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Home My WebLink About08-20-07 ---I 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 Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number eX \ 07 ()675 Date of Birth 188-03-8687 OS/23/2007 12/17/1917 Decedent's Last Name Suffix Decedent's First Name MI Kup~s SR John M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required <:.) 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 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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes 4. Limited Estate Lonny L Gohn, Sr Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address 6381 Stephens Crossing (~ ~::) _.0:-; r--",,) c:--. (- _.J ..-J :-:-.. Second line of address City or Post Office Mechanicsburg State ZIP Code PA 17050 Co) 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. SON RES ONSI RILING RETURN IE ~ DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 --l ~ ---I 15056052059 REV-1500 EX Decedent's Name: John M Kupres 188-03-8687 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) 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 Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. Decedent's Social Security Number 0.00 148,163.16 0.00 0.00 39,681.02 0.00 4,104.24 191,948.42 12,994.35 6,155.80 19,150.15 172,798.27 0.00 172,798.27 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 00 16. Amount of Line 14 taxable at lineal rate X.O 45 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 0.00 15. 172,798.27 16. 0.00 17. 0.00 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 0.00 7,775.92 0.00 0.00 7,775.92 15056052059 ---I REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME John M Kupres STREET ADDRESS 1000 Claremont Road DECEDENTS SOCIAL SECURITY NUMBER 188-03-8687 CITY Carlisle STATE 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) 7,775.92 0.00 0.00 388.80 Total Credits ( A + B + C ) (2) 388.80 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 0.00 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) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 0.00 0.00 7,387.12 0.00 7,387.12 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 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~ c. retain a reversionary interest; or.......................................................................................................................... D ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D ~ 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 {OJ percent [72 P.S. 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 (OJ 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-1503 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF John M Kupres, Sr FILE NUMBER All property jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Oppenheimer PA municipal fund - A (OPATX) 11414.727 sh @ $12.98/sh VALUE AT DATE OF DEATH 148,163.16 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 148,163.16 :;ure Mailbox - View Message Page 1 of2 ~ TUMBLEWEED ~ COMMUNICATIONS ;ecure Mailbox ? HELP VIEW MESSAGE SUBJECT: OppenheimerFunds FROM: info@oppenheimerfunds.com TO: sshupp@metllfe.com SENT: Thu 19 Jul 2007 09:58:01 MDT EXPIRES: Mon 17 Sep 2007 09:58:01 MDT Reply Reply to All Secure Mail July 2, 2007 Re: 7407400208098 Oppenheimer Pennsylvania Municipal Fund - Class A Shares JOHN M KUPRES SR Dear Ms. Shupp: Thank you for your recent telephone call. It was a pleasure speaking with you. A request was made in our conversation to provide you with the balance of the above-referenced account as of May 23, 2007. As of May 23, 2007, the total dollar