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HomeMy WebLinkAbout04-14-11.; ~ ' 1,50561,01,05 REV-15 Q Q ~x {~~- ii} {FI} PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes PO Box 2$o6oi '~~~~~~~"`"'°` "'"`""` County Code Year File Numtr~er INHERITANCE TAX RETURN -- - Harrisbur , PA 1'712$-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW - Social Securi Number ty_ Date of Death MMDDYYYY Date of Birth MMDDYYYY ..199-14-3633 08/04/2010 10/22/1924 . Decedent`s Last Name Suffix... Decedent's First Name.... MI Pagnucco Carolyn R {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 C~ 1. Original Return O 2. Supplemental Return C7 3. Remainder Return (Date of Death O 4. Limited Estate O Prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82} ~ 6. Decedent Died Testate O (Attach Copy of Will} 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 1 Q. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O} CORRESPONDENT - THIS SECTION MUST BE COMPLE TED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name : Daytime Telephone Number (717) 774-1445 First Line of Address 549 Bridge Street Second Line of Address City or Post Office New Cumberland State ZIP Code REGISTE ILLS USE:D]SiLY ~_ _ - ~ . 7 _;. r-_ =r~_ .~ -:-~ __ _. ~_. [ATE FILED ---~-- PA 17011 Correspondent's a-mail address: `1'7 r'~'~ ~ _ ~~ ~ _. ='.~ +' i C% ~-~ 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 inforrt7ation of which preparer has any knowledge. SIGNA URE OF ERSON RESPONSIBLE FOR FILING RETURN DATE Franck C. Pagnucco ADDRESS ~.3 ~ J I 1603 M tr a ment B, Camp Hill, PA 17011 ' SIGN RE P ~ /~~/ ~/ R THAN REPRESENTATIVE DATE Barbara Sumple-Sullivan DDRESS 549 Bridge Street, New Cumberland, PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1,50561,0105 1505610105 J r ~ 1,50561,0205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: Carolyn R. Pagnucco 199-14-3633 RECAPITULATION 1. Real Estate (Schedule A) .......... . ............................. ..... 1. 2. Stacks and Bonds {Schedule B) ........... . , .. ..... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... , 3. 4. Mortgages and Notes Receivable (Schedule D) ...................... ..... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. , , , . , 5. 96,737.34 6. Jointly Qwned Property (Schedule F) C~ Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C~ Separate Billing Requested.... .... 7. 29,012.00 8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. 125,749.34 9. Funeral Expenses and Administrative Costs {Schedule H) ............... .... 9. 4,970.59 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ........... .... 10. 2,973.16 11. Total Deductions {total Lines 9 and 10) ............................. .... 11. 7,043.75 12. Net Value of Estate (Line 8 minus Line 11) .... . ..................... ... . 12. 118 705 59 13. Charitable and Governmental Bequests/Sec 9113 Trusts far which , . - -' an election to tax has not been made (Schedule J) ................ . ... . .. . 13. 14. Net Value Subject to Tax {Line 12 minus Line 13) . . .................. .... 14. 118,705.59 TAX CALCU LATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax. rate, or transfers under Sec. 9116 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 5,341.75 16. 5 341.75 17. Amount of Line 14 taxable , at sibling rate X ,12 17 18. Amount of Line 14 taxable at collateral rate X .15 1$ 19. TAX DUE ......................................................... 19. 5,341.75 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 150561,0 205 REV-150x? EX (FI} page :3 Decedent's Complete Address: File Number : 2110-0826 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ _ B. Discount 252.63 Total Credits (A + B) (2) 3. Interest (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. (q) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. t~) 5, 341.75 5,052.83 288.92 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLt~WING QUESTIGNS BY PLACING AN "X" IN THE APPROPRIATE BLkOCKS 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 ar its income ............................................ [ c, retain a reversionary interest ........................................................................................................... ................... d. receive the promise for life of either payments, benefits or care? ...................................................................... [ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................. 3. Did decedent awn 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 beneficiary designation? .................................................................. . 