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Home My WebLink About11-20-14 (2) Y 15056051058 REV-1500 EX(06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year_ File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg,PA 17128-0601 RESIDENT DECEDENT 21 1400189�� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02/20/2014 03/02/1930 Decedent's Last Name Suffix Decedent's First Name MI Lujanac Patricia V (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 CW 1.Original Return 2.Supplemental Return C=:) 3. Remainder Return(date of death prior to 12-13-82) C=) 4. Limited Estate O 4a.Future Interest Compromise(date of C= 5. Federal Estate Tax Return Required death after 12-12-82) J 6. 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) C 9. Litigation Proceeds Received C= 10. Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Marvin Beshore, Esquire 1 (717) 236-0781 Firm Name(If Applicable) -- REGISTER OF WILLS USE ONLY ru C First line of address a rT1 130 State Street t' c CD Second line of address :a City or Post Office _ State ZIP Code - , y DATE F Harrisburg PA 17108 rrV F- ---, r CAD —r1 Correspondent's e-mail address: mbeshore@beshorelaw.com 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 com fete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. . U�E F PERSO RESP tfSIBL`E FOR FILING RETURN D E ADDRESS 406 Surnu It Road, New C erlan , PA 17070 SIGNA F EPARE'R OTHE RE E NTATIVE D E ADDRE S I 130 State Street, P.O. Box 946, Harrisburg, PA 17108 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 i.l` Y J15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: Patricia V LUjanac ' RECAPITULATION 1. Real estate(Schedule A). ............................................ 1.! 111,102.48 I i 2. Stocks and Bonds(Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. i 0.00 i 4. Mortgages&Notes Receivable Schedule D 0.00 5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E) ........ 5. 27,257.53 i I 6. Jointly Owned Property(Schedule F) TKO Separate Billing Requested ....... 6. 2.58 ' 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. 0.00 i 8. Total Gross Assets(total Lines 1-7).................................... 8. 138,362.59 9. Funeral Expenses&Administrative Costs(Schedule H)..................... 9. i 28,600.20 10. Debts of Decedent, Mortgage Liabilities,&Liens(Schedule 1)................ 10. ; 35,847.33 11. Total Deductions(total Lines 9&10)................................... 11. 64,447.53 I 12. Net Value of Estate(Line 8 minus Line 11).............................. 12. 73,915.06 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. ' 73,915.06 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ i 16. Amount of Line 14 taxable ` at lineal rate X.045 73,915.06 16. j 3,326.18 17. Amount of Line 14 taxable at sibling rate X.12 I 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE......................................................... 19. 3,326.18 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059' Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 14 00189 DECEDENT'S NAME DECEDENTS SOCIAL SECURITY NUMBER Patricia V Lujanac STREETADDRESS 1512 Brandt Avenue CITY STATE ZIP New Cumberland PA 17070 Tax Payments and Credits: 1. Tax Due(Page 2 Line 19) (1) 3,326.18 2. Credits/Payments A.Spousal Poverty Credit B.Prior Payments "' C.Discount Total Credits(A+B+C) (2) 0.00 3. Interest/Penalty if applicable D.Interest E.Penalty Total Interest/Penalty(D+E) (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) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3,326.18 A.Enter the interest on the tax due. (5A) 0.00 B.Enter the total of Line 5+5A.This is the BALANCE DUE. (56) 3,326.18 Make Check Payable to: REGISTER OF WILLS,AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income;............................................ ❑ c. retain a reversionary interest;or......:................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death.occurred after December 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? ........................................................................................................................ ❑ ❑fc IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE.G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three(3)percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero(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 twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,or a stepparent of the child is zero(0)percent[72 P.S.§9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half(4.5)percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve(12)percent[72 P.S.§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. 4 y -.,.ra i J LAST WILL AND TESTAMENT c ' ' CA3 OF PATRICIA V.LUJANAC I,PATRICIA V.LUJANAC,now domiciled in Cumberland County,Pennsylvania,declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. Article I My just debts and expenses of my last illness,funeral,and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance,estate,and succession taxes(including interest and penalties thereon,but not- including any generation skipping tax)payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary esiate without reimbursement from any person. In the event that my residuary estate is not sufficient to satisfy such payments, then such payments shall be equitably apportioned among those beneficiaries to whom any benefit from my estate accrues,in the proportion that the value of the property or interest received by a beneficiary bears to the total value of the property and interests received by all such beneficiaries.This provision ti is not a waiver of any right which my Executrix has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article III I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed,located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death,and if there is a conflict,the memorandum having the latest date shall govern. Article IV I give,devise and bequeath my bedroom furniture to my daughter,MARY D.LUJANAC,of Rome,New York. Article V I give, devise and bequeath a LIFE ESTATE in my real estate located at 1512 Brandt Avenue, New Cumberland, Cumberland County, Pennsylvania to my son, THOMAS P. LUJANAC,of Cumberland County,Pennsylvania and my daughter,MARY D.LUJANAC,under the condition that they be responsible for all costs, including but not limited to all utilities and maintenance of the real estate and timely payment of all associated taxes. In the event THOMAS P. LUJANAC and MARY D.LUJANAC both die or no longer occupy the house,or fail to meet the above conditions,their life estate shall be terminated absolutely and the real estate,house, and its contents shall be distributed IN EQUAL SHARES to my children,MARY D.LUJANAC, -2 - PAUL T. LUJANAC, of Cumberland County, Pennsylvania, MELANIE S. LUJANAC, of Cumberland County, Pennsylvania, MICHAEL P. LUJANAC, of Summerfield, Florida, THOMAS P.LUJANAC,PATTI L.WEBER,of Dauphin County,Pennsylvania,LEANNE M. LUJANAC,of Cornville,Arizona,JOHN M.LUJANAC,of Sandy Hook,Connecticut,LISA V. McGROARTY of Dauphin County, Pennsylvania and JAN M. FOSTER, of Dauphin County, Pennsylvania,PER CAPITA,NOT PER STIPPES. Article VI All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate,I give,devise and bequeath IN EQUAL SHARES to my children,MARY D.LUJANAC, PAUL T. LUJANAC, MELANIE S. LUJANAC, MICHAEL P. LUJANAC, THOMAS P. LUJANAC, PATTI L. WEBER, LEANNE M. LUJANAC,JOHN M. LUJANAC, LISA V. McGROARTY and JAN M.FOSTER. If any of my beneficiaries predeceases me or fails to survive me by thirty(30)days,I give,devise and bequeath the share he/she would have received to my remaining beneficiaries who survive me by thirty(30)days,PER CAPITA,NOT PER STIRPES. Article VII I understand and direct that my life insurance, annuities, individual retirement accounts (IRAs),in trust for bank accounts and any other assets on which I may designate a beneficiary will pass to the beneficiaries that I have named and will not be controlled by the distribution provisions of -3 - this Will. I also understand and direct that any assets I own jointly with another with rights of survivorship or a presumed rights of survivorship(whether the joint ownership was created before or after this Will) will pass to the surviving joint owner and distribution of such assets will not be controlled by the provisions of this Will. Article VIII If any person(s)or entity(ies)singularly or in conjunction with any other person or entity directly or indirectly,by legal proceedings or otherwise in any court,Register of Wills office, department of court records division or other tribunal that in substance contests the validity of this Will,including any gifts,devise,or other provisions,amendments or codicils thereto for that person or persons under the Will,then the right of that person(s) or entity(ies)to take any interest in my estate shall cease, and that person(s)or entity(ies) shall be deemed to have predeceased me without issue. Article IX I nominate,constitute,and appoint my daughter,MARY D.LUJANAC,as Executrix of my Last Will and Testament. In the event of the renunciation, death,or inability to act,for any reason whatsoever of my Executrix,I nominate,constitute and appoint my son,THOMAS P.LUJANAC, as successor Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond and in addition to those powers granted by law,I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified -4. ti disclaimer I could have filed if living, My Executrix or successor Executor shall receive reasonable compensation for services rendered to my estate. Article X In addition to the powers conferred by law,I authorize my Executrix and successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale,any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments,and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, (g) to