HomeMy WebLinkAbout01-25-10 (2)• ~ ""~ REV-1500 Ex (OS-os~
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
u_..:_~...... oe ~7174J1Rfl1
15056041114
OFFICIAL USE ONLY
County Code Year File Number
INHERITANCE TAX RETURN
ENTER.DECEDENT INFORMATION BELOW
Social Security Number Date of Death
225-20-3557 10262009
Decedert's Last Name Suffer
LUTCAVAGE
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's Social Security Number
Date of Birth
08231923
Decedent's First Name MI
VIVIAN V
Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
® 1.Original Return 0 2. Supplemental Return Q 3. Remainder Return (date of death
prior to 12-13-62)
(] 4. Limited Estate 0 4a. Future Interest Compromise (date of 0 5: Federal Estate Tax Return Required
death after 12-12-62)
Q 6. Decedent Died Testate 0 7. Decedent Maintained a living Trust 8. Total Number of Safe Deposk Boxes
(Aiach Copy of Wilq (Attach Copy of Trust)
O 9. ~~ pig R~iy~J (~ 10. Spousal Poverty Credit (date Of death 0 11. Election t0 tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (A ~• O)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
CORRESPONDENT - Daytime Telephone Number
Name
JOSEPH P. GONTKOVIC, JR. 717-697-8197 ~„a
Firm Name (if Applicable) REGIS WILLS US~NLY
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161 BRINDLE ROAD v ~'°'
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First line of address ~ ~~ i-n sty r `
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Second line of address ''~ ~`' ~
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TE FILED ..- ~ ~ {- a
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City or Post Office State ZIP Code Cti
MECHANICSBURG PA 17055-9515
CorrespondenCs e-mail address:
P~Nry, a return, accomparnnng u statements, b my , ~ es
true cornett and oxrlplete Declaration of preparer other than the personal representative is based on aY information of whid- preparer has any knowledge.
SIGNATU~ OF P~RSO~ ESPONSIBLE F_OR FIUyO RETURN DATE
_ ~ ~ ~~ l ~Z ~ /fl
15056041114
-mss:-""`~~ G~,At. FORM ONL'
E, ,'~ ~.,~ l~~I~~J~a~rlA 17111
Side 1
15056041114
~
., ~, a .., ,~, ^-"i. ,~."$"~°::9P~~'"'f~ Fa... ~..
15056042115
REV-1500 EX
Decedents Marne: V I V IAN V LUTCAVAGE
Decedent's Social Security Number
2 2 5- 2 0- 3 5 5 7
RECAPITULATION
1. Real estate (Schedule A) ........................................... 1. 0 . 0 0
2. Stocks and Bonds (Schedule B) ...................................... 2. 0 . 0 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0 . 0 0
4. Mortgages & Notes Receivable (Schedule D) :........................... 4. 0 . 0 0
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 1 O O 7 . O O
8. Jointly Owned Property (Schedule F) QSeparate Billing Requested ........ 6. 0 . 0 0
7. toter-V'rvos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) QSeparate Billing Requested ........ 7 63167.0 O
8. Total Gross Assets (total Lines 1-7) .................................. 8. 6 417 4 . 0 0
9. Funeral Expenses & Administrative Costs (Schedule H) .................... 9. 2 5 5 . 0 0
10. Debts of Decedent, Mortgage Liabilities, $ Liens (Schedule I) ............... 10. 162.0 0
11. Total Deductions (total Lines 9 8~ 10) ................................. 11. 417.0 0
12. Net Value of Estate (Line 8 minus Line 11) .....................::...... 12. 6 3 7 5 7 . 0 0
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ....................... 13. 0 . 0 0
14 Net Value Subject to Tax (Line 17 minus Line 13) ....................... 14. 6 3 7 5 7 . 0 0
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable at
the spousal tax rate, or
transfers under Sec. 9116
0
0 0
(a)(1.2) X .0 0 15. .
16. Amount of Line 14 taxable
at linealrateX.0 45 63757.00
16.
2869.00
17. Amount of Line 14
taxable at sibling rate X • 12
17. 0 . 0 0
18. Amount of Line 14 taxable
0
0 0
at collateral rate X . 15 18. .
19. TAX DUE ............:................................:.........19. 2869.00
20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~
Side 2
~„~ 15D56O42115 15056042115
REV-1500 EX Page 3 225-20-3557
Decedent's Complete Address:
DECEDENTS NAME
STREET ADDRESS
File Number
DECEDENTS SOCIAL SECURITY NUMBER
CITY STATE ZIP
- --.. _ .....,......,,. PA 17055
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) 2869.00
143.45
Total Credits (A + B + C) (2) 143.45
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E )
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.
5. If Line 1 + Line 3 is.greater than Line 2, enter the difference. This is the TAX DUE.
A. Enterthe interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3) 0.00
(4) 0.00
(5) 2725.55
(`~)
(5B) 2725.55
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 :....................................... ^
b. retain the right to designate who shall use the property transferred or its income : ................ ^
c. retain a reversionary interest; or ...................................................... ^ a
d. receive the promise for fife of either payments, benefits or care? ............................. ^
2. N death ocxrrrred after December 12, 1982, did decedent transfer property wdhin one year of death
without receiving adequate consideration? ................................................. ~ ^
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .. ^ ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a benefiaary desgnation? ................................... , .................. ^ ^
IF THE ANSWER TO ANY OF THE ABOVE 4UESTIONS 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 l72 P.S. §9116 (a) (1.1) C)].
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 l72 P.S. §9116 (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. §9116(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-hall
(4.5) percent, except as noted in 72 P.S. §9116(1.2) p2 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is twelve (12) percent [72 P.S. §9116(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.
217
REV-1502 EX+ (8-98)
SCHEDULE A
ColuIMONWEALTH OF PENNSYLVANIA I REAL ESTATE
INHERrfANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
VIVIAN V. LUTCAVAGE
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would Ue exchanged beMreen a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant Tads.
(tf more space. is needed, insert. additional sheets of the same size)
z~~
REV-1503 EX+ (6.98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE B
STOCKS & BONDS
FILE
VIVIAN V. LUTCAVAGE
All property jointy-owned with right of survivorship must be disclosed on Schedule F.
ITEM
1.
VALUE AT DATE
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX+ (6-98) AT
CON~AONWEALTH OF PENNSYlVAN1A
INHERRANCE TAX RETURN
ESTATE OF
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
FILE NUMBER
VIVIAN V. LUTCAVAGE
Schedule C-1 or G2 (inGudinq all supporting information) must be attached for each closely-held corporatioNpartnership interest of the
(If more space is needed, insert aartitional sneers oT me same s¢e~
217
REV-1507 EX+ (&98)
COMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES. ~ NOTES
RECEIVABLE
ESTATE OF FILE NUMBER
VIVIAN V. LUTCAVAGE
(If more space is needed, insert additional sneers of the same size)
REV-~sosEx+c6-98~ SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
InGude the proceeds of litigation and the date the proceeds were received by the estate.
VALUE AT BATE
1 PNCBank Free Checking Acxount # 50-0598-6078 ~
Attached is bank statement for the account. There is a check drawn that was paid on
11/02/09 to Sarah Todd. Memorial Home for $ 6,600.-, which (attached a copy of a statement
from Sarah Todd. This account was opened on October 19, 2009.
2 Members First Federal Credit Union # 328196-00 56
3 Members First Federal Credit Union # 328196-11 193
4 Members First Federal Credit Union # 328196-05 0
5 Members First Federal Credit Union # 372848 704
This includes income received after death such as IBM pension and insurance
reimbursement and refund from overpayment to PA Dept. Of Revenue on personal taxes.