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 {a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed an the net value ofi transfers to or far the use of the surviving spouse is 0 percent [72 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 ar after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age ar younger at death to or for the use ofi a natural parent, an adoptive parent or a stepparent of the child is 0 percent (72 P.S. §9116(a)(1.2)j. • The tax rate imposed an the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116{a)(1)]. • The tax rate imposed on the net value of transfers to ar for the use of the decedent's siblings is 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. 4,800.20 LAST WILL AND TESTAMENT OF CAROLYN R. PAGNUCCO 1 ~ LAST WILL AND TESTAMENT OF CA ROLYN R. PAGNUCCO I~ CAROLYN R. PAGNUCCO, of 708 Beacon Hill Road N ew Cumberland, Cumberland County, Pennsylvania, do make, publish and declare thi s to be my .Last Will and Testament, hereby revoking all Wills and Codicils by me at an time Y made. I-T M I: I direct that all inheritance and estate taxes becomin du g e by reason of my death, whether such taxes may be payable by my estate orb an y y recipient of any property, shall be paid by the Executor out of the property passin under IT g EM III of this Will, as an expense and cost of administration of m estate. Y The Executor shall have no ~ciuty or obligation to obtain reimbursement for any such tax so aid event P ~ hough on proceeds of insurance or other property not passing under this Will. ITEM II: I direct the Executor to pay my just debts and the e xpenses of my last illness and funeral expenses from the property passing under this Wil 1 as an expense and cost of administration of my estate. ITEM III: I devise and bequeath all the rest, residue and remain der of my estate to my husband, FRANK A. PAGNUCCO. In the event my husband red p eceases me or, m ;~ .~~ f the event he does not survive me by thirty (30) days, I devise and be ueath m q y estate as follows: (a) One-half (1/2) to my son, FRANK C, PAGNUCCO; and (b) One-half (1/2) to my son, RONALD W. PAGNUCCO. In the event either of my sons predecease me, his share shall be paid tom surviv' Y u1g son. ITEM IV: In the settlement of my estate, my Executor shall possess anion o g thers, the following powers: . (a) To retain any investments I may have at my death, as lon as the g Executor may deem it advisable to my estate to do so; _ (b) To sell either at private or public sale and upon such terms and conditions as the Executor may deem advanta eons to the est g ate, any or all real or personal property or interest therein owned by the estate; (c) To pay all costs, taxes, expenses and charges in connection with t he administration of my estate; (d) To compromise controversies; and 2 `..~:~ 1 } (e) To do all other acts in the Executor's judgment deemed necessa o ry r desirable .for the proper and advantageous management, investment and dis tnbution. of the estate. ITEM V: Any person who shall have died at the same time as I shall have, or in a common disaster with me, or under circumstance that the order of deaths c annot be established by proof, or within thirty (30) days of m death Y ,shall be deemed to have predeceased me. ITEM VI: I appoint my husband, FRANK A. PAGNUCCO to be th e Executor of my Estate. In the event my husband cannot act or refuses to act a s Executor for any reason, I nominate, constitute and appoint my sons, FRANK C. PAGN UCCO and RONALD W. PAGNUCCO, as alternate Co-Executors. An Execut Y or is specif cally relieved from the duty or obligation of filing any bond or other securi ty. ~ WITNESS WHEREOF, I have hereunto set my hand and seal tot his, myLast Will and Testament, consisting of this and the preceding two 2 a es O p g , at the end of each page of which I have also set my initials for greater security and better id entification this / ~ day of _ 2001. -~ -~ CAROL R. PAG lUCCO (SEAL) 3 We, the undersigned, hereby certify that the foregoing Wi11 was signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and Testament, in the presence of each other, have hereunto set our hands and seals the da and Y year first above written, and we certify that at the time of the execution thereof, the said Testatrix was of sound mind and memory. Basil Sumple La ra J. ghes- yle Residing at: 4216 Nantucket Drive Mechanicsburg, PA 17050 Residing at: 549 Bridge Street, Apt. 2 New Cumberland, PA 17070 4 ACKNO EDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND : SS. I, CAROLYN R. PAGNUCCO, Testatrix, whose name is signed to the attach ed or foregoing instrument, having been duly qualified according to law, do hereb ac y knowledge that I signed and executed the instrument