The URL can be used to link to this page

Home My WebLink About04-12-07 .-1 15056051058 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 Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT d-.\ ooalJl Date of Birth 03/04/2007 05/30/1919 Decedent's First Name MI Decedent's Last Name Zulkowski Victoria T (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix First Name MI Social THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ca:; 1. Original Return c:::l 2. Supplemental Return (=:) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:;:; 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death c:::l 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 Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes 4. Limited Estate ~ c::::; !"""",,'''\ "---...."' REGISTER First line of address i-....,; 3211 North Front Street Second line of address State ZIP Code DATE FILED (' i ~. PA 17110-0300 Correspondent's e-mail address: 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. SIG URE OF PERSO NSIBLE FOR FILING RETURN DATE -11- ast Coover Street, Mechanicsburg, PA 17055 ER THAN REPRESENTATIVE am, Knaus & Erb, P.C., PO Box 5300, Harrisburg, PA 17110-0300 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 .-1 --.-J 15056052059 REV-1500 EX Decedent's Name: Victoria T Zulkowski RECAPITULATION 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) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 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. 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 Subject to 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 45 0.00 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L Decedent's Social Number 206-03-6761 1,977.74 660.00 2,577.74 5,780.00 1,816.45 7,596.45 -5,618.71 0.00 15. 16. 0.00 17. 18. '* 15056052059 --.J REV-1500 EX Page 3 Decedent's Complete Address: i Ii II i DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Victoria T Zulkowski 206-03-6761 STREET ADDRESS 518 East Coover Street CITY I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 0.00 Total Credits ( A + 8 + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 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) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) 0.00 0.00 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 [i] b. retain the right to designate who shall use the property transferred or its income; ............................................ D [i] c. retain a reversionary interest; or.......................................................................................................................... D lil d. receive the promise for life of either payments, benefits or care? ...................................................................... D lil 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D [i] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [i] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D [i] 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 P.S. 99116 (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 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 of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)]. Asibling 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-1509 EX+ (6-98) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Zulkowski, Victoria, T. If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. FILE NUMBER SURVIVING JOINT TENANT(S) NAME A. Gerald J. ZeU ADDRESS RELATIONSHIP TO DECEDENT 518 East Coover Street Mechanicburg, PA 17055 Son B. c. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. PSECU Checking Account No. 0206XXXXXX 213.51 50% 106.76 it;ift.p 2. A. /7f/ l, PSECU Savings Account No. 0206XXXXXX 3,332.71 50% 1,666.36 3. A. 19Cf ~ Sovereign Bank Savings Account No. 1684001496 409.24 50% 204.62 TOTAL (Also enter on line 6, Recapitulation) $ 1,977.74 (If more space is needed, insert addttional sheets of the same size) REV-1510 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Zulkowski, Victoria, T. FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. IRS Income Tax Refund - 2006 660.00 100 660.00 TOTAL (Also enter on line 7 Recapitulation) $ 660.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Zulkowski, Victoria, T. FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Auer Funeral Home, 4100 Jonestown Road, Harrisburg, PA 1,655.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City _ State Zip Year(s) Commission Paid: 2. Attorney Fees 400.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant Gerald J. Zell Street Address City Mechanicsburg State PA .Zip 17055 Relationship of Claimant to Decedent Son 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 200.00 7. Register of Wills - File PA 1500 25.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5,780.00 REV-1512 EX+ (12-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Zulkowski, Victoria, T. Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH FILE NUMBER 1. Claremont Nursing and Rehab, Carlisle. PA 1,627.85 2. Mobile X-ray Imaging Inc. 188.60 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,816.45 1liast ~ilI nf ~idnria '<.iI. ~ulknfuski I, VICTORIA T. ZULKOWSKl, of 518 E. Coover Street, Mechanicsburg, Cumberland County, declare this to be my will, hereby revoking all prior wills and codicils. Disposition of Remains FIRST: I direct that the expenses of my final illness and my funeral, including the cost of a burial plot and erecting a monument be paid out of my estate. Distribution of Personal Property SECOND: All my personal effects, clothing, furniture, furnishings, jewelry, automobiles, other tangible personal property of every kind, and insurance thereon, I give to my son, GERALD J. ZELL. Ifhe shall fail to survive me, my personal property shall be sold and the proceeds added to my estate. Distribution of Residue THIRD: I give the rest of my estate to my son, GERALD J. ZELL, ifhe survives me for a period of thirty (30) days. If he shall not so survive me, I give the rest of my estate in equal shares to my granddaughter, DIONNE C. ZELL and my Grandson, JONATHAN M. ZELL, per stirpes. In the event that either of my beneficiaries predeceases me leaving no issue, his or her bequest shall be added to the survivor of them Protection of Beneficiaries (Spendthrift Provision) FOURTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. Provided, however, any beneficiary may assign any part or all of the beneficiary's interest in my estate to anyone or more of my descendants or to anyone or more of the beneficiary's descendants. Minors and Incapacitated Beneficiaries FIFTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My executor as trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon the termination of minority or incapacity. My executor as trustee shall have the same powers as my executor. Payment of Death Taxes SIXTH: All estate, inheritance and other death taxes, together with interest and penalties on them, payable with respect to property or interests subject to taxation by reason of my death and whether passing under my will or any codicil thereto, or otherwise, including