make distributions in cash or in kind, or in both,and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, -5 - 4 1 (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, (j) to file any qualified disclaimer I could have if living, and (k) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, PATRICIA V. LUJANAC, hereby set my hand to this my Last Will and Testament,on 9'3 2010. PATRICIA V.LUJANA In our presence,the above-named PATRICIA V.MANIAC signed this and declared this to be her Last Will and Testament and now at her request,in her presence,and in the presence of each other,we sign as witnesses. ? Name Address .845 Sir Thomas Court.Suite 12,Han isbure.PA 17109 Au Pa�� if "�j I`� 845 Sir Thomas Court,Suite 12,Harrisburg,PA 17109 - 6 - I,PATRICIA V.LUJANAC,Testatrix,who signed the foregoing instrument,having been duly qualified according to law,acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by PATRICIA V.LUJANAC,the Testatrix on (y �3 , 2010. AotaryVublic PATRICIA V.LUJA AC NOl'ARIAL SEAL JACQUELINE A KELLY Notary public CITY OF HARRISBURG, DAUPHIN COUNTY My Commission Expires Dec 17, 2011 We, the undersigned witnesses who signed the foregoing instrument,being duly qualified according to law,depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will;that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed;that each of us in her sight and hearing signed the Will as witnesses,and that to the best of our knowledge, that she was at that time eighteen(1 S)years or more of age, of sound mind,and under no constraint or undue influence. Sworn to or affirmed and subscri ed to before lie by and rb Z� %I_ , Witness witnesses,on (a .- 2010. Witness N tart'Public �tJOTARIAL SEAL JACQUELINE A KELLY Notary Public CITY OF HARRISBURG,DAUPHIN COUNTY - 7 - My 7 _My Commission Expires Dec 17, 2011 ' REV-1502 EX+(11-08) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule R Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 Single family dwelling located at 1512 Brandt Avenue,New Cumberland,PA;transferred to 111,102.48 decedent by deed dated September 25,2000 and recorded in the Office of the Recorder of Deeds for Cumberland County in Book 229,Page 1049. " Contract sales price,including adjustment for taxes,as shown on attached HUD-1 TOTAL(Also enter on.Line 1, Recapitulation.) $ 111,102.48 If more space is needed,insert additional sheets of the same size. OMB No.2502-0265 B. TYPE OF LOAN A. SETTLEMENT STATEMENT (HUD-1) 1.❑ FHA 2. ❑ FNMA 3. ❑ CONV.UNtNS. 4. ❑ VA 5. ❑ CONV.INS. 6.FILE NUMBER 7.LOAN NUMBER 14-00136-ALT 8.MORTGAGE INS.CASE NO.: C.NOTE: This form is furnished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agent are shown.Items marked"(p.o.c.)"were paid outside the closing',they are shown here for informational purposes and are not included in the totals. D.NAME&ADDRESS Patrick J.Murphy OF BORROWER: 308 Eleventh Street,New Cumberland,PA 17070 E.NAME&ADDRESS The Estate of Patricia V.Lujanac OF SELLER: F. NAME&ADDRESS Maureen.R.Muiphy OF LENDER: 1510 Brandt Avenue,New Cumberland,PA 17070 G.PROPERTY LOCATION: I512 Brandt Avenue,New Cumberland,PA 17070 K SETTLEMENT AGENT: Assured Land Transfers,Inc.301 Market Street,Lemoyne,PA 17043(717)761-4720 PLACE OF SETTLEMENT:Michael L.Bangs,Esquire 429 South 18th Street Camp Bill,PA,17011(717)761-4720 1. SETTLEMENT DATE: 10/29/2014 J. Summary of Borrower's Transaction K. Summary of Seller's Transaction 100.Gross Amount Due From Borrower: 400.Gross Amount Due To Seller: 101.Contract sales price 110 000.00 401.Contract sales price 110 000.00 102.Personal property 402.Personal property 103.Settlement charges to borrower.(line 1400 2,884.5 403. 104. 404. 105. 405. Adjustments For Items Paid By Seller In Advance: Adjustments For Items Paid By Seller In Advance: 106.City/town taxes to 406.City/town taxes to 107.County taxes 10/29/14 to 12/31/14 161.29 407.County taxes 10/29/14 to 12/31/14 161.29 108.Assessments to 408.Assessments to 109.School Taxes 10/29/2014 to 6/30/2015 914.54 409.School Taxes 10/292014 to 6/30/2015 914.54 110.Trash Charge 1029/2014 to 12/31/2014 26.65 410:Trash Charge 10292014 to 12/312014 26.65 111. 411. 112. 412. 113. 413. 114• 414. 115. 415. 116. 416. 120.Gross Amount Due From Borrower: N113,986.98 420.Gross Amount Due To Seller: 111,102.48 200.Amounts Paid By Or In Behalf Of Borrower: 500.Reductions In Amount Due To Seller: 201.Deposit or earnest money 1,000.00 501.Excess deposit(see instructions) 202.Principal amount of new loan(s) 55 000.00 502.Settlement charges to seller(line 1400) 11 125.24 203.Existing loan(s)taken subject to 503.Existing loan(s)taken subject to 204. 504.Payoff Ist Mtg.Ln. 205. 505.Payoff 2nd Mtg.Ln. 206. 506.Deposit To Seller 1.000.00 207. 507. 208. 508. 209. 509. Adjustments For Items Unpaid By Seller: Adjustments For Items Unpaid By Seller: 210.City/town taxes to 510.City/town taxes to 211.County taxes to 511.County taxes to 212.Assessments to 512.Assessments to 213.Sewer Charge 10292014 to 12/31/2014 52.91 513.Sewer Charge 10292014 to 12/312014 52.91 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220.Total Paid By/For052520.Total Reductions 12,178.15 Borrower: 56, .91 In Amount Due Seller: 300.Cash At Settlement From/To Borrower: 600.Cash At Settlement From/To Seller: 301.Gross amount due from borrower(line 120) 113 986.98 601.Gross amount due to seller(line 420) 111 102.48 302.Less amount paid by/for borrbwer(line 220) 56 052.91 602.Less reductions in amount due seller(line 520) 12 178.15 303.Cash(FROM) GTO)Borrower: 57,934.07 603.Cash(Oro) (❑FROM) Seller: 98,924.33 Previous Edition Is Obsolete S134-3538-000-1 Forth No.1581 HUD-1(3-86) 3/86 RESPA,HB 4305.2 X Pagel of 3 ){ X X SETTLEMENT CHARGES Escrow:14-00136-ALT 700.Total Sales/Broker's Commission: Paid From Paid From Based On Price $ %= Borrower's Seller's Division of Commission line 700 As Follows: Funds Funds At At 702.S to Settlement Settlement 703 Commission paid at settlement 704. 800,Items PaXa ble In-Connection With Loan: 80 1 an Origination fee % 802.Loan Discount % 803.ApRraisal fee to: 804.Credit re ort to: 805.Lender's inspection fee 806.Mortmj4e,insurance a lication fee to 807,Assumption fee 08. 809. 810. 811. 812. 83 814. 815 816. 81 818. 1 820. 821. 900.Ttems Reauired 13Y Lender To Be Paid In Advance: 01.Interest from I0/29/2014 to // da 0 days) 02.Morta e insurance Rrernium for mo.to 903.Hazard insurance premium for s.to 4.Flood insurance premium for to 905. 906. 1000, Reserveg Deposited With Lender- 100 . Hazard rance 0 months 04 S 0.00 per month 1002. Morta e insurance 0 months @ S 0.00 per month 1003. Ci roe taxes 0 months 0.00 per month 1004. County roe taxes 0 months @ S 0.00 per month 1005. Annual assessments 0 months g S 0.00 per month 1006 Flood insurance 0 months 0.00 permonth 1007. School Tax Reserves 0 months @ S 0.00 per month 1008, Aiz=eate Adiustment 1009. 1100, Title.Charges 1101 Settlement or closing fee to 1102. Abstract or title search to 1103, Title examination to 1104 Title insurance binder to 1105. Document pre aratio to 1106. Notary fees to 1107. Attorney's fees to (includes above item Numbers: ) 1108. Title insurance to.Assured Land Transfers,Inc.(Sale) (includes above item Numbers: ) 950.00 1109. Lender's covera e 1110. Owner's coverage 110 000.00 Premium: $950.00 1 . 1112. 1113. 1114. Notary Fee to Cash 10.00 10.00 1200, Government Recording and Transfer Charges, 1201. Recording fees: Deed 80.50 :Mortgage 4.00 :Releases 0.00 174.501 1202. City/county tax/stamps:Deed 0.00 Mortgage S 0.00 1203. State tax/Stamps: Deed Z200.00 0 •Morta e S 0.00 1,100.0 1100.00 1204. 1205. 1300, Additional Settlement Chames-, 1301. Survey to 302. Pest inspection to 1303. Held In Escrow For PA Inheritance Taxes to.Assured Land TransfersInc. 9,900.00 1304. 3rd Qtr Sewer to New Cumberland Borough 76.64 1305 4th Qtr Trash to New Cumberland Borou h 38.60 1306. Attomgy Fee to Michael L Bans ire 650.00 1307. 1308. 1400- Total Settlement Chn r;ye (Enter online 103 Section J-and-line 502 Section K 2 884.50 I 125.24 Form No.1582 Page 2 of3 SBA-3538-000-1 X X X X SELLER'S AND/OR BORROWER'S STATEMENT Escrow: 14-00136-ALT I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and disbursements made on my account or by mein this transaction.I further certify that I have received a copy of the HUD-1 Settlement Statement. Bo wers rchase Sellers "3 of Th Estate ofPatriciaV Tan P trick J.Murphy /� By: �Lqjc, /iJ Mary Executrix The HUD-1 Settlement Statement which I have prepared is atrue and accurate account of this transaction.I have caused or will cause the funds to be disbursed in accordance with this statement. J Settlement Agent: Date: Title Officer,.Assured Land Transferolnc. WARNING:It is a crime to knowingly make false statements to the United States on this or any other similar form.Penalties upon conviction can include a fine or imprisonment.For details see: Title 18 U.S.Code Section 1001 and Section 1010. Page 3 of 3 REV-1508 EX+(6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. New Cumberland Federal Credit Union(Acct.No.xx135)-Savings 5.00 2. New Cumberland Federal Credit Union(Acct.No,xx135)-Money Market 1,894.29 3. New Cumberland Federal Credit Union(Acct.No.xx135)-Dividends 21.59 4. New Cumberland Federal Credit Union(Acct.No.xx135)-CD 11 24,363.56 5. PSECU-Interest 0.05 6. PSECU-Savings 5.00 7. PSECU-Checking 377.94 8. Members 1st(Acct No.xxx91-00)-Savings -118.00 9. Health Management Associates,Inc.-Refund 37.59 10. County of Cumberland-Burial Allowance Refund 100.00 11, Spirit Physician Services,Inc.