as my Last Will and Testament• that I ' signed it willingly, and that I signed it as my free and voluntary act for the purposes therein ex pressed. °~ (SEAAL) COOL R~ PAGN CCO Sworn to and subscribed befo e this S-day - ~~ , 2001. NUTARY PUBLIC \ _ My Commission Expires: (SEAL) ~rtat ~.. . ~ St~fe,Suttivara, . ~~tiv V~sm~ Bork Camtber~d Y Go~ssion Ex~res Ito 'F5.2{?!3 s AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. We, Basil Sumple, and Laura J. Hughes-Doyle, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to la.w, do depose and say that we were present and saw Testatrix, CAROLYN R. PAGNUCC O, sign and execute the instrument as her Last Will and Testament; that Testatrix signed willin 1 gY and she executed said Will as her free and voluntary act for the purposes therein expressed• that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time eighteen (18) or more years of age,.of sound mind and under no constraint or undue influence. ~ n `Basil S mple Sworn to and subscribed befor e this ~~ day of 2001. NOTARY PUBLIC My Commission Expires: (SEAL) `~ `/ La r~ J. u es-Doy ~o~,p ~~ ~ ~ ~~fSiLiC:.SK. `= - - REV•115o8 EX+ iii-lo) r pennsyLvania DEPARTMENT OFREbENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Carolyn R. Pagnucco 2110-0826 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. New Cumberland Federal Credit Union S1 Primary Shares - Account No. 09235 30,851.49 2. New Cumberland Federal Credit Union S4 Share Drafts -Account No. 09235 10,000.00 3. New Cumberland Federal Credit Union S1 Primary Shares -Account No 075791 . . 8 95 4, New Cumberland Federal Credit Union Certificate of Deposit -Account No. 075791 (POD Frank Pagnucco) 55,802.82 5 Brockie Healthcare, Inc. Refund ~ 2 . 8 6 Medco Refund . 65.96 TOTAL (Also enter on Line 5, Recapitulation) $ 96,737.34 If more space is needed, use additional sheets of paper of the same size. SCHEDULE E BACK UP STATEMENT OF ACCOUNT PAGE 1 l?O. $oi 658. New Cumberland, l'A 17070 • www.ncfcuonline.org (717) 774-7706 . 1;800) 716-2328 . Faz: (7l 7) 774-799G 2.75% NEW CAR 60 MO 3.90% USED CAR 60 MO 4.74% HOME EQUITY TO 120 MO 6.90% VISA FOR MORE INFO WWW.NCF000NLINE.ORG 793 1 AT 0.357 Joint Owners 092325 ~i~i~~~~i~~~~i~i~~~~~ii~I~~~~~~I~~~~~~~~~t~~~~~~ii~~~~il~~~~~~ SOCIAL SECURITY # ESTATE OF CAROLYN R. PAGNUCCO FRANK C/0 FRANK C PAGNUCCO EX C. PAGNUCCO 1603 MARKET STREET APT B ~ ~ CAMP HILL PA 17011-4845 STATEMENT PERIOD FROM To RANSACTION EFFECTNE 070110083114 DATE DATE DESGRIPTION AMOUNT FINANCE FEES/ CHARGE FINES- BALANCE X701 PREVIOUS BALANCE S1-PRIMARY SHARES ~~.+ )817 TRANSFER 075791 30851 9 p )817 TRANSFER 075791 -5 0 30851 5 )831 DIVIDEND 30846 S THE ANNUAL PERCENTAGE YIELD EARNED IS 0.2 317 30849 E )831 NEW BALANCE DIVIDEND IS CALCULATE • USING A DAILY BALANCE METHOD. 30849 E )701 PREVIOUS BALANCE S4-SHARE -DRAFTS !~,1 817 TRANSFER 075791 10000 / 0 ~ )819 SHARE DRAFT CLEARED 0001 ~--- R --; - ~ 10000 L? )820 SHARE DRAFT CLEARED 4~r i~x 0004 --- F~~'r 214 0 +~ 9701 C )8Z3 SHARE DRAFT CLEARED li:`S~ra>!~ 0055 --- ~~~ -1051 v Z 9686 ~C )823 SHARE DRAFT CLEARED b~.c.:r.~~ f~ 1111 ~ 8635 P )8.24 SHARE DRAFT CLEARED .~~'~-:=;...~~tc~ 111.1. _~-~ -18 2 ~' 6956 7 )831 DIVIDEND . `J 6767 ~ THE ANNUAL PERCENTAGE YIELD EARNED IS O i 3 67681 E _831 . NEW BALANCE DIVIDEND IS CALCULATE USING AN AVERAGE DAILY BALANCE METHO 6?68 P _________________________ SHARE DRAFT UMMARY - -- ------ - 0001 ~~~~ 0004 ~~~~ 0055 ~~~~ 1111 ~~~ -------- 1111 - - ----- - ------------------------ ------ ---- OVERDRAFT AND RETURNED ITEM FE S SUMM R. I TOTAL FOR ~ TO-AL _ ~ THIS PERIOD ~ YEAR-T -DA E TOTAL OVER RAFT FEES ~ $ 0.00 /` ~ S 0.0 'n -TOTAL-RETURNED-ITEM FEES ~ $ 0.00 v- ~ $ a.o **CONTINUED*~ TOTAL DIVIDEND YEAR-TO-DATE for ail savings except IRA savings.. Dividends shown, if over $10, will be reported to the Intemel Revenue Service for this calendar year. INDICATES EFFECTIVE DATE TOTAL FINANCE CHARGE YEAR-TO-DATE for all loans NOTICE: See reverse side for important information 0805917 NE~V CUMBERLAND FEDERAL CREDIT UNION Four Community Credit Zlnion P.O. Boz 658 • lVew Cumberland, ['A 17070 • R'R'R'.ncfcuonline,org (717) 774-7706. (800) 716-2328. Fax; (717) 774-7996 STATEMENT OF ACCOUNT PAGE 1 LOAN ELSEWHERE IS BACK.! NEW-USED CARS 60 MO 2.75% MODEL YRS 2007-2010 3.90% MODEL YRS 2003-2006 4.74% HOME EQUITY TO 120 MO 122 1 AV 0.335 I~~~IIi~~~lli~~~~~~ll~~~ll~l~~ll~~l~~l~~l~l~l~l~~~l~l~~ll~~l~l CAROLYN R PAGNUCCO 1603 MARKET ST ~~' APT B CAMPHILL PA 17011-4845 3ANSACTION EFFECTNE ~,~, DATE DATE DESCRIPTION C, X901 PREVIOUS BALANCE S1-PRIMARY SHARES 1930 NEW BALANCE Joint Owners ~ 0 7 5 7 91 ~vl.lAL 5t(:UHITY # STATEMENT PERIOD FROM TO 090110093010 AMOUNT FINANCE FEES/ CHARGE FINES BALANCE 8 5 8 5 OVERDRAFT AND RETURNED ITEM FE S SUMM R - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - - _ _ _ _ _ i TOTAL FOR I TO AL - I THIS PERIOD I YEAR-TO-DA E ---------- ---------------I ---------------------- - __ ______ _ -I--- - ---------- TOTAL OVER RAFT FEES I S 0.00 I S 0.0 TOTAL-RETURNED ITEM FEES I $ 0.00 I $ 0.0 TOTAL DIVIDEND YEAR-TO-DATE for a-I savings except IRA savings. TOTAL FINANCE CHARGE YEAR-TO-DATE Dividends shown, if over $10, will tie reported 5 4 7.81 to the Internal Revenue Service for this for all loans calendar year. 