value of account number 7407400208098 was $148,163.16, based on 11,414.727 shares and a share price of $12.98 per share at Net Asset Value. I hope you find this information helpful. If you have any questions or need additional assistance, please email us via the DContact UsD section of our website, www.oppenheimerfunds.com. or call us at 1-877-SELL-OPP (735-5677). We are available Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern Time. We will be glad to assist you. Sincerely, Holly Wooley OppenheimerFunds The Right Way to Invest@ HW /ma IDOC# E03913673 This e-mail transmission may contain information that is proprietary, privileged and/or confidential and is intended exclusively for the person(s) to whom it is addressed. Any use, copying, retention or disclosure by any person other than the intended recipient or the intended recipient's designees is .strictly prohibited. If you are not the intended recipient or their designee, please notify the sender immediately by return e-mail and delete all copies. OppenheimerFunds may, at its sole discretion, monitor, review, retain and/or disclose the content of all email communications. ============================================================================== opyright 1997-2007 Tumbleweed Communications Corp. All Rights Reserved , ps:/7securemail.oppenheimerfunds.com/messenger/def/tw-purl/NonUserPurl.do?x=d-963336-XgDvrn. .. \ 7/19/2007 REV-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF John M Kupres, Sr FILE 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. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Wachovia Bank, NA; NE Central PA, Mechanicsburg, PA Certificate of Deposit 27,134.76 12,226.09 320.17 2 Wachovia Bank, NA; NE Central PA, Mechanicsburg, PA Checking Account 3 Wachovia Bank, NA; NE Central PA, Mechanicsburg, PA Savings Account TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 39,681.02 "W"ACHOVIA TIME DEPOSIT WITHDRAWAL CONFIRMATION Office Name Customer Name(s). Address and Taxpayer ID Number JOHN M KUPRES SR NE CNTRL PA I CAMP HILL PA Date 6381 STEPHENS CROSSING 06/14/2007 MECHANICSBURG PA 17050 S188038687 CURRENT BALANCE: $26,658.18 + ACCRUED INTEREST: $476.58 Avail Int WD/PenFree: $2,134.76 - PENALTY AMOUNT: $0.00 - FEDERAL W/HD DUE: $0.00 - WITHDRAWAL FEE: $0.00 - OUTSTANDING PYMT : $0.00 FULL REDEMPTION CD ACCOUNT NUMBER: 247402062256153 PAID TO CUSTOMER: $27.134.76 566594 "W"ACHOVIA TIME DEPOSIT NOT TRANSFERABLE Opening Date Account Number Taxpayer 10 Number This Receipt Acknowledges That The Depositor Named Below Has Deposited With This Bank The SumO! ****************\I()I[)***** Depositor Name And Address Term Maturity Date Interest Rate Per Annum Annual Percentage Yield Interest Payment FrequencylPeriod Interest Payment OisposKion Accountlo Credil PROD-TYPE: PROMO CD: Issued by WACHOVIA BANK, N.A. 566594 W-ACHOVIA Deposit Account Close Confirmation (Debit) WACHOVIA BANK, N.A. Date Customer Name(s) and Address Taxpayer 10 Number 06/14/2007 JOHN M KUPRES SR S188038687 6381 STEPHENS CROSSING MECHANICSBURG PA 17050 ACCOUNT NUMBER: 3030090196593 Available Balance $320.17 + Accrued Int : $0.01 - Fed W/Hd Due: $0.00 - Admin Fee: $0.00 - Outstanding Db : $0.00 - Closing Fee: $0.00 Paid To Customer: $320.18 566596 CUSTOMER COpy Customer Name: JOHN M KUPRES SR Tax ID: 188038687 Customer Address: 6381 STEPHENS CROSSING MECHANICSBURG PA 17050 Home #: 717-691-8711 Serv Account Prod Account Joint/Single Account Area Number ~ Status Indicator Balance CDA 247402062256153 206 Open Single ~26,658.1'8 DDA 1000235132182 AFCG Open Single 12~226.09 SAV 3030090196593 SSSC Pending Closed