-Refund 20.51 12. Miscellaneous personal property 550.00 i TOTAL(Also enter on line 5,Recapitulation) $ 27,257.53 (if more space is needed,insert additional sheets of the same size) New Cumberland Federal Credit Union Your Community Credit Union P.O.Box 658,New Cumberland,PA 17070-0658 .Phone: (717)774-7706 1-800-716-2328•Fax: (717)774-7996•Web: www.ncfcuonline.org May 1, 2014 Law Offices of Marvin Beshore 130 State Street P.O. Box 946 HI arrisburg, PA 1-11108-0946 RE: Estate of Patricia Lujanac Dear Ms. Swartz, Pursuant to your letter dated April 29, 2014, the information you requested is as follows: Account#: 74135 DateOpened: 3/17/2008 Account Title: Patricia Lujanac DOD Balance: Savings $ 5.00 Money Market $ 1,894.29 Checking $ -0- CD 11 $24,363.56 Loan 3 (Car Loan) $14,960.95 Loan 4 (%.Iar Loa-.n) $16,563.63 Dividends DOD: $ - 21.59 Account 75462 Date Opened: 8/11/1998 Account Title: Patricia Lujanac Chelsea N. Foster DOD Balance: Savings $ 5.00 Checking $ .16 Patricia Lujanac did have a safe deposit box with the Credit Union, Box #67, Mary and a representative from the Credit Union did open the box, but the box was found empty. If you need anything additional, pertaining to this matter, please do not hesitate to contact me directly. Sincerely, . i Barbra J. Wright Branch Manager Enclosures 1� e 'd 5��u h j PSECO 05/02/2014 LAW OFFICES OF MARVIN BESHORE TARA L SWARTZ 130 STATE STREET PO BOX 946 HARRISBURG PA 17108 Re:PATRICIA V LUJANAC,Deceased. PSECU Reference#699920.1420417 Dear Tara L. Swartz: The above referenced person has an account with PSECU which was opened on 10/26/2006.The Share accounts were individually held by PATRICIA V LUJANAC. The following are the Date of Death Balances for PATRICIA V LUJANAC's account with PSECU: Account Date of Death Balances Interest—February 1-20 Savings (S1) $ 5.00 $0.00 Checking (S4) $377.94 $0.05 The account has been closed. If you have any questions,please contact our department toll-free at(800)237-7328,press 6,extension 3120 or email accountservices@psee-u.com. SincereI Sherry Getz Member Service Representative PSECU P. O. BOX 67013 HARRISBURG, PA 1 71 06-701 3 800.237.7328 >>psecu.com THIS CREDIT UNION IS FEDERALLY INSURED BYTHE NATIONAL CREDIT UNION ADMINISTRATION.EQUAL OPPORTUNITY LENDER. St e MEMBERS 1" FEDERAL CREDIT UNION REGULAR SAVINGS ACCOUNT Account Number/Suffix 29091-00 Date Account Established 01/08/1982 Principal Balance at Date of Death -$118.00 Accrued Interest to Date of Death $0.00 Total Principal and Accrued Interest -$118.00 Name of Joint Owner None SAFE DEPOSIT BOX: None MEMBERS 1" FEDERAL CREDIT UNION V Tessa L Klugh 07 Lending Insurance Support Specialist May 14, 2014 Estate of: PATRICIA V LUJANAC Date of Death: 02/20/2014 Social Security Number: 5000 Louise Drive P.O.Box 40 Mechanicsburg,Pennsylvania 17055 (800) 283-2328 www.memberslst.org m "i" ED V1 PARTHEMORE Funeral Home & Cremation Services, Inc. February 26,2014 1303 Bridge Street Ms.Mary D.Lujanac. P.O.Box 431 406 Summit Road New Cumberland;PA 17070 New Cumberland,PA-17070 PH:(717)774-7721 Dear Ms.Lujanac, FX:(717)774-5546 www,parthem6re.corn Enclosed, please fmd the following document which I have prepared with the information provided by your father's DD214; (a)Cumberland County Application for Spousal Burial Allowance The Cumberland County Burial Allowance of$100.00 will be sent directly to Gilbert W.Parthemore your home.address. Founder Please sign the document where I have highlighted and mail all pages to Gilbert J.Parthemore 'Cumberland County using the pre-addressed stamped envelope provided. Supervisor Stephen K.Parthemore Please feel free to contact me with any questions or concerns. President,CFSP Respectfully, Bruce R.Parthembre Pre-Need Coordinator,CPC4�b �5�_ Yvonne Sersch �.� -- •_�. .�" .� �.n... Office Manager . Professional Memberships: Enclosures . 2 Pennsylvania Funeral Directors Association M r M li I: R Order of th, Golden Rule REORDER 805•U.S.PATENT NO,5538290,5576508,5641;83,5785353.5484364,80300( 999023254 MARY D. LUJANAC CHECK NUMBER $92$6(} DATE 03j21/14 . INVOICE NUMBER D 'TE:... DESCRIPTION• GROSS AMT. DISCOUNT. :NET.AMOUNT. 30714VA 03/07/14 P. Lujanac - Bu 100.00 0.00 100.00 r "�A County of Cumberland TOTALS: 100.00 0.00 1100.001 PLEASE ADDRESS ANY CORRESPONDENCE REGARDING THIS VOUCHER OR TRANSACTION TO THE OFFICE OF THE CONTROLLER,CUMBERLAND COUNTY COURT HOUSE,CARLISLE,PA.17013. IF PAYING BY CREDIT CARD,FILL OUT BELOW CHECK CARD USING FOR PAYMENT SPIRIT PHYSICIAN 0 0 a DISCOVER 93 MASTERCARD nvow CARD SAMOUNT ERVICES NC SIGNATURE NUMBER CW EXP.DATE I A SERVICE OF HOLY SPIRIT HEALTH SYSTEM STATEMENT DATE PAY THIS AMOUNT ACCOUNTNEIR 02/19/14 -$20.51 15095 I DEMAND ENCOUNTER LETTER 954277 SHOWAMOUNT IPAID HERE $ ADDRESSEE: REMIT TO: nlllulllnlnillnIIIII I Is IIIIIIII IIIIIIIIII fill IIIIIIIIIIIIIII Patricia Lujanac Spirit Physicians Services Inc 1512 Brandt Avenue 205 Grandview Ave New Cumberland, PA 17070 Suite 210 USA Camp Hill, PA 17011-1708 USA 0 Please check box if above address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Information has changed,and indicate change(s)on reverse side. 02/19/14 Dear Patricia Lujanac We have received an overpayment in the amount of -$20.51 for services rendered by Ciccarelliv, Clem A on 04/26/2013 This payment exceeds the amount due. Attached is a check for the amount of the overpayment. If you have any questions, please contact the Patient Accounting office at (717) 972-4490 Sincerely, Spirit Physicians Services Inc HEALTH MANAGEMENT ASSOCIATES, INC. CARLISLE REG MED CTR 1700 0163418 12/03/2013 1408148 OVERPAID 37.59 a • REV-1509 EX+(6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 If an asset was made joint within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A•Chelsea N. Foster 5013 Haverford Road,Apt. D. Granddaughter Harrisburg, PA 17109 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 08/11/98 New Cumberland Federal Credit Union(Acct No.xx462)-Checking 0.16 50 0.08 2• A. 08/11198 New Cumberland Federal Credit Union(Acct No.xx462)-Savings 5.00 50 2.50 TOTAL(Also enter on line 6,Recapitulation) $ 2.58 (If more space is needed,insert additional sheets of the same size) REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Parthemore Funeral Home&Cremation Services,Inc. 7,080.52 2. Wegmans Catering Event Service 145.96 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 3,200.00 Name(s)of Personal Representative(s) Mary D. Lujanac Street Address 406 Summit Road City New Cumberland State PA zip-17070 Year(s)Commission Paid: 2014 Z. Attorney Fees: 7,500.00 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) 3,500.00 Claimant Thomas P. Lujanac Street Address 1512 Brandt Avenue City New Cumberland State PA zip-17070 Relationship of Claimant to Decedent—Son 4. Probate Fees: 358.80 5. Accountant Fees: 6, Tax Return Preparer Fees: 7. Members 1st Credit Union(start-up checks) 16.95 8. Cumberland County Register of Wills(FSA and Petition for Adjudication) 35.00 9. Robin Gasperetti,Tax Collector(2014 Real Estate Taxes) 1,827.82 .10. Verizon(telephonerintemet bill) 151.96 11. PPL(utility bill) 228.59 Total Expenses and Costs listed on additional page 4,554.60 TOTAL(Also enter on Line 9,Recapitulation) $ 28,600.20 If more space is needed,use additional sheets of paper of the same size. Schedule "H" - Continued Funeral Expenses and Administrative Costs 12. Pennsylvania American Water(utility bill) $ 123.07 13. Mark Heckman Real Estate (appraisal) $ 400.00 14. PA Department of Revenue (2013 income taxes)* $ 32.00 15. Internal Revenue Service (2013 income taxes) $2,060.00 16. PA Department of Revenue (realty transfer tax) $15100.00 17. Jan L. Brown, Esquire (estate administration consultation) $ 425.00 18. New Cumberland Borough(sewer)* $ 129.55 19. New Cumberland Borough(trash)* $ 38.60 20. Notary fees* $ 10.00 21. The Patriot-News (legal publication) $ 231.38 22. Cumberland Law Journal(legal publication) $ 75.00 Total Additional Expenses and Costs: $4,554.60 * See HUD-1 attached at Schedule"A" o - r ntwxn f Caring' PARTHEMORE Fund & Crem, ation Services; Inc. Ms.Mary D.Lujan 406 Summit Road . ` 2121/2024 New Cumberland,PAO 0 For the Services of Patricia V.Lujanac 1303 Bridge Street PO.Box 431 New Cumberland,PA 1707,0 We sincerely appreciate the confidence you have placed in us and will continue to assist.you in every way we can. Please feel free to contact us.ifyou have any questions in regard to this statement. The following PFI:(717)774-7721 is an itemized statement of the services,facilities,automotive equipment and merchandise that you selected FX:(7 17)774-5546 when making the funeral arrangements. www.parthemore.com Terms_ Due Date _Ac_co_unt# _ Net 30 3/23/2014 6798.3 Description Amount SERVICES&MERCHANDISE 0.00. Cremation with Memorial Service 4,670.00 Gilbert W.Parthemore. Crerilation Urn 389.00 Founder 2 Gray Terry Bear Keepsake Urns @a $49.00 each 98:00 Guardian Angel Stationery Set 165.00 Gilbert J.Parthemore Supervisor Total Services and Merchandise.• 5,322.00 Stephen K.Parthemore CASH ADVANCE ITEMS 0.00 President,CFSP Death Notice,Harrisburg Patriot 383.52 15 Certified Copies of Ddath Certificate 90.00 Bruce R.Parthemore Clergy Honorarium 200.00 Pre-Need Coordinator,CPC ` Organist Honorarium 125.00 Soloist Honorarium 75.00 3 at$10.each Altar Servers 30.00 Flowers,Red Tulips w/2 White Tulips in Glass Vase 65.00 Cumberland County Coroner Fee,Cremation Authorization 30.00 Grave Opening 700.00 10 Additional Certified Copies of Death Certificate 60.00 Professional Memberships: Total Cash Advances 1,758:52 rPennsylvania Funeral Directors Association kl I. Al B I: R - Order of the n Golden Rule Total _ $7,080.52 PaymentslGredits -$7,080.52 �C88�1 Balance Due $0.00, Catering Event Service Order Wegmans Zarris6urg Thone, 717-791-4510 Contract#:0029233 Fax 717-791-4595 CUSTOMER INFORMATION EVENT INFORMATION Wegmans.com On-Line Orders Event Date: February 25,2014 WEB PREPAY Melanie Thomps oin 2/25/2014 Event Day: Tuesday Melanie Thompson Event Time: 12:00 pm Phone: 717-774-3094 Contact: Melanie Thompson Order Taken By: MENU SELECTIONS Unit of Aprox. —Oty. Measure Name Prep Area Pr'ce I EA COLESLAW-PAN Prevared Kitchen $14.00 I EA COLOR BURST VEGIE TRAY-MD Meal Center $26.99 I EA FRESH FRUIT TRAY-MEDIUM Meal Center $29.99 I EA ARISTOCRAT TRAY-LARGE Deli $54.99 I EA MINI ASST COOKIE TRAY SML Create a Cake $19.99 Total: $ 145.96 SPECIAL INSTRUCTIONS b Confirmation Number: 14220028806 DELIVERY INFORMATION ry Store Copy RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date: 3/03/,2014 Cumberland County - egister Of Wills Receipt Time: 10 : 04 : 03 One Courthouse Sauare Receipt No. : 1077167 Carlisle, PA 17613 LUJANAC PATRICIA V Estate File No. : 2014-00189 Paid By Remarks: MELANIE S THOMPSON HMW ------------------------ Receipt Distribution - ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 25 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15. 