HomeMy WebLinkAbout94-00943
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No. 21. 94 - 943
Estate of Benjamin W~ West, Deceased
, ,
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW,
NOVEMBER 9,
1994, in consideration of the petition on the
reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that
the instrument (s), dated
MAY 22, 1979
described therein be admitted to probate and filed of record as the last will of Benjamin W.
West; and Letters Testamentary are hereby granted to Benjamin F. West.
.' '
. .7ff't ai?"~ 1",f9ni~
RY C. LEWIS . ",'
, Register of Wills
FEEs
Probate, Letters, Etc.
,
Short Certificate,s ( )
Renunciation
X-Page
JCP
,TOTAL
Flied
$'
$
$
$$
$
NOVEMBER 9, 1994
40'.00'
3.00
3.00
5.00
51.00
Randall L. Hartman, Esq.
~upreme Court ID # 6a732
438 Markt'lt Street
PO Box 33
Lemoyne, PA 17043~OO33
"
(717) 761.8490 '
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,Mailed letters and order to attorney on 11.9.94.
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Thl~ I" to l'l'rlHr thai till' Informatloll IU'fl' gl\('1l 1\ t'tlrrtTlly t IIpird !rom till mlglllall'l'rtlflt'illl' III d('alll dill}' IlIl'd wllh lIH' a"
l.1Il':11 nqtl"ilrilr Tht' orIHIIl,11 n'rllllrilll' wIll Ill' Illl\\':lrd('d 10 llll' Still<' \'llal Ht't'tll'll~ I Hll('(' lor Pl'rIll.lIH'\I1 111l1lJt.
WARNING: It is Illegal to duplicate this copy by photostat or photograph,
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1749739
IIi: li \ \'1:\'\
No. DOliI'
COMMONWEALTlI Of PENNSYLVANIA. OEPARTMENT OF HEALTH' VITAL RECOROS
CERTIFICATE OF DEATH
OEct!OINllhtl ......" IUl
Bonjwnin W. Woot
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sr.
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lUll flU kUlolII"
SOCIAISfCUf\ITYNUl,4BfA
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Lowol' Allen Twp. Oumb.~o.
Ino. ~24 llunUllol Avo. Lemoyns
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OESCfUBC ttONIIIJURYOCCURAE(I
1. Roal EllalolSch.dulo AI I 1)__
2, Slack, and Bond. 15ch.dul. B) ( 21
3, Clallly Hold Slack/Patlnorlhlp Inlor.,1 (Schodulo q (31
4, Martgago. and NalOl Rocaivablo ISchodulo 01 I 4) ( ,
5, Ca.h, Bank Dopa.III & Mi".lIanoaUl Po"anal Praporlyl 5) __':II :z.Do.~
(Schodulo EI
6, Jalnlly Ownod Properly ISchodul. F)
7, Tra"lo" (Schodulo GllSchodulo L)
8, Talol Orall Allo"llalallin.. 1,7)
9. Funeral E)I,penuu, Administrative COlh, MlscellaneouI I 9)
Expo"o. (Schodulo HI
10, Dobl., Morlgogo Liabililio., Lio" ISchodulo I)
11. Tolal Doductlont (lolollinOl 9 & 10)
12, Nol Valuo of E'lalollino B minUllino 1 \1
13, Charitablo and Govornmenlol Boquo.l. ISchodulo J)
14, Nol ValuoSublo" 10 Tax llino 12 minUllino 13)
15, Amounl of IIno 14 10' able 01 6% ralo
(Includo volu.. from Schodule K or Schodulo M,)
16, Amounl ollino 14 lo,abl. 01 15% ralo
{Includo valuo, from Schedulo K or Schodulo M,I
\7, Principal 10. duo (Add 10.lram lino 15 and from Iino 16,)
1 B, Crodit. SpoUlal Povorly Crodil Prior Paymonll
------..----- + ----- +--
19. If Ii no IB it groalor Ihan lino 17, onlor Iho dilloronco on Iino 19, Thl. IIlho OVERPAVMENT,
110
20, If Iino 17 i. groalor Ihan lino lB. onlor Iho dilloronco on lino 20, Thl.I'lho TAX DUE.
