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HomeMy WebLinkAbout03-08-13 J REV-100 Ex(ax-ix)(FI) 1505610105 OFFIGIAL USE ONLY PA Department of Revenue Pennsylvania 11 .,.,o, County Code Year File Number Bureau of 2I0601 uatTaxes INHERITANCE TAX RETURN P 2t3060i 4 Box Harrisburg,PA 17i28-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 01/04/2013 02/19/1929 Decedents Last Name Suffix Decedent's First Name MI Gula _ Agnes F (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 CID 1,Original Return 2.Supplemental Return C) 3. Remainder Return(Date of Death Prior to 12-13-82) O 4,Limited Estate O 4a.Future Interest Compromise(date of C) 5. Federal Estate Tax Return Required death after 12.12-82) C) 8.Decedent Died Testate C) 7,Decedent Maintained a Living Trust 8, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) CJ 9.Litigation Proceeds Received q 10.Spousal Poverty Credit(Date of Death C? 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0; Name Daytime Telephone Number John Gula (717)480-0903 REG NAIONLY ISTER OF kWUSE O [7i ;a rn c o rn c, First Line of Address I C 811 Surrey Court :A r M Second Line of Address y z = GO 7t7 v zu_' ;K r_> C> v ry M -rt `n City or Post Office State ZIP Code C7 D FILED '" y C rn Camp Hill PA 17011 > Tt Correspondent's e-mail address:john-gulat @ComGBst.net Under penalties of pedury,l declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,coned aid complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU F PERSOy RESPONSIBLE FOR FILING RETURN DATE e r L_ 03/08/2013 ADDRESS 811 Surrey Court,Camp Hill, PA 17011 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 E 1505610205 REV-1500 EX(Fl) RECAPITULATION 1. Real Estate(Schedule A). ................. .. .................... ..... 1. 0.00 2. Stocks and Bonds(Schedule B) .............. ........ ............ ..... 2. 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. ... 1 0.00 4, Mortgages and Notes Receivable(Schedule D).. .......... .. ............ . 4. 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)...... . 5. 0.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ...... . 6. 119,411.45 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested....... 7. 34,070.04 8. Total Gross Assets(total Lines 1 through 7)............................ . 8. 163,481.49 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 2,623.54 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)..... .. ....... . 10. 224.87 11. Total Deductions(total Lines 9 and 10)....................... .......... 11. 2,848.41 12. Net Value of Estate(Line 8 minus Line 11) ........... ......... .......... 12. 150,633.08 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ...... ............ ...... 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) ...... .................. 14. 160,633.08 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0- 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 150,633.08 16. 6,778.49 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE...................... ... ......... ..... ....... .......... . 19. 6,778.49 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 J REV-1 500 EX(Fl) Page 3 File Number Decedent's Complete Address. DECEDENTS AME Agnes F.Gula STREETADDRESS 811 Surrey Court STATE _.. zip Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 6,778.49 2. CreditsMaymerds A.Prior Payments 0.00 ..........._. B.Discount 338.92 Total Credits(A+B) (2) 338.92 1 Interest (3) 0,00 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 6,439.57 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............................................ ❑ i♦ 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?.............................................................................................................. ❑ 0 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 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)l. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for 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 or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child 21 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 0 percent[72 P.S.§9116(a)(1.2)]. e The tax rate urilposed on 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 RS.