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15. 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1450358 . 50 Total Received. . . . . . . . . 858 . 50 ROBIN GASPERETTI,TAX COLLECTOR TAXPAYER'S COPY 1113 BRIDGE STREET NEW CUMBERLAND,PA 17070-1634 KEEP THIS PORTION.FOR YOUR RECORDS TEMP-RETURN SERVICE REQUESTED 0386116"-........AUTO**5-DIGIT 17019 1612 LUJABRANAC,PDAULT AVEL&PATRICIA V I IIIIII VIII VIII VIII VIII VIII VIII VIII IlII ItFI NEW CUMBERLAND PA 17070-1641 To review the assessment data for this property-, go to: www.courthouseonline.com>AssessmentOffice>Cumber and>PropertyRecords Then enter control# 26000978 and password CUPBNKFF ........... ............I.................................... ...........................-...................................-.-.................................................................... ................ *2 trielzKONET11:11:1 R Wilk,I MIZ6111 a E. 0 1 0 Payable To: ROBIN G I ASPERETTI,TAX COLLECTOR Office Hours: TUES 7-11AM&2-613M DURING MARCH APRIL 1113 BRIDGE STREET APRIL 30 7-11AM&2-5PM NEW CUMBERLAND,PA 17070-1634 CLOSED MAY 20&27,JUNE 10&17,DEC 9-29, - JANUARY,2016&ALL HOLIDAYS Bill No: 1636 PH6NE(717)774-7424 Bill Date: 3/11/14 Control No: 26000978 MAP NO: 26-23-0643-614. Desc: 1612 BRANDT AVENUE Assessed Value: Land:64,900 1 Improvement:94,900 Total: 149,800 -P-efi-aTy— HILLSIDE I Discount Face PO LOT 20 SEC E PB I PG 75 County RE -2.196 $322.23 $328.81 .$361.69 Adres 0.3 Deed 0022901049 County Lib 0.143 $20.99 $21.42 $23.66 11111 11111111111111111111111111111111111111 Munic.R/E 3.9 $572.64 $684.22 $642.64 1$1.00 FEE FOR ADDITIONAL RECEIPTS '`~ \ Tax Paver: LUJANAC,PAUL L&PATRICIA V TAX AMOUNT DUE 1512 BRANDT AVE $91676 $934.45 $1,027.89 NEW CUMBERLAND PA 17070-1541 If Date Of Payment is on 311 llil h-rUz*/3-0/1 �-- 6/11/14 thru 6/30/14 711/14 or Later mrmmulql�- -MMI 11MI.T.16MIF.M.01. .......... ....... ......... ........... ....... ...... ...... ...... TAX YEAR:2014-15 REAL ESTATE TAX NOTICE INSTALLMENT PAYMENT 2 NEW CUMBERLAND PAYABLE ROBIN GASPERETTI,TIC (7171774-7424 ononi iru TO: 1113 BRIDGE STREET PROPERTY ID NEW CUMBERLAND,PA 17070-1634 26230543514 TAX SCHOOL-INSTALLMENT PAYMENT 2 • • • { RATE 9,6$ ON OR BEFORE FACE DATE AFTER PENALTY DATE FACE 456.02 BY 09/30/2014 456.02 PENALTY 501.62 AFTER 09/30/2014 501.62 TAXING WEST SHORE SCHOOL DISTRICT NET AUTHORITY FOR: 1512 BRANDT AVENUE 0/® 141,330 TO: LUJANAC,PAUL L&PATRICIA V " 1512 BRANDT AVENUE NEW CUMBERLAND PA 17070 IF DUE DATE IS MISSED,INSTALLMENT MUST BE PAID AT PENALTY, BILL DATE- 07/01/2014 DUE DATE-09/30/2014 BILL#009742 DELINQUENT BILLS ARE TURNED OVER TO TAX CLAIM ON 12/31/2014 TAXPAYER'S COPY TAX YEAR:2014-15 REAL ESTATE TAX NOTICE INSTALLMENT PAYMENT 3 NEW CUMBERLAND '+ PAYABLE ROBIN GASPERETTI,T/C (717)774-7424 ^^PROPERTY ID TO: 1113 BRIDGE STREET NEW CUMBERLAND,PA 17070-1634 26230543514 1 TAX SCHOOL-INSTALLMENT PAYMENT 3 Q• • ■• 7 RATE 9.68 ON OR BEFORE FACE DATE AFTER PENALTY DATE FACE 456.03 BY 10/31/2014 !!4ES6.03PENALTY 501.63 3 1 i TAXING WEST SHORE SCHOOL DIS RICTTAX COLLECTOR ET AUTHORITY 1 FOR: 1512 BRANDT AVENUE 141,330 TO: LUJANAC,PAUL L&PATRI IAV OCT 14 2014 1512 BRANDT AVENUE NEW CUMBERLAND PA 17 70 PAID ❑ CASH ❑ CHECK IF DUE DATE IS MISSED,INSTALLMENT MUST BE PAID AT PENALTY. BILL DATE-07/01/2014 DUE DATE-10/31/2014 BILL#009742 DELINQUENT BILLS ARE TURNED OVER TO TAX CLAIM ON 12/31/2014 TAXPAYER'S COPY i Account Number Amount Due \_ C 799000 [88340845 05]07 $151.96 verizn N - i%-��xyi¢;'ti'i!FS' = Y•Y ��`::c;',':�;�.;. <<<.,>,�.,v�; Account Information =;1f51:1?I fLOf1fhtyllECl#Oh r ro, Statement Date: 2/19/14 :...t' Y. t.:j .�....:C;�k'ro'•fi:i PATRICIA LUJANAC �' Acsi�t'L�Sansres f�7epatr 1 Phone: 717-774-0253 *v.r.�.•. �zfl�f��>Nand�.�yPer�l�`ty Dglal/$F...�f��r; 1:'r�:;;i:s�>r�!��+�Qi.�rBBl►itQ� '=',Cx„0.?p @l;�d�'8.:�.�i_ti.s>4?:iti:r•. .'.: - :;�.;�..;,;:<�� •c•:>1..,,�s:�� .,,::.:;,:4..�,:,:r:::,:,r.,=.�< _ ��.,, Account Summary. ::;r,;;`- r:3i'� •'.t::j:.4ry ,Yi�;•.b 1 q:}t:�..r :l�irti;r•' ;:t; __..__..___._..._._..__..___.._..—....__.__—_.._._ _ .... .. :tx?,-,.1�'�%r�'::�?:::•ixY•,3?..i5:v;�.1�'.nr!.;+.�.{:;+i;:r`:F�'-_ i.�c' _—_ _ _ i:.:fi.y:.`.,_;;;::z-•':r�<; ::: ::;:y:. ;s:; _ r:= . ;4°r a Previous Balance _ _ _ $151.95 ' il:\Y•.....•t::SL:1•\'.\:i:S,.<} n......�.n..,.:.+..r wa1�.�,.rvi.......... ___ _ Payment Received Feb 6 -$151.96 �� I i H H H H HI H I "AP I S I Balance Forward $.00 Get The Speed You Need Make sure all your devices have the speed they need. New Charges Upgrade to HOS Quantum 50/25 Mbps Internet for just Current Activity - $135.97 $10/month more.Visit FiOS TV channel 500 or call 1-877-896-9904 to get more speed this year. Taxes,Governmental Surcharges and Fees $4.18 Limited time offer.Speeds not available in all areas. Verizon Surcharges and Other Charges&Credits $11.81 Taxes apply. -----' ---._ .. -- — - - — ------ - - -- Total New Charges Due by March 15,2014 $151.96 Get A FREE Month Of Movies With Redbox Instant by Verizon you get 4 DVD credits Total Amount Due $151.96 to use at Redbox Kiosks every month,plus movies you can stream instantly for just$8/mo.(plus taxes).Visit redboxinstant.comArynow and get your 1st month free with subscription.Cancel anytime.New subscribers only.Add'I terms apply. Entertainment Deal For You Give yourself the SHOWTIMEO STARZO Entertainment Pack,enjoy 62 channels of great programming from SHOWTIME,STARZ,ENCORE@&more with 50%off for up to 12 months(that's$9.99/mo.for the 1st yr.). Tune to channel 860 or call 1-888-251-7966.Avail. varies&restricts.apply.Limited-time-offer. Want Automatic Payment? Questions about your bill or service? View your bills in detail at vedzon.com or call 1-800-VERIZON(1-800-837-4966). Enroll below or at Vertzon.com to authorize your financial When asked for your account number,please enter 8834008455.Customers with institution to deduct the amount of your monthly bill from disabilities call 1-800-974-6006 TTY. the account associated with your enclosed check and send payment directly to Verizon.To discontinue Automatic Payment,call Verizon.Please keep a copy of this authorization. Please return remit slip with payment. ° – Please odlne at Page contact us by Mar 24. – | | pphe|acLdc.com �� ' L 1-800-DIAL-PPL' _ _ \��O00-342-S77S) 35420-80010 Mar 24,2014 $166 PPL Elacineuo/10*° M-F:8am to 5pm Your Electric Usage Profile Billing'Summaiv (Billing details on back) Service to: A Balance as of Mar 3,2014 $0.00 PAUL LUJANAC CP Charges-, 1512 BRANDT AVE Total PPL Electric Utilities Charges $166.00 NEW CUMBERLAND,PA 17070 Meter:84573803 Total Charges $166.00 ' Your next meter reading|sonorabout Apr 2,2014. mount Due By Mar 24,2014 $166.00 This section helps you understand your year-to-year Account Balance $166.00 electric use bvmonth. Meter readings are actual unless otherwise noted. PPL Electric UUItl ^ rice to compare fUry yWurrate/ $O.0O754 kWh. 7]2Oi� [7�014 This changes the 1stofar/]u mndD8c. V|sitpapoo«eru��|tch.uom �~ �� ormmvm/'ocm.$tetm.pa.umfor supplier offers. 60 z so Your Message Center � =` 40 ~ Budget � VVebilled you � ao Including this bill,you used � zn After this payment,your budget isbehind � 10 � o01 ill,L..Ll - flm I & VVith aperless billing,you can receive and pay your o | J F y0 A M J J A s G N o Electric The pr process s free, � quick,convenient andsecure.Tolearn more o[sign up, � Months v|sitppYe|m«±ric.momm. w Information about appliance and tips on saving energy are available through the Energy Library onour Web site,pp|akeotdc.ton/e-powar Mar 2014 31 12.06 39 28F Mar 2013 29 1535 53 32F Payment Methods Actual 58221 Online at: By phone:1-800-342-5775 Jan 31 Actual 57015 L/ pp|me#mu.conm � `uvor U BillMatrix(service fee applies) at 1-800-672-2413 to pay using Visa, 31 Days kWh Billed 1206 MasterCard,Discover Vrdebit uard — . should be sent to: ~–� 2 Nth9th Street Customer Services Apr 2013 ''—ar---~ North N1 827Hausman Road Apr 2012-Mar 2013 16326 1361 Allentown, PA 18101-1175 Allentown, PA 18104-9392 Other important information oothe back ofthis bill�� -- ' •'s);: Questions? Please Visit us online at Page 1 contact us by Oct 23. _ U pplelectric.com Bill n�1' ue 1-800-MAL-PPL Due Date • I''M (1-800-342-5775) 35420-80010 Oct 23,2014 $62,59 PPL Electric Utilities M-F:8am to Spm Your Electric Usage Profile A . Wllin Summary (Bluing details on back) Service to: 1� Balance as of Oct 2,2014 $0.00 PAUL LUJANAC 1 p�� Charges: 1512 BRANDTAVE 4 Total PPL Electric Utilities Charges $62.59 NEW CUMBERLAND, PA 17070 Meter:84573803 Total Charges $62.59 Your next meter reading Is on or about Oct 31, 2014. Amount Due By Oct 23,2014 $62.59 This section helps you understand your year-to-year Account Balance electric use by month. Meter readings are actual unless PPL Electric Utilities'price to compare fo'r your rate Is$0.08956 per kWh. otherwise noted. This changes the 1st of Mar,Jun,Sept,and Dec.Visit papowerswitch.com 02013 02014 or www.oca.state.pa.us for supplier offers. :2250 Your Message Center a0 # Budget Settlement Summary after 12 months: ro We billed you $1,840.60 0 30 Including this bill,you used $1,840.60 v 20 9 Next month your budget amount will change to a so $153.00. 