jointly held and other non-testamentary property and those on non-probate property, shall be paid out ofthe principal of my residuary estate without apportionment. Powers of Executor SEVENTH: I confer on my executor the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments, and transfers ofthe property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion; to make distnbution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary.. or appropriate in the management, administration and distribution of my estate Appointment of Executor EIGHTH: I appoint my son, GERALD T. ZELL, executor of my will. Ifhe is unable or unwilling to qualify as executor or having qualified is unable or unwilling to act, I then appoint my grandson, JONATHAN M. ZELL, as executor hereof in his place. I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. I have signed this will this tfT/flay of November, 2003. '-(/L~~~;f !~4fJJJL~ VICTORIA T. ZULKOWSKI Signed by VICTORIA T. ZULKOWSKI, testatrix, as her will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have signed our names as witnesses. j ~" ~ i ~., , / I ' l --;-' " a /!{L!Z~ (. '/1AM~' " ~' ~A'-, ~ ~~ NI L ,0 I-J 13 C-r:!IU'S TC-, tJ Acknowledgment and Affidavit Commonwealth of Pennsylvania : ss County of Dauphin I, VICTORIA T. ZULKOWSKI, testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes expressed in it. 7J~:t -A/A~~~~ VICTORIA T. ZUL WSKI Sworn to or affirmed and acknowledged before me by Victoria T. Zulkowski on this ~day of November, 2003. Notarial Seal .Angela M.. Miller. Notary Public City of Harrisburg. Dauphin County My Commission Expires Oct. IS, 2006 We iY\; I tc f'I Bt In s;./e ; f\ and Sll <;Q n E:, I-k.~ IH me ed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Victoria T. Zulkowski, testatrix, sign and execute the instrument as her Last Will; that she signed willingly and executed it as her free and voluntary act for the purposes expressed in it; that each subscribing witness in the hearing and sight of the testatrix signed the will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind, and under no constraint or undue influence. /7 { If- /1 ~. ~ /1!AJJ.,Ui1;/ ~~~L Witness AFFIDAVIT ,.,/~~;( !. ~ Witness Sworn to or affirmed and subscribed to before me by ffi~ I.tn." (;"r(l~-k;f\ and Sll).l'ln r:. Hcdt"" witnesses, on this fqtt- day of November, 2003. 0,.,'51-.. '111 11t ilL Notary Notarial Seal Angela M. Miller. Notary Public City of Harrisburg. Dauphin County My Commission Expires Oct IS, 2006 f;v ( If )Jot pao rJrre7> &?fl5 r?~5~ ~tt (}ft7rl17!o)) of Ltvl 11 (U1 (/ [( If ::G I tV{ tJw (,(/ eE-S tft'-f PSEC" P.O. Box 67013 (717) 234.8484 (Harrisburg) Harrisburg, PA 171 06-7013 (800) 237-7328 (Nationwide) website - http://www.psecu.com 1 MEMBER NUMBER 02 0 6XXXXXX Post Eff 02/01 10 01 02/01 02/02 02/28 02/28 JOINT OWNER VICTORIA T ZULKOWSKI GERALD J ZELL 518 E COOVER ST MECHANICSBURG PA 17055-4227 STATEMENT DATE I 02/28/07 Description REGULAR SHARES Beginning Balance Payment: Direct Deposit US TREASURY TYPE: CIVIL SERV ID: 3121736156 Payment: Direct Deposit US TREASURY TYPE: SOC SEC 10: 3031036030 Payment: Dividend 1.240% Annual Percentage Yield Earned Based on Average Daily Balance Ending Balance Dividend YTD: Year to Date 312 303 Amount 592.85 494.00 3.13 1.250% from 02/01/07 through 02/28/07 of 3292.94 11. 