HomeMy WebLinkAbout09-14-15 (2) �•`: pennsylvania 1505618403
UEPgR... R .
`EX(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 21 15 0141
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
01 03 2015 01 06 1917
Decedent's Last Name Suffix Decedent's First Name MI
CHONUSKIE REGINA C
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
n1. Original Return 2. Supplemental Return 3. Remainder Return(date of death
prior to 12-13-82)
4. Agricultural Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
n7. Decedent Died Testate 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
EJ10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
r] 13. Business Assets 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
RONALD M KATZMAN ESQ 717 234 4161
First Line of Address
4250 CRUMS MILL ROAD
Second Line of Address
PO BOX 6991
City or Post Office State ZIP Code
HARRISBURG PA 17112 «�
Correspondent's email address: rmk(ftoldberglkatzman.com r. -,•, c>
REGISTER OF WILLS7USE O LY '4 c:)
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY
CD
DATE FILED STAMP
Side 1
III'IIIIIIIIIIIIII1l5
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'III'IIII�II'IIIIIIIII 1505618403
1505618411
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: ChOnuskie, Regina C.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 56-,129 - 29
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D).................................................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 178 ,247 - 57
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 234 ,376 - 86
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 17,149 . 09
.
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 939 - 09
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 18 ,088 . 18
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 216,288 .68
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13. 11000 - 00
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 215-,288 . 68
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.00 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 11 - 011 16. 0 . 110
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 011
18. Amount of Line 14 taxable
at collateral rate X.15 215,288 - 68 18. 32,293 - 30
19. TAX DUE................................................................................................................ 19. 32,293 . 30
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNATU OF PERSON RESPONSIBLE FOR_ ILING R TURN g ara L. Parsells DTE
ADDRESS
467 Rupley Road, Camp Hill, PA 17011
SIGN RE Pfd A=HER THAN REPRESENTATIVE Ronald M. Katzman Esq. DATE
ADDRESS
4250 Crums Mill Road, Harrisburg, PA 17112
Side 2
1505618411 1505618411
REV-1500 EX Page 3 File Number 21-15-0141
Decedent's Complete Address:
DECEDENT'S NAME
Chonuskie, Regina C.
STREET ADDRESS
46 Erford Road
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 32,293.30
2. Credits/Payments
A. Prior Payments 30,000.00
B. Discount 1,578.95
Total Credits(A +B) (2) 31,578.95
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 714.35
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;............................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑
Fil
d. receive the promise for life of either payments,benefits or care?..............................................:............. ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ ❑x
3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. 'Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ ❑x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
a
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
. For dates of death on or after January 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 step-parent of the child is 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 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 decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1503 EX+(08-12)
SCHEDULE B
pennsylvania STOCKS & BONDS
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 21 shares of MetLife, Inc.stock-com shares. Held in 53.49 1,123.29
Policyholder Trust.
2 U.S.Treasury Savings Bond-Serial#V2277071 EE 7,858.00
3 U.S.Treasury Savings Bond-Serial#V2277073EE 7,858.00
4 U.S.Treasury Savings Bond-Serial#V2277074EE 7,858.00
5 U.S.Treasury Savings Bond -Serial#V2277075EE 7,858.00
6 U.S.Treasury Savings Bond-Serial#V2277076EE 7,858.00
7 U.S.Treasury Savings Bond-Serial#V2277077E 7,858.00
8 U.S.Treasury Savings Bond-Serial#V22770770EE 7,858.00
TOTAL(Also enter on Line 2, Recapitulation) 56,129.29
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.08-12)
Rev-1508 EX+(08-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
Include the proceeds of litigation and the dale the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PNC Bank-Checking Account#5070077794. 15,957.69
2 PNC Bank-Savings Account#5003838776. 161,232.88
3 2014 Income tax return 1,057.00
TOTAL(Also enter on Line 5, Recapitulation) 178,247.57
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12)
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITACE TAX
RESIDENT'DEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s)attached 7,851.99
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Goldberg Katzman, P.C. 8,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationship of Claimant to Decedent
4. Probate Fees 435.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 361.60
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 17,149.09
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Funeral Luncheon 86.99
2 Myers-Harner Funeral Home 7,765.00
H-A 7,851.99
Other Administrative Costs
3 Cumberland Law Journal-Publication fee. 75.00
4 Goldberg Katzman, P.C. -Mileage reimbursement 29.90
5 Patriot-News-Publication fee. 246.90
6 USPS-Stamps 9.80
H-137 361.60
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX*(12-12)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
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 aLixaRx-Bill 244,89
2 Dr.James Hardy-Bill 60.00
3 Golden Living-Final Bill. 560.38
4 Mobile-X-X-ray Bill 73.82
TOTAL(Also enter on Line 10, Recapitulation) 939.09
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-12)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Chonuskie, Regina C. 21-15-0141
NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trustee s
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Karen J. Norrell Niece Entire estate 216,288.68
