HomeMy WebLinkAbout11-14-01
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NOV 0 9 2001 U"
IN THE MATTER OF
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, P A
JEANETT A M. SHOPE.
(DECEASED)
ORPHANS' COURT DIVISION
: NO. 21 78-0490
h
NOW,lbis--!3:-daYOf
ORDER
,2001, upon consideration ofthe
Petition of Kenneth J. Suter, Assistant Counsel for the Department of Public Welfare, the Court
approves the Prior payment of all appropriate fees to the Cumberland County Register of Wills
and Cumberland County Clerk of Orphans' Court and Prior payment to the Department of
Health's Division of Vital Records for a copy of decedent's death certificate.
The Court now ORDERS and DIRECTS Velva Morris, Guardian Officer at the South
Mountain Restoration Center to pay the remainder of Jeanetta M. Shope's estate to the
Commonwealth of Pennsylvania Medicaid Estate Recovery.
Order becomes final in ten (10) days unless exceptions are filed.
BY THE COURT:
IN THE MATTER OF
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, P A
JEANETT A M. SHOPE,
(DECEASED)
ORPHANS' COURT DIVISION
NO. 21 78-0490
PETITION FOR DISTRIBUTION OF A SMALL ESTATE
The Petition of Kenneth J. Suter respectfully represents:
1. Petitioner is counsel for the Department of Public Welfare and assigned as
counsel to South Mountain Restoration Center.
2. The decedent was a resident of Shippensburg Health Care Center on the date of
death, April 30, 1998.
3. Decedent's domicile was Shippensburg Health Care Center, 121 Walnut Bottom
Road, Shippensburg, Pennsylvania, in Cumberland County.
4. Decedent's court appointed guardian is the Guardian Officer at South Mountain
Restoration Center, who joins in this petition.
5. Decedent is survived by the following heirs, none of whom are not suijuris:
Candace Arnold (niece)
11960 Mentzer Gap Rd.
Waynesboro, P A 17268
Mr. Paul Reed (nephew)
3135 Orrstown Rd.
Shippensburg, P A 17257
Peggy Tamer (niece)
559 Montgomery Ave.
Chambersburg, P A 17201
6. The decedent left no Will and no Letters of Administration have been granted by
the Register of Wills of Cumberland County.
7. None of the heirs listed above are willing to act as administrator of the estate.
8. The property of the decedent and the value of several items thereof are as follows:
Conserved Social Security Benefits
$3372.16
Total:
$3.372.16
9. The following disbursements have been made from the estate prior to the filing of
this Petition.
Name of payee and nature ofpavrnent
Cumberland County Register of Wills
Cumberland County Orphans' Court
Department of Health. Vital Records - death certificate
$15.00
$15.00
$ 3.00
10. The names of all admitted, unpaid claimants of whom the Petitioner has notice or
knowledge are:
Commonwealth of Pennsylvania. Medicaid Estate Recovery
$98.723.88
11.
Total Debts and Deductions
$98.756.88
Taxable Remainder
$95384.72-
12. An inheritance tax return was filed with the Department of Revenue on
July 24,2001. No taxes were assessed or paid out of the estate's funds. The Department of
Revenue has assessed no interest and penalties against the estate. The total remaining for
distribution is $3,339.16.
13. Twenty (20) days prior written notice of intention to file this Petition has been
given to every unpaid beneficiary, heir, or claimant who has not joined herein. (Notice letters
attached as Exhibit A).
WHEREFORE, Petitioner prays that the Court direct distribution ofthe balance of
property remaining for distribution to the persons entitled thereto as follows:
Commonwealth of Pennsylvania - Medicaid Estate Recovery
$3.372.16
K nneth J. Suter
Assistant Counsel
Attorney LD. No. 56217
Department of Public Welfare
Date: I tP - / '1 - c; I
COMMONWEALTH OF PENNSYLVANIA:
ss.
COUNTY OF DAUPHIN
AFFIDAVIT
I, Kenneth J. Suter, Assistant Counsel for the Department of Public Welfare, depose and
say that the facts and figures contained in the foregoing Petition were given to me by the South
Mountain Restoration Center and were taken from official South Mountain Restoration Center
records. They are true and correct to the best of my knowledge, information and belief.
if~' ~ ~
K eth J. Suter -
Assistant Counsel
Department of Public Welfare
Office of Legal Counsel
3rd Floor West, Health and Welfare Building
Harrisburg, Pennsylvania 17105-2675
SWORN TO AND SUBSCRIBED
7:i{
BEFORE ME THIS /1 DAY
OF {f)CT(~I~rc', 2001.