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent(72 P.S. §9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-IS*EX+(oi-io) pennsytvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Agnes F.Gula 21-13-0026 It an asset became jointly owned within one year of the decedenifs date of death,R must be reported an SchaWle G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A.John Guia 811 Surrey Court Son Camp Hill,PA 17011 9. G JOINTLY OWNED PROPERTY: LERER DATE DESCRIPTION OF PROPERTY %,OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTMMON AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT )DINT IDENTIFYING NUMBER.ATTACH DEED FOR IOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 11 A. 08/06/10 U.S.Saving Bonds 93,212.00 50 46,606.00 Attachment(1A)shows the Date of Death(DOD)Value. Attachment(1B)shows the Date the Bonds became Joint. 2. A. 06124/10 Citizens Bank. Account 6212806849 22,415.61 50 11,207.31 Citizens Bank. Account 6400040572 65,732.18 50 32,866.09 Attachment(2A)shows the date both Accounts became Joint. Attachment(2B)shows the DOD Valve of Account 6212806849. Attachment(2C)shows the DOD Valve of Account 6400040572. 3. A. 06/30/10 Royal Bank America. Account 1000541704, 46,268.47 50 23,134.24 Attachment(3)shows the DOD Valve&Date the Account became Joint. 4. A. 04(08/56 Riverfront Federal Credit Union, Account 003107 11,195.61 5O 5,597.81 Attachment(4)shows the DOD Valve&Date the Account became Joint. TOTAL(Also enter on Lane 6,Recapitulation) $ 119,411.45 If more space is needed, use additional sheets of paper of the same size. REV-1520 EXa (08-04) 'pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Agnes F. Gula 21-13-0026 This schedule must he completed and filed if the answer to any of questions I through 4 on page three of the REV-2500 is yes. REM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE INCLUDE THE NAHE OF 1FA!T11ANSF91ff,THEIR PEINnONShIIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER. ATTAOH A DOPY OF THE DEW FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE VALUE I. IRA. Fidelity Investments. Account 2AB-3555534. Transferee: John Gula 34,070.04 100 34,070.04 (Son). Date of Transfer. January 22,2013. Attachment(5A)shows the Date of Death Value. Attachment(5B)shows the IRA Transfer Date. i I i TOTAL(Also enter on Line 7,Recapitulation) $ 34,070.04 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) Iff pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Agnes F. Gula 21-13-0026 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' John F.Feeney Funeral Home,Inc.(Cremation Um,Container for Cremation,Cemetery Opening& 1,940.00 Closing,Death Certificates,Crematory Charges,Coroner Pemit,Clergy Offering,Obituary). 2. Gethsemane Cemetery&Mausoleum. (Gravestone Marking). 196.40 3. Old Country Buffet. (Funeral Luncheon). 128.64 B. ADMINISTRATIVE COSTS: Y. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City -- __-_-- State ZIP Year(s)Commission Paid: 2. Attorney Fees: 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 358.50 S. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9,Recapitulation) $ 2,623.54 si If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(1212) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHEMANCE TAX RETURN MORTGAGE LIABILITIES &LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Agnes F. Gula 21-13-0026 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Alert Pharmacy Services,Inc.219 N.Baltimore Ave.,Mt.Holly Springs,PA 17065(717)486-8606 Medication from 16 Dec 12 to 31 Dec 12. Paid on 23 Jan 13. See Attachment(6A). 15.85 Additional Medication from 16 Dec 12 to 31 Dec 12. Paid on 18 Feb 13. See Attachment(6B). 12.02 2. Life Star Response of NJ,PO Box 827299,Philadelphia,PA 19182-7299(800)752-3331 60.00 Wheel Chair Transport from ManorCare Nursing Home Laureldale,PA to Physician on 4 May 12. Paid on 23 Jan 13. See Atachment(7). 3. Life Star Response of NJ,PO Box 827299,Philadelphia,PA 19182-7299(800)752-3331 137.00 Wheel Chair Transport from ManorCare Nursing Home Laureldale,PA to Claremont Nursing Home Carlisle,PA on 8 May 12.Paid on 23 Jan 13. See Attachment(8). TOTAL(Also enter on Line 10,Recapitulation) ¢ 224.87 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT DP REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Agnes F. Gula 21-13-0028 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List TrustWs) OF ESTATE I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under Sec.9116(a)(11).j I. John Gula,811 Surrey Court,Camp Hill,PA 17011 Son 153481.49 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: i. 