HomeMy WebLinkAbout05-20-14 ,. _ . �,.u., ,,.,_-�� _ � � � . � . � ,�,.. �� � �.�.�..,�.� �,�� . , r�_�
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REV-150� Ex(o2-t�)�enns�ania OFFICIALU5EONLY
PA Department of Revenue °"�`�`"� "`""" Countv Code Year File Number
Bureau of Individual Taxes INHERI7ANCE TAX RETURN
PO BOX 280601 21, ],3 10 2 5
Harrisburq,PA 17128-0601 RESIDEN7 DECEDENT
ENTEI2 DECEpENT INFORMATION BELOW
5ociai Security Number Date of Death MMDDYYYY Date of Birth MMD�YYYY
�8 23 201,3 ],0 02 ],926
DecedenYs Last Name Suffix DecedenYs First Name MI
D ' Esopo Lois A
(If Appiicabfe)Enter Surviving Spouse's information Below
Spouse's Last Name Suffix Spouse's First Name MI
spouse's socia�security Number THIS R�?URN MUS7 BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Originai Return O 2. Suppiemental Return O 3. Remainder Retum{Date of Death
Prior to 72-13-82)
O 4.Limited Eshate (� 4a. Future Interest Compromise(date of � 5. Federai Estate Tax Return Required
deafh after 12-12-82)
� B.Decedent Died Testate � 7. Decedent Maintained a liting Trust � 8. Total ldumber of 5afe Deposit Boxes
(Atiach Copy of Wiii) (Attach Copy of Trust.)
� 9.Litigafion Proceeds Received Q 10. Spousal Poverty Credit(Date of Death Q 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and t-1-95) (Attach Schedule O)
CORRESPONDENT—TNIS SECTION MUST BE CdMPLETED.ALL CORRESPONDENCE AND CONfIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Narne Daytime Telephone Number
Barbara Lynn Pedersen 212 238 3D6�1,,, �
� C::.;:-J � .
RE�T�OF WILL SE(� Ti
� � � '.� O
f't7 � �-.j —C c;.) �J
First Line of Address ^-� .�, �--- N -� `^�
r'_( ; f�7
Emmet Marvin & Martin LLP "'� �. � �
� ; ��
� -; . <:-:; <:�
Second Line of Address � � c� � ` '��
__�
C7 C� �-i-� � .�._ '�l
I,2� 8roadway — 32nd f 1 :Q r= =`- ra
` �DATE FIL� � I�l
City or Post Offiice State ZIP Code �
New York NY 10271 �"''' � '�
Correspondent�s e-maii adaress: bpedersen@emmetmarvin.com
Under pe ies perjury,i d lare that i have exami this rn,including accompanying schedules a�d statemenis,and to the best of my knowledge and belief,
it is tru corre nd complet eclaration of prepa he th the perso representative is based on all information of which preparer has any know dge.
SIGN TU OF P GSPONSI FILIN ETURN / / DA�O/
s
AUDRESS 104 Sutin PI
Chestnut Ridge, NY 1 977
SIGN RE OF PREPARER HER THAN P ESEN7ATIVE D E
f �i �,� .� � �N � oi
a ss 120 Broad ay-32 d fl
ew York, NY 10271
PLEASE USE ORIGINAL FOitM ON�Y
Side 1
� 7,5�56107,49 1505610149 J
� 1505610249
REV-1500 EX(FI)
DecedenYs Social Security Number
r
DecedenYs Name: L O 1 S A D S O p O
RECAPITULATION
1. Real Estate(Schedule A) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. � • ��
2. Stocks and Bonds(Schedule B) 2. 4 4 7 ,5 7 0 • 8 6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. � • ��
4. Mort a es and Notes Receivable Schedule D 4. � • ��
9 9 ( ) . . . . . . . . . . . . . . . . . . . . . . . . .
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . . . . . 5. S 9 6 ,7 2 6 • 9 0
6. Jointly Owned Property(Schedule F) � Separate Billing Requested . . . . 6. 51,5 5 5 • 5 3
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property ],�8,812 • �6
(Schedule G) O Separate Billing Requested . . . . 7.