'INDICATES EFFECTIVE DATE NOTICE: See reverse side for important information osoai22 0.00 NEW CUIl~IBERGAND FEDERAI: CREDIT UNION `~OZL7` C011Z~'tZZ~7ZZ~ C1'el.~Zt ~LZ1ZZOtZ P.O. Box 658 (717) 7.74-7706 New Cumberland, PA 17070 (&00) 71.6-2328 www:ncfcuonlne.org Fax: (717) 774-7996 "Find us on Facebook" Faceboak.com/ncfcu ~ ..~ 11 ~ _ .,. t L.? i... n ~ s .. t ' .~ ii( .,,a T~ ~'~ t~ ~; N w.i V1 ! ~! . l~ i, r'', a { - ~ ,.. f in 'fit •! F. i!~ _ .,. .>: f.:, ru •~ i, ~, #_j ~t i j ~ ~ i i ~ '°i t, r-. l,. ~y c,.i _ _, i ~ _._ ~ C~ s. ~_ ~,J ~.. f_r , - - .,a t'[ 'M3 f`' ,~, t ~ ,wy A i- Y" ~ t ~ ~' "' ~ ~ 1 ~ 7 ~~ V (`~ ... ~ .~ ~ d, 'tt ~~ ~ ~ ?. ~j - f~ [,_ ~Y ~ ~ A-~ ! rt r~ i ~.. A'~ jr (.y~i '{t- Y ~ ~ r~. ~.. a .:!., r.. ~,- S1 -Regular-Shares S3 -Money Market S8--Xmas Shares J''; ' ~ r ~ ~ ~ ''"` S2 -IRA Shares S4 -Share Drafts S9 -Vacation Shares- proceeds aS described above recelVe~i byf'~`' :'' ~ ~,,,, ,~~•,,~ ~ w--•~'`e AUTHORIZED~/~1G~'N~4TURf __ _ __ _ __ _..._~ _ _- .- - ____ c m 2 ~' m ^~ .i.t C rt :~ Q ~....... _`~: ~-. r-y. ~ l ,M .. y.. ~ ,~• ~~^ .. ~ .. T ~-. ... ' r ... _. 1 ~ ~+ ~ ~ ~' ..... ~ , 1 A '~~ ~ ~~~ ~1 Z Rio ~7L`~~'c~; ~ c ~ O~ ~Q ~~ D X ~~ vo ~ .tom 0 1i ~ `- i - - _ "tl a' t`5 ^~--i r-: a. i? _ ~ wry +. ~ F~ + .~ ~ LG ~ ~~ '~} ~,.{ J + ~ {~ + _ { ~ ~ ~ ~;: r,~ ~__~ ~ ~:•~ a..: Q~ . H _ r.: _;. ~L ~ .. "+ + r ,_ ~! ' • r i..~ ~ -r 1-; ~ , . .-1. ~~ ~' ' ^^' ~ . ~...+ r' ; r c- i ~ i ~ :. . ~ , s 5"' ~ ~~~ .. u1 .. _ >.. .~ _: , ,. . `' J+ ~ _ . . ( f t .. IS i ~~ ~ ~. ~ ~1 : . ~, ~ ~ J ~ ~~ i .. _ ~ ' L ~~ '~ i ~~ 1 ~„ - ~-, .~ ~ ~ ~ E7 1 . . ' . r~ Ui ~rn~ ~~ ~~ : n ~ ~.~, I 1...1 + ~~~ ~, . X ~ f = ~ ~ , _ . r~~,~ ~~ ~ ~ _ _ :' _ --- ~. ~~e co® PO BOY, 14722 LEXINGTON, {<Y 40512 000921 0-E-006241-001-01-02 PAGNUCCO CAROLY 1603 MARKET STREET APT B CAMP HILL 1 ~ ~- ~ rv ~ _ ~:.- ~. i IGHM/UZK. A Medicare Prescription Drug Plan Gom Highmark Senior Resources Inc., , art affiliate of Highmuk Blue Shield, in associaiiun +Nith Independence Blue Cross Indeprnknrr Blue Cruse, H•rhm.vk Blur Shiekf and Highmark 4rriur ICesuurce> art trr<!r/rrnknf ~u-rn;rrt of rhr Blur (Tnia and Irlur Shirldrls;nriaunn. EXPLANATION OF PAYMENT ig>~ 1 :cif:::: 2 _.....;ulber. ®4489001 ,:. N.um~e~:::: HRK019700250010 R e`~3±e}'1~~~~~~~11oR~ ~ ~ > 03 16 - / /2011 6530320 ::::::: :::: ~ ~~l3t of ~~~5tai ::; g date. :.. 01 01 / 2008 / ::: .:;; :::. - ~~=~ <~~ :::t ~ ;~::: - ~~~~.:::..~...:o~r.: ~e~~.: - BLUE RX COMPLETE PA 17011 _~alrr::~er.:[~:um~~>r~: N 3620 Note: Ail members can view their EOP's online anytime at medco.com 'CAROLYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05/23 f 2008. 05J23J2008 ..XXX 63.7.1....... XXX6371 _..._148.23.-_... 148.23 _...148.. 23.-_.... 133.21 ......_0.._00..... 0 00 ..__133... 21,-..... 55 00 ......_ 0_. 00 ........ 15 02 . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . ..........000...._......_....._....._.......... 8 21 12/21J2008_ . XXX4993...... ._.._..2.1_..97.-..... ....._21...97 - . 0. 00 . 2 .25 - . 0 .00 7 . J 6 76 1221/2008 XXX4993 21.97 , ....... 9.01 . ._._ ...... 0.00 . . ........_ ...... 4.00 . ......_ ........ 12.96 , ...__.._ .-..._.........__._..._.__..... 5 01 J 12/21 j2008._ XXX0439 ...... .......23...30.-_.... ....._23...30_-_..... .__.0.,_00..... ..........2.,_25-...... .......0_.00......._ . .._...._3_, 28.-._..._........................... A Federally-Qualified Medicare Contracting Prescription Drug Plan Medco is an independent company that administers prescription drug benefits for BlueRx PDP. OT40414Q Y0037_10_0445 CMS Approved (02/03/2011) Medco is a registered trademarks of Medco Health Solutions, loc. '~v 201 iJ Medco Health Solutions, Inc. At! rights reserved. y i ~~edc ° 0 PO BOX 6052, PARSIPPANY, NJ 07054-7052 JPMorgan Chase Bank, N.A. Syracuse, New York 653032Q )THE PAGNUCCD CAROLYN R 2DER OF Thi S benefit provided by BLUE RX Authorized Signatures 11' 6 5 30 3 2011' ~:0 2 130 9 3 ? 9~: 60 1~~181110 5D 6 211' F ~ I~i~e co° PO BOX 14722 LEXINGTON, f<Y 40512 c-(IGHNtnRK. . ~lueRxu.PD '•'. d P A RSedicare Prescription Drug Plan from Highmark Senior Resources Inc., arf affiliate of Highmark Blue Shield, in association with Ind<•pendencr Blue Cross Indr/x~ndrncr nfu<° Crrns, li~!