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 Use same size. Calculated Value of Your Paper Savings Bond(s) Page 1 of 2 Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 01/2013 Total Price Total Value Total Interest YTD Interest $23,000.00 $93,212.00 $70,212.00 200.40 Bonds: 1-49 of 49 Serial # Series Denom Issue Next Final Issue Price Interest Interest Value Note Date Accrual Maturity Rate M85633130 EE $1,000:1011986,0412013 10/2016 $500.00 $1,468.40; 4.00% $2,968.40 M85633129 EE $1,000 10/1986,,04/2013 10/2016 $500.00 $1,468.40 4.00% $1,968.40 M85633128 EE :$1,000 10/1986 04/2013 10/2016 $500.00 $1,468,40 4.00% $1,968.40, M856331V EE „$1,000 09/19$6 03/2013 0912,0,16 $500.00 $4468.40 , 4.00% $1,9.68.40 M85633126 EE $1,000 08/19$6 0272013 08/2016 $500.00 . $1,468.40 4.00% M85633124 EE $1,000 47/14$6 07%2013 08/2016 $500.00 $1,468.40. 4.004, $11,968.40; / 7/2016 $500.00 $1,508.00 -4.44% $2,008.00 M85633123 EE '$1,000 07/1986,07/2013 07/2016 $500,00 $1,508.00 4.004;563 $2,008.00_ M83122 EE $1,000 07/1986 07/2013 07/2016 $500,00 $1,508.00 4,09% $2,008.010 M85633121 EE $1,000 06/1986 46/2013 06/2016 $500.00 $1,508.00 4.04% $2,068.60 M85633120 EE .$1,000 061,1986 06/2013 06/2016 $500.00 $1,508.00' 4.00% $2,008.00, M85633119 EE ,$1,000 06/1986 06/2013 06/2016 $500.00 $1,508.00 4.00% $2,008.00 M85633118 EE, ,$1,000 05/1986 05/2013 0512016 $560.00 $1,508.00 . 4.00%. $2,008.00_ M85633117 EE '$1,0100,05/1,986,05/2013 05/2016 $500.00 $1,508.00 4.00% $2,008.00; M85633116 EE $1,000;04/1986„04/2013 04/2016 $500,00 $11508.00 4.0,0% M85633115 EE $1,400 0411988 04/.2013 04/2015 $500.00 $1,50$.40 4.00% _ $2,0iis.0o M85633114 EE $1,000,04/1986 04/2013 04/2016 $500.00 $1,508.00 4.00% $2,008.00 M85633113 EE `$1,000,04/1986 04/2013 04/2016 $500.00 $1,508.06 4.00% $2,008.00 M85633112 EE $1,000 04/1986 04/2013 04/2016 $500,00 $1,508.90 4.90°1° $2,008.00 _ D66906357 EE $500 03/1986 03/2013'03/2016 $250.00 $754.00 4.00% $1,004.00' D66906356 EE $500'03/1986 03/2013 03/2016' $250.00 $754.00 4,00% $1,004.00 D66906355 EE ` $500 03/1986 03/2013 03/2016 $250.00 $754.00 4.00°10__ $.1,004.00 D66906354 EE $500 03/1986 03/2013 03/2016 $250.00 $754.00: 4.00% $1,004.00. M85633111 EE $1,000 11/1985 05/2013 11/2015 $500.00 $1,548.00,._ 4.00% M85633110 EE_ .$1,000 11/1985:05/2013 11/2015 $500.00 $1,548.00 4.-66% 48.00 M85633109 E M85633108 EE ;$1,000 11/1985 05/2013 11/2015 $500.00 $1,548.00; .4.90°k; $2,048.04 M85633147 EE '$1'000.11/1985 05%2013 11/2015 $504.00 $1,548.09._ 4.00%__ $2,048.00 E $1,000,10/1985,04/2013 1012015 $500.00 $1,548.09 4.00°10 $2,0+18.00 M85633106 EE $1,000 10/1485 04/2013 10/2015 $506.00 $1,548.00 4.00% $2,048.00 M85633105 EE $1,000 10/1985 04/2013 10/2015 $500.00 $1,548.00 4.00% _ $2,048.00' M65633104 EE $1,000,10/1985 04/2013 10/2015 $500.00 $1,548.00 4.00% $2,048.00 M85633103 EE $1,000 09/1985 03/2013 09/2015 $506.00 $1,548.00 4.00% $2,048.00'. M85633102 EE .$1,000`09/1985 03/2013 09/2015 $500.00 $1,548.00 . .4.04% $2,048.00 D66906353 EE $500.49/1985 03/2013 09/2015. $250.00 $774.40 4.00%. $1,024.00 D66906352 EE $500 09/1985 03/2013 09/2015 $250.00 $774,00 4.00%. $1,024.00 M85633101 EE $1,000 09/1985 03/2013 09/2015 $500.00. $1,548.04 4.000% $2,048.00 M85633100 EE '$1,400 09/1985 03/2013 09/2015 _ $506.00 $1,548.00 4.00%.: $2,048.00 M8563309 EE 1$1,000 09985 03/2013 09/2015 $500,00 $1,548.00 _ 4.00°/g $2�048.