8. Total Gross Assets total Lines 1 throu h 7 g. 1,2 0 4 ,6 6 5 • 3 5
( 9 ) . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Funeral Ex enses and Administrative Costs(Scheduie H 9. 91 ,2 0 9 • 9 4
p ) . . . . . . . . . . . . . . . . .
10. Debts of Decedent, Mort a e Liabilities and Liens Schedule I �o. 4 8 3 • �0
9 9 ( ) . . . . . . . . . . . . . .
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 91,6 9 2 • 9 4
12. Net Value of Estate(Line 8 minus Line 11) �2, 1,112,9 7 2 • 41
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . 13. � • ��
14. Net Value Sub'ect to Tax Line 12 minus Line 13 �q 1+ ,112 ,9 7 2 • 4 1
! � ) . . . . . . . . . . . . . . . . . . . . . .
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 0 � • �0 15. � • 0 0
16. Amount of Line 14 taxable 1 ,112 ,9 7 2 • 41 �g, S O ,0 8 3 • 7 6
at lineal rate X.0 45
17. Amount of Line 14 taxable
at sibling rate X.12 � • �� 17. 0 • �0
18. Amount of Line 14 taxable
at collateral rate X.15 � • 0� �g� � • ��
19. TAXDUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 5�,083 • 76
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505610249 1505610249 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 1025
DECEDENT'S NAME
Lois A. D'Esopo
STREET ADDRESS
824 Lisburn Road
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 50,083.76
2. Credits/Payments
A.Prior Payments 50,800.00
B.Discount 2,504.19
Total Credits f A+B 1 (21 53,304.19
3. 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) 3,220.43
5. If line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE B�OCKS
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 . . . . . . . ❑ 0
c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 0
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 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 tleath 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 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)j.
• The tax rate imposed on the net value of transfers to or for the use of the decetlent'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 or for the use of the decetlenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
untler Section 9102,as an indivitlual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1503 EX+ (8-12)
�: pennsylvania S C H E D U L E B
���� DEPARTMENT DFNEVENUE
INHERITANCETAXRETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lois A. D'Esopo 21 13 1025
All property jointly owned with right of survivorship must be disdosed on Schedule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 FRONTIER COMMUNICATIONS CORP 2,295.23
CUSI P: 35906A108
Shares/Par: 505
Exchange: New York Stock Exchange
COM
2 NUCOR CORP 135,417.22
CUSIP: 670346105
Shares/Par: 2917.324
Exchange: New York Stock Exchange
COM
3 PPL CORP 85,649.15
CUSIP: 69351T106
Shares/Par: 2790.329
Exchange: New York Stock Exchange
COM
4 VANGUARD MUN BD FD INC 59,493.49
CUSIP: 922907860
Shares/Par: 5488.329
Exchange: Mutual Fund (as quoted by NASDAQ)
LT TXEX ADMRL
Daily Div. Accrual as of 08/23/2013: 156.90
Income on above item accrued as of decedent's death 156.90
5 VERIZON COMMUNICATIONS INC 58,209.75
CUSIP: 92343V104
Shares/Par: 1230
Exchange: New York Stock Exchange
COM
6 42 $50 US Savings Bonds Series EE 3,836.06
See Exhibit 3 - list and valuations
7 1 $50 and 10 $5,000 US Savings Bonds 102,513.06
Series EE
See Exhibit 4 - list and valuations
TOTAL (Also enter on Line 2, Recapitulation) 447,570.86
If more space is needed, insert additional sheets of the same size
REV-1508 EX+ (08-12)
�� SCHEDULE E
r pennsylvania
��" DEPARTMENTOFAEVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN pERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Lois A. D'Esopo 21 13 1025
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 disdosed on Schedule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OFDEATH
1 Citibank, N.A. -checking account#9991301541 7,349.79
2 Citibank, N.A. -checking account#74199884 26.20
3 Citibank, N.A. - money market account#9991301568 50,198.04
accrued interest 6.76
4 Capital One-savings account 530,188.57
#8315039747
accrued interest 167.07
5 M&T Bank-checking account#9851651407 2,616.60
(balance remaining in husband's estate checking account at decedent's
date of death. Husband's estate payable to the decedent.)
