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REGISTER OF WILLS OF CUMBERLANO COUNTY, PENNSYLVANIA
Estate of Guy R. Sme Hz
INVENTORY
No. ~ I -q '-I -10 1..3
Date of Death 3/19/94
. Deceased Social Security No. 173-03-B969
also known es
P.,.on.1 R.p,...nl.lly.l.. a. the .boy. EIt,t., d.c....d. y.rily th.lth. 11,m. ,ppllring in the following Iny.ntory includ.1I1
01 the p.,.on.1 ....t. wh."y.r ,ilu.tl .nd .11 ollh. ,"1111'1' In thl Commonwlllth 01 Plnn.yI",nil of lIid Olcea.nt, thlt
Ih. valu.tlon plac.d oPPOllt. IIch i1.m 01 .ald Invlntory rlp'..lnl, II. f.1f vaJu. II of Ih. dll. of th. D.c.d.nt', dlllh. .nd
th.t O.c.d.nt own.d no ,..1111... out,ld. 01 Ih. Commonwlllth of P,nn'ylv.n1. nc.pl th.t which 'PPII,lln. m.morlndum
It Ih. .nd 0' thl. InYlnlory. IfW. y.rlfy thlt th, .t.l.mlnl, m.d.ln this In"lnlolY If. tN' .nd COII.ct, IfW, under.t.nd thDt
,at.. IlIt.m.nl. hlllln Ir. mad. .ubl.al to the p.n.hI.. 01 18 P., C.S. S,olion 4804 ""llng 10 un.worn f.l.lfieatio" 10
IU1hollll...
Plreon.1 R.pr...nl.1iy.:
NItn. 0'
Attoln'V:
G. Raymond Smeltz, Jr.
15
1.0. No.:
Add"..:
T.I.phon.:
Kenneth E. Smeltz
210 So. School
Oa ted
O..cliptlon
1. Cores ta tes Checkin9 #3607-0382
2. Corestates Savin9s #59950-03890
3. Corestates CO #200081406-7711972
4. Corestates CD #2000BI406-7711980
5. Corestates CD #200081407-7711956
6. Corestates CD #200081407-7711904
Value
$ 1,964.16
5,377.74
4,508.02
12,021. 39
4,508.02
12,021. 38
Total: $40,400.71
IAnach AdditIonal Sheets if necellary)
NOTE The Memo,.ncIum at ,ul"',I. aUII.d'I". Comn~llw..Uh of P.nnlyllt.nl. mly, " Ih. .I.etlan of Ih. p.llon.lllpllllnl.u...lI. lncll.ld.
1M v.lue or IKh him, but luc:h IIgu,.. Ihould nol b. ..I.nd.d into Ih. tol.1 of Ih. In....ulory
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
YfAR
1. Rool E.'a'o (Schodulo A) I 11
2. SloQ. and 80nd. (Schodulo B) ( 21
3. Clololy Hold SlocklPortno"hlp Inloro.' ISchodulo CJ (31
4. Mortgogo. ond Nolo. Rocolvoblo (Schodulo 0) ( 4)
5. Co.h, Bank Oopo,ll. & Mllcollonooul Po"onol Proportyl 5)
IScnodulo E)
6. Jolnlly Ownod Proporty (Schodulo II ( 6)
7. Tron,'o" (Schodulo G) (Schodulo II ( 7)
8. Tolol Grall A..o" (Iololllno. 1.7)
9. Fun.ral Exp.n'", Admlnhtratlvl COlli, MI.c.llon,oul.1 9)
Expon... (Sch.dul. H)
10. Dob". Martgog. lIobllillo.. lIon'ISch.dul. I) (101
11. Tolol D.dudlon. (Iolollln.. 9 & 101
12, Not Voluo of Ellol. (IIn. 8 mlnu. IIn. 11)
