HomeMy WebLinkAbout07-09-07
1I
--.J
15056051058
REV-1500 EX (06-05)
PA Department of Revenue '*'
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 1712~1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
~\ 07
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
luE>Y
Date of Birth
178-20-0172
04/09/2007
08/10/1926
Decedent's Last Name
Suffix
Decedent's First Name
ZAJAC
HENRY
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
la) 1. Original Return
2. Supplemental Retum
c::;)
3. Remainder Retum (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4. Limited Estate
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 (.:::::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 Telephone Number ,....~
(""') g
(717) 903-873%=9 -..A
r~'i _:0 c.....
--- - -REGISTERO~~~~~E ON~
!<2m I
'-.c;c -22 ~
. '___ f)-^-
C:J CJ 0
S211
- :::J
--i
j].
~)
Q
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
GARY ZAJAC
Firm Name (If Applicable)
First line of address
2112 NORTH VIEW LANE
'""'tJ
~::.-
Second line of address
N
..
Ul
City or Post Office
DATE FILED
State
ZIP Code
HARRISBURG
PA
17110
ZAJACAIKIDO@HOTMAIL.COM
HARRISBURG, PA 17110
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051058
--.J
15056051058
MI
L
MI
:T:J
rn~~
"--I ': _ J
r' '-"-1
::~j C:J
~
-.J
15056052059
REV-1500 EX
Decedent's Name:
HENRY
L ZAJAC
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) 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.
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 36,134.21
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.
18.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
Decedent's Social Security Number
178-20-0172
2,084.77
43,601.35
45,686.12
9,313.91
238.00
9,551.91
36,134.21
36,134.21
1,626.04
1,626.04
15056052059
-.J
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENTS NAME
HENRY L ZAJAC
STREET ADDRESS
20 NORTH 12TH STREET, APT. 343
DECEDENTS SOCIAL SECURITY NUMBER
178-20-0172
CITY
LEMOYNE
STATE
PA
ZIP
17043
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
1,626.04
81.30
Total Credits ( A + B + C ) (2)
81.30
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(SA)
(58)
1,544.74
A. Enter the interest on the tax due.
1,544.74
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;.......................................................................................... 0 00
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 00
c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 00
2. If death occurred after December 12, 1982, did decedent transfer property wnhin one year of death
without receiving adequate consideration? .............................................................................................................. 0 00
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 00
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 exemDt 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)]. 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-1508 EX+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HENRY L. ZAJAC
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ITEM
NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jolntly-owned with right of survivorship must be disclosed on Schedule F.
FILE NUMBER
DESCRIPTION
Final US Steel Pension Payment (5/10/2007). See attached documentation.
2 Security Deposit Refund (Essex House). See attached documentation.
3 Miscellaneous fumiture from apartment at Essex House retirement home. See attached Salvation Army.
VALUE AT DATE
OF DEATH
542.27
1,067.50
475.00
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2,084.77
REV-1509 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINnY-OWNED PROPERTY
ESTATE OF
Henry L. Zajac
FILE NUMBER
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. Gary Zajac
2112 North View Lane
Harrisburg, PA 17110
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 SANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUM8ER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. ~/t.l~ PNC Bank #00-0701-7091 (see attached documentation), 2,093.79 50 1,046.90
2 A if'Y PNC Bank #00-0148-1547 (see attached documentation). 41,048.64 50 20,524.32
3 A 5j<,<; PNC Bank #000031000138483 (see attached documentation). 44,060.25 50 22,030.13
.
TOTAL (Also enter on line 6, Recapitulation) $ 43,601.35
(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
ESTATE OF
Henry L. Zajac
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
2
3
FUNERAL EXPENSES:
Wiedeman Funeral Home, Steelton PA (see attached documentation).
Patrick T. Lanigan Funeral Home, East Pittsburgh PA (see attached documentation).
Catholic Cemeteries Association of the Diocese of Pittsburgh (marker fee) (see attached documentation)
5,459.91
3,595.00
259.00
1.
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. Attomey Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State
.Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert addftional sheets of the same size)
9,313.91
,
..
REV-1512 EX+ (12~3) .-
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Henry L. Zajac
Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including un reimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Verizon (see attached documentation).
63.26
2.
Apria Healthcare (see attached documentation).
143.86
3.
Pinnacle Health Emer. (see attached documentation).
14.53
4.
Associated Cardiologists (see attached documentation).
12.14
5.
Pulmonary and Critical Care Medicine Associates (see attached documentation).
4.21
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
238.00
-----
- -
\f'\
crI
0
\f'\
. .-I
~ 0
l-) 4\ 0
~ ~ p... r-
.-I
l-) ~ ~ \
4\ ~ crI
~ t:'3 ~~0 ~ C"l
~ t) en4\~ 0 r:t:J
~ en~ p...
itS H en ,.....
~~~ ~ C"l
~ ~4\O ~ ,....I
~ 4'
~ O~~ 0 () .....,
~ ~ 7iH r:t:J ~ ~
0~~.-I ~ '.Z
~~g~~ 0
';:tl
rr3~0"~~ p...
-"" "'-
-
,
r--
LAST WILL AND TESTAMENT
OF
HENRY L. ZAJAC
,
I, HENRY L. ZAJAC of the Township of North Versailles
County of Allegheny and Commonwealth of Pennsylvania, do hereby
make, publish and declare this to be my Last Will and Testament,
hereby revoking any and all former wills made by me.
PART ONE of this my Last will and Testament is to be
effective in the event of my death before the death of my
Wife, EILEEN M. ZAJAC.
PART =TWO is to be effective in the event of my death
after the death of my Wife or in the event my Wife and I die as
a resul t of a common disaster or under circumstances which do
not permit the order of our dea ths to be established wi thout
resorting to inference or presumption.
PART ONE
FIRST: I direct that all of my legal debts and
funeral expenses be paid as soon as it conveniently may be done
after my decease.
SECOND: I give, devise and bequeath all the rest and
residue of my estate, real and personal, unto my Wife, EILEEN M.
ZAJAC and I appoint her Executrix of this my Last Will and
Testament. My Executrix shall not be required to enter bond or
furnish sureties in any jurisdiction.
.
,
PART TWO
FIRST: I direct that all of my legal debts and funeral
expenses be paid as soon as it conveniently may be done after my
decease.
SECOND: I give, deviseand bequeath all the rest and
residue of my estate, real and personal,unto my Son, GARY ZAJAC,
or to his issue surviving per stirpes.
THIRD:
In the event my Son, GARY ZAJAC, does not
survive me and leaves no issue surviving, I direct that fifty
percent (50%) of my estate shall pass unto KATHY BARSIC, and the
remaining fifty percent (50%) unto MADELINE COUSINS, or to their
issue surviving per stirpes.
FOURTH: I nominate, constitute and appoint GARY ZAJAC,
as Executor of this my Last Will and Testament.
As Substi tu te
Executrix, I appoint KATHY BARSIC.
My Executor shall not be
required to enter bond or furnish sureties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this 10)-111 day of /f;1lJCrf 1998.
~J ·
(;). 1. ~ (SEAL)
HEN L.' zA1A'C
SIGNED, SEALED, PUBLISHED AND DECLARED by the
above named Testator,HENRYL. ZAJAC as and for his Last Will
and Testament, in the presence of us, who in his presence,at
his request and in the presence of each other have hereunto
as witnesses thereto.
