 490169838 SSN: 174-05-0547 Date of Death: 4/2/2005 Dear Attorney Risch: Please be advised that the Department of Public Welfare maintains a claim in the amount of $14,557.77 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $14,557.77, 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 6 claim against the estate. ---- Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, Patricia Nace Claims Investigation Agent 717-772-6616 717-705-8150 FAX Enclosure E 'fill 6, f "t3 " .--- CUSTOMER: MARGARET O'HARA DATE: 04/jO/05 FACILITY: THORNWALD !lOME ACCOUNT: 5702-0106407 PHARMERIG\ (111_) 4Yl ABUTEAGLEAVE III' IIARRISRlJRG,PA 17112 . PAGE: 1 of 1 PREVIOUS BALANCE: $676.63 PAYMENTS RECEIVED: CREDITS: DATE I RX NUMBER I DESCRIPTION QTY NEW CHARGES: BILLED IDUE FROM I AMT INSURANCE $35.53 BALANCE DUE: $712.16 INSURA"lCE ADJUST I CHARGES/ CREDITS Balance Forward: 04/01/05 1158547.00 ACETAMINOPHEN 650 MG SUPP 04/02/05 1159722.00 MORPHINE SULF 20 MG/ML SO FINANCE CHARGE 12.000 30.000 8.00 20.76 ~ . 'J)'" .' .._.c,- 676.63 8.00 20.76 . 6.77 /Amount Due: 712.16 .,"'< BILLING QUESTIONS: 08:30 AM - 05:00 PM PHONE: 800-352-9161 MEDICATION QUESTIONS: 09:00 AM - 04:00 PM PHONE: 717-651-9996 PAYMENT ADDRESS: P.O. BOX 6413 CAROL STREAM, IL 60197-6413 1111111 11111111111 1111 Illill 1111111111 11111 III Iml 11111 11111 I 1/11111111111111111111 PHARMERICA 491-A BLUE EAGLE AVE HARRISBURG. PA 17112 PHARMERIG\ (iii~ ru ..!I ru '" ..!I W .c "'" o o [J"" o /.J1 ru o "'" o l-' 31111.U817 IF PAYING BY MASTERCARD. DISCOVER. VISA OA AMERICAN EXPRESS, FILL OUT BELOW. CHI-:'CK CAHD USING FOR PAYMENT ~O _0 -~~; 0 -'''~ 0 ~ MAsrFnCARSl ... D'SCOVER_ VISA O:PRES;; AMI:HICAN EXPRfSS RETURN SERVICE REQUESTED CARD NUMf3[H AMOUNT SIGNATURE DCP. DAT[ CUSTOl\1ER NAl\1E: MARGARET O'HARA DUE DATE - PAY THIS AMOUNT ACCT. # n Please check box if address is incorrect or insurance U information has changed, and indicate change(s) on reverse side. 05/30/05 $712.16 5702-01-06407 1",111",111",11",1",111"",1,1,,1.1,1,,1.,1.1,1,,1",111 MARGARET O'HARA C/O DORIS HESS PO BOX 224 BOILING SPRINGS, PA 17007-0224 1,11"11"",.111,1"1",1,11,,,1,,1,,,11,,11,,"11,,11,1.1,.1 PHARMERICA P.O. BOX 6413 CAROL STREAM, IL 60197-6413 E..Xhf'~, 1- ,\:,,5702010006040007000712163 .cCKS PAYABLE TO: BEL.VEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (717) 243-3120 June 15, 2005 ~ Statem'ent 46994602 BMCl:? }Our &y to Better Health Payment Due 30 Days From Statement Date Accou nt # IF PAYING BY CREDIT CARD, FILL OUT BELOW o MasterCard o VISA o Discover CARD NUMBER EXP. DATE SIGNATURE DORIS HESS POBOX 224 108 2ND STREET BOILING SPRINGS, PA 17007 o Please check box if above address is incorrect or insurance identified has changed, Indicate change(s) on reverse side. Practice: BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 Responsible Party: 46994602 - DORIS HESS Patient 3534201 - MARGARET OHARA Visit 483770 Wednesday, Jamiary12, 2005 OFFICE VISIT DEDUCTIBLE 01/12/2005 Line Item 99311 - NURSING FACILITY CARE,SUBSEQ _ M.__ ""H __~_..'__,...___,_. 'W ~.,_._,_,. 01/26/2005 Ins: HGS ADMINISTRATORS Pmt 03/11/2005 Ins: AETNA Pmt [1~1II[fi..