6 M&T Bank IRA#35004109321753 6,173.87
3 year CD 0.35% matures 6/13/14
Beneficiary: Estate of Lois A. D'Esopo
TOTAL (Also enter on Line 5, Recapitulation) 596,726.90
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+ (01-10)
l,•�
� pennsylvania SCHEDULE F
QEPARTNENT DFREVENUE
INHERITANCETAXRETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Lois A. D'Esopo 21 13 1025
If an asset became jointly owned within one year of the decedenYs date of death,it must be reported on Sdiedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
a. Laurie LaScala 104 Sutin Place Daughter
Chestnut Ridge, NY 10977
s.
c.
JOINTLY OWNED PROPERTY:
ITEM LETTER DATE DECSRIPTION OF PROPERTY DATE OF DEATH �OF DATE OF DEATH
NUMBE FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR VALUE OF ASSET ECEDENT'S VALUE OF
TENANT JOINT SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE INTEREST DECEDENT'S INTEREST
1 A 3/25/11 Capital One-checking account 103,029.28 50.000 51,514.64
#7013176889
A 3/25/11 accrued interest 39.70 50.000 19.85
2 A 3/25/11 Capital One-savings account 42.07 50.000 21.04
#5800989398
TOTAL (Also enter on Line 6, Recapitulation) 51,555.53
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
�: �����pennsylvania S C H E D U L E G
����' QEPARTNENT�F REVENUE
INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lois A. D'Esopo 21 13 1025
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERIY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBE INCLUDETHENAMEOFTHETRANSFEREE,THEIR RELATIONSHIPTO DECEDENT VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
AND THE DATE OF TRANSFER.ATTACH COPY OF THE DEED FOR REAL ESATE.
1 All State - IRA Annuity-account 83,357.95
#GA16152691
Owner: Lois A. D'Esopo
Beneficiary(s): Grace Tvaryanas (33.3333%),
Susanne Welitchko (33.3333%) Laurie LaScala
(33.3334%)
See Exhibit 5 -Alistate valuation letter dated
November 11, 2013
2 Citibank, N.A. - IRA- 11,330.37
5 Year Retirement
Certificate of Deposit
account#5985739848
2.50°/o matures 5/4/15
Owner: Lois A. D'Esopo
Beneficiary(s): Grace Tvaryanas (33.3333%),
Susanne Welitchko (33.3333%) Laurie LaScala
(33.3334%)
3 Citibank, N.A. - IRA- 14,123.74
5 Year Retirement
Certificate of Deposit
account#6025035944
2.26% matures 6/29/15
Owner: Lois A. D'Esopo
Beneficiary(s): Grace Tvaryanas (33.3333%),
Susanne Welitchko (33.3333%) Laurie LaScala
(33.3334%)
TOTAL (Also enter on Line 7, Recapitulation) 108,812.06
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (08-13)
: "pennsylvania S C H E D U L E H
� QEPARTMENT OF NEVENUE
FUNERAL EXPENSES AND
RESID NTDECEDENTTURN ADMINSTRATIVE COSTS
ESTATE OF FILE NUMBER
Lois A. D'Esopo 21 13 1025
DecedenYs debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERALEXPENSES:
1 Bryant Funeral Home-funeral services 12,494.37
2 Swindell Florist-flowers 336.25
3 Anthony LaScala -travel and transportation expenses for funeral including 970.82
airfare -518.60; car rental - 317.59; gas, mileage, tolls,
and parking - 134.63
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 35,000.00
Name(s) of Personal Representative(s) Anthony L2SCala
Street Address 104 Sutln PIaCe
city Chestnut Ridqe state NY ziP 10977
Year(s) Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedenYs address is not the same as claimanYs, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 908.50
5. Accountant Fees: 3,000.00
6. Tax Return Preparer Fees:
7 Attorney fees: Emmet, Marvin & Martin. LLP -30,000 (estimated) 38,500.00
Marston Law Offices - 8,500 (estimated)
TOTAL (Also enter on Line 9, Recapitulation) 91,209.94
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-12)
� pennsylvania SCHEDULE I
� OEPARTMENTOFNEVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lois A. D'Esopo 21 13 1025
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical eupens�.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 Pennsylvania Department of Revenue -2013 personal income tax 483.00
TOTAL (Also enter on Line 10, Recapitulation) 483.00
If more space is needed, insert additional sheets of the same size
REV-1513 EX+ (01-10)
: 'pennsylvania S C H E D U L E .7
�!�' 6EPARTNENT DFNEVENUE
INHERITANCE TAX RETURN BEN EFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Lois A. D'Esopo 21 13 1025
NUMBER NAME AND ADDRESS OF PERSON S RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
� � Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and
transfers under Sec.9116(a)(1.2).]