13. Chorltoblo ond Governmonlol Bequoll. (Sch.dulo J)
14. N.I Voluo Sub eel 10 Tax (IIn. 12 mlnu.lln. 13
15. Amount allln. 14 loxablo ot 6% rol.
(Includ. valu.. Irom Schodul. K or Sch.dulo M.I
16. Amount alllno 14 toxabl. 01 15% rolo
(Includ. valu.. Irom Sch.dul. K or Sch.dulo M.I
17. Prlnclpol 'ax duo (Add tox 'rom IIn. 15 and 'rom IIn. 1601
18. C"dlll Spoulal Poverty Cr.dlt P,lo, Paym.nts
+ +
19. If IIn. 18 I, gr.at.r than IIno 17. .nl.r ,h. dlfforonc. on IIn. 19. Thl.i. tho OVERPAYMENT.
SO
20. If IIn. 17 I. gr.at.r Ihon IIno 18. .nlor ,h. diff.r.nco on IIn. 20. Thl.b Iho TAX OUE.
A. Enl.r the Int.rO'1 on th. balone. due on IIn. 20A.
8. Enl.r 'ho 10101 of IIn. 20 ond 20A on IIno 208. Thb I. th. BALANCE DUE.
Mak. Chock Payoblo to, R.glll.r 01 Will.. Ag.nf
. ," ,", ,...IIISUUTO ANSWIRAU QUUllONS ON IEVlISUID. AND TO IlCHICKMAlH...' ',""
Und., penaltl.. of ptrlury, I d.dar. thot I hay, ..amln.d thlt '11u,", InClu~ln ac(.)mpan~lng schedul.. and Ilat.menll, and 10 th. b.., of my knowl.dge and b.li.f.
1111 lru., corrld and complel', I d.do,. that 011 1101 "'01. has blln }~rt 01 "VI morklt "plllJt..,P.daro 10 of "po", other than th. p.non "pr ~.nt In h
bONd on IIlnfo,mallon of which "por., hal any knowl.dg.. O~ ~...~ ,HA~~/~ )~. ...~. ~.1 'J..-'
I U A D ,v~ ,..." /7011 II _I.
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3310 Market St., Camp Hill, PA 17011 D~~J/f"
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.01 DAn'O'DIATHAPTU 12131191 CHICKHIU
.. A 'POU'AL 0
POVII" CUDIl II CLA'MID
PILI HUM..I
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COUNIY CODE
J:~_l"~
",.~U;
COMMONWIAltH 0' 'INNSYlYANIA
Df'A.tMINT 0' I\YINUI
DIPT. 21060
HARRIUUIIIO. 'A 17 21.0601
91./
/olJ
NUMBER
.11
Smeltz, Guy R.
..
11 Round HIll Road
Camp Hfll, PA 17011
Cumberland
o 3. R.malnd.r R.lurn
Ifordot.. 01 d.ath prior to 12.13.82)
o 5. Fod.rol E,lol. Tax
R.turn R.qulr.d
_8. TOlol Numb.rol Sol. O'po,it 8000'
173-03-8969
3/19/94
10/15/98
CCWfll
01 1. Orlginol R.'urn
o 4. lImitod E,lol.
[11 6. D.codont Di.d To.lol.
,.}.,r,.'f
Timothy C. Wa990ner
Waggoner, Frutiger and Daub
3310 Market Street
Camp HIll, PA 17011
761-1222
40,400.71
8,789.00
( 8)
$40,400.71
312.75
(11)
(121
(13)
(14)
9,101. 75
31,298.96
(15)
$31.298.96
lC ,06.
1.877.94
(16)
lC .15.
(17)
1.877.94
Ollcount
Inter. It
ChC[~ hell' if you OIl' ft..'(IUl!'iling U H.fund of your ovv,pnY01unl.
(18)
(19)
$ 1,877.94
(201
(2M)
120B)
$ 1,877.94
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK ("') IN THE
APPROPRIATE BLOCKS.
YES NO
1. Old decedent make a transfer and:
a. retain the use ar Income of the property transferred, ....................................... X
b. retain the right to designate who shall use the property transferred or Its Income, X
c. retain Q reversionary int.rest or .........11.............9.................11........11..............
d. receive the promise for life of either payments, benefits or care' ....................... X
2. If death occurred on or before December 12, 1982, did decedent within two years
preceding death transfer property without receiving adequafe consideration' If death
occurred after December 12, 1982, did decedent transfer property within one year of
death without receiving adequate considerationV ................................................. X
3. Did decedent own an 'in trust for' bank account at his or her death"'.................... X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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(OMMONWIAUH O' rlNNl't'lYANIA
lNHllltANCI tAl InUIN
_"IDINT DICIDINT
SCHEDULE F
JOINTLY-OWNED PROPERTY
IITATI OP
PILE NUMIIR
Gu R. Smeltz
Joint tonantl.).
NAMI
A, G. Raymond Smeltz, Jr.
ADDRESS
15 Round Hill Road
Camp Hill, PA 17011
RELATIONSHIP TO DECIDINT
son
I. Kenneth E. Smeltz
210 South School Lane
Lancaster, PA 17603
son
C.
Jolnllv-awnod p..porty.
