HomeMy WebLinkAbout03-23-06
REV-1500 EX + (6-00) REV-1500 OFFiCIAl. USE ONL Y
'* COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE INHERIT ANCE TAX RETURN .---- -~~-.._-_._----_.- . -------"
DEPT 280601 FILE NUMBER
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 2 1 - 0 5 0 9 1 8
C'O'U"NTY""C'CDE ~AP- - - NLjMBEq--
DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
.... LOUISE
Z SWAIN DOROTHY 1 7 7 - 2 4 - 7 4 7 0
W DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
C
W 1 0/08/2005 12/10/1928 REGISTER OF WILLS
()
W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
C
- -
w [X] 1. Original Return o 2. Supplemental Return o 3. Remainder Return (date 01 death prIOr to 12-13-82)
....
~ :$00 o 4. Limited Estate o 4a. Future Interest Compromise (date of death aher 12-12-82) o 5. Federal Estate Tax Return Required
(,) a:~
w 0.(,)
J: 00 o 6. Decedent Died Testate (Attach copy of Will) o 7. Decedent Maintained a Living Trust (Attach copy ofTrust) 8. Total Number of Safe Deposit Boxes
(,) a:...J
o.lD -
0. o 9 Litigation Proceeds Received o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1.1.95) o 11. Election to tax under Sec. 9113(A) I,Attach Sch 0)
~
I- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED .TO:
z NAME COMPLETE MAILING ADDRESS
w
c DOUGLAS G. MILLER ESQUIRE 60 WEST POMFRET STREET
z
0 FIRM NAME (If Applicable)
0.
00
w IRWIN & McKNIGHT
a:
a: TELEPHONE NUMBER
0
(,) 717) 249-2353 CARLISLE PA 17013
OFFICIAL USE ONLY ----.--
1. Real Estate (Schedule A) (1) :
2. Stocks and Bonds (Schedule B) (2)
3, Closely Held Corporation. Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash. Bank Deposits & Miscellaneous Personal Property (5) 1,995.00
(Schedule E)
Z 1,123.70
0 6. JOintly Owned Property (Schedule F) (6)
j:: 0 Separate Billing Requested I
<t
....I 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ,
::J _____u"
t: (Schedule G or L)
a. 3,118.70
<t 8. Total Gross Assets (total Lines 1-7) (8)
() 8,804.25
w 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
a: 23,768.43
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10) (11) 32.572.68
12. Net Value of Estate (Line 8 minus Line 11) (12) -29,453.98
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) -29,453.98
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
Z 15. Amount of Line 14 taxable at the spousal tax
0 rate. or transfers under Sec. 9116 (a)(1.2) 0.00 X _(15) 0.00
~ 16. Amount of Line 14 taxable at lineal rate 0.00 X 045 (16) 0.00
....
::J 0.00 0.00
0- 17. Amount of Line 14 taxable at sibling rate X .12 (17)
:E
0 18. Amount of Line 14 taxable at collateral rate 0.00 X .15 (18) 0.00
()
>< 19. Tax Due {1 Q\ 0.00
\''''/
~20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > .. BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
I STREET ADDRESS
11 BUTTONWOOD LANE
I WY CARLISLE
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
I STATE PA
ZIP
17013
(1 )
0.00
Total Credits (A + B + C)
(2)
0.00
3. lnterestlPena:ty If applicable
D. Interest
E. Penalty
0.00
TotallnterestlPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
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; ........................................................................... 0 IX]
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IX]
c. retain a reversionary interest; or ...................................................................................................... 0 IX]
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 IX]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?..................... ..... ........ ....... ... ... ...... ............ .......... .............. ..... 0 IX]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 IX]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 IX]
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of periury, I declare that f 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.
DATE.3 --? '7 --('7(:-:'
PA 17013
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. S9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. S9116 (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 twenty-one 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% [72 PS. S9116(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%, except as noted in 72 P .S. S9116(1.2) [72 PS S9116(a)(1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. S9116(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-15G8 EX + (6-98)
'*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
SWAIN
FILE NUMBER
DOROTHY LOUISE 21 05
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.