A, Enlor Iho inloro.1 on Iho balanco duo an Iino 20A,
B, Enlor Iho 10101 ollino 20 and 20A on Iino 20B, Thh illho BALANCE DUE.
Mako Chock Pavablo tal Rogl.,.. 01 Will., Agoot
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. . BE SURE TO ANSWER ALL QUESTIONS ON REVERSE 510ft AND TO RECHECK MATH"" '. ,
Under Plholtle. of perlury. I dlclar. thol I hay, uomlned this relurn, Including accompanying Ich.dul.. and Ilol.mlnt., and 10 thl bill of my knDwl.dg. and b.ll.f,
II II IruI, correct and complete, I dlclare Ihol all fllal tllal, hOI bun r.por1ed ollruI market value, Declaration 0' pr'parClt oth.r than thl plnonal r'pr.tlnlcllvl I,
baled Ilnformallon of which preparer hOI any knowledgl.
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~,'.,~ INHERITANCE TAX RETURN
'1~'@J~ RESIDENT DECEDENT
COMMONWW1H O. PlNNlYlVANIA (TO BE FILED IN DUPLICATE
OEPAUMENl m llvENUE ) 1\ I
HAllllrJ:& ~~nI2'.0601 WITH REGISTER OF WILLS COUNTY CODE "'-"- .L1l../>,R q
\N + "iA DMiOtLe "<ITIALI ~ 3$'~ L.t>.r\t..".r' s.\~-e.-\-
10CIAI$E~U~fYNUMI!l e'~J~\EA H A 0 i" t-ew.~M, PA- \?tl-{.3
17-'1. -0 - b82..a~ -3D:'~3
1. Original Rolurn 0 2, Supplomonlal Rolurn
CfP'
NUMBER
POI DATil 0' DIATH Anll 1213119 1 CIIlCK Hili
I' A I'OUIAL
I'OVIUY CIIDIT II CLA1!IIID 0
PILI NUM."
03,
05,
Romalnder Rolurn
(for dolo. of doalh prior 10 12.13.82)
Fodaral e.lato To.
Relurn Roqulred
_ 8, Talal Numbor of Safo Dopa.1t Bo...
o 4, limlled Ellale 040, Fuluro InlorOlI Compromilo
(for dolo. 01 doalh allor 12.12.021
o 6, Docodonl Dlod T 011010 0 7 Docedonl Malnlalnod 0 living T rutl
IAllach copy 01 Willi _ IMach copy of Trull)
ALL COIRIS'ONDENCE AND CONfiDENTIAL TAX INfORMATION SHOULD BI DIReCTED TOI
''&5\ MAlL~ ~~$N. S-\-N'i1-
--- l-e1N\'ll1 ~. PA ~'7'DY'!>
oetJ\o...w\\N t=". _we.~T
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(12)
(13) .
(14)
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ctH~(k tl(~'rc if you arc 'C(ful~\Iin9 I, H.luml of yOlt, overflPvmcnl
(18)
(19) _____
(20)
(20A)
(208)
Riv,llOO IX> (j 1,911
~,~ ~ INHERITANCE TAX RETURN
~~:I(l~ RESIDENT DECEDENT
COMMONW,AIT" O. P1jjNlVlVANIA (TO BE FILED IN DUPLICATE
DIPA' MINI 0' ',VI NUl
"A"II~J,~' l~nll8.0601 WITH REGISTER OF WILLS) COUNTY coDe yeAR
\1-.le~+ 'i.' :DLIINII'AlI ",I Ai 3S"~ L.'() ..."."s.\.t-eoe.~
I ~'Tr-~~~,'oul1r--71ioT1m-'. L.eIMbjrVt I PVCI- \~'l.3
I ~'\ ~O\ - 2..S.2.6.-l_\ ~3o -t31 3~2.1-~ C"'!L 0u.v.~\CVJo.)-
o 2, Supplemenlal Relurn 0 3, Remainder Relurn
(for dol II of deolh prior to 12,13,02)
o Aa, Fulure Inlerlll Compromhe 0 5, Federal E1lale Tax
Ifor dalll of dealh aher 12.12.82) Relurn Required
o 6, DlCedenl Died Tlllale 0 7, D"odent Malnlalned a lI,lng Trull _ 8, Tolal Number of Safo DepollI BoxlI