�10 M8563 499 9 EE $1 00.49 9$6 0372 013 09/2015 $500.00 $1,548.00 4.00°/0 $2,048.00 M85633097 EE $1,000 09/1985 03/2013 09/2015 $500.00 $1,548.00 4,06% $2,048.00, M85633096 EE °$1,400 08/1985 02/2013 08/2015 $500.00 $1,548.00 4.00% $2,04800' M85633095 EE $1,000 08/1985 02/2013 08/2015 $500.00 $1,548.00, $2,048.00 - M85633094 EE_ $1,000 08/1985,02/2013 08/2015 $500.00 $1,546.00 4.60%: $2,048.00 M85633093 EE $1,000 08/1985 02/2013 08/2015 $500.00 $1,548.00 4.00% $2,048.00 M85633092 EE $1,000 08/1985 02/2013 08/2015 $500.00 $1,548.00 4.00% $2,048.00 M85633091' EE $1,000'08/1985 02/2013 08/2015 $500.40' $1,548.00 4.00% $2,048.00, ArTAc.k-lmentT C1A) C=4W2 Stkepv11_ http://www.treasurydirect.govBC/SBCPrice 1/4/2013 Calculated Value of Your Paper Savings Bond(s) Page 2 of 2 Mi&33090 EE :$1,000:00/1985,02/2013 081,2015 $599.09 $-1,5481!.00 4.109%- #2,048.00 I M85633089 EE $11000 07/1985 07/2013 07/2015 #500 00 $1,588 80 4 00°yo #2a08B.80 M85633088 EE $1,000 07/1985 07/2013 07/2015 $500.00 $1,588.80 4.00%; $2,088".80 Totals for 49 Bonds $24,M0.00;$70,212.00: 933 212.00: Notes NI :Not Issued NE Not ell giMe for payment P5 Indudes 3 month InterestpenaRy MA Matured and not eamInj interest http://www.t vasiuyduwt govBC/SBCPnce 1/4/2013 Fbr tliliciat 9tdry:; aa9afaa�ess REQUEST TO REISSUE UNITED STATES SAVINGS BONDS °�� tsas ooze (tZzwieed#Herat,2040) wttwr traeauyd4rer. qvv af114., flofssr: . its. , oxt.ettis Yea tr".ewoAre arst 1A► 9 d rs+y tetra,t1a11e00rrs,OF ltwergetwrt dattm w IIA �dt11MMM�91 sAl�e js YSMY btr lttsre atrdla iwtprtaottarwN. tefilNT11RANt t1R TYPE lit 1ATldt PART A— sIII REGNIMT110H 1.Bond Deecrtpiiotr Woe reque st nalasue of the bads descrt to below.in the amount of$ 3.000 (total Taos amount). FACE NT BONG T4'+r►r+ds coen 1,1, gseW 8eartgr Number ISSUE GATE AMOU par I I 11 and nones, kKkKvm saiddts maces or WHoW on iha treed&. 1014188 $1,000 M1574775M 166-24.7869 Andrew J.Gul a or Agnes F.Gule t`'�$S(,331 cptz 1310 Stott 91110%Reading,PA 19607 See CoMtmuatlon Pages,4,41A.&48 (if you Heed more space to dewrft your bonft rue Paos 4. 2.Exfor*of nNecue: In lull ❑ Anxxxd.Fradional Shane,or Pavwft4 e 3.Requested R gdetraW a.Taxpayer ldetsgllrabion Number 204-22-17 (Social Secunly Number or Employer Idenli cation Number) b.Registration: Agnes F.Gula (Feet Name.WKk1s Name or In OW,Last Name,or FkWary Inscription) c.Adder: 1310 Scott Street (Number and Street or Rural Route) Reading,PA 19607 (CO) (State) (ZIP Code) d.To name a coowner or bene0 lery. the toNawetg: ®000rtn er ❑beneficiary(PM) John Guia (if a name is shown and neither (Feat Name,Middle Name or lutist,Last Name) box is marked,coownership will be assumed.) TAX 46iWTY. M the treme4 a HFrbt0 otrerer er ptirtoipd aWaner of tfw binds is N 1 - 11 1 fan Nw.e&bvGx tlne asM+er or 0riitetlf e4 boaNrNr-asrst indud0p+e ililanet aenlaA nd pwAouiy umvorbd an ft baWS to ihs d is Of fstrare A*On an his or her fede n i$home test rai►an Tar the yew of the nplRrae. (901h at91 eaamis ire oarMidnred ie"be otortrteri wttert kends gee tegtnered in fie tor►rt: W or"B." The prkrcipei coownx is Vw coertatw wha(1- ft kmds w0h his Itad d ar tr own kax1s.or(R)moaK d 6rem ae a OR biWdfsnee.or kgecy,or as a cM*of)Xft pooesdMo.ed roeuad i aoaMesr NO f41 1'. . d Ite or die h e retsired ne carteibrttlort in mww or monW*worth tar d hp fie taw oeowr w.on the bonds. d 10-race is s"sepert0 to eveK the Irtierest earned on the bonds to the data of ft reimus we be reporttd to the wwao Rsre m Service t a Federal ReMrwe Banc or ttrandt crew tseau of the Pubes Debt under the Tan 6gdty and Fi mW Resportaft Act of 1982. TIC OSLMGi4UM TO DORY THE WMPEST CA PM BE TRANSFERRED TO SOMEOW ELSE TMROUG"A Re&*rUE TRANSACTION. If you hove 4ues0ooa a. 1 ,1 lha Wr corso*m we course ite IRS;or weft b fee CornnMwkmm of l -P s 1 Rvverrrt.V"0 qPx DC 20M.Untie s wears nd 'Pvobo bdwm rod.tlwr*s$4umed coewnw w#br conmbl ed the prinopd eoownwfwnre parposo of UNe tsisaaWke 4.DOOM in eWctlone,if John Grda (Name) 011 Surrey Court (Ntxrtber end or Rural RouW) Cmap FM,PA 17011 P Code ia•T"1'f'+C-4[mtr�T t.tc3) FoR 5c4rt�vu�-�= "F'' 3T�'A✓r 1 �,ovcrz� PAW 9-JtMA* NfORRIIIIIIIIIIIIN tl..th of Y r Aeduw . s i.it 8...u.ohrd Death CoNlosba. M ttie iaasen siierrti aeeve is to eansat stn aevir Yi pleaitle tts beloittrtlon_ (i)who pumhasod to bonds? (2)Mose frurds weir assn (3)How did the error ooait PAKr C—MMTtN=AND t111IRTN"THMIS Uwe GWWI under paaew of parJmy fact an* 0, o.a proM/MI heraai is tics d ooaraot b Go bast of�ba~sad beast. VWO ages to r I a go bads as bdk Md In Pat A and aa�lint tM arfteea is adlsiesd VM hereby 13M oasettiOk our hats.Mgisaas, srssrsois,and avdgns,jo*and a an*.b hold Me Unled SMMS hander on aceeint athe raissire rsyiieeled l J oe&,b win v*� and p onq* eay the l l ill d Sale loMavat of albe vdddr nmft inn Y n*mK b abg aI - add , - I ca t.and psiiewes IAW careers b tae aiesee a.y rrbmuron ngtNng Mite trasracIori rnab ft b=q pi*hvi9 an p or enireiirert htMtiads. Sbrin h*6t U11s clan stwtorin aaf#lllbiO indvkkmL (.'