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Home My WebLink About01-0845 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of JO ANNEITE SERLUCO also known as c:iL-o/-%!.lV Social Security No. Deceased. 199-30-4593 No. To: Register of Wills for the County of CUMBERLAND in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl V for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in Cumberland County, Pennsylvania, with h er last family or principal residence at 302 Walnut Circle, Borouqh of (list street, number and municipality) Shiremans town Decendent, then 62 years of age, died ~ 302 Walnut Circle July 4, 2001 Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $l()', 010 $ ~- petitioner~ after a proper search hall( ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Suzann S. Staiqer Sister 310 Glendale Drive Shiremanstown. PA 17 Michael A. Serluco Brother 400 N. Front St. Wormlevsbura. PA 170 011 43 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. .-. ~ u u t: 11.1 ~3 Suzann S. Staiger 11.1 ... ~~ -g.g tU",= 3~ 11.1.... BO ~ c ClO en 7-(p.-ll OATH OF PERSONAL REPRESENTATivE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } ss 10.. The petitioner(s) above-named swear(s) or affmn(s). that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as p nal representative(s) of the above decedent petitioner(s)' and truly administer the estate according to law. . 'fn' ....... GJ ~ ..... ~ Q iZi Estate .of No. ~L-o/-i~ 0Q AwJEf1E\-~llA{2() , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW \Sl2P-r. 1,3 . 2001, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented bef~re me, IT IS DECREED that Suzann s. Stalger & Ml.chael A. Serluco is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration Suzann s. Stal.ger and Ml.chae~ A. Ser~uco are hereby granted to in the estate of Jo Annette FEFS ~fi Letters of Administration ..... $ . Short C~rt.ificates<5> . . . . . . . . .. $ , .. RenuncIation ...... ~ rt!'? ~ .. TOTAL_$ ,Ol> Filed ..................... A.D. 19_ ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE p RENUNCIATION In Re Estate of ]0 ~f>TNJ;'TrpF SlO'RLTTCO To the Register of Wills of CUMBERLAND The undersigned ~T~'T'RR the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters n~ AnMTNT~rpRATTON be issued to MICHAEL A. 5E:~LTTCO WITNESS MY deceased. County, Pennsylvania. of hand this 12 day of 5EPT ,J1:,"Y ? 0 01 ,} f?O -l J. Jt...~.'irV / (signature) S/tJ A~~ tlfJ& ~~,~ r (Address)'" ~ /1tJl/ I (Signature) (Address) (Signature) (Address) 105.805 REV 9/86 This is to certify that the information here given is correctly copied fron: an original certificate of death dul~ filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fiVng. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~ ~P/l 61~. .. Local Registrar . ! Fee for this certificate, $2.00 p 7555106 9~ . ;; c2P~o I ( Date Hl05. .43 R.v 2/87 COMMONWEALTH Of PENNSYLVANIA. DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH TYPElPRINT IN PERMANENT BLACK INK 5. COUNTY OF llERH 62 UNDER I OM Hours 1 MlnuI_ BIRTHPlACE (C.tv and Stale Of fore.gfl COUf'WYJ NAME OF DECEDENT (fwSl. 1.4_. lasl' CUmber land .... Shiremanstown .... white SURVIVING SPOUSE (11_. ijOve.-nomel DECEDENT'S USUAl. OCCUI'lQ"IOH ~':n~.:!'~'='~~:1 . lIe. Teacher 1111. Education DECEDENT'S IWLING ADORESS (SIr". ClI'ylbwn. SIaIe. 1"11I Codel DECEDENT'S 302 Walnut Circle ~~~~ Shiremanstown, PA 17011 ~:=- -} . it! 17b. CUmber land Did - Mine -.....,.7 17e.o _,__in - 17e. StaI.Ppnnsy 1 vani a ... FATHER.S NAWE IFwSl. M_ lastl .. Michael Serluco INFORMANT'S NAME {T ypeiPlonIl 2001. Michael A Serluco METHOD OF DISPOSITION _ KJ C,_ion 0 RemovellromSlal.O 0IheI (Specll'y ""Y- PA 17055 21a. ACTItf!i AS SUCH DATE PRONOUNCED DEAD (MonU>. Day. Yo..) 4. 7: I fJ- t?~ 21. Ju I ;'00 I 27. PART I: Ent... the diseases. inturiesor complical1Ofl5 which caused the death 00 no......... the mode of dyi . SUd'I s cardiaCOI.espttatory allest, shOCk or Man I.....,.. llal only one c..... on 88Cll1ine. PART II: Odlet,,- _ conu......inglO_. buI _ .-..gin... ~_gNenin PiUIT I. l/ .Mlt - Snca.-I/ ('!A..,t / t"a y(! (~) C,) ~ l-f l';1 OUE1OIOIIASACONSEOUENCEOf): f"(.l /'-v:L-'/ ~.!1LL-, It: I :b ' DUE 10 1011 AS A CONSEOUENCE Of): OUE 10 (011 AS ACoNSEOUENcr6f)'---------. I : --.------------, ; weRE AUlOPSY FINDINGS -.lA8lE PRIOR 10 COMPLETION OF CAUSE OF DEATH? UANNER OF DEATH DATE OF INJURY lMoo'" Day. Yo..) TIUE OF INJURY INJURY lIT WORK7 DESCflIBe HOW IN.JtJRY OCCURRED Suicide ~ o o Horntcide AcCldenl Pendtng Irwesugalion o o o PLACE OF INJURY. AI home. 101m, ."..., lactafY. _ buoldng. Me ,Spec.., 308. L2LWL.lli2l Y_ 0 NoW _. Nolural \~1 ~ S ~ o o '" ~ z 'fe. 0 No~ _0 NoD Could 001 be deletmtned 2". 2.... elM WIIR ICheck oruy onel .ClRTlFYlNG PHYSiCIAN .PhySK:iCUl CefWyulg Colusa of deatn w1'\ef' anOV\ef' ptlvSIC.an OdS ptOf'lOllllCed lJealtl ana ccmpu~tt!C Item 2Jl To the be.. 0' "'W knowledge, death occuned ChHlIO the c.uM(s) and """'nef a. a'.ted. . . . . . . . . . . . . . . . . . PRONOUNCING AND CERTIfYING 'HYSlCJAN (PhySolCW1 t'xXh j)fOllQuftCiOy uedtr. dod c;erllfylflQ to C;duse of dedl"\ To 1M belli of my knowledge, death ~c;Ufred at ,he lime. Ate, .nd place. .od due 10 the c;i1uaeCa) and manner.. a.aled. . ,l4~ 'MEDlCAL EXANlHERlCORONER ~~~~~;t:l::=.