Allach cO y a' Willi IAllnch copy of Trulll
ALL CORRISPONDENCE AND CONfiDENTIAL TAX INfORMATION SHOULD BE DIRECTlD TO,
'3 'F:T- '55"\ MAL.o~~'e~ 'S..\-N'~
I II~~~~t\N.__...__~e~___ l--eW-'1l1 M', PA {tDY~
-{(7 I 77:l-Z:..1.C?c}
1. Renl Ellote ISchodulo AI ( 1) __.
2, Slack, and Bond, ISchodule BI ( 2)_
3, Clollly Hold SlocklPallno"hlp Inlerlll ISchedule C) (3)
A, Morlgagll and Nolo' RlCol,ablo ISchodule D) I 41 _
5, Ca.h. 8ank Dopo.llI & MIICollanooUl Po "anal Properlyl 51 _-..-.:l, 'Z-Do, oJ" __
(Schedule EJ
6, Jointly Ownod Properly ISchodule F)
7, Tranlfo" ISchodulo G) ISchodulo l)
8, TOlal Grall Allollllolallinol 1.71
9, FUlleral E.pen..'. Admlnhlrallvo Co." Mhcollaneoul I 91
Expenlll ISchedulo Hi
10, Oebll, Morlgoge llabllll;.., lion. ISchodulo I)
11. T 0101 Deduction. Ilolalllnol 9 & 101
12, Nel Value of Ellale llino B mlnulllne 11)
13, Charlloble and Go,ornmonlol BoquOlII ISchedule J)
14, Nel Value Sublectlo !a, Illno 12 mlnu, line 13)
15. Amount olUne 14 taKablo 01 6% role
Ilncludo 'a lUll from Schodul. K or Schodule M.)
16, Amounl of lin. 14 la,ablo 01 15% role
Ilncludo ,aluOl from Schodule K or Schedulo M,)
17, Principal la' due (Add 10' 'rom line 15 and from line 16,1
10, Credlll SpoUlal Po,olly Crodll Prior Paymenll OIICounl
hm. ._..__.__._. + __h. + __..
19, If line 18 h groaler Ihan line 17. onler Ihe dllleronc. on line I~, Thh 1,Iho OVERPAYMENT.
1110
20, If line 17 II groaler than line 18. onler ,he dllleren.. on line 20, Thlllllhe TAX DUE.
A, Enler Iho Inlerll' on Ihe balan.. duo on line 20A,
8, Enler the 10101 of line 20 and 20A on line 208, Thll II ,he 8ALANCE DUE.
Make Chock.Pavable tOI Regl.tor af Will., Agen'
.. BE SURE TO ANSWER ALL QUISTION. ON REVERS. SIDE AND TO RECHECK MATH.. ;
Under ponolll.. of perlury, I docloro Ihol 1 h." "0 mined Ihl. rllurn. I..ludlng accompanying "hodulll and Ilalemonll, and 10 Ihe bill of my knowl.dge and b.lle/,
II h tru., (olted and COmplete. I d.clar. Ihat aU real tllal. has been '.ported ollrUlf morhl value. DeclaratIon of prepare' other than th. plrlonal r.presentatlve It
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fOR DATU 0' DUTIl AnlR '2/3' '" CHICK HIli
IP A IPOUIAL
'OVIIlY CIIDIlII CLAIM I!, 0
PILI NUMIII
NUMOER
1. Orlolnal Relurn
o A, limited Ellalo
I 6)_
I 7)
lot Z,DD.O 0
5";c.,ctC. C;) Q
( 8)
(101
51 Cc~O, iN
('"D~~;' L.
as
,
(11)
(12)
(13)
(14)
(151
)( ,06 a
(161_
)( ,15 a
117)
Inlerlll
C"cck hote if you me fccIUl.....tinU n ,duml of yOlll OVltfJlUvrnl..'nl.
