HomeMy WebLinkAbout96-02733
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: IN THE COURT OF COMMON PLEAS :
8 OF CUMBERLAND COUNTY 8
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j STATE OF ,...... PENNA. ,
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8 $
8 ()IIVID IILIIN, FELIX, 8
u N().96~2733 . . .,..., \I)J6
~ ,. Plaintiff 8
8 V"l'ollS 8
8. QQHE KIIY FELIX, i 8
8 Defendanti .
8 i
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8 DECREE IN :
~ DIVORCE ~
I AND NOW,... .0.:1:.60.2>>......... 19 .,'1... It I. o,d.,.d ond !
.. decreed that ,~!\,~~~. !\~~~..~~':-~~.... ........ , ......,..,......, plaintiff, III
! and ,.... .. I;JPRF; .1({\.Y..Jff:1->.I;l(.. , , .. .. , .. .. .. .. .. , .. , .. .. .. .. .. . defendant, ~
; are divorced from the bonds of matrimony. .,
_ The court retains jurisdiction of the following claims which have !
8 been raised of record In this action for which a final order has not yet '
~ been entered: ·
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prollliscs. CIl\'CIllIll\S. I\IlIl ullrces liS follows:
\. I'AlnmS TO HESI'ECT EACII OT"'~It'S I'IUVACV
Nci\hcr pllrly will Illulesllhe olhcr. or cOlllpellhe olher 10 cohllh\t ur 1IIlIIIY WilY hUnlss
or Illlllillll Ihe olher. 1I0r in uny wuy Inlerfere wilh Ihe peueeful exlslence of Ihe olher,
2. HEAL I'IWI'ElnV
The pllr\ies own reul properly silullle 104 Cumberlllnd Drive, Cump lIill. Cumberlund
Coullly, I'ellnsylvllnill w\lh u fuir murkel vlIlue of IIpproximUlcly $75,000,00, The property is
encumbcred by one (I) morlllllge w\lh Allied Mortgulle wilh nn npproximnle bnlnnce of
$33,000.00, The pnrllcs hercby ugree IIIl1I upon pnymenl In full 10 Wife of nil funds due
hereunder Wife shnlllrnnsfer 10 lIusbnnd nil her righI, lille nnd inleresl in 104 Cumberlnnd Drive
10 Husbnnd subJecllO ull liens nnd encumbrnnces which lIusbnnd ngrees 10 pny. lIusbnnd shnll
Indemnify nnd hold Wife hnrmless from nny nnd nil c1nims Including nllorney's fees which mny
nrise us Ihe resull of nny presenl or fulure debls or oblignlions wilh respecllo Ihe renl property.
Conlempornneous wllh Ihe execulion hereof Ilusbnnd nnd Wife shnll execule n Deed ns nbove
10 IIusbund which shnll be held in escroW by Richnrd C, Ruben, Esquire pending Ihe pnymenl
of nil sums und complelion of nlllerms hercof nl which lime escrow ngenl shull deliver Ihe Deed
10 Ilusbund,
3. l'EHSONAL I'HOl'EllTV
The purlics ugree Ihul lIusbund shnl! relllin such \lems of property personullO him nnd
Wife likewise ns 10 such \tems us c1olhing. Jewelry, sporls equlpmenl. elc, lIusbnnd nnd Wife
ugree 111lI1 Ihc pllrlics huve divided Iheir personll\\Y. insllrunce, blink uccounls, cush nnd securilles
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ussocinted with u delimit or u c1uim hy uny crcditor uguinst the other,
6, COUNSEL FEES
Euch purty ugrees to puy their own eounsel fees nnd costs,
7, MUTUAL llISCIIAItGE
Wife relinquishes her inchoute intestute right in the estule of Ilusllllnd und Ilushund
relinquishes his inchoule intestule right in the est ute of Wife, und euch of the pnrtlcs hercto hy
this prcscnls for himself or hcrsclf, his or her heirs, cxccutors, udministrutors or ussigns does
remisc, releuse, quitcluim und forever dischurge lhe other pnrty hereto, his or her heirs,
executors, udminislrutors or ussigns, or nny of thcm, of uny nnd all claims, dcmands, damagcs,
nctions, cnuses of uction or suits nt law or in equity of whatsoever kind or naturc for or bccausc
of a mallcr or lhing donc, omilled or suffercd to bc done by said party prior to nnd including the
dnte hereof, including alimony, support, nlimony pendente lite, etc.; except that this relense shall
in no way exoncrate or discharge either pnrty hereto from the obligations and promises mnde and
imposed by rcason of this Agrccment. Furlhcrmore, in considerution of the mutual covenants
contained hcrcin, the parties agree to incur no debt or obligalion which may result in an
obligallon on the purt of the othcr and hereby agrce to indemnify nnd hold harmless the othcr
from uny claims, cost or expense which muy result therefrom nnd furthermore agrce to the
spccifie pcrfornmncc of uny of the covcnants nnd agrccmcnts contalncd hcrcin inluw or in cquity
ulong with the cost of compelling sueh compliance including cosls of suit and rcusonuble
u\lorney's fees,
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K. ()JVORCE
Thc partics hcrctougrcc to conscuttoullo,lllUlt divorcc und cxccutc such conscnts, ifthut
shull hc rcqucstcd, us muy hc ncccssary to complctc thc divorcc within 30 duys of thc dutc hcrcllf.
Any dcfuult in complying with thc tcrms hcrcof shull hc u matcrial dcfault cntitling thc non,
dcluulting party to counscl fccs und costs ussocintcd with rcmcdying thc nlln,compliuncc.
9, EXECUTION OF nOCUMENTS
Thc partics hcrcto ugrcc to cxccutc and dclivcr all papcrs nccdcd to cffcctuatc thc tcrms
and intcntions of this Agrccmcnt.
10. CONSTRUCTION OF AGREEMENT
This Agrccmcnt cncompasscs all agrccmcnts bctwccn thc parties conccrningthc malleI'S
sct forth hcrein and may not bc altcrcd or llmillcd cxccpt in \\Titing cxccutcd by thc partics; thc
waivcr of any tcrm, condition or provision of this Agrccmcnt shall in no way bc dccmcd a waivcr
of any othcr tcrms, conditions, or provisions of this Agrccment,
If any tcrm, condition or provision of this Agrccmcnt shall bc dctcrmincd to bc void or
invalid in law or othcrwisc, thcn only thattcrm, condition or provision shull bc striekcn from this
Agrccmcnt. und in all othcr rcspccts, this Agrccmcnt shal1 bc valid und continuc in ful1 forcc.
This Agrccmcnt shull bc construcd undcr thc luws of lhc Commonwcalth of Pcnnsylvunia,
This Agrccmcnt is intcndcd by thc partics as a post-nuptial agrccmcnt with full knowlcdgc
IInd IIncr ful1 disclosurc by cllch pllrty tll thc othcr of al1 IIsscts of thc partics IInd liS such is
Intcndcd to bind thc purtics inthc futurc irrcspcctivc lIf uny rcconcililltion prior to Ill' subscqucnt
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to the execution hereot: This Agreement is intended us u fiuul ugrcemcnt us to nil rights of the
parties,
This Agrcement is executed in triplicate nnd Husband and Wife, as parties hereto,
acknowledge the receipt of n duly executed copy hereof,
II, AGREEMENT 1'0 liE INCOIU'ORATED IN mvonCE DEClmE
The pnrties ugree thatthc terms of this Agreement may be incorporuted into any divorce
decree which mny be entered with respect to them, however, it shnllnot be merged with the said
decree,
12, IIREACII
If either party brenches nny provisions of this Agreement, the other party sholl have the
right, at his or her election, to sue for dnmages for such breach, or seck specific performance or
such other remedies or relief us may be available to him or her in law or in equity, and the party
breaching this Agrcemenl shall be responsible for payment oflegal fees and costs incuITed by the
other in enforcing their rights under this Agreement,
13. VOLUNTARY EXECUTION
The parlies hereto have had nn opportunity to review this Agreement independently of the
other, and hnve been informed of the right to have this Agreement reviewed and examined by
nn nllorney of his or her own choice, II being clenr to each party that DonE KAY FELIX has
been represented by Richard C, Ruben, Esquire, nnd that DA VII) ALAN FELIX is not
reprcsented by counsel but ncknowledges thnl the udvisabilily of sccuring independent counsel
hns becn I11l1lle known to him by Wife nnd Wife's counsel. Ench pnrty hns been given nn
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opportunity to read and review this documcnt, nnd have this document read nnd reviewcd by his
or her attorney prior to the signing of lhis Agreemcnt. Each party acknowlcdges that thc
Agrccment is fair and equitable and is being cntercd into voluntarily, nnd that it is not the result
of nny duress or undue influence; lhat anixing thcir respective signature lo this Agreemcnt is an
indication that thcy have read this Agreemenl wId arc infornled of its content, Each party is
satisfied that an equitable overall resull is being accomplished by the tenns of this Agreemcnt,
IN WITNESS WHEREOF, the parties hereto have set their hands and senls the
date first above wrillen,
WITNESS
//'~de
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Dnvid Alnn Felix
,J'>tu:--
Dore Kay Feli.
,
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COMMONWEALTII OF PENNSYLVANIA )
COUNTY OF :/JII" JJ /."L )
SS.
On this, the ....:;~.d dnyof d1,j.,j.h'< , 1997, before me n notnry public, lhe
undersigned oflicer, personnlly nppenred Dore Kay Felix, known to me (or sntisfaetorily proven)
to be the person whose nnme Is subscribed to the within instrument, and neknowledged tllllt he
executed the snl1le for the purposes therein contained,
IN WITNESS WHEREOF, I hereunto set my hnnd and officinl senl.
ilj;;,1'{I'>1 .,? ~j"
Notary P e
6 NOlanal Sua I
Sharon n KyltJ, Normv Public
.'nrflr.burg. O.1UptUtl Counl
My .COmllll.,o;,lorl r.J}lrus Jail 22~ 2000
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IN TilE COURT OF COMMON I'LEAS OF
CUMIJEHLANI) COUNTY, I'ENNSYLVANIA
NO 96-2733 CIVIL TEHM
DAVID ALAN FELIX,
I'lulntlrr
DORE KAY FELIX,
J)crcndunl
CIVIL ACTION. LAW
ACTION IN mVORCE
"Il^ECII'E TO TIlANSMIT IlF.COIlIl
To Ihe I'rolhonolnry:
Trnnsmlt the record. IIlgelher with Ihe following Infonnnllon, lolhe Court for enlry of n divorce decree:
I. Ground for divorce: Irrelrlevnble brenkdown onder Secllnn (3301(c)) ~ho 1>I\'orgo Co~o.
(Slrlke oUllnappllcnble seellon,)
2, Dale nnd mnnner of service of Ihe complaint: l'el'5on.1 service. h.nd dellverv on Mnv 23, 1996.
3, (Contplele either pnragraph (0) or (b) ,)
(n) Dnle ofexecullon oflhe nmdnvlt of cons en I required by Secllon 3301(c) oflhe Divorce Code: by Ihe
plnlnlll1' Ocl, I. 1')97; by the defendnnl Del, 3. 1997;
(b)(I) Dnle of execution of the plnintlll's nmdnvit required by Secllon 3301(d) of the Divorce Code:_
(2) Dnte of n1lng nnd service of the plnlnUll's nmdnvlt upon the defendnnt:
4. Relnled claims pending: None. Parties sinned Sepnrnllon Aureemenl dnted Del, 3. 1997,
S, (Contplete either (0) or (b))
(n) Dnte nnd mnnner of service of the nOllce of Intenllon 10 file praecipe 10 lransmlt record, a copy
of which is nUnched, if the decree 15 10 he entered under section 330I(d)( 1 )(1) of Ihe Divorce Code,
(b) Dole I'lolnlll1's Waiver of Notice In Secllon 330I(c) Divorce wns med with the I'rothonolary _
Dole Del'cndont's Wnlver of NOllce in Secllon 3301(c) Divorce wns lTIed with Ihe Prothonolary
Dnle: I~l( /91
Ilespeelfully suhmlu~
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lIy /n
IlIchnrd C. Iluhen, Esquire
345 Old York Ilond
New Cumherlnnd, I'A 17070
(717) 236.4041 eXI, 2916
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IN TilE COURT OF COMMON PLEI\B OF
CUMDERLI\ND COUNTY, PENNSYLVI\NII\
NO 96-2733 CIVIL TERM
DI\VID I\LI\N FELIX,
plaintiff
DORE J(I\Y FELIX,
Defendant
CIVIL I\CTION - LI\W
I\CTION IN DIVORCE
CERTIFICI\TE OF SERVICE
I, SHARON R. KYLE, hereby certify that on this 0::;(0 day of
May, 1996, I served a copy of the foregoing Answer and counterclaim
by first claee united statee mail, poetage prepaid, addreeeed ae
follows:
John M. Shugars, Esquire
2459 Walnut street
Harrisburg, PA 17103
HANSON & RUBEN
By:
S at'on R. yl
Paralegal - egal Secretary
100 Cheetnut street, suite 307
Harrisburg, PA 17101
(717) 236-8015
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IN TilE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO 96.2733 CIVIL TERM
DA VJJ> ALAN FELIX,
1'181nllrr
DORE KAY FELIX,
Derendllnl
CIVIL ACTION . LAW
ACTION IN J>JVORCE
AFFJI)A V 11' OF CONSENT
I. A Complaint in Divorce under Section 3301(e) of the Divorce Code was filed on May 16,
1996 and served on '7.'/1:/ ):J ,1996.
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2. The marriage of Plaintiff and Defcndant i~ irretrievably broken and ninety (90) days have
elapsed from the date of filing and service of the Complaint.
3. I consent to the entry of a linal decree of divorce after service of notice of intention to
request entry of the decree.
I verify that the statements made in this Affidavit are true and correct. I understand that
false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn
falsification to authorities.
Dated: /tl,1'tj<l1
,
'~LI.~ I\:..~
Dore Kay Felix. Defend
.
DAVID ALAN FELIX,
Plaintiff
VS.
IN 'ritE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 96 - 2733 CIVIL
DORE KAY FELIX,
Defendant
IN DIVORCE
ORDER OF COURT
AND NOW, this
\ "/' Irf .' ". f ' '/'--
_ day of C ( (.: ';JL ,
1997, the economic claims raised in the proceedings having been
resolved in accordance with a separation agreement dated october
3, 1997, the appointment of the Master is vacated and counsel
can file a praecipe transmitting the record to the Court
requesting a final decree in divorce.
BY THE COURT,
cc:
John M. Shugars
Attorney for Plaintiff
- (' "'/........, rn\~.t
101 :1.0/" 'I.
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Richard C. Ruben
Attorney for Defendant
promises. covenants. IInd IIgrees as follows:
I. PARTIES TO RESPECT EACII OTIIER'S PRIVACY
Neither party will molest the other, or compel the other to cohabit or in any way harass
or malign the other, nor in IIny way interlere with the peaceful existence of the other.
2. ImAL l'lWl'ERTY
The parties own real property situllte \04 Cumberland Drive, Camp Hill, Cumberland
County. Pennsylvania with a fair market value of approximately $75,000.00. The property is
encumbered by one (I) mortgage with A\1ied Mortgage with an approximate balance of
$33,000.00. The parties hereby agree that upon payment in full to Wife of all funds due
hereunder Wife shall transfer to Husband all her right, title and interesl in 104 Cumberland Drive
to Husbund subject to 1111 liens and encumbrances which Husband agrees to pay. Husband shall
indemnify and hold Wife harmless from any and all claims including attorney's fees which may
arise as the result of any present or future debts or obligations with respect to the real property.
Contemporaneous with the execution hereof Husband and Wife shall execute a Deed as above
to Husband which shall be held in escrow by Richard C. Ruben, Esquire pending Ihe payment
of all sums and completion of all terms hereof at whieh time escrow agent shall deliver the Deed
to Husband.
3. l'ERSONAL PROPERTY
The parties agree that Husband shall retain such items of property personal to him and
Wilc likewise liS 10 such items liS cluthing, jewelry, sports equipment, ete. Husband and Wife
ngrce thllt the parties hllve divided their persunalty, insurnnce, bank IIccounts, cash and seeurities
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and busincss interests ond eoch sholl kcep IInd bc cntitled to sole possession of their rcspeetive
property.
Each of the parties docs hereby specifically waive, release, renounce and forever abandon
whatever claims, if IIny, he or she may have to the sole and separate property of the other,
including IRA, pension and prolit sharing plans held in the individual names of the parties. The
parties agree speeilically to execute any and 011 documents required to effectuate this release.