~~.i~t.l~~ ...~O~ ~~~~~l~~~'.i~~: i.~ ~.y. ~~i.n.~~: ~~~~~ ~~~~~~e.~ ~~ ~~~ ~l~~..~~t~: ~~~.~'~~~: ~~~.~~~ ~~ ~~~ ~~~~~~~).~~~ 0 31. . vJ, ~ AtJd r-- c:.. Date of Death: CERTIFCATION OF NOTICE UNDER RULE 5.6(A) ~ BI\JNefIe Sef(~ fA etJ :Ju~ 'II ()Of) / Name of Decedent: Will No.: Admin No.: ~J 01- 01'1S To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on N6Uf/JJ1tJI. I ~J ~I s U 111'" TtJ flJJ c1Ml Addres~ . S, ~ JulL ~. ~&ttIJ Name Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: !XrtmlJ(J{. J 3, a:lJl o 17) j.' ;( "'50... t/M /\J1JItf'- fit,AJi rJ~ ~ J&mft~tjfUb 1?t>'13 Telephone g 55' r Capacity: ~ Personal Representative ~ ~) -- o Counsel for personal representative - 8: CV"l - . ')1..." ("1.0:1 4,AJ ~.'H, am Q,)CI: a:: u c:::J :,.." ()) ,> .0 't:: ~ (0)= Gu p COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX( 11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT CONSOLIDATED PROPERTIES 400 N FRONT STREET WORMLEYSBURG, PA 17043 -------- fold ESTATE INFORMATION: SSN: 199-30-4593 FILE NUMBER: 21-2001- 0845 DECEDENT NAME: SERLUCO JO ANNETTE DA TE OF PAYMENT: 09/26/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/04/2001 NO. CD 000317 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $12,469.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CONSOLIDATED PROPERTIES CHECK# 010107 SEAL INITIALS: PB RECEIVED BY: REGISTER OF WILLS $12,469.00 MARY C. LEWIS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT MICHAEL A SERLUCO 104 CUMBERLAND ROAD LEMOYNE, PA 17043 -------- fold ESTATE INFORMATION: SSN: 199-30-4593 FILE NUMBER: 21-2001- 0845 DECEDENT NAME: SERLUCO JO ANNETTE DA TE OF PAYMENT: 11/08/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/04/2001 NO. CD 000502 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $608.40 I I I I I I I I TOTAL AMOUNT PAID: $608.40 REMARKS: MICHAEL A SERLUCO CHECK# 7340 SEAL INITIALS: DO RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGIS1~R'OFWILLS: /;-6-// BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT * REV-U07 EX AFP (12-00) MICHAEL A SERLUCO .01 400 N FRONT ST WORMLEVSBURG NOV 26 All:48 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-19-2001 SERLUCO 07-04-2001 21 01-0845 CUMBERLAND 101 Allount Rellitted JOANNETTE Recorded-Omes. .01 Register of Wifts (Mr~t'1'43 Court Cumberland Co., PA MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE~ PA 17013 NOTE: To insure proper credit to your account~ subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=i6o'7-i:x-AFP--ri2"=oo.r------...-iNH"ERITANci"-YAX-STATEMENY-ifF-ACCouiff--...--------------------- ESTATE OF SERLUCO JOANNETTE FILE NO.21 01-0845 ACN 101 DATE 11-19-2001 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE~ APPLICATION OF ALL PAYHENTS~ THE CURRENT BALANCE~ AND~ IF APPLICABLE~ A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-12-2001 P R I NC I PAL TAX DUE: ........................................................................................................................................................................................................................... 13~733.40 PAYMENTS (TAX CREDITS): PAY PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-26-2001 CDOO0317 656.26 12~469.00 MENT MUST BE MADE BY 04-05-2002*. TOTAL TAX CREDIT 13~125.26 BALANCE OF TAX DUE 608 . 14 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE~ SEE REVERSE TOTAL DUE 608.14 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $l~ NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) /1-6--// COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z806C'1 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX I MICHAEL A SERLUCO 400 N FRONT ST WORMLEVSBURG .01 OiDA TE '!Vilis ESTATE OF DATE OF DEATH FILE NUMBER NOV 16 All :~UNTY ACN RecorOE; d Re9i:, 11-12-2001 SERLUCO 07-04-2001 21 01-0845 CUMBERLAND 101 '* IEV-1547 EX AFP UZ-DOl JOANNETTE Allount Rellitted PA 1704{;lerk~(- . CumbenanC1 PA MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv:i54j-Ex-Ai:p--(i2-:ooi--N()fiCE-oF-'rNHERi;:ANcE-'~fAx-;'-PPRJfisEMEN=r;-ALLowANci-ifi----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JOANNETTE FILE NO. 21 01-0845 ACN 101 DATE 11-12-2001 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE ESTATE OF SERLUCO RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets Cl) (2) (3) (4) (5) (6) (7) .00 40.369.00 .00 77.112.00 11.313.00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) ClO) 9,697.00 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. AlIOunt of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due NOTE: 4.652.00 Cll) (12) Cl3) Cl4) . DO X DO = . DO X 045 = 114,445.00 X 12 = . DO X 15 = NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYll8nt. 128,794.00 14.349 00 114,445.00 .00 114,445.00 Cl9)= .00 .00 13,733.40 .00 13,733.40 TAX CREDITS: PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) PAYMENT MUST BE MADE BY 04-04-2002*. TOTAL TAX CREDIT .00 BALANCE OF TAX DUE 13,733.40 INTEREST AND PEN. .00 TOTAL DUE 13,733.40 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1470 EX (6-88) INHERITANCE TAX EXPLANATION OF CHANGES CCJAMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128.0601 DECEDENrS NAME Joannette Serluco FILE NUMBER Sheila Megonnell ACN 2101-0845 101 REVIEWED BY ITEM SCHEDULE NO. EXPLANATION OF CHANGES The decedent did not have a "Last Will and Testament", so, therefore, no monetary contributions can be given to charitable organizations. ROW Page 1 A..,.. . r~ \. I 0J:r- STATUS REPORT UNDER RULE 6.12 , Name of Decedent: lJe ~~\t-f Se.