SL- [elvle b
R-
c;< / )l7 p., -:/- 0 0
FINAL PENSION PAYMENT
1-1 e..r\ ~ L ~ Z a 1 a. G.
N of Deceased .-J
1.(- <{- 07
Date of Death
COMPLETE #1, OR #2, AND #3
1. If Legal Administration of the Estate IS required:
a.
Name of Executor or Administrator
Address of Executor or Administrator
Federal Tax Identification No.
LJ
Phone Number
b. Attach necessary Short Certificate or Court Order of Appointment.
(payment cannot be made without this infonnation.)
2. If Legal Administration of the Estate is NOT required:
Ga.. r 'y Z a ].a- G
Nam~f nearest living relative or
person who cared for the deceased
,-/-' . (" e. I L4-rJ e.. &. ril(.l {<
Address of nearest living relative or person who cared for the deceased
a.
5'0/\
Relationship
/7/10
/7!- 5~ -7S ~d-6
Your Social Security Number
(payment cannot be made without this infonnation)
tJ- ~ ~
y -~~4:
Pension payments from the United States Steel and Camegie Pension Fund are made at the close of each month and
terminate with payment for the month in which the death of the retired employee occurs.
'". -'''''''7
(2{!) -6 ./~ - '9 ./ :;'
Phone Number
3.
,,/ -., --. /7""'1
7-~";>-c...../1
Date
It is, therefore, the policy of the Pension FlDld to direct the final payment to the executor or administrator of the
decedent's estate. If there is no estate, final payment is made to the nearest living relative or person who cared for
the deceased prior to his death or to the person who paid the funeral bill. If:final payment is to be made to the
person who paid the funeral bill, enclose a copy of the paid funeral bill.
We wiD deduct the amount of any overpayment made to the deceased from the Final Pension Payment. H tbe
gross benefit is reduced by previously authorized deductions for insurance and other items, the taxable
amount of this Final Pension Payment reported to the IRS at year-end may be significantly larger than the
net Final Pension Payment amount you receive. Contact your tax advisor.
In order that disposition of the :final payment may be made this form should be. completed, signed, and returned to
this office for processing.
FORM D-210 REV. 6/03
UNITED STATES STEEL AND CARNEGIE PENSION FUND
600 Grant Street, Room 2618
Pntsburgh,Pi\ 15219-2800
United States Steel Corporation Plan for Employee Pension Benefits 2 8 7 9 8 9 5
500 Grant Street. Pittsburgh. PA 15219-2800
Telephone (412) 433-5790 000075'
Use social security number in any correspondence regarding this benefit.
Changes to home address. direct deposit, life Insurance beneficiary or
health coverage must be made by writing to the above address.
111.11111.1,,111,1.11111,,1,11.1,111,,111..,11,"11,,1,1,.11.1
R-218727-00 G3
GARY ZAJAC
ON BEHALF OF HENRY L ZAJAC, DECEASED
2112 NORTH VIEW LANE
HARRISBURG PA 17110-3911
Soc. Sec. No.
I ***-**-8326
PaYlHnt for
the .onth of PaYlHnt date
II II 05-10-071
$
TRUST PAYMENT
361 RETRO PAYI1T
GROSS BENEFIT
802 RETRO HlTH
NET PAYMENT
$
.00
686.27
686.27
144.00-
542.27
PENSION BENEFITS TERMINATE WITH THIS PAYMENT. THERE WILL BE NO CONTINUING BENEFIT TO ANY
SURVIVOR.
- ---- - - ......... - - - - - -- - - - - - - "- - - - -- .- - - .- ..- .- -- - - - - - - -- - - - -- - -- -
\
Security Deposit
Worksheet
Facility: Essex House
Resident: Henry Zajac
Move-In Date:
Move-Out Date: 04/30/2007
Total Amount of Security Deposit
Cleaning Charges (if applicable) :
Cleaning $
Carpet $
JDaint $
Other $
Total Cleaning Charges
Final Month Rent Charges
Prior Balance
Payments Received For Final Month
Non Refundable Fee Refund (ifapplicable)
Security Deposit Interest (if applicable)
Rent Allowance (if applicable)
Balance due to resident
OrBalance due to facility
Signature
'~/fh1aP
.....h-I ~:r::&::1fJ^
Title.
Billable/Payable to: Gary Zajac
Address:
2112 North view Lane
Harrisburg PA 17110
Facility #: 5119
Resident #: 263603
Unit #: 343
$ 947.50
$ 0.00
$ 2,065.00
$
$ (2,065.00)
$ 0.00
$ 0.00
$ 0.00
$ 947.50
$
1/~2~1
Date I
* The estimated balance assumes no past due billings *
, USA
ttttttt}:~:~:W~~:Ij#.,iijl:~ittt:tl'ttlftttt rw'_~'-At, tttt";tt::::'~~ftttf\t:fi"li~~:::i::::::):::t:ttl:rttt:'tt:fl: :j.ii~ijlfi@ m<<@fMM ,t:m:::Ji.tiiM.ti'f:}:t
RU 72 04/30107 Refund on Account 947.50 947.50
RN 04 05/07107 Refund on Account 1 20.00 1 20.00
VENDOR # 263603 PAGE 1 OF 1 I\~l~:~~~~~ll:i!:i~lllliil:ll:::lll!ill~!illlll:~:~~:l:i:::::!ii:ii::~::!::::::!:i::::l~\~1 1 ,067 50
.
CHECK DATE: 05/08/07
CHECK NO: 5570353
,..
/
r-
('
r
~Af-;~~tit'J---- L0 19133
THE SALVATION AB.lVIY
ADULT REHABILITATION CENTER
3650 Vartan Way. Harrisburg, PA 17110
Phone: (717) 541-0203
l'i<( 6)
Date I -/ 2O--=-
,"
gme (.:..) D V..,1 Z Ct I C{ c Ie.
_I . 1 ,
Iddre.. ;;{ () () Dv" t- Vl- I.).t y-. S 1- .
~Ity (..p V~Y'I ()\-A n-e State PA z./;cf.-i)
?~ ~/~~ c70Q
t!)r Floor~_ \ Y ) Te' No. "1 1-- ) - \.\ ').
Appliance D. Clothing D Furniture 0 Sundrlea 0
/_~~~ (~':of ( "
V; ,;)~. ~'. ~_ :\}\7~.
V~l;J c~~~~),
\ \ I.n'i~ C()~'~~!>j<L.'h i e
() IV" (iJ ,~.....rJ 0.... .' \ :....L ''''.. ,,;/ (' /1.
7J'- ,,\:\ ,,>) .;. '. I ~V. JJ
/ 'I
\0./ ,
\
CUSTOMER COpy
("
I
.,
J
"
i
i
,
1
I
I
!
I
I
I
5LWU(t.- (
"" PNC Bank Online Banking
My Accounts
Deposit Accounts
Checking/Savings Accounts
Interest Checking
... ',", ....., ...,..".."...............,...,. .. .. ........................
Money Market
Account Number
".~
XXX7091
.~........................,............ '.~............
XXX1547
Ledger Current
Sa/ance Depoalta
$1,693.63 $0.00
..............,..............................................."..............
$41,048.64 $0.00
Current
Withdrawals
$0.00
...............................,........,
$0.00
Page 1 of 1
Help?
S.llInce
Available
$1,693.63
.....-....."..........,..........