Furthermore, the parties agree that each party shall convey, by executing such title
documents as may be required if any, all their interest in the vehicles to be kept by the other.
Specifically, Wile shall retain and be solely responsible for the deb.t associated with her Toyota
automobile and Husband shall retain and be solely responsible for the debt associated with his
Toyota Iruck.
a. Husband shall pay to Wife $30,000.00 in consideration oflhis Agreement. Fifteen
Thousund ($15,000.00) Dollars shall be paid contemporaneous with the execution
hereof and the remaining $15,000.00 within 90 days. Defnult in the execution of
such documents necessary to transfer title to the real property or pay the sums
provided for hercin shall entitle the non-delaulting party to liquidated damages of
$100,00 per day, inlerest, costs und fees until the default is remedied up to thc
maximum of $5,000.00.
4. ALIMONY
The parties hereby waive any and all rights to receive alimony, support or alimony
pendente IIle from the other.
5. DEnTS
Eueh party ugrccs to he solely responsible for thosc credit eard and olher dcbts solely in
coch purty's numc and to hold the othcr party harmless including any costs or attorney's fees
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associated with a dcfault or a c1l1im by lIny creditor against the other.
6. COUNSEL FEES
Each party agrees to pay their own counsel fees and costs.
7. MUTUAL DISCHARGE
Wife relinquishes her inchoate intcstate right in the estate of Husband and Ilusband
relinquishes his inchoate intestate right In the cst ate of Wife, and each of the parties hercto by
this presents for himself or hersell~ his or her heirs, cxceutors, administrators or assigns does
remise, releasc, quitelaim and forever discharge the other party hereto, his or her heirs,
executors, administrators or assigns, or any of them, of any and all claims, demands, damages,
actions, causes of lIction or suits at law or in equity of whatsoever kind or nature for or because
of a matter or thing done, omitted or suffered to be done by said party prior to and including the
date hereof, including alimony, support, alimony pendente lite, etc., except that this release shall
in no way exonerate or discharge either party hereto from the obligations and promises made and
imposed by reason of this Agreement. Furthermore, in consideration of the mutual covenants
contained herein, the parties agrce to incur no debt or obligation which may result in an
obligation on thc part of the other and hereby agree to indemnify and hold harmless the other
from uny claims, cost or expense which may result thcrefrom and furthermore agree to thc
specific perfonnance of any of the covenants and agreements containcd herein in law or in equity
along with the cost of compelling such compliance including costs of suit lInd reasonable
attorney's fecs.
.4.
8. J)JVORCE
The parties hereto agree to consent to a no-limit divorce and execute such consents, if that
shall be requested, us muy be necessary to complete the divorce within 30 days of the dute hereof.
Any default in complying with the terms hereof shall be u material default entitling the non-
defaulting purty to counsel fees IInd costs associllted with remedying the non-eompliunee.
9. EXECUTION 011 DOCUMENTS
The parties hereto agree to exccute and deliver all papers needed to effectuate the terms
and intentions of this Agreement.
10. CONSTRUCTION OF AGREEMENT
This Agreement cncompasses all agreements between the p\lrties concerning the matters
set forth herein and may not be altered or omitted except in writing executed by the parties; the
waiver of any term, condition or provision of this Agreement shall in no way be deemed a waiver
of any other terms, conditions, or provisions of this Agreement.
If any term, condition or provision of this Agreement shall be determined to be void or
invalid in law or otherwise, then only that term, condition or provision shall be stricken from Ihis
Agreement, and in all other respects, this Agreemcnt shall be valid and continue in full force.
This Agreement shall bc construed under the laws of the Commonwealth of Pennsylvania.
This Agrcement is intended by the parties as a post-nuptial agreement with full knowledge
IInd aner full disclosure by each purty to the other of 1111 assets of the parties and as such is
intended to bind the parties in the future irrespective of any reconciliation prior to or subsequent
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to the execution hereol: This Agreement is intended as a linal agreemcnt as to all rights of the
parties.
This Agreement is executed in triplicate and lIusband IInd Wile, liS parties hereto,
acknowledge the receipt of II duly executed copy hereot:
I]. AGItEEMENT TO liE INCOJU'OItA TIm IN J>JVOItCE DECIUm
The purties agrce that the terms of this Agrcementmay be incorporated into any divorce
decree which may be entered with respcet to them, however, it shall not be merged with the said
decree.
12. mmACH
If either party breaches any provisions of this Agreement, the other party shall have the
right, al his or her election, 10 sue for damages for such breach, or seek specilie performance or
such other rcmedies or rclicf as may be available to him or her in law or in equity, and the party
breaching this Agreemcnt shall be responsible for paymcnt oflegal fees and costs incurrcd by the
other in enforcing their rights under this Agreement.
13. VOLUNTAltY EXECUTION
The partlcs hereto have had an opportunity to review this Agreement independently of the
other, and have bcen informed of the right to have this Agreement reviewed and examined by
an attorney of his or her own choice. It being e1ear to each party that DORE KAY 11ELlX has
been represcntcd by Richurd C. Ruben, Esquire, IInd tlJUt J}A VIJ} ALAN JlELlX is not
represented by counsel but aeknowlcdges thllt the advisability of securing independent counsel
has hcen mude known to him by Wile IInd Wile's counsel. Euch party has been given an
.6.
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parties on the pre-trial statements have indicnted n value of
that property at $75,000.00 although wife's attorney has
indicated that he would like to reserve the right to have the
property appraised if necessary, If the property is to be
appraised that should be done at least a month prior to the
hearing and the results of that appraisal shared with opposing
counsel,
The property is subject to a mortgage with Allied
Mortgage company, The balance on the mortgage is $J3,000,OO,
The mortgage payment monthly is around $404,OIl, lIusband has
indicated that he would like to retain tho houno an part of his
equitable distribution settlement.
The parties havo various accountn inclUding savings
and checking and stock accounts. 'I'ho 'ollowlnl] accounts, with
the values assigned, woro provldod by counnol at tho conference:
York Federal Savings and Loan chocklnl] account in
husband's name -- $ 4,526,00
York Federal Sav ings and I.Oi\ll chocld nl] nccount
in wife's name -- $ J,6110.00
Joint account at York FOllernl /lilV I nqs and Loan
$1, :lllll, 00
Schwab One Account --
$ 1I,IlOO,OO
Belco account in husband's
name --
$
6116,OD
Horizon account --
$16,326,OD
Stratford account --
$
2110.00
20 Century Group Mutual Fund $16,036.0D
(Counsel havo indicated thIn may bo a duplication of
the Horizon account.)
lIusband has II ponslon with tho rnww Union which
counsel has indlcnted hOlD ol minimum vllluo, Counsol for husband
is going to get a lottol' rOlJllnllnlJ that .1ccount. Wife has a
pension with Snmmonn which Willi vnlued au of March 1996 at
$2,351.04,
1I0th p,lrll Oil hllvo IIl^n. lIusband' s IRA has a value
of $14,000,1l1l .11111 wllll'lI 11l^ hMl .1 valuo of $2,700.00,
.
wife had a Prudential life insurance policy which
she cashed in and received $531.00.
Because the parties have a fairly large
disagreement over the value of the household tangible personal
property, counsel are going to have to have that property
appraised to establish a value for purposes of equitable
distribution, Husband says that he has property in his
possession of around $2,500,00 and that wife has property in her
possession of around $7,475,00. Wife's position is basically in
reverse, Therefore, the appraisal will be needed to clarify the
values of the property in each party's possession,
wife has a 1992 Toyota Paseo which the parties
agree has a value of around $3,000.00. Husband has a 1985
Toyota truck which husband says is worth around $650.00 and wife
claims is worth around $1,000.00.
The values that have been provided today at the
conference are the date of separation values. Obviously when we
get the appraisal of the household tangible personal property,
those values will be closer to the date of hearing, Also,
assuming that the accounts have not been utilized, we will need
to have updated values of those accounts close to the date of
hearing which would account for any interest accrued on those
accounts from the date of separation to the present,
A hearing is scheduled for Tuesday, october 7,
1997, at 9:00 a.m, Prior to the hearing if counsel have
developed a list of the property with values and they wish to
request a conference to discuss the distribution prior to the
hearing, we will accommodate counsels' request and schedUle a
conference with parties and counsel some afternoon prior to
October 7, 1997. Notices of the hearing date will be sent to
counsel and the parties,
E, Robert Elicker, II
Divorce Master
cc: John M, Shugars
Attorney for Plaintiff
Richard C. Ruben
Attorney for Defendant
RICHARD C. RUBEN, ESQUIRE
~~
".- -....
34S OLD YORK ROAD
NEW CUMBERlAND. PA 17070.3122
(7171 938-2922
FAX. (717) 231-6186
Oetoher 15, 1997
Cumberland County Courthouse
Prothonotary's Office
Alln: Janie
One Courthouse SqulIre
Carlisle, I' A 1 7013
1m: FELIX v. FELIX, mVOUCE
Dear Janie:
Enclosed please lind the following documents to linalize the ahove relerenced divorce.
1. Acceptance of Scrvice and 1 copy
2. I'laintiffs Affidavit of Consent and I copy
3. Defendant's Affidavit of Consent and I copy
4. Plaintirrs Waiver of Notice of Intention to Request Entry of Divorce and I copy
5. Defendant's Waiver of Notice oflntcntion to Request Entry of Divorce and I copy
6. Praecipe to Transmit and 1 copy
7. Praecipe to Withdraw and I copy
8. Separation Agreement and 3 copies
9. Vital Statistic's forn\ and I copy
10. (3) Divorce Decrees
Please file the originals and time stamp the copies, certify the three copes of the
Separation Agreement and return the copies to me in the enclosed self addressed, stamped
envelope.
This matter was referred to Rohert Elicker, II, Esquire llnd the original tile Is probably
in his possession.
Sincerely,
;Lichc
Shllrnn It Kyle
I'lll'uleglll - I.egal Secretlll'Y
Enclosure(s)
lIushnnd - Twentieth Ccntury <irnup Stocks - $15,000.00 npprox.
(See Foolnole ~ I)
Wili: - Snmmons Pension - $2,351.04 ns of Mnr., 1996
iii. Ilousehold goods IInd furnishings:
n) Ilushnnd's possessions:
refrigcrutor - $600.00
wnsher/drycr - 300.00
couch/reelincr - 900.00
(3) cnd tllbles - 300.00
entertnlnment center - 350.00
onk TV trays. 100.00
bed. 600.00
most other household
impedimenta - 2,000.00
b) In Wifc's possession:
stereo - 800.00
misc. items, knick
knacks, small furniture,
& utensils 850.00
iv. Automobiles:
Wili: - Toyotn Pasco (1992) lIequired in 1992 - present value $3,000.00
Ilusbnnd - Toyotll Truek4
h. Non Mnritlll Assets:
i. Real Properly - Wili: inherited in 1967 nl/, remainder interest in mountain
Innd in Cumberlnnd County subject to 5 prior life cstates . value at
Inheritllnce, dnte of mllrrlage lInd dlltc of separution unknown. Wife has
insufliclent resourccs to IIp(1ruise lInd eomputc the value of her reminder
intercst.
· Value and particulars requested but not provided.
c. Pcrsonalty:
i. Husband - TV, microwavc ovcn and VCR - vuluc unknown
ii. Wili: . 19H5 Dodge Shelhy - value $9,000.00 in 19H5 - present value
$HOO.OO - sale priec in 1996
2. EXPERT WITNESSES: Wili: docs not expect to call any cxpert witnesses unless
Husband's pension valuation becomcs at issue.
3. WITNESSES: Wili: intcnds to call no witnesses other tllUn thc partics.
4. EXIIIBlTS: Wili:'s exhihits are attached
Wili: reserves the right to suhpocna and introduce evidence regarding Husband's assets
if not satisfactorily providcd promptly.
5. INCOME: Sec Income und Expense statement und Fcderal Tax Returns, attached.
6. EXPENSE: Sce Expense Statement, attached.
7. PENSION: See Pension Statement, attached and response to item 2 above.
8. N/A
9. N/A
10. DEBTS:
a. Marital -
i. Homc Mtg. - 33,000.00
ii. Mcdical Bills - 340.05
h.
Non-Marital -
i. Visa-
$2,127.00
II. PROPOSED RESOl.UTION:
That Witi: is u 35 yeur old high school gruduutc with somc non-degree Community
College courses. She is presently (post scparntion) cmployed as u $6.00 per hour laborer. Prior
to sepurution Witi: curncd in thc mid Twenty Thousund Dollar brneket but us the direct result of
Husband's publicullonof thc Iilcts surrounding thc purties' scpllrntion \Viii: wus tcrminuted from
her joh with Sammons Conlll\unicutionthus halving her carning cupllclt)'. Wili: hus withheld the
identit)' of her currcnt cmployer 10 prevcnt a similar occurrence,
Ilusband's enrning potential is three to four times that of \Viii:. Ilusband has contributed
nothing to Wife's support or maintenance since separntion but he continues in possession of the
marital home. Ilusband has signilieant individually titled pension, savings and stock accounts
representing marital property but has not provided an accounting flu them to \Viti:,
Interrogatories were served on February 28, 1997 but no response has yet been received.
Given Ilusband's signilienntly grellter earning power nnd potential Wili: asserts that she
should be awarded 66%% of the marital assets, She furthermore wishes to receive speeilically
the following personal items of insignilicant intrinsic vnlue which nre heing held by Ilusbnnd:
a. cast iron Christmas tree stand
b. reeliner
c. \Vili:'s tiunily Christmas decorations
d. \Vhitewater rnning photographs
e. duplicate set of \Vomers and Aikens Cove Trip photographs
f. oak TV trays
Date:
:;/,.$"),/
, I
Respectfully submitted,
~
By
Richard C. Ruben, Esquire
Attorney for Defendant
113 Locust Street
Ilarrisburg, I'A 17101
(717) 232-2227
J.D. 1/27767
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DATE ACTIVITV OFSCRIPTI1N P.r.FE?~Nr.r: C~fn TS D[" [J ITS
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INCOME AND EXPENSE STATEMENT OF
DORE K. FELIX
SSN 204-48-1518
DATE November 6. 1996
THIS STATEMENT MUST BE FILLED OUT
.................................
(If you are eelf -employed or if you are oaladed by a buolneoo at' which you are In
wholo or in part, you muot aloo fill out the Supp)cmcntnl Income Stntement which
appearo on the loot page of thin Income ilnd Exoenoc Statement. 1
INCOME
(A) Wages/Salary
Employer & Address INTENTIONALLY WITHHELD
Job Title/Description
Pay Period (Weekly, DI-weekly, Monthly;
Gross Pay Per Pay Period . . . . .
Bi-weeklv
. . . . $
464.23
Payroll Deductions:
Federal Withholding $ 51.56
Social Security 27.56
Local Wage Tax 4.64
State Income Tax 13.00
Retirement
Health Insurance 19.57
Other PA SUI/sDI 0.14
Medicare Tax 6.45
NET PAY PER PAY PERIOD. . , . , , , $ 341. 31
(B) Other Income
Interest/Dividends $
Pension/Annuity
Social Security
Rents/Royalties
Expense Account
Gifts . . . .
Unemployment Compensation
TOTAL, OTHER INCOME , . , , , . , , $
I verify that the statements made in this Income and Expense
Statement are true and correct. I understand that false statements
herein are made subject to the penalties of 18 Pa, Cons. Stat. ~
4904 relating to unsworn falsification to authorities.
DATE: ,.3..1;\- IL; 7 IJJ\..L-- /(: v:f~:>L
Dore K. Felix, Defendant
EXHIBIT
I .( J (
___1_~
EXPENSES
Total
Monthlv
Parent
Monthlv
child lren)
Monthlv
Home
Mortgage/Rent
Maintenance. ..
utilities (Telephone,
Heating, Electric, etc.)
Employment (Transportation,
Lunches) ..
$
150.00
0.00
$
0.00
0.00
$
0.00
0.00
0.00
80.00
0.00
10.00
0.00
0.00
Taxes
Real Estate
Personal Taxes
Income
51.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Insurance
Homeowners
Automobile ..
Life/Accident/Health
Other . .
14.58
56.00
40.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Automobile
Payments, Fuel,
Repairs) . .
Medical
Doctor, Dentist,
Orthodontist .. .
Hospital .. ...
Special (Glasses, Braces,
etc.,). ....
40.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Education
Private, Parochial School
College .
Personal. . . . .. .
Clothing. . .. ...
Food. . . I .. ...
Other (Household Supplies,
Barber, etc.,). . .
