The URL can be used to link to this page

Home My WebLink About08-01-06 (i'lU:F:FI'E & J\sSOCIJ2lT'ES Attorneys and Counselors at Law Robin J. Goshorn Office Manager 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 Bradley L. Griffie, Esquire Hannah Herman-Snyder, Esquire Reply to: Carlisle July 20, 2006 100 Lincoln Way East, Suite D Chambersburg, PA 17201 (717) 267-1350 (800) 347-5552 Fax (717) 243-5063 Department of Revenue Bureau of Individual Taxes PO Box 280601 Harrisburg, P A 17128-0601 -,--OJ !'-.., ~:.;) t.',). c.;'' ;,,:, ) :n rn C) C:) ::-J t:;j ) (--) I - .0' -rj ;:;:1 RE: Estate of Mildred A. Bartch 21 06-099X , : t,._) Dear Sir or Madam: ('1 C.) _,' J Please be advised that I am the attorney for the above referenced estate. I am providing this correspondence as an attachment to the Inheritance Tax Return that I am filing in this matter to clarify issues associated with the delay in filing the Return in this estate. At the time of Ms. Bartch's death, she was widowed, her only child had predeceased her, and her three grandchildren, who were next in line to serve as administrators for her estate, did not care to serve. The Decedent had an elderly sister who likewise was unable and unavailable to serve. The next individuals in line to serve as administrators for this estate were some twenty-two nieces and nephews, none of whom expressed any interest in dealing with the estate and none of whom maintained any type of relationship with the Decedent. The only individual who we were able to contact to assist in probating the estate was the Decedent's daughter in-law. She had served as Power of Attorney for the Decedent prior to her death and actually was a logical choice to serve as the administratrix. However, we needed to secure renunciations from the grandchildren, the sister, and the multiple nieces and nephews. This was a rather extensive and exasperating process, particularly in an estate of such nominal value. In addition, though, as we were concluding the estate, it was brought to our attention that there may have been some unclaimed property listed by the Commonwealth of Pennsylvania in the Decedent's name. We filed a claim and ultimately, on or about June 6, 2006, we received a disbursement from the Commonwealth of Pennsylvania as is identified on the Inheritance Tax Return. That disbursement in and of itself did not create additional complications, but this was a matter where the Decedent was on Medicaid and we had to return to the .. Department of Public Welfare Estate Recovery Program to advise them of the additional asset we had received. As such, they made an additional claim, which required additional disbursements that were just made. We bring this to your attention in an effort to have you examine the nature of this estate. This is a very small estate, with little net benefit. The Inheritance Tax due is extremely limited. Weare asking that there be a waiver of any interest or penalties on this matter due to the circumstances described above. Should you have questions on this, please do not hesitate to contact me. VeryTrulYYour'B .:iLl 1/ ~e7f. BLG/tbf Cc: Mary A. Weir; Administratrix -..J 15056051047 REV-1500 EX (06-05) PA Department of Revenue *' Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (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 OVALS BELOW _ 1. Original Return c:::J 4. Limited Estate c:::J 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:::J 2. Supplemental Return c:::J c:::J c:::J 4a. Future Interest Compromise (date of death after 12-12-82) c:::J 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c:::J 10. Spousal Poverty Credit (date of death c:::J 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Tele hone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received ---.0.. 8. Total Number of Safe Deposit Boxes c:::J Correspondent's e-mail address: bqriffie@qriffielaw_ com Under penalties of perjury, I declare that 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 personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE Mar A. Weir b~ ADDRESS 7 Kerrs ADDRESS 200 Nor DATE 6 Side 1 L 15056051047 15056051047 --.J~ -.J REV-1500 EX Decedent's Name: RECAPITULATION 15056052048 1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) c::::) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c::::) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Decedent's Social Security Number 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) .. . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - 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_ 16. Amount of Line 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 18. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L ,., 15056052048 Side 2 - 15056052048 -.J R~E\"~ 500 'EX Page 3 File Number 21 -06-0099 Decedent's Complete Address: DECEDENT'S NAME Mildred A. Bartch ---~--~,-----'-'----------"--"'------'-"----'--'" STREET ADDRESS ___~____f~Q~!,!,est Park Health Center CITY STATE Carlisle PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 15.85 _______ 00__ .00 .00 Total Credits ( A + B + C ) (2) _00 3. Interest/Penalty if applicable D. Interest E. Penalty .00 ----- .00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) .00 .00 15.85 .00 15.85 -------- ~------ Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, 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. Make Check Payable to: REGISTER OF WILLS, 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;.......................................................................................... D KJ b. retain the right to designate who shall use the property transferred or its income; ............................................ D Kl c. retain a reversionary interest; or.......................................................................................................................... D 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... D KJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D KJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D KJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D KJ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 99116 (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 zero (0) percent [72 PS. 99116 (a) (1.1) (ii)]. The statute does not exemot 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 zero (0) percent [72 P.S. 99116(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 four and one-half (4.5) percent, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use ofthe decedent's siblings is twelve (12) percent [72 P.S. 99116(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. . REY-1S11ex.11-47l . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN ICENT DECEDENT Mildred A. Bartch FILE NUMBER 21-06-0099 ESTATE OF Include the proceeds of fdigation and the date the prnceeds were received by the esta1B. AU property jaintly-owned with ttle right of survivorship must be disdosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Commerce Bank 7,773.22 Checking Accou~t No. 0513105890 (see attached statements) 2. Blue Cross / Blue Shield Insurance Reimbursement 462.63 3. 2004 Rent Rebate 496.20 4. Claim of Unclaimed Property from Commonwealth of Pennsylvania 2,297.06 TOTAL (Also enteron line 5. Recapitulation) $ 11 ,029.11 _.,,~.:~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Mildred A. Bartch FILE NUMBER 21-06-0099 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: 1. 1. ADMINISTRATIVE COSTS: PelSOn8l Represen1ative's Commissions Name of Personal Represen1ative (s) Mary A. Weir Social Security Number(s) I EIN Number of Personal Representative(s) SlreetAddress 7 Kerrs Avenue City Carlisle Slate PA 436.60 B. Zip 17011 I Year(s) CommISSion Paid: 2006 2. 3. AttomeyFees Griffie & Associates Family Exemption: (If decedent's address is not the same as claimants, attach explanation) Claimant SlreetAddress 2,246.00 City Relationship of Claimant to Decedent State Zip 4. Probate Fees 205.00 5. Aca>untant's Fees 6. Tax Retum Preparer's Fees 7. TOTAl (Also enteron line 9. Recapitulation) S 2.888.60 (If more space is needed. insert additional sheets of the same size) REV.",12 ex + (1.931 ESTATE OF '*' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS Please Print or Type FILE NUMBER 21-06-0099 COMMONWUI1H OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DecEDENT Mildred A. Bartch ITEM NUMBER AMOUNT DESCRIPTION 1. 6,486.14 2. 3. 4. 5. 6. 7. Department of Public Welfare Estate Recovery Medicaid lien Forest Park Health Center Final Nursing Home balance 37.30 Omega Medical Labs Medical bill 16.00 Carlisle Regional Medical Center Medical bill 323.37 Cumberland Goodwill Fire & Rescue Ambulance Service 856.72 Moffitt Heart & Vascular Group Medical bill 8.73 Graham Medical Clinic Medical bill 60.00 TOTAL (Also enter on line 10, Recapitulation) I $ 7,788.26 (If more space ;s needed, insert additional sheets of same size.) -~~.~ . COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J ~ BENEFICIARIES ESTATE OF FILE NUMBER Mildred A. Bartch 21-06-0099 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 (indude outright spousal distributions) 1. John R. Weir grandson 1/3 7 Kerrs Avenue Carlisle, PA 17013 2. Debra L. Johnson granddaughter 1/3 2612 Keeler Run Court Travelers Rest, SC 29690 3. Linda A. Weir grandaughter 1/3 Bugalow Bogend Farm Catrine, Maucline Ayrshire, KA5-JNJ Scotland ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. . B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART IT. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ .. Commerce .Bank Commerce Bank/Harrisburg N.A 100 Senate Avenue Camp Hill Pa 17011 888-937 -0004 Page 1 of 2 STATEMENT DATE --- --- MILDRED A BARTCH POA MARY ANN WEIR FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM ROAD CARLISLE PA 17013 I051.3105B9g ACCOUNT NO. CYCLE-016 1 *** CHECKING *** 50 PLUS CLUB ACCOUNT NUMBER 0513105890 PREVIOUS STATEMENT BALANCE AS OF 01/24/06 ................ ........ PLUS 1 DEPOSITS AND OTHER CREDITS........... ........ LESS 1 CHECKS AND OTHER DEBITS...................... CURRENT STATEMENT BALANCE AS OF 02/23/06 ......................... NUMBER OF DAYS IN THIS STATEMENT PERIOD 30 8,164.35 .56 7,773.22 391.69 ----------------------------------------------------------------------------------- *** CHECK TRANSACTIONS *** SERIAL DATE AMOUNT 876509 02/10 7,773.22 SERIAL DATE AMOUNT ----------------------------------------------------------------------------------- *** CHECKING ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 02/23 INTEREST PAYMENT DEBITS CREDITS .56 ----------------------------------------------------------------------------------- *** BALANCE BY DATE *** 01/24 8,164.35 02/10 391.13 02/23 391.69 23-2324730 1. 63 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE ---------------------------------------------------- *** *** INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD ......................... INTEREST EARNED ...... .................. ANNUAL PERCENTAGE YIELD EARNED (APY).... 30 .56 0.15% ---------------------------------------------------- Attachment to Schedule E _ __ ___ _____ ___... """,,,1"'\ ........,^,""ora ...,T I"I~"D"I ATU''''\1Ir.1 Mp.mhp.r FDIC COIlJIlJerce .Bank Commerce Bank/Harrisburg N.A 100 Senate Avenue Camp Hill Pa 17011 888-937 -0004 Page 1 of 1 STATEMENT DATE --- --- MILDRED A BARTCH POA MARY ANN WEIR FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM ROAD CARLISLE PA 17013 IOS1310:ia2Q ACCOUNT NO. CYCLE-016 *** CHECKING **'* 50 PLUS CLUB ACCOUNT NUMBER . 0513105890 PREVIOUS STATEMENT BALANCE AS OF 02/23/06 ........................ PLUS 2 DEPOSITS AND OTHER CREDITS............... .... LESS 3 CHECKS AND OTHER DEBITS.................. .... CURRENT STATEMENT BALANCE AS OF 03/23/06 ......................... NUMBER OF DAYS IN THIS STATEMENT PERIOD 28 391.69 9.01 409.13 8.43- ----------------------------------------------------------------------------------- *** CHECKING ACCOUNT TRANSACTIONS *** DATE 03/01 03/03 03/03 03/17 03/23 DESCRIPTION ACH RECLAMATION RETURNED ACH ITEM AC-AD 800-252-2148 -INS PREM AC-AD 800-252-2148 -INS PREM INTEREST PAYMENT DEBITS 391.13 9.00 9.00 CREDITS 9.00 .01 ----------------------------------------------------------------------------------- *** BALANCE BY DATE *** 02/23 391.69 03/01 .56 03/17 8.44- 03/23 23-2324730 1. 64 8.43- PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE ---------------------------------------------------- *** INTEREST EABNED THIS STATEMENT PERIOD DAYS IN PERIOD ......................... INTEREST EARNED. ......... ..... ......... ANNUAL PERCENTAGE YIELD EARNED {APY).... *** 28 .01 0.19% ---------------------------------------------------- Attachment to Schedule E ...I"....~a ___ __"'_....~r"" ~In.~ t:I"\D 'AIDt"\OTAMT II\ICnDA"^TIr'\M M~mh~r Fnlr. Commerce .Bank Commerce Bank/Harrisburg N.A. 3801 Paxton Street Harrisburg PA 17111 888-937 -0004 Page 1 of 1 STATEMENT DATE --- --- MILDRED A BARTCH POA MARY ANN WEIR FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM ROAD CARLISLE PA 17013 ACCOUNT NO. CLOSED *** CHECKING *** -SO PLUS CLUB ACCOUNT NUMBER 0513105890 PREVIOUS STATEMENT BALANCE AS OF 03/23/06 ........................ PLUS 1 DEPOSITS AND OTHER CREDITS ................... LESS 0 CHECKS AND OTHER DEBITS...................... CURRENT STATEMENT BALANCE AS OF 04/24/06 ......................... NUMBER OF DAYS IN THIS STATEMENT PERIOD 32 8.43- 8.43 .00 .00 ----------------------------------------------------------------------------------- *** CHECKING ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 04/17 TO CLOSE OD ACCT DEBITS CREDITS 8.43 ----------------------------------------------------------------------------------- *** BALANCE BY DATE *** 03/23 8.43- 04/17 .00 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 1. 