0918
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
1,995.00
1970 Mobile Home - SOLD
Parcel No.: 21-06-0015-002.-TR01027
TOTAL (Also enter on line 5, Recapitu!ation) $
(if more space is needed, insert additional sheets of the same size)
1 995_00
r,
!Y'
REV-1509 EX + (6-98)
,.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SWAIN
FILE NUMBER
DOROTHY
LOUISE
21
05
0918
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. William S_ Yiengst
1343 Willow Mill Road
Mechanicsburg, PA 17055
Son
B
c
JOINTL Y-OWNED PROPERTY:
LETTER DATE DESCRIPTiON OF PROPERTY %OF OA TE OF OEA Tf;
iTEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTIO~I AND BANK ACCOUNT ~IUMBER OR SIMILAR DATE OF DEATH DECO'S VALiJEOF
I~UI\i5t:M Tci'lAi\l"1 JOINT IDEN [ieYING NUMBER. A fTACH DEED FOR JOINTL Y.HELD REAL ESTATE. V ALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. 6/04 I M& T Bank - Checking Account 9833888465 200.08 50. 100.04
2. A. 11/04 M& T Bank - Checking Account 9838443498 2,022.32 50. 1.011.16
3. A. Members 1 st Federal Credit Union 25.00 50.1 12.50
TOTAL (Also enter on line 6, Recapitu!ation) $ 1 123.70
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF
SWAIN
DOROTHY
LOUISE
21
05
0918
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Myers Funeral Home, Inc. 6,632.25
2. Woodlawn Memorial Gardens - Opening and Closing 950.00
B. AOMi~iISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address ~--~-~'-'~~--'--"~~--~'-"~"--"-"-~~"~"'--'-~'-&~~-;~--*',
I City State lip
Year(s) Commission Paid:
2. Attorney Fees Irwin & McKnight 750.00
') Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
v.
Claimant
Street Address
City State lip
I Relationship of Claimant to Decedent
4. Probate Fees 72.00
5. Accountant's Fees
6. Tax Return Preparer's Fees 350.00
7. Register of Wills, Filing Fee 30.00
8. Notary Fees 20.00
TOTAL (Also enter on line 9, Recapitulation) I $
(If more space is needed, insert addilional sheets of the same size)
8,804.25
REV-1512 EX + (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SWAIN
FILE NUMBER
DOROTHY
LOUISE
21
05
0918
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
Holy Spirit Hospital - Medical
8,931.00
2.
HCR Manor Care - Nursing
1,978.80
3.
East Pennsboro Ambulance Service, Inc. - Ambulance
150.00
4.
West Shore Health & Rehab Center - Medical
4,371.50
5.
UGI - Gas/Utility
111.34
,-.
o.
nQ Q 1 r!,_~ _~:'-".; ,....,
I' .. <Xl.... - Colt'"''' ,,",
b~./~
7
Heaithsouth Rehab #4 Accnts - Medical
8,162.00
TOTAL (Also enter on line 10, Recapitulation) $
23,768.43
(If more space is needed, insert additional sheets of the same size)
REV.1513 EX + (9.nm
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SWAIN
NUMBER
L
1.
2.
3.
SCHEDULE J
BENEFICIARIES
0918
AMOUNT OR SHARE
OF ESTATE
1/3 Remainder
1/3 Remainder
1/3 Remainder.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
11. NON-TAXABLE DISTRIBUTIO~jS:
A SPOUSAL DISTRIBUTiONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEiNG MADE
1.
1.
DORnTHY
FILE NUMBER
21 05
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
LOUISE
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
William S. Yiengst
1343 Old Willow Mill Road
Mechanicsburg, PA 17055
Russell E. Yiengst
20 Cabin Road
Jonestown, PA 17038
Sharon Yiengst
829 Walnut Street
Lebanon, PA 17042
Lineal
Lineal
Lineal
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
I
I
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE~ $
(If more space is needed, insert additional sheets of the same size)
LAST lVILL AND TESTAj}IENT
I, DOROTHY L. SW AI~, of Middlesex Tmvnship, Cumberland County, Pennsylvania,
being of sOllnd mind, disposing memory and full legal age, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made
byrne.