-\v(.O Date of Death: Jl.!!iJ 0 I -=,', ,"-'"'," Will No.: ,,- ~oo \ -Qt> ~u 'J Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes~ No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes )(' No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ~ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be file the Clerk of the Orphans' Court and may be attached to this po . Date: ~J en ~~ lf_-- 2: f"'l I -l ::::J J ) .~1 h_ ~ :;~ S ~..J G Address 7~/- 35sT Telephone No. C""l P Capacity: KPersonal Representative o Counsel for personal representative PE':'. ,::;\}\~ E~ If"€, COMMONWEALTH OF ~ .\~, PENNSYLVANIA , .' r~l~.~.. :' DEPARTMENT OF REVENUE ~iA DEPT. 280601 ,~,~~. HARRISBURG, PA 17128-0601 I- Z LLJ Cl LLJ U ill Cl DECEDENTS NAME (LAST. FIRST, AND MIDDLE INITIAL) Se.r\ /, -~ - if REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ~ FILE NUMBER cl. i-iLl COUNTY CODE YEAR Og4-S_ NUMBER \oJ \ ;l.O 0 \ tI\. " 'i ').. (IF APPLlCA LEi SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) w >- '<:~(/) uO::'<: wCl..U IOO uO::-' Cl..(l) Cl.. <0: Iv ~ 1 Original Return D 4 Limited Estate D G. Decedent Died Testate (Allach copy of Will) D 9 Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (dale of death after 12.12.82) D 7. Decedent Maintained a Living Trust (Allach copy of Trust) D 10. Spousal Poverty Credit (dale of dealh between 12.31-91 and 1-1-95) FIRM NAME Ilf Applicable: SOCIAL SECURITY NUMBER \ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER ,\J I Pr D 3. Remainder Return (dote of death prior 10 12-t3-82( D 5. Federal Estate Tax Return Required 8 Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (AIIachSch0) THIS SECTION MUSTBECOMel.'ETEDJALLCORRESPONDENCEANDCONfIDENTIAL TAXINFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS 400 NCf't'-' t:"'tO~"\ W 0 f"YY\ \" 5 bv':1 fV/Pr 40; 3bct A.tIA , 'I r 1 I "l.... 1','3\~ (1) (2) (3) (4) (5) Mortgages & Notes Receivable (Schedule D) 3 Closely Held Corporation, Partnership or Sole-Proprietorship St~;- 1>4 110 (8) l~~J,qy >- z w o z o Cl.. (/) W 0:: 0:: o U TElEPHONt NUMBER "2.. l'i"',-,-~ Casll, Bank Deposits & Miscellaneous Personal Property (Schedule E) (11) (12) (13) 'Lf,~~~ tl~,Y45" , S,OC.b 1 Reai Estate (Schedule A) 2. Stocks and Bonds (Schedule B) z o ~ ...J ::J 1-- a... <t U LLJ 0:: G Jointly Owned Property (Schedule F) D Separate Billing Requested (6) N 1J4r tv/Pc-- 7 inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) 8. Total Gross Assets (total Lines 1-7) 9 Funeral Expenses & Administrative Costs (Schedule H) 1 D. Debts of Decedent. Mortgage Liabilities. & Liens (Schedule I) (9) (10) ct.l-q, 'tlfoS~ 11 Total Deductions (total Lines 9 & 10) 12 Net Value of Estate (Line 8 minus Line 11) 13 CI:antable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14 Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o S :::J a.. ~ o u >< ~ 15 i\111Ount of line 14 taxable at the spousal tax rate. or transfers under Sec. 9116 (a)(I.2) 16 Amount of Line 14 taxable at lineal rate 17 Amount of Line 14 taxable at sibling rate 18 i\ll1uunt of Line 14 taxable at collateral rate ',9 Tax Due 2U D 1~:I::(~~.~I~:~~~.I~I~~iiID!I~1I~Z!~m!tP!1,.41'11~~~~ (14) , 0,"" I 3'0, x .0_ (15) x .0_ (16) x .12 (17) 1"3, l ')..S" x 15 (18) (19) t~ I I~ t Oql ~ "l~ > > BESURETO ANSWe;RALCQUESTlqNSON.REVERSESIDEANDRECHECK MATH < < Decedent's Complete Address: STREET ADDRESS CITY s Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2 Credits/Payments A Spousal Poverty Credit B. Prior Payments C Discount (1) ,,~c- Total Credits (A + B + C ) (2) " 5" b 3 Interest/Penalty if applicable O. Interest E. Penalty Total Interest/Penalty ( D + E ) 4 If line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund \ ~ ,\ "')...5 5. II Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS o THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred;...... ....................................... ............................ 0 b. retain the right to designate who shall use the property transferred or its income; ........................................... 0 c. retain a reversionary interest; or......................................................................................................... ..0 d. receive the promise for life of either payments, benefits or care? ............. ..................... .................... .. 