$41,048.64
.."p............"....... ...... ....., .,........._ '. ........".................~'......"..............................~.............................................M...................................................._.............. ............"............ ................ ................
CD Accounts
Certificate Of Deposit
XXXXXX 1759-XXXXXXX8483
$44,060.25
. ,':;..,'..':.~.;~..;-c" '.......:;r.-,...:.\t:'::...;:""".,,#~~~~_~.....,,~~',.......~........;\...,.~~'~.lt,~.7 ,~'",,,,~-,,,,,,,:,,:,".:'.~.
Deposit Account Totals: . '$42;74i27, . ' :" $0.00 $0.00 $86,802.52
@ Copyright 2007. The PNC Financial Services Group, Inc. All Rights Reserved.
._,_,__.._..j~;:::-:;:;.~.....~'-;;O.............~~. ~~-... .. .........- .._._,. ......--...-..
p{ ?fA!)]
ce -"'- :/13+ a--'
:/r;r
'~-:--~~_r- ,.....;,,:;a..-.......~~... ~ ~;,.;".~~- -~.~ -..- --
'':'.'_ ..~~- I
..,-. ..~,-, '.~_.- '.-. .....-.-..-.-
~-:-~"'~~+..~,,,.~-;.:.~......;.,;.::.ao:;'-.:::.':;;.:-..__...:~..... ~=,;
_.'. .,.:~_.:::.~~"......~;;::..__< ..__'-__...., _w.,_..
Piemium Plan Account Statement
PNC Bank
~ PNCBANK
'"
For the period 02128/2007 to 03/28/2007
Primary account number: 00-0701-7091
Page 1 of 3
Number of enclosures: 0
x
HENRV L ZAJAC
GARV ZAJAC
EILEEN M ZAJAC DECD
20 N 12TH ST APT 343
LEMOVNE PA 17043
Q For 24-hour banking, and transaction or
interest rate information, sign on to
11' PNC Bank Online Banking at pnc.com.
For customer service call 1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
Para servicio en espal'lol, 1-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
I:!!SI Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Q Visit us at pnc.com
I TOO terminal: 1-800-531-1648
For hearing impaired clients only
Do you receive a Social Security or SSI check by mall? Bere are three good reasons to sltitch to direct deposit. It's Safer, malled
checks can be lost or stolen; Easier, your funds are deposited to your PNC account electronically; and best of aU it's Convenient, your
money invallable without making a trip to the bank. Enrolling is easy. Stop in at any PNC Bank branch or call us at 1-888-762-2265
6am-n midnight for more information on how to enroU.
Buying a New Bome or Looking to Refinance? Let PNC Mortgage Show You How.
We can help you find the right mortgage to meet your needs.
> First time home buyer
> Building your dream home
> Purchase & Renovate (SM) loans
> Vacation & Second Homes
> FHA & VA Loans
BomeOwnership Made Possible by PNC(SM)
For More"Information :
> Asktospeak with your PNC Home Mortgage Consultant
> Visitwww.pncmortgage.com
> Call 1-800-778-6678
All first mortgage products are offered and provided by PNC Mortgage, LLC. PNC Mortgage, LLC is licensed in New Jersey as a Depal1ment of Banking Mortgage Banker and
Secondary Mortgage Loan Ucensee. PNC Mortgage, LLC may not be available in your area. Credit subject to approval. Infonnation is accurate as of the date of printing and
subject to change without notice.
(12007 PNC Mortgage, LLC. All Rights Reserved.
Equal Housing Lender
Pr.emi... Plan
Intere.' -Checking Ace..... Summary
Account number: 00-0701-7091
Henry L Zajac
Gary Zajac
Eileen M Zajac Deed
Beginning
balance
Deposits and
other additions
1,525.69
Checks and other
deductions
232.58
Endi ng
balance
Please see the Activity Detail section for
additional information.
Balance Summary
1,340.25
2,633.36
Average monthly
balance
Charges
and fees
2,677.19
.00
FORM953R-l005
Premium Plan Account Statement
Q. For 24-hour information, sign on to PNC Bank Online Banking
on pnc.com.
Account nwnber: 00-0701-7091 - continued
Transaction Su......ary
For the period 02128/2007 to 03129/20,
HENRY L ZAJAC
Primary account number: 00-0701-7091
Page 2 of 3
Checks paid/
withdrawals
Check Card POS
signed transactions
Check Card/Bankcard
POS PIN transactions
1
o
o
Total ATM
transactions
PNC Bank
ATM transactions
other Bank
ATM transactions
1
1
o
Interest Su......ary
Annual Percentage
Yield Earned (APYE)
Number of days
in interest period
Average collected
balance for APYE
I nterest Paid
this period
As of 03/29, a total of $.86 in interest was
paid this year.
0.19%
30
2,677.19
.42
Activity Detail
Deposits and Other Additions
Date Amount Description
02/28 542.27 Direct Deposit. Benefit
Uss Pension Fund 21872700
03/02 983.00 Direct Deposit - Soc Sec
US Treasury 303 XXXXX0172A
03/29 .42 Interest Payment
There were 3 Deposits and Other Additions
totaling $1,525.69.
Checks and Substitute Checks
Check Date
number Amount paid
3225 9.80 03/09
Reference
number
005265493
Banking/Check Card Withdrawals and Purchases
Date Amount Description
03/15 200.00 ATM Withdrawal32ND and Rt 15 Camp Hill PA
There is 1 check listed totaling $9.80.
There was 1 Banking Machine Withdrawal
totaling $200.00.
Online and Electronic Banking Deductions
Date Amount Description
There was 1 Online or Electronic Banking
Deduction totaling $22.78.
03/09
22.78 Payment,E-Check Check Pymt Verizon ARC 3226
Daily Balance Detail
Date
02/28
03/02
Balance
1,882.52
2,865.52
Date
03/09
03/15
Balance
2,832.94
2,632.94
Date
03/29
Balance
2,633.36
Spring cleaning? Why not tidy up your credit too. Whether you want to consolidate, refmance or make home improvements, managing your
credit is important. Order your 3-bureau credit report to get your current status and tips on improving your credit score, plus receive $25,000 in
identity theft expense reimbursement insurance for no additional charge. Visit www.pnc.comlcreditreport.
Relax and let your PNC Bank Visa@ Check Card pay the bills. Use your card to schedule one-time or recurring payments. You pay what
you need without looking for stamps, writing checks, or traveling to the post office. It's that easy. Find out more at pnc.comlpaybycard.
For the period 02123/2007 to 03/23/2007
x
HENRY L ZAJAC
GARY ZAJAC
EILEEN M ZAJAC DECD
20 N 12TH 5T APT 343
LEMOYNE PA 17043
nu~'ing a New Home or Looking to Refinance? Let PNC IvIortgage Show You How.
W(O c:un help ~'ou find tbe right mCII1gage t.o meet your needs.
> First time home buyer
> Building your dream home
> Purchase & Renovate (SM) loans
> \'acation & Second Homes
> FHA & VA Loans
nOIlll' Ownersbip l\Iacll' Possible by PNC(SM)
For 1\I0re Information:
> Ask to speak with your PNC Home l\'lortgage Consultant
> Visit www.pncmortgage.com
> Call 1-800-778-6678
o PNCBANK
Primary account number: 00-0148-1547
Page 1 of 3
Number of enclosures: 0
a For 24-hour banking, and transaction or
interest rate information, sign on to
tI' PNC Bank Online Banking at pnc.com.