1 Susanne Welitchko Daughter 353,805.59
185 AJK Blvd. #160
Lewisburg, PA 17837
2 Grace Tvaryanas Daughter 353,805.59
38 Market Lane
Greenwich, NJ 08323
3 Laurie LaScala Daughter 405,361.23
104 Sutin Place
Chestnut Ridge, NY 10977
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:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
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.
7121494
Estate of Louis A. D'Esopo
SS#238-32-0863
PA Form Rev-1500
Schedule J - Beneficiaries
Beneficiarv: Amount
Susanne Welitchko
Annuities 36,270.65
1/3 share Pennsylvania taxable residuary estate
(see attached calculation) 317,534.94 353,805.59
Grace Tvaryanas
Annuities 36,270.65
1/3 share Pennsylvania taxable residuary estate
(see attached calculation) 317,534.94 353,805.59
Laurie LaScala
Joint tenancy property 51,555.53
Annuities 36,270.76
1/3 share Pennsylvania taxable residuary estate
(see attached calculation) 317,534.94 405,361.23
Total 1,112,972.41
Schedule J Estate of Lois A. D'Esopo
7121494
ESTATE OF LOIS A. D'ESOPO
SOCIAL SECURITY NUMBER: 238-32-0863
Form REV-1500, Pennsyivania lnheritance Tax Return
Index of Exhibits
EXHIBIT 1: Attorney certified copy of Will
EXHIBIT 2: Copy of Decedent's death certificate
EXHIBIT 3: US Savings Bonds, Series EE - list and valuations (Schedule B, Item 6)
EXHIBIT 4: US Savings Bonds, Series EE - list valuations (Schedule B, Item 7)
EXHIBIT 5: Copy of Allstate Valuation letter dated November 11, 2013
(Schedule G, Item 1)
PA Index of Exhibits Estate of Lois A. D'Esopo
STATE OF NEW YORK )
) ss..
COUNTY OF NEW YORK )
I, BARBARA LYNN PEDERSEN, an attorney-at-law admitted to practice in the
Commonwealth of Pennsylvania, do certify that the annexed copy of the Last Will and
Testament of LOIS D'ESOPO is a true copy of the original thereof.
Dated: May 19, 2014
Barbara Lynn Pede en
7126832_1.DOC
....-----'
...._--�
_. _
�
��� � �n� �. ,Q �111�'�l�
� �
��
LOIS D'ESOPO, 1423 Lower Demunds Road,Dallas,Luzerne County,
Pennsylvania,being of sound and disposing mind,do make,publish and declare this to be my
Last Will and Testament,hereby revoking all Wills and Codicils heretofore made by xne.
��: I direct that a11 my f•ar.eral exp�nses,cos±s of placi:.g a g.r�ve marker and
the sum necessary to arrange for the perpetual care of my grave shall be paid ftom my residuary
Estate as soon as practicable after my decease,as part of the expense of the Administration of my
Estate �direct that my place of burial be at Celestial Garder�=,is V:an�mF.r?,?v�.L:;Cw o'.iiia.
,F�OND: All tangible property,real as well as personal,of every nature and
wheresoever situate,owned by me at the time of death,I hereby give,devise and bequeath my
husband,MICHAEI,D'ESOPO,as his sole and absolute property.