Single 320.17 DDA 1010118640930 HPMM Closed Single ~O.Oo' RVC 4386542211312381 PEL Purged Single 0.00 -S1t6Lf.'f'l FOR BANK USE ONLY. SHARING ANY OF THIS INFORMATION WITH ANYONE OUTSIDE OF THE BANK COULD BE INTERPRETED AS CREDIT REPORTING, WHICH IS UNLAWFUL. REV-1510 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER John M Kupres, SR 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 DATE OF DEATH ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RElATIONSHIP TO DECEDENT AND % OF DECO'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. General Electric Capital; Lynchburg, VA - Annuity Contract - term certain 2,331.36 100 0.00 2,331.36 259.04/mo x 9 mo. = 2331.36 2 MeUife, NY, NY interest only annuity - balance = 1772.88 1,772.88 100 0.00 1.772.88 TOTAL (Also enter on line 7 Recapitulation) $ 4,104.24 (If more space is needed, insert additional sheets of the same size) GENERAL ELECTRIC CAPITAL ASSURANCE COMPANY Administrative Office Lynchburg, Virginia ENDORSEMENT Contract Number: SlR0086051 Owner(s): JOHN KUPRES Contract Date: 04/29/91 The Proceeds of the above captioned Deferred Annuity Contract are applied to the Settlement Option to provide annuity payments to the Payee. Upon election of this option, the only benefit remaining under the- contract is the payment of the annuity benefits described below. These payments may not be advanced, accelerated, or commuted. Therefore, the above captioned Deferred Annuity Contract is amended as follows: Effective Date of Settlement Option: 02/19/03 Annuitant(s): JOHN KUPRES :)roceeds Applied to Settlement Option: $14,090.46 ;ettlement Option: 'he Benefit Amount is to be paid tn the Payee each modal period beginning and ending nn the dates specified. ayee Benefit Amount Beginning Date Ending Date Mode OHN KUPRES 57 SAND DRIVE APLES FL 34104 $259.04 03/19/03 02/19/08 MONTHLY TIlls Endorsement is made a part of the above captioned Deferred Annuity Contract. It will not, except"" stated above, waive, alter, extend or otherwise amend any of the conditions, provisions or _ents of the Deferred Annuity Contract. Form No. 8564 D:$Z J ~ Secretary ~~t~,... - - ....~!~..... r" Genworth Financial Genworth Life P.O. Box 6158 Lynchburg, VA 24505-6158 888 322.4629 Ext 4729 434 522.2979 fax July 13, 2007 JOAN M GOHN 6381 STEPHENS CROSSING MECHANICSBURG PA 17050 RE: Decedent: John Kupres Annuity No.: S1 R0086051 ?44Jt/it Dear Ms. Gohn: We have received all information necessary to resume payments on the above referenced annuity contract. John Kupres was receiving an annuity income for a guaranteed period of five years. The benefit began March 19,2003. As a beneficiary of the policy, you are entitled to receive your share of the remaining income. The payment will be $86.35 per month, beginning with the payment due June 19, 2007 and will end February 19,2008. The benefit contains a taxable portion of 54.8%; therefore, $47.32 of each payment will be reported to the IRS as taxable income. You will receive a yearly 1099R from our Company until the benefit expires. Based on the taxable portion of your payments and the amount of exemptions you are requesting, our tax tables indicate that no withholding is required. Therefore, no amount will be deducted from your check for withholding. If you need further assistance with this claim, please contact us. If you have future servicing needs, please contact our Benefits Service Area at 888 322.4629 Ext. 4242. Sincerely, Annuity Claims .3 ro.,..IIOTIC.J....<.\~ , J 0 ",...J C~~ ,.J J <.. (2...... . l5"'a v""'- __~ o~ J 0"'..( k'v ",en,. \ ~ Co) ~~bl.1:> A ~.rrr REV-1511 EX+ (12-99. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF John M. Kupres, SR FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Keffer Funeral Home 902 Mt. Rose Ave. York, PA 6,937.90 B. 1. APMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Lonny L. Gohn, Sr (executor) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 6381 Stephens Crossing 5,758.45 City Mechanicsburg Year(s) Commission Paid: 1 (3% of gross estate) State P A Zip 17050 2. Attorney Fees 0.00 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 298.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 12,994.35 902 Mt. Rose Ave. York, PA 17403 717-854-9211 Fax: 717-846-5229 John W. Keffer, Supv. Website: www.KefferFH.com FUNERAL HOME AND CREMATORY INC. 2114 W. Market St. York, PA 17404 717-792-3239 Fax: 717-792-3764 Email: KefferFH@aol.com June 4, 2007 ESTATE OF JOHN M. KUPRES LONNY L. GOHN, SR. EXECUTOR _ 6381 STEPHENS CROSSING .j l).JtIe 2 u ~tJ~7 MECHANICSBURG. PA 17050 --- ~ Date ;~d~~:;r_~i!e1C fi1AJP~M~ I $S579c) __hve 1I4JflpJ-4j!~s.e(}~ ~~~- _ HIGH PERFORMANCE MONEY MARKET ~ WACHOVIA 3-50/310 1001 Mrs. Joan M. Gohn 6381 Stephens Crossing Mechanicsburg, PA 17050 For service for John M. KUj Wachovia Bank, N.A. waohovla.com For Our service including: 1:0 llOOO SO 11: lO lO l 1;00 q I; ?B lll- 00 l Transfer from Claremont Nur~ Professional service Supervision of service and necessary office work A Carver bronze finish steel sealed casket with a rosetan crepe interior and a blanket to match A casket crucifix Funeral coach and service car for flowers and lead Register book, prayer cards, and acknowledgement folders Use of funeral home and equipment and service of assistants A standard concrete vault Total for services and merchandise: $5,505.00 Items for which we advanced payment: Grave Opening Charge Cemetery Equipment York Newspaper Obituary Organist Clergy Offering Certified Copies of Death Certificate Flowers Ordered Clergy offering at cemetery Total advanced Total for service: Balance due $500.00 150.00 202.40 100.00 125.00 60.00 245.50 50.00 1,432.90 $1,432.90 $6,937.90 Thank you, Mrs. Gohn. ~!;~4: cfj" ~~~~ ~ - 1 ~J.-7.'# 5r::;;/f? ~ Y~~~~7~. f~. r~~f'o.~o 17~ '-r~r~ r~. $6,937.90 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 KUPRES JOHN M SR Estate File No. : Paid By Remarks: 2007-00575 JA ------------------------ Receipt Distribution -------_________________ Fee/Tax Description PETITION LTRS TEST WILL AUTOMATION FEE SHORT CERTIFICATE JCP FEE Check# 3982 Total Received......... PaYment Amount 260.00 15.00 5.00 8.00 10.00 ---------------- $298.00 $298.00 Receipt Date: Receipt Time: Receipt No.: 6/14/2007 08:31:58 1048813 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D \ , REV-1512 EX+ (12-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF John M. Kupres, Sr 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. PRISM - Rehabilitation, Industrial & Spine Medicine, PC - service date 03/28/2007 & 4/19/2007 45.00 2 Mobile X-ray Imaging, Inc - service date 4/19/07 405.80 5,705.00 3. Claremont Nursing Home - final bill TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 6,155.80 f! !iCHOVIA To The lr Of I . OFFICIAL CHECK 23-97 1020 2 '1. 8. '';,[ Q A ~) n.! i: . < '. .':)u'4r I.. ,J i,,' $ n H~ ,~, ~. _/, 7/7:~>;,;:J' /,' r,. ,. .," T' t......."""...7.n "--'~ >':-V:--~b,..i--{ C...t' ~ itter .- / ' . Issued by Integrated Payment Systems Inc., Englewood, Colorado JPMorgan Chase Bank. N.A., Denver, Colorado / \ 'J'" /, ~{, r ,/ I (rON N / _T!~~~. ( 1":;,/ l ~Jhi~'OOPY; Sendo. r . uired for any furthEi~L'Y' CUSTOMER COpy Dollars >- 0.. o o a: w :IE o ~ en ::::) o /r MenKDII..11 '" IIV'., .....,""..,. . """ WL ..... ....