•nmark Blur SF.i<•IJ.rru~ H%f;Anvrk Seni,v Rc•s<rurc< an• hdC/x•rH/enl L ~«•nfres nl tf:e Olue Cans .Intl (flue Sfurfrf .•1«n(rafrnn. EXPLANATION OF PAYMENT Page 2 ,~~~ Z 0-E-006241-001-02-02 PAGNUCCO CAROLYN ~~ ~~ Me der>N~r~ erg ..:.:.. ®4489001 ..: .•,.•p::;~I.~;rn~er~_: HRK019700250010 l~~L~tel~c~C~~l~~~~ 03 16 2011 - 6530320 / 1 .::..B~~~e%f;_5tart~:~g.?,~t~Y~~ O1 O1 /2008 :.~~:::::;~ro~cte~ BL ERX COMPLETE: ::_::~::::~::>~ar~~-~e ~:Numb~:r>: 3620 Note: All members can view their EDP's online anytime at medco.com CAROLYN-----------------------------•------........----------------.CCQNT.~. D.)_..-------........------------------._._._...- . 12,/21-/2008.. . XXX 0439........-_. .----- 23-.-30---------- ---------5 .-53_..___.__ ._.._..0 .-00------ 4 . 00 ---....__ 17 . 77 ~ ~ ' 3 ~ 12/21%2008 XXX0440 50.73- 50.73- 0.00 . _ . .--- 2.25- - - --------- ----- Q.00 ----------...- - - - ---- 13.66- -.._-__._........_.._._._._..._. -- 12-/21/2008.. _~(XX~440---- --- ------50--~3--•-------- -----1-5.-91.-------- _..----0.-00.----- 4 00 --------- ~ 34 . 82 -g 11 1 ~ ].2/21~2008 XXX0441 30.72- 30.72- 0.00 - ----. . - 2.25- - - ..-----. ...-- -0.00 - ----------- - ----- 8.51- _ _.___...------------------------ 12/21/2008.. _ X-XX044.1 .......... ......30-..72----------- .....10 .-76.-------- 0-.-00 ------ 4. 00 , 96 19 6 . 7 6 ~ 12/23/2008 XXX7784 10.22- 10.22- - ------ 0.00 - ..._._.._. ----. 2.25- ._._. _..----- _ 0.00 _.._._..._._.. . _ - .---- 6.33- -----._..._..__._..------------- - 12- - 23 2008.._ XXX 7784--- ---- - 10 . 22 8 . 58 0 . 00 4 . 00 1 ' 64 4 . 58 ~ 12/26 f 2008 - - XXX9039 - .---- --•-- -----•- 4.92- ~ - ...---. ---------- 4.92- - .._.._. -----. 0.00 - -..------ - ----- 2.25- ----------- - - ---_ 0.00 ~ _ ___ _ - ---.. ~ -- --~ 2.56- _ ....._.._.__.._.--------------.. 1Z/26/2008-._ XXX9039----- --- .92 4 -- --- 4.81 0. 00 4 . 00 Q 1 1 ~ $ ~ 1 ~ 12 29/2008 XXX9414 - -- - ----------- 10.22- ------. ------._.. 10.22- - _----- ---•--- 0.00 - --------- - ----- 2.25- - .-..-- ----------- - - 0.00 - --------.._.. -~ ----•- 6.38- - ----------------• 12/29/2008 -- -XXX 94.14 ......... .....10_, 2Z___.__....-- ------ 8. x.63...------- ----•-0 .-00-----._ ._...----4-.-00...... _..-------1-~_' 9..._._ _...._..__...4-. 63..... .~-----...---..._..._._.....------- PATI-ENT---TOTAL .......................... ........0_..00._._......._ _103.-87-'------- ------~.~-00.------ ------65_,_96----- ---.103-._87.----- ----- ._.6~_.96~`!- - - - - ----------------..._..___..__ -- - EXPLANATION CODES: J - If you have questions about this refund, please call the customer servic e number ---------------on---you r-.-pharmacy.- -member- ID card ACCOUNT SUMMARY: _ CURREN -S~'AT~MENT YEAR TO DAT~ ................................----.....__----.--- --------.._.._ DEDUCTIBLE CAP OUT-O~-POCKET DEDUCTIBLE CA_P OUT-OF-POCKET ._..... PA~`~-ENY .. ... . .......... APPL-~-~D•--•--- ----hPPL~~E~--- .. .....Ap-~LL~D ...__ ... -R-E~IAIN-IN.G.....-REMA-tNING_..._..-~EMAININ~._ .........----- CAROLYN N/A N/A N/A N/A N/A N/A 'N/A' MEANS NOT APPLICABLE TO PLAN. .............................. ... . .................................._..~---.~....---_.__._.._.....___._._____..-------.__-----------------------------_.._..-----------------------------------------------------........---a-~--..._----•-------.. OUR RECORDS IfVDI-GATE THAT THE FOLLOWING PHARMACIES WERE USED; BROCKI E PHARMATECH --------------------------------------~_.........------------------~------------- OT40414Q Y0037_10_0445 CMS Approved (OZ/03/Z011) Medco is a registered trademarks of Medco Health Solutions, Inc. ©')A'I!~ 11Anrli-n Lln~lth Cnltttinnc Inr All rinhtc rccc--~icr+l REV-1510 EX~ {08-OS j ~ .~ ' , SCHEDULE G ~. ~ Pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ~~iw~t ur FILE NUMBER Carolyn R. Pagnucco 2110-0826 This schedule must be completed and filed if the answer to any of questi ons 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY NUMBER INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH % OF DECD'S VALUE OF ASSET INTEREST EXCLUSION TAXABLE 1• Savings Bond - X5459298EE (POD to Son Frank Pa n (IF APPLICABLE) VALUE , g ucco) 9,660.00 100. 9,660.00 2 Savings Bond - X5459297EE (POD to Son, Frank Pagnucco) 9,676.00 100 9,676.00 ; 3 Savings Bond - X5459296EE (POD to Son, Frank Pagnucco) 9,676.00 100 9,676.00 TOTAL (Also enter on Line 7, Recapitulation) $ 29,012.00 If more space is needed, use additional sheets of paper of the same size. SCHEDULE G BACK UP ~~ _-~- . gg, ~ ~ ~ __ - - _- -- z ~ -- ~.~-: ~~` *~ l.L~ :~`t ~ 4I;~ '~l'$~~4)C'~''?:<~.~$~~``A)[~7',~ ,.~..'