THIRD: In the event that m��husband;MICHAEL D'ESOPO,predeceases
me or fails to survive me by thirty(30)days,I d rect that my Estate be divided in the following
manner:
A. I hereby give,devise and bequeath my property located at 1423 Lower Demunds
Road,Dallas,Luzerne County,Pennsylvania,to my children.in the fo�lowing percentages:
(l) Forty(40%)percent to my daughter,SUSANNE WELITCHKO;
(2) Thirty(30%)percent to my daughter,CifiACE TVARYAIvA.S;
�;;� Thiriy(30%)percer.t to my daughter,L_AiTRLE LaSCAI,A;
B. Al]tangible property,real as well as personal,of every nature and wheresoever
situate owned by me at the time of my death other than the items specifically bequeathed in Sub
Paragraph A of this Paragraph Third above,the bequest of which have not lapsed,I hereby give
to my children, SUSANNE WELITCHKO,GRACE TVARYANAS,and LAURIE LASCALA,
to be divided among them by my Executors in as nearly equal portions as may be practical having
due regard to the personal preferences of my beneficiaries.
FOURTH: In the event that any of my children,GRACE TVARYANAS,
SUSANNE WELITCKO or LAURIE LaSCALA,predeceaC.e me or fail to survive me,I direct
that any portion which said deceased child would have received under this,my Last Will and
Testament be given to the surviving children of said deceased child. In the event any of my
daughters,G_itACE TVARYANAS, SUSANNE WELITCHKO or LAURIE LaSCALA,
predeceasec�me without having any of their own children surviving them,I direct that any portion
which said deceased child would have received under this,my Last Will and Testament be divided
among those of my children,GRACE TVARYANAS, SUSANNE WELITCHKO or LAURIE
LaSCALA,who survives said deceased cluld.
� I hereby nominate,constitute and appoint my husband,MICHAEL
D'ESOPO,as the Executor of this,my Last Will and Testament. In the event that my husband,
MICHAEL D'ESOPO shall fail to qualify or cease to act as Executor,I name,nominate,
constitete and appoint ANTHONY LaSCALA,±o act as Exe.cutor in tiis place.
�IXTH: I direct that any Executor should not be required to give any bond and that
if not withstanding this direction any bond is required by any law,statue,or rule of court,no
sureties shall be required thereon.
IN WITNESS WHEREOF,I have hereunto set my hand and seal to this,my Last Will
-r��
and Testament,this '�-�day of� 1998.
� r� / �
_ ,� ��� l,�i.r �
IS D'ESOPO
SIGNED,SEALED,PUBLISHED ANil DECLARED by the above-named Testatrix,
LOIS D'ESQPO,as a.^.�?for her.Last Will.and Testzmen;,i:�t�E�resence of us,who,in her
presence,at her request,and in the presence of each other,have hereunto subscribed our names as
witnesses thereto.
�'t�^',� /r 1
— �
j -,�residing at '
��
� /'
� , � � '��'�..�<�.l% ,i;,G.�1'.�- > Y�'
� �(,p/� ) ' ` YL� residing at � ,
�
COMMONWEALTH OF PENNSYLVANIA .
. SS.
COUNTY OF LUZEI2NE •
I,LOIS D'ESOPO,the Testatrix,whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law,do hereby aclrnowledge 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 stated.
Sworn or ai�irmed to and acknowledged before me by LOIS D'ESOPO,the Testatrix,
,��y�- ,.
this�"day of ��,1.L: �� , 1998.
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.�L IS D'ESOPO ,
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JOS H PROCIAK,ESQUIItE
Me er the Bar of the
Supreme Court of Pennsylvania
COMMONWEALTH OF PENNSYLVANIA .
. SS.
COUNTY OF LUZERNE •
� �/"� �, .y� d ���I l tA � � �,the witnesses whose names
WE, — —�'
are signed to the attached or foregoing instrument,being duly qualified according to law,do
depose and say that we were present and saw the Testatrix sign and execute the instrument as her
Last Will and Testament,that she signed wiilingly and she executed it 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 the time
eighteen(18)or more years of age,of sound mind and under no constraint or undue influence.
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70SEP J. ROCIAK,ESQUIRE
Memb of, e Bar of the
Supreme Court of Pennsylvania
COMMONWEALTH OF PENNSYLVANIA .
. SS.
COUNTY OF LUZERNE .
�/`�El
On this,theG7�`day of��� 1998,before me a Notary Public,the undersigned
of�icer,personally appeared JOSEPH J.PROCIAK,ESQUIRE,known to me or satisfactorily
proven to be a Member of the Bar of the Supreme Court of Pennsylvania,and certify that he was
personally present when the foregoing Acknowledgment and Af�'idavit were signed by the
Testatrix and witnesses.