1347 East 25th Street residue.
Idaho Falls, ID 83404
Barbara L. Parsells Friend $1,000.00
467 Rupley Road specific bequest.
Camp Hill, PA 17011
Total 216,288.68
Enter dollar amounts for distributions shown above on lines 15 through 18 or Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 The Church of the Good Shepherd 1,000.00
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI 1,000.00
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
C-D
C.
1,AST Vi? 1, A N 1) TFSY/k M ENT
c-n
OF
REGINA C. CHONUSI-1'11
r 11
1, REGINA C. CHONUSKIE, now of Camp Hill, Cun-ilberland County, Pcilils)NJ\ania..
bcjiin� of sound and disposing rnind, do hereby make., pUbliSh, aild declare this to be my Las' VVill
aild 'Festarl-I.Cat, hereby revoking and malting null and void all prior Wills and Codicils rnulc by
i,,-jc at anv Linic herciolore.
ITEM 1. 1 direct that all my legally valid debts, Aiiieral aild administrative C\P(:;"scst
aild debts *1110-Urred or payable because of my death, shall be plaid by my E'xccuLor, lierciriafter
I1u111:-'(11, 1,1,0111 1,2), YcSiduar), estate as soon after my death as, practicable. All dcatill luxes,
f0dC1111, SLE11c, and other death taxes, with respect Lo the property forininO ITIV
(-,state for tax purposes, whether or not passing under this Will, including any interest or pci,,al .,ty
Imposed thereon, shall be considered an expense of administration of iny estate, 111 c)L I
or right of rell-ribu i's eni ent, c`�ccpt for negligence or -fault on the 1TI::
Executor. 1',cixcs oil future interests may be prepaid.
IT1131\11 11. 1 give and beclueCA11i certain licnis of' tangible personal Property uh.'I� arc
ScIdely Owned: by 1-1"0 at the time of my CICL-11,11 alld that are 1CIC111LI15(:cl. In )I-IV
directing cilstrIbUtion ther-ol' er i-) CL1111Nlii ' mn- ' !'
aflabat i ,
to 111osc p,*,rurs deli gilat
cd in sucl sc,paratc V, 11ilWho SLIN'Ve 1110. If ally tec, L, ,,oI'bI
"'
personal property is identified in more than one separate writing, I direct that, unless stated to the
contrary, the separate writing bearing the last date shall govern the disposition of such item.
ITEM III. I make the following specific bequests:
A. I bequeath the sum of One Thousand Dollars ($1,000.00) to THE CHURCH OF
THE GOOD SHEPARD, in Camp Hill, Pennsylvania, or its successors in
interest, for its general purposes, given in memory of Joseph and Regina
Chonuskie.
B. I bequeath the sum of One Thousand Dollars ($1,000.00)to my friend,
BARBARA PARSELLS,now of Camp Hill, Pennsylvania, if she survives me by
thirty(30)days. If she should not so survive me, then this bequest shall lapse into
the residue of my estate under Item V.
ITEM IV. I bequeath all my household and personal effects,jewelry, automobiles,
and all other tangible personalty of like nature that are solely owned by me at the time of my
death, and that are not named in any list prepared pursuant to Item II hereof,to my niece,
KAREN J.NORRELL,now of Idaho Falls, Idaho. Any item that my said niece does not want
shall be sold by my Executor, either at public auction or private sale and such proceeds shall pass
as part of my residuary estate under Item V.
ITEM V. I give, devise and bequeath all of the residue of my estate, whether real,
personal, or mixed, and wherever situate, to my niece, KAREN J.NORRELL, if she survives
Page -2-
me by Any (30) clays. If she docs not so survive ine, then I male such bequest to Jr'SMES P.
now oflrvin, Idaho (or to his estate if he has predeceased me).
ITEM V1. The interest of beneficiaries !hereunder shall not be subject to anticipal ion
or to voluntary or involuntary alienation.
ITEM Vit. 1 hereby appoint DONALD M. I'.A ZMAN to serve as executor (the
'EXCCU1o1"). ol'this, n1y Last Will and 7'cstarnm In the event of his refusal or inability to so
serve, I the!1 grant to hila the rkdit and power, exachabie in A exclusive diSereAwl, to
nominate and appoint, Mither in advance Able competerit, or at the timC of a renU illation )r
resignation, ;a successor person of persons to;Serve as Such Executor, which nomination AS be
honored as if I had made such an appointment in this Will.