ONE.
I direct my Executor or Executrix, as the case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore,
i dIrect that aU state, mheritance, succession and other death tax.es imposed or paYClble by reason
of my death and interest and penalties thereon with respect to all property composing of my gross
estate for death tax purposes, whether or not such property passes under this \ViU, shall be paid
by the Executor or Executrix of my estate.
T'VO.
rvIy Executor or Executrix may, at his or her discretion, compromIse
claims. bOITO\v money. retain property for such length of time as he or she may deem proper:
lease and sell property for such prices, on such terms, at public or private sales, as he or she may
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authorize and empower my Executor or Executrix ta sell
any realty and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficienc deeds and/or bills of sale
[herefor, in fee simple, as I could do if living. My Executor or Executrix is authorized and
d . . 'b " , .~ ,,,h:~h I ~n., b ,~-~",- ,j ..- ~.. d ,_: r~~"l, _ .' ,.' . t'
ernpo'"",;.!crc_ to engage In dD)' JUSlncss Lu VVUi\"'i! lu!1...Y Ie v!!6dbCU a.t t1!Y c!.lu1.. iLl! ~L1,-!! PC!lud 01
time after my death as seems expedient to said Executor or Executrix.
!
I
THREE.
I give, devise and bequeath all of my estate of \\'hatever nature and
wherever situate as follows:
A. In the event I have any remaining interest therein, I give and devise the
hunting ground and all improvements thereon, as well as all rights and easements
appurtenant thereto, located at 247 Stoneridge Court, Saville Township, Perry County,
Pennsylvania, to my sons as tenants in common, and subject to any mortgages, liens, real
estate taxes or other encumbrances, in the following percentages:
1. Seventy-five percent (75%) to my son \VILLLi\iVI S. YIENGST,
per stirpes, which provides that the child or children of any deceased beneficiary
sh:lll tak-:: the share their purent would have tlken if Iivir.,;; ar.d
2. Twenty-five (25%) to my son RUSSELL E. YIENGST, per stirpes.
B. I give, devise and bequeath all of the rest, residue and remainder of my
estate in equal shares to my son \VILLIAM S. YIENGST, my son RUSSELL E.
YIENGST, and my daughter SHARON YLENGST, per stirpes, \'ihich provides that the
child or children of any decea::;cJ beneficidry shail tdke the share their parent wuuld have
taken if living,
C. I hereby specifically exclude my daughter CATHY M, J\lcKEE from any
inheritance \vhatsoever under this my Last \Vi11 and Testament for rC:lSOflS kno\vn unto
her.
FOUR
If, under any of the provisions of this Will, any principal becomes vested
in an individual under the age of twenty-one (21) years, my Executor or Executrix, as the case
may be, including any administrator c.La., shall retain tbe same as trustee of a po\ver in trust for
/,/1'. !
l .. I .' Y f' .
nltla._~~,
C/ /
)
the benefit of such individual or individuals in separate shares in the name of each heir or
beneficiary in the amount equal to the share inherited hereunder, until they attain the age of
twenty-one (21) years. Any of the principal thus retained, and any of the income therefrom,
including the whole thereof, may be paid to or applied for the benefit of each such individual
from time to time in the discretion of the trustee of such power. When each such individual
attains the age of twenty-one (21) years, the funds so held shall be paid over to such person, or, if
he or she shall sooner die, to his or her legal representatives. In so holding any principal or
income, the trustee of such power shall have all the rights, powers, duties and discretions
conferred or imposed upon my fiduciaries acting under this Will. I further direct that no bond
shall be required from any person receiving a payment hereunder and receipt fro[n sllch pers\)O
sh~ll be a f:'lll discharge to the trustee of s'Jch povver \\'ho shall net be bL1unJ tL) oCc; tl:) t~lt:
application or use of such payment. The trustee of such pO\ver shall be entitled to commissions
at the rates and in the manner payable to a testamentary trustee.
FIVE.