TOTAL (Also enter on line 5, Recapitulation) S 1,007
(If more space is needed, insert additional sheets of the same size)
Total Banking Statement ~ PNCBANK
PNC` Bank
For ttfN period 10/19/2009 to 11/10/Z008
v
VIVIAN LUTCAVAGE
JOSEPH P GONTKOVIC
161 BRINDLE RD
MECHANICSBURG PA 17055-9515
Primary account number: 50-0598-6078
Page 1 of 3
N umber of enclosures: 0
For 24hour banking, and transaction or
interest rate information, sign on to
PNC Bank Online Banking at pnacom.
'a For customer service call 1-888-PNC-BANK
Monday - Friday: 7 AM -10 PM ET
Saturday & Sunday: 8 AM - 5 PM ET
Para servicio en espaf5ol, 1-866-HOLA-PNC
Movinyt Please contact us at 1-888-PNC-BANK
® Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Visit us at pnc.com
TDD terminal: 1-800-531-1648
For hearaig impaled clients only
Relationship Overview
Bank Deposit Accounts
Description Account Number Deposit Balance
Free Checking 50A598-6078 .00
Premium Money Market 50-0613-3229 .00
T Deposits .00
Your everyday banking and purchases just got more rewarding with PNC points(sm). Use your PNC Visa® Check Card and points Visa
credit cards". Earn points. Pay a bill online. Earn points. Elect to receive your checking account statement online. Earn points.
Enroll today at pnc.com/points or call 1-888-PNC-points. See how quickly you earn rewards! And, the best part...it's free!
"Subject to credit approval. Note: PNC Bank Select Rewards Visa Platinum, Visa Signature Rewards, and Visa Platinum Credit Cards are
not eligible for enrollment in the PNC points program at this time. The new points Visa® credit cards will be available to customers
11 /9/09.
PNC points is a service mark. of The PNC Financial Services Group, Inc. PNC Bank reserves the right to change. or terminate the PNC
points ~roctram. See Terms and Conditions for complete details.
Free Checking Account Summary Vivian Lutcavage
Account number. 50-0598-6078 Joseph P Gontkovic
Overdraft Protection Provided By: contact PNC to ostablish Overdraft Prataction
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
.00 74,221.51 74,221.51 .00
Average monthly Charges
balance and fees
3,508.50 .00
Transaction Summary
Checks paid/ Check Card POS Check Card/Bankcard
withdrawals signed transactions POS PIN transactions
1 0 0
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
0 0 0
FORM953R-1005
Total'Banking Statement
For the period 10/19/2008 to 11/10/2009
For 24hour information, sign on to PNC Bank Online Banking VIVIAN LUTCAVAGE
on pnc.com. Primary account number: 50-0598-6078
Account number: 50-0598-6078 -continued Page 2 of 3
Interest Summary As of 11/10, a total of $.08 in interest was
paid this year.
Annual Percentage Number of days Average collected Interest Paid
Yield Earned (APYE) in interest period balance for APYE this period
0.00% 0 .00 .00
Activity Detail
Deposits and Other Additions There were 6 Deposits and Other Additions
Date Amount Description totaling $74,221.51.
10/19 10,000.00 Deposit Reference No 523874714 ~
10/21 1,400.00 Branch Deposit Te10400008406 0014
10/22 .08 Interest Pymf - 0 13 %APYE For 3 Days
10/22 11,400.08 Trnsfr To Free Checking
10/22 45,350.31 Transfer From Sub~Account 0000005006133229
10/26 6,071.04 Te104000084010032 Transfer From XX}CXXX3106
Checks and Substitute Checks
Check Date Reference
number Amount paid number
6,600.00 11/02 083447921
Online and Electronic Banking Deductions
Date Amount Description
11/09 54.43 Transfer To Account 0000005006133106
Other Deductions
Date Amount Description
10/22 11,400.08 Trnsfr Fr Interest Checking
10/22 30,204.00 Debit Memo Reference No 522773270
10/22 .25,963.00 Debit Memo Reference No 522779051
11/09 .00 Outstanding Item Close
There is 1 check listed totaling $0,000.00.
There was 1 Online or Electronic Banking
Deduction totaling $54A3.
There were 4 Other Deductions totalir
$87,507.08.
Dad/ Balance DetaE
Oate Balance Date Balance Oate Balance
10/19 10,000.00 10/22 583.39 11/02 54.43
10/21 11,400.00 10/26 6,654.43 11/09 .00
premium Money Market Accoilia>tt Smnmary Vivian Lutcavagge
Joseph P Gontkovic Jr
Account number. 50-0613-3229
Overdraft Protection Provided By: Contact PNC to ostabBoh Q?vordrak Protection
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions .balance
.00 45,350.31 45,350.31 .00
Average monthly Charges
balance and fees
4,122.75 .00
Activity Detail _
Deposits and Other Additions There was 1 Deposit or Other Addition
Date Amount Description totaling $45,350.31.
10/20 45,350.31 Deposit Reference No 522544007
'Tota1'Banking Statement ~ PNCBANK
` Foy sfi. boa ~oi~aisoos to ~ v~oisoos
For 24hour information, sign on to PNC Bank Online Banking VNIAN LUTCAVAGE
~n pnc.com. Primary account number. 50-0598-6078
._ _ mount number: 50-0613-3229 -continued Page 3 of 3
Online and Electronic Banking Deductions There was 1 Online or Electronic Banking
Date Amount Description Deduction totaling $45,350.37.
10/22 45,350.31 Transfer To Accotmt 0000005005986078
Other Deductions There was 1 Other Deduction totaling
Date Amount Description $.00.
10/22 .00 Outstanding Item Close
DaEy Balance Detail
Date Balance Date Balance
10/20 45,350.31 10/22 .00
FORM963R-700
ti
Reviewing Your Statement
Please review this statement carefully and reconcile it with your records. Call the telephone number on the upper right side of the fast page
of this statement if
• you have any questions regarding your account(s);
• your name or address is incorrect;
• you have any questions regarding interest paid to aninterest-bearing account.
Balancing Your Account
Update Your Account Regtster
Compare: The activity detail section of your statement to your account register.
Check ON: All items in your account register that also appear on your statement. Remember to begin
with the ending date of your last statement. (An asterisk {*} will appear in the Checks
section if there is a gap in the listing of consecutive check numbers.)
Add to Your Account Register Any deposits or additions including interest payments and ATM or electronic deposits
Balance: listed on the statement that are not already entered in your register.
Subtract From Your Account Any account deductions including fees and ATM or electronic deductions listed on the
Register Balance: statement. that are not already entered. in your register.
Update Your Statement Information
Step 1:
Add together
deposits and
other additions
listed in your
account register
but not on your
statement.
Dam of Dspoa~it Amount
TKaI A
Step 3:
Enter the ending balance recorded on your statement
Add deposits and other additions not recorded Total A
Step 2:
Add together
checks and other
deductions listed
in your account
register but not on
your statement.
Subtotal= $
Subtract checks and other deductions not recorded Total B - $
The result should equal your account register balance = $
c~k~
Mdi,ctis,~ psscuirtiow Amount
Ta~tal B
Verification of Direct Deposits
To verify whether a direct deposit or other transfer to your account has occurred, callus Monday - Friday: 7 AM -10 PM ET and Saturday
& Sunday: 8 AM - 5 PM ET at the customer service member listed on the upper right side of the first page of this statement.
Electronic Funds Transfers
In case of errors or gaestiomaa abort Yom elechonic transfers or if yon need mare information about a transfer, callus Monday - Friday: 7 AM - ]0 PM ET and Saturday 8c
Sunday: 8 AM - S PM EI' at the customer service mm~ber fisted an the upper right side of the first page of this stimtement. Or, if yon prefer, please write us at Cti-stomer Service,
P.O. Box 609, Pittsburgh, PA 15230.0609. If yon believe there is a problem, yaa mast contact ua no later than 60 days after the ending date of the first statement as which time
error ar problem appeared. Yon will need. in provide the following information:
• Your name and accoaat number(s);
• A description of dme error or fhe transfer yon are questioning: Please explaia as clearly as yon can why yaa need more inforation or why yon befievt as error was mu.