IN WITNESS WHEREOF,I hereunto set my hand and official seal.
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NOTARY PUBLIC
Notarial Seal
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WARNlR3�: It is illegal to du�lieafe th6s cc�pY bY pt�ot�s#aY or phcatograph.
�ee foz•this certificaEe. $b.OU ,,�r�' Th15 is to certif'� that the infonnation here �iven is
,�i''"�,P��.�---��Fry,y'= c�ireet�v cupie��fi�ou��n orib na1 Cef•tificate af Death
��'„'��% ��=, c�tily filecl with me as Local Regist��ar. The ori�ina]
�a`�,� °� p� c�rtificate t��ill b� foru arded to the 5tate Vital
;�� �`3 n, Rcct�rd� Office for permanent fiiing.
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Certificatian Nuinbe�- ~```="°""""""F� Locai R�:� st��ar Date Issued
pe/VMnI In COMMONWEALTH OF PENNSVIVANIP��EPARTMENT Of HEALiH•VRRL RECONOS
^^a^<^� CERTIFICATE Of DEATH Sta[eF1leNUmber:
31xk InM
1.Decedent's Legal Name�Flrst,MMCIe,last,SuHiv) 3.Se* 3.Soclal Secunry NumEer 6.Dare of peath�MO/Day/Y�I(Spell Mo�
Lo�S za1; �'rs F aa - .�- s�3 /�.. �zs ao 3
Sa.PBeiart BirtMry�Yrs� Sb.Under 1 Vear Sc.Under 10 6.Dah ot 81rt��MO/Day/Vear�(SpeII Month� ]a.8irthplace�Clry an Sta� reign Country)
Months Days Hours Minures
g�o �C:rn�er .2 19:?b in.�nnoi.alcW�M
Ba.Residen<e�5ta[eorfarelgnCOUn[ry) Bb.Residence�5[rcetandNUmber�IncludeAplNO.� &dd�ecedenllivelnatownshi07
p �fae�.e���n�am Lo �er ���e.-� �wo.
Bd.Pesldence�Counry) $a 2e
�'Um I 8e.Pesiderrce(Lp Cotle� �'7 O// � ❑NO,decedmt llved within limih of oN/��°�
9.Ever In US�A.�rmed Fortes] 10.Marital Status at Tlme of peath ❑Marrled ��'✓idowed 11.SurviNng Spouse's Name�II wife,gNe vme Oriw to Hrs[marrlage�
❑Ves pdno ❑UnknoWn ❑OWOrced ❑NeverMarrled ❑Unknown
13.FatM1er's Name(Flnt,Middle,last SuHIV1 13.MotheYS Name Vrior W First Marrlage(ilrrt,Mlddle,last)
�i'u E. L i. 's L
l0a.1n10/mant'tName 16b0.lI�HansAlplaDecedent lOt.inb�man�'iMaillneRdEflss�5heeaMNUmbe/.CIry,51a[e,21DCOde� �a977
a /�, ' L a S'c a_ I� L.• I o vp '� a. 2,'
G tsa.r ce o ea� c �ry o�e ......... ..... .............. _.
A ....................._a.......................................................................................... .
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........... ..... . ........... ..... ..........