I nominate and appoint my son, VlILLlAJ.\l S. YIENGST, to be the
Executor of this my Last "Will and Testamem. 1'1 the event he has predeceased me, failed to
quaJify or is not able or does not serve for whatever reason, I then appoint my son, RUSSELL E.
YIENGST, to be the Substitute Executor of this my Last Will and Testament. In the event he has
predeceased me, failed to qualify or is not able or does not serve for whatever reason, I then
appoint my nephew, GARY HOOVER, to be the Substitute Executor of this my Last "Vi!I and
T estamem, whereby the S:.lid substltme personal representatives shall have the same po"vcrs a..;
arc gi vcn to the original Executor hereunder.
SIX.
No person(s) shall benefit hereunder unless such beneficiary shall surVive
me by sixty (60) days.
,-I i /"
Initial (Z;~C/ ...~
3
SEVE~. No Executrix or Executor acting hereunder shall be required to post bond
or enter security in this or any other jurisdiction.
EIGHT. No beneficiary may assign, anticipate or pledge his or her interest in any
income or principal held or distributable hereunder, and no beneficiary's creditors may levy,
attach or otherwise reach any such interest.
NINE. If any person or institution entitled to share in any distribution under the
terms of this my Last vVil1 and Testament becomes an adverse party in any proceeding to contest
the probate of this Last vVill and Testament, such person or institution shall forfeit his, her or its
entire interest inherited hereunder and all provisions in favor of such person or institution shall
be dccl~ed \/oid J.nd of llG effeCt. The share of such pcrSDn or InstitL~tion so furfeltcu shall be
distributed as part of the residue pursuant to Paragraph Three B. hereof except that if such person
or institution is entitled to share in the said residue, thar interest shall be distributed
proportionately to the other residuary distributees.
[THE REi\I!AINDER OF THIS PAGE HAS BEEN INTENTIONA.LL Y LEFT BLANK]
InitjaL.~_
4
lli \VITNESS \I/HEREOF, I have hereunto set my hand and seal this
1\ .., ,':i
:r"<j davof
December, 2004.
., ] (SEAL)
Signed, sealed, published and declared by the above-named person as and for a Last \Vill
and Testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
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5
ACKNOvVLEDGiVIENT AND AFFIDAVIT
"VE, DOROTHY L. S"V AIN, DOUGLAS G. MILLER and 1\IA TTHE"V A.
MCK.'HGHT, the testatrix and witnesses respectively, \vhose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
testatrix signed and executed the instrument as her last will and that she had signed willingly, and
that she executed it as her free and voluntary act for the purpose herein expressed, and that each
of the witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that
to the best of their knowledge the testatrix was, at that time, eighteen years of age or older. of
sound mind and under no constraint or undue influence.
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D~;lTH'f@s~ AiNck'<<u- i .. ,
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DOU 'LAS . .MILLER./
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l\L\TTHE\V A. MCKNIGHT
CO",LVlON\VEALTH OF PENNSYL VANIA
5S:
COUNTY OF CUMBERLAND
Subscribed, s\.vorn to and acknowledged beforc me by DOROTHY L. S\VAI.'-;", [he
testatrix herein, and subscribed and s\vom to.b,cfofe me by DOUGLAS G. MILLER and
MA TTHE\V A. MCK.~IGHT, witnesses, this . '" day of December, 200-+.
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Notary Public
November 17, 2005
I, William S Yiengst executor of the estate of Dorathy Swain
and Glenn Swain. I am selling trailer located at
11 Buttonwood Lane, Carlisle, Pa 17013 for the amount of $1995.00,
with the agreement of SOLD AS-IS. I am giving the Refri~erator,
Freezer, Washer and Dryer and Stove and also the Shed along with the
sale of the trailer.
To your atterition the roof leaks and there is water marks on the
ceiling.