• The dollar amount of the suspected error.
We wrll investigate your complaint and will correct any error promptly If the investigation takes longer than 10 basinesa days, we wm71 caedit your account far the
amo~t you think is in error, so 9mat you will have use of the fonds daring Ae/tim\e it takes ns to complete our investigation.
__ ~....~ ~~i Cn~~~l L.In~~cinn 1 pnt~IP_r
T~utal Banking Statement
'NC Bank'
For t(he Mrlod 11/11/2008 to 12/11/2009
VIVIAN LUTCAVAGE
JOSEPH P GONTKOVIC
161 BRINDLE RD
MECHANICSBURG PA 17055-9515
PNCBANK
Primary acxount number. 50-0598-6078
Page 1 of 2
Number of enclosures: 0
For 24-hour banking, and transaction or
.interest rate information, sign onto
PNC Bank Online Banking at pnc.com.
'a' For customer service call 1-888-PNC-BANK
Monday - Friday: 7 AM -10 PM ET
Saturday & Sunday: 8 AM - 5 PM ET
Para servicio en espaffol,1-866-HOLA-PNC
Mov~t Please coMad us at 1-888-PNC-BANK
f~ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Visit us at pncoom
® TDD terminal: 1-800-531-1648
For hearinE impaired cliena only
teiationship OYanriarlr
tank iD~pesit Account
:scrtptlon Account Number Deposit Balance
rce Checking 50-05986078 •00
remium Money Market 50.0613-3229 .00
ota' posits .00
APORTANT ACCOUNT INFORMATION
ummary of Changes: Sections of your Account Agreement have been updated as follows:
Inactive Accounts: The time period after which the bank considers your account to be inactive is being defined as six or more months.
he time period after which your atx;ount is determined to be abandoned property is determined by applicable state law.
Payment of Overdrafts for Card Transactions: A sentence has been added to provide examples of when the bank may not be able to
•event overdrafts if you've requested we decline transactions that overdraw your account.
Tective December 12, 2009
~-e information stated below amends certain information in our Account Agreement for Personal Checking and Savings Accounts. All
:her information in our Agreement, as amended, continues to apply to your account.. Please review the following information and retain
with your records.
active Accounts
your Acxount is inactive as defined by law and you have not otherwise communicated with us about your Account for the period
•ovided by law, we will be required to transfer the balance of your Account to the state, as abandoned property. If your Account is
active for six or more months, your Account will remain subject to all applicable service charges and fees, and we reserve the right to
pose a nonrefundable inactivity charge on your Account. You also agree that if your Atx:ount is inactive for six or more months, it will
- -~-abject to any new charges or fees or increases in charges or fees which go into effect during the period of inactivity, and that we
ay reduce the frequency with which we send you a periodic statement for your Account.
ayment of Overdraft for Card Transactions
e will exercise our discretion in allowing you to complete a card transaction that may cause an overdraft to your checking or money
arket account when using your PNC Bank Visa Check Card or PNC Bank Banking Card at PNC Bank ATMs, non-PNC ATMs, and-for
enchant purchases. At PNC Bank ATMs, we give you the choice to cancel the transaction if it would cause an overdraft. We are not
ale to provide you this choice when using anon-PNC Bank ATM or when making purchases.
you would prefer that we not allow overdrafts for card transactions at the ATM or merchant, you. must contact us and request that we
st i such overdrafts. If you do so, we will decline transactions if your available funds are not sufficient to crnrer them. We may not
s a-... to prevent all overdrafts (examples include, but are not limited to, (1) because transactions are not always received and
oceased in the same order in which you complete them; or (2) a merchant may not submit a transaction for authorization because it is
small dollar amount).
FORM953R-1005
Total Banking Statement
For the period 11/11/2009 to 7?J1'!/.~009
For 24-hour information, sign on to PNC Bank Online Banking VIVIAN LUTCAVAGE
Z-J on pnc.com. Primary account rnunber: 50-0598-6078
Page 2 of 2
~...,
car rnure In urma lun, or v up -vu v ie paymeli ei over ra s or car ransac ions, N ease ca - - - - ~) .ii, n /
am - 10 pm (ET) Monday-Friday, and 8 am - 5 pm (ET) Saturday-Sunday.
Your everyday banking and purchases just got more rewarding with PNC points(sm). Use your PNC Visa•'i±Check Card and points Visa
credit cards'. Earn points. Pay a bill online. Earn points. Elect to receive your checking account statement online. Earn points.
Enroll today at pnc.com/points or call 1-888-PNC-points. See how quickly you earn rewards! And, the best part...it's free!
'Subject to credit approval. Note: PNC Bank Select Rewards Visa Platinum, Visa Signature Rewards, and Visa Platinum Credit Cards are
not eligible for enrollment in the PNC points program at this time. The new points Visa~~i?` credit cards will be available to customers
11 /9/09.
PNC points is a service mark of The PNC Financial Services Group, Inc. PNC Bank reserves the right to change or terminate the PNC
Dints ro ram. See Terms and Conditions for com lete details.
~ii'L~" ~~iceCkiLl, A~iCUtUnL~9Eaiiliic"3i'y Vivian Lulcavage
Joseph P Gontkovic
Account ,number: 50-05 9 8-607 8
Overdraft Protection Provided By: Contact PNC to establish ~verclraR Protection
balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balanr_e
.OO .00 .00 .00
Average monthly Charges
balance and fees
.0O .O0
Transaction Summary
Checks paid/ Check Card POS Check Card/Bankcard
withdrawals signed transactions POS PIN transactions
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
U . ~ 0 ~ (>'
Interest Summary
Annual Percentage Number of days Average collected Interest Paid
Yield Earned (APYE) in interest period balance for APYE this period
O.(.)07. 0 .UU .00
As of 12/11, a total of 5.08 in interest was
paid this year.
Rremium Money Market Account Sulmmary Vivian Lutcavage
Joseph P GontkovtaJr
Account number: 50-0613-3229
Overdraft Protection Provided By: Contact PNC to establish Overdrak Protection
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
_ _ _ .00 .QO .00 .OU
Average monthly Charges
balance and fees
.00 .00
Statement
United Church of Christ Homes
Sarah A. Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Statement Date: 11/13/2009
Joseph Gontkovic
1.61 Brindle Rd.
Mechancisbrug, PA 17055
Due Date: 11/25/2009
Re: Vivian V Lutcavage
Account Nr: 101847
--------------------------------------------------------
Date Description Days Rate Charges Payments Balance
10/25/09
10/01/09
10/13/09
10/20/09
10/25/09
10/25/09
10/25/09
10/25/09
10/31/09
Quant
BALANCE FORWARD
PAYMENT
Room & Board - Semi 31
Beauty & Barber 1.00
Beauty & Barber 1.00
Personal Laundry Se 1.00
Personal Supplies 1.00
Incontinence Suppli 1.00
Medical Supplies 1.00
Room & Board - Semi 25
7,949.19 7,94 .19
,600. 1,349.19
247.00 -7,657.00 - ,307.81
15.50. 15.50 -6,292.31
.15.50 15.50 -6,276.81
30.00 30.00 -6,246.81
2.52 2.52 -6,244.29
19.50 19.50 -6,224.79
143.32 143.32 -6,081.47
247.00 6,175.00 93.53
Nf1M ! 8
S11RAH A. tODD
CHECK # 0"11
.7.5~~
NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN
THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on
your statement. Include the ACCT# from the statement on the MEMO LINE
of your check. Payments after 11/12/09 do not reflect on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25$ LATE CHARGE PER MONTH **
'1 $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
MEMBERS 1~
FEDERAL CREDTT UN10N
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
INVESTMENT SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: VIVIAN LUTCAVAGE
Date of Death: 10/26/2009
Social Security Number: 225-20-3557
328196-00
04/21/2008
$55.00
$.96
$55.96
None
328196-11
04/21 /2008
$192.18
$.46
$192.64
None
328196-05
04/21 /2008
$.00
$.12
$.12
None
E ' BERS 1ST FEDERAL CR T UNION
~~ ~ ~
anielle A. Kline
Insurance Services Specialist
December 9, 2009
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org
JAN-07-2010 10:31 AM
GONTKOVIC
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VN1AN VIRGINIA LLIM.AVAOE ESTATE
1e~ 9RNrC1.E RD.