For customer service call 1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
Para servicio en espatiol, 1-866-HOLA-PNC
Moving" Please contact liS at 1-888-PNC-BANK
~ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
C Visit us at pnc.com
,!;;;3
I
TDD terminal: 1-800-531-1648
For hearing impaired clients only
,\Jllirstmortgage products are ofTered and provided by PNC M0I1gage, LLC. PNC Mortgage, LLC is licensed in New Jersey as a Department of Banking Mortgage Banker and
SecomL11)' M011gage Loan Licensee, PNC l\1011gage, LLC may not be a,'ailable in your area. Credit subject to approval. Information is acclU'lIte as of the date ofplinting and
,ubjectto change withoutuotice.
(J 2007 PNC Mortgage, LLC. All Rigllts Reserved.
Eqnal Housing Lender
Premium .Plan
Money Market Account Summary
A.ccount number: 00-0148-1547
Balance Summary
Beginning
balance
Deposits and
other additions
17.61
Checks and other
deductions
2,065.00
Endi ng
balance
41,048.64
43,096.03
Average monthly
balance
Charges
and fees
41,886.12
fransaction Summary
Checks paid/
withdrawals
Check Card POS
signed transactions
Check Card/Bankcard
POS PIN transactions
1
o
o
Total ATM
transactions
PNC Bank
A TM transactions
Other Bank
ATM transactions
o
o
o
Henry L Zajac
Gary Zajac
Eileen M Zajac Deed
Please see the Activity Detail section for
additional information.
.no
FORM953R.1005
Premium Plan Account Statement
Annual Percentage
Yield Earned (APYE)
0.53%
Number of days
In Interest period
Average collected
balance for APYE
Interest Paid
this period
For the period 02123/2007 to 03/23/20,
HENRY l ZAJAC
Primary account number: 00-0148-1547
Page 2 of 3
As of 03/23, a total of $57 A2 in interest was
paid this year.
Q For 24-hour information, sign on to PNC Bank Online Banking
on pnc.com.
Account number: 00.0148-1547 - continued
Interest Summary
29
41,886.12
17.61
.cdvity Detail
I)eposits and Other Additions
late Amount Description
)3/23 17.61 Interest Payment
There was 1 Deposit or Other Addition
totaling $17 .61.
Checks and Substitute Checks
:heck Date
lumber Amount paid
l78 2,065.00 03/07
Reference
number
004794084
There is 1 check listed totaling $2,065.00.
I)aly Balance Detail
late Balance
)2/23 43,096.03
Date
03/07
Balance
41,031.03
Date
03/23
Balance
41,048.64
~pring cleaning? Why not tidy up your credit too. Whether you want to consolidate, refmance or make home improvements, managing your
:redit is important. Order your 3-bureau credit report to get your current status and tips on improving your credit score, plus receive $25,000 in
dentity theft expense reimbursement insurance for no additional charge. Visit www.pnc.comlcreditreport.
LertIticate of Ueposit
Maturity Notice
~PNCBANK
Certificate Number:
Maturity/Renewal Date:
Maturity/Renewal Value:
Renewal Im'estment:
000031000138483
01/24/2007
$43,850.24
6 MONTHS FIXED RATE
1474
HENRY L ZAJAC
GARY ZAJAC
20 N 12TH ST
LEMOYNE, PA
APT 343
17043
Dear Customer:
. Thank you for investing in a PNC Bank Certificate of Deposit (CD). TIle CD shown above, will be maturing on 01/24/2007
with a value of $43,850.24.
A Certificate of Deposit is a safe and easy way to keep your savings growing at a guaronteed role. We'd like to see you continue
that growth by reinvesting your funds. However, if your needs have changed, or you want to explore other products or services
to help you reach your financial goals, we can help you do U,at, too. Here are just some ofthe re-investment options available
to you:
AutomaticaDy Renew For An Additional Term - Your CD is scheduled to automatically renew for the amOlmt and renewal
investment period shown above, which may be different from your original ternl.
TIle Account Agreement on the back ofthisletter provides additional infonnation about the renewal afyour CD and should be
retained willi your other account records. Upon renewal, interest will be credited to your CD, unless you receive a periodic
interest payment.
When your CD renews, your funds will earn the interest rote and annual percentage yield in etTect on 01/24/2007. Because
interest rates and annual percentage yields may change between now and 01/2412007 , please call] -877 -BANK-PNC on or
after this date for renewal rate infonnation.
Add to Your CD and Earn More... Even Change Your Investment Selection - To add to your CD, sinlply complete the
Renewal Authorization attached and return it to us no later than ten days after 01/24/2007. A postage-paid envelope is enclosed
for your convenience. You can also change Ule investment period of your CD using the Renewal Authorization. Terms between
seven days and ten years are available.
Once we receive your Renewal Authorization, we will send a continnation showing the changes you have made to your CD, as
well as the new interest rate and almual percentage yield.
Explore Other Investment Choices - From time to time, you may need to re-evaluate your investment strategies to meet your
ever-changing needs. No matter what your situation, we can help you make the right saving and investment choices based 011
your fmancia] goals and personal dreams. In today's enviromnent, we think it's particularly important to ask:
- Do you have enough savings that can be accessed in case of emergency?
- Do you have longer term investments working for you?
- Are your borrowing costs as low as they can be?
Stop by your local branch office at your convenience or call us between the hours of 6:00 am and midnight at 1-877 -BANK-PNC .
We appreciate your business and thank you for banking with us.
Sincerely,
~F.~
Q
David F. Ross, Vice President
Product Management and Marketing
Member FDIC Equal Housing Lender
... ......~~rti~~at~"'w:. ...:
. .... OPOP~10Q01~~~&~. .
~QfefenceNUMJ:)~r.. .
. .. '_' -"_,', .' , -',.. '__; :;'., . . ',- ~.c:. ~: :', ~.,; ,,'
000003600Q11759
>1-
~ . .'. '...... '. " ." .
":.c" > -.._'-....,..... c" .,..' ':.,'_ .,' .
. :" .:'-,'.:: '-, " ~.'.: -- ,-..;:',;'-' .:: ': -'::. ;', ';,- -;' .:}::-.' .. .,','.:- .,-' ':.:':-'i",'. ,,',:
.... "e.n'!!!r Q!Y .,.~~,~ '~r ....!!!!!:If'1tt v.\!!~,.~ ~f
. .. ':' or.,. .... >
. 'no,~a!tI ~a !lII1Ct;';" Ct' lilY. ~~rti"!JlIt, t~ $
AI11Qunt l'dded:$
Pllyn,a~t IIIIlttIJod:
~~3!~50.24
Check Enclosed
Charge my PNC Bank: Checking Accqunt
Account Number
2. Chang. tl.a ta,... of my Cartifioata
(Select any term from 7 days to 10 years or a specific date)
_ Days _ Months Years
_ Month _ Day Year
I acknowledge that I have received a copy qf the PNC Bank ACCOU'lt Agreement
for CD Investments and agree to any amen~ments to the agreement.
Signature
Savings Account
Daytime Area Code and Telephone Number
( )
rLLdlf(~ ff
~/I
Ofl i e d e man
/"V FUN ERA L H 0 M E
Dennis l. Wiedeman. F .0. - Supervisar
James W. Talon. F.D.
Wiliam A. Sibert. F.D.
.