�f�s��i rii�a�neti6rtatwmudiral�) Mile) \ ft) 1310 Scott Street (Number and Stied or Ruat Route) (Number and Stleet or Rust flails) PA 19WY (may) (Stab) ( (may) (fib) (23P) 204-22-3637 (Social Security Number) (Social Security Mrnber) (157W Address) (Emai Address) (610)77743 (Caytlrrta Telephone Number) (Oaylkrie Telcowne Number) Irrst iuMons lD bNBvkbial: 1.PMrris of paraori(s) appeared and dale a appearance MUST be com filsMd. 2 ttsdarioa d�ttps r.p an; 11;1 1 t sass 3.Pesai(s)miaifaign b ymr ftrdsaioe.-NO'7'� To cw*a second sipialum use the next pegs. whose IdendLy Is knwm t or vas I CERTIFY the i'�C,�IV f'-� �of Person Who APPOMed) pfw4en b me.peiaansly aPPeor'ed before me We t el day of /fie G 5 r / L' i C{ (ttcrdhKarr) at 5,-:3)Sri G .-r and abad this form. ) ( irrbn and VIVO atoblop"k0bume r i, 46;-/li S �r Fr -y-k's=- CrtS,rC iZ (Aedrer) ACCEPTABLE G�RT_PICATiON3: �i£f��)�E l�� ( �/tt" 22 t-it instft- 1 end C3WN Seat or 5ila+-iG (CxY mew 7JP Code) (much 7a Ccpmate Seal 3igrraitwe Guarardeert Su mV orMeaai im Stwo). Snokon nam 0 use a Madallon gyp. 2 PD F 4000 E "` " + One Citizens Drive Citizens flank ROP912 Riverside,RI 02915 February 26,2013 John Gula 811 Surrey Court Camp Hill PA 17011 Estate of AGNES F GULA Date of Death:Jan 04,2013 SSN: 204-22-3637 Dear Sir/Madam: In accordance with your request,the attached information sheets have been provided in the above decedent's name as of his/her date of death. Your name was added to both accounts as of June 24,2010,per our signature card. For Installment Loans or Line of Credit accounts,contact our Loan Department at 1-800-708-6680. For all other inquiries,please call 877-579-2667 option 2. Sincerely, 6),; 1 r9U� Kristen B. Correia Decedent Account Processing REF#: 578205 RT-TACtimawr (;LA) 5CNEVkLr- ",F- M-rar., Citizens Bank- Account Number 6212806849 Account Title AGNES F GULA/JOHN GULA Date Opened 7/5/2005 Account Type Checking Principal Balance as of DOD $22414.61 Interest from Last Posting to $ .80 DOD Account Balance as of DOD $22415.41 YTD Interest to DOD $ .00 tt rr � MTTR cu &,ca C-r xe) Fox. 5c-ot PL4L#- � X-1 LA W) ;L January 24, 2013 John Gula 811 Surrey Ct Camp Hill PA 17011 RE: Estate of Agnes F Gula SSN#204-22-3637 Agnes had the following account with Royal Bank America on 1-4-2013: Premier Interest Checking#1000541704 Titled:Agnes F Gula or John Gula DOD Principal:$46,267.33 Accrued interest:$1.14 Total DOD balance:$46,268.47 Account opened on: 30-31-2008 The title on the account was changed from Andrew Gula or Agnes F Gula,John Gula POA to Agnes F Gula or John Gula on 6-10-2012 If I can be of any further assistance please call me at(610)777-3300 or my fax is(610)777-5099. SAAnROor sk i Community Banking Manager Shillington Branch Fp/k 5r—He4p KLd= "Fa 3 7& " 3 W W W.ROYALBANKAM ERICA.COM NASDAQ:RBPAA JUMMEAMMAM 430 South 4th Sweet,Reading,PA 19602-2630 (610)374-8351 • (800)451-3477 January 7,2013 Re: Anges F Gula 811 Surrey Ct Camp Hill, PA 17011 To John Gula: Anges F Gula balances on her account on January 4,2013 were: ❖ Savings Share balance as of January 4,2013 was $6,195.61. ❖ Life Insurance Share balance as of January 4, 2013 was$5,000.00. John Gula became joint owner of the account on April 8, 1996. You may contact me if you have any further questions. Si cerely, Desiree Freytiz Branch Manager Riverfront Federal Credit Union l�}7 FRGH/rJENT (�!) Fore.. $Gt/cp�,a[ != r .Z 7�•✓1 '�► Growing Stronger Together Portfolio Positions by Account: Fidelity Investments Page 1 of 2 _="t ,,a`�-. ;,: �I,.SSSa•Aa) �G_.k'WmIM}yl Customer Open an Account Loa But Service Accounts&Trade News It Inial" Rowarith Guidance&RaiNamrft investnrom Products Friday Jam dry 4,2013 Accounts a Trade tistptG m ary Download Print Summery Portfolio Posftiotns Portfolio Research Performance Analysis Statemerita NEW—Neville g Ponfdia Positions-This video provides a quick overview of tow to pet stKW with Portfolio Positions on Fk$ft.con kickrding tow to navigate and ruatomiza the papa,as west as a few quick Bps de&Vnad to sinpNty are overall