0 2. if death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 4 Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................... ........................... No g I -g' K 8' JK' xamlne his return, including accompanying schedules and statements, and to the best of my knowledge and belief. It IS true. correct and complete o re ative IS Dased on all information of which preparer has any knowledge. t S1-~ . ENTATIVE ADDRESS Rl>~ , t.\c~~"'C&~ry, P'4 S-J7~ E. T~.:t:NDL& f '70h-O For dates of death on Dr 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 3% [72 PS 391161a) (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% [72 P.S. 39116 (a) (1.1) (ii)]. The statute does not exemot 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 dales of death on or after July 1. 2000: Tile 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 0% (72 PS s9116(a)(1.2)] The lax rate Imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 39116(1.2) [72 P.S. 39116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 39116(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. . . RE'/I'"''-X'{1-9''''' ~ (J;df2to:O 13Jf!jl);:~ ;';~~~~'~~_(~:1~~- COMMONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF 5er-~r_ J jo ~~.~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. FILE NUMBER ~'-O\- 09 "I ~ ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH lac. ~ s~~ ec,,,,,W\et'C. ~~~.,t" ~1.~ C'\ t . o~. 00 per s~.. Per FAo..'^'''-/filt6T:JM- N"'M~..&~ pe.C' ~~,.~~ ~1- CoDW\~ ~,~t. o...CEa 4!)r,~~~\ '!a~c::t~ I'w\\"~~~ . . 35) Il~ ~, '.5'. ~~fr PnJJa.~~~\ ~ b~\ C:;;f'GW~ ~ At A"t ~~ ~'te. cO-(- it 15"'. o~ per 1oR>ka\ S~~~~~/Let+er. " , ! 1 '3. A ~~,()', PnJd~~~~ \ E"if"':"'y ~N:J A A-\:- 4"--~e... pn~ ~t.,'t."1.) per ~ lc4n s"" ~t-J Ie.. tte-- S- ^-(, 3.. TOTAL (Also enter on line 2, Recapitulation) $ 4 e I a~c; (If more space IS needed, Insert additional sheets of the same size) SEP 24 2001 14:28 FR PRU SEe HARRISBURG 717 975 8426 TO 97638582 P.02 .~ Prudential September 24,2001 ",_mi.1 s.cvritift 11ICOfponlted 3 Lemoyne Drive l~mO'fl\e. PA 17043 P.O. Box 7. Camo Hill, PA 17001-9852 Tel 717 761-7344 800 468-8685 Fs.l 717 97~26 Mr. Michael a. Serluco Consolidated Properties 400 North Front Street Wormlysburg, PA 17043 Re: Jo Annette Serluco Acet #044-155141-47 Dear Mr. Serluco: This letter is in response to your fax earlier today as of the value ofthe two Equity Mutual Funds in Ms. Jo Annette Seduco's account. The information is as follows: QuantftV S'Imbol OescrlDtlon of Fund Closlna Date Closlna Price 115.228 PRGAX Pru Glb Growth FD A 7/3/2001 $ 7/512.001 $ 14.94 15.09 239.077 PBQAX Pru Equity FD A 7/312001 $ 7/5/2001 $ 14.59 14.90 Please feel free to contact me at (717) 975-8442 should you have any questions or would like any assistance. :z~ Nicole Anderson Client Service Assistant To Joseph Krichten The informatiorl contained herein has beerl obtained from sources believed reliable but not necessarily ccmplete and cannot be guaranteed. Any opinions expressed are subject to change wittloutootice. Neitllerthe information preserrtOO nor any opinion expressed constiMlls representation by us 0( a solieitatiorl of the purchase or sale of any security. ** TOTAL PAGE.02 ** . , RE<'/-1501 EX + (1-97i (I) SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER ?"\-O\- 08Y5"" TOTAL (Also enter on line 4, Recapitulation) (If more space IS needed, Insert additional sheets of the same size) VALUE AT DATE OF DEATH q &.,.l~S < It\ ~).a) ESTATE OF ~-e.~ \\)(..0. Jo A~Y\t.t\e.. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION ~~c!' C"t..U''''b\L fr'OM. Qc-.\1W '. )..f~lo' M.'~"--<<.l A. Serl\K..O i400 N. m~~\-. WOt'W\\yS\Jun;" pq. \'Te't~ T-a,tf\ ~: O~"':JI~' ~'~<<:e..: t <<',000 ~~~'1 1\.1\ \e.. 1S"~(, Te.'<"W\ ~~ ~c...'1 ~ t (~~"'Y) <ir, \. as' - s~ ~~"",\ AW\EX"''\\~...~~ ~~ L.e~' 1\.Jcl.\~\'o,^",' t>n'w..~\ ~\IV~'" tlw.cJ ~Q~Y t\vn.~ ~ rt\e,kCC4l ~)C~~~ ,,-:..fe)~ ~ OA" ~O-t) .~~~~ k\\y Au,"It~ t..'^~ " '~b-- \', OW ~~("'~ ~~ l ,,,')... W"~v\'" C.,'""k Sh~-e.._,"'6\o""'" Cl&\. 110" $ ,,\\")... # ----------------------------------------------------------------------------- Serluco Mortgage ----------------------------------------------------------------------------- Compounding interval: Monthly Annual percentage rate......: Effective annual rate.......: Rate per compounding period. : Equivalent daily rate. . . . . .. : 8.000% 8.300% 0.6667% 0.02192% Valuation date: 02-15-2001 Value: $ 97,000.00 CASH FLOW DATA ----------------------------------------------------------------------------- First date Payment amount -#- Interval Last date ----------------------------------------------------------------------------- 03-15-2001 02-15-2021 $ $ 811.35 239 Monthly 809.47 1 01-15-2021 AMORTIZATION SCHEDULE Normal amortization ---~------------------------------------------------------------------------- Pmt Date Payment Interest Principal Balance ----------------------------------------------------------------------------- Balance at 02-15-2001 97,000.00 1 03-15-2001 811.35 646.67 164.68 96,835.32 2 04-15-2001 811.35 645.57 165.78 96,669.54 3 05-15-2001 811.35 644.46 166.89 96,502.65 4 06-15-2001 811.35 643.35 168.00 96,334.656) 5 07-15-2001 811.35 642.23 169.12 96,165.53 6 08-15-2001 811.35 641.10 170.25 95,995.28 7 09-15-2001 811.35 639.97 171.38 95,823.90 8 10-15-2001 811.35 638.83 172.52 95,651.38 9 11-15-2001 811.35 637.68 173.67 95,477.71 10 12-15-2001 811.35 636.52 174.83 95,302.88 2001 totals 8,113.50 6,416.38 1,697.12 CD ~C\ \CA.