MlCFMNIt.9BIJRG PA 17006
717 697 5969
8tawm6M of AooouMs
Dac 01, 2000 thru Dec S1, 2009
Account Numbbr: ~7~d4a
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Meng Manapsrt~ent: 0.00
Papb: 1 of 1
109~MiT's a1r not Inchrlded In thh startnent. K you gored at Nast i10 In dhrldonds on your account Tor
tOblt yeu wNl neelw your 10!!-NIT In a sopOrale nudNnO In catty Jsnuary 2010. 1019-INT i~ormatlon will
aMe be avallabN on Man+bo/s 1st Or~Nne e~rh- le Jan<atry.
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Account Summary
Page 1 of 1
NAME ABOUT US CONTACT US NEWS S EVENTS PUBLICATIONS
Aecant Summary . Transfers sStatemenls . Bip Payer Services ;Pisa ` loan Applications ! My Profit ! Msasapss
,//
V
Accounts Q n a New De osit Product on Your Account _ ___ ___ -
-'-- -- --- Prior Year;
Account Description ~ Available; Balance YTD Dividend Dividendsi
_372848-50000 R~IJtAR SAVINGS ~ X703.93_- j ____#708.93 _..-i 0.00 __-_;0.13 E
Total ` 5703.93 ( 5708.93 j0.00 f 0.13
Phase Nob: YTD tohls displayed above do oat include dosed shares. To view YTD Touts aAlich iodide dosed shares Dlsa:a ~Sh4[!.
Loans A I for a Loan ___ __ ~_--_- _ _ ---- _
Account Description; Open Dabs--?- Available; Jdalance Payment Due ~- Rate -
-- N/A ---
Total
Credit Cards AppIY for. a Visa Credit Card
- N/A - --.._~
&+2009 MEMBERS 1ST FEDERAL CREDIT UNION
MECHANICSBUR3; PENNSYLVANIA
~IMERNET TERMS OF i1SAC~ I PRIVACY STATEMEhi l FRALKJa SECURITY CENTER
https://mlonline.memberslst.org/OnlineBanking/AccountSummary/AccountSummary.px 1/4/2010
217
R~'-'~~`'~~' SCHEDULE F
conAMONwEA~THOFPENNSnvANiA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
NUMBER
VIVIAN V. LUTCAVAGE`
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
A.
B.
C.
ADDRESS
)INTLY-0WNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY
ITEM FOR JOINT MADE xuxuDE NN+E of FiNArMaA~ ~ ANO avac A~O~ ~ °R StMn.AR
_ _ -- ._ IOENTIFYMI6 NUMBER. ATTACH DEED FOR JOINTLY-FELD REAL ESTATE.
1. ~ A.
RELATIONSHIP TO DECEDENT
% OF DATE OF DEATH
DATE OF DEATH DECD'S VALUE OF
0
0
0
0
0
0
0
0
0
(If more space is needed, insert additional sheets of the same size)
' REV-1510 EX+(698) SCHEDULE G
INTER VIVOS TRANSFERS &
COMMONWEALTH OF PENNSYLVANIA
INHERfTANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
VIVIAN V. LUTCAVAGE
This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
I,f EM DESCRIPTION OF PROPERTY
°+ccwoE n~ NAME o~ Tf+E T~+ TM+~+ ~'~"."ONSHIP To °ecEDE"r u~o Tt~ w~TE of
DATE OF DEATH % OF DECD'S EXCLUSION
°~A""`~'
TAXABLE
rRA-+.sr:FR.~TrACH~coProF~rr~o~or-oNR~ESr~~. VALUE OF ASSET INTEREST VALUE
NUMBER 0
1 Joseph P. Gontkovic, Jr. ,Son -There were 2 transfers or gifts
. during 2009. The first occurred on August 17, 2009 and the 0
second occurred on October 22, 2009 35,963 100.00% 3,000 .32,963
2 Joseph P. Gontkovic, Jr., Son -Transfer occurred October 22, 0
4
. _ _ _ _ 30.204 100.00% 0 30,20
(If more space is needed, insert additional sheets of the same size)
Joseph P. Gontokovic, Jr.
Page 2
October 21, 2009
Once the period of ineligibility is over, your mother should be qualified for Medical
Assistance. If you take the above actions, your mother should be qualified for Medical
Assistance benefits in March, 2010, as long as the gift and loan payments are made in October,
2009.
During the process of applying for Medical Assistance, the State often requests financial
information with very limited time for response. We advise you to get the information to the
State within the time constraint or request an extension. Please remember, this office submits the
application to the State, but does not submit the additional information requested due to the time
constraints. Please save all your mother's monthly financial statements so you will have them
available when you apply for Medical Assistance.
Step 4. File Form 709 With Vivian's 2009 Income Taz Return (by 4/15/2010)
CHECK WHEN COMPLETED
When you transfer the $35,963 (includes the prior gift of $10,000) from your mother's
ownership, because the amount is over IRS's $13,000 per person, per year allowable gift amount,
a gift tax filing form (form 709) should be filed with your mother's 2009 federal income taxes.
Neither the giver or rec~ient of the ¢ift will have to pay a gift tax, only the giver should file the
gift tax return. I do not believe your mother's estate will incur any federal gift tax, as only
estates with over $1,000,000 are liable for federal gift tax. It is expected that your mother's
estate will be under the federal gift tax level. However, if your mother's wealth status changes
and she has accumulated substantial additional assets, then tax may be due.
Step 5. Begin Monthly Gifting (after November, 2009, depends on Nursing home
bill, prescription costs, and VA benefits)
CHECK WHEN COMPLETED
Our calculations for the loan and gift amounts discussed above were based on your
mother's Social Security income, pension income, IBM income, average nursing home bill and
prescription costs, and estimated VA benefits. In order to keep your mother's assets below
$8,000 during this time period, your mother can begin to gift a total of $499 from her funds to
you on a monthly basis. The amount cannot exceed a total of $499 in one calendar month. To
do so, you can write a check from your mother's account and deposit it into the new account that
does not have your mother listed as an owner.
_ Remember, your mother's assets must equal $8,000 or less in order to qualify for
Medicaid benefits. Therefore, it will be important to make sure that the checking account
with your mother's name on it stays below that amount on a monthly basis.
Step 6. Consider Joint Accounts CHECK WHEN COMPLETED
Assets, such as her bank accounts, if solely owned are passed via her Will. If you title
your mother's remaining assets (the checking and savings accounts) with you as co-owner not
Power of Attorney, you may be able to avoid those accounts being part of an Estate Recovery
JAN-07-2010 10:16 AM
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Total $anking Statement
For the p.rioa ,la~sizoos to ~~i,toizoos
For 24-hour information, sign onto PNC Bank Online Banking VIVIAN LUTCAVAGE
primary account number. 50-0598-6078
on pnc.com. Page 2 of 3
Account number: 50-0598-6078 -continued _
As of 11/10, a total of $.OIB in interest was
Interest Summary paid this year.
Annual Percentage Number of days Average collected Interest Paid
Yield Earned (APYE) in interest period balance for APYE this period
0.00% 0 .00 .00
Activity Detail
There were 6 Deposits and Other Additions
Deposits and Other Additions totaling $74,?27.51.