eppaYenm. Open Position$ Closed Positions Refresh I AAA Select Account(*) include Posklen Type Grote ey Security Description View As TRADITIONAL IRA(2AB355534) All R Accounts r Positions G Pull r Short Vhtta Ssved7 TRADITBONAL VA(2AR350" Select Action v ethy ®� F Mod wReosm 3wp Brm tasa Cwp5ic Putilafi... Cost Buis Svnw" ( .wLoO Ems vy�� v i OR& nir yywsyom Ift Action 1 UFGRIX FIDELITYGROWtHaINCOME 1,51111 $21.71 40.05 $34,070.04 478.47 -0.23% $17,531.19 106.00% $10.64 $16,638860 � Talk $34A7AM .N{.4j. 4.23% $17,11XIII, 110111.011,% Totals: $$4,070.04 4711.47 $17,531.18 IndicaNa toddi prima andfor activity.Moro on pricing. *Mutual fund accounts;reported as of:011042013,11:42 AM ET. Mutual funds are priced as of the previous business day's market does when the market is open.Mutual fund positions dust priced as of the official market dose(typically 4 p.m.)and prices are generally available between 5 p.m.and 6 p.m. Quotes am delayed at least 15 minutes for seconders.If the currant market once is unavailable or the market is dosed,Fidelity will factor in the most recent dosing market price to determine the dosing market value. If current mallet prim is unavalable.Fidelity we display the mat recent dosing market once and closing market value in the Price and Most Recent Value columns. For details and Terms of Use on positions for a spedfic account,select the account name link. For a detailed word for a security,select the symbol link. Cost basis is currently not evadable for this position.We are actively processing updates to your cost basis based on trades placed earlier today. Cost basis is currently riot available for this position.Updated mat basis will be available prior to market open tomorrow. c-Customer provided cost basis In some cases readily does not apply wash sale miss to tax lots with customer provided cost basis. a-The Cost amount for this security was estimated based on the fair market value of this security when It was ongin by deposited in your account or based on the earliest date Fidelity has transaction history available for this account.You may change this amount d it does not coincide with your records. 1-Third party provided cost basis.In some cases Fidelity does not apply wash sale runes to tax lots with third party provided coat basis. 6 in the case of a shat sale,total mat ordinady equals the cost of the asset(Inducing cwmrrdsaim r,it any)when purchased for delivery when the seta is dosed or covered.However,as mat basis is unknown unlit the date the short sets is dosed or covered,the value Fidelity reports in the Cost Basis column is equal to the prim at which the short sale was transacted(total saes proceeds).When calculating the unrealized gain/loss.Fidelity adds the negative value reported in the Closing Mkt Value Column to the positive value reported in the Cost Basis column. in-This position has bean marked to the market.The cost basis and acquisition date were adjusted to reflect the market value of the security on December 31 of me previous year See the IRS Publication 550 for mare information about the IRC Mark to Market requirement for Section 1256 Contracts.For all other securities,see the IRS Publication 475 for more information about the IRC Mark to Market Election. ©--Adjusted due to previous wash salt disallowed lose If you sell shares at a loss and you purchase additional shares of the same or a substantially identical security(in the some or a crescent account)within the 61 day,period that begins 30 days before ofd ends 30 days enter the sale,the purchase may msuk in a wash sat.it a wash sat occurs,the fees loan ate transaction should be'disallowed'for tar purposes,and the amount of the lose should be added to the mat basis of the nowly�purchaa dl shares.U01eas otherwise requested or noted,Fidelity adjusts cost basis information related to newly- purchased shams when a wash-10 occurs within an amount as the crack of an identical security purchase.Fidelity does out report disallowed losses or adjust mat basis information related to wash saes triggered by salsa and purchases of the same security within different amounts or by sales and purchases of substantially identical securities worth the same or different accounts.Fidelity was not apply any wash sale