Credit Payments & Loans
0.00
0.00
0.00
130.00
15.00
150.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Miscellaneous
Household Help/Child Care
Entertainment (Papers,
Books, Vacation, Pay TV,
etc.) ..
Gifts/Charitable
Contributions .
Legal Fees. . .
Other Child Support/
Alimony Payments.
Other (Specify)
20.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
20.00
0.00
0.00
0.00
TOTAL EXPENSES, . . , . . . . , $
776 , 58
$
0.00
$
0,00
11111111..11..1:111.11
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2311 Your IRA deductIon (lee instructions) . . . 238
b Spouse's IRA deduction lsoe Instrucllons). . .. 23b
24 Mov,ng e'pen.e., AIt.ch Form 3903 or 3903,F .. 24
25 One.hell a' .ell,employmenll.., Altech Schedule SE 25
If hne 31 IS under 20 Self.employed health Insurance deducllon (see msl.l. 2e
528,4951under 27 Keogh & .ell,employed SEP pl.n. II SEP, check" 0 27
59,500 If . child 28 Penally on early withdrawal of savings . 28
did not Ilvl! with
28 Ahmon\l paid. Reclptonl'l SSN .. -- 29
youl. lee the ,
Instruchons for 30 Add lines 23a through 29.. '"
line 54 31 Sublract hne JO from hne 22. TIuI IS our Id ult.d rOil Income
Fa. Pnv.cy Act .nd P.porwork R.ducllon Act Nolle., H' p.g. 7.
L1040
.. Label
IS..
pog,'1.)
u.. th. IRII
I. b.'.
Olherwlse.
pl...e P'lnl
or Iype,
P'"ldlnllll
Election Campaign ~
See a 111, ,
1
Filing Slalus 2
3
4
Ch.ck only
one box.
Exempllons
If more than lix
dep.nd.nl.,
lee the
Instruction'
'or hne 6c.
Income
AlI.ch
Copy e 01 you.
Farm. W.2,
W.20, .nd
10000.R h....
II you did not
gel. W.2,
le.lh.
Instructions
lor lin. 7,
Enclo.e. bul do
not .1I.ch, .ny
p.ymenl. AI.o.
please enclose
Farm 1040.Y
(.e. Ihe
InSlructlonl
'01 line 621,
Adjusled
Gross
Income
Single
M."led liI,ng loinl ilium (even II only on. h.d Income)
Mamed flbng ..paral. r.tum. Enter IPOYIt'llOClal IIcunty no. lbove and rull name hit'.... /.-' 1 ,_ ~: I~.._.. y
H..d 01 housohold IWllh qu.llfylng por.onl. (See In.lruclion.,) 1I1h. qu.lllYlng per.on I. . child bul nol your
d.pend.nl, onlor Ihl. child'. n.m. here, ..
8 QUill In wldowler with dependent child ( ear spouse died'" 19 I. (See InSlructlons,)
e. IJ You,..l'. II your parenllor lomeone ellO) cln claim you III dependent on hil or her tax} No. 01 'Dill
retum, do not check box 6a. . . . , . . , . . . . . . .. cllUll' on
IIl1uhllldU
b 8 OU". . . . . . . . . . . . . . . . . . . . . . . . . No. 01 rour
c D.p.nd.nt.: I I ,prnctrnlllOClI1 t ,p,nctlnl, II g Cl mO~lns Chlldll" on 1111'
Ucunly nllmber II tlatn relationshIp 10 h\td I~ royl Ie who:
111 Fltl1 Nmt Lasl nlmt In 01 1 & sr. In I au hOI!\ ~ 1996
. UVI' with 'ow
. .1. nOIIl" wUh
rou 'Ultl dlworce
Irll,lflllan
1I111"'lrveIlGllII_
DI,ln'lnll on Ie ."
nol'....II' Ih\'t .:.--
Ad'"umhrs
tIltlllll Oft
11I111 no" lit
/ ""
o.panmenl 01 Ihe T,...ut'J'-lnt.rNIl Revenu. 8~lce ~tO\96
U,S, Individual Income Tex Return IL) U@
FOf tt'II ~&I' Jan. 1-o.c. 31. t8N. 01' othe' III YII' beO'Mlno
Your 'I'" n.m. Ino IMIII LlII nlm.
"r'i.~
( L'
IRS U.. .\'. 0
. 1896. .nOlno
L
A
.
I
L
II II00nl fllurn. '!:lDu"'1 "'11 nlrne .nd IMI"
LlII nlme
H
I
R
I
Hom. 100r.lI!numbe' .na Willi II you hl~' I PO bOl, ... ~'g. 11
AIlI no
c.ry. '0"""" or POll oft.C'. 1111.. Ina ZIP coo. If you h.~. I 10"'0'" 'OOflll. '" ~'O. , 1
Dayouw.nI5310gotalhl.'und1. , . . . . . . .
It. oInt retum. does our SPOUII want 53 to 0 10 this fund? .
d
7
110
b
8
10
11
12
13
14
1110
1110
17
111
18
200
21
TOlal number 0' uem lions claimed
W.g... III.rI... lip.. .Ic. AII.ch Forml.1 W.2
T.ubl. Int....1. AII.ch Schedule B II ov.r 5400 .
T......mpllnl.,..I, 00 NOT Include on I,ne e.
Oivld.nd Incom.. Alllch Schedul. B II over 5400
Tox.bl. r.'und.. crod,I.. a' oll..t. a' .1.le .nd loc.llncom. t.... (... In.lrucllon.)
Alimony received , , . . . . . . . . .
BUllne.. Income a. (10..), AII.ch Schedule C a, C.EZ . . . . , . , , ,
C.plt.1 g.ln or 110..). II required. .1I.ch Schedule O. . , , . , , , , .
Oth.r g.In. or OOlle.), AII.ch Form 4791, . , '8 . , . . . . . .
TotlllRA dl.l"buUon.. . ~I " b Tsubloomounl(I" Inll,)
Total pon,ian. .nd .nnuill.. l!!!.l --,,, b T.'.bloomounlt,..,n.1.)
Rental real e"ale. royaltle.. pl11neflhips. S corporallons, trultS. etc. Attach Schedule E
Form Incom. 01 (10..), Att.ch Sch.dule F . , . . . . . .
Unemployment compensalion . . . . . .. ........
5ac1.1 IIcurlly ben.',I. . 1200 I ' I b T.uble .mounl I... 10.1.)
other Income. list type and amount-see Instructions ................................
lib
.
....,
Cal t~o 12600W
..
7
80
~
8
10
11
12
13
14
15b
18b
17
18
19
2Gb
~
21
22
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,I.~.:.~. "'"
. 10 OMS.No 15.5.0071
'tour locl.1 IICurt!)' numb.r
Le. (,/ : :,'::: ,.-' 8
apou.... tacl.l..eun!)' numb.r
Fa. h.lp finding IIn.
In.lructlonl, ,.. p'gll
2 .nd 3 In th. boakl.t.
v.. No
Not.: CllteAIIflQ
_ -YIS- WI" nor
ChI"g. )'OUI ra. 01
ltauC. rout ,,'uno
,
/
r'
)
[J
O~
~ .:
--
,':"0
/- .;-..-~
."
.
30
31
, ~ .. ,
.0
lorm 1040 "0961
form t040 n'HI
Tax
Compu-
tation
It you want
Ihe IRS to
Ilgure your
ta., lie the
InstfUcllO"S
lor hne 37.
Credits
43
44
45
45
47
48
48
50
51
Payments 52
53
54
Other
Taxes
Mech
Forml W.2.
W.2Q, and
1099.R on
tha Irani,
Refund
Ha.. 1IIInl
d"lclly 10
your blnk
account! See
Inlt, and 1111 In ~ d
6Ob. c, and d, 51
Amount 52
You Owe
Sign
Here
Keep a copy
of thll return
tor your
records.
Paid
Preparer's
Use Only
32
3300
. Amount t'om Ilnl 31 ,adjust.d grolllOcoml) , , , . , , , , , , , .
ChICk .1, 0 You ..ere 6~ 0' older. 0 Bhnd; 0 5pou.. ..a, 650' oldor, 0 Bhnd
Add the number 01 b011l checked above and enler Ihe tolal he". " .. 33a
)
~
~
P.gI 2
32
"",,,'
~"-~"
I
I
~
~~
'~L
34
.
35
I,
~.,
34
b It you ar. mamed 'Iling IIpa,ately and your Ipouse Itemizes deducllons Of 0
you w.... a dual'ltatul Ihen. lee Instruchons and check he'. . . .. .. 33b
j lIemlnd deduction. hom Schedule A. line 28. OR
Enter Standard deduction ahown below lor your filing stalus But see the
th, In'tructlonsll you checked any bOI on line 331 or b or lomeone
larger can claim you I' a dependent.
~~r: · Stnglt-So1,OOO . Mamed '1lIng JOlntlv or Oual.tylng wldowlel)-S6,700
. Head of houlehold-S5.QOO . Mamed Ilhng lep8'8Iel)'-S3.350
Subtract lIne 34 Irom hnl 32 . . , , . . , . , . . . , . .
II hne 32 la S88,475 Of II", mulllpl)' S2,~SO by 'he tolal number 01 eaemptlons claimed on
IIn. 6d. II lIne 32 II over S88,475. lee the worklheet In the In51. for the amounl to enter
TI.able In com.. Subtract line 36 from line 35. III.ne 36 II more than hne 35. ente' .0.
TI., 5eelnatructlon.. Check II 'otlllncludel an)' tll horn a 0 Form(s18814
b 0 Form 4972 . , , , , . . , . , , , , , , . . , .
39
40
41
~~~
42
~ (/~
.-~"l IJl'
'" ," .. ~~ L.'
" ,1 ."
~ .", , "
'(1.; 'i o c.'
3ll
37
~
3ll
~
~
~
I
43
44
45
45
47
48
49
50
51
~-:...;
tc:-(':
.-",
wu
3ll
3ll
37
3ll
38
40
41
42
Credit for child and dependent care elpenses. Attlch Form 2441
Credit tor the elderly or the dlllbled. Allach Schedule R. ,
For118r. t.. crldll. AIIach Form 11 16 ......
Other. ChIck ilfrom I 0 Form 3800 b 0 Form B396
cO Form BBOl d 0 Form I,poclfy)
Add hnll 39 th,ough 42 . . . . .
Subtract line 43 from line 38. II hne 43 II more than hne 38. enter .0. .
-
.~..... -r-
()t.>
55
155
57
155
58
BOa
~ b
SIII.employmlnlla" MaCh Schadule SE . , . . . . . . .
A1t.maUve minimum ta.. Attach Form 6251 . . . . . , . ,
Social HCunty and Medicare ta. on tip Income nol repor1ed to employer, Attach Form 4137
Tax on qualifIed relirement plans, including IRAs. II requIred. attach Form 5329 ,
Advance earned Income credit paymenls from Formll' W.2
Houlehold amploym.nll...., MaCh Schedule H. ,
Add hnel 44 Ihrou h 50, Thllll our totelta. . . . . .
Fedllallncoml I" ..tlhhlld I,om Forml W.2 and 1099.. 52
1996 al,,"1Ilad I.. paymlnll and amount appl,oO Irom 1995 '.tum. 53
EImtd Incom. crldlL Anach Sched\lle Ele I' you hive a Quaittylng ~~.~
child, Nonla..blo .pmad 1I1C0mo: amounl ~ I I I ~
and typo ~ .................................................' 54
Amount paid wilh Form 4B68 (requllllo, ..llnlion). .. 55
E,c"1 loclalllcunly and RRTA la' wllhheld (I.e tnll.) .. 155
Other paymlntl, ChICk .llrDm a 0 Form 2439 b 0 FDrm 4136 57
Add lin.. 52 Ihrou h 57, Those a'e au' tolll a mlntl . ~
II hnl S811 more Ihan Ilnl 51.lubl,act hne 511rom I,nl 5B, Th'" illhl amoun! vOU OVER~AID
Amount olllnl 59 you ..anI REFUNDED TO YOU. . . . . . . . . . . . ~
Roullng number DTITITI:JJ c Type: 0 Ch.ck,ng 0 SaVlngl
" -;-"Jj
::'-'''.
n
'c":
. ",
~ 7~
,
:::,
Account number
Amounl 01 lon, 59 DU Wlnt APPlIEO TO TOUR 1117 ESTIMATED TAX ~
II hne 51 II mo,elhln hne 5B, lubtraclllnl 58 from hno 51. Tl""lllha AMOUNT YOU OWE,
For details on how to pay and ule Form 1040.V. lee Instructions, , . . , . ,"
83 Estimated 111 penalt . Also Include on 11nB 62 . 83
UnOI' penattltl ef pe'IUI')'. I O.Cllr.Inll1 hl~1 ,.,,,",n.d Uu "Iuln ....eI .::cOI'N~.n~I"O ICh.dul., ....d llal,m.nll.'nd 10 lhl belt el my knOWitClgt.nd
bI~ll. t".y art 'ru.. CO'"ct. .nel complll' Oeclllll.en 0' pllpal" 10ltl"lhan IIIP3)'Qll balea on IlIlnlorml"O" 01 which prtpa,,, hll InV knowledg'.
~ You' "O"llur, Oal. \'oul OCCuPlllon
~ SDOUII'II'onalut. 11'10,1'11 '"u'n DOTH mult I'gn
Oat,
Spoule, occupatIon
PftPf.t,r'1 ~
"gnalu" ,
f,tm', name 10' )Cu'S ~
,'"I,.tmplo~.a, I"~
8(101""
0.1'"
C"PCk .,
\@"'l11pIO~',(j
@ Pnnr.d on recrct'd ,,_pit
liP cOOP
Pr,pal't'I'OCI.1 IICU'lt)' no
.
'us ~"""'IPmlIfltOb '.-40NU
)r,T::[~ia'
P.O, BOX 15068, YORK, PA 17405.706E
DORf KAY FELIX
1821 SUSQUEH4NN4 ST
HARRISBURG PA 11102-223B
''';''1 II
.~~ NT
BANK FIN 23-1410158
",-:.:.'1','
I': "(
'.i:
01-16-91 1
1'[11"
t: ;~ ")1 ' I "
CI-CI-96 12-J:'-9b
SOCIAL SECURITY NO. 204-48-1518 RETIREMENT 10. NO. 0204481~18
lll/"~,':':'~:ll' ',.t,~. :,'-'1 ",
TRANSACTION DESCRIPTICH; 11"" ,.,,' lIl.' 8AlAt,CE
._.._._-------.~-_..- -~-_._-_.._-
EARLY DISBURSEMENT 10-02-2021 RE~UIRED DISBURSEMENT lC-C2-2032
ACCOUNT 111-0001645 TYPE - V4RIAhLE
MATURITY 02-19-91 PRIOR BALANCF
INTEREST Dl-31-96
INTEREST 02-29-96
CONTRIBUTION FOR 1996 03-21-9b
INTEREST 03-31-96
NEW INTEREST RATE AS OF 04-15-96: 5.660
INTEREST 04-30-96
NEW INTEREST RATE AS OF 0~-15-96: 5.960
INTEREST 05-31-96
NEW INTEREST RATE AS OF 06-15-96: 6.100
INTEREST 06-30-96
NEW INTEREST RATE AS OF 01-15-96: 6.300
INTEREST 07-31-96
NEW INTEREST RATE AS OF 08-15-96: 6.270
INTEREST 06-31-96
NEW INTEREST RATE AS OF 09-15-96: 6.030
INTEREST 09-30-96
NEW INTEREST RATE AS OF 10-15-96: 6.230
INTEREST 10-31-96
NEW INTEREST RATE AS OF 11-15-96: 5.910
INTEREST 11-30-96
NEW INTEREST RATE AS OF 1,-15-96: 5.100
INTEREST 12-31-96
- - - - - - - - - - - - -
,
,r,r~~:/~ff
_. _,I' t -.f 1~
(J' ,-' I '
" ("I
,'l, I
. \ .
.-
R4TE !C.78e
136.42
.64 137.06
.59 137.65
1.00 138.65
.65 13<;.30
.64 13'i.94
.69 140.63
.70 141.33
.74 142.01
.76 142.0J
.72 143.55
.75 144.30
.7~ 14!;.O2
.71 14~.73
- - - - - -
,,( I,'
i ',I
SUI.1!M.R',' 01' J\CCCJU'.-
136.42 DISRU~SEHtNTS
1.QO =En TAX HITHHELC
8.31' H TAX WITHHELC
.00 CONTRIBUTICN~ SINCE
14~.73 fan 1995
FOR 1996
. TOTAL PLAN VALUE 145.73 ROLLOVERS
FAIR MARKET VALUE OF PLAN AT THE END OF 1996
- THE FAIR MARKET VALUE INFORMATION IS BEItlG
FURNISHED TO THE INTERNAL REVENUE S!RVIC~.