(18)
(19)
120)
(20A) _
(208)
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (,., )IN THE
APPROPRIATE BLOCKS. " "
1. Old decedent make a transfer anel:
a. retain the use or Income of the property transferred, ..........,.........................0..
b. retain the right to designate who shall use tho property transferred or Its Income,
c. retain a reversionary Interest or ...................................,....,.........,.................
d. receive the promise for life of either payments, benefits or care~ .......................
2. If ,death occurred on or before December 12, 1982, did decedent within two years
preceding death transfer property without receiving adequatE! conslderatlon9 Ifdeath
occurred after December 12, 1982, did decedent transfer property within one year of
death w,lthout receiving adequate consideration V .................................................
3. Old de,cedent own an 'In trust for' bank account at his or her death?.....................
, IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF,THE RETURN.
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COMMONWIAITH 0' P1NNIYWANIA
INHllllANCI1AlC IIlU!N
mlOINT OICIOINT
5CHIDULI H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
'Bet.) o..w,\tJ _rJ.
ITIM
NUMBIR
wes+
DISCRIPTION
AMOUNT
--
1.
Puntlalllep.nlu,
Wlu~~",h,...\o.M.., t-vN~""" \ ~OMej -..ellle... .
, 'R.. \ \\....~ G .ee.~ e.~ Me..1'U,'J .
5;t:lBO.oo
{q\D,DC
A.
B. Admlnlltratlv. COlli,
1. Perianal Repr'lOntatlv. Cammllllonl
Social Security Number 01 P.nanal ReprelOntotlvlI
V.ar Comml"lons paid
2. Attorney F...
.3. Family Exemption
Claimant Relationship
Addre" of Claimant 01 dec.dent'. d~alh
Street Addre"
City State Zip Code
4. Probate Fe..
C. Mllc.lIan,oul llep.n..... .
1.
2. "
3.
4.
" 5.
. 6.
7.
8.
TOTAL (Allo .nter onlln. 9, R.capltulatlon) $
(II more Ipac. II n..d.lI, Inl.rt additional Ih..tlof lam. III'.)
PURPOSEill'
NOTICE,
PAYltENT,
REFUND (CAli
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To fulfill tho roqulrtotntl of "'tlon 2140 of tho Inhorltonol ond Eltete Te, A.t, Aol II of 1"1. (71 P.I.
loeUon 21401.
Dtt.ch thl top portion of thl. Noticl end .ubllt with your Ply.."t to thl A"I.t.t of Willi printed on the
rlv.r.. tide.
~. "-kl chick or toniV' ordtr Plv.all tOt REGISTER OF WILLS, AOENT.
All Plv-ent. rlc.tvld .hell flr.t b. applied to any Int.r..t which .Iy be duI, with any t..llndlr applied to thl tlM.
A r.fund of I tlM oredlt, which WI' not rtque.ttd on the tlM r.turn, 'IY bl ,.quetted by co.plltlng In "Appl10ttlon
'or Rlfund 0' Pennulvantt Inhtrltencl and e.tlt' Tile" (REY~U1S)' AppllCltlon. .t. 1",llabl, It the OffScI 0' I
the A.,ht,r of N11l1, any of tM 25 RlvenUl Dhtrlot Of,lcI. or bv clllJn, the 'Plolt' 24-hour ..,IWlrlnt IIrvlel
nu.ber. for for.. orderlngl In PlhI'lIvlvanlD 1~lIIOO-16Z.20S0, auttlde P,nn,vlll...l, end within locll
H,rr.lbur. Ir.a (717) 117-1094, TOOl (717) 772-2252 CH.arlng I~..r.d Only).