ITE,N,1 VIII. i direct that my Executor shall not be required to gtve bond or post an, -
c)lhcr se—urity for the faithful performance of duties in any jurisdiction.
Ft', M IX. Any person who shall have died at the same time as i11c, or in a con-inmri
disaster ividi me, or udder such circurnsiances that it is difficult or inipossibic to determine % ho
died first, shall be deemed to have predeceased
ITEM My Executor shall Have the following powers in addition to tho:_c invcsteu
by 1mv and by other provision: of rriy 'v`HI applicable to all properly, whether principal or
income, c�:ercisabie •,vithoiit wi,rt c:pproval and effective until distribution of all property:
Page -3-
A'. TO retain any investrricnls 1 may have at my death so long as my Executor
dc,cnl it advisable to my Estate so to do.
11 It vary investments. Nvllcn deemed desirable by my Executor, and to invest ii;
such bonds, common trust fluids, stocks, notes, real estate mortga<pes, or other
securities or in such other property, real or personal, as my Executor deems .vise,
"Thou being rw ictal to so-called "lcgal investments".
C1 in order to effect a division of We principal of my l-'statc, or for any otter- puir ose.
including any linai distribution, my Executor is authorized to make saki divisOns
or distributions of the personalty and realty partly or WAly in kind. I r such
Wdon or distribution is made in kind, said assets arc required to be Widcd or
d1trib_uted at their respective values on the date Or dates Of their division or
di`irlli:M.
I). To soil either at public or private sale and upon such terms and conditions as illy
1 xccutor may deem advnntag;ous to my Fstatc, any or all real or persowd es.;lte
or interests therein owned by my Estate severally or in conjunction •with other
persons or acquired after my death by nay E.xccutor, and to consurnmate said sale
Or sales by sufficient deeds or other instruments to the purchaser or purchasers,
conveying a fee simple title, We and clear off all trust and without obligation or
liability of the pu1'ch;.1se1- or purchasers to sec to the application of the purchase
money or to make inquiry hao the validity of said salt: or sales; also, to make..
execute, ackr o"Iedge, and deliver any and A! dards, assignments, options, or
Page -4-
\N,-rlt111`'s which 11-,w be i1CcC5sary or dcslrable, ;n carrylllg oul any of the;
po',vcrs conferred upon m',- 17xCCLltol' 111 this jDara"i'al)h or ClsCwllcrc in lrl)l Will.
l;.
To mortgage real cstalc, and to make leases of real estate for ally period of tine aS,
my l',xccutor may L1cern reasonable.
F. To borrow money from arty party to pay indebtedness of Mine or of illy (;state,
ex,penscs of administration. of lnheritalice, legacy, estate, or other taxes.
(J. 10 l,ay all costs, tags, expenses, and charges in connection N:vith the
i dmii]istr ation of my Lstate. My Executor shall pi.y expenses of lily last illil(:"s
and 1L11]Cl'al CxpC11SCs.
votc a:]y shares of stool: which 101'111 a part of ir;y Estate, and to ot11c ;vise :
exercise all the 1powers incident to the ownership of such stock.
%. I'o compromise claims and to abandon any property which, in my l;xecutor's
ol)iiljoll, is of little or no value.
IN �VRI?IZ.I;O , I have hereunto set lily hand "."Id seal to tills lily Last !1%iil
and I CStar11C11. cons]siiri� of live (5) tyl)cv%r;ttcn pa gcs, this day of !.. - , 2G C.
/ (1
J J
1U."GINA C. C'Ti, tJyi�l :
Page -.I-
c. lil,' Lill, crsi-ned, hereby ccrtiiy that t1-1C Col'C�('oin`1' Will VVaS Sl"FICC1, SCaIcCL nub'ished
and duciared by the above-llallled i CStaU-ix, 1�t1:C;lA14 C. CHONIJ..ME, as and for her i as; ti'ill
and :CSt,!i11CIlt. Ill the OrCSC11CC 01 LIS, who at her rCCILlest and In her presence and ill the l)rescrice
of.,each otll i', have hereunto SCt 01.11- 11a11dS and Seals the day and year above writtell. an-d vvc
certify that at the tulle of the execution thereof, the Said Testatrix was ol'sound and dishosin,
Illind and memory.