~,',:- ~Nr~KESr c~:~.s~s ;~~ Ys,~Ra ,~~ q,{~~~.~F.;:v,~`X'~`'~ .. .. .. ... FFtOH igSU6S, A'fE ' . ' t~ ~:~- ,;, CAROL~'Pt R PAONUCCO ~~- __ -_ t~Vi X4.1- ~'~ ~ ` ' ~ ` . `~~ ~ ~~RB PITT ~.: {' 7 p ~ B ~ A CU H ~I I L ~. R D ~ V ~ p ~ U,~2 ~'~ ~ ~'~`~, _ _.~.. fiiEW CUMBERLAND PA l?'p~~ ,~ 'Z'~ ~ ~`,-+`:r . ~ ..f ~` ~aaati~[ta~~~aat~ata~~laaeea~~~~ft~r~a~~aaas~~~~rtr~re-~t:~~ .._.~. ~~~~,,u ~-;,p..,. ~,y~--P~3B CRANK PAOt+tt1CCQ JR~.`~_' -."",.:~-,. `~ ~~ RTttb1$04tffl001 062120©~ ~22402,~ 4aB133!# AQQ5459~9~8 1 fy,,.. r t. ~ ~ ~ - .::`x"'''t '~Irl+zi k~2'r1?r -' LU J'? ±: ~ i. ]4r~ti.uti f..' vxi,A.;~a~'"r~ S.'.c~<.ti. ;rN - ~ ~fi ~r.- .. '°u4x,~liu''t'*r..i".SStiSuusu~'tii.`.tkf:4~r1Y'!•dr"y ra:ttl~'~ ~YAt{a4t`dk'EF`H4S~-ti"s/``-_ ~~ ~` ..rCa~f• .- -.-_.-'- --._ .. _.._. -_. -`. ... __-___._..----__ _ _ _ -`--"~'~~ f;_ \ ttlfi:~~ h..~ ~'7'-r1~°.ta.~+.~a ~'~$~.ii'~i1 w-3-" ` 1 ~ ~~~~ ~~ ~ ~ . --~ - i .~ REV-1'511 EX~ {10-CSj "~ ~~ Pennsylvania SCHEDULE H ~, v DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Carolyn R. Pagnucco 2110-0826 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Gate of Heaven Cemetery 125.00 2. Pathmore Funeral Home. 64.10 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 0.00 Name(s) of Personal Representative(s) Frank C. Pagnucco street Address 1603 Market Street, Apt. B City Camp Hill State PA ZIP 17011 Year(s) Commission Paid: 2010 _ __ Z• Attorney Fees: 3„000.00 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 • Probate Fees: 313.50 5• Accountant Fees: 216.00 6• Tax Return Preparer Fees: ~. Patriot News 176.99 $~ Cumberland Law Journal 75.00 TOTAL. (Also enter on Line 9, Recapitulation) $ 4,070.59 If more space is needed, use additional sheets of paper of the same size. SCHEDULE H BACK UP s (~ r (~ ~._ /~ / Name •~U r ~~~~C~ !"1 tt7 ~ Account No C ~~~ ~ ~ ~ 3 ~~~ ~ i ~.. ,.:.. ~ ,~ ,~ 60-8255/2313 /, ~` j Date ;'~~; Pay to the Order of __ ~-- ~ s d~ cr ~ tt C.~ L' ~ t~l C i ~ ~;.~ .,~"C; t~ ~' ~ ~ / ~-..y ~,. Vii= ;r C.11/C}fUf~t~bR --~~; GG c.1~1 ~ Y'ly"•i ~~• ~'. Dollars ~ ~ ~,_°_- ~, >:,,: , r; nnwcun~t~xt.nwoFr•.nrRnr.cr:~nrru`rox ~` NcwCumberl nd~l'A 17070 ~ 1 ij • ~: C31382555~: ~ ~ ~~~G~ ~ - -- ~... - - -- - - - GUnn)~i4;J SP+~I'!i•fiLUE, .. ' y ;'1 ~ti~ ` M "~' ,. ,... E ~~, 'o E U ~;- t~ ~ ~] V T ~ C 0 >. ~. W .. 0 ~ vv = ~ v ~ ~ W ~ ~ ~~~RR ~ ti ~ V L17 ~ ~ ~ Ln .C ~ ^ ,~~ X V ~ ti V c$ a- _ n>, z ~ .~a ~ ~ ~ ~ `~ ~` ~ EE E a~ U V _ Vti Ur ~~ N~ '""'N y Oti ~ ~~ •~ ti U n~`." c~ c~ cq n ~ti ~'~ `o ¢n =~ _ D ^ ~ ~ J _J ~ m ~ N '~ _ ~ ~ L y' 0] j W_ u ~ ~ ~. ~° ~~ ~, ;m ~~ ~~ ESTATE OF CAROLYN R, PAGNUCCO -'' FRANK C. PAGNUCCO, EXECUTOR 101 ;~ ~; 1603 MARKET STREET ~ ,~ i !~ CAMP HILL, PA 17011 ~ 60-6255%1313 , ~, Pay to the Date ~.~ Order of ~ ~.'~~ ~~y i... f-t~i ~ ~ ~ ~ rp. ~" i C /~ a ~~~ Fe al~~e ~+. %` ` Dollars '°-J °, 4" ~`~a'u+uriV./1[\L~~aayyl1 va"Vl~ '~._~i~~ ~ New ClrmherLwd. PA 17070 .For ~- ~ '?"~ ~ ` s ~ ~.~:; /~ ~ _ ~ ~ ~ ~.~:`°,~,/ a ,~' ~: 2 3 i. 3 8 2 5 5 5 ~: 0 0 ~^ q 2 ~3 a S n ~~~ n i n i -- ._ ._ __ .__ __.____. __ ,r~ Frank Pa nucco Apt. B 1603 Market 3t. Camp HiO, PA 17011-4845 ~ 1.7 ~ "~ 1; 0 ,,:K ::~: ~~ d ~ _~ I - N ~ _ V ' ~, ~~' t ~ ~' ~ ~ ':. {rye ~; ^ ~ ~ M I + ~I ~..~ ~' _,! ^ t ~r ~ ~ .` ru U o a ~ ° , _ o T O V ~ ,i r~..~ ~ ~. ,~ O '~ ~ z ~ : ' ~ ~ 0 a W'SC a ~`'~ ~,~ ~ ~ f ~ /~, ~ ~ ~ ,.. O ~ f ~. ~ V !~ '~ ,~ i? 1 1 ^ ^ ~ ~ '~ O Z T y~ ~.Vi ~ ~~ ~ ~ VVRR ~ tir! < C 'i 1V+^~ ~i ' _ _ t, ~ 4 1 I• Va~r r ~ '~I ~ S+~ ~ 1' y~M~t" ~ ~ ~ ~ ~ G., O ~ w •' ° ~' n= 071X3W h53N F ~ ~. -r ~ "b:... .~~r~ (ll~• -- -. - j~'~ , F' 1 f z m h„{ 0 a ~ '" z J ~ J W f" aa`~N } W Z _ ~ W W ~ Z a ~ a m o ~ ¢ ~ W QI LD M W 1+~1 Z 0 ~ ~' . ~~a `~ `~~ Q ~ Ot a y ~ 3 ~D a ~ ~ N J i ~ o ~ ~ O Z Q ~ ~ i ~ ~- ,~ m ~~.. _ U WW ~ ~ U U ~O ~~ ~ ~~- - o 0 . ©~ '~ .~ v ` ` ` ~.. w - ~ ~ O 0 (~ p W Q ~ OO LL d p 1d13~321 C~j RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 PAGNUCCO CAROLYN R Estate File No.: 2010-00826 Receipt Date: Receipt Tlme: Receipt No.: r•` 8/7! 2/2010 14:59:25 1062238 Paid By Remarks: FRANK PAGNUCCO wz ------------------------ Receipt Distribution ------------~-----=------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL RENUNCIATION SHORT CERTIFICATE JCS FEE AUTOMATION FEE 210.00 15.00 5.00 40.00 23.50 5.