64 Attachment to Schedule E ..II',TI:. .."'''' D"'''CD~1: c:un!: !:OA IMPORTANT INFORMATION Member FDIC For Paper./iork Reduction Act Statement And Burden Estimate Slatement See Reverse Stde "Notice to Account Owners' Copy 24000002 OMB NO. 1510-0043 ,J/' 7~ ..~EPOSI' \ FROM: DEPARTMENT OF THE TREASURY FINANCIAL MANAGEMENT SERVICE ELECTRONIC FUNDS TRANSFER SF REGIONAL FINANCIAL CENTER FEDERAL RECURRING PAYMENTS P.O. BOX 193858 SAN FRANCISCO, CA. 94119 NOTICE OF RECLAMATION I 11111111111 11111 11111 UIII lUll III" IInllllll 111111lU 1111 DATE: 11/28/2005 10022937 3831500288 RECIPIENT AND/OR BENEFICIARY NAME CLAIM NUMBER DATE OF DEATH MILDRED A BARTCH 082b238WF 07/02/2005 AGENCY TRACE TYPE OF DEPOSITOR DATE OF AND/OR AMOUNT PAYMENT TYPE OF NUMBER ACCOUNT ACCOUNT NUMBER PAYMENT 08/01/2005 OPM-CSF 12173615 1184340 C 513105890 391.13 \ X~~~~X~~~V~X \ ~~~~XXXXXXXXXXXX OUTSTANDING TOTAL 391.13 A Immediately mail NOTICE TO ACCOUNT OWNERS (lasl copy ot this 10rm) to current address 01 the account owner. lnlorm the account owner(S) 01 any actions your financial institution has taken or intends to take. Sign Certilication No.1 on the back of the DISBURSING OFFICE COPY. e Correct any error in the fact at death, date of death and/or outstanding total on the back of the DISBURSING OFFICE COPY. e Take, as appropriate, one of the tour steps below: 1 II the outstanding total was previously returned to the Government, anach copiesol the Iront and back 01 the cancelled checks and/or proof thai the payment was returned by ACH . Proceed with step D below. 2 lithe pmount in theaceaunt is equal to orexceeds the outstanding total, prepare one ACH return !oreach full payment dest:ribed above. TheACH i retum method should always be used when returning one or more full payments. Proceed with step 0 below. 3 If the amount in the account is less than the outstanding total, and there is... 2.(1) only one payment listed above, then return the panial payment by check. (See 3b). i a.(2) more than one payment listed above, then prepare ACH return(s) tor amount(s) equal to each lull payment. Any remaining amount that does I not equal a full payment must be returned by check. (See 3b). b. Prepare a check made payable to: U . S . DEPARTMENT OF THE TREASURY ONLY FOR AMOUNTS LESS THAN ONE FULL PAVMENT. (Note: The amount in the account includes any additions to the account balance made alter Ihe receipt of this NOTICE.) Provide the names and addresses of the wlthdrawers on the backol the DISBURSING OFFICE COpy .If it is a true statementolfact, you must Sign Certification No.2 on the back of the DISBURSING OFFICE COPY. Proceed with Step D below. I 4 "the amount in the account is zero and no funds are ava liable to return to the Govern ment, provide the names and addresses of the withdrawers on 1he backo' the DISBURSING OFFICE COPY. If Itls a true statement affact, you must sign Certification No.2 on the back olthe DISBURSING OFFICE i COpy. Proceed with Step 0 below. 0 Unless lhe outstanding totalis returned byACHwithin 45 daysofthe date on this NOTICE,return the PROGRAM AGENCY and DISBURSING OFFICE COPIES of this form to the disbursing office address shown in the upper right hand corner 01 the torm. YOUR FINANCIAL INSTITUTION IS LIABLE TO THE GOVERNMENT FOR THE ABOVE PAYMENT(S) AND FOR ALL GOVERNMENT BENEFIT PAYMENTS RECEIVED AFTER THE DEATH OR LEGALlNCAPACITY Of THE RECIPIENTDRTKE DEATH DFTHE BENEFICIARY AS SET FORTH IN 3t CFR PART 210. YOU MUSTTAKE THE APPROPRIATE STEPS OUTLINED IN A THROUGH D ABOVE AND IN THE GREEN BOOt< INSTRUCTIONS IN ORDER TO LIMIT YOUR LIABILITY. (See GREEN BOOK: RECLAMATIONS CHAPTER tor detailed instructions.) IF YOU DO NOT RESPOND APPROPRIATLY WITHIN 60 DAYS FROM THE DATE OF THIS REaVES.. YOU WILL NOT LIMIT YOUR LIABILITY AND YOUR FEDERAL RESERVE ACCOUNT OR THE ACCOUNT OF YOUR CORRESPONDENT WILL BE DEBITED FOR THE QUTST ANDING TOTAL. TO BE COMPLETED BY PROGRAM AGENCY ROUTING NUMBER: 0313-0184-6 $ $ TO: DIRECT DEPOSIT COORDINATOR Amount Recovered AmOUnll0 Recover COMMERCE BANK/HARRISBURG N.A. P 0 BOX 8599 CAMP HILL, PA 17011 Signature Date OEPARTMENT OF THE TREASURY FINANCIAL MANAGEMENT SERVICE ~n~~~~.~4iN"GEMENT DI\IIS10N PROGRAM AGENCY COpy Attachment to Schedule E