-esiding atd
akresidmo at I•i
OF PENNSYLVANIA
Subscribcd, Sworn to and acknowledged before me by the Testati-ix R'E11'1NA C.
ii ON'USK 12,, ailt Stlbsgibed and Sworil to before 1110 by
}
and � f� 4'!� itA _` 9 .4 - —... ._ witnesses, thi:i --`' ;.a— da)
of' 1Y
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,010. tPl
.x
Notary FLiblic
(SEAL)
195183.1
COMMONWEALTH OF PENNSYLVANIA
Notarial Seat
Jennifer L.Boltz,Notary public
City of Harrisburg,Dauphin County
My Commission Expires May 30,2013
Member,Pennsylvania Association of Notaries
Pa-c -6-
FIRST CODICIL
TO THE WILL OF
C3 nq
REGINA C. CHONUSKIE Mr' '
cr1 :J
I, REGINA C. CHONUSKIE,now of Camp Hill, Cumberland County, Pennsylvania,
being of sound and disposing mind, do hereby make, publish, and declare this to be a Frivvi
Codicil to my Last Will and Testament, dated September 8, 2010 (my "Will").
I hereby amend the following sections as follows:
ITEM VII. Delete ITEM VII and insert the following:
"I hereby appoint BARBARA L. PARSELLS to serve as executor(the
"Executor"), of this,my-Last Will and Testament. In the event of her refusal or inability to so
serve, I then grant to her the right and power, exercisable in her exclusive discretion,to nominate
and appoint,whether in advance while competent, or at the time of a renunciation or resignation,
RONALD M. KATZMAN to serve as such Executor, which nomination shall be honored as if I
had made such appointment in this Will."
IN WITNESS WHEREOF,I have hereunto set my hand and seal to this First Codicil to
my Last Will and Testament, consisting of one(1) typewritten page,this day of
January,2012.
REQINA C. CHONUSKIE
1 .
{00581576;Vl}
We, the undersigned, hereby certify that the foregoing First Codicil was signed, sealed,
published, and declared by the above-named Testator, REGINA C. CHONUSKIE, as and for a
codicil to his Last Will and Testament, dated January 24, 2012, in the presence of-us, who at his
request and in his presence and in the presence of each other, have hereunto set our hands and
seals the day and year above written, and we certify that at the time of the execution thereof,the
said Testator was of sound and disposing mind and memory.
Ilip
residing
at
X,
''I:Z--�4icsiding at
2
{00581576;v1}
COMMONWEALTH OF PENNSYLVANIA
. SS..
COUNTY OF CUMBERLAND
We, the Testator, and Ronald M. Katzman, and ht'hor.1 the
witnesses, respectively, whose names are signed to the foregoing instrument,being first duly
sworn, do hereby declare to the undersigned authority that the Testator signed and executed the
foregoing instrument as aFirst Codicil to his Last Will and Testament, that he had signed
willingly, that he executed it as his free and voluntary act for the purposes therein expressed, that
each of the witnesses, in the presence and hearing of the Testator, signed the First Codicil as
witness, and that to the best of his/her knowledge the Testator was at that time eighteen years of
age or older, of sound mind, and under no constraint or undue influence.
''REGINA C. CHONUSKIE
Witness f
Witness
Subscribed, sworn to and acknowledged before me by the Testator,.REGINA C. CHONU KIE,
and subscribed and sorn to befor• me by Ronald M. Katzman and �jr l:Y"7"S
witnesses, this c ' day of 9�; , 2012.
'o ublic
( AL)
: isiil ;`9` a' F1tI Cir=F'ENPlS'f
+afrg: Boltz,f+10taiy Public t
1 p... ^rrGbutg.,1:1;�.�hisGoun4y
i
ri'iy !"rt(!Cf i $1v1 SsplP4's'Eiw` 30.2!r3
J„,.. ,i%earai u1J«r!i;t gc,, jai<an of Notaries
3
{00581576;v1}
Calculated Value of Your Paper Savings Bond(s) Page 1 of 1
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 02/2015
Total Price Total Value Total Interest YTD Interest
$17,500.00 $55,006.00 $37,506.00 $0.00
Bonds: 1-7 of 7
Serial # Series Denorn Issue Next Final Issue Price Interest Interest Value Note
Date Accrual Maturity Rate
V2277071EE! EE !$5,OOOiO9/1991;03/2015iO9/2021� $2,500.00! 4.00W
.................................-................. ...... ................... ................ ...............
V2277073EE� EE �$5,OOoiO9/1991�03/2015iO9/2021� $2,500.00,' $5,358.00:� 4.00%1 $7
..........1.......... ......—....-.....I--.................