357 South Second Slreel
Sleellon. PA. 17113
Phone: 717.939.2344
Fax: 717.939.1999
email: wiedemanfh@comcast.nel
www.wiedemanfuneralhome.com
STATEMENT
o F
ACCOUNT
May 1, 2007
Mr. Gary Zajac
2112 North View Lane
Harrisburg, PA 17110
The Funeral Service of: Mr. Henry L. Zajac
IA. CHARGE FOR SERVICES SELECTED: t
1. PROFESSIONAL SERVICES $. 2630.00
2. FACllITIES/SERVICES/EQUIPMENT:$
3. AUTOMOTIVE EQUIPMENT: $
I C. SPECIAL CHARGES:
Forwarding of remains to
$ -0-
195.00
(Funeral Home)
Receiving of remains from
926.00
$
(Funeral Home)
Immediate Burial
Direct Cremation
(A) TOTAL OF PROFESSIONAL SERVICES. $ 3751.00
FACILITIES AND AUTOMOTIVE
lB. CHARGE FOR MERCHANDISE SELECTED: I
Casket. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 1395.00
(Description) 20 Ga. Steel Gasketed
Outer Receptacle . . . . . . . . . . . . . . . . . . . . .. $
(Description)
Outer burial container. . . . . . . . . . . . . . . . . .. $
(Description)
Acknowledgement Cards . . . . . . . . . . . . . .. $
Register Book(s). . . . . . . . . . . . . . . . . . . . . .. $
Memory Folders . . . . . . . . . . . . . . . . . . . . . .. $
Prayer Cards . . .. ..................... $
Temporary grave marker. . . . . . . . . . . . . . .. $
Burial Clothing ........................ $
Other Clothing . . .. . . . . . . . . . . . . . . . . . . . .. $
Custom Graphic Design & Printing ........ $.
Flowers .c;fl~k.e.t.~P.rpy.~ TfJ~. . . . . . . . . . . .. $
$
$
Cremation Um . . . . . . . . . . . . . . . . . . . . . . . . . $
Interior & Exterior Crucifixes. . . . . . . . . . . .. $
Refrigeration. . . . . . . . . . . . . . . . . . . . . . . . .. $
(B) TOTAL MERCHANDISE SELECTED
-0-
$ -0-
$ -0-
$ -0-
SUB.TOTAL OF SPECIAL CHARGES. . . . . . . . .. C $
t D. CASH ADVANCES: I
Opening Grave. . . . . . . . . . . . . . . . . . .. $. -0-
Cemetery Equipment. . . . . . . . . . . . . . . . $. -0-
Newspaper Notices - Local. . . . . . . . .. $ 83.91
Newspaper Notices - Out-of-town. ... $ -0-
Telephone & Telegrams. . . . . . . . . . . .. $ -0-
Airfare . . . . . . . . . . . . . . . . . . . . . . . . .. $. -0-
Clergy Honorarium . . . . . . . . . . . . . . . . . $ -0-
Pallbearers . . . . . . . . . . . . . . . . . . . . . . . $ -0-
Certified Copies of Death Certificate. .. $. 18.00
Crematory Charges. . . . . . . . . . . . . . . . . $. -0-
Organist. . . . . . . . . . . . . . . . . . . . . . . . . $. -0-
Soloist. . . . . . . . . . . . . . . . . . . . . . . . . . . s. -0-
Other $. -0-
Other $ -0-
Other $. -0-
SUB-TOTAL OF CASH ADVANCES ........ D $
-0-
-0-
-0-
.c-
-0-
-0-
-0-
-0-
-0-
212.00
-0-
-0-
-0-
-0-
SUMMARY OF CHARGES:
A. Professional Services, Facilities and
Equipment and Automotive
Equipment. . . . . . . . . . . . . . . . . . . . . . . S
B. Merchandise............. . . . . . . .. S
C. Special Charges. . . . .. . . . . . . . . . . .. !Ii
D. Cash Advances. . . . . . . . . . . . . . . .. $
3751.00
1607.00
-0-
101.91
$
1607.00
TOTAL OF ALL SELECTIONS ................. $.
LESS PAYMENTS.RECElVED................. $.
BALANCE DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Family Owned and Operated....We Care
I
-0-
-0-
101.91
5459.91
100.00
5359.91
700 Linden Ave. at Cable
East Pittsburgh, PA 15112
PATRICK T. LANIGAN
Supervisor
412-824-8800
Fax 412-824-7515
www.1aniganfuneralhome.com
Patrick T.
~!:!llg~!'In~
Turtle CreekIMonroeville Chapel
1111 Monroeville Avenue
Turtle Creek, PA 15145
ANDREW J. BOTTI
Supervisor
412-823-9350
May 11, 2007
Gary Zajac
2112 North View Lane
Harrisburg, PA 17110
Statement of Funeral Expenses for: Henry L. Zajac
Date of Death: April 9, 2007
PACKAGE:
Receiving Service with 1/2 Day Visitation
Receiving Service/1/2 Day Visitation
$ 2,620.00
Sub Total: $ 2,620.00
$ 755.00
Sub Total: $ 755.00
$ 3,375.00
$ 195.00
$ 25.00
Sub Total: $ 220.00
Total Funeral Expense: $ 3,595.00
Total Payments Made: $ 3,595.00
Balance: $ 0.00
MERCHANDISE:
Outer Container: Deluxe Norwalk
TOTAL FUNERAL HOME CHARGES:
CASH ADVANCES:
Pittsburgh Post Gazette
Pittsburgh Tribune Review
~~/uJ2- ~/r; 2dV7
flJ~~-6z:iWf ~w.- :'(
/#~
Third Generation, Since 1905
~- nl:;; II'\IL ....;;:) II'\LLIVII:;;I" I \"UI" I nl'\\" I I'\I"LI ;;:)I:;;\"unll , I'\UnI:I:;;IVII::::" I
'\ AGREEMENT No.13 8 2 2 3 cf-.
. J\tISAG8J;EMENT between The Catholic Cemeteries Association of the Diocese of Pittsburgh, 718 Hazelwood Avenue,
Pittsburgh, PA 15217, hereinafter referred to as ,Seller,.and Buyer(s) indicated below:
Cemetery # / Mausoleum #Ja.L G -(-",(.r-! '~',.,A <~,() It r--/1r~ .. Date 0<;-_) 3 -0 7 Owner #
Buyer{s) --::: .(i
Address ,-.}.J!L L." J <C
Telephone # (:1.Il-) (~:7 t.;' ~ - '.'i :.~ <; -)
Certificate To Be Issued InName{s) Of:
Cemetery: \0ifraves 0 Lawn Crypt
Section 10
f- j /'..... ,~
/") /1
!~ /-t.