Date Amount Description
10/i9 10,000.00 Deposit Reference No 523874714 r
10/21 1,400A0 Branch Deposit . Te10400008406 0014
10/22 .08 Interest Pymf - 013 % APYE For 3 Days
10/22 11,400.08 Trnsfr To Free Checking
~
Account 0000005006133229
10/22 45,350.31 Transfer From Sub
10/26 6,071.04 Te104000084010032 Transfer From XX7~~X3106
Checks and Subsftlttnte iCh• pks
Reference
Check id number
number Amount Da
6,600.00 11/02 0884479Y1
There is 1 check listed totaling ~d,600.00.
There was 1 Online or Electronic Banking _
c Banking Deductions
Onrnte and Electroni Deduction totaling $54A3.
Date Amount Description
1~/Og 54.43 Transfer To Account 0000005006133106
talir
t
ctio
d
D
ns
o
e
u
There were 4 Other
Other Dedactions gs7ss7.os.
Date Amount Description
10/22 11,400.08 Trnsfr Fr Interest Checking
10/22 30,204.00 Debit Memo Reference No 522773270
0/22 25,963.00 Debit Memo Reference No 522779051
/( 11/09 .00 Outstanding Itcm Close
Daly Balance Detai e
Date Balance Date Balance DMe
10/19 10,000.00 10/22 583.39 11/02-
09
1 flalanc
54.43
~
/
IO/21 11,400.00 10/26 6,654.43 1 .
Pr91t111tf11~ Money Market Accow~t Stunmary yivian uncava e
Joseph P Gont ovic Jr
Axount number. 50-0613-3229
Overdraft protection Provided By: contact Pf111c to .stabSsh Olr.rdrak Protection
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions .balance
- -- - .00 45,350.31 45,350.31 ~
Average monthly Charges
balance. and fees
4,122.75 •~
Acdvitl/ Detail - _-
There was 1 Deposit or Other Addkion
Deposits and Olther Addictions ~ totaling Sss,3so.3t.
Date Amount Description
10/20 45,350.31 Deposit Reference No 522544007
LOAN AGREEMENT
Amount of Loan: $30 04.00
Date: October 21, 2009
FOR VALUE RECEIVED, the undersigned, JOSEPH P. GONTKOVIC, JR., of 161
Brindle Road, Mechanicsburg, Pennsylvania 17055 (hereinafter referred to as "Borrower"),
hereby promises to pay to the order of JOSEPH P. GONTKOVIC, JR., Agent for VIVIAN V.
LUTCAVAGE under Power of Attorney document dated. May 22, 2002 (hereinafter referred to
as "Lender"), in lawful money of the United States of America the principal sum of Thy
Thousand Two Hundred Four Dollazs and 00/100 Cents ($30,204.001, together with interest
accruing on the outstanding principal balance from the date hereof, subject to the terms and
conditions set forth below:
1. REPAYMENT TERM. The "Repayment Term" shall be 5.00 months,
beginning October 22, 2009. If on February 22, 2010, the Borrower still owes amounts under
this Loan, the Borrower will pay those amounts in full on that date, which is called the "maturity
date". Payments received will be applied to chazges, fees and expenses (including attorneys'
fees), accrued interest and principal in any order the Lender may choose, in her sole discretion.
2. INTEREST RATE. Amounts outstanding under this Loan will bear interest at a rate
of 2% percent per annum beginning on the 22nd day of October, 2009. Interest will be
computed on the basis of a year of 365 days and paid on the actual number of days elapsed. In
no event will the rate of interest hereunder exceed the maximum rate allowed by law.
3. MONTHLY PAYMENT. The Borrower shall repay the loan in equal monthly
installments of principal and interest, with no deferral and no balloon payments made, in the
amount of Six Thousand Seventy-One Dollars and 04/100ths ($6,071.04), with the first payment
due and payable on October 22, 2009 and subsequent payments due and payable on the 22nd day
of each month thereafter until the entire balance due hereunder, including principal, interest and
any other chazges owed by Borrower under this Loan are paid.
4. PROHIBITION ON CANCELLATION. Upon the death of the Lender, any
balance then due under this Loan shall not be cancelled.
5. DEFAULT AND ACCELERATION. If Borrower fails to comply with any of the
payment obligations herein, and upon thirty (30) days advance written notice to Borrower of
such failure, Borrower has not rectified such default by paying the entire amount then due under
this Loan, the entire principal balance under this Loan shall become due and payable.
6. NON-ASSIGNMENT. This Loan is not an instrument governed by Article III of the
Uniform Commercial Code, is not negotiable and shall not be assigned by Lender. The Lender
shall have no right and no power to assign this Loan and any attempted assignment shall be void
and ineffective for all purposes. Borrower's obligation under this Loan is to Lender only, or to
Lender's estate. Notwithstanding any purported voidness, statutory or otherwise, of this
prohibition of assignment by Lender, under no circumstances shall Borrower have any obligation
under this Loan to Lender's purported assigns. Nor shall Lender have the power or authority to
assign the income stream from this Loan to anyone, including factor companies or other
prospective secondary market purchasers.
7. MODIFICATION & WAIVER. No modification or waiver of any terms of this
Loan shall be permitted unless evidenced by a written agreement signed by all the parties or their
duly authorized Agents under Power of Attorney. Failure of the parties hereto to exercise any
rights they may have in the event of any default hereunder shall not constitute a waiver of the
right to exercise such rights or any other rights in the event of any subsequent default, whether of
the same or different nature.
8. SEVERABILITY. The unenforceability or invalidity of any provision of this Loan
shall not affect the enforceability and validity of the remainder of this Loan, which shall continue
~in full force and effect.
9. BINDING EFFECT. The covenants, obligations and conditions contained herein
shall be binding upon and inure to the benefit of the Borrower, the Borrower's heirs, legal
representatives and assigns, the Lender, the Lender's estate, and not to any other entity.
10. DESCRIPTIVE HEADINGS. The descriptive headings used herein aze for
convenience of reference only and aze not intended to have any effect whatsoever in determining
the rights or obligations under this Loan.
11. GOVERNING LAW. This Loan shall be governed, construed, interpreted, and
enforced by, through and under the laws of the Commonwealth of Pennsylvania and the United
States of America. It is intended to comply with federal law requirements of 42 U.S.C. Section
1396p(c)(1)(I), so as not to be construed as a transfer of assets.
IN WITNESS WHEREOF, this Installment Loan has been executed, as of the date first
above written, with the intent to be legally bound hereby, by Borrower and Lender on this
day of (,~~-n1~ a i , 2009.
SIGNED, SEALED AND WITNESSED
resence of:
~ ~~~~
~~~
JOSEPH P. GONTKOVIC, JR., Agent for
VIVIAN V. LUTCAVAGE
BORROWER:
~~1~ ~
J EPH P. GONTKOVIC, JR.
Total Banking Statement
For qN p~rlod 10/19/2009 to 11/10/2009
For 24hour information, sign on to PNC Bank Online Banking VNIAN LUTCAVAGE
Primary account number. 50-0598-6078
on pnc.com. page 2 of 3
Account number 50-0598-60'78 -continued _
As of 11/10, a total of $.08 in interest was
Interest Summary paid this year.
Annual Percentage in iinterest period balance fort APE Inthre period
veld Earned (APYE)
. 0.00% 0 .~ .~
Activity Detail
There were 6 Deposits and Other Additions
Deposits and Other Addtions totaling $74,221.51.
Date Amount Description
00 Deposit Reference No 523874714 ~
000
10
.