PP.IOR CASH BAL
PLUS CREDITS
PLUS INTEREST
LESS DEBITS
NEW CASH flAL
I
.c:
.00
.OC
01-0J-')6
.00
1.00
.00
l4r,.73
-
-
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J 1040
label
(5M
Wlltr\JC\ron,
on page \1,)
U.. the IR8
_I.
Othlf'Wlll.
ple... pml
Of Iype,
Pluldlnllll
fllCtlDn Clmpllgn ..
See , II, ,
I
2
3
4
Filing Status
(See P19' 1 1 ,)
Check only
one box.
Exemptions
(See PIg, 12,)
If more than IUI
dependenl.,
... Plgl 13,
Income
A\IIIch
Copy B 01 your
Fonno W.2,
W.2Q, Ind
1000.R he..,
If \'OIl did nol
gel a W.2. ...
Plgl 14,
EncIoIe.buldo
not .nach. your
Plymenl Ind
Plymenl
Voucher, S..
page 33,
Adjustments
to Income
L
.
a
I
L
H
I
R
I
e
o.partment 0' lhe 'r...u~nt~1 R.v."u. &.l'Vtc. <1tO\95
u.s. Individual Income TBx Return III Ui!!J
IRSUt.Qr\ly-()dnot~.ar IlaP'I WlthIIlNCe
, tgg!t. Ifldlng . HI OMS No '6045-00"
'tour aocl81 NCUrtty ~
...@.!t: : ttH; I SIR
Ipouel', RC..llMCurfty number
FOIlht.,..a' Jan_ 1-o.c:. 31, '"!l. Of Olhtf Lal ~..' beginning
Your ''''1 name .nd .".,,&. Uti name
It. }OInt tatum, IPOU.... 'It'll Nine and Inlllal
LUI nlm'
Home .del',,, InutnlMl' and "'MIl II you hI~. . P O. bol, ... page' t.
.
AIllno
For Privacy Acl and
Paperwork Rlducllon
Acl Notlc., ... pagl 7.
V,. No NoIe: CI1e<."'lI "1'01'
d not chlngt fOUt'
ru ", fIlOUC'e rour
,.fund
Do you wlnl S3 10 go 10 Ihlllund? . . .
It . 10lnt ,.tum, doe. our IPOUII want S3 to 0 10 this fund? .
61ngll
Mimed flhng ,olnl ilium (.ven II only on. hod Income)
MIITlOd f,"ng MIlI"" rotum, Enl", JPOUIO" OOCllll4lC\lnly no, .bo.. and !uN noml he<e, ~ r."tL. \'.
/-I,
H..d of hou...hold (Wllh qualifying peraon),15ee p.g. 12,) 11th. qu.llfylng parson I. I child bul nol you, d.pand,nl,
,nle, this child', name here, ...
OUall In widow!e'" With depend.nt child 11I8' II lJII died ... '0 . (See a. 12.
Yout'H". II your parentiOf' tomeont ,IH) can cl&Jm you U 8 dependent on his Of' her tal }
relum. do nol check box 61, But be ,u,"lo check Ihe box on hno 33b on PIg' 2 .
b 8 II, , , , , , , , , . , , , , . . . . . . . . . , .
c Dlpendents: 121 o.no.nlllOCIJI m pena.nll It' ilia Ol~.
111 f I "'1 .'m. ItCullty number" born tllatlon,rllp 10 WN III rou'
Irt Nmt "'"' '.. In 1 r f t u IIotnf 11I1
5
ea
H..IINnl
I~IAI' 1ft I.
..I I.
No. of ytWI
,tllI'tln,lIk
"'1:
. IIn_.Ilt1,.u
. ",o'llIn wllll
,.IIl..11
.""".,
"'IliUM I'"
"..14)
01,""1.... II k
'''_III.1m _
~. "..FI
.It.,., II
Iin"'Mn .
1
d II you, ch'ld d~n' 1M W11h you bullS c~lm.d as you, a.lltllllenl under a pre.198S a9l/1manl. chtck here ~ 0
. Total number at ...m lions claimed . . . .
7
ea
b
o
10
11
12
13
14
lea
lea
17
18
10
20.
21
22
23a
b
24
25
25
27
28
29
30
31
7
ea
~
o
10
11
12
13
14
1511
18b
17
18
10
2Gb
21
22
Wlge., lllan... I,p., elc, Anech Form(.) W.2
r...bl, Inl....llncom. (... PIg. 151. Anlch Schedul. B II ov.. S4DD
rll..lOmpllnl"a" (let pig. 15), OON'T Includ. on I,ne 81 8b
Dividend Incom., Anlch Schedul. B II ov.. S4DD
Tuable ,.fundl. credits, or oHael1 01 state and local Income lues (lee page 15)
Alimony received
BUIIMIS.lncome or (lOll). Ahach Schedule C or C.EZ
C.Pllll g.'n or (lOll), II ,eqUlfed. anach Schedul. D I..e page 16)
Other gl'n. 0' (10....), Al1ach Form 4797. . . . . . . . . . . . . .
Tol.IIRA dlltnbullon. , l..!!!J Q, rnn U b TllIbI. lmount 'lot pig' 161
TaiJl pe..IOns Ind annullles l..!!!J " U b 7...1>10 amounl (lot pog. 15)
Renl.1 ""' OIllle. roYln"s, pannershlp" S corporellon., Iru.I.. elc, Anlch Schedul. E
Firm Incom. or (lOll), Anlch Schedule F ,
Unemployment compensallon (lee page 1 n. .
Soc'al .ocunty benellls I 2Da I I I b Tlllbl. lmounlllOt pig' 18)
Other Income, List type and amounl-see page 18 ....................................
Add the amounlSln 'he ta' n hi column '0' lines 7lhrou h 21. Thill IS ur lotallncomt ~
You, IRA oeducllon I'" page 191 231
5pou..'. IRA dOducl,on I'" page 19) , 23b
MOVIng ..pan..., AUach Form 3903 0' 3903,F 24
One.hal' olllll.employmenltax , 25
Self.employed health Insurance Oeductlon IIN page 21) 26
Keogh & ..."..mployed SEP plan., II SEP, check ~ 0 27
Penahy on early Withdrawal of I4vlngs , 28
Alimony Plld. ReclPlent'1 SSN ~ 29
Add lInes 230 throu h 29. These life our lotal ad ultm.nts ~
Subl"'1 Ion. 30 ham hne 22 This" youlldl"tld 9,an I.com. "1m lOIn S26,673 and a child hved
'WIHl vou /IUS lhan 19230 It a child (hdn'l hve wl1t! YOUI_ ue .hrnel1lncome Cledlt" on Dl e 27 ..
ell t40 12600W
30
31
3~ 'iD
Foon 1040119911
Form 10101111911
Tax
Compu-
tation
lSee pagl
23,1
II you wonl
Iho IRS 10
'Igure youl
Iax._
pago 35,
Credits
l500 plgl
24.)
45
4G
47
4G
48
IlO
81
82
D3
D4
Payments es
eo
87
Other
Taxes
~ pagl
Attach
Fllm11 W.2,
W.20. Ind
10811.R on
Iho Iron!.
eo
88
IlO
81
Relund Dr 82
Amount D3
You Owe D4
85
Sign
Here
K..p I copy
01 this relum
lor your
records,
Paid
Preparer's
Use Onlv
32 Amounl from hnl 31 IldJu'IO<I grail Incomo) " ",."...
Il3lI Chock II 0 Vou Wlfl 65 01 aldor, 0 Blind, 0 6pou.. WI' 65 ar oIdol, 0 Blind,
Add thl number of 00." checked above and enler the 101al hef'. ., ." 3:s..
b II your plllnl (or Borneone elle) can claim you as 8 dependent. ChKk her, .. 33b
c "you ." mamed fihng "parllely and your lpouse Itemllfl deduction, or
you ",. dual'llaluI allen, ... page 23 Ind check here. . . . . 33c
I hlmllld d.ducbonl Irorn Schedule A, hne 28. OR )
34 Enlef 8t8ndi1rd deduction shown below for your "hng 1181ul. But " you checked
'he Iny boa on line 33Ii or b, go to page 23 10 find your ltandard deduction.
lali" If you checked bol 33c, your standard deduC1lon IS lira.
01
your. · SUlQle-$3.900 . Mamed flhng to1nlly or Ouallfylng wtdowlerr-&6,5!tO
I Head 01 hou..holll-$5.750 . MarTIe<! "llng .opallloly--S3,275
5ublllClhno34fromhnl32 , , . . . , . , . , , . , . ,
It hne 32 &. $86,U25 OJ ten, mulllply $2.600 bV the tatttl number ot eumpllonl claimed on
line 6e. II hne 32 is OVef $86.02&, 6H the worksheet on page 23 1m ,he amount 10 enter .
Taubl,1ncome. Subtract hne 36 from line 35. It hne 36 is more than hne 35. enter .0. ,
TIU, Chock II Irom 10 TIU lablo, b llll TIl RalO Schodul", c Oeaprt.. Ga,n TIU Woo,
aI1ool, ar dO Form 8615 I'" page 2~ Amounl Irom Formlol BBU ~ I I
Addlllonat laxlS Chock II '10m I 0 Form 4970 b 0 Form 4972
Add hn..3B and 39, , " ,,'.'
~
34 ::1 7
3B
:Ml
3B
37
3B
:Ml Dt)
37
38
40
41
42
43
44
..
41
42
43
Credit tor thtld and dependent care e.penses Attach Form 2441
Credit lor the elderty or the disabled. Attach Schedule R, .
FarOlgn llU Clod,!. Anach Form 1 I I 8 , , , ,
OIhor crodllolo.. pagl 25), Check II Iram I 0 Form 3800
b 0 Form 11396 c 0 Form 8801 d 0 Form Ilpot'fy)_ 44
Addlin1l411hmugh44 . , . . . , , ,
Subtract hne 45 from line 40. If hne 45 II more than hne 40. enter .0. .
45
.. 4G
47 :J
4G
48
150
81 5
82
D3
D4
Sell-employmenl llU, Anlth Schedull 5E, . . . . , ,
Ahom.llvl minimum lax, Anlth Form 8251 . , . , ., '"
RocaplurlllU.., Chock II from .0 Form 4255 b 0 Form 8811 cO Form BB28
5oc1Bl aoamty and Modlcorllll on I,p Income nolllportod 10 amployor, Mach Form 4137
TIU on quollf,od rellllmonl pllno, Including IAAs, II ,equllod, Inach Fllm1 5329 .
Advanc. .amed Incoml credit payments from Fonn W-2
HauHhald Implaymlnl llUlI, Attach Schodull H .
Add Ima. 48 Ihmu h 53, Thlllo ur 10101 lax , ,
Fl<llllllncomt \1J w,lhhtld IIIOY lIlrom Formll) IOU, ChICk ~ 0
1995 "\JmIled IBl poymen!land lmounl BPplOOCl lrom 1994 ilium.
Eomod Income c,odll Mach SCh1llu11 EIC II you ha" I qualifying
child. NonllUOblo oamod Incoml amounl ~ I I I
Ind typo" ..................,.........................,......
Amaunl paid Wllh Form 4868 lulanl1an roquI") .
ExCISI aocrallocunty and RRT A lax Wl1hhald I'" plgl 321
Clhar POymlnll, Chock II from a 0 Form 2139 b 0 Form 4138
Add hnll 55 lhmu h 80, Thl.. orl our 10101 I Inll
eo
..
If hnt 61 IS mort thin lint Sol. subtrlt1 Ilnl 54 f'rotI"I line 61. ThIS IS tntamount you OVERPAID.
Amaunl 01 hna 62 you wanl REFUNDED TO VOU, '..""
!.mounl 011'"1 82 you WIOI APPLIID TO YOUR 1m UTlMATlD TAX ~ 64
If 1101 S4 II more than hne 61, sublract hne 61 'rom lIne 54. ThiS IS lhe AMOUNT YOU OWE.
For delalls on ho~ 10 pay and UII Form 1040.V, Payment Voucher. see page 33 , ,~
estimated 'all penalt 15ee pa e 331 Also IMctuoe on line 65 6fJ
'~":~~~~: ~~~~- -~~,~~\~.,'S'X~~-
Ur\M1 pef\l"~' 01 Pf'tlury, I df'C..,.I~11 n&ve ..amlnf'd 1h" ,,,ur., and accom~"V'''Q s.chedulfl and "'lem.nts. and 10 thl be" of my llnowledoe l~'
bellel, they ate true, tonKl. ana compl'!t (Mew.llOn 01 p1'flar.' toltler 1M" la.PIV"I" be,to on III Information 01 'I'lohtCh P/ep&rlf has tnv knoww-Itcc
~ Vour 'JQrlIlu" 0." 'four OCCuPltIO"
~ Spou...' ''O"llu't II a loml "Iu'n. OaTH mUll "0'1
O.t,
flpoule', OCCUPllIon
Plepare"s ~
'IQ"IIUI, r;
fIrm', "amew" ~
II aell.emptO'JedllntS
add'"'
~-
o ~Ir(l' nn ,..nrJr-d rUIIW"
'U ~ Go~"'IFT"'" ",rlrQ 0Il.u 199~. Jl~"
,. 0A06lI PEHNBY\.VAHIA OOMPENIW1ON,............,..........,................,.... "
III UNREIlrlBUFISED EMP\DI'E BUSINESS EXPENSES ..,..'......,....,..........' '"
Ie ~ PA OOMPENIWlON, _ Uno '" ""'" Uno I.......,................,..............,....,.................... "
I ~LE INnREST, Complo\l 1'0\ _ult A. ...'11.000 ......'............ ..........,....................'............, 1
3 ~LE DMOEHD5. Compltt. PA _ult B' ...,.,.000........,......,....,.............. ..,..", I
. NET INCXlME ..1UlSS1 '""" IhI OPERATlOH... BUSINES&. PROfESSION 0' fARM........,.......... ,.. ·
. NET GAIN ..1UlSS1..... IhllW.E. EXCHANGE.. DISPOS/TlCIH" PROPERTY......, ........,..',....,..' 1
AI AI.lOUHT of GAIN EXC1UOED on 1'0\ Sdltdult P....18..............,......,...., '" III
I NET INCXlME.. (l.OSlll1rom RENTS. ROI'AlJIEI. PATEHT8 0' COPYRIOtllli ......,..............,......,........' I
7 UWl ond TRUST INCOME ........,................,.......,..........,..........................................................,........,.. 7
I _ end lDTTEIlY WlNNNOS ....................,.......,.........................,.......................,..,.......,............ ·
I TOW. 1'0\ tAXABlE INCOME, Me! Unot Ie. I, 3, ., l .. 7, and I Do NoI 0_ I
10 "" we UAIIILITY, ..."""'" Uno llIy..1i COJlll)..,....,.........,..,......,.........._..............................,..,....... 10
1\ TOW. "" lAX WITHHELD ....................,.."...............,............,.."........,..,....,....,......,........,....,...."..........,.. 'I
,"' UT*Al"ID ""YMEHlW AND CIWlIl1. ROId lht _..... on _ Ill,
I2a CfWlIT '"'"' 11M "" lAX REllJRN .....................,...........,..,................., III III
lIII _ UT1IoIAI'ED INIlW.UlEHT PAVYEHT8 ..,........,..............,............,.. \a 'III
\Ie M'IrIEHl _ I," EXTENSION REOUEST ....,......................,....,......... I" III
lid TOW. EIIT1lIRUl alEOIl', Me! Unot ,to, 'Ill and "'.................,......,..........................,..,......,.......... ,~
'laX l'OIIQIVINUI _ "" ICHlDUU.Po Rood lht 1ntWcIl_ btglMInt on n
\30 HOUSEHOLD "'E"'BERS 'rom Uno ., PIlI II, PA _ult SP .............. I
131I EUDIIIlITY INCOME'"'"' Uno I. Parllll, PA $choduIt BP .................., ,31> 110
1:Ie VOUR TDW.INCOME '"'"' Uno II, Slop" 8P v.oRKSHEET ..,.........., \3c III
I3d we FDROIVENESS '"'"' Uno I. Parllll, 1'0\ _It BP,......,..,..,....,....,................,....,..,..........,.......... 13d
I. TOW. alEOIl' lD<1lUWl PAID" OTHER STlnB.. lXlIlNTRIES.... ....'........................,..,..'......'...., ,.
" PlP\Dl'YEHT INCENTIVE PAYIlENTB atEDIT............,....,....,......,..,......,..................... "
\I TOW. alEDII'S ond Po\YYEHT8 MIl ~ II, lId, lid, I. .rrd II......, ,....,....,......, "
17 TAX DUE Clt Uno .0 II ...... Nn UllI 'I, "II' to pig' II .nd ,ornpltl. 1'0\ ...,...nl \Iouchl, on pi · II
\I ClYVU'AYIlEHl (Uno 'I II ...... IhIn Uno '01.. ' " "".... "
,to AIlOUHT of UNE 'I .. be REfUNDED ..
lib AIlDUHT 0' UNE \I .. be CIlEDITED to "'u, 'M EmMATED TAll ACCOUHT '
,.. AIlOUHT ot UNE " .. be DOIlATED ID Vr1LD RESOURCE CONSERVATION fUND
lid AIlDUHT of UNE II.. be DOIlATEO ID US Ol~MPIC lX)/,lMmU, PA DIVISION
ThI TOTAL 0' L_ '" ""Ollth 'Id MUn Eo'" Uno '"
.. IIUI UT\IU, ..........." .-.rJ.IIMl' .. .....1....1lIt 1'_' ""...-........ ................. ....... --.. ~....... ,-,...., ...... ...............