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i IIOea[hOCCUneLlnaHOSpital: I��nO���ent �IfOea,.[h./OCC�rretl5wnewhereOMerThaneHOSpkal: CYMOipittFatlll[y [�JDecedent'sHOme
❑Emer{mryPOOm/Ou[patient ❑DeadonArrival �yr.ursiiyHome/lung-TermGreFaclllly ❑Other(Speclfy)
ag 15b.Faciliry Name�1f not instltutlm,give strcN and number, �15c.Cty or Town,State,and 2ip Code SStl.Coun[y ot DeatM1
�,.. /�o�� G.,,�.beJ-lo.n
„ 16a.Me[hod of DisposHbn ❑Bu�lal ❑CremaHOn i6b.Dale of sposi[ion .Vlace of 0i5pasition(Name ot cemetery,cremalory.or ather place�
o �moval(rom Sla[e ❑Dona[ion � � �
� ❑an�.tsacihl 5�..;ts e7o%3 C�Ies' G r r
36d.Loo[lon ot Dlspositbn(Olyo�Town.Sta[e,and ID) 3]a.5lgnatu funeral i Licensee or Person I Charge of Intermeni 1Ib.Ucenu N�mber
y G � ' ,�J FpD�37u�(L
� iu.r++m�+�eeomoi�eenee«::o cuo�niv+�a�n � _ , , �7°�
s . , ,,• m �<.L..�
18. cMent's Eduotlm eck[he box that best desaibes[he 19.Deced<nt o(Nispan rlgin-Check the 30.Oeceden['s Race-Ueck ONE OX MORE nces m Indiw hat
r° �IghestEe(reeorkvelolschoolcanplehdattheHmeotdeath. bo+tha[best4scribeswhethuMetlecMen� ihe�d edentconsideredhlmselforhenel(tobe.
❑8thpaCeatlezs IsSpanish/Hlspanlc/Latino.Checkehe'NO" B'�/hrte ❑I(orean
❑�,(Nadlploma,9M-I1Ngratle b�o,�/ildeceEmtisno[Spanlih/HlspaniJ�atino. ❑BlackorAfricanAmerlcan ❑Vielnamese
�nl`�schoolgraduateorGEOrompltteE �nO,�mSpaNSh/Hispanic/LaHno ❑AmerlcanlndlanorRlaskaNanve ❑OtherASian
❑Same wllege cretli[,but iw degrce ❑Y<s,Mexican,Mex�can Rmerkan,Chkano ❑Asian Indlan ❑Nati�e Hawailan
❑nssocwc�aee�•e I�.a.�+.�I ❑res,w.rto aK.o O��^e:� ❑Guamanian or Chamorto
❑e��,�ror:a.a.H i..s.ea ne,esi ❑r�.,cow� ❑FIIlpino ❑s.mo,�
�Mazter's EeQree(e.g.MA,MS,MEng.MEC,MSW.MBA� ❑Yes,othe�Spanlsh/HYSpanic/ln[ino �lapanese ❑Other Paciiic IslanEer
❑pocrorste(e.g.P�O,EEO)w Vrohssbiul Ee6�ee �so«iNl_ ❑oener 15oeciryl
.M0,DDS,DVM LLB 10
I1.Oec�Q ent's5ingleRaceSelf-Desi{natlon�CheckONlYONEloindlatewhatNeEecetlmtcanslderetlhlmselforherseH[oEe. 23a.Deceden['sUSUalOttuOation-IndlcateryDeofwork
�4htte ❑lapanese ❑Samoan donetluringmoslofworkinglife.DONOTUSERETiqED.
❑Blad or African American ❑Korean ❑Other va<Iflc islander ��I e
❑Amarkan Indian or Plaska Na[We ❑Vletnamese ❑Don't Know/Nm iu�e
❑Aslan InAlan ❑Other Asian 0 RehuE E2b.Kind o(Busineu/Industry
�����e 0 NativeHawallan ❑Othe��Specihl
❑Flllpino ❑GuamanianorChartrorra �'��
ITEM523s-t3d MUST 8E COMVLFTED ]3a.Date Proiwunced 0ead(MO/Day/Yr� 23b.5lgnacure ol Verson Yronounung�eaM IOnly when applicabl<) 13c.Liwnse Number �
BV VERSON WHO�AONOUNCES ON �
CENTIFIES OE/TN
73d.Oa4 Signed�Ma/OaY/Yr� za.nm�oi oe��h... � �
� 35.WasMe0ln�ExaminerorCoron<rCOntaclM? ❑Yes No
CAUSE OF DEATH � - - � : non�o.im.re � -
16.YaR L Enter the chi n of events--dlseaus,In�uries,or mmplioHOns-lhat directly nused the doth.DO NOT enhr terminal ev<nls such as ardiac arres[ Interval:
respinmryarrest,arvenMcularfibrlllatbnwlthou[show/in�()t�eetiob�y.DONOT/A$�/EVIATE.EnttronWonecauuonaline.AddaEdltlonallinesilnecessary : OnsettoDea[h
IMMEqATEGlISE �--------> ` ��C '"'u�''�'�
�Flnal Jlsease ar wnEkbn � /� Due ro� a wnsequence o�:
resuhin`in tleathl /�^n�u 'ts� . .