0 e We have subtracted$56.18 from this bill to settle your J F M A M J J A S 0 N Budget Billing Plan. o Months a With paperless billing,you can receive and pay your PPL Electric Utilities bilis online.The process Is free, quick,convenient and secure.To learn more or sign up, Monthly Days kWh Average Average visit pplelectric.com. Comparison Billed kWh/Day Temp. e Keep light bulbs and fixtures clean. bust and dirt absorb Oct 2014 30 857 29 66F light and can reduce light output by as much as half: A- n1 hWl_ F ' BILLING PERIOD AND METER READINGS BILLING SUMMARY • Billing date:March 5,2014 For Service To: 1512 BRANDT AVE • Due.Date:March 27,2014 For Account 1024-210029765648 • Billing period,:Feb 05 to Mar 03(27 Days) Prior Balance • Next reading on or about:Mar 31,2014 • Balance from last bill 48.85 • Customer Type:Residential Payments as of Feb13.Thank you! -48.85 • Meter Reading Measurement: Balance Forward 0.00 1 unit=100 gallons of water • Billing Measurement:100 gallons(CGL) Current service • Wateerr Service Charge 15.00 Meter No. N042446201 ° Water Usage Charge($1.02140000 x 17.00) 17.36 Size Of meter 5/8° ° Total water Service Related Charges 32.36 Current Read 7,185(Actual) Protection Program Pians Previous Read 7,168(Actual) ° Customer Protection In Home 3.99 Total water used this 17 units ° Water/Sewer Line Protection 12.50 billing period (1,700 gallons) Total Protection Program Pians 16.49 TOTAL CURRENT CHARGES - Total Water Use Comparison(in 100 gallons) 17.00 CGL • Samenbillllinlg ing period 201034 21.00 CGL TOTAL AMOUNT DUE �` $48•$5 Billed Use Graph(100 gallons) Pay your bill online:www.water.paymybill.com 30 0 Pay by phone:24-hours a day,every day at 1-866-271-5522 24 Pay in person:Residential customers may obtain a listing of payment locations by visiting www.amwater.com/myh2o• 18 2A Pay by mail:Remit your payment to the address shown above 12 6 2 M A M J J A S 0 N D J F M 2 iwhk 0 a p a u u u e c o e a e a 0 •3 r r y n I g p t v c n b r 4 LTi Important messages =. . American Water • ***IMPORTANT WATER QUALITY INFORMATION: • Your annual Water Quality Report can be viewed electronicallyFR/-ccx 6c�csburg.pdf.If you prefer a paper copy t0 be sent to you,please contact our Customer Service Center at 800-565-7292. ° Approximately 4.44 percent,or$2.17,of state taxes are included in your current bill. • Any portion of the water charges which is not paid as of 03/27/2014 will be subject to a 1.50%penalty. •Sign up for paperless billing! It's a convenient and environmentally friendly way to receive your water and/or wastewater bill. Users must enroll online.To get started,visit www.amwater.com/myh2o.Go to Account Detail and click on the green Paperless Billing button.Follow the steps,press submit and you're enrolled! Questions about this!bill?Call our 24-Hour Customer Service Center:!-800-565-7292 www.pennsylvaniaamwater.com 646250144785 013288l013358ACRBU5ETMIC00212 (ACRBU5 0132880101300) a _._.. _....__.. __......._ _..._........ ........................_.........................._.............._..................................._............. BILLING PERIOD AND METER READINGS BILLING SUMMARY • Billing date:October 1,2014 For Service To: 1512 BRANDT AVE J � • Due Date:October 23,2014 For Account 1024-210029765648 • Billing period:Aug$0 to Sep 30(32 Days) Prior Balance (j • Next reading on or about:Oct 31,2014 • Balance from last bill / 40.68+' • Customer Type:Residential Payments as of Sep12.Thank youl -40.68 • Meter Reading Measurement: Balance Forward 0.00 1 unit=100 gallons of water Current Water service . • Billing Measurement:100 gallons(CGL) • Water Service Charge 15.00 Meter No. N042446201 • Water Usage Charge($1.02140000 x 12.00) 12.26 Size of meter 5/8° • Total Water Service Related Charges 27.26 Current Read 7,246(Actual) Protection Program Pians Previous Read. 7,234(Actual) • Customer Protection In Home 3.99 Total water used this 12 units • Water/Sewer Line Protection 12.50 billing period 1 (1,200 gallons) • Total Protection Program Pians 1.6.49 Total Water Use Comparison(in 100 gallons) TOTAL CURRENT CHARGES 43.75 • Current billing period 2014: 12.00 CGL •. Same billing period 2013: 29.00 CGL TOTAL AMOUNT DUE $43.75 Billed Use Graph(100 gallons) 16 Pay your bill online:www.water.paymybill.com 30 -- © Pay by phone:24-hours a day,every day at 1-866-271-5522 24 Pay In person:Residential customers may obtain a listing of 18 payment locations by visiting www.amwater.com/myh2o �31 Pay by mail:Remit your payment to the address shown above 12 - 6 2 S O N D J F M A M J J A S 2 0 e c o e a e a p a u u u e 0' 3 .p t v c n b r r y n I g p 4 Important messages from Pennsylvania American plater • Have you recently changed your primary phone number?If you have,please update your account information online using My H2O Online at www.amwater.com/myh2o or call us at the number below so that we can update our records. • Approximately 4.44 percent,or$ 1.94,of state taxes are included in your current bill. • Any portion of the water charges which is not paid as of 10/23/2014 will be subject to a 1.50%penalty. Questions about this bill?Call our 24-Hour Customer Service Center:1-800-565-7292 www.pennsylvanlaamwater.com 675000426505 014499/014603 ACS69G ETMIC002 12 (ACS69G 0144990101300) Mark Heckman Real Estate Appraisers 1309 Bridge Street, New Cumberland,PA 17070 File No.1512Brandt INVOICE««««««««« File Number:1512Brandt 05/15/2014 Mary Lujanac 406 Summit Road New Cumberland,PA 17070 Invoice#: 151213randt Order Date: 05/01/2014 Reference/Case#: PO Number: 1512 Brandt Avenue New Cumberland,PA 17070-1541 Single Family Appraisal Report $ 400.00 .............. Invoice Total $ 400.00 State Sales Tax @ $ 0.00 Deposit ($ 400.00 ) Deposit ($ ) -------------- Amount Due $ 0.00 Terms: Thank you for your payment Please Make Check Payable To: Mark Heckman Real Estate Appraisers 1309 Bridge Street New Cumberland,PA 17070 Fed.I.D.#: Thank you for using our services PH(717)774-7202 FAX(717)774-0383 EMAIL heckmanappraisers@comcast.net REV-1512 EX+ (12-08) pennsytvania SCHEDULE DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 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. New Cumberland Federal Credit Union(Acct.No.xx135)-Loan 3;Car Loan 14,960.95 2. New Cumberland Federal Credit Union(Acct.No.xx135)-Loan 4;Car Loan 16,563.63 3. Quantum Imaging&Therapeutic Associates(medical bill) 104.93 4. Holy Spirit Hospital(medical bill) 375.76 5. Camp Hill Emergency Physicians(medical bill) 95.45 6. Pinnacle Health Medical Group(medical bill) 20.00 7. Capital Cardiovascular Associates(medical bill) 69,86 8. Lewin&Madar Cardiology Associates(medical bill) 1.84 9. Spirit Physician Services,Inc.(medical bill) 61.68 10. Kohl's(credit card) 878.76 11, Boscov's(credit card) 273.75 12. AscensionPoint Recovery Services,LLC(Toys-R-Us credit card) 113.65 13. AscensionPoint Recovery Services,LLC(JC Penney credit card) 251.53 14. GE Capital Retail Bank(Value City Furniture credit card) 1,288.54 15. GE Capital Retail Bank(Mattress Warehouse credit card) 787.00 TOTAL(Also enter on Line 10, Recapitulation) 35,847.33 If more space is needed,insert additional sheets of the same size. a II STATEMENT OF ACCOUNT (1) CAMP HILL EMERGENCY PHYSICIANS Statement Date: April 20,2014 PO BOX 13693 ACCOUNT NUMBER: HYP47313432 PHILADELPHIA, PA 191.01-3693 Patient Name:PATRICIA V LUJANAC Tax ID#: 20-4667340 Account Balance: $54.18 Amount Pending Insurance: $0.00 I�1�'1111'Il�lr1.1�"'Il�rrll�r�'��IIIII"�"�'�II111�1"��III�1 Amount Due From Patient(Current): $54.18 082.516-0000047313432-06 Amount Due From #BWNJFDB Patient(Past Due): $0.00 #OOOOOOHYP8470159# rPay This Amount: $54.18 PATRICIA V LUJANAC 1512 BRANDT AVE PLEASE REMIT PAYMENT BY"PAYMENT NEW CUMBERLND PA 17070-1541 DUE BY"DATE.THANK YOU. Please refer to coupon below for payment instructions. Pay your bill securely online anytime at www.MyMedicalPayments.COM Date # Description Charge Paid By Paid By Paid By Amount Due From PATIENT First Ins. Other Ins. Patient Adjusted Insurance BALANCE 02/18/14 1 99285 EMERGENCY EVAL&MGMT(LVL 5) $1,303.00 DX:410.71 DR.BARAN/HOLY SPIRIT HOSPITAL 03/11/14 MEDICARE CLAIM DENIED-PRIOR TO COVERAGE -$0.00 04/15/14 INSURANCE CONTRACTUAL ALLOWANCE $-1,130.84 04/15/14 INSURANCE PAYMENT $-120.51 $51.65 07/18/14 2 93010 EMERGENCY INTERP 12 LEAD EKG $100.00 DX:410.71 DR.BARAN/HOLY SPIRIT HOSPITAL 03/11/14 MEDICARE CLAIM DENIED-PRIOR TO COVERAGE -$0.00 04/15/14 INSURANCE CONTRACTUAL ALLOWANCE $-91.55 04/15/14 INSURANCE PAYMENT $-5.92 $2.53 TOTALS: $1.403.00 T $0.00 7$126.43 $0.00 -$1,222.39 $0.00 $54.18 Important Messages: . This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Holy Spirit Hospital.The fees for this private physician are billed separately from any hospital charges or other professional fees for which you may also be responsible.Therefore,should you receive a bill from the hospital or other physicians for charges in connection with this visit,it will not include the items listed on this statement "Payment Plans"Accepted Questions about this statement?/Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM -4:OOPM. `Your automated system access code is 0801-47313432, or you can send email to billing_questions@emcare.com. 91384-01-3367 44 Please detach and return bottom portion with your remittance. �� National Association of Letter C;amers Health Benettt Plan w114Y Yf� 20547 Waverly Court,Ashburn,Virginia 20149-0001 d (703)729-4677 or 1-888-636-NALC(6252) „ 00319 Member: PATRICIA V LUJANAC Identification#: N32575220 Patient: PATRICIA V LUJANAC Claim#: 0-0001245 Claim Date: 05/05/2014 Patient Account#: 002/123508 Paid To: LEWIN-NADAR CARDIOLOGY ASSOC Fed Tax ID#:251766971 PATRICIA V LUJANAC 1512 BRANDT AVE NEW CUMBERLAND PA 17070-1541 EXPLANATION OF BENEFITS Provider/ Dates Billed Not Discount/ Covered Copayment Deductible Payable %Paid Contract Coinsurance Remarks Description of Service Charges Covered Disallowed Charges Allowance Code STANLEY LEWIN SURGICAL MISC. 02/19/14 25.00 12.71 12.29 12.29 085 10.45 1.84 4N g i:::::::::::i:: 1. 