rtes to tax lots with customer or 3rd-party provided cost bade.You must check your own mwms access Wi of your Fidelity and non-Fkieiity accounts to ensure that you are correctly acmunkng for losses related to any wash sales. NFS will report mrtain cost basis and holding perked information to you and to the IRS on your annual Form 109"as required or allowed by law,but such irdormation may not reflect adjustments required for your tax reporting purposes.Taxpayers should verify such intamabon when calculating reportaers gain or loss.Fidelity and NFS spec'if'ically dnedaim any liability Wising out of a wsbmets use of,or any tax position taken in mwom upon,such information Urge"othowiise specified,NFS determines cost basis at the time of sett based on the average met method for open-anti mutual funds and based on the first-in,first-out(FIFO)method for all other securities.Consul your lax advisor for further Information If securities held in your account are reelected for sate under your company's stock plan rules,Fidelity will use the FIFO method for lots available for sate. For holdings purchased in a currency other than USD,the ma basis provided in USD was determined by converting cat"ton currency mat into USD based on exchange rates on the trade date of purchase.For tax repomng purposes,you may be required to determine your actual USD mat basis for holdings purchased in foreign currency based on exchange rates on the settlement date or purchase.Consult a tax advisor for further information. For certain foreign seamy holdings,Change Since Purchase in USD is broken down into market gaiMoas and currency fluctuation mmpcoacre for informational purwa06 only The market gair0oss and wrrtncy fuctuatlon components should not be used for tax reporting purposes.For details regarding how market ganmow and wrrency fluctuation were calculated,pies"carer to Heip/Glossrdy I-Cost Basis is provided by the investment adviser or outside third parties and is included for informational purposes only.Fidelity Brokerage Services is not msponsible for the information provided.Pleaded consult your tax advisor. Hui c_Hm_-.or ( "'J) r=oe. https:lloltx.fidelity.com/ftgw/fbe/ofpositions/brokerageAccountPositions?ACCOUNT'=2AB... 1!412013 History: Fidelity Investments Page 1 of 1 Accounts!Trade>Poitfol, > History Help/Glossary I Download I Print Account TRADITIONAL IRA(2AB355534) Name This Account ................................................................. Time Period: Past 30 Days Sort by: rDate - `' Ascending Descending Transaction Nbatory for the pant 30 Dap As of 01/23/2013,3:33 AM ET 01122/2013 IRA-TFR TO BENIFIC VS 218-361358-1 FGRIX FIDELITY GROWTH 9 INCOME Cash Shares:-1,569.325 Dsted above Is account transaction history for the Past 30 Days. See account statements for transactions that occurred over 2 years ago. 1998-2013 FMR LLC. All rights e Terms W Use Privacy Security Ses ite rity Site Map p �C}TTrrGH✓hE'NT C .r+g� �+�,t,. ScN6'OccLt>< `'G " https://oltK.fidelity.com/ftgw/fbc/ofaccounts/brokerageAccountHistory?ACCOLJNT=2AB... 1/23/2013 -v A FINANCEi CHARGE OF 1.50 fi PER MONTH 219 i1kMtl1 ItfItlI1110R AYE PHUrwct9�rs�n�c Mt floffy bWioM PA 1 (AN ANNOAL Pjt•RCHNTArz RATS OF 18.OY) OR A Responsive. Innovative. Rcliabic. soo'Za;r. M 4"460JUNIMUM SERVICE CHARGji OF $ 1.00 WILL BE CHARGED www' °°m ON ALL AMOUNTS 30 HAYS OR MORB PAST DUE STATEMENT OF ACCOUNT IF YOU RECEIVE A NE-W INSURA 0Cji CARD FOR YOM PRSSCRIPTIONS BE MRB TO SUPPLY US WITH A COPY. Date 12/31/2012 PMT DUE, 01 28 23 GULA, AGNES GUI+AA JOHN GULA GRP-CNRC �J•�� 811 SURREY COURT PAGE 1 CAMP HILL PA 17031 Amount Paid PLEASE DETACH AM RETURN TOP PORTION WITH VOIJA FAVININT ALERT PHARMACY SERV.- lXC.219 NORTH BALTIMORE AVE. NT HOLLY SPGS, PA 11065 ** ACTIVITY FOR GULA, AGNES` -GOLAA -5758 10/24/12 7958681 90 TRAHADOL 50MG 01 8.00- - :00 8.00- 11/23/12 7958681 90 TRAMADOL SONG 01 8.00- .00 8.00- 12/07/12 7958682 300 ALBUTBROL 0.83 MCA 01 " 8.00 00 8.00c 12/12/12 Payment-Thank YOU 33.52- .00 33.52.. 