/J4-j)-UI}l ~ ~
NOTARY PUBLIC
NOTARIAl SEAl
NANCY N. REEDtNGER, Notary Public
Harrilburg, Dauphin County, PA
My Commission Expires May 13, 2002
Hl0'.90' RFY(09100)
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
~)/~
C\~5.~/~.
Robert S. <ZinJnerman, Jr., MPH
Secretary of Health
Charles Hardester
State Registrar
1677862
OCT 0 3 2001
Date
Hl05. t43 Rev. 2117
COMMONWEALTH OF PEMfSYLlJAMA . DEPl'RTMENTOF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
037644
TYPElPNNT
IN
PERMANENT
IIlACK _
NAME OF DECEDENT (Fir.. Middle. Las)
SEX
.. Female
STATE FIlE NUMBER
SOCIAL SECURITY NUMBER
3.195 -50
.2/
BUUHPlACE (City and
Stale or For8lgOCOUfltry)
~,o
5.
COUNTY OF DEMH
70 V<s.
RACE - AIMrican Indian. Black. WhiM. ..
('-",
White
. ",-Cumberland
DECEDENT'S USUAL OCCUPRlOH
{~~W:~~::~:f
Never Employed
SUFMVING SPOUSE
(If........ giWl maiden namel
170.
Q;d
-
....in.
(l1mnprl ;:mrl tovmship? 17d.0 ~~~aI
MOTHER'S NAME (Fils. Middle. Maiden Surnmnel
...Ruth F. Hosfeld
INFHC75~~f24':"~~O~:{r;burg, PA 17211
-
PlACE OF DISPOSITION. Name at CetMotery. c~ LOCAJlON. CityiTown. State. ~ Code
",,,,,,",Place Southampton Township
.,,Cumberland County, PA
.....
.......
i21 Walnut Bottom
..?hippensburg, PA
F.lITHER'SNAME (Fitst. Middle. last)
... Frank M. Sho e
INFClRMANrS NAME (Type.'PrinC)
~ Candace S. Arnold
METHOO OF 0ISP0SI110N
Burialrn~o
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I-
ai
fil
frl
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...
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17257
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P /\I el.( htOfl / IJ
DUE 10 (OR AS A CONSEQUENCE OF):
e-t1 f=
DUElO(ClA ASACONSEOUENCE OF):
R€.i
0UE1O (OR AS A. CONSEQUENCE OF):
...
I Appoximale
IInl~betWMn
: onMI and dMIh
I
i
PART.: Ottwsigniflcanl:~oontribudngtodNttl.~
noI~intM~C*-giwninPlflRTI.
WERE AUTOPSY ANOINGS MANNER OF DEATH
-""JLA8l.E pRtOft 10
COM'lET1ON OF CAUSE ~ 0
OF DERH? N..... Homicide
- 0 Pending InwMiglIIlon 0
_0 ... 0 Solcido 0 Coukl not be de1ennined 0
ORE OF INJURY
(Monlh. Day. 'Mar)
TIME OF INJURY
INJURY lIS WORK? OESCRtBE HOW INJURY OCCURRED.
_ 0 ...0
....
CERTIFIER (Check onv one)
"CERTIFYING PHYSICIAN (Phy5lClat' certifying cause 01 death wh8l" anOll18f pnysician has Pl'onounced dealtt ana completed Item 23J
Tothebntof"'Yknowtedgll.de.moccurndduetolheeauM(.).nd~nMf''' Nted.................................
29.
- _.
PLACE OF INJURY -AI home. harm, strHC, ladory, omc.
buitdng, etc. CSPecifv)
_.
...
OPAONOUNClNG AND CERTIFYlNG PHYStclAN (Physician tx:llh j)fOllCllJnclflg death and certifyJog 10 cause of death)
To the bnt ot my knowtedge, death OCCurrM at the time, date, and place, and due to the cauM(s) and lmInt'Ief" statlld
SIGNATURE AN
ffj 31b.
LICENSE NUMBER
o 3lc. 1\11J e> -
NAME AND ADDRESS
(Ilem 27) Type or Print
m/J
"MEDICAL EXAMINER/CORONER
On the beaJ. of eumln.tlon and/or Investigation, in my opinion. death oecurred at the time, date, and place. and due to the causa(s) and
mannera. statM......................... -........................................................................