~ t)-. ~e~ .t>ec.;~" ~ "'. 3~S- ~ 0 ^,~'WODe) ~\,~"'~ ~ \os:> (A) l:::.t.1 \)' f>>~,~~ L,"") < 1 <t, 01f1f ) Ne, t ~, '~w..-e.... - 7',1)')... -- (fJ) ~tlowb ~\'t...\ b ~ y 1~\lL~J Serl\.JCo .::4.& Ad\1O.~ R€doc...-h'ot--... . 1>0'"",-, 'pt.\ \ F;r.'I-l:;OHEX.i1-97)!I) r,,, fJ:, & ~.7n. l~" 1ff('_.iJ.i.~ ' , 1 ~,;3::t_ ?~~ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Se.("lVt.O, Jo A\AM..\le. Include Ihe proceeds o;htigaliOn and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. VALUE AT DATE OF DEATH FILE NUMBER ")... \ "'0 \ - OCZS' 'i~ ITEM NUMBER DESCRIPTION 1. ~... <C"'(..~ 1>.~ \... ~ S~~~ 9\~~~ CA~ W\l, Ptt\ \, 40\ I C\t.e.t..l,""1 ~~"" * S'-~11CS'8'~ 3~O ~. c.0W\Me..C'te.. ~"\ t.. ~~ 5~,,:~s ~V'-\ i!\- t., \- ,,,,... ,S",~ 3J5~'~ 3. Jew<t.\~ 4-~~ J\~\..- soo (. UlE.'WW\e.~,,-) ~. l.\~~~\c) 800ds dr W~'^~~"Cf~ :.s;oco 5. ~~'t:s "1S'O ~. c.Q.~ h ()~ ~~ 138' ,. "'I~~~-\ ~ ~'" ~\cj~,- · ",,'). '" '0.)( .Ooo-:a.,~').. 3"-' 8". f).'W,~"^,~ Q..~~\.. S~ ""60 ~I ~C~I '-1:> a~ cf- V\~"'~ AS-O TOTAL (Also enter on line 5, Recapitulation) $ "~ 6 \ ~ (If more space IS needed, Insert additional sheets of the same size) Commerce ~Bank, Commerce Bank/Harrisburg N.A. 100 Senate Avenue P.O. Box 8599 Camp Hill, PA 17011 STATEMENT DATE JO ANNETTE SERLUCO 302 WALNUT CIR SHIREMANSTOWN PA 17011 07/05/01 ACCOUNT NO. 0512019886 *** CHECKING *** REGULAR CHECKING ACCOUNT NUMBER 0512019886 TAX 10 NUMBER PREVIOUS STATEMENT BALANCE AS OF 06/05/01 .... PLUS 1 DEPOSITS AND OTHER CREDITS LESS 15 CHECKS AND OTHER DEBITS... CURRENT STATEMENT BALANCE AS OF 07/05/01 ..... NUMBER OF DAYS IN THIS STATEMENT PERIOD 30 199-30-4593 1,766.23 530.02 1,712.80 _ 58.3.45 ------------------------------------------------------------ *** CHECK TRANSACTIONS *** SERIAL DATE AMOUNT 5 ER I A L DATE AMOUNT 3273 06/0B 671.96 3274 06/07 30.21 3275 06/08 36.87 3276 06/06 100.06 3277 06/06 64.30 3278 06/06 21.50 3279 06/12 60.00 3280 06/08 45.00 3281 06/18 180.00 3282 06/27 361.23 3283 06/29 28.08 3284 06/27 20.00 3285 06/25 40.00 3286 06/28 17.20 3287 07/02 36.39 ------------------------------------------------------------ *** CHECKING ACCOUNT ~RANSACTIONS DATE DESCRIPTION 06/25 DEPOSIT DEBITS CREDITS 530.02 ------------------------------------------------------------ *** BALANCE BY DATE 06/05 1,766.23 C6/08 796.33 06/25 1,046.35 06/29 619.84 *** 06/06 06/12 06/27 07/02 1,580.37 736.33 665.12 583.45 06/07 06/18 06/28 1,550.16 556.33 647.92 i3 Cl\. \~ ~C4!. Pe.c- ~'" \;.. j !i' ~ l · ~ S l!)ui~~"'C,),~ e~ ~ ~? ~- ~~\-\.. # 3 ~~ "V,,}: ~ ~~~O-~A~ < \1..<0. b>b) (10.. c'4) (" ").. '-t . 00 > II ~t-o, l~ - - --, NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Commerce ;_f~1JI( .~. ,,-. . "-,' ., " -'-:':" . ,.... -'" ': : ,'~. " Commerce BankIHarrisburgN.A. 100 Senate Avenue P.O. Box 6599 Camp Hill, PAHOH ( STATEMENT DATE JD ANNETTE SERLUCO 302 WIlLNUT CIR SHIREMANSTOWN PA 17011 06/30/01 ACCOUNT NO. 0616227578 *** SAVINGS *** STATEMENT SAVINGS BEGINNING ACCOUNT NUMBER O~16227578 TAX ID NUMBER PREVIOUS STATEMENT BALANCE AS OF 03/31/01 .... PLUS 3 DEPOSITS AND OTHER CREDITS LESS 2 WITHDRAWALS AND OTHER DEBITS CURRENT STATEMENT BALANCE AS OF 06/30/01 ..... NUMBER OF DAYS IN 'THIS 'STATEI-4ENT PERIOD 91 CYCLE-051 RATE 2.00000 199-30-4593 6,517.98 16.10 3,000.00 3,534.08 ------------------------------------------------------------ *** SAVINGS ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 04/10 TELEPHONE TRANSFER 105388 C4/13 TELEPHONE TRANSFER 105396 04/24 PATE CHANGE TO 1.50000 04/30 INTEREST PAYMENT 05/31 INTEREST PAYMENT C6/30 INTEREST PAYMENT DE BIT S 1,000.00 2,000.00 CREDITS .00 7.26 4.49 4.35 ------------------------------------------------------------ *** BALANCE BY DATE *** 03/31 6,517.98 04/10 04/30 3,5~5.?4 Q5/31 .5,5Fl.98 3,5t9.73 .04/13 06/3(1 3,517.98 3,534.08 PAYER FEDERAL ~D~NUMBER INTEPEST PAID YEAR ~O DATE 23-2324730 34.08 ---------------------------------------------------- *** INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD ...............i......... INTEREST EARNED .......................... ANNUAL PERCENTAGE YIELD EARNED (APY).... *** 91 1~.11 1.67"- ---------------------------------------------------- NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION RE'.' '~~ 1 EX . (1-97) 0) l-"~ -~ T~> ~'iT~ Wr" 'Y"'A~ ~~::~"~~ '~~ ....~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF 5p-t" k.c..O, ..>0 ~",t,,~ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ""\~l-~~S Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER ,r:.. FUNERAL EXPENSES: ~~ ei-~~-~c:>~~~~ _P\Q+ It ,00 1. (.w..e. Eo'~Jt.-,) ..l\'\\er~ -, 5'0 - ",-..~-e.r I .,. ~S ~'\~"t.'Z. i I=",~ \ 'i()~ .. De.."-', Pt-r I ell. ~'- wa.) ~'~8' ~(~~ ~"'-"~, 1:'01(.