V2277074E-E'i E....E5,000
..-.--- - 5,0.._0......�..0.**9
....... $ ...- . -.-.-/-1---9*"9"1..*........��...0...3..../
2*..0.......1.......5.......-��0..9..../.....2..-.0,-2.*,.*1-�------$-2-,5**.0..0,....0.....W.*.*.-'.*.".
$...5,.35.-.8..........0....0....
..........4........0...0..
%....'.......$7,
85
8..00
V2277075EE EE $5,000;09/1991�03/ $5358. . _4,00% $7,85800
. EE ...:$5,00009/199103/2015.09/2021� $2,50000 $5,358.W 4.00% $7.,858.00
V2277077EEE......$5f000 09/1991.03/201509/2021� $2,500,0W $5,358.00 4.00% $7858.00
Vi277670Eff" EE -$5,OOOiO9/199103/201509/2021 $2,500 00 $5,358.00 . 4.00% $7,858.00
. :
Totals for Bonds $17,500.00
.'
............
$37,506.00 �$55,006.00
Notes
NI Not Issued
............ ......
eligibleNE ;Not
-------- - ......
PS Includes 3 month interest penalty
...........
MA Matured and not earnin interest
http://www.treasurydirect.gov/BC/SBCPrice 2/20/2015
Page 1 of 2
&mputershare
Me L fe Computershare
PO Box 30170
College Station,TX 77842-3170
_ Within USA,US territories 6 Canada 800 649 3593
Outside USA,US territories 8 Canada . 201 680 6578
043214 Hearing Impaired(TDD) 201 680 6611
-_ [rll�lr��llll��ll��ll"X1111'I"'11'llll�llrl�'1'I'1'lllllllllll�
www.computershare.com/metiffe
MetLife,Inc.is incorporated under the laws of the
REGINA CHONUSKIE State of DE.
467 RUPLEY RD
CAMP HILL PA 17011-1839
Holder Account Number
C0009361162
Ticker Symbol MET
CUSIP 59156R108
MetLife Policyholder Trust-Transaction Advice
Transaction(s)
Date Transaction Description I Trust Interests CUSIP I Class
(Shares) Description
07 Apr 2000 Opening Balance 21.000000. 59156R108 Trust Interests
Account Information: Date: 13 Mar 2015(Excludes transactions pending settlement)
Trust Interest Price Value($)
(Share)Balance Per Share I .
21.000000 51.35 1,078.35
This Transaction Advice is your record of the indicated Trust Interests being credited to an account on the books of the referenced transfer agent.The Transaction Advice should be kept with your
important documents as a record of your ownership of these securities.These Trust Interests are transferable only as permitted under the MetLife Policyholder Trust Program.Please read the
important information on the back of this form and in the MetLife Purchase and Sale Program Brochure.
IMPORTANT:Carefully cut along the dotted line and return the form BELOW to the address provided. 01JEUA
.Purchase Instructions Holder Name:REGINA CHONUSKIE.
(See reverse side to SELL)
If you wish to request a purchase,detach,complete and return this form. Holder Account Number
Make check in U.S.dollars payable to the MetLife Purchase Program.
C0009361162 I N D
Attached is a check in the amount of:
11111111 IIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII 11111 IIII IIII
• No third party checks,money orders or credit card payments will be accepted. 'III"IIII'lllllll'lllllll�'IIII'IIIIIIII'Illl'111'I'lllllllll"I
• Please write your holder account number and the company name on your check.
• This form should ONLY be used for MetLife,Inc. Computershare
The enclosed amount will ONLY be applied to the account referenced to the right. PO BOX 6006
Minimum investment$250(except as described in the Purchase and Sales
brochure). Carol Stream, IL 60197-6006
00000000METL SPP3 C 0009361162
Please detach this portion and mail it to the address provided on.the right.
001 CS0003.d.mix.052412 5294/043214/055317!3
MET Historical Prices I MetLife, Inc. Common Stock Stock- Yahoo! Finance Page 1 of 1
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Enter Symbol Look Up Wed,May 6,2015,10:35AM EDT-US Markets close in 5 hrs and 25 mins Reportan Issue
Dow i0.66%Nasdaq i0.49%
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MET �TRADE I d r: :,A:
MET OPEN AN ACCOUNT
------—� raG6
MetLife,Inc.(MET)-NYSE *Watchlist Add to Portfolio II Like 91
------—
Historical Prices Get Historical Prices for.I I GO
Set Date Range 1` "S
� QQ DailyIf
JanV_�'
Start Date: —2015 —_.Eg.Jan 1,2010 O Weekly
End Date: Jan v 2015 a Monthly
O Dividends Only
rGei Pis No-pen
required.