'" I ...
pA=4~~1F{~Mo~"'!~~'L~,~JURN: R
0___ _ .- E_ ....5
Com_Ifth of "-nMYlWonll PA OIpI.m,,,,, 01 A.....nu.
':lD 't -t.t 9 - I 51 b
f)'iJr'(.. 1'\ Fe1...f
I 0 't c.w,..h ~~JI
c.ft""f 14~ Nt
Ph,t(!.
17011-"'"
MAICI! CORRECTIONS 8ElDW
--~ ' ' --._~~';.:'.......':
1lDLJ.J OJ]] ---'~'CID LUU.llf~~~'-~
_.....___-.. . .._.. ..._-"o__.~...~._r-.__.._,.""t.'..IIo-:..A .
~ "'-.'. .:.' "~'."
',-
.'
" ,
.
.-::,i".....;.."....tr 1#'''. '''':',
'.' ....
-...... - ..
... .. ~ -.
" ,
....
U'UII Y1lU lAND Y1lUI IrDUII) IIIN t~1Cl AU MilH anAlH AU ItHIDUUI AND fDIMI
.
.)
r
ornQAL USI ONLY
f7'
-
;D.I:~C>w'JD '0
..., .... .... fN&
...-
o.a","Orfr"""-"'~ 0
~ ...... '"'
...... 01 TIC tcHOClO. OOITlllCl
C~",""
......Cl COOl
~
e><E"'.""'WUllOloA_'" TUIOOlU1
bl
110
INDICRI HCM WAHY
01 ...... I'ONl OH
ICH:DUl.III Ar"W)4(O
III ''''formtW,1 .J.
III ,.._UE
III,.._A
III '''''-u",B
III'''_C
, "'_fUl,I _
1II'''_f
III,.._~
110'''_0
110 '''_'''0."
III ''''_I'o\,It_
III ,.._...E
, .. .-uIt. J
'''_0.1
v
III
.-uIt IP 0
(Chtc* onty . NlrN"O
1u1orD_1
III
III
III
III
IT
III
I"
, , ......".., Itb
Itc
lid
'''_'''0
, '" Schtdu'" W
00
.0.
-0-
-0-
...
.-' ..,
~mrLU. .. DUOl......OI~
E " Ham. I EmplOY'"
c;~~ Cf}IMt\LUu '
bncr1bI... D..... 01 "'" .lob In _ V... 1_ 1110.. E_.
Emp6oyer'. , ,"phone Nuftbef
'ARI... UIlIOII DUll IN........ .",,,."111
'ART.' WOIlll a.Oncl ANO UNIPOIItII 1_ II . oond.oon of .rnpIol'""nl ond not ,u'ObI. 10' ...rydI, UNI
'ART C IlIALL TDOLI ANO IUPPUlI '-",,141 II . _'oon ", .rnpIol'""nl .neI not pr"""od by .... .mplo,.'1
'ART Dc 'IIOnlllONAL UClNII ml, IlALPIlACTICIINIUIlANCI ANO flOlLln IONO 'AUIIUIII
.-_ II' oondOllOn of _ ...-"1
'ART E: TlIAVIL AND IlUADlI1_ '.....1..... 11010< PA _.... UE,' - 6ft 1ntW<t_1
TOTAL um.OYl _II IXNNIII Add PIIlI A ""'ugh E, EnltI h.... .... on Unt III of PAo4OA
A
B
C
D
E
DO
DO
DO
DO
DO
~:;::~..-
NImt(.).. _ on "'"' PA TII -:
PA SCHEDULE SP
1b 00
1995
B_ &tc:uI1Iy NumbO..
I I
__ "'" .... """'llItlt ... _It, I'"" MUSI llllftlPItI' "'" BP WOAKSHEE7 on ptgt "
PART I, Cenlflcatlon 01 ElIglbllltyl
111Nl1ll'/ 1pou101__ 1110 1ntl1U<l",", ond 0tIllIy ....11...1.. WI .,.) .ltgobl.1or I.. FO<\l.......'
a.ctIon AI Filing.. "8", 8lngl. or "M", M.nted Filing 8.p.r... A.lum
t, 0 ,0tIllIy 1,..1O<1AIy.._ OI_ono-NIl of "" own 7010I SupjlO<1ln 1111I& .nell.m tl~ lor Tu ""-""..
"Mng f'U", trMrned FNinO &.tparall Return, """)'OU' IPOU"', Nlm. and
lIocIIllltcultyN_' I I
I. 0 I ClItUty hi 111III . dependent 01 . pI~ trho .. Ihglbll tor Tu FDl1J~. 11m b'lng dllmlld U I dIpendIm on &hi ',nnlttv,nil P.~I
_Tu_mol:
N.... INllloclll -"'I' Nu_
PLEASE PAINT
s.ctlon II flUng .. "J", Mlrritd Ind c1llmlng Tu Forglv.n... Jointly
3. 0 ,... mr _ -Ir .... .. lit ..... tllgIblo lot Tu Fo<U'w_ ond tl<<11O ftIt . Jolnl PA Bchodulo 6P, AIoo UMIhlt llal.. " I'"" ftIt join"" but on/)'
_ _ "'"""" 10< TlI fGrgIwtn_ ond "'" Illhtl _ II . deptIldtnl _ no - .-nt,
a.ctIon CI '1IIng .. "'''. FInal PA A.lum lor I d_Iatd Indlvldull
_ lit ~'Il11 ' II lot thlo 1Il1ng lltuo, , 0tIllIy h"
4, 0 Tho _II on ..gIbIt Dolmlnl 0< on oIgIIlIo 00_ lot TlI FO<\J'YfI'III purpotO'
PART II. Number at HOUllhold M.mlll" lor Tax Forglvlnl" PUrpoll.1
t, N... lot TlI F ,tIIllI ..,", N AND ... 10TH tl ;tilt.... fth
","U-"Ip Ioclll "cu,lIy Numbt, PA Tuab.. Incomo
N "'" ... duntna "'"' _ III'"'" dtptndonl, llllftlPItI' lint a, " 10lH 01 rou .rt .Ilglbl. .... rOIl Irt nllng )oInllr,
DO NOT COIIPLtTa UNa I.
a.
,
o NO
00 DYES o NO
00 DYES o NO
00 DYES o NO
00 DYES o NO
00 DYES o NO
G
S.lnIIf thlr.lonnabDn lot uch dtpencilnl child datmed bllow. Ent., the number calln," hili
,
,
,
S
I
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PART III. CelcullUng Your TI. Forglvln... Crtdlll
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I>A VII) AI.AN FELIX.
1'llIlnllff
: IN TilE counT OF COM MOM PLEAS
: Clll\lIIEIU.ANI> COUNTY,I'ENNSYLVANIA
V5.
: NO. 96-2733 CIVIl. TEIlM
I>OIU: KAY n:I.IX,
J)cfcndanl,
: CIVIL ACTION - I.A \V
: ACTION IN U1vonCE
INVENTOIlY AND APPRAISEMENT
OF
DA VIJ) ALAN FELIX
(X) 1'lnintllT () Deli:ndnntfiles the following inventory nnd appraisement ofal
property owned or possessed by either pnrty at the time this action \Vas
commenced and nil property transferred within the preceding three years.
(X) Plaintiff () Deli:ndllnt verifies thllt the stlltements mnde inlhis inventory
and Ilppraiscmenl are lrue and correct.
(X) Plnintln' () Deli:ndnnt understands tlmt the flllse stlllements herein are made
subject to the penalties of 18 I'Il.C.S. 4904 relating to uns\Vom falsiliclltion to
lIuthllrities.
---/~~t! -./~'n'.._"___.._
(X) Plllintill' ( ) Dcli:ndlllll
If.
, -...A \
.
ASSETS OF PARTIES
(X) PlaintilT( ) Defendant marks on the list below those items below those items applicable to the
case at bar and itemizes the assets on the following pages
(X) I Real Property
(X) 2, Motor Vehicles
(X) 1 Stocks, bonds, securities and options
( ) 4, Certificates of deposit
(X) 5, Checking accounts, cash
(X) 6, Savings accounts, money market savings certificates
() 7. Contents of safe deposit boxes
() 8. Trusts
(X) 9, Life Insurance policies (indieate face value, cash surrender value and current
beneficiaries) (Defendant)
() 10, Annuities
() II Gifts
(X) 12 Inheritances (Defendant)
() 13, Patents, copyrights, inventions, royalties
() 14, Personal property outside the home
() 15. Businesses (list all owners, including percentage of ownership, and ol1icer/
director positions held by a party with company)
( ) 16, Employmentterminntion benefits .. severance pay, workman's compensation
claim/award
5
() 17, Prolit sharing plans
(X) 18, Pension plans (indicate employer contribution and date plan vests)
(X) 19, Retirement plans, Individual Retirement Aeeounts (Defendant)
() 20, Disability payments
() 21 Litigation claims (matured and unmatured)
() 22 Milltary/VA benelits
() 23, Education benelits
(X) 24, Debts due, including loans, mortgage held
(X) 25, Household furnishings and personalty (include as a total category and allach
itemized list if distribution of such assets is in dispute)
() 26, Other
6
.
MARITAL PROPERTY: (X) PlaintilT( ) Defendantllst~ all marital property in which either or
both spouses have a legal or equitable interest individually or with any other person as of the date
this action was commenced
ITEM NO, I
DESCRIPTION: Real Estate: 104 Cumberland Dr. Call1)1l1i11, l'A
VALUE aprox, $75,000,00 DATE OF V ALUA TION present
NON-MARITAL PORTION None
AMOUNTINATURE OF ANY LIEN: Approx, $33,000.00
ITEM NO, 2
DESCRIPTION IlJll5 Toyota Tmck
VALUE: $650,00
DATE OF VALUATION: present
NON-MARITAL PORTION: None (In possession ofPlaintiO)
AMOUNTINATURE OF ANY LIEN: None
ITEM NO, 3
DESCRIPTION: 1992 Toyota Paseo
VALUE: $3,000,00
DATE OF VALUATION present
NON-MARTIAL PORTION: No (In possession ofDefendanl)
AMOUNTINATURE OF ANY LIEN: None
ITEM NO, 4 DESCRIPTION Household Furnishings, See Exhibit "C",
VALUE:approx, $2,500,00 DATE OF VALUATION: present
NON-MARITAL PORTION: None (In possession of Plaint ill)
AMOUNTINATURE OF ANY LIEN None
7
NON-MARITAL PROPERTY: (X) Plaintiff () Defendant lists all property in which a spouse
has legal or equitable interest which is claimed to be excluded from marital property,
Nonr
ITEM NO,
VALUE:
REASON FOR EXCLUSION
AMOUNTINATURE OF ANY LIEN:
DESCRIPTION:
DATE OF VALUATION
ITEM NO,
VALUE:
REASON FOR EXCLUSION:
AMOUNTINATURE OF ANY LIEN:
DESCRIPTION:
DATE OF VALUATION:
ITEM NO,
VALUE:
REASON FOR EXCLUSION:
AMOUNTINATURE or ANY LIEN:
DESCRIPTION:
DATE OF VALUATION:
ITEM NO,
VALUE:
REASON FOR EXCLUSION:
AMOUNTINATURE OF ANY LIEN:
DESCRIPTION:
DATE OF VALUATION:
ITEM NO,
VALUE:
REASON FOR EXCLUSION:
AMOUNTINATURE OF ANY LIEN
DESCRIPTION:
DATE OF VALUATION
8
OTIIER INCOME: WEEK MONTH YEAR
Interest. $ 289 69
Dividends'
Pension
Annuity
Social Security:
Rents
Royalties
Expense Account:
Gifts
Unemployment Comp $352,00 $1,408,00 $2.881.00 to
date
TOTAL INCOME: $352.00 $1,408.00 $2,881,00
EXPENSES
Weekly Monthly Yearly
1I0ME:
Mortgage: $404,00 $4,848,00
Rent:
UTILITIES:
Gas: $143,00 $1,716,00
Elcclric: $ 2500 $ 300,00
Telephone: $ 3500 $ 420,00
Trash & Sewer $ 22,00 $ 264,00
Water: $ 1.100 $ 168,00
SUBTOTALS: $ 643.00 $7.716.00
12
Weekly Monthly Yearly
EMPLOYMENT:
Public Transport:
Lunch: $ 10.00 $480,00 $ 480,00
TAXES:
Real Estpte: escrowed in mortgage $ 75 \.00
Per Capita School Tax $ 200,90
Personal Tax: $ 39.00
Local Tax: $ 240,00
INSURANCE:
Homeowners: $ 352,00
Automobile: $ 356,00
AUTOMOBILE:
Fuel: $1040,00
Maintenance: $ 20,00
MEDICAL:
Hospital: $ 93,00
Medicine: $ 26,77
Group Therapy: $ 520,00
SUBTOTALS: $ 1000 $48000 $4119,00
13
Weekly Monthly Yearly
PERSONAL:
Clothing: $ 322,64
Food: $3,380,00
MEMBERSIfIPS:
York Grotto: $ 15,00
West Shore Health Club: $41,00 $ 492,00
MISCELLANEOlJS:
Money Magazine $ 39,00
Online Service Provider: $ 240,00
Entertainment: $ 50000
Tools: $ 135,82
Vacations: $ 1,164,00
Gifts: $ 500,00
Legal Fees: $ 680,50
SUBTOTALS $41.00 $ 7.468.96
TOTAL EXPENSES: $19,303,96
PROPERTY OWNED: DESCRII'TION VALUE Ii ':Ii. J
Checking Aecounts: York Federal $ 1.800,00 X
Acet No, 9-1158662
Schwab One $ 8,078,00 X
Aecl. No, 1103241-3082
Credit Union: Belco $ 586,00 X
Ace\. No 737600
Stocks/Bonds: Horizon $16,325,00 X
Stratford Acquisions $ 280 00 X
I.RA York Federal-Fidelity $14,000,00 X
Real Estate 104 Cumberland Dr $75,000,00 X
Camp Hill. PA 17011
14
P A V E R MAIN OffiCE:
403 N, 2nd S~..I
P,O, 80. 82
HIITI.bIrg, PA I 7\ OB
BRANCH OffiCE:
354 N, Prilc. St. SullO 120
t11'j CrDIIIng.