OBJECTIONS, Any p.rtv In Int.r..t not ..tl.ft.d with tn. eppr.l...-nt, allowanc. or dl~.llowlnc' pf Deduction. or .....talnt
of tiN (Including dl.count or Int.r..t) .. .hown on thl. Notlcl .av obJ.ct within .Ixtv (60) day. of rec.lpt of
th1l MoUa. bVI
..wrltt.n prot..t to thl PA D'Plrt-.nt of R.v.nu., laard of ApPIII', D.pt. 211021, H.rrllburg, PA 17121-1021, OR
ull.oUnt to have thl ..U.r det.ralnld .t the audit of the Iccount of the p.r.onll tlpr...ntaUv., OR
..IppI.1 to thl Orphan.' Court
ADNIN-
IITl1ATlYE
COlIRECTlON!Il
DIICOlMT I
INTEREST'
FlOtuel arror. dllcov.rld on thl. ......-.ot .hould be addr...ed In writing tal PA D.p.rt-.nt of A.venue,
Buraau of Individual T.x.., ATTN' P~.t A.......nt R.vl.w Unit, DEPT, 280601, Hlrrllburg, PA 17121-0601
Phone ~717) 717-6505. S.. P..- S of the bookl.t "In.tructlon. for Inh.rltenc. Tlx R.turn for I R..ldtnt
OIclldent" (REV"liOl) far ar'l .xplanltlon of .dllnlttr.Uvltv uorroottbll error..
If InV ta. due It p.ld within thr.. (5) calendar lonth. Ift.r the dac.dant'. death, I flvl percent tile)
dl.count of thl t.x paid I. a110N1d.
Int.rllt 11 chlrttd b.glnnlng Idth flr.t dlV of dellnquencv, or nine (9) tonth. Ind ana (1) day
froe thl dttl of d..th, to thl dati of Ply-.nt. Tlx.. which bIG'" dlllnqu.nt blfor. Janulrv 1, 1982
bltr lnt.rl.t .t thl r.t. of .IN (6lC) Plrcent p.r annua cal~ulat.d at a dlllV r.t. bf ,000164.
All t'XII which bee... delinquent on or after JlnUlrv 1, 1912 will bltr Int"..t .t . r.t. NhJch wll1 vary froa
c.lendar v..r to c.lend.r y..r with th.t r.t. announc.d bv thl PA O.p.rt-.nt of R.venue, ThI epplletbl.
Interl.t "t.. for 1982 thrOUlh 19M "1'
'tW tnt.r'lt Rlh O.ll~ tnt.r..t F.otor ~ tnt.rut R.b RlJJv tnt.f.lt FAotor
1912 lOX .0'0541 1916 lOX .000174
illS 161 .000451 1917 9X .000147
19" IIX .000501 1911-1991 IIX .000101
1915 m .000U6 1991 9X .000147
1991-1994 1X ,000191
.~Int'r..t I. e.leul.tld .. folION"
INTlRElT . BALANCE OF TAX UHPAID X NUNBER OF DAYS DELINQUENT X DAILY INTERElT FACTOR
".Anw NoUe. ll1ued Ift.r the tlK bMOM' delinquent will raft"t an Intlr..t cllcullUon to flft.1n (1S) daVI
bevond the det. af thl .....lMnt. If P.y.."t It IIdI .fter thl Inter..t COlP\lt.tlon dlt. .hawn on thl
Hotlc., addltlone1 Int.r..t IUlt be ellculatld.
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Wills
'9~i FEB 22i~11':4 8
Register of Wills
Cumberland County Courthouse
Carlisle, PA 17013
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CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: Benjamin W. West
Date of Death: 1anuary 30,1993
Will No. 1994-00943
Admin. No,
To the Register:
I certify that notice of beneficial interest required by Rule 5.6 (a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on
March 2, 1995:
Name
Address
Benjamin F. West
351 Louther Street, Lemoync, PA 17043
Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except
None
Date: March 2, 1995
~~~~O'~v..
Signature
Randall L. Hartman, Esq.
438 Market Street
Lemoync, PA 17043
(717) 761-8490
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Counsel for personal representative
(.~.. ".._;~,.,.. ..- ..... ,,,'0 _'''_;''
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, ~1547 EX AFP (12"94*
;ll"R~~AlTH Of PENHlVlVANIA
Df:PARTHfNT Of REvtHUE
IUREAU Of INDIVIDUAL TAMES
Df:PT. Zl06DI .