First I Previous i Next I Last
G�Qpen atveng.rerd RA"
Prices !�onlin&in just
ecp.
Date Open High Low Close Volume AdjClose' = OrrirnAes.
Jan 5,2015 53.42 53.63 51.88 52.11 6,520,200 51.74 ;.
Jan 2,2015 54.48 54.76 53.63 53.91 3,911,700 53.53 ]
'Close price adjusted for dividends and spills. y,
First I Previous i Next I Last S.
ADownload to Spreadsheet
Currency in USD.
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I+b.�anp roaa..te.o�erw.
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http://fmance.yahoo.com/q/hp?s=MET&a=00&b=2&c=2015&d=00&e=5& 2015&g=d 5/6/2015
Date Open Close Avg.
1/5/2015 53.42 52.11 52.77
1/2/2015 54.48 53.91 54.2
106.97
*.5
Share price on date of death $53.49
Mar. 1U. 2015 2: 39-FM No. UU I 1 Y. 1
,TPN
March 20,2015
Goldberg Katzman Attorneys
Attorney at Law
4250 Crinis Mill Road
Harrisburg PA 17112
RE:. Regina C Chonuskie
SSN: 196-03-3151 ;
DOD: 01-03-2015
Dear Sir/Madam:
In response to your request for Date of Death(DOD)balances for the customer noted above,our
records show the following:
Checking Account
Account 45070077794 Established: 01-01-1979
REGINA C.CHONUSKIE
DOD balance: $15,957.69+ 0.09 accrued interest
Savings Account
Account#5003838776 Established: 02-07-2002
REGINA C CHONUSKIE
DOD balance: $161,232.88 + 14.60 accrued interest
Please note that this office provides date of death balances for deposit accounts(IRAs,'CDs, Checking and
Savings). We do not process-any financial transactions or provide statements. If you need assistance with
any of these items,please call 1-888-PNC-BAND.(1-888-762-2265)or stop by your local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank,N.A.
Member FDIC
Page 1 of 2
'
Form 1040(2014) REGINA CHONUSKIE 196-03-3151 Page 2
39a Check N You were born before Jan.2,1950, [] Blind. Total boxes
Credits F]Spouse was born before Jan.2, 1950,n Blind.J checked * 39a
Standard b If your spouse itemizes on a separate return or you were a dual-status alien,check here 0, 39b
Deduction 1 40 10, 365.
for. 40 Itemized deductions (from Schedule A)or your standard deduction(see left marg n) 41 6, 512 .
check any 42 3, 950.
box on line 42 Exemptions.if line 38 is$152,525 or less,multiply$3,950 by the number on line 6d.Otherwise,see Instructions
39a or 39b or 43 Taxable Income. Subtract line 42 from line 41,If line 42 is more than line 41,enter-0- 43 62 .
who can be 254 .
claimed as a 44 Tax (see instructions).Check if any from: aE]Form(s)8814 bF]Form 4972 c n — "
dependent, 45
see 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . . .
instructions. 46 Excess advance premium tax credit repayment.Attach Form 8962 . . . . . . . 46 254 .
Single or
Married filing 48 Foreign tax credit.Attach Form 1116 if required. . . . . . 48
separately, 49 Credit for child and dependent care expenses. Attach Form 2441 . 49
Married filing
jointly or 51 Retirement savings contributions credit.Attach Form 8880 51
Oualitying
widow(er), 52 Child tax credit. Attach Schedule 8812,if required . . . . 62
$12,400 53 Residential energy credits.Attach Form 5695 53
Head of 47
household, 54 Other credits from Form:a 0 3800 bF1 s8o, c Els P1 54 1 55 47 .
66 Subtract line 55 from line 47,If line 55 is more than line 47,enter-0- 110. 56 207 .
Other 58 Unreported social security and Medicare tax from Form: aF]4137 bFJ8919 . . . 58
Taxes 59 Additional tax on IRAs,other qualified retirement plans,etc. Attach Form 5329 if required 59
b First-time homebuyer credit repayment.Attach Form 5405 if required . . . . . . . . . . . 60b
rVi
61 Health care:individual responsibility(see instructions) Full-year coverage JAI . . . . 61
62 Taxesfrom: anForm8959 b[]Form8960 CO Instructions;enter code(s) 62 --TO—7 .
64 1, 264 . FORM 1099
Payments 64 Federal income tax withheld from Forms W-2 and 1099
65
If you have a 2014 estimated tax payments and amount applied from 2013 return 65
66a Earned income credit(EIC). . . -_ I
child ch bat pay electionj 66b
ac
at
07 Additional child tax credit. Attach Form 8812 . . . . . . . 67
68 American opportunity credit from Form 8863,line 8 . . . 68
70 Amount paid with request for extension to file . . . 70
71 Excess social security and tier I RRTA tax withheld . . . 711
72 Credit for federal tax on fuels.Attach Form 4136 72
Re. Re-
73 Credits from Form: an2439 lbu.rvedCFI�served dd 73 1
Refund 76 If line 74 is more than line 63,subtract line 63 from line 74,This is the amount you overpaid 75 1, 057 .