P,O, 80. 1026
loneall", PA 17603
RECIPIENT'S NAHE AND
. BRANCH OffiCE:
360a TrhdIo Road
CIIIf HI. PA \7011
BRANCH OffiCE:
ClC>ital H.1I1I1 SylU'"
HIITI.bIrg Ilolflltal
Brody HII
2a& S, front Slnll
HIITI.bIrg, PA 17 1 0 I
ADDRESS
" . .~ ! d-~',' - Li \.t-~..~, t,_1 \'" If. _~"~": r\ "~', -.1"ii-.~eit'."-~- >;. :~1"~t ,',
lftC-;iV;\i.~~'t".~..\;r\'; '~:~ll ~"..."- ~f",~;\'~ l:;~~';~1j '::
I~~;.~ 'Il.TAT""EHT~F,O~ ~ RE,OIP.xEHr$l,'QF~,
~l il il,l ~ I ',':-'t- '/I~:~NTERESTf~'1 J4COHEi~':n~~)'lI'~
.'. ""',"'1 '. ", ' ',",...,. I' ,,'" \\ . \ . \1.....' ..'y " ,
f,"'" ..~l ,,'J.'~"'.."'./. "'t,\~\~.,/.:\;' i:l> 'l\"""i;\.~\.:!'~
"", " ,1'::;\\,QHB,iNO~"1'5!t5'~P)12\' :1;-/;+';
t,\tl,i J...~.J,f!<.'t.;:\ 'orn..lb :'\ .,.,;.:...i:,..JC"l~1.:'L.....d~ 1.: I~-"'.~'-'
ACCOUNT NUMB
737600
DAVID A FELIX
104 CUHBERLAND DR
CAHP IIILL PA
i~~x~~
RECIPIENT'S
IDENTIFICATIDN
NUHBERI
170 II
~~ ~,~ : ,'.;.~\; o!~ 11. 4'~ f.~'(.\
jo .; ':':. , .\'~; ~ "~"..j. \'_: ~- - ,
, . ,',' llrillf,'j""',":"'"
FORH 1099-INT
COPY B FOR RECIPIENT
~ ~ IHPORTAHI lAX INFORHATION
AHD ~ BEING FURNISIIED In IHE
INTERNAL REVENUE SERVICE, lE ~
ARE REOUIRED In E1Lf A RETURN. A
NEGLIGENCE PENALTY DB OTIIER
SANCTION HILL ~ IMPDSED nu ~
lE ~ INCDHE ~ TAXABLE AHD IHE
lRS DETERHINES lHAI 11
JlllH REPORTED.
INTEREST PAID TD YOU DURING THE
CALENDAR YEAR BY BEL 0
2072
INSTRUCTIONS RECIPIENT
I' YOU RECllVI A PORM 10' INT FOR IHTER.IT PAID ON .
TAX-EXEMPT 08LIOA'ION. PL Qt.. 'OR
YOUR INCOME TAX RETURN.
If YOUR 'IDERAL IDENTIPICATION HUHIER II SHOWN ON THII
FORM. AHD TWO OR MORE RECIPIENT' ARE lHOWN OR 1HI FORM
INCLUDE' AMOUN'. BELONGING TO ANOTHER PERIOH, yoU ARE
CON_IOERID A NOHINEE RICIPIENT. YOU HUI' fILl FOAM
10"-IN1 Fon IACH OP THI OTHER OWNERI lHOWING THE
INCOME ALLOC'ILE TO EACH. PILE 'ORMe.. 10"-IN1 WITH
FORM 10'6. ANNUAL SUMMARY AND fRAN'HITTAL OF U.I.
INFORMATION RETURN'. WITH THE INTERNAL REVENUE BEAvleE
CENTEA FOR YOUR ARIA. ON FORHI 1099-IN1 AND 10". YOU
SHOULD BE LI8'ED .1 THE .PA'ER,- ON FOAM 10"-IHT.
THE OTHER OWHERIBI SHOULD BE LIlTED A8 THE -RECIPIENT,.
A ttulDAND OR WIFE II NOT REQUIRED TO FILE A NOMINEE
RETURN TO 8UOW PAYHENTS FOR TUE OntEA.
Tlii-Al DIVIDEND YEAR. TO.DAn------I----'---~---'.ToTAidFINANcE CItARGE yEAR~iO..OATE,l-.
t.. 01 living. llcoptlRA f.. 011 loan.
OIvklond..hown, 1111 0...... wiD be - --, d_'_____,_d ..
rlpO(lOd 10 1110 Inlll1lll Rov.nu. S.rvIc.
f.. iii. colondor y... NOTICE: Soo 10\'1111' .Id. lor ~r"'nllnformJllOn
'INOICAHS EffECTIVE DATE Ex IlltJ rr I fJ - 3 1/
(~..owth I nvc~tol'~ Stntclllcnt
Account Number: 020-000802640
0000605120950200008025402000000
1'~U I1linillllllU)
1IlIlIoIL\'IUllhMilhlil;IIIIlh'\llIl\'111
Inhllh\'lka'llllllllhl,',llIh,lh',
tl'l.tdIIUIIIl\'lIlllllhl,hlilll'lllllt'
\\lIh )'ll'l in\\'\IUh'ul,h\',L IlI.Ilk
11;1) IIhl.: III hh'lI11~11l f -\'11111I) Ill1
nllt ";1111-: )tlUI dl~'\~ Illlhh
hlllll
o1~n'1 '18M""
D.vId A roll.
104 Cumbllllnlld Olive
C.n", 11111 PA 17011
$
-----..---------------------------------------------------.---
TWENTII~TII CENTURY
MUTUAl. FUNDS
G ..owth Invc~tot'~
Account Number: 020.000802540
Dovld A Felix
Slnll'llIl'IIII'l'rlnd
January 1,1995,10 December 31,1995
Poge 2 of 2
I
Tn~lm)'l'r Idl'lIl1nrnllnll Nlllllhl'tl 200.52.8511
VeRl'-To-J)ate Investment Stlnlltlnry
Account Value
On 01.01.95
T 01.1 Amounl
Inyelled Glooe
01.0'.95
Total Arnounl
Withdrawn 61nol
01.01.95'
Nel Amounl
Invllted
Blnee 01,01.95
Ch.ngeln
Account Valu.
Blnce 01.01.95"
Account Value
On 12.3,.95
$2,400,20
$000
$000
$0,00
$500,27
$2,994,55
'The number In fhJe column re".cla the total .moulI' oonVflrf,d. rede,m.d or tl'anlf.rred out ol.n 'lX'Oun'. fHa .nd .n)' dMdlmd .nd CapltAlg.in
d,.mbulfofl. p.1d In cuh.
.'The number in 1fI1. oolumn ,,/fee" fund 'PpreolJJ&onld",tlId.tion .nd reJnWHIIwI dividend .nd c.'pllca'ga/n di.tnbutJon..
I Yenl'.1'o-l)ntc Account Activity I
Dh.,.. Till.
Dele Tfanaaotion Ooll.r Anlounl Sh... Pole. T,onuctlon Tol.ISh.,e.
---- -- --
01.01,95 Balanoe lotward 132,779
12.18,95 Dividend dloblbullon pe' ohn,.
009tOOOOO $018 $t9,18 ,479 133258
12.tG.95 Cnp goln. dleloibullon p.r olon,.
3,050300000 $405,81 $19,10 2 t.t 80 154438
12.31.95 Total acoount value $2,994.05 $19.39 154.438
"'lI11n,
E'iHIt3/T
,f "
ll-tI
l\lI'flltl \NI It \'''1 h",I.III,lllltun.llh 1I.1Il'.1I 111'11111111"1'" "'"" 'pi 1111'1 '.II.lu\l1 11"11,'\\ ,.1I.,IIIIl' 11I""'11.111"111'11'11""" tlt.ll \~I'I""I""lh mh'II'"1 "'11I
III,tllh 11'''1' 1'1.',1'" 11"1111 I" ,,111I\ Ill'" III "1I11"J' III loll' III .Il~ ' 111111111.., ..",1 1.11110' ,. ,1i"1lU"1l! '1'1 ,.k. '" ~ ,'11 ".11 h. Ik,'ml'd hi 1I.I\I'I"IlIIl',IIIII"I' 11,1Il';I~II'llh
1l.1.'tlllll... "'\1"'," .j,t.- 1"1 ;l,t.l'I"" .1Il,lt,t"l'lll'II" II 11111"-11,,1111111"""1
, .
Irl\'c~t mcnt POl't folio SUIIIIIIUI'Y
.
+
01UM 7111 04118
David A r.lI.
104 Cumbelland OllvI
Ca"1lIlIIlPA 17011.60'0
Sluh'nll'nll',...hlll \o:n.llul!
Deoember 31. 1995
l.lllll.lIllI.ll...II...II.II.llll..lI.III.lllll....llIl.lllll
Poge 1 of 2
TUXIIU)'I'I'I.h'nllnl'ulInn Nnllllll'n 200.52.8511
Invc5t1ncnt Portfolio SlIlIIlIIllry
The 'ollowing provtdlllnlo'matlon on Illv'lhnent, rlom the tlrn.the looount WII opened/llopened.
Fund Name, AccQunt Numb., and Tolal Amounl Tolnl Amount Nel Amount Change In
~~untOp.nedlR.optned Oat, __~~ell~ __ _..~~~~~~~~~. _____~1~~.~~~ __ Acoo~~'y'''~~.!"'
Tnxable
Growth Inva.lor.
020.000802540
Account opened 09.10.90
Tax.Deferred
No .haru owned In thl. cotegory.
Tnx.Exempl
No .hore. owned In thl. category,
Account Vnlu.
On 12.3,.95
$2,11000
$1000
$2,10000
$894 55
$2,994.55
Tolnl Portfolio
$2.100.00
$894.55
$2,994.55
'n,. nunlb,,'n 1#,,, column ,.nee" th. fota/.moullt con\-'ft,'tHI, rede.med or ',anlf,rred au' ol.n .tWU"', ((Jet and any d'-\',d,nd ,,"d c.",;,." O'In
d..rnbulion. paid In CMh.
. 'The number In thl. ",,'umn ""lCtI fund appTl'Cla"on t1ppmclal1ol1 and re/m',.,kfd d/vtdend .Il1d capltat glfn diatrlbulion.
I ni\'ldelld nlld Cnllllnl Gnln SlIlIIlIIn,')'
V.If.To.Dal'
Vea'. To.Oole Velll' To.Ont, Veal.To.Oal. OIv1d.lld Tolal0l,hlbutlol11
!llvld.nd 8hol1. TII", catfc:hl.l lon~' lelm CnfcltAI & CapUn' Gnln Blnee Account
~~unl Numb'l-____ ______. etllllbutionl Gain OIll1lbu 0"1 Gn n Di'"lbu Dill OIlhlbutlonl ()p_.n~.!2P!'l~
--_._--_._- --------- ---- ..-----
020.000802540 $9.18 $8130 $32461 $41499 $995 85
Tolal Dlvldond & Cnpllnl Gnln $9.18 $81.30 $324.51 $414.99 $995.85
NOM' Dwldtrnd and co1pII.' g.ln di.tnbution. are ,.,'ll\'f!liIttrd IInleSllloltJd at "DI.ttlbutlon. 'Mid 111 C'alilh .
Ili'''"d'
""'IUtl,\NI II \Jlull.lol all .11lhIlH,ltil 11.111'." 11"111'111", 1'11'\1"11' '1',Uk' , Itdlllh Inln\ ,III Hlllu 1I11,.tllI '''''"l'' rll'IIH' IILlI \\1' 1""1" d\ .11 1".lpll \t""
111'111I111,,", l'Ie-,I'" 11"111\ 11'111 ;lIn 1'''11' iu \\1'111',' ",11111 111.1,\, III'tIllh,' .''',' ..Ithr ,11"'''11'111 '1",111.' p, \""" .111'0' ,1.'1'11I...11..1..11, I.IIII!. .III" 'I' 1I,1tI,:u 1I"'h
t1rlr'.lllh..Il.\'.'.I....".'.., rlll.hl'\\;llhlll'l"l'lh'Il"IlIIlUhllllll"IlI;ltll'll
P.....UI S Nlmf 6I1H."'ddl'" e,l, Gll" lop c.ltJ. I"" f'tlolf" t4un'Ilf"
STATE STREET BANK & TRUST
FIDELITY INVESTMENTS
PO BOX 145423
CINCINNATI OH 45250 5423
nECIPlE'" S Nlmf Sh..l Add.,,, llfltllld.ng .~, tlu I e"t E;lllr 1114 I,p Cud..
, ,
1,,,111,,,111,,,,,,11,,,11,11,,,11,,,,,111,1,,11,,,,1,,1,1,,II
STATE STREET BANK & TRUST CO
CUST FOR THE IRA or
DAVID A FELIX
104 CUMBERLAND DR
CAMP Hill PA 17011.6619
TAX YEAR 1996
Dopartmonl 01 tho Troasury.ln'ernal Rovonuo Sorvlco
(Keep lor your Recorda)
'h,lnlo,maUOllln Do." '.2.4. Ind r.., bllng lurnl,h,d '0 'hlln'"nl'
nev.nuI Se1\1C8.
TRUSTEE'S or
ISSUER'S
Fadora'
Idanllll allan No.
04.3120181
PARTICIPANT'S
Social Security
Number
o Co"oclod (II chec~od)
20052.8511
rOMONo 16U.0741J
e'
. '
, ,
2.
Rollovor IRA
Conlrtbutlon.
Fund Nam.
Accounl Number
FIDELITY ADV GAOWTH OPPOATUNITIEST
467 6589856
Summary
Instructions for Participant
The Inlolm.llon In bo,ol l. 2, 4, Ind 511 lubmlllod 10 the Inlornal
Revenue SlIvlee by the trullee or luuor 01 your Individual rellleme"1
.".ngomonl (IRA) 10 .epolt .ogular ol.ollover conlllbullonl modo 10
your IRA and the v.lue 01 your IAA 01 Ilmplllled employee pons Ion
(SEP) account
II you 01 you. Ipoule wu .n .cllv. palllclpanlln an omployel"
penllon plan, youIIRA conhlbulion. may nol be deducllblo. Soolhe
Inltrucllon.'o. your ,.. relurn '01 delall..
Caution, II you alo a' loul70 112, you mUll 'a~o minimum dillllbullonl
I.om your IAA. II you don1- you may be .ubjocllo a 50% o.cll8l.. on
the amoun' 'ha' lheuld havo been dlltllbulod. II you Inhollled 'hIIIRA,
ce.taln minimum dllhlbullon rulel .pply. Soe Pub. 890, Individual
Rellremenl Anangomenll {IRA I), 101 minimum dlllllbullon melhodl.
Box 1.- The amoun'"hewn 1.lhe conhlbullons lor 1996 modo In
1996 and Ihrough April '5, 1997,10 an IRA.
Box 2.- ThI.I.lhe .mount 01 any .01l0ver,lncluding a dl.oel rollovor,
you mad. In 1816. You mUllropol' ,he 10111 dlltribullon you .ecelvod
from your IRA on the applopllelolino 01 your Ineomola. lelurn
Subl.acllhe pal' 01 the dl.hlbullon Iha' wu rOllod over end entol
lhe I..ablo romalndor on lhe epplOprlale IIno 01 your Incomo ,..
filum. But II you havo ever made any nondeductible contributionl
Fo.m 5488
1lllllmlllllilllllilll~11
e .
.
,. Regular IRA
Conhlbullonl made
In 1998 .nd 1997
For 1996.
o 00
4,
Fair Mark.t Value
of Accounl
A. of t2/31/98
'0.811.08
10,811.08
8.
Chock for
SEP
0.00
0.00
0,00
LI
to yourlAA. uso Form 8606, NondoducliblolRAs IConhlbullon.,
Dlltllbulionl, and a..lll. to Iigurolho t...blo amount II plopelly
W8I follod ovor, iDe Pub. 090, Individual Retirement AflangemBnl1
IIRAsl
Box 3.- Lilo Insurance Cosl: Thll box II nollncluded bocausollll nol
apphcablo.
Box 4,- Thi.11 ,he lair mer~ol valuo (rMVI 01 your account.t ,he end
ollhe year. Howevel,lI. deeedenlII Ihown ,"Ihe partlclpanl on Ihll
lo.m, II may bo Ihe FMV on lhe date 01 dollh. II a docondenl'. neme II
Ihown II lhe partlClpanland lhe FMV shown I. zero, the executor
a. admlnlslratol ollha docedonl'. ellllo may .oquIII' dale-ol-dealh
valuation ham the tlnanclalln.lllutlon
Box 5.-11 tho bo.ls marked, 'ho Inlolmallon on thl. form/llalomonlll
101 a Ilmphllod employee penllon ISEP)
You .'0 nol IIquilod 10 altaeh a copy of FOlm 5498 '0 your Income
lall lelurn. Keep 'hl.lorm lor your ,eeord.. For more Information
ebouIIA".. "0 Publication 590.
NOTE Thle 101m hel. your contrlbution.,lcllovolI. .nd FMV 10' 81eh
aecounl wltllin the tund comple.. A summery 01 your IRA lor lhe
entire fund compl81lllilled on 'hi. lorm.
t X If 113 17 " ;/ . tl
"
h...'''..''.........'I....'..,..,...q...,l>I' t. ''''-1'' .....