- ...--. -.. ..-, . . -" ,oulevard .d ,Durg, PA 17055 1-3755 ': (717) 691-4879 .I~"ffiY;I.w2~:' ~fi$. .. 4310 Londonderry Road Bloom Bldg. Suite 106 Harrisburg, PA 17109 (717) 561-4242 Michael F. Lupinacci, M.D. William A. Rolle, Jr., M.D. Eric E. Hansen, M.D. www.prismdrs.com 4950 Wilson Lane Mechanicsburg, PA 17055 (717) 691-4847 Christopher Royer, PsyD Amy J. Kurcirka, PsyD 05/15/07 Lisa A. Eaton, PsyD ACCOUNT Please retain this portion of statement for your records. NUMBER 6p~~~~1QN;9ft;$'ERyl~E;$, ..... OIAGNOSlS " I /"\ I t:: \VU::.. '\I I STArEMEN'f DATE PAGE 01 Tax 1.0. #25-1651500 P,4,:t1E~ 'PR~tJ.~ 8/07 9/07 9/07 L JOHN JOHN JOHN 90804 50 14 AMOUNT REVIOUS BALANCE ND PSYCH,INSIGHT 20-30 LUE SHIELD ADJUST AYMENT-BLUE SHIELD 29043 30.00 60.00 6. 14- 38.86- YOU HA WEEN 8 ENDLY ANCE. S, PLEASE CAL 691-4879 P . AC OUNT IS PA T DUE. PLEASE REMIT 5.00 30.00 . '. '~~~'a41i~ e.~:o.'/S OVfiB~~A-'i~ oveR 120 DAYS TO..TA. L....... ..... AJlOUNT '. OO~" 45.00 cuAAEtff " PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE ACCOUNT NO. J 045763 ""i""~::I1',1"'~...1" ., 05/15/07 , . '. . . . JOHN M KUPRES SR CLAREMONT 1000 CLAREMONT ROAD CARLISLE,PA 17013 _-rs;_oo__._.~_______~~~~~__. PLEASE MAKE YOUR CHECK PAYABLE TO PRISM. MU111l.JC ^-l'J"\.' un. .~.. . -, -- 945 ~AST PARK DR SUITE 102 HARRISBURG, PA 17111 WE ACCEPT MAJOR CREDIT CARDS If paying by credit card: VI, MC, DISC or AM EXP-acct# 3 digit# on back of card _, name on card address expiration date I ,L\CCOUNT NUM8ER BILLING DAl E I PAGE OFFICE USE ONLY I" RP33953 OS/24/07 FREED LONNY GOHN SR. 6381 STEPHEN'S CROSSING MECHANICSBURG PA 17050 - ~S:cPQ_J -.J L ,,,,-,,~' "~.i) ';;'l:U:,,;,'''_'lFR.~\CE.S..&biC. - .. PLEASE DETACH HERE AND RETURN TOP STUB WITH YOUR PAYMENT ... Et:RFHT CARE @ - ,--- .--,,-_._._-_.__."~-.- ,--.',- _.-- -.-.-" ._--- -.- ~.~ 2-lf, 2.4d7 Date f'av to the /11. / / d'..!? A . --c-.. 4 - $ ~/. <JrfJer9LL/.tLJ.bL~-':...L~ ~> rtJ. :5gc) ___5~~L ~ /'t. Dollars {D a?~:'- ESTATE OF JOHN M. KUPRES LONNY L GOHN, SR. EXECUTOR 6381 STEPHENS CROSSING MECHANICSBURG, PA 17050 3-50/310 1002 HIGH PERFORMANCE MONEY MARKET ~~... WACHOVIA Wachovia Bank. NA w8chovia.com fll' 1:0 j .000 SO jl:.O.O .(;OOg(; 18.nl ;PT4 ROO 7 0 )18/07 Q0092 U19/07 Q0092 U19/07 R0070 .JV"l.IIII."_.Il".~ ~UIUIU~~tM.r"iii151-- :l!11' _-.,..ft.._..~.U"''''.__''-lI.i_'''.__ .....__~. ._ _ __ _._, Transportation Xray Equipment TEGX 1.00 Patient: JOHN KUPRES - 174174 05/18/2007 FREEDOM BLUE Not a covered service Set Up Fee TEGX 1.00 Patient: JOHN KUPRES - 174174 05/18/20Q7 PREEDOM BLUE Not a covered service Set Up Fee TEGX 2.00 57.20 Patient: JOHN KUPRES - 174174 05118/2007 FREEDOM BLUE 0.00 0.00 Transpottation Xray Equipment TEGX 1.00 160.00 Patient: JOHN KUPRES - 174174 05118/2007 FREEDOM BLUE 0.00 0.00 /--...... \ " 160.00 I j 160.00 0.00 0.00 28.60 ~/ 28.60 I ! i 0.00 0.00 ; I 57.20 i i I I 160.00 I 1 I 1 ! , I I . I i I I I I I I , I i i i I ! 405 80 I .1 I LONNY GOHN :~EASE PAY I 12.86~ Mobile X Ray Imaging Inc. 945 EAST PARK DR. SUITE 102. HARRISBURG, PA 17111 385 MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS.... I."~r- widrin 30 day'.O#~ . . ,-,.~; .",.",!,~ RJl3~953 NEW CAARGES , NEW PAYMENTS NEW INS P1n ACC00',r 'W~.1BER SINCE LAST BILL I SINCE LAST BILL SINCE LAST BILL 646.90 9.18 <fJ'G-iMAAJ(. Ciil FREEDOMBLUE_ ~ A McdicucAdvaatogc Pro Highm;lfk Blu~ Sht<i:ld I~ an If)Je~,defll. lKenr~ Of tM 811J~ Cross and el,)€- Shield Ano.:lalie:n Firth Avenue Place . 120 Fifth Avenue Pittsburgh. PA 15222-3099 1...111...111....1.1.11.....1.1..11..1..11...11..1....11..1.11 :lBWNDBQH :lOCS8965214916219:1 JOHN KUPRES SR . 