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F\FILES\DA T AFILE\EST A TES\l 1787.I.small.estate.petition
Created: 1/4/05 244PM
. , Revised: 2/13/06 10: 55AM
"
,
,
IN RE: ESTATE OF
JANET ST AVER JACOBS,
DECEASED
:IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS ' COURT DIVISION
:2005-0898
PETITION FOR SETTLEMENT OF THE EST ATE OF
JANET STAVER JACOBS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
The petition of CONNIE L. JACOBS by her attorneys, MARTSON DEARDORFF
WILLIAMS & OTTO, respectfully states that:
1. Janet Staver Jacobs ("Decedent"), died a resident of Shipp ens burg Health Center, 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania on April 12, 2005. See
attached Exhibit "A".
2. Petitioner, whose address is 23 Medford Drive, Mebane, NC 27802, is the Decedent's
daughter.
3. Decedent died intestate and no letters have been granted.
4. Decedent was survived by the following persons entitled to share in her estate:
Petitioner, Connie L. Jacobs, and Sandra J. Jacobs, of300 Vuemont Place NE, Apt. F-302, Renton,
W A 98056, Decedent's other daughter.
5. Decedent's sole property consists of Mony Annuity No. SN162838, held by Mony
Life Insurance Company, One MonyPlaza, P.O. Box 4830, Syracuse, NY 13221-9958 with a value
of$6,562.65. See attached Exhibit "B".
6. No disbursements have been made from the estate prior to the filing ofthis Petition.
7. Decedent's funeral expenses of$7,020.00werepaid to Fogelsanger-BrickerFuneral
Home, Shippensburg, P A 17257, by a prepaid funeral plan. See attached Exhibit "C",
8. The Pennsylvania Department of Public Welfare has made a claim against the
decedent's estate in the amount of$160,652.55. See attached "Exhibit D".
9. The Petitioner states that to the best of her knowledge there are no other unpaid
claims.
10. A Pennsylvania Inheritance Tax Return was filed with the Register of Wills on
October12, 2005; a statement of "No Tax Due" was thereafte~J~su~d. Se~ attached'fExhibit E".
PI.
11. Notice of Petitioner' s intention to file this Petition and a proposed settlement of claim
have been given to the Pennsylvania Department of Public Welfare and the Department of Public
Welfare has signed a Release accepting the proposed settlement. See attached Exhibit "F".
12. Written notice of Petitioner's intention to file this petition has been given to Sandra
L. Jacobs and the consent of Sandra J. Jacobs is attached hereto as Exhibit "G".
WHEREFORE, Petitioner requests that the Court award the Estate of Janet Starver Jacobs,
Deceased as follows:
Connie Jacobs, reimbursement of funeral and estate travel expenses
Sandra J. Jacobs, reimbursement of funeral travel expenses
Pennsylvania Department of Public Welfare, balance of estate
for medical assistance claim # 550152134
Connie L. Jacobs, Executrix commission
MARTSON DEARDORFF WILLIAMS & OTTO, Disbursements advanced:
Certified mailing, Department of Public Welfare 4.42
Filing fee, Small Estate Petition 30.00
Register of Wills, filing fee, Inheritance Tax return 15.00
MARTSON DEARDORFF WILLIAMS & OTTO, attorney's fees
$ 492.52
481. 68
3,214.03
325.00
49.42
2.000.00
TOTAL DISBURSEMENTS:
$ 6,562.65
MARTSON DEARDORFF WILLIAMS & OTTO
dJ i1] 'y: a 0-' (I r
By. / L /( -. ;. ,J L. ( /
./ -
Hillary A. D
10 East High Street
Carlisle, PAl 7013
(717) 243-3341
Date:
Attorneys for
Connie L. Jacobs, Petitioner
VERIFICATION
I verify that the statements contained herein are true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa.C.S.A. 94904, relating to unsworn
falsification to authorities.
cc- C "{V1 ~~ ~ () ~'J)
ConnIe L. JaCobs. "'[
STATE OF NORTH CAROLINA
COUNTY OF !tJarna'lU--
)
): ss.
)
On this / gt! day of fYktrcl1
, ~tJ~ ~ , before me personally appeared
the aforesaid declarant, to me known to be the person described in and who executed the foregoing
instrument and acknowledged that she executed the same as her free act and deed. IN WITNESS
WHEREOF, I have hereunto set my hand and affixed my official seal in the County
of It/tur'l.ance.. , State of North Carolina, the day and year first above written
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~j f)" Xtf/n?Y1 (SEAL)
Notary Public
;\\:'i;';0';; RE\ I/O.'"
~1is is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
tllcal Re~istrar~ The original certificate will be forwarded to the State Vital Records Office for permanent fi'ling.