I,
Purchaser #
/ I !j
Parish
"..-
rl"
See page 2 for names:
Upright Memorial Permitted: 0 Yes --iJ. No #_ Spaces $
Block ~ Lot 3C) Row _ Grave(s) 3
o Cremation Entombment $ + Lettering $
Tier #_ Spaces $
plus
Sec. Name: Type Lettering $ = Total $
Memorialization: 0 Bronze 0 Granite 0 Cemetery Incising 0 Additional Crypt Incising/Lettering__
Memorial $ + Foundation $ + Memorial Foundation Care Fee $ = Total $ .d 57 :lj
Burial vaults: "'0 R~gal ;j 0 Jaiestic 0 Im~e~ia I b Ultim~ 0 tthe"r I , !> i ~".it ~'Va~ltsx'r$ ~;;:;; $~
Preneed: 0 Interment 00 0 Interment ED 0 Entombment 0 Inurnment (Monday - Friday only) # _ x $ _ = $
At Need: 0 Interment 00 0 Interment ED 0 Entombment 0 Inurnment (Monday - Friday only) # _ x $ _ = $
-
= $
Privilege: 0 Double Interment 0 Cremation Interment
Mausoleum: Crypt{s) Niche(s)
= Total $
Other (Specify)
Other (Specify)
$
$
NOTICE TO BUYER- Itemization of Amount Financed
1. You are entitled to a completely filled-in copy of this 1. Total Purchase.Price $ ....., <~::i Ji.- (1)
~..-
agreement at the time you sign it. A. Memorial Discount $ ,
j
2. Do not sign this agreement before you read it or if it B. Vault Discount $ I
contains blank spaces. C. Grave/Crypt Discount $ I
3. Under the law, you have the right to payoff in advance D. Grave Enhancement $ I
the full amount due and under certain conditions to 2. Total Deductions......... .(A+B+C+D) $ - (2)
obtain a partial refund of the finance and/or service 3. Total Cash Price ............ . . (1 - 2) $ .~~, <'1 ):) (3)
~ . ,
charge. E. Cash/Check $
Any holder of this Consumer Credit Contract is subject F. Credit Card $
to all claims and defenses which the debtor (buyer) could
assert a.gainst the seller of the goods or the services G. Trade-in $
-) .-.'..... ')::."
obtained pursuant hereto or with the proceeds hereof. 4. Total Down Payment. . . . . . . . . . (E+F+G) $ .",:7' ~ / (4)
- "
Recovery hereunder by the debtor (buyer) shall not 5. Unpaid Balance-Amount Financed (3 - 4) $ . I (5)
exceed amount paid by the debtor (buyer) hereunder. 6. Finance charge $ f (9)' .
, "1' ..
If you do' not meet your contractual obligations,.you may lose i:.-F .. . ~ ~ . , .,. ...... ., .. ..
7. Total Payments Due (5 + 6) $ of- . (7)
the funds paid under this agreement held in a trust account. ~ I
8. Total Sale Price (4 + 5 + 6) $ ;;-,<; 7 ),:.,- (8)
(...,,'. CONSUMER CREDIT DISCL()SURES
1. ANNUAL 2. FINANCE CHARGE 3. AMOUNT FINANCED 4. TOTAL OF PAYMENTS 5. TOTAL SALE PRICE
PERCENTAGE RATE ~, The. doliar amount the (unpaid balance) The amount you will have The total cost of your
The cost of your credit will cost you. The amount of credit paid after you have made purchase on credit,
credit as a yearly provided to you or on your all payments as scheduled. including your down
rate. behalf. payment of $ -
- _. --
% $ $ -. $ $ -_.
(Box 2-+ Box 3) (Box 4 + down payment)
Number of Payments Amount of Payments When Payments are Due: Monthlv Bealnnlnn on:
-'. - -
INTEREST FREE PERIOD: You will not be charged a Finance charge during the first _. months from the date of this agreement.
SECURITY: You are giving a security interest in the goods or property being purchased.
LATE CHARGE: II payment is late (10 days or more after due date), you may be charged 5%'01 the payment due or five dollars ($5.00) whichever is lesser,
with a minimum charge of one dollar ($1.00). Only one late charge will be collected on each installment regardless 01 the period during which the installment
remains in default.
PAYMENT: if you payoff early, you will not have to pay a penalty and you may be entitled to a refund of part of the Finance Charge.
DEMAND FEATURE: This obligation has a demand feature.
NOTICE: See the remainder of this agreement for additional information about nonpayment, default, security interests, any required payments in full belore
the nato ann nr.o._no\lrYu:tnt rofllnnc- an" "n"~I+il"\C'"
-""
5Lhedl(~ ~
I,
~
HENRY L ZAJAC
Account Summary
Previous Charges
No Payment Received
Past Due Charges (please pay now)
$21.71
.00
$ 21.71
New Charges
Verizon (page 3)
Other Providers (page 6)
Total New Charges Due
Total Due: (Past Due + New)
- $ 9.33
50.88
$41.55
$ 63.26
Please pay upon receipt
- FINAL BILL -
This Final Bill may have already been referred to an outside collection
agency.
CONSUMER ALERT!
Check your bill this month for a new service provider.
Questions about your bill? Call 1 800 660-2215
See page 2 for all other Verizon contact information.
Change of billing address?
Go to verizon.com/billingaddress or see page 2
Billing Date: 04/24/07 Page 1 of 6
Telephone Number: 717 761-5783
Account Number: 717761-5783 79712Y
--
Moving? 1-866-VZ-MOVES
Across the street or across the
nation, one call can do it all.
Call us for internet, phone and
entertainment in your new
home.
ONE-BILL"
Are You A ONE-BILL Customer?
Get your Verizon and Verizon Wireless
charges on a single bill each month!
Sign-up is easy at verizon.com
Already a ONE-BILL customer?
Find out about important
changes in the "For Your
Information" part of this
bill.
[!B
Enjoy A Little Bi/l-Free Bliss
Find out how at verizon.comlvisa5k
Sign up and pay your Verizon
bill automatically with your Visa lID
carel. It's convenient, easy and safe!
Or sign up for Verizon broadband
and use your Visa II card
to pay. Learn more at
verizoo. comlvisa5k
.., Detach & return payment slip with your check, payable to Verizon.
-----:~~:=:w:;::::;-~-~~~~:.~~-~~~----------------------------------------------------------------------
Thank you for the opportunity to serve you. You have b~en a .valued
Verizon customer. If you need to establish telephon7 seTV1c~ WIth ~other
utility, please use this message as a record of your pnor Venzon servIce.
33 P063 7177615783
05 PA212*HBRDA1
00009629 3T0000063797
Apria Pharmacy Network
2150 No. Trabajo Dr. Suite A
Oxnard, California 93030.8800
APIlIA HEALTH CAllE Billing Dept. 1.800.872.1866
STATEMENT 05-11-07
*
Credit Card Authorization (this form authorizes payments ONLY
for the following patient) :
Please print your name:
ACCOUNT # F686647 MC7
Name as printed on credit card (if different)
Type of card: Visa 0 Mastercard 0 Discover Card 0
..liI
Card #
Exp. Dale
BALANCE INCLUDES YOUR MEDICARE
PART B DEDUCTIBLE. THANK YOU.