47 Balance 2223.73 2816.58 I 3310.58 i 3313.71 ============================================================================================= 3313.71 Eff Description 10 04 CHECKING Beginning Balance Check 000187 Check 000188 Payment: Dividend 0.250% Annual Percentage Yield Earned 0.260% from 02/01/07 through Based on Average Daily Balance of 510.81 Ending Balance Dividend YTD: Year to Date 0.31 Post 02/01 02/02 02/22 02/28 02/28 Number 000187 Amount Number 6407.10 000188 Amount Number 91. 43 Amount Number Amount 6407.10- 91. 43- 0.10 02/28/07 Amount Balance i 6711. 94 I 304.84 213.41 213.51 213.51 ============================================================================================= Total Dividend YTD: Year to Date Total YTD Finance Charge: Year to Date 11. 78 0.00 Savings Account Summary ~.Jf Sovereion Bank ~~': ,"" - e Savings Account Summary Account Number: 1684001496 Summary Information Available Balance Today's Deposits Today's Withdrawals Interest Accrued This Statement Interest Paid YTD Next Statement Date Posted Activity Date 02/08/2007 01/24/2007 12/29/2006 12/04/2006 09/29/2006 07/31/2006 07/10/2006 07/03/2006 Activity Description DEPOSIT DEPOSIT INTEREST CREDIT DEPOSIT INTEREST CREDIT DEPOSIT DEPOSIT DEPOSIT $409.24 $0.00 $0.00 $0.41 $0.00 03/31/2007 Page 1 of 1 >>CL9_~~J'ILLndQlN I )) PrinLWJnaow ---- Current Date~05/200 -.......... Ledger Balance Ledger Balance as of Last Deposit Last Deposit on Balance Last Statement Last Statement Date Deposits $10.90 $10.90 $0.57 $10.90 $0.54 $20.95 $88.37 $10.90 Withdrawals $409.24 03/02/2007 $10.90 02/08/2007 $387.44 12/29/2006 Balance $409.24 $398.34 $387.44 $386.87 $375.97 $375.43 $354.48 $266.11 htt:m:://www_~ite-~e~llre~om/~0";-h;n/~0";on4 pyp/c;:mrn!'lnlr/'::;mr7 ('\Rl'n'/ .::; 1 r;;S.!SlLl.{){) 1 ')~ ~ D":...+(\ 'J 1:::'/")()0'7 rt; , BlueCrossll BlueShield Il .., ., Federal Employee Program www.fepblue.org Camp Hill, Penn.~ylvania 17089 Explanation of Benefits THIS IS NOT A BILL 2580 FEDERAL EMPLOYEE PROGRAM PO BOX 890037 CAMP HILL PA 17089-0037 MEDICAL QUESTIONS CALL 1-800-779-6945, DENTAL QUESTIONS CALL 1-800-746-5687, TTY QUESTIONS CALL 1-800-345-3848 VICTORIA T ZULKOWSKI 518 E COOVER ST MECHANICSBURG PA 17055-4227 GLANCE I I I I ID Number: R01291488 I Claim Number: 07592616071 I Claim Paid On: 04/11/2007 I Claim Received On: 03/30/2007 I Claim Processed On: 04/03/2007 I Patient Acct No: 160492 I I EXPLANATION OF BENEFITS AT A I I IWe Sent Check To: MOBILE XRAY IMAGING INC 1 IPatient Name: VICTORIA ZULKOWSKI I IDates of Service: 02/16/2007 - 02/16/2007 I IYou Owe the Provider: S18B.60 Pronder:MOBILEXRAYIMAGINGINC Type: NON-PARTICIPATING PROVIDER Dates of Service: 02/16/2007 - 02/16/2007 TYPE OF SERVICE I I DIAGNOSTIC XRAY I I DIAGNOSTIC LAB TEST I XRAY . TECHNICAL CHRGI TOTALS: I SUBPlITTED I CHAll.GES I 65.001 I 28.601 160.001 S253.601 PLAN IREP1ARKI DEDUCT I COINSURANCE I PlEDICAREj I lLLOWlNCE I CODES I I OR COPlI 10THER INS. I 24.091 303 I I I 19.271 I 310 I I I I I 165 I I I I I 165 I I I I S24.091 I SO.OOI SO.OOI S19.271 EXPLANATION OF REMARK CODES WHAT IYOU OWE THE WE PAID I PROVIDER 4.821 I I I S4.821 28.60 160.00 S188.60 165--BENEFITS ARE NOT PROVIDED FOR SERVICES/SUPPLIES LISTED IN THE GENERAL EXCLUSIONS SECTION OF THE BLUE CROSS BLUE SHIELD SERVICE BENEFIT PLAN BROCHURE. YOU ARE RESPONSIBLE FOR THESE CHARGES EVEN IF ORDERED BY A PROVIDER. 303--YOUR HEALTH CARE PROVIDER HAS AGREED TO ACCEPT ASSIGNMENT OF MEDICARE BENEFITS. THIS MEANS YOU ARE NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE MEDICARE - APPROVED AMOUNT AND THE ACTUAL CHARGE. 310--YOU ARE ENROLLED IN MEDICARE, WHICH IS PRIMARY. THIS MEANS MEDICARE PROVIDES BENEFITS FIRST AND YOUR SERVICE BENEFIT PLAN PAYS SECOND. WE HAVE PAID 100% OF THE ALLOWABLE CHARGES ON THIS CLAIM AFTER MEDICARE'S PAYMENT. NO DEDUCTIBLE OR COINSURANCE/COPAYMENT APPLIES. CONTINUED ON NEXT PAGE H 105.805 REV 1105 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Lll107723 No. .