4...+........... ?:;::8'%�' : t i ::::: :' '`;:2':; :is i::2 j:::....:....:..... t3r.....•.•:.•..•::.•::::.::.•.:•.::•::.•::::::. ::::::.•:.::.•.::. 'Ot �''`:isi;:;;," `:::'>:i?? ::::::: D[::::::;`: i: ::2:: 2.29 .:.:.:.:.:.....:::':' <`:< i::'< 12.29 is i>i5: 25.0 12.71 1, Claim Summary Cl m S y :...................::::...:.::::. :::::..:..:........:........... APPLIED: 1.84 TO PPO AND NON-PPO CATASTROPHIC PROVISION Total Billed 25.01 Less Discount/Disallowed .12.7: NALC Paid Provider 10.4! Patient Liability 1.8 REMARKS CODE: 4N CUSTOMER:THANK YOU FOR USING CIGNA's OPEN ACCESS PLUS NETWORK.THE DISCOUNT SHOWN IS HOW MUCH YOU SAVED.YOU DON'T NEED TO PAY THAT AMOUNT.IF YOU ALREADY PAID YOUR HEAL'T'H CARE PROFESSIONAL MORE THAN THE"WHAT I OWE" AMOUNT,PLEASE ASK YOUR HEALTH CARE PROFESSIONAL FOR A REFUND.HEALTH CARE PROFESSIONAL:YOUR CIGNA AGREEMENT DOES NOT ALLOW YOU TO BILL THE PATIENT FOR THE DIFFERENCE.IF YOU ARE IN INDIANA,CALIFORNIA OR TENNESSEE,PLEASE CONTACT CIGNA CUSTOMER SERVICE AT 1-800-88CIGNA(8824462)FOR MORE INFORMATION ON YOUR DISCOUNTED RATE.SEE SECTION 4.YOUR COSTS FOR COVERED SERVICES. 934 UNDER THE PRIVACY RULE,WE CANNOT RELEASE INFORMATION ABOUT YOU TO ANYONE WITHOUT YOUR CONSENT.THIS CAN BE DONE:BY COMPLETING A PERSONAL REPRESENTATIVE AUTHORIZATION FORM.THIS FORM IS AVAILABLE AT W W W.NALC.ORG/DEPART/HBP.VERBAL CONSENT IS FOR ONE TIME ONLY AND MUST BE VERIFIED THROUGH YOU. WITHOUT YOUR WRITTEN CONSENT,WE WELL ONLY ADVISE THE CALLER IF A CLAIM HAS BEEN RECEIVED OR PROCESSED.. Applied year-to-date: I Patienti Family *The deductible and catastrophic out-of-pocket amounts listed are PPO/Non-PPO Calendar Year Deductible 1 $300.001 $300.00 cumulative totals as of the end of the processing day. PPO/Non-PPO Catastrophic Provision 1 $1226.991 $1226.99 If the Plan corrects or voids a claim,these amounts may change. PPO Catastrophic Provision 1 $615.961 $615.961 Please contact the Plan if you would like updated information or visit our website. www.nalc.org/deparUhbp Please read the Important Information about Your Appeal Rights notice enclosed with this Explanation of Benefits Keep This Statement For Your Records.No Additional Copies Are Provided. Page 1 MEMBER COPY DATE OF DOCTOR CHARGE INSURANCE PATIENT SERVICE NAME CODE DESCRIPTION CHARGES RECEIPT RECEIPT ADJUST BALANCE 02/19/14 NADAR 93010HSH ECG INTERP/REP HOLY SPIR 25.00 10.45 .00 12.71 1.84 ------------------------------------------------------------------------------------- PLEASE PAY THIS AMOUNT: 1.84 STATEMENT MES SAGE MAKE CHECKS PAYABLE TO: FOR BILLING QUESTIONS, CALL: 717/214-1032 Lewin & TTadar Cardiology Associates OFFICE HOURS: 8:00am - 4:00nm PO Box 1292 Camp Hill, PA 17001-1292 R-; DO NOT SEND PAYMENTS TO THIS ADDRESS For billing questions call: (717)932-5955 Dept. 19687 or: (877)932-5955 P O Box 1259 Fax: (71.7)932-4856 Oaks,PA 19456 Office Hours: 8:00 AM-4:30 PM IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII) Tax ID: 251792806 To pay your bill online and register for eStatements, please visit us at: www.gita.com Final Notice Date: 5/14/2014 Patient Name: PATRICIA V LUJANAC Personal&Confidential Account#: 2119 Balance Due: $103.38 Illlfill lllllllll�lnilnlrll�llllllllllrl�ll�lllnlll�l�nnl, 19672.1 PATRICIA V LUJANAC 1512 BRANDT AVE NEW CUMBERLAND PA 17070-15411 FINAL NOTICE According to our records,your balance of$103.38 is delinquent and remains unpaid to our practice. Please pay the amount in full immediately using the bottom portion of this letter or call.(717)932-5955 or(877)932-5955 to make payment arrangements. To pay your bill online and register for eStatements,please visit us at: www.gita.com If payment is not received within ten(10)business days your account maybe placed for collection without further involvement by Quantum Imaging and Therapeutic Associates. Please understand that failure to pay could adversely affect your credit rating. Respond to this final notice today. FINAL NOTICE! Please detach and return bottom portion with„your payment in the enclosed envelope ..................................................................................................................................................................................................................................................................................................... IF PAYING BY VISA,MASTERCARD OR DISCOVER,FILL OUT BELOW { DO NOT SEND PAYMENTS TO THIS ADDRESS •— Dept. 19687 CAD NumOVISA® ❑MASTERCARD 0DISCOVER PaER EXP.OATE AMOUNT P 0 Box 1259 Oaks, PA 119456 PRINT CARDHOLDER NAME MUST 1SEr-URNYCODE FROM IIIIIIIVIIIVIIIVIIIIIIIIIIIIIIIIIIVIIIVIIIVIII IIII IIIIBACK OF CARD STATEMENT DATE PAY THIS AMOUNT ACCOUNT NO. For billing questions call: (717)932-5955 or. (877)932-5955 3/20/2014 $1.55 2119 71 ( Fax: ( 7)932-4856 Office Hours: 8:00 AM-: 71 )9 CHARGES AND CREDITS MADE AFTER STATEMENT SHOW AMOUNT To pay your bill online and register for eStatements, DATE WILL APPEAR ON NEXT STATEMENT. PAID HERE please visit us at:www.gita.com ®MAKE CHECKS PAYABLE/REMIT TO:- 111111 "�'1111 11111 111IIIIII1'1111111I'I'I'I111 111 I1 1111 19670-1 Quantum Imaging and Therapeutic Associates PATRICIA V LUJANAC P0Box 62165 1512 B R A N D T AVE Baltimore,MD 21264-2165 NEW CUMBERLAND PA 17070-1541 111111111111111111111J1111J1L111111LI11111JL11L11111111 ] Please check box if above address is incorrect or InsuranceAMMM PLEASE DETACH AND RETURN TOP PORTION WITH Information has changed,and indicate change(s)on reverse side. YOUR PAYMENT IN ENCLOSED ENVELOPE Patient: PATRICIA V LUJANAC Account: 2119 Services Rendered At: HOLY SPIRIT IMAGING OUTPATIENT CEN Proc Payments Date Code Description Charge Adjustments Balance 12/5/2013 71020 CHEST 2 VIEWS PA&LATERAL 45.00 1.55 2/19/2014 PMT CIGNA 8.80 2/19/2014 CR Adjustment CIGNA 34.65 2/14/2014 71020 CHEST 2 VIEWS PA&LATERAL- 45.00 10.90 3/16/2014 CR Adjustment CIGNA 34.10 2/14/2014 70450 CT SCAN BRAIN W/O CONTRAST 198.00* 42.19 3/16/2014 CR Adjustment CIGNA 155.81 2/18/2014 74176 CT ABDOMEN AND PELVIS W/O CONTRAST 252.00 252.00 2/18/2014 71010 CHEST SINGLE VIEW FRONTAL ✓ 36.00-1- 36.00 2/18/2014 70450 CT SCAN BRAIN W/O CONTRAST t-*' 198.00*-y 198.00 2/19/2014 76700 ULTRASOUND ABDOMINAL SURVEY 1/ 250.00"1' 250.00 2/19/2014 93880 US DUPLEX.CAROTID STUDY BILAT 250.00* 250.00 2/19/2014 70551 MRI BRAIN INCLUDING STEM "'- 175.00' 175.00 2/19/2014 70450 CT SCAN BRAIN W/O CONTRAST 198.001 198.00 �r. Current 31 -60 61 -90 91 -120 Over 120 BALANCE DUE $1.55 0.00 1.55 0.00 0.00 0.00 PAY BY Due Upon Receipt THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing questions call: (717)932-5955 PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955 OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856 INSURANCE INFORMATION IS NECESSARY. Office Hours: 8:00 AM-4:30 PM Those charges shown with an *11 Indicate pending insurance. To pay your bill online and register for eStatement STATEMENT please visit us at:www.gita.com IIIIIIIIIIIIIIIIIIIIIIIIII�I��I�IIIIIIIIIIIIIIIIIIIIIIIIII SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ____ Important We have received the explanation of benefits MHOLY from your insurance company(s)and have applied whatever payments and/or adjustments are appropriate. Please make payment for the balance due of$417.51 OR take advantage of a The 9H— P f Caring 10%prompt payment discount and remit $375.76 on or before 10/05/2014. Here are 3 convenient ways to pay: 47288527 1. Make payment online at www.hsh.org. PATRICIA V LUJANAC 2. Mail tear-off coupon below with payment 1512 BRANDT AVE in the enclosed envelope. NEIN CUMBERLND PA 17070-1541 3. Call Customer Service below to make payment by phone. Account Summary charge Summary Patient Name: Lujanac,Patricia V Previous Balance: 4.00 Statement Date: 09/05/14 Total Charges: 46,363.50 Service Date(s): 02/14/14 Payments/Adjustments: $5,945.99- Account Balance: 4417.51 Account Number: 47288527 Please Pay This Amou 417.51 OR Medical Record Number: 158421 Discounted Amou of $375.76 if p id on or before 10/05/2014 Insurance Information Contact Us Please call Customer Service at 717-763-2138- Ins. 1:CIGNA to add or make corrections to your insurance Ins.2: 5M information, or to make arrangements for a Ins.3: payment plan. If you are unable to make Ins.4: payment, phase contact the Patient Financial t f, Advocate's Office at(717)763-2885 to discuss financial assistance options. Please Note. Your physicians vui/l bili separately for professional services. STATEMENT OF ACCOUNT (1) CAMP HILL EMERGENCY PHYSICIANS Statement Date: August 31,2014 PO BOX 13693 ACCOUNT NUMBER: HYP47288527 PHILADELPHIA, PA 19101-3693 �� Patient Name:PATRICIA V LUJANAC Tax ID#: 20-4667340 Balance' 41.27 lJ 1 Amount Pending Insurance: $0.00 Amount Due From Patient(Current): $41.27 082516-0000047288527-06 Amount Due From t #BWNJFDB Patient(Past Due): $0.00 N #OOOOOOHYP8443958# FFay This Amount: $41.27 PATRICIA V LUJANAIC 1512 BRANDT AVE PLEASE REMIT PAYMENT BY"PAYMENT NEW CUMBERLND PA 17070-1541 DUE BY"DATE.THANK YOU. Please refer to coupon below for payment instructions. Pay your bill securely online anytime at www.MyMedicalPayments.corn Date # Description Charge Paid By Paid By Paid By Amount Due From PATIENT First Ins. Other Ins. Patient Adjusted Insurance BALANCE 02/14/14 1 94760-26-26 NON-INVASIVE PULSE OXIMETRY $57.00 DX:298.9 DR.MAGUIRE/HOLY SPIRIT HOSPITAL 04/10/14 INSURANCE CLAIM DENIED-COVERED BY ANOTHER RAYER -$0.00 06/05/14 INSURANCE CLAIM DENIED-NON-COVERED SERVICE -$0.00 08/14{14 INSURANCE CONTRACTUAL ALLOWANCE $-21.00 08/14/14 INSURANCE PAYMENT $-25.20 $10.80 02/14/14 2 93042 RHYTHM STRIP INTERPRETATION $84.00 DX:298.9 DR.MAGUIRE/HOLY SPIRIT HOSPITAL 04/10/14 INSURANCE CLAIM DENIED-COVERED BY ANOTHER AYER -$0.00 06/05/14 INSURANCE CLAIM DENIED-NON-COVERED SERVICE -$0.00 08/14/14 INSURANCE CONTRACTUAL ALLOWANCE $-76.93 08/14/14 INSURANCE PAYMENT $4.95 $2.12 , 02/14/14 3 93010 EMERGENCY INTERP 12 LEAD EKG $100.00 DX:298.9 DR.MAGUIRE/HOLY SPIRIT HOSPITAL 04/10/14 INSURANCE CLAIM DENIED-COVERED BY ANOTHER AYER -$0.00 06/05/14 INSURANCE CLAIM DENIED-NON-COVERED SERVICE -$0.00 08/14/14 INSURANCE CONTRACTUAL ALLOWANCE $-91.55 08/14/14 INSURANCE PAYMENT $-5.92 $2.53 02/14/14 4 99285 EMERGENCY EVAL&MGMT(LVL 5) $1,303.00 DX:298.9 DR.MAGUIRE/HOLY SPIRIT HOSPITAL 04/10/14 INSURANCE CLAIM DENIED-COVERED BY ANOTHER AYER -$0.00 06/05/14 INSURANCE CLAIM DENIED-NON-COVERED SERVICE -$0.00 08/14/14 INSURANCE CONTRACTUAL ALLOWANCE $-1,130.84 08/14/14 INSURANCE PAYMENT $-146.34 $25.82 TOTALS. I CONTINUED CONTINUED CONTINUED CONTINUED CONTINUED CONTINUED CONTINUED Important Messages: This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Holy Spirit Hospital.The fees for this private physician are billed separately from any hospital charges or other professional fees for which you may also be responsible. Therefore,should you receive a bill from the hospital or other physicians for charges in connection with this visit,It will not include the items listed on this statement. "Payment Plans"Accepted Questions about this statement?/Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM -4:00113M. . Your automated system access code is 0801-47288527, or you can send email to billing_questions@emcare.com. 91384-01-482 4044 Please detach and return bottom portion with your remittance. 444 -AL- .. .............W.1111111 ..... ..... Full payment on your account balance is now due. If this bill does not reflect the PINNACLEHEALTH correct insurance information please contact Medical Group our office immediately to resolve the issue. For account information Please call(717) 231-8960 or(800) 565-6229 for Out of Area Calls. See details on the back of this statement. PATRICIA LUJANAC If payment has been sent, please disregard. 1512 BRANDT AVE NEW CUMBERI-ND PA 17070-1541 E Ri i 11M.171177 T Responsible Party:Patricia Lujanac Total Charges: 4140.00 Account ID: 149766 Payments and Adjustments- $120.00- Bill Date: 03/19/14 Bill Number: 8029605 Please Pay This Amt: $20.00 TM _................. Cigna For questions, call Customer Service at: 717-231-8960 for local calls or 1-800-565-6229 for Out of Area Customer Service Hours: Mon-Wed-Fri 8:00 AM to 4:30 PM Tues-Thurs 8:00 AM to 6:00 PM -------------------------------------- --------------------------- ------------------------------------------------------- Please P This Amount 8029605 Bill Number: Patient Name: PINNACLEHEALTH PATRICIA LUJANAC 29 MedicalGroup 0M -OU3 0 E� Po BOX'd Exp_Dater HARRISP RG PA 17108-1129 Card Number. Sec Code E I . Signature: Amount Paid: ElCheck box if your address or insurance information has changed, Please make changes on back. I The Security Code is the lqst 3 digits an thh back of your credit card,by your signature Make Check Payable To:PINNAME W4 MOT HF1 NW. ML G-RQUIP0 00013137 001 0.53 Pay online atter PATRICIA LUJANAC Please do not send cash through the mail_ 1512BRANDT AVE NEW CUMBERLND PA 17070-1541 PINNACLE HEALTH MEDICAL GROUP PO BOX 1129 HARRISBURG PA 17108-1129 00000000090008024L050000000001497L600000002000201403193 IF PAYING BY CREDIT CARD,FILL OUT BELOW CHECK CARD USING FOR PAYMENT 11 0 SPIRIT PHY S.ICIAN DISCOVER M3 MASTERCARD MVISP CARD NC SERVICES . AMOUNT , SIGNATURE NUMBER CW EXP..DATE I A SERVICE OF HOLY SPIRIT HEALTH SYSTEM STATEMENT DATE PAY THIS AMOUNT ACCOUNT NEIR 04/03/14 $61.68 15095 DEMAND A SHOWAMOUNT . .ACCOUNT LETTER, IPAID HERE $ ADDRESSEE: REMIT TO: I 1 111 111 fill I I I I I 1 111111 .Patricia Lujanac Spirit Physicians Services Inc 1512 Brandt Avenue 205 Grandview Ave New Cumberland, PA 17070 Suite 210 USA' Camp Hill, PA 17011-1708 USA 0 Please check box if above address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT information has changed,and indicate change(s)on reverse side. 04/63/14 To the Estate of Patricia Lujanac Please accept our condolences on the-deft of Patricia Lujanac. We understand this time may-be very difficult for you, however, we need to resolve the financial obligation with Spirit Physicians Services Inc. Our records show an outstanding balance of '$61.68 that is due immediately. Please send the payment in with this statement or call the billing department at (717) 972-4490 to discuss a payment arrangement. Should the estate be insolvent, we will adjust the balance after we receive a copy of the death certificate and a notarized letter from the estate administrator detailing the terms of the estate. Thank you in advance for your cooperation. Sincerely, fd Spirit Physicians Services Inc • 0 lit CQ Asce 010 RECOVERY SERVICES, LLC 200 Coon Rapids Blvd.,Suite 200 Coon Rapids,MN 55433-5876 Phone:888-420-2510 Fax:763-235-4055 3/24/2014 To Whom It May Concern: We are filing a claim on a probate/estate filed in reference to the individual listed below. AscensionPoint Recovery Services, LLC is filing this claim on behalf of GE Capital Retail Bank-"""R" "Us MasterCard". Please see our claim form (enclosed)for details. Decedent information: Case`Number: 2014-00189 Balance:$113.65 Date of Death: 02/20/2014 Name: PATRICIA LUJANAC If you have any questions please feel free to contact our office at your convenience. Respectfully, AscensionPoint Recovery Services, LLC --__ --- ----- _---_ ----------------------detach coupon----------------------------------------------- Reference No:1622357 Phone Number:888-420-2510 PLEASE SEND PAYMENTS&CORRESPONDENCE TO: MARY LUJANAC 406 SUMMIT RD t 'ASCENSIONPOINT RECOVERY SERVICES,LLC NEW CUMBERLAND,PA 17070 200 COON RAPIDS BLVD.SUITE 200 COON RAPIDS,MN 55433-5876 CVRLTR v1.3 20131107 AscensionPoint Kecovery Services, LLC . 200 Coon Rapids Blvd. Suite 200 Coon Rapids,MN 55433-5876 Ascension Ii ,. (888) 806-9073 Phone-(763) 235-4055 Fax RECOVERY SERVICES,LLC Hours: Monday-Friday 8:OOAM to 5:OOPM CST Creditor: GE Capital Retail Bank Account No.: XXXXXX3CXXXXX7695 Reference No.: 1632718 Balance: $251.53 March 20, 2014 Dear estate of PATRICIA LUJANAC, We would like to offer our deepest condolences during this time of loss for you and your family. Thank you for promptly attending to this important matter in the life of PATRICIA LUJANAC. The GE Capital Retail Bank-jcp credit card account in the amount of$251.53 for PATRICIA LUJANAC has been placed with our office for collection. Please contact our office toll-free at(888)806-9073 to discuss options for the estate. Payments and/or the estate information coupon on the reverse side can be mailed to the address listed above. All payments should be made payable to the creditor listed above. Please remember that only the estate of the deceased is liable for the debt owed and family members are not personally responsible for payment of this debt. Again,please accept our condolences during this difficult time. Very truly yours, Christina Mallen,AscensionPoint Recovery Services,LLC Federal law requires that we give the following disclosure: Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof,this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof,this office will obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request of this office in writing within 30 days after receiving this notice this office will provide you with the name and address of the original creditor,if different from the current creditor. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. This is an attempt to collect a debt from the estate and not from the assets owned by you personally. You personally are not required to pay any of the debts from the estate. *:* *PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION ABOUT YOUR RIGHTS AND THE PROBATE COUPON. ACA INTERNATIONAL TheAssociation of Credit and Collection Professionals PLEASE DETACH AND RETURN BOTTOM PORTION WITH THE ESTATE'S PAYMENT Member ............................ .......................•----------------------------............--------------------------...--•--------------.......-•-•--------------------------------............................................................. DEPT 303 2897933814030 Phone Number: (888)806-9073 PO BOX 4115 Amount Enclosed: CONCORD CA 94524 Creditor: GE Capital Retail Bank Account No.: XXXXXXXXXXXX7695 Reference No.: 1632718 Balance: $251.53 ADDRESS SERVICE REQUESTED #BWNFTZF#TAM2897933814030# All payments should be made payable to the creditor listed above. I�tt��tl�I�tIIIIII11111111111111111111 �I��I��tll��tit��Ii�Ilt PLEASE SEND PAYMENTS&CORRESPONDENCE TO: 1632718 MARY LUJANAC 406 SUMMIT RD ASCENSIONPOINT RECOVERY SERVICES, LLC NEW CUMBERLAND PA 17070-2851 200 COON RAPIDS BLVD.SUITE 200 COON RAPIDS,MN 55433-5876 TAMNLB-0320-458197461-00621-621 ~ / � Page of �� 8 ��» account online: - -�� - - --�� Click onmyKohl's Charge at Account Number 040-8728452 expect great thinQsr ymwukobIsxcom ACCOUNT SUMMARY IT INFORMATION Previous Balance $ 863.76 New Balance $ 878.76 Payments and Other Credits ' 0.00 Payment Due Date 04/14/2014 Purchases + 0.00 Minimum Payment Due 33.00 Amount Past Due 25.00 Fees + 25,0> Total Amount-Due 8I08 �. Interest Charges + O.OQ To Avoid | t @2OO —New Balance $ 878.76 Late Paymentmarning: Ifwadonot receive your minimum by�edate|io�dabovo youmayhavo�paya|�nheeufup��s Opening/�|oo/ngDa�o DlY1�2O14'03/100O14 ' . Days inBilling Cycle 31 Minimum minimum payment Total Credit Line $1.500 each period,you will pay more ininterest and|twill take you longer to Available Credit None payoff your ba|anoo For example: ' Questions? charges using this card and shown on this statement In paying an estimatpd*' each month you pay... -about... total of.. Click mmMyKohl's Charge atKuhin.cumpr the minimum pay ent 3 years $879.00 tuuCustomer Sanxwa1'u*o's6�oz47 Only Sunday AM PM If you wouldlike Information about credit counseling services,call m*nclay-Saturdaym:oo4M to11;00;M(EST) 1-877-*99m467. Automated service iaavailable 24 hours. kCTIVITY Transaction Date Transaction Description Amount Fees 03/114 LATE FEE $26.00 TOTAL FEES FOR THIS PERIOD S25.08 2014 Totals Year-To-Date Total fees charged in 2014 $25.00 Total interest charged in.2014 $28.04 INTEREST CHARGES -' ' ' - � /yle-miBalanue AnnualPen:onbs�e Rate(APR) Balance Subject Interest{ hmrge-o — ' Interest Rate Purchases 0.00Y& $0.00 $0.00 KOHL'S MVC SUMMARY Current Kohl's. ..