HARRISIURG, PA 17121-0601
NOTICE OF INHERITANCE TAX
Ap~RAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAK
ACN 101
~oil
DATE 05-01-95
DATE OF DIATH 01-30-93 ~~b~T~O. CUMBERLAND
HOTEl TO INSURE pROpER CREDIT TO YOUR ACCOUNT, SUBHIT THE UPpER pORT1OH OF THIS FO~H WITH YOUR TAK
pAVHENT TO THE REGISTER OF WILLS, HA~E CHECK pAVAILE TO HREOUTER OF WILLS, AVENT"
REMIT PAYMENT TO:
BENJAMIN F WEST
351 LOUTHER ST
LEMOVNE PA 17043-522B
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
AMount -R.!.ltt'~-==j
CUT ALONG THX8 LINE ~ RETAIN LOIlER PORTION FOR YOUR RECORDS ....
il i V: lAW" ilf" A F p'r 1'2.....94 T"Niifi crop" i"N'Hiiiii Aifcii" 'fAx' APpii'iiiiiii1iNr; - ALreiwANci .iili..........."""...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF WEST BENJAMIN W FILE NO. 21 94-0943 ACN 101 DATE 05-01-95
TAK RETURN WAS I (X) ACCEpTED AS FILED
RESERVATION CONCERNING FUTURE I~TEREST . SEE REVERSE
APPRAISED VALUE OF RETURN BASED ONI ORIGINAL
1. R..l E.t.t. (Sch.dul. A)
2. Stock. ~d Bond. ISchodul. I)
S. Clo..\~ H.ld Stook/p.rtn.r.hlp Int.r..t (Schodul. C)
4. Horte..../Not.. R.o.lvobl. ISch.dul. D)
i. C..h/lonk D.po.lt./HI.c. p.r.on.1 prop.rt~ ISoh.dul. El
6. Jolntl~ Ownod prop.rt~ ISoh.dul. Fl
7. Tron.1.rl (Soh.dul. G)
ll. Toto! Au.to
I CHAHO~ ()
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III
121
Ul_
(4)
IS)
C61
(71
:...,
100 :t:
,00 hI
,00 .--.)
.00
,
4.200.00 .,
.\j I 00 1 '.
I. . -- lJl
(.J c,
.00
(ll)
4,200.00
APPROVED DEDUCTIONS AND EXEMPTIONS I
9. Fun.ro! EKpln.../Ad.. Co.to/Hllo, E.p.n... ISoh.dul. HI 191
10. Dobto/Horte'" LlobUIU../Llon. (Soh.dull Xl 1101
11. Tot.1 D.duotlon.
12. N.t V.lu. 01 T.. R.turn
IS. Ch.rlt.bl./Oov.rnftRnt.l a.qu..t. (Schedule JI
14. "-t V.loo of E.t.t. Subj.ot to T..
5,690.00
.00
111 )
1121
(U)
(14)
Ii. ~Qn no
1,490.00-
.iiii
1,490.00-
NOTE I
If .n ........nt WI' i..u.d prlviou.ly, linl. 14, 1S Ind/or 16, 17 .nd 18 will
r.fl.ot figur.. thlt inoludl the tot.l of ~ rlturn. ...I..ld to d.tl.
ASSESSMENT OF TAXI
Ii. AMount of Lln. 14 .t Spou..1 r.t. Cli)
16. AMOUnt of Lln. 14 t...bl. .t Lln..I/CI... A r.t. CI61
17. Aoount of Lln. 14 t...bl. .t Coll.t.r.I/CI... . r.t. (17)
II. prlnelp.1 T.. Du.
.00 K .00.
.00 X ,06.
.00 K ,15.
IlllI
.00
.00
.00
.00
TAX CREDnS,
pAYHENT
DATE
RECEIpT
HUHUR
DXSCOUllT It I
INTEREU 10 I
AHOUNT pAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
.00
.00
.00
,00
. If PAID AfTER DATE INDICATED, SEE REVERSE
fOR CALCULATION OF ADDITIONAL INTEREST.
C IF TOTAL DUE IS LESS THAN 81, NO PAVHENT IS REquIRED.
IF TOTAL DUE XI REFLECTED AS A "CREDIT" (CR), YOU HAY aE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
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