,
10/i9
TO/21 1,400.00 Branch Deposit Te10400008406 0014
10/22 .OS Interest Pgmt - 013 % APYE For 3 Dags
10/22 11,400.08 Trnsfr To Free Checking
~
Account 000000500.6133229
10/22 45,350.31 Transfer From Sub
10/26 6,071.04 Te104000084010032 Transfer From XXX~~XX3106
s
le
Checks and Sabsftituts ii;hse
t
D
Reference
Check Amount paid number
number
6,600.00 11/02 1)83447921
ere is 1 check listed totaling $8,800.00.
Th
_
There was 1 Online or Electronic Banking _
Deductions
Once and Electronic Banlrntg Deduction totaling i$s4A3.
Date Amount Description
l~Og 54.43 Transfer To Account 0000005006133106
There were 4 Other Deductions totalir
Other D1s~ctilOns $87ss7.o8.
Date Amount Description
10/22 11,400.08 Trnsfr Fr Interest. Checking
10/22 30,204.00 Debit Memo Reference No 522773270
10/22 25,963.00 Debit Memo Reference No 522779051
11/09 .00 Outstanding Item Close
Daffy Balance Detai e
Date Balarwe Date Balance Date
00 10/22 583.39 11/02
000
19 10 Balanc
54
00
.
,
10/
10/21 11,400.00 10/26 6,654.43 11/09 .
Market Accoitmt Swltmary
~6111ni11~ Mpi11Ay vivian Lutcavagge
. Joseph P Gontkovic Jr
Acxount number. 50-0613-3229
: Contact Pf111c to ~sltabish Ov~rdrah Probctlon
ided B
P
y
rov
Overdraft Protection
Balance Summary
Beginning Deposits and Checks and other
balance other additions deductions Ending
.balance
,i)D 45,350.31 45,350.31 •~
Average monthly Charges
balance. and fees
4,122.75 •~
Activity Detail
There was 1 Deposit or Other Addition
Deposals and Other Additions ~ totaling $4s,3so.31.
Date Amount Description
10/20 45,350.31 Deposit Reference No 522544007
REV-1511 FJ(+ (10-06)
CpMMONVdEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES &
I,DMINISTRATNE COST;
FILE
VIVIAN V. LUTCAVAGE
Debts of decedent must be reported on Schedule I.
q, (FUNERAL EXPENSES:
1.
g, DMINISTRATIVE COSTS:
1, Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
Ciy State Zip
Year(s) Commission Paid:
`-.
2, Attorney Fees
3, Famiy Exemption: (If decedents address is rat the same as daunant's, attach explanation)
Claimant
Street Address
City State ~P
Relatbnship of Claimant to Decedent
4, Probate Fees
5, Accountant's Fees
g, Tax Return Preparers Fees
7.
TOTAL (Also enter on line 9, Rt
(If more space is needed, insert additional sheets of the same size)
255
2`
1071 Country Hill Drive
Harrisburg, PA 17111
Telephone: 71757-5340
Fax: 717-541-5402
L TAX 8 ACCTG
B &
S E RV ICE S
January 22, 2010
Estate of Vivian Lutcavage
161 Brindle Road
Mechanicsburg, PA 17055
INVOICE FOR THE FOLLOWING SERVICES:
Preparation of Inheritance Tax Retum
TOTAL DUE
ALL INVOICES ARE PAYABLE WHEN RECEIVED.
THANK YOU FOR YOUR BUSINESS.
$ 255.00
$ 255.00
B8~L TAX AND ACCOUNTING SERVICES IS A MEMBER OF THE HARRISBURG REGIONAL CHAMBER
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERrfANCE TAX RETURN
ESTATE OF
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
FILE NUMBER
VIVIAN V. LUTCAVAGE
Report debts incuned 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
1. ~
Sarah Todd Memorial Home
2. Millinnium Pharmacy Systems East 68
TOTAL (Also enter on line 10, Recapitulation) S~ 162
(ff more space is needed. insert additional sheets of the same size)
Statement
United Church of Christ Homes
Sarah A. Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Statement Date: 11/13/2009
Joseph Gontkovic
161 Brindle Rd.
Mechancisbrug, PA 17055
Due Date: 11/25/2009
Re: Vivian V Lutcavage
Account Nr: 101847
Da s Rate Char es Pa ents Balance
Date-----Description --------------Y ------- g ~
Quant
BALANCE FORWARD
10/25/09 PAYMENT
10/01/09 Room & Board - Semi 31 247.00
10/13/09 Beauty & Barber 1.00 15.50.
10/20/09 Beauty & Barber 1.00 15.50
10/25/09 Personal Laundry Se 1.00 30.00
10/25/09 Personal Supplies 1.00 2.52
10/25/09 Incontinence Suppli 1.00 19.50
10
/31/09 Room & Board - Sem'
p ~ --- ~
~~
SARAH A. 70DD MEMORIAL
CHECK # o'~.I 3
7,949.19
-7,657.00
15.50
15.50
30..00
2.52
19.50
6,175.00
.9...
NOTE: *****. PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN
THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on
your statement. Include the ACCT# from the statement on the MEMO LINE
of your check. Payments after ll/12/09 do not reflect on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25$ LATE CHARGE PER MONTH **
'1 $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
7, 949.19
6,600.00 1,3.49.19
-6,307.81
-6,292.31
-6,276.81
-6,246.81
-6,244.29
-6,224.79
-6.081.47
93.53
Milbnnium Pharmacy Systems East
1500 Industry Road, Suite A
tieMti~W P~t;,19440 .....
INVOICE
1018/2009
10/20/2009 7688534
10/26/2009 7627276
10/26/2009 7627277
10/26/2009 7627282
255.00 Polyethylene Glycol 3350 Oral Powder
51991-0457-58
33.00 DaiN Multiple Vitamins Oral Tablet
10135-0115-10
30.00 ~~ate Oral Tablet 10 MG
p2
-0123
6838
45.00 10 ablet 25 MG
00310-027
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Account Number: sTMIH~ s~ - ;
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$ 21.16 c $ 0.00 $ 21.16 RX
$ 0.53 $ 0.00 $ 0.53 OTC
$ 5.04 c $ 0.00 $ 5.04 RX
$ 40.87 c $ 0.00 $ 40.87 RX
$ 0.00 $ 76.56 10/14/2009 $ 0.00 $ 0.00 $ 0.00 $ 67.07 $ 0.53 $ 0.00 $ 0.00 ~-67.E
217
REV-1513 EX+ (9-00)
CONN~AONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SDHEDULEJ
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY
I. TAXABLE DISTRIBUTIONS [mdude outright spousal distributions, and transfers under
Sea 9116 (a) (1.2))
1. Joseph P. Gontkovic, Jr. - 161 Brindle Road Mechanicsburg, PA 17(
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
FILE NUMBER
AMOUNT OR SHARE
OF ESTATE
100%
I 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
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
0
0
TOTAL OF PART N -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I;
(n more space is needed, insert addillonal sheets of the same size)
?, J
-.~
\ ~ 1 1.
i.1
LAST WII.L AND TESTAMENT
OF
VIVIAN L. LI7TCAVAGE
1. i _. - __~ ---.
;t
I, VIVIAN L. LUTCAVAGE, a resident of Ocala, Florida, and a citizen
of the United States, revoke all prior wills and publish the following as my last will and
testament.
ARTICLE ONE: F~nily. I am married to CHARLES A. LUTCAVAGE,
who is referred to as "my husband" in this will. I have one child, JOSEPH P.
GONTKOVIC, JR. Reference to "my child" means that child named above; reference to
"my lineal descendants" means my child and tus~sp~ectiwe ineal descendants. In applying
the provisions of this will, a person who is legally adopted and his lineal descendants are
to be considered lineal descendants of the adoptive parent, but only if the petition for
adoption is filed before that person reaches the age of sixteen.
ARTICLE TWO: Payment of Debts. I direct that my legally enforceable
debts (except debts secured by mortgages or other security instruments) be paid in the
order and manner prescribed by law.