6381 STEPHENS CROSSING MECHANICSBURG PA 17050-2347 ND00041B ..-. 'ont JVUr8i ~Q;~ ~ aC} ~ ?-- 1000 Claremont Road Carlisle. PA 17013-8805 main (717) 243-2031 fax (717) 240-1952 C/(ehabilitation Center June 25, 2007 PAID Mr. Lonny Gohn 6381 Stephens Crossing Mechanicsburg, Pa. 17050 RE: JOHN KUPRES JUN 2 ~ 2007 CMck No.-1 0 0 ~ Paid Amt. . .5705. 00 Dear Mr. Gohn: Please accept the following as a Final Statement for Mr. Kupres from Claremont Nursing and Rehabilitation Center. The final balance due Claremont for Mr. Kupres' bill is $5,705.00. The following is an accounting of the April and May 2007 private pay bills: April 2007 May 2007 Subtotal Less Room Deposit Balance Due $ 7,110.00 $ 4,950.00 $12,060.00 $ 6,355.00 $ 5.705.00 Should you have any questions, please feel free to call Denise Lehman in our billing office at (717) 240-1908. ~cere1~ VI'- Denise Lehman Billing Analyst fi service agency of Cumberland County REV-1513 EX+ (9-00) '-* COMMONWEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF John M. Kupres, SR FILE NUMBER 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 [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Theresa A. Peel. 6363 Stephens Crossing, Mechanicsburg, PA 17050 daughter 25% Joan M. Gohn, 6381 Stephens Crossing, Mechanicsburg, PA 17050 daughter 25% John M. Kupres, Jr, 539 N. West St., York, PA 17404 son 25% Lonny L. Gohn, Jr., 823 Laudermilch Rd., Hummelstown, PA 17036 grand son 6.25% Joseph Gohn, 586 Old York Rd" Etters, PA 17319 grand son 6.25% Krista A. Kupres, 1798 Irish Blvd. Sanford, NC 27332 grand daughter 6.25% Amy M. Kupres, 8810 Teresa Ann Ct., Alexandria, VA 22308 grand daughter 6.25% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) COpy, LAST WILL AND TESTAMENT OF JOHN M. KUPRES, SR. I, JOHN M. KUPRES, SR., a resident of Collier County, Florida, declare thi$ to be my Last Will and Testament. I revoke all other wills and codicils previously made by me. ARTICLE I Debts and Funeral Expenses I direct that all my just unsecured debts and funeral expenses be paid as soon after my death . as may be reasonably convenient, and I authorize my personal representatives to settle any claim against my estate in their absolute discretion. ARTICLE II Expenses of Administration I direct that all expenses of administering my estate (including expenses payable with respect to assets not passing under this will) be paid out of my residuary estate. All expenses of packing, storing, and shipping my tangible personal property shall be paid as expenses of administration. ARTICLE III Tangible Personal Property I give, devise and bequeath certain items of my tangible personal property to the persons named in the last dated writing signed by me and in existence at the time of my death. If no separate writing is found and properly identified by my personal representative within thirty (30) days after the qualification of my personal representative, it shall be presumed that there is no such writing and any subsequently discovered writing shall be ignored. I give, devise and bequeath all of the remainder of my tangible personal property TO MY (or all of my tangible personal property in the event there is no such writing in existence at my death) as follows: A. Twenty-five (25%) percent thereofto my daughter, Theresa Ann P~et. ('t 'Ac ~ G. Six and one-quarter (6-1/4%) percent thereof to my granddaughter, Amy M. Kupres. ARTICLE V Di~abled Beneficiaries Whenever any asset of my estate is required to be paid to a minor, to a person under legal disability, or to a person not adjudicated incapacitated but who, by