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r!1 M&TBank
-I9'J MItchdl Road, !\Iillsboro, DE 19966 Mail Code DE-i'vlB-12
Phone (888)502--13-19
Fax (302) 93-1-2955
October 25, 2005
Law Offices
Ir'win & McKnight
\Vest Pomfret Professional Building
60 \Vest Pomfret Street
Carlisle, Pennsylvania 17013-3222
Re: Estate or Dorothy N Swain
Social Security' 177-24-7470
Date of'Death: October 08, 2005
Dear Sir or Madam:
Per your inquiry dated October 19 2005, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type alA ccount
Checking Account
Accounl Nwnber
9833888465
Ownership (Names of)
Dorothl' N Swain *
William S Yit!ngsl *
Opening Dale
o.6/2i /0.4
Balance on Dale olDeath
20000
Accrued inleresl
5 GOO
Total
200, DO
intereSI Paid YTD
5 0. 08 (Accrued interest is nol included)
')
TJp<! of,!ccounl
Checking Account
Al.:counl/'/umber
9838443498
OHnership (Names oj)
Dorothy IV Swain *
William S Yiengst *
()pening Dale
ii/ i6/0,j
Balance un Dale of Death
52,02036
.-1 ccrllt!d interest
5
0.20
To Ii t!
52,0.2056
illlt!res{ Paid YTD
5
1. 76 (4ccrued interesl is not included)
Please be advised, there was no safe deposit box found for the above decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call
the West Shore Plaza Office # 717-255-2271.
Sincerely,
-,
/)1<-'~ '/
Nancy Clagett
Records Management
10/25/2005 12:58
71 7751 g458
105
L B SHITH FORD
PAGE 02
Myers Funeral Home, Inc.
Bovd L. Mvers Jr., Supervisor
37 East Main Slreel
MecnanlCsourQ. PennSYlvania 17055
(717)785-3421
Fax (717) 795-7291
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Ch8fge:;. are only for {h,ose items that you selected or that are required. If we, are required by law or,oy ~ cexp.etery or crematory to use any items, we will
explain In wrltlng beto'W. Ifvou selected, a funeral thatmay reqUlre embalmmg, such as a funeral with vlewmg, you may have to pay for embalm 109. You
do not have to pay for embarmm~ you did not approve If vou selected arrangements such as direct cremation or immediate burial.lf we charge "au for an
embalming, we will explain why oelow. ' ,
For Services of Dorothy Louise Swain
Charge (0 William S Yiengst
t-Jaml:
Date Of Death October 8, 2005 Date of Contract
1343 Old WjlfowMill Road M.echanicsburg, Pa.
Adllres5 Cn)' :,tate
Oerober 9, 2005
17050
lip
3. AUTOMOTIVE EQUIPMENT S
VehicIe to tramfcr r"'main~ to J7uncral !Iome $ 350.00 SUB-TOTAL OF CASH ADVA~CED D$ 667,25
-
Hearse (Casket Coach) $ 295.00 We charge you for oIJr services in obtaining th(': following:
.-..._...- ..
I Flower Car / Floral Distribution $ lncl NONE
Family Car $ rncl
I L",ad Car / Clergy Car $ 195.00 SUMMARY OF CHARGES
i
I l'tility Car $ TOTAL ABOVE ITEMS (A,B.C.D) $ 8,227.25
Out Of town transportation $ Sales Tax (if App) @ % $ 0.00
$ -----
I St:B- TOTAL AUr0l\10nVE EQUIPMENT A3 $ 840.00 TOTAL OF ALL SECTIONS $ 1i,Z27.25
TOTAL SERVICES, FACILITIES, AUTOMOBILE <'\,$ 5,490.00 LESS: Paym<::nt Ml1llt; $
B. CHARGES FOR ~IERCHANDISE SELECTED LESS: Credits Pending $
Casket Baron $ lO25.00 LESS: Credits grantd Package Price Discount 3> 1,595.00
Other RecepmcJe $ BALANCE DUE Nov 8, 2005 $ 6,632.25
Outer Burial Container Guardian $ 950.00 A late charge of 1.5% per month on the outstanding balance (annual rate of 13%)r\,
Acknowledgment Cards $ wdl be added to the balance. "".~
Register Book $ 95.00 REASON FOR REQUIRED SERVICES OR MERCHANOfSE
,\!cmorial Folders $
Prayer Cards $ I Family Viewing
Temporary Grave Markers $ , Ceme~ry Requires outer burial contain.or ,
Burial Clothing $ I
DISCLAIMER OF WARRANTIES
Othe)' Clothing $ Our funeral home makes no reprasentallons or warranties regarding caskets
Cremation urn $ or ouler burial containers. The only warranties, expressed or implied, granted
~. in connection wilh goods sold Wlln lne funeral service are the eJ<preaa wmten
$ warranties, if any. elClended by the manufacturer thereof. No other warranties
S including lhe Implied warranties of merchantability' or fitness fer part;cul"r
TOTAL MERCHANDISE SELECTED B$ 2,070.00 purpose are extended by the seller.