ARTICLE THREE: Payment of E,x~enses and Taxes. I direct that
expenses of my last illness and funeral, all administration expenses of my estate, and all
estate, inheritance, and other death taxes assessed or imposed with respect to property
comprising my gross. estate for federal estate tax purposes, whether or not passing under
this will, together with any related interest and-penalties,. be paid by the trustee of the
LUTCAVAGE FAMILY TRUST, created today prior to the execution of this will, as
provided in that trust agreement, as now existing or amended after the execution of this
will. To the extent these amounts are not paid by the trust named above, they aze to be
paid from my residuary estate, without apportionment.
ARTICLE FOUR: Gifts of Personal Property. I give all of the items of
tangible personal property that are designated in the most recently dated separate writing
in existence at my death, which is signed by me and describes the items given with reason-
able certainty, to the persons specified in that writing. It is to be conclusively presumed
that I have left no separate writing if one has not been found by or delivered to my
personal representative within sixty days after this will is admitted to probate. I give all
my remaining tangible personal property not disposed of by the separate writing (whether
by omission or because I have left no valid separate writing), including furniture,
household furnishings, clothing, jewelry, personal effects, and motor vehicles (together
with all insurance on those items), to my husband if he survives me. If he does not
survive me, I give all of those items, together with all insurance on them, to my child, or
if he is not then living, then to his lin ~~endants, Per stirpes. All devises of property
under this article aze subject to the following conditions:
A. Division by Personal Representative. If the persons entitled to these
items cannot agree upon a division within six months after my death, the personal repre-
sentative shall divide these items, as determined in its absolute discretion, among those
persons, and that division will be conclusive and binding.
2
B. .Shipping Expenses. I direct that the expense of packing, shipping,
and delivering these items to these persons be paid as an expense of administration of my
estate.
C. Alternate Gift to Charity. If all beneficiaries under this article
disclaim their interest in -any of these items, the personal representative shall distribute
those disclaimed items to any one or more of the exempt .organizations described in
Section 2055(a) of the Internal Revenue Code of 1986, as amended. The selection of
specific organizations and the amounts allocated between any of these organizations, if
more than one, is to be determined by the personal representative in its discretion.
ARTICLE FIVE: Residuary Estate. I give all my residuary estate to the
then serving trustees of the LUTCAVAGE FAMII.Y TRUST executed today prior to the
execution of this will, as that trust may be amended from time to time, to be added to the
principal of that trust and held, administered, and distributed in accordance with all of its
terms, conditions, and limitations. If the devise to that trust is ineffective for any reason,
I give all my residuary estate to my personal representative, as trustee, upon the same
terms and conditions set forth in that trust agreement as of this date, those terms being
specifically incorporated by reference, but only for the purpose of this contingent devise.
ARTICLE SI%: Survival Provision. If there is insufficient evidence to
determine that my husband and I have died other than simultaneously, my husband will
be deemed to have survived me for all purposes, including the determination of ownership
of all nonprobate assets (to the extent not otherwise prohibited by law). If any beneficiary
other than my husband cannot be located within one year after the admission of this will
3
to probate, then, upon a showing by the personal representative that reasonable attempts
were made to locate that beneficiary, the beneficiary will be presumed to have predeceased
me.
.ARTICLE SEVEN: Annointment of Personal Representative. I
appoint my husband as my personal representative. If he fails or ceases to serve, I appoint
my son, JOSEPH P. GONTKOVIC, JR., as my personal representative. If he fails or
ceases to serve, I appoint my daughter-in-law, CAT~:[ERINE E. GONTKOVIC as my
personal representative. I direct that no personal representative be required to post bond
or other security.
ARTICLE EIGHT: Powers of Personal Representative. I grant to the
personal representative, including any ancillary and successor personal representatives
(referred to in this article as the "fiduciary," whether singularly or collectively, as
appropriate), fullest power to deal with any property held by my estate as freely as I might
do if living. This power may be exercised without the approval of any court. No person
dealing with the fiduciary will be required to inquire into the propriety of any of its actions
or into the application of any funds or other property. The fiduciary shall, however,
exercise all powers in a fiduciary capacity for the best. interest of the estate. Without in
any way limiting the generality of the foregoing, I grant to the fiduciary the following
specific powers in addition to any other powers conferred by law:
A. Except as otherwise provided to the contrary, to hold funds uninvested as the
fiduciary deems appropriate, and to invest in any assets the fiduciary deems advisable even though they are
not technically recognized as legal investments for fiduciaries, without responsibility for depreciation or loss
on account of those investments, or because those investments are nonproductive.
4
B. To retain the original assets it receives for as long as it deems best, and to dispose
of those assets as and when it deems advisable.
C. To expend whatever funds it deems proper for the preservation, maintenance, or
improvement of assets.
D. To employ and compensate attorneys, accountants, managers, agents, assistants,
and advisors without liability for any act of those persons, so long as they are selected and retained with
reasonable care. Fees may be paid from my domiciliary estate even if the services were rendered in
connection with an ancillary administration.
E. To execute deeds, leases, contracts, bills of sale, notes, and other written
instruments.
F. To make distributions, whether of principal or income, to any person under the
age of twenty-one or to any incompetent person according to the terms of this will by making distributions
directly to that person whether or not that person has a guardian; to the parent, guardian, or spouse of that
person; to a custodial account established for that person under an applicable Uniform Transfers to Minors
Act; to any adult who resides in the same household with that person or who is otherwise responsible for
the care and well-being of that person; or by applying any distribution for the benefit of that person in any
manner the fiduciary deems proper. The receipt of the person to whom paymea~t is made will constitute full
discharge of the fiduciary with respect to that payment.
G. To make any division or distribution is money or in kind, or both, without
allocating the same kind of property to all shares or distributees, and specifically without regard to the
income tax basis of the property. Any division will be binding and conclusive on all parties. The fiduciary
is excused from any duty of impartiality with respect to any division or distribution.
H. To render at any time an accounting to a majority in interest of the income
beneficiaries who are then sui juris, or to file a judicial settlement in account with a court of competent
jurisdiction. Written approval of the accounting by a majority in interest of those beneficiaries, or by the
court, will be binding and conclusive on all persons interested in my estate or any trust.
I. To hold any assets in the name of a nominee without disclosing the fiduciary
relationship, or to hold the property unregistered, without increasing or decreasing its fiduciary liability.
J. To borrow money from any source (including the fiduciary in its nonfiduciary
capacity) for the benefit of my estate or any trust created by this will, and to secure the loan by mortgage
or other collateral.
K. To compromise, arbitrate, or otherwise adjust claims in favor of or against my
estate or any trust created by this will and to agree to any rescission or modification of any contract or
agreement.
L. To participate in any type of liquidation or reorganization of any enterprise.
M. To vote and exercise all rights and options, or empower another to vote and
exercise those rights and options, concerning any corporate stock, securities, or other assets, or to delegate
those rights to an agent, and to enter into voting trusts and other agreements or subscriptions that the
fiduciary deems advisable.
N. To buy, sell, exchange, or lease any real or personal property, publicly or
privately, for cash or credit, without order of court and upon the terms and conditions that the fiduciary
5
deems advisable. Any lease so made will be valid and binding for its full term even though it extends
beyond the time required for administration of my estate or the duration of any trust.
O. To perform in a fiduciary capacity any act and make any and all decisions or
elections under state law or the Internal Revenue Code, including but not limited to, joining is the filing of
income and gift tax returns with a surviving spouse, claiming the whole or any part of the expenses of ad-
ministration as income tax deductions, electing the marital deduction in whole or in part, and selecting tax-
able years and dates of distribution. I excuse the fiduciary from malting equitable adjustments among benefi-
ciaries because of the results of any election that it makes.
P. To exercise all powers granted by this will, even though it may also be acting
individually or on behalf of any other person or entity interested in the same matters. The fiduciary,
however, shall exercise these powers at all times in a fiduciary capacity, primarily in the interest of the
beneficiaries of my estate or any trust created by this will.