reason of illness or mental or physical disability, is unable, in the opinion of my personal representatives, to properly administer such property, then payment may be made: (a) Directly to such beneficiary; (b) To the legally appointed guardian of the person or guardian of the property of such beneficiary; (c) To some near relative of such beneficiary, to be appli~d for the benefit of such beneficiary; (d) Directly for the benefit of such beneficiary; or ( e) To a custodian for a minor beneficiary under the Florida Uniform Transfers to Minors Act. A~TTCLE VT Simultaneous Death Clau.c;e Notwithstanding anything to the contrary contained in any statute, if any of my beneficiaries and I die under any circumstances where there is insufficient evidence concerning which of us died first, or insufficient evidence to prove that we died otherwise than simultaneously, all my property passing under this will shall be disposed of as if my beneficiaries had predeceased me. ARTICLE VTI Confirmation of Ownership I hereby confirm that all properties, real, personal, and mixed, including bank accounts, that are held either in my name, in my name and that of any person as joint tenants with rights of l\\ / survivorship, are intended to pass by operation of law and not under this will. ~ '( ~ DISPOSITION OF PER..~ONAL PROPERTY 1. ---.., .1,1; 2. 3. 4. , 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 'I, JOHN M. KUPRES, SR., do intend the following disposition of items of tangible personal property (other than money or property used in a trade or business) after my death. I have prepared this list pursuant to Florida Statutes 732.515 (or its successor), and I intend said' , list to be supplemental to my Last Will and Testament. III ~/ ~ "').. . ~Fli1AIfrz )- ~ ',n~ ~1~.;:r. ITEM ~ t; COl\~ PROOF OF WILL STATE OF FLORIDA COUNTY OF COLLIER ' We,JOHNM.KUPRES,SR., Ah)\.J1!i A:c~-e.. and-1YlQrt;:u~ :S.l?tl/rothe Testator, and the witnesses, respectively, whose names are signed to the attached Last WUd Testament of JOHN M. KUPRES, SR., being first duly sworn, do hereby declare to the . undersigned officer that the Testator, in the presence of the witnesses, signed the instrument that he identified as his Last Will and Testament, that he signed voluntarily, and that each of the witnesses, in the presence of the Testator at his request, and in the presence of each other, signed the Will as a witness and that, to the best of the knowledge of each witness, the Testator was, at that time 18 or more years of age, of sound mind, and under no constraint or undue influence., Subscribed, sworn, and acknowledged before ~ by JO~ M. KUPRES, SR., the TxsJ..at9r.'- anp subsqibed and sworn to before me by -d n ~ ~-e. 'd-S -e and t V '(V4\,u :\. I mI 'J ' the witnesses, on APRIL 3-. 2002. ill A .1.. dG.A. ~,- ~ ' Personally known J,plli M.-KUi>2~ Produced Identification (0 TypeofIDF/JYJ1:- KJ0;;:l~~73'1 ?q.s-7.Q Personally, known Produced Identification ~~ N M. K~PRE , SR. ......... l A Polaski /~lJ.;\~.. orrene .'.: ~*~ MY COMMISSION I CC9m84 EXPIRES ',.1.. ~j October 5, 2004 . ,.::;:..: :~., IONDlO Mill TROY 'AIN INSURANCf.1NC. P~1:: To whom it may concern, This letter serves as explanation for executor fees imposed on the estate of John M. Kupres, Sr. in the amount of$5,758.45 (the equivalent of3% of the gross estate). Executor fees include time spent on the following: Executor/Administrator of the estate duties - 20+ hours Inheritance Tax Filing - 10+ hours Power of Attorney duties for Health and Financial executed over the previous 5+ years. Primary health caregiver - 5+ years Lonny Oohn, Sr