L ,
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
Fee for this certificate. $6.00
p
11337429
tti !h'f, 7/)0;-
"1 '
Date
H105 143 Rev. 2187
COMMONWEALTH OF PENNSYLVANIA ., DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
STATE FILE NUMBER
lYPElPRINT
IN
PERMANENT
BLACK INK
~I
NAME Of DECEDHIT (first, Middle, Lasl)
1. JANET B.
_ AGE (I..asl Binhday)
SOCIAL SECURITY NUMBER
3. 162 - 22 - 0293
CXJ5
onl n - inst
5. 76 Y",
COUNTY OF DEATH
8b. CUllberland
DECEDENT'S USUAL OCCUPATION
MARITAL STATUS. Mamed,
Never Married, W~owed,
Dtvorced {SpeCify}
14. Widowed
Reljd~ee 0 =~ify) 0
RACE - American Indian, Black, W'lite, el
(Specify)
10. White
SURVIVING SPOUSE
{If WIfe, gi\le maidennarne}
Cumberland
Did
cIece<lenl
live in 8
township?
11e. ~ Yes. decedent lived in
11d. 0 ~~h\~e=?~i~i~~ of
Shippensburg Township ~p
Cltylboro
fa
ig
'"
4:
OJ
'"
r. 16 2005
LICENSE NUMBER
221>. FD 011776-L
MOTHER'S NAME (First, Middle, Malden Surname)
19. Louetta Haberli
INFORMANrs MAILING ADDRESS (Street, CilyrrOWn. State, Zip Code)
20b. 23 Medford Dr. M bane NC 27 2
PLACE OF DISPOSITION- Name of Cemetery, Crematory LOCATION ~CityfTown, State, Zip Code
Of other Piece Shippensburg
21<5 Cumberland Count PA
17257
26,
27. PART I: EnterQte diseases, injuries()f"comvllc8bon$wt!.icl\~.unclttledhth', Do not eotrl" lhe mocleofd g,luehnCllrd*orrespil1ltoryams.t,shoek orheartlalture. : Approximate
list only one calS. on t1Kh line. , interval between
: onset and dealh
Other significant cond\\ions contributing 10 death, but
not resulting in the underlying cause given;n PART I
Sequentially list conditions
if any, ~adjng 10 Immeaiate
__ cause. Enter UNDERLYING
. CAll.SE (Disease Of injury
. thallniliated even\s
resulting on death) LAST
WAS AN AUTOPSY WERE AUTOPSY FINOINGS
PERFORMED? AVAIL"BLE PRIOR TO
COMPLETION OF C"USE
OF DEATH?
I:
MANNER OF DEATH
~
r
NalUral
Accident
IB"'"
o
o
DATE Of INJURY
(Ml)f'.\h,OlIy,Y.ar)
TIME OF INJURY
INJURY A1 WORK? DESCRIBE HOW INJURY OCCURRED
YasO
NOD
Suicide
Homicide
Pending 1000estigahon
Could not ~ determined
o
o
o :~CE OF INJURY -At home, ::~, Slreet, factory, 0;
bullding,ett, (SpecIfy)
30e.
28&. 28b.
CERTIFIER (Check only one)
~l~':h~F~:'Gor~~~'~~~~~71.s~~:~{.g~~~i~~C:S~: t~ &':~.~::~I:r~W3r~X~~~sh:~p:~~~~. ~~~~~ ~~ .~~~~~~~.~ ,j.t~~ .:~).
29.
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'MEDICAL EXAMINER/CORONER
On the b.sls of ex.mlnatlon .nd/or investigation, In my opinion, de.th occurred .t the time, d.le, and place. and due to the tause~s) and
manner as atated
31a.
. REGISTRAR'S SIGNATURE AND NUMBER
RTIF.l ~/J M D,
.....00 31b. 1'\Yi'C1 -
LICENSE NUMB. 0 DATE SrGNJ=.O (Monlh, Day, Year)
o 31<. fY)!)" ~-Ci ?, 11} -L 31d, If II'; /0 ~-
~,:%NT~:'~%~f O!./'J't'::v7;S;fO;:PlE~D C~hC 0:;; /2A
o '7 i /. FiFfH A-f/Ec
32, c...- ,50
DATE FILED (Month, Day, Year)
"PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronouncing death and certifying 10 cause 01 dealh)
To the best of my knOWledge, death occurred at the time, d.te, and place, and due to the C'USes(8) and manner IS 51,'ed.
ILfZ-1'1
I I I I
34,
&LL-~ tJ
OCT-12-2005 11 :57AM FROM-
,/ '"
T-205 P.001/00,1 F-337
1--
~A ·
An AXA Flnanciaf Company
MONY Life insurance eompany.'-..J-
One MONY Plaza
P.O. Box 4830
Syracuse. NY 13221
315477-3000
www.mony.com
Fax
Date 10-696
# of Pages including cover sheet:
-L
To: Victoria Otto From: Carol Gosson
MONY Life Insurance Company
One MONY Plaza Mail Drop 32-52
Syracuse, NY 13221
Phone (711) 243-3341 Phone (315) 477-4471
Fax (717) 243-1850
cc: Fax (315) 477-4357
Phone
REMARKS:
SN152838 JANET S JACOBS
Ms. Otto,
Per your request the date of death value on the above is $6,562.65 (April 12, 2005). Please Jet
me know if you need anything else or have any additional questions.
We will wait to hear from you regarding filing the Affidavit.
rely,
This facsimile transmission contains information that is confidential and intended for usa of the individual or entity named above.