31..
REGISTRAR'S OONATURE AND NUMBEA
~l ~I{,ST
DATE A
34.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
KENNETH J SUTER
CMWLTH DEPT OF PUBLIC W
HLTH & WELFARE BLDG
HBG PA 17105
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
09-11-2001
SHOPE
04-30-1998
21 78-0490
CUMBERLAND
101
*'
REY-1547 EX AFP (l2-DDl
JEANETTA
Amount R_itted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
ifiv=is'4j-EX-AFP-n'2-:00Y-NOTicE--OF-YNHErfifANCE-TAX-APPRAisEifiNT~--AL.i-OWANCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SHOPE JEANETTA FILE NO. 21 78-0490 ACN 101 DATE 09-11-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
2,863.98
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
4,512.80
98.723.88
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
2,863.98
103.236 68
100,372.70-
.00
100,372.70-
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 = .00
.00 X 06 = .00
.00 X 00 = .00
.00 X 15 = .00
(19)= .00
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE OUE
COMMONWEALTH OF PENNSYL VANIA
DEPARTMENT OF PUBLIC WELFARE
OFFICE OF LEGAL COUNSEL
P.O. Box 2675, Harrisburg, PA 17105-2675
Kenneth J. Suter, Assistant Counsel
Neoma P. Minium, Legal Assistant
Telephone: 717-787-1619
Fax: 717-772-0717
E-mail: ksuterra1state.pa.us
October 19, 2001
Mr. Paul Reed
3135 Orrstown Rd.
Shippensburg, P A 17257
RE: Estate of Jeanetta Shope
Dear Mr. Reed:
Please be advised that I have received a Notice of Approval from the Department
of Revenue, and I will be filing a Petition to settle this Estate on November 8, 2001. I
have enclosed a copy of the petition to this letter.
If you have any objections to the petition, you must file them with the Clerk within
twenty (20) days of the date of this notice, or the Court will assume that the matter is
uncontested and will sign the proposed Order. If you have any objections or any
questions concerning this matter, please feel free to contact me at the above-listed
telephone number.
Very truly yours,
~~;L~
Kenneth J. Suter
Assistant Counsel
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
OFFICE OF LEGAL COUNSEL
P.o. Box 2675, Harrisburg, PA 17105-2675
Kenneth 1. Suter, Assistant Counsel
Neoma P. Minium, Legal Assistant
Telephone: 717-787-1619
Fax: 717-772-0717
E-mail: ksuter@state.pa.us
October 19, 2001
Candace Arnold
11960 Mentzer Gap Rd.
Waynesboro, P A 17268
RE: Estate of Jeanetta Shope
Dear Ms. Arnold:
Please be advised that I have received a Notice of Approval from the Department
of Revenue, and I will be filing a Petition to settle this Estate on November 8, 2001. I
have enclosed a copy of the petition to this letter.
If you have any objections to the petition, you must file them with the Clerk within
twenty (20) days of the date of this notice, or the Court will assume that the matter is
uncontested and will sign the proposed Order. If you have any objections or any
questions concerning this matter, please feel free to contact me at the above-listed
telephone number.
Very truly yours,
y~'7~
Kenneth J. Suter
Assistant Counsel
Enclosure
. .
COMMONWEALTH OF PENNSYLVANIA
DEP ARTMENT OF PUBLIC WELFARE
OFFICE OF LEGAL COUNSEL
P.O. Box 2675, Harrisburg, P A 17105-2675
Kenneth J. Suter, Assistant Counsel
Neoma P. Minium, Legal Assistant
Telephone: 717-787-1619
Fax: 717-772-0717
E-mail: ksuter@state.pa.us
October 19, 2001
Peggy Tamer
559 Montgomery Ave.
Chambersburg, P A 17201
RE: Estate of Jeanetta Shope
Dear Ms. Tamer:
Please be advised that I have received a Notice of Approval from the Department
of Revenue, and I will be filing a Petition to settle this Estate on November 8, 2001. I
have enclosed a copy of the petition to this letter.
If you have any objections to the petition, you must file them with the Clerk within
twenty (20) days of the date of this notice, or the Court will assume that the matter is
uncontested and will sign the proposed Order. If you have any objections or any
questions concerning this matter, please feel free to contact me at the above-listed
telephone number.
Very truly yours,
~9~
enneth J. Suter
Assistant Counsel
Enclosure