I agree that I have examined the items of goods and services selected above and found them to be correct and according to the; arrangements I have
requested, I acknowledge receipt of e copy of this Statement of Funeral Goods and Services Selectsd. I represent that I have suffiCient. funds available lor
payment of the cash price for the gOOdS and services selected. I also agree to make payment of $ ,6632.25 Within 30 days.. J agree to be jOIr:"y and severally
liaole with :anyone elss who signs slow. ALATE CHARGE of 1.5% per month (18% ler annum) will be. applied Ie the unpaid balance beglnnlnR 30 days after
the date of this contract I will also pay the Funeral Director all reasonable cosls Will b~ the Funeral Director, to coned ?mounts I owe under t Is agreement,
Those cost., m"v inglude !'Illorney faes and court costs. Any Items rBauesled after he dOl e of thiS agreement will be conSidered part of thiS agreemenl and Will
.-\. CHARGE FOR SERVICES SELECTED:
L PROYES.sIONAL SERVICES
Services offuneral Director and Staff $
Embalming $
Casketing, dressing, cosmetology S
Other Preparation of body $;
Hairdresser / Barber $
AUtopsy Remains $
S
1895.00
895.00
295.00
95.00
SUB.TOTAL PROFESSIONAL SERVICES
2. USE OF FACILITIES AND SERVICES
For visitation I wake service .s
Fm fimeral ceremony S
for memorial service $
E(priprn~nr & ~e\vice_; for ~alJe~i,de :,:ervi,ce $
~--$
Sl1B-TOTAL fACILITIES AND EQUIPMENT
Al Lll~80.00
525.00
550.00
39500
A2 S 1,470.00
I be rstlected on the final bill.
, (Seal)
I ----~~-
i (,.."j,
Purch~s~r
C. SPECIAL CHARGES
Forwarding Remains to other Funeral Hom~
Receiving Remains form other Funeral Home
Immediate Burial
Direct Cremation
s
S
$
S
_.-
S
SUB-TOTAL OF SPECIAL CHARGES
D. CASH ADVANCED
Opening Grave/Crypt
Newspaper Patriot
Newspaper Sentinel
Clergy / Mass Offering
Certified Copies of Death Certificate 10
Family Flowers
$er UP
C$
$ FamiJr
$ 1-'.5..50
$ 89..25
$ 100.00
S 60.00
$ 132.50
S 150.00
$-".-
.5
A
(/ ft~05 J
,I' :(' ...--Co ,I ate ~A
10/25/2005 12:58 7177519458
L B SMITH FORD
PAGE 01
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be~
Claim Against Decedent's Estate
Estate Of: Dorothy Swain
Case #717-240-6345
The undersigned hereby presents for filing against the above estate this statement of
claim and alleges:
Beverly EnterpriseslWest Shore Health & Rehab Center
P.O. Box 180970 Fort Smith, AR. 72918
The basis of claim is: See Attached
The amount of the claim is $4371.50
Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best
of my knowledge and belief.
Signed on: January 19,2006
~.,' ~A~5(
Claimant Sandra Burnett
I Swear this statement is correct
Subscribed and sworn to before me
~'~~li~".
f(::~)1
~'~~A;'\~"
'''Ill'
TWYLA LENSING
Sebastian County
My Commission Expires
June 17, 2015
On ~~ 11)AJ~G
~UbliC~
jJ;/y Commission EXPires~{ 5
1'.0. Box I St)'J'O
Fort Smith, .'\R 72" IS.()970
4:'9.201..'.IJ[)I!. SnS2UF'i
\\iWW. heverlvc;l res.C()fn
oo-'~
'--"".