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN Check# 1049 Total Received......... $298.50 $298.50 The Patriot-News Co. 2020 Technology Pkwy Suite 300 Mechanicsburg, PA 17050 Inquiries - 717-255-8213 BARBARA SUMPLE-SULLIVAN 549 BRIDGE STREET NEW CUMBERLAND PA 17070 INVOICE c'~.,e~latriot News Now you know ALL CHARGES ARE NET T # NAME AD ORDER # DATE EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT ~7 BARBARA SUMPLE-SULLIVAN 0002095349 09/22/10 REGULAR BOLD TEXT CHARGE $4.00 7 BARBARA SUMPLE-SULLIVAN 0002095349 09/22/10 REGULAR 7 BARBARA SUMPLE-SULLIVAN 0002095349 09/29/10 REGULAR BASIC AD CHARGE $89.33 7 BARBARA SUMPLE-SULLIVAN 0002095349 10/06/10 REGULAR BASIC AD CHARGE $89.33 BASIC AD CHARGE $89.33 AFFIDAVIT CHARGE TOTAL: REMITTANCE ADDRESS The Patriot-News Co. 23794 Network PL Chicago, IL 60673-1237 $5.00 $276.99 Please include the Account # or Ad Order # (above) with your remittance--Thank You NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 October 8, 2010 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Barbara Sumple-Sullivan, Esquire Carolyn R. Pagnucco Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: September 24, October 1, and October 8, 2010 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director REV-1'512 EX~ ;12-CRj "~ " ~ t: pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS CDIAIC Ur FILE NUMBER Carolyn R. Pagnucco 2110-0826 Report debts incurred by the decedent arior to death that rpMa~~p~ ~~~~~~a ~* *tie a,~e ,.~ a,._« :__,._,.__ ___ _. __ •~ ~~~~~~ ~Na~~ ~~ ~~__~_~, ~~~~C~~ auai[ionai sneers or the same size. SCHEDULE I BACK UP -- -_- _._ _ _~ BROCKIE PHARMATECH ' A FINANCE CHARGE OF 1.50 o PER MONTH "~ PO BOX 5 04 7 ,YORK, PA 174 0 5 (AN ANNUAL PERCENTAGE RATE OF 18.0 1 WILL BE PHONE - 7 l 7- 8 5 4- 9 0 2$ CHARGED ON ALL AMOUNTS 3 0 DAYS OR MORE PAS T '- DUE STi~.7CEi1~IENT BATE: 0 8/ 0 2/ 2 010 PLEASE PAY. BEFORE THE- 25TH OF THE MONTH. MAKE CHECKS PAYABLE TO: BROCKTE PHARMATECH w.~~~ PHONE; 717-854-902 PAGNUCCO, CAROLYN R P ~~ FRANK PAGNUCCO ~ GRP-HL 1603 MARKET STREET-APT B PAGE CAMP HILL PA 17011 PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT .. _ __ .~ ~- Name ~y ` _. ~ ~~ ,~ `J~.. ~ ~ ~~' 1" ~F ~~A C'.~~ }i Account No ~~~/~.,..~~' C~ ~~~~`~ r 6D-8255/23 J3 ~ ~~ Pay to the Date ~~~' • - _ !i' Order of _ t~~~~...K 1 ~ ~~-l.~ l~ /`''i f~ ~ t L:.~~+ ~ ~ 1 ~c = ~~ "~ ~"~ ,. ~ !: Sgll(l~.S ~~CrfL~~V X17.5 ` - ~~, ! ~~ 'I ~ I w i t1A ,Q s~<vruy Det.~f, erg i~i Eact. I'~ rr ri j;71 rr-,w cvimrRt~vn ~~n«_ atenrrttito~ 1Jcw Cumbcrlu~d, PA 17070 ~ Ala' II... ry ciarka ......... ..... . - iA' r .. k~1 Frank Pagnucco 1 b03 Market St Apt B Camp Hili, PA 1701 1 G I1 ,f"'f +~ " J ;,~ ~7~~E ,~ ., ~'~: ~~~ ~~ ~~7 Y~~K PA ~ 7~-as C~ Statement HOMELAND CENTER 1901 N-FIFTH STREET HARRISBURG, PA 171.p2 Telephone: (717) 221-7900 Statement Date: 08/'01/2010 CAROLYN PAGNUCCO C/O FRANK PAG 1603 MARKET ST., APT B CAMP HILL, PA 17011 Re: CAROLYN R PAGNUCCO Account Nr: 2316 ------------------------------------------------------------------------------=--- Date Description .Days Rate Charges Payments Balance Quant BALANCE FORWARD 07/14/10 PAYMENT 07/02/10 GUEST MEALS 07/20/10 TELEPHONE 07/25/10 SUNDAY .NEWSPAPERS 07/30/10 SEMI-PRIVATE ROOM 07/30/10 SEMI-PRIVATE ROOM 07/30/10 SEMI-PRIVATE ROOM 07/30/10 SEMI-PRIVATE ROOM 07/30/10 SEMI-PRIVATE ROOM 07/31/10 INCONTINENT PRODUCT 07/31/10 NEWSPAPERS 07/31/10 PERSONAL SUPPLIES 07/31/10 MEDICAL SUPPLIES 08/01/),0 SEMI-PRIVATE ROOM 1.00 1.00 1.00 10 4 2 27 11 1.00 1.00 1.00 1.00 3 7.00 17.00 8.00 274.00 264.00 274.00 264.00 264.00 63.92 15.00 1.95 26.85 264.00 7.OQ 17.00 8.OD 2,740.00 1, 056.00 548.00 -7,128.00 2, 904.00 63.92 15.00 1.95 26.85 792.00 8, 589.81 8, 589.81 8,589.81 .00 7.00 24.00 32.00 2,772.00 3,, 828.00 4 ,, 37 6.00 -2,, 752.00 152 . Ot) 215.92 230.92 232.87 259.72 1, 051.72 ~~ ,. - .. --....... ....... tytf it o ~ -• ~ .7 .. ,~ a Name ~L ; ~~;-- (~ F"C`1~t~/l~ r""~l~C_(:'_(r= ~~ Account No ~ = ~ :, (~~ ~~ - l -~--~j ~-~`~~ ~ S ~ ~ ; 60-8255/Z313 ' Pay to the Date .~ Order' of ~ L~/~-q~.~ ~(l~-~. ~1V 7 ~~ ~ ~ , ~ ~" -Z°~' ollars Q F•=I i. Cili i= c~ 1,1 °3: . s °r~'~-r .~~ nr~vcuntecR~vnF»t.w~~.c~rnTC,ti-n;v ;~;qpp~-,~: n~ cw~n~iru,a, rn i ~n~u ~ j/L9 i / ~ Jd For J= .~.c;~~l~' i'UJ~ ~ ~ ~~~ ~~ '. -- _. r - ~ ~ 5 5 -- ,....... ._- c- ~~ - --. . ~ !M ;. = .... -- Ia •ie rid Car~c --=~-- --.:~...V ~ -. -- r.-'--••-------. - _.:. _ ivy _ r ~ ~ + Statement HOMELAND CENTER -1901 N-FIFTH STREET HARRISBURG, PA 17102 Telephone: (717) 221-7900 C Statement Date : 09,/01/-20:10 CAROLYN PAGNUCCO C/O FRANK PAG 1603 MARKET ST., APT B CAMP HILL, PA 17011 Re: CAROLYN R PAGNUCCO Account Nr: 2316 Date Description Days Rate Charges Payments` - Balance Quant ----------------------------------------------- BALANCE FORWARD 08/17/10 PAYMENT 08/03/10 INCONTINENT PRODUCT 1.00 22.51 1, 051.72 1, 051.72 1,051.72 .00 22.51 2 51 `~ J~ATC Dq~i.`~r~~=+~ry .......... . ........ ._.... -- - - -~ - ~ ye , r 'l 03 ESTATE OF CAROLYN R. PAGN OR O S ~ r`1 T e'er ~' !'~ ~' SAT FRANK C. PAGNUCCO, EXECUT 60.8255!1313 1 g03 MARKET 8TREET A ~ i ~ ~. a ! ~- ~ PA 17011 ~ ~ .. t ~ J Date CAMP HILL, ,,, ,;,_, 7 r ~ -:f ~ l 33.E $ ~ .o~o~..