- ~~~ '. O~~ B. ADMINISTRATIVE COSTS: 1 Personal Representative s Commissions Name of Personal Representative (5) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address State Zip City Year(s) Commission Paid. 2 Attorney Fees 3 Family Exemption: (If decedent s address is not the same as claimant s, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent 4 Probate Fees .~ "'-..." ~""""~\e..:> ~S'5" 5 Accountant s Fees 6 Tax Return Preparer s Fees t 7 TOTAL (Also enter on line 9, Recapitulation) $ ~. c,C\., insert additional sheets of the same size) (If more space IS needed, . Cf) < () Q ro \l) ;:;: \l) c '< 3 en ;:; ro ~ - 0 0 0 0 0 0 0 0 ro -< ~ -< 0< 4 Cf) ~ ,,- , b :;- m t~ ....\l) ... \l) ...:::l 0 Cf) \l) \l) 0:- - o.c en - ..... ro ro- :::l "0 30 9 () .... 0 ....- !II en 3 ro "... \l) 0. " :P \l)g. () a. ro ~ 0 c.o \l) :::l :J:J 3 ~ 3'" ... - <Il ~ ~ 0. (l n , -< \l) 0 ~ ... ... z ~ ~ 0. 0. 0 (') 0 ~ ~ ~ ':S' <Il C') i\ 25: 0 0 0 0 0 0 0 0 0 iii" "- to (l , to 0 s: to :;- Cf) - ;"" \l) S c C1" 'e!. ... < '< t -0 ..., ... ;:;: 0 0 3 ro -0 ~ :::l P. c o' -0 P. \l) :::l N "0 c.o ro ro \l) p. -0 -< - ro ::!! en =r ..., - '< 3 ro co 9 ;:;: ... :::l -0 :::l a} :> () " 0 :P t' Cf) ~ - =r - 0. ~ :::l C 0 0 ~~ 0 en ~~ - =r ro ~~ Cll ~ ~ s: 3 3 "0 Cll ~ C :::l .. 0 0 G> ro 3 n ro ro - =r ~i ~ \l) o' Q. " ~03 \l) \l) ~~ rs g: Cll =r cn ",g: <c <:::l0 - - :::l Cll :::l :;- \l):::l ro ~. o' -0 0' \ - 0. ~ - cCll !!!.. :::l Cll :::l :> h-, ~ Cll ~~ ... ~ ~ 3 -... en -l c -\l) 0 \l) - } ~ ,- :::l x ~\ =r r--. . 0 ~ ro -'0 . ro !!!. Cll ~ ~ Q ":\. ... :::l 0. -' C I :::l :::l "- ~ :\.. ~ ~ - -o<il "0 ~~ CD N' ~ ~ N -0 -< ..., ~ Cll ~ \ \l)..... rEO '< 0. t".! 00 m ~\ ~ Cll'" Cf) =r ~ to ~ 30 - ~ '< l1-J 0 ~ , % '\ '\ ::0 ro=r 0 ~ ~ , '. \l) :::lCll a. 0 ~ \ \ I't\ :::l -0 ? ~ [\ ~ c.o x ro ~ ~ ~ Cll ... Cll ,.,:: ~ 0. J:! " V\ & 0 z " ~ ~ & ~ \l) 0 C ~f ~ - en ~ , ~ ro 0 =r ~ \5 ~ ~ CS Q. ~ ~ ~ , :;- 0 :( ::! ~ tv. . 0 ~ - ? f'> ..... ro ~ 3 ~. ~ t' .... -< Cll f'}, ~ ~ ~ 3 m ~ t:: ro Cf) ~ ~ "- :::l -< " o. r) - 0 m C c. Cf) , CJ ~ Cll en :! ~ 0 ..... =r ~ 'i\ ..... ,~ \\ Cll to ... ;"" ::0 "0 G> 3' .... I--- 0 ~"\ ~ " \l) c.o ~ ~ f..-.-- Q ~ \l) < ~ ..... ro 0 t Cll o' ~ \ \l) :::l ~ Z CO z - 0 z "- 0 ~ ~. Cf) 0 -{) ~ <' 0 0 :J ~ b \l) 0 Cll en ~ !!!. 0 .... Q. - ~. cn , () ::! :I: ~ ~ -< 0 () "0 ~ 3 0:: ..... Cll ~ Q (')~ to 0 < (lCf) 5' xO \l) 0 \l) =r\l) ..... :0 :>~ i>> :E c \l):::!:. ro ~ ;:; c3:r: .... -o(l~ -< ,,:> :::l :::l 3 \l) Cf) Cf) G')r- 0 -0 CllQ. ..... z:P:r: m Cll Cll Cll Cll ~ o' Cf) :::l 000 :::l m \l) a: :::l "z- a. c. CIJ '< ..... :::l 5;~ 0 3 \l) " ..... 5" to ":I:' ~ '< 0 -< (3 ro Cll 0 - c Cll 0 :J Cll Cll . . . :::l :::l -."'" 4 ... ..... ~ ~ Cll .... ~()O ~ Cll .... :r: 0 3 !=! ~ Cll o Cll " ~ Q. t ~ Cll ~ \l) ro ... 3 :> .z , - a. ~ en :::l - "'Cll 0 ;:;: Q Cll ~ ~ ~ Cll Z en _ Cll .... 0. =rCll 0 .... <il !=' ~-< \l) A C- o ~ - ..... < .... 0 '--' ~ ~ .... Cll ..... ";'- " (') ~ :t o .- o (') m 3: !!1 m 22 m CJ) - z -c m :D 3: m z -c o :D c m :D c o (') m CJ) m o "T1 :I: ~ :D :D Cii to c: :D G> Malpezzi FUNERAL HOME Michael J. Malpezzi Owner 8 Market Plaza Way. Mechanicsburg, PA 17055 Phone: 697-4696 July 27, 2001 Michael A. Serluco Consolidated Properties 400 North Front Street Wonnleysburg, PA 17043 The Funeral Service for Jo Annette Serluco We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff Other Preparation of Body 2. FACILITIES AND SERVICES Funeral Ceremony 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home Hearse (Casket Coach) Flower car or floral disposition Lead car/Clergy J,n'" h ~_ ~.J ~o $,5' 7c7;< #--7d FUNER<\L HOl\1E SERYlCE CHARGES SELECTED MERCHANDISE: Steel Protective Casket Grave Liner Acknowledgments Register Memorial Cards THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Cemetery Equipment Newspaper Notices - Out-of-to\\11 Organist Certified Copies of the Death Certificate Soloist TOTAL CASH ADVANCES AND SPECIAL CHARGES SUB-TOTAL INITIAL PAYMENT / DISCOUNT / CREDITS TOT AL Al\IOUNT DUE (~--~---_._----------- --... Please 51485.00 5125.00 5395.00 5230.00 S265.00 S110.00 S110.00 52720.00 51970.00 $640.00 $21.00 $23.00 $42.00 $5416.00 $95.00 $42.88 $75.00 $24.00 S75.00 $311.88 S5727.88 $5727.88 -------- . i 'i ~ ~ S is <J> ,. ~ ~ -;; ! ::t: ~~ ~ rfi :J: ""tl) ","'" ....0. () -l -. :l>0:3 ~ 5 f.O_ ::tQ(/) prn:D )~~ \l(/).... :l>CJtl) cc. ....::0"'" -lQtl) s::o:3 ....o~ :l> - 0:3 ~ v o Co ..., () o ~ % ~ ~ n (tl V'J. ~ o ~ o c ~ p.. ~ % ~ a ~ '3 .:;!~ "'0 ~z ~rn (Jl .' "" cD 'l~ ~ 1':-- ~J.'; \' 0 ,< N--'" ~ ...... ~ '> \.~; \.0 ~ c.s. \ 0 C? ....J ~- ^ Vl Vl OVlO ~~'@~~~ ..-~g.V'J.a.s r./l ...... ~ ~ . ~ a. ~no...,I-]'" ~(tl............(tlto V'J. ()~~~c ~ ::r g....... ~ ~1:; _......(tl x QCl (tl g....... (tl (tl ~ ..., g ~ ~ - - 0'\ ~ - 0'\ vJ '0 '0 ;,.0 \0 \0 0 0 -Vl Vl Vl ":f?":f? o _0 ~~~\.OvJ$ \O\O\.O:-J~-.1 '-.\ 'vJ '-.1 Vl -.1 Vl \.OO'\VlOVlO ~~~ - .;, . .. , RF':-'S:;>i:P(1-07I(1\ f~~ ~ ~nQn" ~~-'..'.;;siI,~ y i~",':;"k::t!i}& . "::,):,,;~1R.%~ COMMONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF s...,...\VL01 Jo ~'f\~e.~.\:e.... FILE NUMBER ~ \-0\ -O~4~ Include unreimbursed medical expenses. ITEM NUMBER 1. ~ ~ 4. s-. (.. DESCRIPTION AMOUNT ~\\'f As~"'15W L\,,~ -~~f\~t.