If you are not the intended recipIent, be aware that any disclosure, copying, distribution or LJse of the contents of this 111formation
is prohibited. If you have received this facsimile transmission in error, please notify us by telephone (315) 477-4471
immedIately. Thank you for your cooperation.
GLLIg
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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
September 8, 2005
MARTSON DEARDORFF WILLIAMS & OTTO
HILLARY A DEAN ESQUIRE
10 EAST HIGH ST
CARLISLE PA 17013
Re: JANET JACOBS
CIS #: 550153134
SSN: 162-22-0293
Date of Death: 04/12/2005
Dear Attorney:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $160,651.55 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 $24,164.46, 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 $136,487.09,
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,
~~.~
Brian M. Holler
Claims Investigation Agent
717-772-6607
717-705-8150 FAX
Enclosure
~L&-tO
12-19-2005
JACOBS
04-12-2005
21 05-0898
CUMBERLAND
101
APPEAL DATE: 02-17-2006
(See reverse side under Objections)
Amoun~ Remi~~edl I
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 +-
REv:is4'-Ex-AFP-ioi:osi-NOYICE-OF-INHERIYANCE-YAX-APPRAISEMENT:-ALLOWANCE-OR---------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
JANET S FILE NO. 21 05-0898 ACN 101
'BUREAU' Of INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE O~ INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
Of DEDUCTIONS AND ASSESSMENT Of TAX
HILLARY A DEAN
MARTSON ETAL
10 E HIGH ST
CARLISLE
ESQ
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
PA 17013
ESTATE OF
JACOBS
.
REV-1547 EX AFP (06-05)
JANET
S
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
DATE 12-19-2005
If an assessmen~ was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflec~ figures ~ha~ include ~he ~o~al of ~ re~urns assessed ~o date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxeble 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 R IT
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. Hortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Hisc. 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
6.562.65
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. funeral Expenses/Ad.. Costs/Hisc. Expenses (Schedule H)
10. Debts/Hortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
10,464.20
160.651.55
(11)
(12)
(13)
(14)
NOTE:
.00 X
.00 X
.00 X
.00 X
DATE
NuttBER
+
INTEREST/PEN PAID (-)
AMOUNT PAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
credit to your account,
submit the upper portioi
of this form with your
tax payment.
6,562.65
171.111) 78
164,553.10-
.00
164,553.10-
00 =
045 =
12 =
15 =
.00
.00
.00
.00
.00
(19)=
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
fOR CALCULATION Of ADDITIONAL INTERES~... '- I I c.If TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
e~A:.i.~1t:'A REfUND. SEE REVERSE SIDE DF THIS FORM FOR TN!COTRIJI":TTnN!CO.l
F\FILES\DA T AFILEIESTA TES\11787.l.releasc
..
ESTATE OF JANET S. JACOBS
CUMBERLAND COUNTY FILE NO. 21-05-0898
RELEASE
KNOW ALL MEN BY THESE PRESENTS that the ESTATE RECOVERY PROGRAM OF
THE COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, does
hereby acknowledge receipt from Connie L. Jacobs and Sandra J. Jacobs, heirs ofthe Estate of Janet
S. Jacobs, of payment in the amount of Three Thousand Two Hundred Fourteen and 03/100 Dollars
($3,214.03), which represents the balance of all funds in the Estate of the said Janet S. Jacobs, after
payment of allowable administration and funeral expenses, in payment of its claim against the within
estate dated September 8, 2005, CIS # 550153134.
Should any additional probate assets become available in this estate, the within office will
accept payment of same to the extent of their claim as referenced above.
IN WITNESS WHEREOF, the undersigned has hereunto caused this instrument to be
executed this 10 day of j Ct r1 U <1 1'l'1 ,d-O:;) &.
Witness:
(d)~ ~ .').V
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
ESTATE COVERY PROGRAM
By: /2~;';'<:/. '--~~~~~da~'~
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Po.,,,-,--))ru--...J
)
: SS.
)
On this the r c: day of J (~ v\.u (~~ , d<c:t>iL> , before me the undersigned o~ficer,
personally appeared E i 0\ \l\ Q;- rjZ Uk\'U.LLV , who acknowledged that Mtshe IS the
~\ Ac ~ ~ili \,.;\l-l..0V-.J ofthe Commonwealth of Pennsylvania,
Department of Public Welfare, Estate Recovery Program, and that as such, being authorized so to do,
executed the foregoing instrument for the purposes therein contained.
IN WITNESS WHEREOF I hereunto set my hand and official seal the day and year aforesaid.
/1' I /J
/(f/iU .Iq~17M~
No Public
NWE TH OF NN
NOTARIAL SEAL'
~otE l. lIPSCQMB, Notary Public
City of Harrisburg, Dauphin County
__ CGrMIua E~ MIy 29, 2006
(~ ;,. t~+- i?
t
..
CONSENT OF PARTIES
The undersigned, a party interested in the Estate of Janet Staver Jacobs, deceased, hereby
consents to the foregoing petition for Settlement of a small estate.
~~cj)~
Sandra J. Jacobs
SJui fCPL &.