~~, Visit 490023 DEDUCTIBLE 02/02/2005 02/24/2005 Line Item 99311 - NURSING FACILITY CARE,SUBSEQ Ins: HGS ADMINISTRATORS Pmt $46,00 -$12.97 Visit 495389 Wedriesday,March'09,2005 DEDUCTI BLE/COI NSURAN CE 03/09/2005 Line Item 99311 - NURSING FACILITY CARE,SUBSEQ 04/01/2005 Ins: HGS ADMINISTRATORS Pmt $46.00 -$29.49 Visit 500034 COINSURANCE 03/30/2005 04/27/2005 Line Item 99311 - NURSING FACILITY CARE,SUBSEQ Ins: HGS ADMINISTRATORS Pmt $46.00 -$39.39 Current 30-600a S $0.00 $0,00 $6.61 $16.51 $89.18 THERE WILL BE A $25.00 CHARGE IF A CHECK IS RETURNED FOR INSUFFICIENT FUNDS BMCl:? $23.12 "URGENT**PAST DUP' CALL 243-9463 }Our &y to Better Health $66.06 BELVEDERE MEDICAL CORPORA nON 850 Walnut Bottom Road Carlisle, PA 17013-3698 (717) 243-3120 FED ID NO. 23-1869105 Exh,b, t \\0" Account: O'Hara, Margaret H (161569) Program: Consult-Older Adult Admit Date: 12/17/2003 Discharge Date: I Statement Date: June 6, 2005 Please Pay This Amount: Due Date: June 21, 2005 Amount Enclosed: $ i ~;o." .......i :,,!,SA, 0 ~D ~D - Catd# $50.50 E:<p Dot.: '::;ig.tH,t'ure=: ___ 828-21 Printed N EartLe: DORIS HESS C/O MARGARET H. O'HARA PO BOX 224 BOILING SPRINGS, PA 17007 DPkase check this Jl.OX if Your address or insurance ha~ chaneed and then comDlete the [onn on the back of this ~ ----------------- ----------------------- < Detach Here and Return Top Portion with Your Payment. Bottom Portion is for Your Records.> Please mail your payment and this payment stub using the supplied pre-addressed envelope. (Uyou are paying for multiple accounts with one payment, please include all payment stubs.) -------------------------- ---------------------- Account: O'Hara, Margaret H (16 I 569) Program: Consult-Older Adult Admit Date: 12/17/2003 Discharge Date: Summary Statement of Services I Due Date: June 21, 20051 June 6, 2005 $50.50 $0.00 $0.00 $50.50 Statement Date: Previous Statement Balance: Payments Received Since Last Statement: Total New Charges: Amount You Now Owe: The account balance for the services received is now due. All insurance activity, if any, has been processed and the remaining balance is due from you. Please remit the balance in full within fifteen (IS) days using the enclosed reply envelope. Our office accepts checks and credit cards. If you are unable to pay your balance in full or need assistance in understanding your statement, please contact our office at (717) 270-2413 or toll free at 1-800-932-0359, ext 2413 Monday - Friday 8:30AM - 4:00PM or e-mail the Payment Processing Center at ppc@philhaven.org. Someone will be glad to assist you. Thank you for choosing Philhaven for your heaIthcare services. 0-59 ""i"",~~ ~ 1 L ~ PO Box 550 Mt Gretna, PA 17064; Phone (800) 932-0359 Ex!. 2413 or (717) 270-2413 ltr JOVen Billing Office Hours: 8:30am - 4:00pm Monday through Friday _h'ghDp<;h,a1lng"'uh,lwI""", !Omail Questions to PPE~hv;6:rt '.t::' I' Statement United Church of Christ Homes Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Statement Date: 06/01/2005 Doris Hess C/O Margaret H O'Hara P.O. BOX 224 Boiling SPrings, PA 17007 Due Date: 06/25/2005 Re: Margaret H O'Hara Account Nr: 563 -------------------------------------------------------------------------------- Date Description Days Quant Rate Charges Payments Balance -------------------------------------------------------------------------------- BALANCE FORWARD 11/30/04 Incontinence Suppli 11/30/04 Medical Supplies 11/30/04 Personal Laundry Se -1.00 -1.00 -1.00 77.40 23.11 15.00 7,118.01 -77.40 -23.11 -15.00 7,118.01 7,040.61 7,017.50 7,002.50 r::; . I 7. '\ F I' L'N7/D,t 6250 ** TAXPAYER COpy ** BILL DATE 3101/2005 BILL NO 6250 "~I ?005 PERSONAL TAX NOfICE COUNTY OF CUMBERLAND BOROUGH OF CARLISLE UNPAID TAXES SUBMITTED TO DELINQUENT COLL 12/12/05 r 1- __I 1 )illliiiJ:lii!ill.~Ulli],'i'i!l'ill~J.T;]jU;~il 1.~.t'.'Ul:<.ojJ~ i 5.000001 490i 5.00! 