Cardholder Signature
HENRY ZAJAC
20 N 12TH ST APT 343
ESSEX HOUSE
LEMOYNE, PA 17043
Please return top portion with your payment of:
Paid Amount:
125.78
DATE DESCRIPTION PATIENT DUE CHARGES PAYMENTS
.-------------------------------------------------------------------------------
)2-12-07 DISP FEE 3 o DAY .00 33.00
)2-28-07 MEDICARE PAYMENT 26.40-
CHECK 70581454EMR
)3-22-07 INSURANCE PAYMENT 5.28-
CHECK 2970148
)4-30-07 PATIENT PAYMENT 1. 32-
CHECK 3228
)2-12-07 DUONEB ALB+IPR 2.5+0.5MG 3ML .00 94.68
12-28-07 MEDICARE PAYMENT 75.74-
CHECK 70581454EMR
3-22-07 INSURANCE PAYMENT 3.29-
CHECK 2970148
4-30-07 PATIENT PAYMENT 15.65-
CHECK 3228
3-16-07 DUONEB ALB+IPR 2.5+0.5MG 3ML 3.79 94.68
E 2
*
FOR BILLING QUESTIONS, PLEASE CALL
TOLL FREE 1-800-872-1866
PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT
HENRY ZAJAC
STATEMENT 05-11-07
ACCOUNT # F686647
Apria Pharmacy Network
2150 No. Trabajo Dr. Suite A
Oxnard, California 93030.8800
Billing Dept. 1.800.872.1866
APIlIA HEALTHCAIlE
\
*
Apria Pharmacy Network
2150 No. Trabajo Dr. Suite A
Oxnard, California 93030.8800
Billing Dept. 1.800.872.1866
Credit Card Authorization ( this form authorizes payments ONLY
for the following patient) :
Please print your name:
APIUA HEALTHCARE
STATEMENT 03-23-07
ACCOUNT # F686647 MC7
r~j 1/01
Name as printed on credit card (if different)
Type of card: Visa 0 Mastercard 0 Discover Card 0
..~
Card #
Exp. Date
Cardholder Signature
HENRY ZAJAC
20 N 12TH ST APT 343
ESSEX HOUSE
LEMOYNE, PA 17043
Please return top portion with your payment of:
Paid Amount:
18.08
DATE DESCRIPTION PATIENT DUE CHARGES PAYMENTS
--------------------------------------------------------------------------------
10-09-06 DUONEB ALB+IPR 2.5+0.5MG 3ML .00 98.01
10-26-06 MEDICARE PAYMENT 78.41-
11-16-06 INSURANCE PAYMENT 15.68-
01-19-07 PATIENT PAYMENT 3.92-
10-09-06 DISP FEE 3 o DAY .00 33.00
10-26-06 MEDICARE PAYMENT 26.40-
11-16-06 INSURANCE PAYMENT 5.28-
01-19-07 PATIENT PAYMENT 1.32-
11-08-06 DISP FEE 3 o DAY .00 33.00
11-24-06 MEDICARE PAYMENT 26.40-
12-18-06 INSURANCE PAYMENT 5.28-
02-19-07 PATIENT PAYMENT 1.32-
11-08-06 DUONEB ALB+IPR 2.5+0.5MG 3ML .00 98.01
11-24-06 MEDICARE PAYMENT 78.41-
12-18-06 INSURANCE PAYMENT 15.68-
02-19-07 PATIENT PAYMENT 3.92-
12-12-06 DISP FEE 3 o DAY .00 33.00
01-05-07 MEDICARE PAYMENT 26.40-
01-18-07 INSURANCE PAYMENT 5.28-
PAGE 1
*
FOR BILLING QUESTIONS, PLEASE CALL
TOLL FREE 1-800-872-1866
PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT
HENRY ZAJAC
Statement 03-23-07
F686647
Apria Pharmacy Network
2150 No. Trabajo Dr. Suite A
Oxnard, California 93030.8800
Billing Dept. 1.800.872.1866
APRIA HEALTH CARE
:ount #: PHE 178200172
Please Pay: $14.53
Payment Due: 06/04/07
119/07 THOMPSON
CC E/M CRITICALLY ILL/INJ
MEDICARE PAYMENT 60 lh
MEDICARE ADJUSTMENT
BC/BS PAYMENT
EMER DEPT HIGH SEVERITY&T .1/
MEDICARE PAYMENT 17~
MEDICARE ADJUSTMENT
INSURANCE PAYMENT
APPLIED TO YOUR CO-PAYMENT, PLEASE PAY
PLEASE REMIT PAYMENT TO OUR OFFICE
478.00
451.00
)(~{
:)& L ~1
, PAST DUE ***
:ASE NOTE THAT YOUR ACCOUNT IS PAST DUE.
~ENT IN FULL IS REQUIRED. IF YOU ARE UNABLE TO
, IN FULL, PLEASE CONTACT US IMMEDIATELY TO MAKE
:MAL PAYMENT ARRANGEMENNTS.
ient Name: HENRY ZAJAC
fsician Services Provided By:
, NACLE HEALTH EMERG
BOX 8500-55168
LADELPHIA PA 19178-5168
Account
Balance:
$14.53
To Pay Your Bill Online
Please Visit: f
www.shc1billpay.com/PHE '-.
Billing Inquiries:
440-717-5555 or 800-579-7777
E-MAIL: questions@shcservice.com
MON. - FR!. 8:00am to 5:00pm EST
'(12I-.j
Total
Current
31.60 Da
61.90 Days
91.120 Days Over 120 Days
Amount Due:
$12.14
ance Balance
1m Balance
$12.14
$ .00
.00
$ .00
ASSOCIATED CARDIOLOGISTS
856 CENTURY DRIVE
MECHANICSBURG, PA 17055
untBalance $ 112.13
. Wali, M.D., FACC
. Bosak, M.D., FACC
I,M.D.
. Dave, M.D.
,M.D.
All billing questions can be made between
the hours of 8:30 AM and 4:00 PM.
For Billing Questions Call: (717) 591-7122
For Toll Free Call: 1-800-845-1742
Patient Name: HENRY ZAJAC
1'--0
'I ~lllllllllllllll H~ I~I ~IIIIII
STATEMENT
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
0122 - 548
\
Pulmonary and Critical Care Medicine Associates, P.C.
and billing for Capital Region Sleep Center
1631 N. FRONT STREET
HARRISBURG, PA 17102
PHONE: (717) 234-2561
FRANKLIN J. MYERS, III, M.D.
RICHARD G. EVANS, D.O.
SAFA P. FARZIN, M.D.
BABA H. L1MANN, M.D.
RUBINA KERAWALA, M.D.
ROBERT C. GilROY, M.D.
WilLIAM M. ANDERSON, M.D.
STATEMENT DATE
OS/25/07
HENRY ZAJAC
20 NORTH 12TH STREET
APT 343
LEMOYNE PA 17043
ACCOUNT NUMBER
51521 (1)
H105.905MS REV. 6/06
This is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WA.RNING: It is illegal to duplicate this copy by photostat or photograph.
/J.JI ~d
v-o "'"'"7 ~~ lfiMlfoL
No.
Frank Yeropoli
State Registrar
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
1083387
APR 2 4 2007
Date
Hl05-143 REV 1112006
TYPE I PRINT IN
PERMANENT
BlACKlNI<
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and exsmples on reversal
STATE FILE NUMBER
!
l!;
!
"iiENRY~Z'AJAC 12M~le 11__""_ 14. DIte of Dedl (MonIh. day, ye.r)
178 -20 - 0172 April 9, 2007
5....80'.._1 ......,- Ul'lder1d8y 8. DateolBirlh (Month. 7._1 Ind Nta or I '""" 1 a.. PIIce 01 Oelllh Check OMI
; y,. 1- I "'" I - 1 -I Aug 10, 1926 1 Center, PA I;;::'" DE"''''-'' DOOA 1;'~"""Homo 0...-.. DOlh<<._
lb. County 01 DeaIh I'" C<y. -. Twp. '" Dea" ed. FICIIly NaJM (I not institution. give strHl and number) 9._Cecanl"'_~' [](No oy" 110._'_...."'.................