January 19, 2006
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, P A 17013
Whom It May Concern
Enclosed please find an itemized statement and a claim form to be used to file a claim
against the estate of Dorothy Swain. Mrs. Swain incurred these charges while a resident
in our facility, West Shore Health & Rehab Center. Enclosed please find a check for the
amount of $1 0.00 and a self addressed stamped envelope.
If you should need additional information or have questions regarding this please feel
free to contact me at 877-823-8375 ext 2270 fvlonday thru Friday from 8:00 to 5:00 PM
Central Time.
S incerel y,
Rita Donnelly
Healthcare Collection
Beverly Enterprises Inc
PO Box 180970
Ft. Smith, AR 72918
ROC
encl:
cc: Client's File
69343
F.().h()\ i S~>1-()
" -.- -------,'-------.-.-- ---"---- -"-"--'--"'~'--'-" --~.__. ---'-_..~--,_._--~--_.,-,-~- ..._-----,..
f'"rr \nl1[h. .\R -:-2') I k-ilq~1)
4Cl.).2()1.2\)1}1). >C7~.;";2 ')'l_';_l'
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BEVERLY ENTERPRISES
POBOX 180970
FORT SMITH ARKANSAS 72918
Itemized Resident Statement
RESIDENT ACCOUNT #:
69343-00285-40055
Dorthy Swain 01/19/06
DATES OF SERVICE DESCRIPTION DAYS I aTY CHARGES CREDITS
01/03/05 Beautician 1 $12.00
01/12/05-01/31/05 Part A Coinsurance 20 $1.630.00
02/01/05 Part A Coinsurance 1 $81.50
04/18/05-04/21/05 Room Charqe 4 $300.00
04/01/05-04/30105 Part A Coinsurance 26 $2.119.00
05/18/05 Beautician 1 $40.00
OS/27/05 Beautician 1 $12.00
05/01/05-05/27/05 Part A Coinsurance 27 $489.00
02/18/05 Payment $12.00
05/13/05 Payment $300.00
An additional $1141.00 will be due
privatelv should insurance not pay.
I
CHARGES CREDITS TOTAL AMOUNT DUE
$4,683.50 $312.00 $4,371.50
Dorothy Swain
C\O William Yeingst
Old William Mill Road
lviechanlcsburg, PA 17005
IN THE COURT OF COMMON PLEAS
CUlVIBERLAND COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
IN RE: ESTATE OF DOROTHYN. SWAIN,
DECEASED
O.C. No. 21-05-0918
PROOF OF CLAIM
HCR ManorCare - Camp Hill files this claim against the Estate of Dorothy N.
Swain in the sum of $1,978.80, in accordance with the invoice attached hereto, plus
interest and attorney's fees. The sum of $1,978.80 is a priority claim under 20 Pa. C.S.A.
93392(3) for the value of nursing care and services rendered to the Decedent within (6)
months of death.
Respectfully submitted,
SCHUTJER BOGAR LLC
.7 -d- 7 Jo'V,/,
l .....-...L.A.,,(,,;..