~..~.. ~~... PATRICIA , LU~`.,.`~ throughTo requalify for exclusive MVC privileges February 2016 your Kohl's Charge purchases(Feb. 2014-Jan.2015) must be$600. Your current Kohl's purchases are$0.00. How does$ iO off sound? Save when you sign up for paperless statements at It's just another great thing that makes you goKDHL'S! YOUR ACCOUNT|SCURRENTLY CLOSED. . NOTICE:SEE REVERSE SIDE FOR IMPORTANT INFORMATION y VALUE CITY FURNITURE/GECRB cardholder Name: PATRICIA v LUJANAE Account Number: 6019 1938 0207 8302 CE Capita(Retail Bank Statement Closing Date: 03/02/2014 Summary of Account Activity Payment Information Previous Balance $1,298.54 New Balance $1,288.54 + New Purchases $0.00 Minimum Payment This Period $79.00 Payments $47.00 Amount Past Due $56.00 +/- Credits,Fees&Adjustments(net) $37.00 Total Minimum Payment Due $135.00 +/- Interest Charge(net) $0.00 Payment Due Date 03/2512014 New Balance $1,288.54 PAYMENT DUE BY 5 P.M.EASTERN ON THE DUE DATE. We may convert your payment into an electronic debit. See Credit Limit $6,000.00 reverse side. Available Credit $4,711.00 Days in Billing Period 28 Late Payment Warning: If we do not receive your Total Pay online for free at:gogecapital.com Minimum Payment Due by the Payment Due Date listed above, For GE Capital Retail Bank customer service or to report you may have to pay a late fee up to$35.00. your card lost or stolen,call 1-866-396-8254. Minimum Payment Warning: Making only the Total Minimum Best times to call are Wednesday-Friday. Payment Due will increase the amount of interest you pay and the time it takes to repay your balance. For example: If you make no You will pay off And you'will end up N additional charges the balance shown paying an estimatec using this card and on this statement total of... each month you in about... pay... Only the minimum 2 years $1,291.00 payment r �\ If you would like information about credit counseling services, call 1-877-302-8797. Promotional Purchase Summary Promotional Promotional Deferred Tran Date Description Initial Expiration Balance Interest Charge Purchase Date Amount 09/02/2016 $1,195.54 $0.00 08/29/2013 Equal Payment No Interest $1,441.54 A summary of your promotional purchase is provided above. If you have a DEFERRED INTEREST/NO INTEREST IF PAID IN FULL promotion:To avoid paying Deferred Interest Charges on these promotion(s),you must pay the entire applicable Promotional Balance by the Promotional Expiration Date. To make more than one payment see Make Payment To address or pay online at gogecapital,com. Transaction Summary, Tran Date Post Date Reference Number Description Amount 02/14/2014 02/14/2014 P907300DZO1 B4PDK8 PAYMENT-THANK YOU $47.00 CF FEES 02/25/2014 02/25/2014 LATE FEE $35.0c 03/02/2014 03/02/2014 MINIMUM INTEREST CHARGE $2.Oc PURCHASES TOTAL FEES FOR THIS PERIOD $37.0( INTEREST CHARGED 03/02/2014 03/02/2014 INTEREST CHARGED ON PURCHASES $O.Oc TOTAL INTEREST FOR THIS PERIOD Moc 2014 Tat als Year-to-Date Total Fees Charged in 2014 $99.00 Total Interest Charged in 2014 $0.00 Total Interest Paid in 2014 $2.00 "NOTICE: See reverse side and additional pages(if any)for Important information concerning your account. 5302 0007 CYH 1 7 2 140302 D PAGE 1 of 3 91173 3800 FRJ2 OICA5302 188056 MMATTRESS WAREHOUSE/GECRBCardholder Name: PATRICIA V LUJANAC Ive Account Number: 6034 6109 1910 5456 GE Capital Retail Bank Statement Closing Date: 02/15/2014 i Summary of Account Activity PAVrhent Informat on ; Previous Balance $788.00 New Balance $787.00 + New Purchases $0.00 Total Minimum Payment Due .$35.00 Payments $28,00 Payment Due Date 03/11/2014 +/- Credits,Fees&Adjustments(net) $27.00 PAYMENT DUE BY 5 P.M.EASTERN ON THE DUE DATE. +/- Interest Charge(net) $0.00 We may convert your payment into an electronic debit. See New Balance $787.00 reverse side. Credit Limit $6,000.00 Available Credit $5,213.00 Late Payment Warning: If we do not receive your Total Days in Billing Period 28 Minimum Payment Due by the Payment Due Date listed above, you may have to pay a late fee up to$35.00. Pay online for free at:gogecapital.com Minimum Payment Warning: Making only the Total Minimum For GE Capital Retail Bank customer service or to report Payment Dug will Increase the amount of interest you pay and your card lost or stolen,call 1-866-396-8264. the time it takes to repay your balance. For example: Best times to call are Wednesday-Friday. If you make no You will pay off And you will end up additional charges the balance shown paying an estimated using this card and on this statement total of... each month you in about... PAY— Only ay— Only the minimum 8 years $2,519.00 (0 ®� payment $44.00 3 years $1,596.00 J (� (Savings=$923.00) If you would like information about credit counseling services, call 1-877-302-8797. Promotional Expiration Notification YOU MUST PAY EACH PROMOTIONAL BALANCE IN FULL BY ITS EXPIRATION DATE TO AVOID PAYING DEFERRED INTEREST CHARGES. PLEASE SEE THE PROMOTIONAL PURCHASE SUMMARY SECTION ON THIS STATEMENT FOR FURTHER DETAILS.YOU HAVE A PROMOTION(S)EXPIRING ON 07/18/14. Promotional Purchase Summary Promotional Promotional Deferred Tran Date Description Initial Expiration Balance Interest Charge Purchase Date Amount 07/18/2014 $722.00 $257.61 04/17/2013 Deferred Interest/No Interest If Paid In Full $1,099.00 A summary of your promotional purchase is provided above. If you have a DEFERRED INTEREST/NO INTEREST IF PAID IN FULL promotion:To avoid paying Deferred Interest Charges on these promotion(s),you must pay the entire applicable Promotional Balance by the Promotional Expiration Date. To make more than one payment see Make Payment To address or pay online at gogecapital.com. Trarisaction Summary Tran Date Post Date Reference Number Description Amount 02/14/2014 02/14/2014 P912200DZ01B4PDMW PAYMENT-THANK YOU $28.00 OR FEES 02/11/2014 02/11/2014 LATE FEE $25.00 02/16/2014 02/16/2014 MINIMUM INTEREST CHARGE $2,00 PURCHASES TOTAL FEES FOR THIS PERIOD $27.00 ontinued on next page NOTICE: See reverse side and additional pages(if any)for important information concerning your account. 5302 0052 CXH 1 7 16 140216 PAGE 1 of 3 9122 0900 GNJ2 OICA5302 200776 Boscov's Account Statement Account Number 0000-0000-0329-2886 Page I of 4 From February 28,2014 to March 30,2014 II I�I 11111J.tur�T-ary-ofAc-c-o-unt-A ctivaty- 1,Payment,in rimition 4 s Balance $244.64 New Balance $273.75 -REWARDED 1 Previlou' VV Payments $0.00 Minimum Payment Due $5 .00" Other Credits $0.00 Payment Due Date April 24,2014 Purchases/Debits $0.00 Past Due Amount $25�00 Late Payment Warning:If we do not receive your minimum -:r payment by the date listed above,you may have to pay a late Fees Charged + $26-00 fee of up to$35.00 and your APRs may be increased to the Interest Charged + $4.11 Penalty APR of 25.90%. New Balance $273.75 Credit Limit $5,000.00 Minimum Payment Warning:If you make only the minimum Credit Available $0.00 payment each period,you will pay more In interest and it will Statement Closing Date March 30,2014 take you longer to pay off your balance.For example: Days in Billing Cycle 31 If you make no You will pay off And you will end additional charges the balance up paying an using this card shown on this estimated total and each month statement in of.. you pay_ about... Only the minimum 11 Months $300 Payment If you would like information about credit counseling services 1 L call in 1-866-569-2227. Questions? Payment Address:Boscovs,PO Box 71106,Charlotte,NC Customer Service 1-800-755-7872 28272-1106 TDD/Hearing Impaired 1-800-365-0186 Billing Inquiries:Retail Services,PO Box 5893,Carol Stream,IL 60197-5893 Earn Up to Manage Your account online at 4% Back www.hrsaccount.com[boscovs portant Information As a reminder,you may pay your credit card bill online or through our automated phone system for no fee. pPROMOfJON EXPIRATION ALERT! Thank-you f6iPromotion Expiration Date Promotional Payoff Amount Deferred Interest Promotion Type being a valued 06/24/2014 $30.98 $0.00 Waived Interest Charge 0- scov"s customer! Interest charges will begin to accrue at the Regular credit plan APR if the Promotional Payoff Amount(s)is not received by each Promotion Expiration Date. i—an-lacti—ons Trans Date Post Date Description of Fees Reference Number Amount 03/24/14 03/24/14 LATE CHARGE Reg-Purch 1000001014032499907 $25.00 ASSESSMENT 0030 Total Fees for This Period $25.00 ......... .......... .............. Description of Interest Charge Amount INTEREST CHARGE ON $4.11 PURCHASES Total Interest For This Period $4.11 rewarded REV-1513 EX+(11-08) pennsytvania SCHEDULE i DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia V. Lujanac 21-14-0189 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under Sec.9116(a)(1,2).] 1 Mary D.Lujanac Daughter 1/10 2. Melanie S.Thompson Daughter 1/10 3. Patti L.Weber Daughter 1/10 4. Leanne M.Lujanac Daughter 1/10 5. Lisa V.McGroarty Daughter 1/10 6. Jan M.Carelock Daughter 1/10 7. Michael P.Lujanac Son 1/10 8. Thomas R Lujanac Son 1/10 9. Paul T.Lujanac Son 1/10 10. John M.Lujanac Son 1/10 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,insert additional sheets of the same size.