~ . \ '^,,"" j "05~'~ ()~ U,~\ 1>A "'}>e.r A~~ ?.5"S~ J 'P /it A~"'CAtJ "'-'ATwA.. C.O~PAtJ't -A-~\eJ 'J... V-e't\~ - J\1c.~ L~~"'-v \ 1 \., .. '~"'i"'O\ - "lO~ crt)' -V~~ -~~l ').., 18 '"' '"' \0 Li').... ~'S- J:", \~ ~ k. - \J~~I\- \. ..~~ Pl)~~ 4 'SOl "3 H~Ob(,~ 1=\~ \ \3\~ ~y ~~Ic..E.$ -l.q"cl~~/~~~ (J\'M. ~~~) TOTAL (Also enter on line 10. Recapitulation) $ ... (,S ~ (If more space IS needed. insert additional sheets of the same size) U~/~~/Ui nu~ i~:40 t~ Iii IJi ~UI~ ~U~~UL1V^1~V ~KUr. ~~~ ~~U!l ~lAlbCft IlfJVU':: 8M DATE 07/08/0' :~~:--:'''';-'; ",' ..............."1; .~. c,.o:<~' 27322325 JO ANNETTE SERLUCO 302 WALNUT erR SHIREMAN$TOWN PA 17011 CL.I!NT NAME PO~lCY o~ P.O. NO. Z ~UREO 'S N~"f' 1~lU~!O'5 s.s. NO. .. . '..~ -: _ . .;, I' 'I ", PLbS( $1i"1:) ICFL l 'r ASSISTED LIVING SERVICES, TNC:. ::;~~NT WITU P.O. BOl 8204 t 6 COpy TO PHILADELPHIA. PA 19182-04" 'Lf"'! a!fAII TNII P...' .011 '04Ift 1lIC0Il0S DUPLICATE CUSTOMER copy . '."",.:..t"-"'- ....:'I>"...........:~~.. ~..'....I.- .._..,..... '. ...... .... ...... BRANCH LOCATION 8RANtH PHD!fE rtCL. DROES NO .~ST~" NO t-4A~RISBURG. PA 717-731-8280 5180 N3SSl 01Z099-0t CIROGn 0025 ... ~'I' .. ...- J. .' l . . .). . I. .: ....,C...,"... ;; I) \..u~,,;U.~""lIl.':i.;:'.. ~"'CIIO~S O. ." "gu~ all! JPIO.. I. Df"CIIIA1S A~ ~ouows. .n.lt III".; ,50.'0 .,,~ ",.., _ OV HaURS 8.00 6.00 ~._. ElllLOY!! JE DERN VL JOHNSON PJ KEAST to~OI'lATE TAX to.. U'l110... - $lIllVICE. DUCAIPT1(lN HOMe HEAL'tt-t HOlliE HEALTH Howe HEALTH JIIIUCT 47 1 . 20 JJ4 . eo 2'3,20 ...... 19.00 1:i.DD 16.00 AATI 15.20 111.20 15.20 lATE 22.80 22.80 AlOE AIDE AIDE TOT AI I~"'.: reF 10(8.80 TU.: PAUlL! UPON arCt!tPT 0' 11W01CI ~ ~ .---... ------- --~ - ~----- --....------ \, --.......--------------------------------------------------..._------- II:. Kelly A.,,~i$1P.d Lhirq( "...toft. DUPLICATE RETURN COPY Ll~:ON P L E A S E o E T A C H H E R E IItANeH S180 27322325 .>:'" . :~ --- EMTE CUSTmlER ....,1Il .. .....- ...............,.....-HI., ......~.~~ 07/08/01 e12889-ot W _, n. COIWOl\A TE T.... lO., .,.. 2 Ito'" I JO ANNETTE SEALUCO 302 "ALNUT CIR SHIREMA~SiOWN PA 11011 KELLV ASSISTED LIVING SFRvTr.~S, P.o. BOX 820.'8 PWILAOELPHIA. PA "'82-0416 IN<;. I I 2732232S~OOlOq6603 LO'; Q 9L :9L LOI L2I60 .. V~/~~/Vi nu~ i~;~O rAA IiI IJi ~VI~ JO ANNETTE SERLUCO 302 WALNUT CIR SHIRE~lNSTOWN PA 170" . . j. ~LIEJO" !'CAME ~..q~ P,D. NQ. 1N~UIt.n'..i N.M~ INS~JQ:.S..$.S. NO. C~T! TAX LO.; U-l1l0841 ... - SERVICE PlPUnE~ DESCRIPTION 72 JE DEAN HOME HEALTH AID! MT GAy HOM! HeALT~ ~10E PJ KEAST HOME HEALTH AIDE MM SLAUGHTER HOME HEALTH AIDE ~V~~V~!V^!~V r~ur. ~~~ ~~U!l ~!^!~L^ eM D~lE 08/18/01 U398&U 19J lIlI,) I'LE....S! SENO KELLY ASSISTFn LIVING SERVICES. INC. ~:.,"'~~""T WITI-I P.O. 80X UocHI eo"" TO PHILADELPHIA, PA 19'82-0.'6 PlEur AfTA,It TItI$ P_' '011 .011. M~ DUPL.ICA~ CUSTOMER Copy BftANCH LOCAHON BRANCH Pt4QNE NO. ~NQ..... kU.5 TQJ!I~Il; NQ . HARRISBURG, PA 717-731'1280 5180 N3S6? e 12899-.0l ., ;:...." CIROGl~ 0025 . :..,,;.. ""~. ~~~;"':"";~ . .. c COO! ENDI.. HH78 08/17 HH7, Oel17 HH1' 06/11 HH78 06/17 ....\: IIUIoS 0. .... "gilA AIll; S~ I~ DECllAl.S ~. routlWt. .21..1 MII./ .1O.se _'.., .710.." _. LM lATI ....S ItAft 15.20 15.20 15.20 15.20 7,00 22.80 TfIlIQ: PAYMll UPCIIIlCll'T Of' INVOICE ::. :., J'J, (I:U $ 17~60 u.u BA. -------------.----~------------~.---------------------------.-------------------------------r______. ~l~;ON "'l(a.jly Assisted LMng I a. . .. .. . (' <<' , ~: L : i, A' ~ J cO~OlU" ,... lO_ ".2' 'OUl I 01 E: Tl ^ : JO A,...ETTJ; SiRI.UCO C I 30~ WALNUT CIR H ; SHIREM.ANSTOWN PA 17011 , H: E' A: E: 1 1 I 20: Q 91. :9L ~Ol ~c/60 DUPlICATE RETURN Copy DATe \~~Tf!!ir~::~-~'~~:3 .;.h:",.~:'. ..,~~ 8R.U1Ol QlSTa.rR MJIOIER ..~.,~,~. ..~...,. -.". ~-:,.,+ttt ..' ,2w~ '~""f' Oe11G/01 ~feO 612899-01 2439915Z3 $ 1998.eO - KELLY ASSIStCD ~l~lNQ SERVICES, INC. P.O. sox 820418 PHXlADElPHrA, PA 18182-041' c~3'~~~3l001"&eO~ A V~/"'i/V.1 llIVI' .1<>.'ii> r~ /.1/ 1.).1 ~UI,? \,<VI'.>V.L..lLll\U:.LI rJ:\vr. ~~~ ~~Vi~ ~~n~~Ln ~VV.L .' 213 Capital BlueCross EXPLANATION OF BLUE CROSS BeNEFITS Harrisburg. PA 17177 Aft ll\dll~'" UC~a' I'le Blue ero;, and Stilt S'd.1d As8OdatIO" THIS IS NOT A BILL , -eoo.ll5a.s.s5& This is a benefit statement for the patient noted. If you have any questions, please contact your nearest Blue Cross office. Locations are noted on the reverse side. W'WW.:aQDlUfCtaU.com 1IIIIIIIulllllllllllt 1111.11..11111111.1.1.1.111111.1.11111.' JOANNETTE SERLUCCO 302 WALNUT CIR. SHIREftANSTOWK PA 17011-6725 07/30/3001 Group No. JOANKETTE 19930LlS93 661358000 ClaIm 0086L128 PatIent Contract ProvIder HOSPICX - CEKTlUI.L PEHNSYLVAKIA Group Name COKSOLIDATED PROPEp..'x:nS DATE RECEIVED 07/19/2001 Type of servIce Service Date(s) DATE PAID OUTPATIEKT 05~.~ 1~2_0~)1: - .