5501 i ,.",,, S.OO! 5001 5501 --- -+ --< OISC~: F^~~OO I PCN^:~.~I 3/01/2005 5/0]/2005 AFTER i TO TO i 130/2005~_ 6/~O/200~i 6~~_~~_~0~5.J DARLENE L. MOYER, CIO CTCB 19 S HANOVER ST, PO BOX 128 CARLISLE. PA 17013-0128 JFS" cn 2 611? SSN 174-05-0547 -AXL_S lUE \ND lA'{ASLE ROM O'HARA, MARGARET %DORIS HESS 108 N. 2ND ST. BOX 224 BOILING SPRINGS, PA 17007 AX ;ou lFFIC[ IOUHS MONDAY 8:30AM-4:00PM TUESDAY-FRIDAY 8:00AM-4:00PM CLOSED HOLIDAYS PHONE: (717) 243-3725 - h ,\ r '. t::.. y.. ,'b, r ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO BOX 280"'31 HARRISBURG, PA 17128-0431 PREASSESSMENT NOTICE REV-364C EXAFP (Ol-OSl DATE OF NOTICE: SOCIAL SEC. NUM: TAX YEAR: ASSESSMENT: MARGARET H OHARA DORIS H HESS POBOX 224 BOILING SPRGS PA 17007 JUN 07 2005 174-05-0547 2004 BALANCE(Sl DUE FOR YOUR ACCOUNT AS OF JUN 17 2005 * BALANCE INCLUDES ESTIMATED TAX UNDERPAYMENT PENALTY OWED PAID BALANCE .00 .00 .00 11.63 .00 11.63 .00 .00 .00 .00 .00 .00 443.00 443.00 .00 YEAR(Sl LIABILITIES .00 11. 63 COUPON BELOW LTE/UNDER EST PNLTY LEGAL INTEREST TAX/RFD PLUS OTHER TAX TOTAL DUE NOW PLEASE PAY THIS AMOUNT USING THE DETACHABLE YOUR 2004 TAX RETURN WAS PROCESSED AS FOLLOWS. lA. GROSS COMPENSATION. . . . . . . . . . . . . . . . . . . . . . . . . . lB. SCHEDULE UE EXPENSES........................ Ie. l:OMPENSATION... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. INTEREST (SCHEDULE AJ....................... 3. DIVIDENDS (SCHEDULE BJ...................... 4. NET INCOME OR LOSS.......................... 5. TAXABLE SALE - GAIN OR LOSS................. 5A. CAPITAL GAIN EXCLUSION...................... 6. RENTS, ROYALTIES, PATENTS, COPyRIGHTS....... 7. ESTATES AND TRUSTS (SCHEDULE Jl............. 8. GAMBLING AND LOTTERY WINNINGS............... 9. GROSS TAXABLE INCOME (ADD LINES lC,2-5,6-8l. 10. CONTRIBUTIONS TO MEDICAL SAVINGS............ 11. NET PA TAXABLE INCOME(LINE 9 MINUS LINE 10l. 12. TAX LIABILITY (MULTIPLY LINE 11 BY .03070l.. 13. TAX WITHHELD (FROM W2'SJ.................... 14. CREDIT FROM PREVIOUS TAX yEAR............... 15&16 ESTIMATED TAX & EXTENSION PAyMENTS.......... 17. TAX WITHHELD AS REPORTED ON NRK-l........... 18. TOTAL CREDITS (ADD LINES 14-17J............. 19B. NUMBER OF DEPENDENTS.... . . . . . . . . . . . . . . . . . . . . 21. TAX FORGIVENESS CREDIT...................... 22. RESIDENT CREDIT (SCHEDULE GJ................ 23. CREDITS (SCHEDULE OCJ....................... 24. TOTAL CREDITS (ADD LINES 13,18,21-23J...... 25. TAX DUE (LINE 12 MINUS 24J.................. 26. PENAL TIES AND INTEREST...................... 28. OVERPAYMENT (LINE 24 MINUS 12J.............. 29. REFUNDED.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30. CREDITED TO NEXT YEARS ESTIMATED TAX........ 31-35.TOTAL DONATIONS (LINES 31-35J............ YOUR FIGURES .00 .00 .liO 16.00 318.00 .00 14,085.00 .00 .00 .00 .00 14,419.00 .00 14,419.00 443.00 .00 .00 .00 .00 .00 o .00 .00 .00 .00 443.00 .00 .00 .00 .00 .00 OUR FIGURES .00 .00 .00 16.00 318.00 .00 14,085.00 .00 .00 .00 .00 14,419.00 .00 14,419.00 443.00 .00 .00 .00 .00 .00 o .00 .00 .00 .00 443.00 .00 .00 .00 SEE REVERSE SIDE FOR MORE INFORMATION DETACH AT PERFORATION 'PIT BUREAU OF INDIVIDUAL TAXES PERSONAL INCOME TAX REV-364C (01-0SJ " m .... ". n :I: ". .... "C m '" ." " '" 100 ". .... ... ~ TAXPAYER NAME: NOTICE -DATE: SOCIAL SEC. NUM: TAX YEAR: MARGARET H OHARA JUN 07 2005 174-05-0547 2004 PAYMENT AMOUNT: $ HAKE CHECK OR HONEY ORDER PAYABLE TO: "PA OEPT. OF REVENUE". 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