12/16/12 9019688 8 AVELOX 400 MG TAB O1 42.00 .00 42.00c 12/19/12 9020751- 4 VALACYCLOVIR 1GM 01 15.85 .00 15.85c 12/24/12 7952435 30 ISONIAZID 300 M 01 7.56 .00 7.56c 12/24/12 7991661 60 RANITIDINE 150 MG 01 8.00 .00 8.00c 12/24/12 7949967 30 LISINOPRIL 5 MG 01 4.00 .00 4.00c 12/24/12 7949968 60 HEMOPROLOL 50 MG 01 4.00 .00 4.00c 12/24/12 .7949977 60 MUCIN= 600 NG 01 25.00 .00 25.00 12/24/12 9019688 2 AVEIAX 400 MG TAB 01 42.00 00 42.00c 12/30/12 9024378 6 PROMETIMINB 25MG 01 20.12 .00 20.120 12/31/12 2048927 30 NORPHnm SULFATE 01 24.04 .00 24.04c 12/31/12 36001652 5 ATROPINE It EYE 5': 01 21.39 .00 21.39 CItANG Ho6e%c% PA+c'D f4w- dry TH't5 Rl�( L.la 55*( 5AS .00 180.96 25.00;: LEGEND NON-LEGEND FOR MONTH . FOR MONTf this soon& .. ANOUKIr DUE 33 .52 + 221.96 + .00 = 255.48 49.52 - 205.96 I FOR ALL PHARMACY RELATED WOUIRES PLEASE CALL Alod PhaMuloy Swvioss,Inc at j4XX)-266-9854 j Twnwmdo y on roww t Ei 2,9N*MB2b*W=ANi n $acs CHARGE �1 1. a Pitt Marrrx 98RncaxnsG )& PA 1706.5 (AN ANNUAL PERCSNTAGR RATR OP 19.0*) OR A Res=ponsive. Innovative. Retiabte. W-266-9434 (717)48646044INIMM SERVICE CHARGE 4F_ $ i_00 WILL BE CHUG= wwwA +com ON ALL AMOUNTS 30 DAYS OR MORE PAST DDS STATEMENT OF ACCOUNT I T» YOU XXCRIVR A NU INSURANCE CARD FOR YOUR PRESCR.IMOKS BE MRS TO SUWPLY US WITH A COPY. Dates 01/31/2013 PMT .00. .02/26. 13 GULA, AGNES GULAA JOHN GULA GRP-CNRC 811 SURREY COURT PAGE 1 ��►��o)-► CAMP HILL PA 17011 Amount Paid ai EAW DETACt AND REMM TAW►PORilON wrm VWM FiIIY_AMT ALXRT PWUVV= SERV. INC.219 NORTH BALTII+IO) AVE. Mir HOLLY SPGS, PA 17065 ** ACTIVITY FOR GULA, AG'' ES GuLAA - -5758 12/16/12 9019688- 8 AVELOX 400 MG TAB: 01> 42.00- 00 42.00 12/24/12 7949977 46 MUM= 600 MG 01 * 17.33- .00 17.33- 12/24/12 7952435 -30 ISONIABID 300 MG 01 7.56- .00 7.56- 12/24/12 7991661 60 RANITIDINH 150 MG 01 8.04- .00 8-00- 12/24/12 36001652 5 ATROPINE It EYE 5 01 21.39- .00 21.39- 12/24/12 2048927 30 NORPHINR SU14rAT& 01 24.04- .00 24.04- 12/24/12 9019688 2 AVELOX 400 'AG TAB 01 42.00- .00 42.00- 12/24/12 7949977 14 MUCINEX 600;MG 01 * 7.67- .00 7.67- 12/24/12 7952435 7 ISONTAZID 300 MG 01 5.79 .00 5.790 12/24/12 7991661 14 RAN'TTIDTNE "150 MG 01 6.23 .00 6.23c 12/30/12 9024378 6 PROM MMINE 25MG 01 ' 20.12- .00 20.12- 01/23/13 Payment-Thank YOU ]5.85 .00 15.85- I t4 rTi#c H-07c=,v r L r3) PDA Scx&7Pu1_C r rF,wi / ; l .00 LEGMTD NON-LEC3E N13 r�rr��rr►�c FOR MONTH FOR 'MOWM I AMOUNT DUM 205.96 + 12 .02 + .00 s 217.98 205.96 - 12.02 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALL AW Phmmy Services,Inc at 1-800-266-9954 Tirnrtralom.on rsbiwaa I— _j LifeStar Response of N.J. P.O.BOX 827299 PHILADELPHIA,PA 19182-7299 (800)752-3331 Paticat same: GULA,AGNES F Ran Number. 12-66624 Dabs of all: 5/4/2012 Than of all: 10:00 Caller: FAX From: MANOR CARE-LAURELDALE AGNES F GULA To: 2211 QUARRY DR 811 SURREY COURT CAMP HILL,PA 17011 Primary payer. PRIVATE PAY Secondory payer: Payment Deseription Ayer Check 0 Qurtity Usk Priee Date Amount Maeo:Cselmuddale PP WC RT 1 560.00 $60.00 /3rrftc-14 olor ( 7) r-00- 5GH1FP4&bs xr'FOI a. PLMW MUMM TFW aorraoMTM Awuo PXD ABOVE AND RMMW Min WM MR PAYMOU.a:AM YM. PLEASE PAY THIS AMOUNT 560.00 This account k SERIOUSLY PAST DUE!Payment must be nude 11M EDIATELY!Uwe do not receive your payment is 10 days,we may have no choice but to refer this account for COLLECTION ACTION! Patiat name: GULA,AGNES F Ran Number: 12.66624 AMOUNT S J_ Cnrrsal dale_ 113/2013 ENCLOSED. �i REMIT TO; Lit iEwResponseofNJ. Dwvs� 01/13RA13 P.O.BOX 827299 PHILADELPHIA,PA 19182-7299 LifeStar Response of N.J. P.O.BOX 827299 PHU-ADELPHIA,PA 19182-7299 (800)752-3331 Patient aa®a: GULA,AGNES F Rm Norbert 12-68454 Date of em: 51812012 Tim of aa: 11:30 Caller: DEBBIE Frm: MANOR CARE-LAURELDALE AGNES F GULA To: 1000 CLAREMONT ROAD 811 SURREY COURT CAMP HILL,PA 17011 Primary payer: PRIVATE PAY so—Wary pay-: Payseat Deaerilorsea Payer fbeek# Qsont9 Uakrdm Bale Awmat M=wrCwe • nMale PP WC 1 Way 1 $35.00 533.00 M=orC PP WC>15 M se $1.50 $102.00 I�TT�s;Mlrtic.l�T C $� Fort 5GFl�pu t� �''L�` L TB',�i Pty DETACH THM BOT OW PMTxa+ewNc raa eeova AM RE11M SnIa WITH xam rwYMUwr.THANK YOU, PLEASE PAY TMS AMOUNT $137.00 This account is SERIOUSLY PAST DUE!Payment must be made IMMIATELYS If we do not receive your payment is 10 doM we may have no choice but to refer this account for COLLECTION ACTIONS Patient vane: GUL.A,AGNES F Ron Nanbcr: 12-68651 AMOUNT $ Gomfnt tliltst 1!312013 RKMIT 7Y): Life9tar R"ponit of N.J. Due oat 01/11/2013 P.O.BOX 827299 PHLLAVELPHLA„PA 19182-7299