~ftl~, Fee for this certificate, $6.00 Local Registrar MAR 0 0 2007 Date o .-i':.'n -.:: r--" ~ "r' 1'.....-_1 1--;=1 r..::.::...;. -.J > -;J I ~- -,~ ..-..., N -n ,'-' : REV 11/2006 I PRINT IN MANENT ~CK INK COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) 87 Victoria T. Zulkowski 6. 0aI0 01 Birth (Month. da . 5-30-1919 7.B1r1hp1ace C and stale or I -6761 STATE FILE NUMBER .. o.te 01 Death (Month, day, year) 3-4-2007 c.) ~ \ a-rob 'YS lD ,. Name 01 0acadanI (R"", _. last, suIIlx) 5. Aga (1.asI Birthday) Pittsburgh. Other. 1'.Oecedent'sUsual KlndolWori< Claremont Nursing Facility 12. Was Decodent .....In the 13. Decedont's Education (SpecIfy only highes1 g_ completed) U.S. Armed FOltOS? Elementary I Secoodary (()'12) CoIIago (1-4 or 5+1 Dvas IJ]NO 12 o Other . Specify 10. Ra<:e:Amarican Indian. Black, White, ale. (Spocif)1 White Vrs. lib. Counly 01 Death Bel. Facility Name (N noI _, give..... and numbe!) Cumberland 518 East Coover Street _'s ActuafResid8nc8 17a.State P~nnAylv::lni.A 17b.County Cumberland DId Decedent liveina Townsh~? 17e. 0 Yes, Decedent LJved in 174] ~~r-Mechanicsburg Top. Ci1y/Boro John Peciukas 19. Mothef's Nama (FlrsI. _. maidan surname) Sophia Rostonovicz 19. Fa"""'s Nama (FIrsI. _last, suIIlx) 208. I_s Nama (Typa 1 PrInt) Mr. Gerald Zell 21a. Method 01 DIsposltion Pennsylvania 17055 21d.l.ocalion(Ci1y/Iown."'te,Z;P_1 PA 17109 Dvas DNo 31.~oIOeath Ef NaI1nJ 0 - o Aa:idant 0 Pandng Investigation o SuiOda 0 Cou~ Not ba Da<ennined I ApproxImate interval: I Onset 10 Death I I I I I I I I I I I I I I I I Part It Enterotherslonlllcanlc0rdti0n8contriJu1inalodath bot noI ....Ilillg " the -.:y;ng CIUIO Iivan " Port I. 28. Old TOOAoco Use Col'lIrilu1e 10 Death? Dv" DProbably ~DUnI<nown 2Q. N F",me: ~ NoIpnlQ1\81\l_npaslyear o Plegnanl allima 01 daath o Not pregnant. but prog18"' "'Nn 42 days oIdaa~ o Not pnlQI\8I\l. bot prog18nt43 days to 1 year baIonldaath DU,,",-Npregnant_thepaslyear 32<:. P1aca of Injury: Homa. Fsnn. Slraal, Factory, Olfica Building. etc. (SpecIfy) ~=~=)~ a. IN~mo../ ~ist condtion8, N any, to cause IilJtIld on line a. EnIaf UNIlEIILYING CAUSE =-~~~tha b. Due to (or as a consequence of): j) i;:M~A- Due to (Of as a consequence 01): c. Due 10 (or as a consequence 01): d. 308.. Was an Autopsy Partonnad'I o Vas me 3Q). w... Autopsy Findngs A_ P""toeon-. 01 Cause of Death? 32<:. Time 01 Injury M. 321. NTransportalloo injury (SpecIfy) o Drive< I Openl"" 0 Pss8enger Dp- Othar-Speclfy: 331>. Sip'" and TIlIa 01 CartitIaI 32g. l<<ation 0I11jury (_, city 11own. slalal 35.RagisIrar's . ~ ~ II~ /1 33<1. o.te S~nad (Mon~, day. yearl oi-!!>-r:>7 338. CattiIiIr (chod< only onel COrtIly1ftg pIIytIdon 1Pl1ysk:ian corlIt.,;ng cause 01 daath whan another physician has pronouncad daath and complaIod IIam 231 To tho bast of my-.adga.__ duatothecauoa(l)1IId _as allied.. _ _ __ _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ ==:=~.J.=::U~and~~~toto~=mamaruallled.._________________ 0 __ e-tnor 1 Coronar On tho _ of"""'_ and I" I~~. in my lJIllnlon. _ occurred at the lime, date, IIId pIIco, and due to the eausa(s) and manner as allied.. 