,1-,t"l ~'IM1IA""I\l1 A"O,tJ'lOkl~\
AllIEO GROUP HORTGAGE COHPANY -597
1701 98111 ST SUITE 100
HEST OES HOINES IA 50591-2009
5152297100
000007b282
l31-b0515'\112
HARMING. SfE HOTE 5
,'~(h15HC01All{l(h1 ~
"2115'1294
.fR fli60RnO'fl'(A' hll,l[ .,..0 ,t.t}()1l1!.!l
~&'I fI ~ !;.IXI&\ ~lClll'" toll
200-52-8511
20,802
DAVID A FELIX
DORE L MILLER
104 CUMBERLANO DR
CAMP HILL PA 17011-6619
Escnow ACCOUNT
STATEMENT
THIS NOTICE CONTAINS
INFORMATION
REGARDING YOUR
ESCROW ACCOUNT AS
REOUIRED BV THE REAL
ESTATE SETTLEMENT AND
PROCEDURES ACT
(RESPA) AND IS A RECAP
or YOUR ESCROW
ACCOUNT
" .
rom
out oat(
PRH:lPM. t IITtRlIT
[SCRO.....'\lPOu..O
CRlDlTIfSl.IRAHCI
6(R~'I(( [IIAI<GE
RlPlA(E"'E",T flESfRvt
\llse
TOTALP'.UENT
lRA"SACTlOlj
&\lO\j~T
IljHRI~'
l'lell
SUBSTITUTE FORM 109B
ANNUAL STATEMENT OF
MORTGAGE ACCOUNT FOR
--~--,-- --iJ.jiliill,l&iiJii'filA'Ti"lrUl\i>oSls-
FoIUl",lIOIlY '..I 11ll;
~'~'T.i:::i""i::lMi >>"'(.I:i-I,.,~". -j,~u:-~""i
..lill---- H('I(I IolllM
ow, "" """'" 12I01/9b 01/01/97 000007U82
IUMIUA' lOU-LI
nra'NNINO
GALANtE
59.817,10
I,Ob2.28
Al,lOlJI41
l'A,n
INTlRfIl6tIOflTM)E
o\OOlOIOrfW:lPAL
Al,lO\JI4I
1l1!,IIlJIl!,11l
55.75'\,82 0.00
. Thll 11 lmpOllantll1 mlo/mlllon and II being ll,lrnlshed 10 lhe
Inlornal le....enue Ser....ICI. II you all reqUired 10 Ille I reluln, ·
neglloence penally Of other IAnchon may b, imposed on
rOu tllhe Ins delermm8llhal an underpaymenl 01111 rnulll
because you oyelllaled . deduchon lor Ihll mOltgage ml"est or
10' these poln!1 Of because you did not repon Iflll felund 01
Inle1811 on your return, the amount shown m Ihe NET INTER.
EST PAID bOI may nol be lulIl deduC!lble by you on your
Fodoral mcome III relu," llmll Ilonl bued on lhe Call and
....alue ollhe secured prorelty may apply. In addlllon. you mly
only deduclan amounl 0 mongage mlerelllo the ellenl1! wwu
mcuffed by )ou. actually paid by you, and nol relmbulled by
anolher person
(tj[)jNQ BAlAHCE
YOU HAY CDlITACT AGHC OVtR THE INTERNET
AT HTTP./IIMl.AGHC.COIt DR SEHll EHAll TO
CUSTOlER SfRVICE AT CUSTStRYOlAGHC.COH
5.3.11'\ 8EGINNtHG BAl.AHCE 592.66
U.9b 10tAll5CA(M~[CEiP'S 795,99
rot .lII.ls:IOIl:IIl&MlDTI -825.97
(SCROW INnRnT
EN~NO BAlANCE
o
DRaBS lHltREST PAID
I'IIIS 1'1l11'Ailll~1 tj\)!
AllUill1l "IUOIl ~ I All!.
\UIINtEnUl
IUI510'l' IIU'I'OOWNl
II ., ~i ItHIIl! 51
!;I1l)ll'~nr
\fUmrAlDlHf,tfQT
AI.\(W<<Of...IYfAR
PtU5llftrnSI
f.IIOH1Al:\lrAO
tlET ItHEREST PAID ,.
POlHTI PAlO
nnUND OF
OVERPAID INTEREST
5.25'\.20
.
5,25'1.20
DU'I'DOWH ACCOUNT BALANCE
BEGINNING BALANCE
DISBURSEMENTS
ADJUSTMENTS
ENDING BALANCE
BEGINNING BALANCI
ADO INT 61l0RTAGE
LUIlHT,IHOR1AGEf'R[fIAQ
ENDlNG BALANCE
nUL [STA TE TAns PAlO
LA,TE CHARGES PAID
l'TtCh.&AGlIOl.-:IIlI\JN'.lD
LIFE AND DISABILITY
rEESI'AID
FEES DUE BUT UNPAID
-80, 9 REf~O TO ORROHER 59817.1
40b.9 275.b b7.90 54749.7
100.0 100.00 59&49.7
~9lii!L _.__~l'h~ _.u_.~~.Ln 5"~lh 9
100.0 100.00 5""aO.9
905.0 272.9 70.07 59"10.
TAX 59910,9
_" .....19~b --1~"9~
71.18 592b9.1
71.79 54197.5
72.51 54125.0
14125.0
72.88 '-'5t;05Z:1
75.96 55978.7
7".11'\ 55909.b
..1~,n _HOl9.._ ..-
75.22 5575't.0
t~,rIl\\\''''''Uf.) IAl[ I,.htl"'Nl'fi
1~~ll~11~:~~~JrI (tlAnm 1~-::~1I~~\.:J.
-'''-:00-., -'-.'--~i'l. 79 ----- -
bJ.9 !lS.67
0.0 H5.H
___~~ ___~H,U__
0,0 "H.n
b1.9 (.'91),69
-198. 101.05
_._~I,~ _.._..l~l&l-..
blo9 (12'4.97
U.9 40&.95
&1.9 5't8.89
-5',&.5 .. .J, 8.
&1.9 &9.59
bl.9 12b.10
&1.9 188.2b
&1.9 250.22
&i:9 ~;:rI8 --- -r
IRI4CII'Al
1"'0
8'1.)../1
0.00
. "
0.00
795.05
0.00
0.00
0.00
0.00
0.00
021929
UtiArM.l(O t'
lutiDS t u
I CHECK NUMB.. E.R I '
_-.!!.B_li\i3_4,16 _
I PAGE. N-UM.-ii. ER.'I
027.724 .. .
FEDER"L WITHHOLDING TAX STATEMENT
BI-weeklv Compensallon Federal Withholding Tax Cumulallve Tax Withheld
$724.00
. "-"Week! Amouiii"--
$352.00
___~ ___" _~___.. H_+ ______
Wllek 2 Amount
$362.00
.. NOTICE TO ALL UNEMPLOYMENT INSURANCE (UI) RECIPIENTS ..
THE OPTION TO HAVE FEDERAL INCOME TAX WITHHELD FROM UI BENEFITS WILL BECOME AVAILABLE,
EFFECTIVE WITH PAYMENTS MADE ON OR AFTER JANUARY 1. 1997. IF YOU CHOOSE THIS OPTION, THE
AMOUNT OF TAX WITHHELD WILL BE 15% OF YOUR GROSS WEEKLY UI BENEFIT AMOUNT.
THE NEW CHECK STATEMENT FORMAT ABOVE WILL IDENTIFY UI PAYMENT AND TAX WITHHOLDING DETAILS
FOR EACH CHECK ISSUED, AS WELL AS FOR THE CUMULATIVE TAX WITHHELD DURING THE CALENDAR YEAR.
IF YOU DESIRE TO BEGIN TO HAVE FEDERAL INCOME TAX WITHHELD, CALL THE PA TELECLAIMS (PAT) SYSTEM,
OR CONTACT YOUR JOB CENTER FOR FURTHER INFORMATION ON HOW TO OBTAIN A FEDERAL INCOME TAX
WITHHOLDING FORM, FEDERAL INCOME TAX WILL ONLY BE WITHHELD FROM YOUR UI PAYMENTS IF YOU
REOUEST IT.
aOB66341603259710072400Da
I' L - (1/1
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NN _EDWIN L. HElM CO, ItAnnlsDuna.PA, 1710. GGI' 20()--\'52-.851..1
HOURS nATE EARN IN OS OTHER PAY
nEnUl An OVERlIM! REGUlAP OYERTIME OASIS RATE AMOUNT
'I~.'.I)() l'7ol~.~()() I..U,fJ4
CHECK No.2 4 8959
DESCRIPTION
(>l/()t~/9'7
PAY PEAlOD
TOIAlOROSS
F.I . l.
r'll:t'I/HEB
Olt'llF: lAX
l. Ol:t'Il.. r::, J , T .
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1.,9,74
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I)EOUCTlONS TlUS PERIOD
or TAX
UN HlN IJl.IE8
Ot"l'J VI'C
10,O()
1.8.3(,
32,()()
B~MO:e.~1
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Ex H/I3/1 \(1/- 7 II
· Conholnumbol ._._. _____ r= ,,,,,....'"
b EmplQy.....ldenliflcallon number
;,r-,"11\63602
c Emptoy.r'. nAme, adthell. end ZIP CodA
r,'(1I.1E EL.ECTRIC nlr,p(lRA11Iltl
PO BOX 90
630 FIFIH AVENUE
F.AS f HCKEESPORf PA 1 ~,OJ~,.()n'~I)
d Employ.... loclal ncurlty numbe,
200-52-8511
. Employee', name, adcheu, end ZIP codo
DAVID A. FF.LIX
lOll CUHBERlAHI1 DRIVE
CAMP HIll PA 17011'~~19
Copy B To Be Flied with employee's
FEDERAL lex relurn
WA~. ~l. other lXlfT(leI\Mhon 2 r{'df1tRllnCOfllO tnlt Wilhheld
1~~9.60 2~O.')'~
3 SorlAI !ieculity wages
1 r:,;}q .60
i Medicllfc wago!! and lips .
1529.60
1 Soclnl.ecurily lip.
9
nnco Ie pavment
4 Sorinl f>ccurily lnx wilhhckf
'').1.811
6 Metli(,~'lro lnlt wilhhokf
.?~ . 1.~
.-.-.------.-.-
8 Alloealed lips
'D O('flendf'nl cnm~nerlls --~
'2 Ommlils Inrluc1nd in holt ,--
14 Olhm
o .II~, "AUN
5 SUMorr o....ted ~ r,1llIon ll9* -~--
'''1'''''" t1f ll'p 1'f'I~
Del,nee!
~"ulllVl
18 SIIiI EmpIoyo(..I.lol.O. No.
PA I 251463602
.........................-...
17 Sl1~.l9'lI\O...
1':,29 .1,(
1BSIIII"lnoomelal 19locatitynome 20 lDCAlJllIQM,"",1'1c 21 hr....rom.llll
42.8. MUNIC 1529.6l 15.Jr
(l)
i W.2
Wage end Tax
Statement
1996
" NonquAlified pkms
t 3 flee Insh!. tor OOx 1:J
............ .......... ............. ............
Opp8ltment 01 the Trf'R5Ury . 1"lelllal neyenue Servk:e
this Informa"on Is 001110 ftlmishod 10 lho Ifllern.,1 nr.ventlfl SoMce.
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J)~~_~' l."~~~.
b E~e'" kJemlhcl\lkJn number
23-1488'.111
c r:~I~r'. "ameti'~lenJ..fnd ZIP coo.
G.I(. SP NRUulE & SONS.
P.O. BOX 445&
HARRISBURG. PA 17111
II~C.
d Empkl.x..ee'Llloclalleeurlty number
2010-::12-8511
------
. rmptoy~." "1\100. address, nod 111" rorlp
DAvID A. FELIX
10/. CUMBERLRND
CmlP lUll, PR
DRIVE
17011
Copy B To Be Flied wllh employee's
FEDERAL lax relurn
W'!Jl!S'~~',Y"""" 2 r"'tc''tI';!1.':''MllWl,,~..kt
3 Soclitlll'CUf!I'l.!t'RlJ!!S
6225.36
i. MedlCluP Wl!A!.1 And tips
(,225..3(,
7 Social SNtJIIly lips
.00
8 (fviUI('ft Ie payment
.00
11 NOIklllahlir.d,lIi1ns
.00
'3 R"n III..!I!; lor 11In \3
4 Bonn! SCC\lllty tox Wllhhrlrt
385. elf>
6 MPfliCl\l9 tn. wilhheld
Q0.27
8 - Aiii"lcnied!;l;S--- -+
.00
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SCHEDULES A&D
(Form 1040)
("'J'*I,,~oIth.h"Il"" II
1nt..1\tI ~ Ifrrkl I
NlIll1ttf'llho'lfn 011 rorm 10"0
Medioni
ond 1
Dentol 2
Expenses 3
4
Tnxes You 6
Pnld 8
(5.. 7
pno. A. q 8
Interest
You Paid
IS..
png. A.2.)
110111
Personal
Interest Is
nol
deduclibl..
Gille to
Charily
If you mid. I
gin .nd gal I
bonellllor If,
I.' pogo A.3.
Calually and
Tha" LOIIII 19
Job Elpenlll 20
and MOil
other
Mllcallaneoul
Daducllonl
(s..
png. ^.a lor
"lp8nses 10
d.ducl h... )
23
24
25
28
other 27
Mllcallaneoul
Deductlonl
Tolol
llemlled
Deduellone
..I, -./1
T'. .
"
. /,"
Schlldule A-ItemIzed Deductions
(Bchedule B lion bockl
OMD Uo. 154500'.
~@g5
AII.chm,nl 0
6equonc. No. 7
Your 10cl.1 ..eurll.- numb.,
;kXl : S-~: f"/
D
10
11
". h.'i><
Ceullon: Do nollllcludo .''''.'SOS I1l/mbtllsed 01 paid byo'''ols. :~
M.dlcol nnd dOlllnl .'P01'0. ('00 pnq. A.II, . ,. ~
[nllllmounl hom 101m 1040.11111 31, L~.J___.______-::I_ ~.
Mulllply IIno 2 nhovo hy 7.5% (.0751. , , . . .. 3
Sublracllllla 3 hom IIn. 1. \11111. 3 I. moro Ihollllno I enler -0. . . ,. 4
Slnl. olld InCllllllcom. 11,.. . . .J!_ _-1._aJ.5:...'l - ~
n.nl..lnto In... (.00 P"\lO ^'21. . .JL __'l'~:/_ ~:L
".r.onnl propOlty In... . 7
Olh.r In..., lI.t typo nlll) mnollnl ~ . ~
8
Ad,j'linos5 ii,;oug'tio, . , , . ,
Iloml morlOloolllllleslllld 1I011llS IIpOllld 10 you on lonnl098
Hom. mortgage Inllllesl nol "I1"'led 10 you on rom, 1090.11 paid
10 Ihe JlOIson I,om whom y"u hOllght the heme, Illll pege A.3
and ahow Ihal petscn'a 118n!!, Id.nlllylng no, .lId ndd,8S1 ~
............................ ...................................
.~
~
11
. . . . . . . . . . . . . . . . . . . . . . . . . . .. .............. ............ .......
12
Polnln not r.ported 10 you on Form t098. S.o pog. A-3
lor np.c101 rul.. . , , . . , . . , , . . , .
Investm.nllnl.loal. II requlr.d, olloch Form 4952. (S..
pogo A.3.) . . . . . , . . . . , . . . .
Add IInno 10 Ihrongh 13. . , . . . . . . . .
GIIII by cash or check. 11 you mod. ony gill 01 $250 or
moro, noe pogn A.3 , . . , , , , , . . . .
Olh.r Ihan by c.ah or chock. 11 ony gill 01 $250 or mar..
n.e page A.3.11 ov.r $500. you MUST olloch Form B283
Carryovor Irom prior y.or . , . . . , . ,
Add lines t5 Ihrough 17. . . . . . , . .
19.
13
13
14
15
18
17
18
21
22
Casually or Iholllonn(.". Allach Form 4684, (Soe . 0 A.4.)
Umnlmburaod .mployen ..p.nnon-Iob trav.l, union
du.n, lob .ducnllon, .Ic. II r.qulred, you MUlI,T, nttoch ~
Form /1\06 or 2\?6.EZ.,IS.0 pog. A.5.) ~ ,M~r.. 3~\'1 ~
.~'Mn....-:I.SI".u;~'\,,~ 1.1!\'~.r:~!\!'................ ~.