e. _�,([
xnueomiM��s�conemoo:, we m�o.as.�onseQUeoce of1�
If any,ka�lny to the cause . �
IisttL on RM a.Ente�Me q�e la 1�as a conseyu<nce o�:
UNOERLYING GUSE �
(dlsea winjurythat �
� Initiahd Me evenK refulHn` d. -
In death)LAST. D�e ro(or as a conupuence o�'
s 16.Part II.Enter othe�I Ifl tlltl t Ibutl [d Nbut not resultinpin[he undMying cause gWen In Part I � 21.Was an autapsy Oerf inedl
❑Yes �No
� 29.were autopry Ilndings available
f
m o plere[lienuseaftlea[h7
c Q Yes�� �NO�
Y I9.If female: 30.OIE tobacco Use Cantribu�e to Death] 31.Manner ol Death
a �Nat pregnant wlMln Oast year ❑Yes ❑Probably �Natural ❑HpniGde
�Pregnantallimeoldeath [�'NO ❑Unknown ❑Accident ❑FendinglnvesH@ation
�Notpregnant,bulpregnan[wi[hlnaldaysoldeath �Sul<Ide �Cauldnotbetlettrmined
�Natpregnam,WtpregnmtC3daystolyearbeforedea[h 3E.Daleoflnjury�MO/Day/Yr��5pe11MOnN� 33.Pmeofln�ury
❑Unknownlfpregnantwithin[hepastyear
34.vlace ot In�ury�e.g.Mme;mnsttuction site;farm;schoall 35.Loca[ion of In�ury(Stree[anE Number,City,Stale,Zip CoEe�
36.In�ury at Work 3].If iransporta[lon In�ury.SOecify�. 38.Describe How In�ury Occurred'
�Yes ❑�rlver/Oper to �Pedestrlan
�No 0 iassenger J r ❑OtM1er�50ecifYl
39a CertlHerl�ecMOntyone�:
�Certllyln8 0�1's���+�-To the best ol my knowletlge,death accurrtE tlue ta tM1e causels�anE manner stateE
❑pronouncln8&Certilyin hysic �to�h best oi mv knowleEge,death occurred at the time,dale,and Dlace.and Cue to Me cause�sl anE manner sbted
❑MeElcal E�aminer/Car e basl xam�na[1on,and/o�investi8auon,in my oo��ion,death occu�r`retl at the ume.date,and vlare,and due ro the cause�s�r nd�man\nei sbtea
Slenature of urtlller: � Title o!rsrtifier�. �1 v Licerue Number: ��`�S V
�����y �Pe om01etln8UUSeo1/eat�tetei36�,�/��/� .r 39c.Ovae65i��M�V� . .
6 s an (l.s<(I" a
60.P<gishai5 s[rk[N be�` G1.0.eg15[�ai Signature � . 43.RegislrarFlle a[e�MO/Oay/Vr)
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� 43.Amendments
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Alistate�
You're in good hands.
December 20,2013
Anthony La Scala
104 Sutin Place
Chestnut Ridge, NY 10977
Re: Lois A. D Eso o --
P _ _ _ ____ _. _ _ __
-- - � -- - — --
Contract No: GA16152691
Dear Mr. La Scala:
We received a request to complete IRS Form 712 for the above referenced contract. The purpose of FoRn
712 is to provide an estate or donor with the value of a I'rfe insurance contract or its proceeds as of a certain
date(usually the owner's date of death or date of transfer of the contract).
Because this corrtract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
following information for estate purposes:
. Date of Death: August 23,2013
. Annuity Value as of Date o#Death: $83,357.95*
Cost Basis: $0.00
Named Beneficiary: Laurie La Scala,Susanne Welitchko,
Grace Tvarganas
"The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
If you have any questions,please corrtact me at 1-877-499-6418 Ext.24688.
Sincerely,
��9�CS�-�-^-Q
Valarie Mefton
Sr.Claim Examiner
Atlstate Life Insurance Company
Life and Mnuity Claims
P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523