0 1;l.J()l__A- ,P ~ 1"70 ~ REV-346 EX (8-92) FOR REGISTER'S OFFICE USE ONLY PA DEPARTMENT OF REVENUE ESTATE INFORMATION SHEET County Code do \ Year File Number I0J () 3::) lp DECEDENTINFO~ATI : nter ata as It WI appear on a ocuments su mltted to the department. Name (Last) (First) (Middle) Zulkowski Victoria F. Decedent's Social Security Number Date of Death Date of Birth 206-03-6761 March 4, 2007 May 30,1919 ON E d "II lid b TYPE FILING: Enter check (.I) mark to indicate the nature of the return to be filed with the department. o Probate Return o Joint Assets Only Ii] Estate Tax Only o Litigation Purposes (No Other Assets) LETTERS GRANTED: Enter check (.I) mark to indicate the nature of the proceedings at the Register of Wills Office. (Attach additional sheets if explanation is necessary.) o Testamentary o Administration Ii] No Letters o Other (Please Explain) ATTORNEY/CORRESPONDENT: Enter all data concerning the attorney or other individual to receive all tax information and d correspon ence. Name (Last) (First) (Middle) Supreme Court I.D. No. Grubb Robert P. Grubb P.O. Box 5300 76057 Street Address Metzger, Wickersham, Knauss & Erb, P.c., P.O. Box 5300 City State Zip Code Telephone Number Harrisburg, P A 1711 0-0300 717-238-8187 PERSONAL REPRESENTATIVE INFO~ATION: Executorl Administrator Enter all data concerning the personal representative(s) ofthe estate authorized by the Register of Wills Name (Last) (First) (Middle) Social Security Number Zell Gerald J. 160-40- 7 540 Street Address " c.::":" 518 East Coover Street (:) -.. I .,.., ,......, City State Zip Code Telephone NUtnt?~rc) ~,-' r-- -~..... .. Mechanicsburg, P A 17055 .:-C: l:r1 - ~ , ,'-' of'-. ',' Co-Executorl Administrator ,( <~~" -0 " .. Name (Last) (First) (Middle) Social Security~~mber "'-j : i i .. > ~ , Street Address -.J City State Zip Code Telephone Number Co-Executorl Administrator Name (Last) (First) (Middle) Social Security Number Street Address City State Zip Code Telephone Number Prepared By i1 ~~-a.\ R 6-,!Cv rev. 10.13.06 ~ \ ~\ ~C)~) \] April 11, 2007 Cumberland County Register of Wills 1 Courthouse Square Carlisle, P A 17013 SINCE 1888 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 717-238-8187 Fax: 717-234-9478 RE: Estate of Victoria T. ZuIkowski Estate (deceased) Other Offices Lancaster Mechanicsburg 717-431-0138 717-691-5577 Shippensburg York 717-530-7515 717-843-0502 Wilkes-Barre 570-825-7500 Dear Register of Wills: Please find enclosed for filing, two (2) original copies of the P A 1500 Inheritance Tax Return for the above referenced decedent. Also enclosed are two (2) additional copies, which I request you time-stamp and return to my office in the enclosed self-addressed, postage paid envelope. Because there will not be a probate estate raised for the decedent, enclosed is a check in the amount of$15.00 as the required filing fee for the PA 1500. Should you have any questions please feel free to call my office at the above phone number. Thank you for your prompt attention to this matter. Sincerely, :...:..:J f'.) -D '\ \ ( . ') C'~l James F. Carl Edward E. Knauss, IV' Clark DeVere' Francis J. Lafferty, IV Andrew W. Norfleet 374900-1 Robert P. Grubb Of Counsel * Board Certified in civil trial law and advocacy by the National Board nfTr;nl Ad710rnr1/ m ''- .- (')~(') tu (') c :::l.o3 -. 0- CIl C CD CD ;::1. ...., ~ ::T tu -UO::J )>5ic. ~CD(') -...Jcno O..cC ~C::J Wtu_ ....,'< CD:;o CD CQ. CIl - CD ...., o - ~ n T ....'I:IUJ ....... tv ~ 0...... ... ...... ::t 0:1 Z i!J.. 0 0 i:: X .. .. U1 :T QQ g 'Tj '1:10.. > @ ...... ..... '-J [JJ ...... ..... o @ 6 ~ UJ o o T ;;0 o CT CD ~ "'tJ G> .., c: CT CT m C/) .0 c: :::;. CD T o ]~~iF :.:; '2 ~- \.-. J -1) -":.f,'" """ w I",..) ~ ,,1 C" . - -.--- I .- - - - - -- . .- - ........... - - - - - --== .- - - .::;. - -- ~ - - -.-: , "--',-- . ~; ...... ;---r-t U~ o to "-'