By:
14/ ;!~._-----
'vV. Srt Foster
Attorney I.D. No.: 90266
305 N. Front Street, Suite 401
Harrisburg, P A 17101
(717) 909-5924
Dated:
Rx OatelTime FEB-05-2005(MON) 15: DB
FEE 06 2006 16:18 FR M~NOR C~RE-CAMP
717 737 2189
737 2189 TO 9095925
P 002
P.02/02
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CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Proof of Claim was
served via first-class, United States mail, postage prepaid, upon the following:
Douglas Miller, Esquire
IRWIN & McKNIGHT
60 W. Pomfret Street
Carlisle, P A 17013
Dated: ():J-Io"7 ItJb
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HOLY SPIRIT HOS~:ITAl
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503 NORTH 21 ST iT ':EET
CAMP Hill, PA 17bl ~1~2288
Iliil~lilll~liliijili;lilllilrlill~ll~jjiillllllllllllllll
DEC 10 2005
Patient Name:
DOROTHY N SWAIN
Service Date Account Number
Patient
Responsibility:
107/08/05 25857632 i
'02/19/04 22580690- ---~--
1",111"1111.,.,1.1,11"",.11.1.1.,.1,1.1.1..1.,1.,11,1",11
10201 1 AT 0.292
DOROTHY N SWAIN
1343 OLD WILLOW MILL RD
MECHANICSBURG, PA 17050-1525
TR00039
Dear Patient/Guarantor:
Payment has pot been received in response to our rer:ent requests. Your account is now past
due. Please remit payment in full, or contact our Patient Financial Services at (Toll Free)
1-877-254-9239 if you have any questions.
If you have already paid the balance, thank you, and please disregard this letter.
Sincerely,
Patient Financial Services
If you have multiple accounts. please indicate the account numbers and the amount applied to each on
your check. Payments received without an account number may be applied to the oldest account.
If Payment Has Already Been Jvlade Please Disregard This Letter
------------------~------------------~----------------------
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
Check
Piease Indicate Method or Payment:
Payment Amount $
Visa
CredIt Card #
Money Order
MasterCard
Expiration Date:
Cardholder Name:
Signature:
Patient Name:
DOROTHY N SWAIN
Service Date Account Number
07/08/05 25857632
'OZT19iou4 22580690u
Patient
Responsibility:
1,"111",111"111,11".11,,1,1,,1,11.,1.1, , 1,11.".,11.1 , 1.111",1
HOL Y SPIRIT HOSPITAL
503 NORTH 21 ST STREET
CAMP HILL, PA 17011-2288
1111111111111111111111111111
PO BOX 67015
HARRISBURG. PA 17106-7015
RETURN SER vlCE REQUESTED
DIVERSIFIED BILLING SERVICES. liVe
Affiliated with NatIOnal Recoven Agency
(800) 3()()-2998
(717) 5-l0-762-l
[:'-: RL IlEALTIlSOLTII REfL \13 '~4
.\CC\:TS
.\Ccro: 440R90
T()]. \1. A\IOl XI' DLE SR. I (,2.00
01!30/06
D\TE OF SERVICE 01 ]}.()4
C92496/0D3 201 4239921 0000819/0003
1",111".111",.1,1.11"""11.1.1,,.1,1.1,1,.1,,1..11,1",11
Dorothy N Sv,ain
13-l3 Old Willow Mill Rd
Mechanicsburg. PA 17050-1525
SEND TO
DlVERSfFIED BfLUNG SERVICES, fNC.
PO BOX 67015
HARRISBURG. PA 17106-7015
I" .111., .1...1111""11..1".111",, ..11.1,1.,.' .11
Dear Dorothy N Swain.
Your account with HEAL THSOUTH REI-lAB #-1- ACCNTS is presently delinquent. The aIllount due and
owing is $8.16200
Unless vou dispute this debt or anv part thereof. within 30 days after receiving this notice. the debt will be
presumed to be valid. Should you notify the above-named creditor in writing that you contest the elebt. or
any portion thereof. the creditor will obtain verification of the debt or obtain a copy of a judgment and
mail you a COPy of such j uelgment or verification. ([You request the creditor in writing within 30 days
after rccei\Ing this notice. the creditor will proVide you With the name and address of the original creditor.
if different from the current creditor.
Should your payment or dispute not be received within 30 days from the date of this notice. this debt wil!
be considered for referral by our client to National RecO\ery Agency. lnc for collection activity
The purpose of this COllllllUI1lCation is to collect a debt and any information obtained will be used for that
purpose.
Sincerely.
DiversifIed Billing Services, Inc.
This communication is from a debt collector.
DBS/ALS-D3
ID #: C92496
Inventory of the real an personal estate of
DOROTHY LOUISE SWAIN
, deceased
1. 1970 Mobile Home
$1,995.00
TOTAL
$1,995.00
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