~.L.. v Pay to the - :',i,,, ~, L 1 Oeuiia nn Order of ~ $"""'y ~. ~ -Dollars ~"'°"' ~~~. ~,~ rttFnrS'UNION ~ I ~ ~ K~.annf ~YY7 ~ ~~ / - v ~ ~ ~ 51 NnvQunbetbmd~ ~_~~~aLA'"~_y_..7 - - .__ __~__ -_______-- I~ji Y ~~ ~ ~ ~ ~ i ~ ~~~~ For ~- !-uE r' 23 i~38 2555: 0000 9 2 3 2 5011' 03.03 ~ " "" ~ ~ UAHDIAH SAffi = Ytl l0'N -- - - -- -- 3HONLY Art=TCR ~2/Q712010 BAH N(7: ~ i 616 2010 Statement of Persanai Taxes Control No: 001 - 013167 Bill 17ate: 7/01/2010 \BLE JANET L, MILLER, TAX COLLECTOR 1939 WALNUT STREET CAMP -HILL PA 17011 ~ CAROLYN PAGNUCCO :~ 1603 MARKET STREET #B CAMP HILL PA 17011 ce WED 11-2 AND 4-6JULY-OCTOBER 13 Rs: SPECIAL HOURS: AUG 17,24 4-6 AUG 19,26 12-2 PHONE (717) -763-0177 CAMP HILL SCHOOL DISTRICT Qiscount Face I Penalty Rate 5.00000 SCH P C 21; 4.90 5.00 10 ~ 5.50 Rate 10.00000 SCH RES ~ 2'~ 9.8U 10.00 10$ 11.00 TAX AMOUNT DUE > $1a.7a $1s.oo $lsso If 1Paid On or !liter If Paid Oa or Sefore 7/01/2010 8 31 2010 9/01/2010 10 31 2010 11/01/2010 RETURN BILL WITH PAYMENT. FOR A RECEIPT ENCLOSE SELF-ADDRESSED STAMPED ENVELOPE AND 2 COPIES OF THIS $ILL. ~/1~ ~ C. ~ f~ ~- f7,A T'e~ t~ ~~ j ~-~ ,~ ~ Pic? _~ Name .~ ~~ v ~ ~ 1 :, ~:. *~I Account No ~ ; ~..;~.: ~ j ~ ~ ~~-~ r~- ~~~ •- ,~~ fi0-8255/2313 1 i,'~ ~~' ~ j ~'~' `f' ~ t ~' .~ ~ ~ ~ Date a~ w, ~' Pay to the ,,. Order of ~-~ lV ~! ~.a. ~ ,.. J i.i.rf~ ~ =~ ~ .~ t~c..c.,c c ~~~ , I r F,~~ $ 1 '~; '~. ': ~>/~' ~~rj~~ar Paar~rae ollars ~ g,~. a .~.; ~ „~;I 11 ~' ~~~~ ~~ ~R ~ t~ i t t+ • ;i~ ,; ~ ~ NflYQITrIDI'sR[/1.~IDFr~L•RALCRFJ)iTU.~(ON Tvcw (5uubcrlxnd. PA 17D70 ~ (4 4 ~~C? % ° L.~~tC7 ~ fJ C~ ~ V ! v ` ~ _ .;~ ~I ;! ~__ r~____.._._ ~;~; '~" :23 L38 2555: ~' ''~ ~` DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT AMOUNT _DUE 188.72 PATIENT NAME: PAGNUCCO, CARULYN R CALL NUMBER 2OG~J31VII ~k'MtSUNT ~ ~-. `'~~-- - PATIENT NUMBER: 17434 BILLING DATE: 08/12/2010 c~ ENCLOSED _ ~ ~ Da.~~„ 4 j THIS SERVICE 1S NOT COVERED BY MED L ASSISTANCE. • ,~C~jr ....,. VlsA %_'~i'T~G~ f~ AND ~~ ~ ~ ~ t' ~ ~ MASTER CAR D ACCEPTED WEST SHORE EMS -BLS" 205 GRANDVIEV1f AVE CAMP HILL, PA 17011 'r ~.,. Name V . ~,.~`'~ ~~ r=.~ 4'~-.~"(~~~ ~t~,•l~~C~~ l~l ~ -- _" ~~ ~ ~ ~i i ~~ ~,; - r~ ~~~ ~~~~C• ~ ~ ~~ ~ ~~ • - ~~ Account No 60-8255/2313 ;~~ ,: ~' ~ 1 ~ "' `t''~..! "" .~ ~~ .~ ~ Date ~~ ~-~' ~,_ ;,; Pay to the ~_ ~ Order of ~! C ~ i ~ ~t~? ~ ~ ~ /~°j~ - ~ L.:S ~ -~ ~ l ~~ ~ , ;,., ~ ~; ~'1~1 ~"~i L'!~{~r~t~~s7 ~C ~~ { 'Y ~ iLY '~"' ~ ts?.~ ~ ~ ~.:r~°y, Dollars ~ o.,..,, ~ , ;. r~~ ~' ~;, a•~r. { ~: ~,, ~ ~ ~~ `~r ,. i, " '~; ~ ~r~ L i.• f'Ij h71yL11r411:RL1.VDT7?DF.R/U.CRE?D1TU~IDV C~!'7/ `~i~,;tt' j ~ hcw L'um6crland, R'A t7U70 ~l ~~~, 'h HH '' ~~ ~ `• For-~-[ ! ~"~i -r ~ ~ ~'~`~~" L L '-~% '~'S ~' ~' ~ . _ _ _ _._ ~ _._ W _ . 2 3 L 3 8 2 5 5 5 ~. ~ ~~J %Cj I ~- ~ ,;: r~! V il.,~. ..~ Frank Pagnucco Apt. B . 1603 Market St. ,Camp Hlll, PA 17011-4$45 ~C~ .~~ C•~ ~~ fY ~ ~~! ~' fit,/ ~ ~°~=~ Gri't`-~1'~ 1~~~~, ~~ I r7 ~ ~ ~ '~ e ::-: 201,0 PA-V PA PAYMENT VOUCHER • 1,99- 1,4-3633 PA 1,DDD9],9082 PAGNUCCO CAROLYN R APT B 1,603 MARKET ST CAMP HALL PA 1, 7 D 11, L 717-421,-3338 DEPARTMENT USE ONLY PAYMENT AMOUNT ~'~~ $ ~, 1,7.OD '~.. -~.----.-4, . Make check or ciwr>fey oi:der payable to the Pennsylvania Department of Revenue J ESTATE OF CAROLYN R. PAGNUCCO 106 FRANK C. PAGNUCCO, EXECUTOR 1603 MARKET STREET ,~ !`''t ~ ; ~,` CAMP HILL, PA 770 1 ; _-~ ~~// ,-,c;, ~_~_~-- GO-8255/2313 ; Y~~r to the , NEW ~-V'~~IAND FI?DF.RAI.CR~R'111V10N Ytw Cumt+~YlanJ. PA 1711711 ~: ~. 2 3 i 3B 2 5 5 5~. 0000 9 2 3 2 $011' 0 LO 6 ;, ::.:...... .:... --._ s----- _ . .. fop f; ii I ock ;'i ~~~ t~1j~.1 i~ ~ f 'i +lf .... 1(irlil.f 1; ~'l'1J~j~` ._I~ "+ , 11,'x; `j11 (!- ;: i .t'?iC ; l,1't{;(Jl.~1`t'i E~rlliiji.!i~~[;!1 -Mf ~~r; }~!~t~litj? i.7t ;tit'! 1~~ I ,tfJ ~~ ir~t~l 141.O(1 i:f .i...i;. # ? i,!; 1~~.'i ~~ ii; ! i~~t.i 1,~ 1 . i:~? - Iria~!~: i'11t! fig! I.fii~(~;~i?i~ (f~ft >jlui;k fC;t '';~i)lll l:~X tiiE1! V ii.~l;i;. H&R BLOCK ~'•~ } Janet L ~raCkbill ~.;.}~~,,~1~~~,:rr~f Franchisee 70 W Plain St A4echanicsburg, PA 17055 / `~ [ , Tel 717,766.0901 Fax 717.691.3372 jbrackbill ahrblock.com :i%~'•r''..)11 ~I.'ltS,~)~S F'f~1 `~f''_l;.itia ~ • M REV-1513 EX+ (01-10) r:Y ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE .............. INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: Carolyn R. Pagnucco FILE NUMBER: 2110-0826 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under ~o Not List Trustee(s) OF ESTATE _ Sec. 9116 (a) (1.2).j L Ronald W. Pagnucco - 701 College Avenue S, Apt. 29 St. Joseph, MN 56374 Son 50% 2. Frank C. Pagnucco -1603 Market Street, Apt. B., Camp Hitl, PA 17011 Son 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size.