76a Amount of line 75 you want refunded to you,If Form 8888 is attached,check here *n 76a 1, 057 .
:H Checking n savings
Direct deposit? 0. b Ru mutnar
10. d Account
See instructions 77 number 77
Amount of line 75 you want applied to your 2015 estimated tax Do, y,se..a instructions
Amount 78 Amount you owe. Subtract line 74 from line 63.For details on how to pa
79 Estimated tax penalty(see instructions)
Third Party Do you want to allow another person to discuss this return with the IRS(see instructions)? Li Yes. Complete below. No
Personal Identification
posignee's,,, phone number (PIN) Bo.
Under penalties of pedury,I declare that I have examined this return and accompanying schedules and statements.and to the best of my knowledge and belief,
Sign they are true,correct,and complete. Declaration of preparer(other than taxpayer)is based on all information of wNch preparer has any knowledge,
Here Your signature Date Your occupation Daytime phone number
RETIRED 717-763-8486
Joint return� If the IRS sent you an Identity
See in ions 0i Spouse's signature,if a joint return,both must sign. Date Spouse's occupation Protection PIN,enter
Keep a copy for it here(see inst.)
your records, Print(Type preparers name eparees signature Check E
Paid AARP FOUNDATION I self-empic
Preparer Firm'sname io-AARP— TRINITY LUTHERAN CHURCH Firm'sEIN 10-
Use Only Firm's.ddress *2000 CHESTNUT ST Phone no.
www.irs.gov/form1040 CAMP HILL PA 17011 Form 1040 (2014)
BCA
IIIIIIIVIIIILIIVIIIIIIIIVIIIIIIDVIIIVIII IIIIIIIIIIII T"' STATEMENT
0127612228
alixa
QUESTIONS ABOUT
YOUR BILL ?
(877) 308-4632
billingQa alixarx.com
PRIV Pittsburgh 04580 PAGE 01
Date Invoice Patient Name Account Number
02/25/15 REGINA CHONUSKIE 1012228
Previous Balance New Charges Payments Adjustments New Balance
$ 244.89 $ 0.00 $ .00 $ $ 244.89
Date Rx# Drug Name ' Qty Price Ins Pay Amt Pat Pay Amt
Previous Month Balance 244.89
PAYMENT 03/25/15
MAIL YOUR PAYMENT USING THE COUPON BELOW DUE DATE
AMOUNT DUE
Your account is over 90 days past due. $ 244.89
DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING
------------------------------------------------7-------7----------------------------------------------------...... -----------------------------------------
AlixaRx LLC ACCOUNTNUMBER
1000 Fianna Way 1012228 REGINA CHONUSKIE
Fort Smith, AR 72919BILLING DATE DUE DATE
02/25/15 03/25/1511 $ 244.89
Check here to pay by credit card and enter credit card information below.
❑VISA ❑DISCOVER
Check box if address below is incorrect or CARD NUMBER CVV CODE' ZIP CODE
insurance information has changed. Indicate CARDHOLDER NAME EXP. DATE
changes on reverse side.
SIGNATURE AMOUNT
The CVV code is a three"digh number usually found on the back of your credit card.
REGINA CHONUSKIE Please Make Check or Money Order Payable To:
C/O BARBARA PARSELLS AliXa RX Billing Department
467 RIPLEY ROAD 1000 Fianna Way
CAMP HILL PA 17011 Fort Smith, AR 72919-5299
1045800000000010122280225201500024489D0000000000
F - - Please detach and return top portion with your payment
f4essages L'
NOTICE:THIS IS A BILL.BASED UPON INFORMATION FROM YOUR HEALTH PLAN,YOU OWE THE AMOUNT SHOWN.
PAYMENT IS DUE UPON RECEIPT.