.................................................. 20 --B2!i_
To. prepornllon feos . . . , . . , , . , .. 21
Olh.r e.pen..s-Inv..hnenl, sol. d.poslt ho., .Ie, Unl ~
type and omounl ~... . ~'"
22 ~
Add IIn.n 20 Ihrongh 22. . , , . , , . , ., 23 ~1i_--=-
[nllllmounllromrOlOlI040, hili 32. ~tLJ.';"-"ILlJ.! m~ ~
Mulllply IIn. 24 nbov. hy 2% (.02) . . , . . ,. 26 ~
Subtroclllno 25 110m line 23. II IIno 25 I. mOlo Ihonlln. 23, enl.r .0- 28
Olhor-lrom 11.1 011 pog" A.5. li.'lyp. ond omount .. ~
28 In rOlln '040.II01e 32, ()vnl $lt4,700 (over $57,350 II mOlllnd IllIOIg .epnrolely)?
NO. Vnlll d.dllcllonl. ',olllmlled. Acld Ihn nmollnll In the lor tight cohll"n }
lor III1.s 4 II110ugh 2/. ^I.n, eOllor on renn 1040, linn 34, Ih.larger 01 ~
Ihla nmonnt or your nlnndald dodllcllon. '
YES. Your doduellon mil ho IImlloo, Soo In n A.6 for Ihn nmounllo entor.
ror Pnplrwork noducllon Aclllollc., '" Fo". '040 Inlhucllolll, c.. 110 11U0'
27
~
3~' -U
t1chldulo A (rOtm 10401100S
;;. X Ii / I:J IT II H - q '1
G(;h~lul'l 1\&0 (rOml to.OI 190';
U"ff1f1(IIllhnw" nil rnuu 10.0 Un nol ,nlfll "llIIft anr' lod,lIlf1tUlllr lIun,l"" If ahown on plh&! .lde,
Pnrt I
Inleresl
Income
(5no
png.. 15
"nd 1\.1)
Noll: II vou
locolv8d n form
1000.INI, rnrlll
1000.0111, nr
luhslllulll
Ilnhmu!lIl "om
n luokelAge IIrm,
1i~llh9 'Inn's
flAllln os the
IInym nnd 011101
tho lolnllnlel8!t
ahown 011 thnt
fOlIn
Port II
DIvidend
Income
(5..
pog.. 15
ood 0.1)
NollIlI you
rDcelvod n Form
1000.DIVor
lub.lllul.
slelement f,om
a b,oke,oge
flnn,ll.llhe
fl,m's nomB 01
Ih, poye, ond
enl., Ih. 10101
dividend.
shown on Ih81
10'"1.
Port III
Foreign
Accounle
Dnd
nuels
OMU No. 'Sls.o074 Poge 2
Your IDcl.1 ..cuflly numb"
Schedule B-Interest Bt1d Olvldend Incolne
Alllthmnnl
SfK1\Jftflce Uo 08
~o.I.~~u II0d ovor $400 III _,!,~Ibl.-'~I,!!!!!~ Ille,!!lIo, ~J mu.' e/.o complo/e PSI' III.
1 L151 no~e of pOY"" II ony IlIlorost Is flOlll 0 soller.llnunced morlgogo nlld Iho
buy", usod Iho prope,ly os 0 pOlsonol losldollCO, SOO pogn D.' nnd IIsl this
Inlolesl fl,sl. Also, show Ihol buyo,'s soclol socurlly numbol olld oddross ~
/'
.'.................;,...............'...
...............,0......
/
........Z........................
....:/.::::: ::::.::::::::::::
-.---
Amounl
........................ ....................
1
-
i
,
/
........................, .......,,,.
.............................."...... ......".............................................
............................................................................................
2 Add tho omounls on IIno 1 . , , . . . . . . . . . . . . . ., 2
3 Excludoblelnlolost on sorlol EE V,S. sovlngs bondslssuod nllol 1989 from Form
8815, IIno 14. You MUST olloch For," 8815 to Form 1040 . . . . . .. 3
4 Subtroct line 3 Irom IIno 2. Enlol Ihe losull hero and on Form 1040 IIno 80 ~ 4
NaIll II you had Ol'Or $400 In fl!E.!;s dlvldollds slIdlor oilIer dl.'ribullons on sloc~. u musto/so com
5 lIslllomo of POYOI, Includo gross dlvldonds ond/ol olhel dlshlbullons on stock
hore, Any copilot goln..!1!JlrlloyllOltS nnd norllo.oble dlolrlbullqlls Wil' bo do<;tuclod
on lines 7 ond 0 ~ ...I."'.'1,..iI'.~..!\..(''';\t'i!.f....C-tf':\).I,l.1!t.... n..~!1d1?!.",
'0'" Port III.
Amount
" ('I .i:/.-
............................................................................................
....................................,.......................................................
................................. ..........................................................
.............................. ....................................................,..,.....
...,.......................................................
..............................."..........................
6
.,.............................. ...........................................................
................................ ...........................................................
................................ ......................,....................................
................................ ...........................................................
................................ ...........................................................
................................ ...........................................................
...,............................ ...........................................................
6 Add Ihe nmounls on IIno 5 , , , , . , . . . .
7 Copllol goln dlshlbullons. Enter horo ond on Schedulo 0' , 7
B NonlA.oblo dlshlbullons. (Seo Iho In51, fOl Fornl 1040, IIno 9.) 8
9 Add IInos 7 ond 0 . . . , . , , . , . . .. ...."
10 Suhhoclllno 9 from IIno 6. "nto, tho rosult horo ond on Form lO~O, IIno 9 . ~
'/1 you do nol noed Sc/lodu/e 0 10 ropoll OilY olllor golnl or 108sos, soe 1/10
Ills/ruellons lor FOlm 1040, /1110 13, on 0 e Ill,
II you had ovor $400 of Inlo,osl or dlvldonds at hod n forolgn occounl or woro 0 grantor 01, or 0 tronsforol
to, 0 forolgn husl, you must comploto Ihls port,
'__..._.~.n
'1.LL t'1-
8
:i, i..,/~ it
~,
9
10
11 n At nny limo during 1905, did you hovo on Inler081 In or n slgnoluro or olher outhorlly ovor ollnonclnl
ncctlunt In 0 forolgn cllunhy, such os 0 bonk nccounl, aocurlllos occounl, or othol financial
occourll? Soo pngo D.2 for o.copllons ond filing loquhemonls for Form TO F gO.22,1 . . . .
b II "Yos," onler tho nomo of Iho foreign country ~ ............................ ........................... ~ ~
12 Woro you lho gronlor 01, or tronsforor 10, 0 forolgn trust lhul o.lstad during 1095, Whelhor or not ~ ~
you hove ony bonellclollnlo,eslln It? II "Yes" au md hovo 10 fIIo FOlm 3520 3520.^ 01926 .
For Pepllwork n,ducllon Acl Nollc., III Form 10411In.truclloo.. Bch'dul. b (Fotm 1040)1805
(Se.
pogo 11-2 )
;::::.~:.:::~...."" ALLOWAIUE EMPLOYE BUSINESS EXPENSES 1995
~':m:~I'~ '~~: ~ 1~ :~~~'i\t~.IU=- __ _._ _ _. 0--1 _......,,_ "/,,-,-1 ,,'., \.S1'------I.-l,-,-_L~j~:'LuL~.?: I.lr
.,-: ~ ..,~W~~'lIf1!'.rJ". v.. ," I.,,,:, ..... J "', , "" , 'I' In'p''y'''' Ai ,n... ' ..,.... "J,.n c.".'."..., r", I .... .'" I... "6 flA 17.
I .D..;lt"''''''..d_'-!.:.LG u.l,J,i~~. <..u 'l.b!' ~'I t I,'~.l ~... r1\c_' 1.J..J1__LLJ:l.:J r,r,.\ )__ __._.___ 'd.l:1. ."
\ . Oll,rll~ th. DuU" (lllh, JW 11Wh+ch You I"CIIIII'!I , I"'. ['1'111111I1 k " El1lploye"s hlflphone tlunlbll'
/"f', .,t.'\ .i',\'_VI..!..!i_,.I.\~l!,l!!, '-!.~'\,bn"'\t\-\. .1\...-. ~t..(.Llr'\~'=-!' :-.\:~.l..Mdj._______ _ .l___ __.1.__u.___ .-"____
r~~~~ON DUEl tN.m. Ind .moun,lll Dr ..~ 1'1 J; "d,!, If _\J '!..!~ '\'_.Lt~uJ~1_~!t .!"..:..__.____ __~ _ __. IS _ 8._ .__~
~_~n' 0 _ wonk clon'E. AND UNIF2nM!.~~!~IIII.d_~!, ._c~dll~~~!~.!'~\'m.nl.nJ nol~ulllbl. lor ,vlI)d.)' Ute) _~_ __+_ _ _.5_~~ 00
rAm C 8MAll TOOLS AND IUPPLlES ~.~~~~~ _~,_~ ~~dlllo.'~~~~.!!'~'fmflnl_~~ovld.d bt1he tmploverJ . __~ __:h~1 !._ .-_~
PAnr D pnOfESSIONAL LIClNB! tE~S, IIALPnACTlCE INsunANCE ANO fiDELITY 10ND pn~lIlUllS 0 00
-_. cntqUlrtdl"cond"IonDI~~~.mP!c!t'~~'l_~_._..___.+ ___._____. _-.!1..3_0_ _
~~~_l..~-!~~YU AND MrLtAol crIDn~~.~!.'!! .~D!~ ~~D' Of rA Sch.dul. UE,t _ St!.'n.llucllon.) ~_ ___.___ ~
TorAL EMPLOYE IUIINEBI UPENI~S_~!_P~'." A ~'O"D~!;.!:.~tll hll. And on L1n'lb 01 PA.'OEZ 1 b ~.\t'i. _00
-. PLEASE PnlNT ALL INFORMATION
....1(1(",.""."
"DI""U"", Of flIYIN\II
SPI!CIAl TAX PIlOVISIONS SCHEDUL~
I
Nlme(.) II tho.n on t'DUI PA.40EZ "'Iuln'
1995
Soclll SlcullI)' Numbel:
I I
PLEASE PIIINT.
ntlotl tou tin complel. lhl. tch.dul., tou MUS r ('oITlpltl. Ihe SP WOn)(SIlEI:T on pagl '5
PART I. ellUl/c.lIon 01 Eligibility:
Illnet m)' SPOOtl' hlVI lead lhllnlhucllon. .nd ('(lllif)' Ihall.,n (or "'. III) .lIglblll lor Tu rOlglvflnll.'
SecUon A: FlllnQ el "S", 11I"QIS Dr "M", Mlrrled Filing Seperali Relurn
I 0 I clrlll)' I ptrlOf'lab)' prO'fid,d 111...1 one hili 01 m)' own Tolll Supparlll1 1905 end I 1m ellglbl. for fl. rorglvenelt.
If Mlng "M", tJI"ltd FIlinG SeJlI'II. "filum '/1ler )'our .pou.... Nam. ________ ._, __ __. ~ _ _._ ______ Ind
Soclll SKUllt)' Number I I
2. (J I clftlf)' thlll 1m I d.p.nd.nt of a pellon "'0 I. .Iiglbl. 'Of TII Forglvln..a_ 11m b.lng clllmtd.. . d.pendenl on Ih, P.nnaytvanll I.. r.lurn 01:
Nlm. .ncl Socl.1 Slcurll)' Numbe, I I
Slctlon H: Flllng.1 "J", Me"led end c',ln"ng Ts. ~OrDlyen&.' Jolnlly
3 0 lend m)' 'POUII IClfUty Ihll....II ."h ellg bl,'or Ta. rOlglv.n... end ,1'c1lo fll. a JoInl r^ Schldule SP. AI.o UII Ihl. ,'alullf you file folnll)', but only
on, lPOUII qu.IlIl.. tOf 'a. Fotglytn... Ind th, olher ,poul.l. . d.pertd.nl _lIh no t".,bI. Incom..
Slctlon C: ~lIInD ee "~". Flnsl PI. nelurn 'D' I deceeled Indlvlduel
"lid IhI InltrUCllon1 tOf Ihl, liIing 1IIIu.. I CI till)' Ihll:
.. 0 rh. d.ctdtnll. In Illglbl. Clalmlnl Of In .1~Jlbl. Depend.nl fOf ,.. FOlglven". purpal"
PART II, Numb&t III HOUUhold Members lor T.. ~orglven'U f1urpous:
!.:J~~ lIt IIIQIbIa IOf TI' t: n.... .nl~!!.)!>U AND ~~.. all loUt .llglbl. and Illlng_!J~~ITl~ cl.lm "J", .nl., "2", [!J
D.p.ndlnl'l Nems AQ' I Rlllllenlhlp Soclilllecurlly Nu~ PI. Tidbit IncDml . Is D.pind.nl Filing e
~. PI. 8ch.dull SP7
II you I" c1llmlng ~Uf 'twit .. )'OUr dep'ndt"l, cOfflplfll. lIn. 2.
II loth 01 rou If. .IIOlbl. Ind you .'1 ""nllolnll" 100 N07 COMPLETE LINE t.
t. I=C---~
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., Tal.1 Numb.. ollloUl.~.ld 111mb.... Add lIn.. 1,2 'od 3. Enl.. h"e Ind on lInl II of '0.' PA..DEl, _ ____
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PART III, eefculsllng YOUr Te. Forglven8l1 Credll:
, FlIOIDlIITY INCOME '10m lint 12 of Vt!ur IP wonkllllEET, lIullng IllIng 1IIIut "J" 'l1d cllllmlng r.. rDfglvl"'lIlolnll)', ",111
tI,. TOT Al (JOINt COlUMUJ Uglbltlly Incom. lor YOIl Ind YOIIf Srxm.. If u.lng filing Illlul "S" Blngl., 0' "M" Mlnl.d rUing
S~"lfl" n~luln. or "F", Oltch.td, r1nll "'luln. IInllllllll Ellglhlllly Incom, 110m voun Column.
2. I AN lIAOlllTY I,,,,,, lIno Sol vnul nA.lOEl
3 pmCEIlIAOE or IAN rOnOlVENESS loom I~. ElIglhllltr Incom. Tobl. Dn p.O' II. SOl In.Ioucllo",
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.'!7m"k,'(~ 'rhur1.tn, & ,4ddndn/pd; /hlr/o
AcllJntlal and Adinlnlstrnllvo Consllltants
ann tJn.hnllll"y I"Iolplnw, Sulln 200
Tlnvosn, I'onn.ylvnnln, 1n05~.0970
(2 t 51 631l.3002 T o!ocoplol (2 t 5) 630.1294 1.000-003.3602
I.B.E.W. LOCAL. UNIoN H14j PENSioN FUND
STATEMENT OF BENEI'll FOR:
Dnvld A. Follx
200.62-8611
PLAN YEAn ENDING:
DECEMbER 31. 1996
The boold 01 Ttllstoes 01 tho I.B.E.W. Locnl Union 11143 Ponslon Fund Is plonsod to
plosont yoUt Slelomont of Bonollllot Ihol'Iot1 VODt ondlng Docombet 31. 1996. This
Slotomont tollocls tho Plnn's rocotds rogoldlng your stotlstlcollnlotmotlon end tho
nllochod schedulo Itsts tho sOlvlco thel yoU oOlnod dUllng 1996.
DATE OF BIRtH: 0/01/61
SEX: M
DATE OF HIRE: 9/11196
Service to Docembor 31. 1970
0.0
Service frOIt1 Jonunry 1, 1977 thtough Decotllbot 31, 1994
Sorvlce eotnlld from Jnnunry 1. 1996 Ihrough Decolnhor 31, 1996
0.0
0.2
Totnl Servlco
0.2
Vesting Serlllco
0.0
Vesting I'erollnlnltd
0%
Pleese levleW Ihls Stetomont cDtelully end conlecl Fronk M. Vecceto & AssGcleles
Inc., tho Plnl1's Conllec! Admlnlsttelor. 0112161 638-3682. llhould you heve eny
questions ot notice Ilny dlscropnncles In the Inlollnotlon bolng provIded.
FnANI( M, VAccARO & ASSOCIATES INc.
L \IVY_IO'I
J::.~HltJlr n
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,Jf"",1t ,ff; r~'rrntn &, rV'JJfJr"'/f'J; .rJJlr;
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11"IIF.11I1I ,r; OF ('ONTR] nUT IllNfI
Fllll Tllr; ('1m lOll
,JI\NIlI\IlV 1. l'l'l'i TIIROIJ!lIl llr:cF.t~J\lm 31. 199'i
FF.ldX
~n[) ';~- or.] 1
JJ/IV 111
1\
110NTII EMPWVF.R 1l0llRS CONTR InUT] ONA
10/95 CJ. R BPaNI\UGlJE " nO~1R INC. ]:1.lJ.00 $ 1 '1] .60
1I I'lS CJ. R BraNI\UGI ,E " nONS INC, 1(;'/.00 $ 238,01
1:1/95 (]. R SPONI\IlGl,F. " AONfI INC. 144 .00 $ 20'i.92
MEMBER '1'0'1'1\1, 131.00 $ 616.33
IFlw/96018BO'/
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