Q. To determine, in a fiduciary capacity, how expenses of administration of my estate
or any trust created by this will are apportioned between principal and income.
R. To refrain from funding or to terminate any mist created by this will whenever
the value of the principal of that trust would be or is less than X50,000. Rather than funding, or upon
termination, as appropriate, the fiduciary shall distribute the remaining principal and all accumulated income
of the trust to the beneficiaries then entitled to receive income in proportion to their shares of that income
(or on a per capita basis if their shares are not fixed). The fiduciary shall exercise this power to terminate
in its absolute discretion as it deems prudent for-the best interest of the then current income beneficiaries.
S. To treat premiums and discounts on bonds and other obligations for the payment
of money in accordance with generally accepted accounting principles and, except as otherwise provided to
the contrary, to hold nonproductive assets without allocating any portion of the trust principal to income,
notwithstanding the provisions of Section 738.07 and Section 738.12 of the Florida Statutes or any similar
laws, rules, or regulations now or later in effect.
T. Except as otherwise provided in this will, and in addition to all other available
sources, to exercise its absolute discretion in the use of income from the assets of my estate to satisfy the
liabilities as described in Articles Two and Three, without accountability to any beneficiary. No such
liabilities, however, are to be paid from income accruing with respect to assets Qualifying for a deduction
for federal estate tax purposes if other assets are available to pay those amounts. The fiduciary, considering
the reasonable availability of other assets for the payment of all liabilities, may make payments of income
or principal beginning on the date of my death to those persons or trusts and for the purposes specified in
this will.
U. To commingle the assets held in any trust created by this will with the assets of
any other trust held by the fiduciary for the benefit of the same beneficiaries, and to administer them as a
single trust for all purposes, except that separate accountings always must be maintained for each bene-
ficiary's interest.
V. Unless inconsistent with other provisions of this will, to hold two or more trusts
or other funds in one or more consolidated funds, in which the separate trusts or funds have undivided
interests.
W. To incorporate any business or venture in which I was engaged at my death, and
to continue the incorporated business or any other business owned by me at my death that the fiduciary
6
determines is not advisable to incorporate, throughout the period of administration of my estate and the
duration of any trust.
X. To delegate periodically among themselves the authority to perform any act of
administration of my estate or any trust.
y. To make cash advances or loans to beneficiaries, with or without security.
Z. To employ any investment management service, financial institution, or similar
organization to advise the fiduciary and to handle all investments of the estate and render all accountings of
funds held on its behalf under custodial, agency, or other agreements. If the fiduciary of the estate for which
this service was furnished is not corporate, these: costs may be Paid as an expense of administration is
addition to fees and commissions.
AA. To hold, manage, and develop real estate, to grant easements amd to make
dedications as it deems advisable.
BB. To deduct from all receipts attributable to depreciable property a reasonable
allowance for depreciation, computed in accordance with generally accepted accounting principles consistently
applied.
CC. To disclaim any assets otherwise passing or any fiduciary powers pertaining to my
estate or any trust created in this will, by execution of an instrument of disclaimer meeting the requirements
of applicable law generally imposed upon individuals executing disclaimers. No notice to or consent of any
beneficiary, other interested person, or any court is required for any such disclaimer, and the fiduciary is
to be held harmless for any decision to make or not make such a disclaimer.
DD. To pay premiums on all policies of insurance that it holds and to elect any options
or settlements or exercise any rights under those policies; provided, however, that no fiduciary who is the
insured of any insurance policy that is subject to disposition under this will may exercise any rights or have
any incidents of ownership with respect to that Policy, including, but not limited to, the power to change the
beneficiary, to surrender or cancel the policy, to assign the policy, to revoke any assignment, to pledge the
policy for a loan, or to obtain a loan against the policy or ita surrender value.
ARTICLE NINE: Non Mutual Will. This is not a mutual or reciprocal
will with any will executed by my husband and he may amend, revoke, or redraw his will
at any time, regardless of any interest he may receive under this will.
Executed at Ocala, Florida, this 17th day of December, 1991.
U,u,-cct,-,/ ~° ~~°~^''°~~ (SEAL)
Vivian L. Lutcavage
7
This instrument was signed, sealed, published, and declared by the testatrix
as her last will and testament in our joint presence, and at her request we have signed our
names as attesting witnesses in her presence and in the presence of each other this 17th
day of December, 1991.
ue~
C:\Wp51136963\VLi,1g91.WII.:47
ADDRESS
~~ 1~ ~
o
STATE OF FLORIDA
~;
3^
_:,
<-a
,~
~,:.
'#_ -
N ? the testatrix and the witnesses,
and - ~
tivel whose names are signed to the attached or foregoing instrument, having been
respec y~
declared to the undersigned officer that the testatrix, in the Presence of the
sworn,
es si ned the instrument as her last will and testament, that she signed, and that
v~ntness g
h of the witnesses, in the presence of the testatrix and m ttie presence of each other,
eac
COUN'T'Y OF MARION
c,A ~ ~N N F h~oR P ~
We, VIVIAN L. LUTCAVAGE,
signed the will as a witness.
Subscribed and sworn to before me by VIVIAN L. LtTTCAVAGE the
testatrix, and by sH f}NN~
~~~P oNio and ~~y SIN
N' ~-- B~NN~`TT the
witnesses, on the 17th day of December, 1991.
Notary Public
My commission expires:
NOTARY PUBLIC; STATE OF FLORIDA AT LARG>•
MY COMMiSS10N EXPIRES MARCH X05 , 1993
BONDED THRU NUCRiEBERRY >4 ASSOCIATES
. ---'
/ ~~T ~~
REV-1514 EX+ (12-03)
CON9~AONWEALTH OF PENNSYLVANIA
INHERfrANCE TAX RETURN
ESTATE OF
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
ck Box 4 on REV-1500 Cover S'
FILE NUMBER
This schedule is to be -used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to
5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Speaalty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
^ Will
^ Intervivos Deed of Trust ^ Other
^ Life or ^ Term of Years
^ Life or ^ Term oYYears
^ Life or ^ Term of Years
^ Liife or ^ Term of Years
^ Life or ^ Term of Years
1. Value of fund from which life estate is payable ..................................$
2. Actuarial factor per appropriate table ......................................... 0•~0
Interest table rate - ^ 31/2% ^6% ^10% ^Variable Rate
3. Value of life estate (Line 1 multiplied by Line 2) ..........................:... $ 0
^ Life or ^ Term of Years
^ Life or ^ Tenn of Years
^ Life or ^ Terin of Years
^ Life or ^ Term of Years
1. Value of fund from which annuity is payable ....................................$
2. Check appropriate block below and enter corresponding (number) .................. ~
Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monihly (12)
^ Quarterly (4) ^Serni-annually (2)~ Annually (1) ^ Other ( )
3. Amount of payout per period ................................................$
4. Aggregate annual payment, Line 2 multiplied by Line 3 ........................... 0
5. Annuity Factor (see instructions)
Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate
6. Adjustment Factor (see instructions) ..:..................................... .
0.0000
7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 .................. $ 0
If using variable rate and period payout is at beginning of period, calculation is:
n:_~~..~s..e6..lineR-.~lina3 ... ......................................$ 0
NOTE: The values of the funds which create the abrnre future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulti life or annu' interest(s) should lie reported at the appropriate tax rate on Lines 13 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
H105.905 REV.(3/09)
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the \jit'al Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
`~ ~, ~%a-
Linda A. Caniglia
State Registrar
5265420 NOV 0 32009
>F HEALTH • VITAL RECORDS Date
Htos143 REV 11RW6 NO. COMMONWEALTH OF
,~~ CERTIFICATE OF DEATH
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Dislwaltbn Permit No. 038968?.
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