Date. Procedure: — . ` -Provider Amount '
11/07/2014 NURSING FAC CARE SUBSEA HARTY $79.00
01/12/2015 PAYMENT-INSURANCE ($47,29)
01/12/2015 WRITE OFF-INSURANCE ($11.71)
Insurance Pending: $0.00 Patient Balance:$20.00
12/05/2014 NURSING FAC CARE SUBSEA HARTY $79.00
12/16/2014 PAYMENT-INSURANCE ($47,29)
12/16/2014 WRITE OFF-INSURANCE ($11.71)
Insurance Pending: $0.00 Patient Balance:$20.00
01/02/2015 NURSING FAC CARE SUBSEA HARTY $79.00
1 015 PAYMENT-INSURANCE ($47.18).
01/12/2015 WRITE OFF-INSURANCE ($11.82)
Insurance Pending: $0.00 Patient Balance:$20.00
Current 30 Day - 60 Day 90 Day 120 Day ., Total Balance
Insurance: $0.00 $0.00 $0.00 $0,00 $0.00 $0,00
Patient: $40.001 $20.001 $0.001 $0.001 $0.00 $60.00
Unapplied $0.00
Payment Due: $60.00
CO-PAY
DUE
Please Remit Top Portion To:,
JAMES R HARTY MD PC Patient Statement Date Chart#
448 WALTON AVENUE REGINA CHONUSKIE January 19,2015 1231
168 Page 1
HUMMELSTOWN,PA 17036-9998
Phone#:(717)805-1046
�� �n STATEMENT
1662893745
QUESTIONS ABOUT
living centers
lers .YOUR BILL?
(866) 325-5606
CAMP HILL
STATEMENT DATE PATIENT NAME ACCOUNT NUMBER
02/01/2015 REGINA CHONUSKIE 03959937450001
PREVIOUS BALANCE NEW CHARGES PAYMENTS ADJUSTMENTS NEW BALANCE
8, 052.51 -7,492.13 0.00 0 .00 560.38
DATE/PERIOD COVERED ACCOUNT ACTIVITY jQTY/DAYSj CHARGES I PAYMENTS I ADJUSTMENTS
01/01/15 01/01/15 ' CANNULA,SOFT,CURVED 14 1 1.30
01/01/15 01/02/15 ROOM CHARGE 2 516.79
01/01/15 01/31/15 REV LAST MO RC -31 -8, 010.22
C�/
v
When returning home, patients often require ongoing care that family members cannot easily provide.
In these cases,AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for more information.
Thank you for choosing Golden LivingCenters.
MAIL YOUR PAYMENT USING THE COUPON BELOW `PAYMENT 02�
DUE DATE
- OR -
PAY YOUR BILL ONLINE AT www.goidenliving.com A OUNT DUE
• $ 560 .38
DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESS
---------------------------------------------------------------------------- --------------------
r'
Contact Customer Service Al E S S A G E S
O b i l e X U S" at(800) 786-8015, Option.2 These charges are billed directly to the patient because a copay,
deductible is due or your claim was denied by your insurance
Symphony Diagnostic Services company. It is the patient's responsibility to provide current insurance
information(see reverse side).
Payment due-upon receipt of statement.
ACCOUNT NUMBER PATIENT NAME SERVICES PROVIDED AT: STATEMENT DATE DATES OF SERVICE DUE UPON RECEIPT PAGE I
5683658ihs REGINA C CHONUSKIE GOLDEN LIVING-CAMP 02/19/15 11/07/14-11/07/14 $73.82 1 of 1
HILL
Procedure Insurance Patient Balance
Date Code Description Charges Payments Adjustments Payments Due
11/07/14 71010 CHEST 1 VIEW 82.50 -16.86 -56.57 .00 9.07
11/07/14 00092 SET UP FEE X RAY 35.00 -22.75 .00 .00 12.25
11/07/14 R0070 TRANSPORT X RAY 2 150.00 -97.50 .00 .00 52.50
o
0
0
0
THIS BILL IS FOR PORTABLE XRiY SERVI ES
A
Insurance_ _ _ Your Payment Optlons
- CURRENT ACCOUNT BALANCE $73.82
Primary: HIGHMARK BS 17846 ---
800-786-8015 -
TOTAL AMOUNT PENDING INSURANCE .00
Secondary:SELF PAY ® P O Box 17452
SECONDARY Baltimore, MD 21297-1452 BALANCE DUE UPON RECEIPT $73.82
IllklKifRIG4"dficf�Il 1138-MXRSTM-2551053-1882014945-P; 11678305-1-1807;35712136-1; 1 �GC, �' `7
PLEASE DETACH HERE AND ENCLOSE BOTTOM PORTION WITH YOUR PROMPT PAYMENT. THANK YOU! �O/