Dauphin Lower Paxton Twp. Conmmity General Osteopathic Haspi a~~~:,eIc.l (-~
White
11.0ecIdenf'1UIuII "'-- -'" ... Do nall11M 12. Wu o.c.dInt ever In the 13. Decedent'a Education (SpecIfy rrit highest ~ completed) 14. _lIIluo, _ __'1'" """"" _III .... ,Ne...-, '''''''I
""''''- ,~ KN fA EUilIII/Induny u.s.AtmlldForcr.l? I EIemenI'lt"'........lo-1211 College (1-4 or 5+) 1-.-1-
Metallurgist Steel Industry e9... DNa Widowed
. '"in': "nt'h'g'~.dIyl-' -. ,,-I -', PA . I);d_
Actual RaIdInce 171. Elate L.Jvelna 17c. 0 Va, 0e0IdInl: UwId in Twp.
Lemoyne, PA 17043 Cumberland T_' 17d.[3 No,DeoIdInI:l.J\Iedwll*1 Lernoyne
17>. County ActiIllinbof Cl!yl-
1~""" Name (First. middIt.1ut. auffix) 19, MaIher', NIIme (Fnl. middle, maiden ..mamel
wrence Zajac Katherine Tadla
~_r~rTw>e/_1 2(lb. InIormanI's U.g Address ISIrMt. city I kMn, ..... zip axil)
ary Jac 2112 North View Lane, Ha=isbur~, PA 17110
21..MettIodof~ 10-0- 21b. OllIe of 0IIp0dI0n (Month. diy, yw) 21c. PIece 01 DiIpoIIIon (Nlrneofcemetefy,~ lJ' oIwrplece) l21d.""""'I"~/_.""'......_J
~...... 0 __Slate _~orDclNlloft............ * 13, 2007 Good ShePherd Cemeterv 15146
DOlh<<.~ ",__,_ O...DNo Apn.l Monroeville PA
22a.~oIFunertII~IOl'~ICtIng.IUdI) "..t) lB. Ul:8nII Pbnber I ~ Heme II1d Add..... of FecIIty
~ _ A ~ "/"6 t'i'/-'- WIEDEMAN FUNERAL HOME. 357 S. Second St. Steel ton PA 1711-'.1
~""''''~'''''-- 231i. To the belt or my knowtIdge. dNIl oa:untd II fit line. dati_ _ silled. (5lgnllUre n;l title) 23), licenH Nt.mber 23c. Dale 5qIed lMoolh, day, year)
phpIcIInllnotavllllblllltlmloldea!hto
C8Itft C&lIt of dIaIh.
1IemIZ4-26tnu11bt~bypetlOl'l 24. TlmI of Death 125. 0.. Pronounced Dead (Month, clay, VMrl 28. Wu C.. Rftrred 10 M<<Ic8I EXllminef I Coronet'Of a Reason Dll'ler than Cr&m8tlon lIl' Donatfon1
...............- 4:39 t' M. April 9, 2007 Oy. I!5lNo
CAUSE OF DEATH (See Ntructiona and aumplH.) ~ Approlcir!.w internl: pllft II: Enlerotherlllkrilant condIlIrInt; OllMbJllmID ttMIh. 2'8. Did ToblIcco UIe ContlINtI to DMlh7
1Iem%l~Paf'll; EMIr"~ -.......InJINI, or ~1onI '**dI caweclthe dNIh. 00 NOT enIer Iem1inaI r.oents -..ch as cardac arrest. """" to 00a0> bJtnol.l8euIing.,the~Clt.RgMn1nPartI. "0""' 0-
~.... or vwntrlc:tMr IbIIeIian witIout shcMhg ItW 1tioIogy. lII1 aNy one cauM or'I teCh..... 0" 1:i!I"'-
::m--==l~ ~05f\fCo.-1vrj, ~I",v-e 29.IfF~:
.. o NoI"-_,,,_
alllleondtionl,illq, b. Clolor...~: ",.,oJl~r'\-\\ rX}-e~' o PregnanlII lime ofdNltl
tI C8UMlIlIdonllntL J\fc.,('\i ~ o\.g\'t-("vt..ttv~ o Not 1lf8l1lant. but Jn9lant within 42 clays
Enter lHIdLYINOCAUSI! Due ao (or as. conllllqLl8tlOt of):
=- ..::.tI,':..."rt'M" c. "'-
. Due to (or as I coneequence of): D Not prep'lt, but ....ant 43 days to 1 year
-. .....
d. 0_................,......_
30a Wu ."AuIopty 3Ob.__R_ 31. Manner of 0NltI 32., Olde of Ir-;ury (Monlh, day, year) 1321:1. Deecribe How I~ Occurred 32c. PlI~ d Injlly. Home, Farm, StrHl. Factory,
........., AvaIIbIePrioltoCompletion ~ 0- Olfice....... Me. (_~)
of c.us. of 0elIIh1
Dy" I]JNo Dy. DNo 0- OP__ 32d. "nmtof\njlMy 132e.,,*,~._ ~'IT~'u;u.y(_) ,132g.l.o<allon~In;..yISl"".cltyll<1wn.'....1
0- OCooldNol..-.- M. Dy" DNa o Dri""_ Dp"""", 0-
oo.r- SpecIfy.
33II.~(checkontyane) ".f~andTlhofCer1tli...
. ~~~===::.~..-::r.:=r~~..~..~~~~~~____......____.._____ ~ ~~~ ---eo .-
. =::c":,:=~Ltn~;=~.nd-:::o~:::.c=~_Iblled.._________________ 0 lSo6SdO(?t1 (L- I,.O...~':"i/~i,.7-,
. = ~= nl'Of 1nwItig;Ition, In myoplnlan. dIIIh occurred II lhll1me,.... nI ,...IM due to ltIrt C111111(.) and manner n 1IIIed.. 0 ~"Ce:"~~'t:~ed.ft'r.;'~I"""271 Type I ""'"
,.. _co _..Jnd 1>ob'd.""/1 t?.1 J, . \f 136. OoteF,",,_.dey."'" 2l?o P 0\"'40 f'oS r (2.cIk\O '~(l~ VIi:, !Pc.... 1/110
~ AJI",~. "I""A~ IdtJ.;lJ.;l..,I~ I 4-;I-h1
I'
'}
~
~
D11pCl111on P.mW. No.
OI,~1 '1',,3
- .--
.....
~. ~ OJ'-r -,
,--rG/("lrR ^t" ' i <;, ' ^'
nc v t Ur \'ilL:"J
'-"
N
'" a: ~~
~ 0: ~ \J '.'S
..- <.:ltD'.~ ~~
'GpcC<;:'r-? ........ 0
c.-.....j?,I-O<i $ 0
,,&~- -><:1:
<fl cC ~
? ~
:r:
2001 JUL -9 PH 12: 51
ClERi< OF
ORP~jf,l\J .:; (','O/!RT
I 1"1, '. '.';'. Jl..) I
C1J'/ "1'--,. I, ",
"ft..,-.__..:: ,
'j!' .'
--- ~
~~
- ~, ~
~ -~-
~
~/~ ----i
~\ ~
~:~
'\
\
"
\\
-
............
~ r-
~
~ \l ~
\, ~ ~
~ ~~ \
~~ U ~
~~,-,""""'"
~~~~
~ ~~ '-
c.-'~
~~~~
1 ~ ,
, ~ l:t ~
\", -- \, ~
ti \, ~ ~
.J:) \\) 0
~ -Q. 'J \,
~ 6 ,~,
"~~,,