-05/31/2001 08/01/2001 SeMCN Provlded Provider Blue Cross Non-Covered Remarks Charges Benefits Charges COde 230.00 230.00 .00 2140.00 2L10.00 .00 2,9~0.OO 2,940.00 .00 1.067.40 1,067,40 .00 3140.00 3lfO.OO .00 4,817.lfO If,817.lfO .00 PHYSICAL tHERAPY ----------- MEDXCAL SOCIAL SERVICE ----- SKILLED HURSING ------------ IV THERAPY ----------------- DURABLE MEDICAL E2UIPnEKT TOT A 1. S YOUR BEKEFIT COST SHARIKG - SEE BEJ.,OW YOUR. T071t RESPOKSIBILITY THE CUftULATIVE MAXIKUM ALLOWANCE HAS BEEK OF 2,552.47 EXCEEDS THIS MAXIMUn AND IS TitE--A-fit01lAXCE I-8----B1S1:D Up.eJt ',UE--'MS-SER. 1)' PROVIDER'S CONTRACTED PAYMENT RATE. OUR RECOR.DS INDICATE THAT YOU HAVE nAJOR. nEDICAL COVERAGE CROSS. 7HE AMOUNTS IN THE HOH-COVERED CHARGES COLUMN nAY FOR PAYMEHT BY MAJOR MEDICAL. HOWEVER., YOU MUST SUBMIT 1 KAJaR MEDICAL CL1Xn fORn TO CAPITAL BLUE CROSS. 2,552.47 2.552.47 APPLIED TO THIS CLAIn. THE BALANCE YOUR RESPOKSIBILITY. THE AMOUNT OF Tn -MtttVI-DElt" 5 tJSUAt--CHARGE 0"Jt. THE- 2,552.47 WITH BLUE BE XLIGIBLE SEPARATE IF YOU HAVE AKY 2UESTIONS ABOUT THIS EXPLANATION OF BENEFITS, PLEASE CALL 1-800-958-5558 BETWEEN THE HOURS OF a,oo A.n. AKD 6:00 p.n. ~. 00 j; '1 ~l17 ' /f; D t} !Jt{CO/i i1;; PLEASE SEE THE REVERSE SIDE FOR ADDITIONAL INFORMATION THAT MAY PERTAIN TO YOU. f)~ ~ mfJtt/;n5 o ploL V fJ) (3.u 5HZ 5 · --rib m ~&~ ( UIIJ~5) CLi4AJ ~ s e 10"1 flV f j,t:; tJ () -- ~rJ - ;) /5 ot:) so ~o ~l 00 -.f j /5 --= l hi 111 A ~ntY- ';' See Billing Rights Summary on reverse side regarding telephone calls. N Customer Service telephone number - 1-800-322-2595 Send Inquiries To: FULTON BANK PO BOX 506 EAST PETERSBURG PA 17520-0506 Transactions Trans. Date Reference Number Description Amount 07/01 07/19 07104 07/19 24399005PSA5GOGN4 KMART 00042754 MEGHANIGSBURG PA 74301736800XSL35H PAYMENT - THANK YOU 42.30 445.74 . Account Summary 42.30 L J:\'~l DID YOU KNOW THAT A HOME EQUITY LINE OF CREDIT FROM FULTON BANK IS TAX-DEDUCTIBLE IN MOST INSTANCES? AND USING THE INVESTMENT YOU'VE MADE INTO YOUR HOME, A HOME EQUITY LINE OF GREDIT IS SIMPLE TO OBTAIN AT A RATE THArS TOUGH TO BEAT. INQUIRE ABOUT A HOME EQUITY LINE OF CREDIT AT YOU LOCAL BRANCH OR BY GALLING US AT 1.800-FUL TON-4. New Purchases Cash Advances Average Monlhly Corresponding Daily Periodic ANNUAL Balance Rate PERCENTAGE RATE Fees Rales 0.00 1.146% 13.75% 0.00 0.00 0.00 1.146% 13.75% 0.00 1.146% 13.75% 0.00 0.00 Old Purchases Annual Percentage Rate: Purchases 13.75 % Cash Advances 13.75 % ~~ ~ NOTICE: See reverse side for important information. 5572 SFD 1 2 7 Page 1 ofl 3602 1000 VISA 0001 010803 01AB5572 8062 l",usu)rllerR.,;counc InformaCIon For Service To: Joannette Serluco 302 Walnut Cir Account Number: 24-0639548-9 Premise Number: 24-0378072 Meter readings in current billing period: Meter Number N000178776 is a SIB-inch meter. Present-actual 174600 Last-actual 171000 Gallons used . o II II ng ;:'UflJf1IcUY ~-----~-Prior Balance----------------" Balance from last bill $ 2 8 . 08 Payments prior to JuT 13,2001. Thanks! - 28.08 Total prior balance, Jul13, 2001 .00 ----------Current Water Charges---------- ----------..----------- Service Charge 9 . 75 Water Volume ($.004864 x 3,600) 17 .51 State Tax Surchg Water -0.43% - .12 DS/- Charge 1.76% .48 Total water charges, Jul13, 2001 ~ ----------AMOUNT DUE ----------------- ~ ,v Bil/ing Period & Meter Information Billing Date: Ju113, 2001 Billing Period: Jun 11 to Jul 11 (30 days) Next reading on/about: Aug 09,2001 Rate Type: Residential Water Usage Comparison Monthly usage in hundred gallons. &0 . .' 48 3& 74 12 0 2 J A 5 0 N 0 J F M A M .J 0 u u e c 0 e a e a r a u 0 I 9 P t v c n b r y n 0 J 2 u 0 I 0 , .' _._.~, - - ____ ._._~. __.. __~ ...;.._~~. __ _~,,--__"':'. ..____....._ _~_'___."_~_' _._ _' n' -' .. )11 ~ Page 3 of 11 717 737-8709-706 89Y of your account August 1, 2001 from last month ,ount of your last bill.............. $27.15 lount you paid through Aug 3...... -27.15 lount you s till owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....yc> ,P'f $.00 for this month 1'( r charges.......................... $18.19 - ~ ~ ' all 1 800-660-7111 if you have a question tal for this month.. ...Due Date Aug 28 ......... $18.19 unt due late payment charge of 1.25% may apply to any lance carried forward to next month's bill. nish speaking customers: j no entiende 0 tiene alguna pregunta sobre esta Ilame at 1 800-479-0305. Preguntas sobre pagos 0 ; de pago Ilame al 1 800-834-0709. $18.19 ~ ~ REV-1513 EX+ (9-00) . ~., ';, J.., '" ~~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~J BENEFICIARIES ESTATE OF S ~ FILE NUMBER ~\-t)\-~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE ~WMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) SUl.Q.yt~ CS. S~,,~ ~ \ 0 " \e~ 'e. l>t-, S ~~'tC-~.."'W~" ~"\"l~~C ~,'~~ ~O<7c ").... M. \'c.~\ A. ~~lvco \ 0,"\ ~~\>>r- ~ tv {) &..e..~~ I 9 f.\. \'<<9 ~ ~ ~re~ SO~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS' A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS REt> (.~::> I \ t'c"t ~~ ,~t I+~, C)f\- -nt>w.~ S ( c..\",-h'~ ~YJ )\0) t"1'",,~""Qc)J C"~Q"'\\\, p~ 'R.,O'\\~-tlt , A.~p\I~:J J l>OOk.) c.\O'\'\~""11 l>\:a~/~b ~,\\4.c1 ' ").,S"~ ~". (!:b S (XX). CD TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 5"0,*. W (If more space is needed, insert additional sheets of the same size)