ITEM LmlR DATI
POR TOTAL VALUE DICD'S DOLLAR VALUI OP
NUMliu JOINT MADI DISCRIPTION OP PROPERTY OP ASSET '"' INT. DICIDINT'S INTIREST
TlNANT JOINT
1.
See attached
TOTAL (AlIa In'.r on IIno 6, Rocapitulollon) S 40,400.71
(If more 'poce it nttrJ.rJ In.,rf orJc/ilional.h..,. 0' lam. III1J
--....-._n.'",..,.,."."',.,"__'._A.',""'" "","""""""",,,-,,,'o,,,,,~,>~..;f,,,,,,,,,,,,,~~;<,,".-{;7,1>""'''~"""""".",.",,,,,,,,,''''0''
PENN8YLVANIA INHERITANCE TAX RETURN
B8TATE OF GUY R. 8MELTZ
CONTINUATION 8CHEDULE
8CHEDULE F - JOINTLY OWNED PROPERTY
Letter
for Date
Ite. Joint Hade Total Value Decd's Dollar Value of
Nuber Tenant !l2!ni DescriDtion of PrODertv of Asset , Int. Decedent's Interest
1. A 12/66 Cores tate Checking
. AIC 13607-0382
Date of Death Value
per attached letter $ 3,928.:n 50' $ 1,964.16
2. A 5/12/87 Corestates 8avings
. AIC 159950-13890
Date of Death Value
per attached letter 10,755.49 50' 5,377.74
3. A 10/27/92 Coreatatea CD
. AIC 1200081407-7711956
Date of Death Value
per letter attached 9,016.04 50' 4,508.02
4. A 10/27/92 Coreatatea CD
. AIC '200081407-7711904
Date of Death Value
per letter attached 24,042.77 50' 12,021. 38
5. B 10/27/92 Corestatea CD
~' . AIC 1200081407-7711972
rg. Date of Death Value
\' per letter attached 9,016.04 50' 4,508.02
,
, 8ee Note (1)
"
~ 6. B 10/27/92 Corestates CD
l; . AIC 1200081406-7711980
Date of Death Value
per letter attached 24,042.77 50's 12,021.39
Sub-total $40.400.71
.A11 assets were jointly owned for more than one year prior to death or were purchased with
assets so owned.
..'--"i"''-;'-''.,.':''f.
'CoreStates FtnsnClal Corp
CPA & Clovatnmenl
Raquasl Deparlmenl
PO Box 8667
Phllsdelphls PA 10101..~67
215973 4619
Banking Subsld/arlas
CoreSlales Benk NA
. PhiladelphIa Nalional Benk
. CoreStetes Fllst PenMylve",e Bank
. Core States Hemtllon Bank
New Jersey Nallonal Bank
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Cor.Stst..
september 20, 1994
Timothy C. Waqqoner
waqqoner, rrutiqer , Daub
certified Public Accountants
3310 Market street
camp Rill, PA 17011
RB. Estate of GUV R. Smelts - 000. March 19. 1994
Dear Hr. waqqcnerl
Xn response to your letter of August 30, 1994, please be advised
that the decedent held the fcllovinq account(s) with our bankl
{
,
ACCOUllT TnB: Chackinq CD
ACCOUllT RO: 3607-0382 200081406-7711972
TXTLII. GUY R. Smal ts GUY R. SlIal ts
G. Raymondy smelts, Jr. Kenneth B. smelts
DA'l'II opmnm: 12/66 2/28/94
DOD BALAJlCII: $3,925.98 $9,000.00
ACCRUJID XIIT: 2.33 16.04
'1'O'fAL . $3,928.31 $9,016.04
109' XIIT. PD.: $ .00
ACCOUJl'l' 'l'YPB: CD CD
ACCOUJl'l' BO. 200081406-7711980 200081407-7711956
TXTLII. GUy R. Smelts GUY R. Smelts
Kenneth E. Smelts G. Raymond smelts, Jr.
DATil opmnm. 2/28/94 2/28/94
DOD IIALAIICII: $24,000.00 $9,000.00
ACCRUBD XH'l': 42.77 16.04
TOTAL : $24,042.77 $9,016.04
ACCOUJl'l' TnB: CD
ACCOUJl'l' RO. 200081407-7711904
TXTLII. GUy R. Smelts
G. Raymond smelts, Jr.
DATil opmnm: 2/28/94
DOD BALAJlCII: $24,000.00
ACCIlUJID XIIT: 42.77
TOTAL : $24,042.77
10" XIIT. PD.. $ .00
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Co,eSlal89 Bank, N A (Philadelphia National Bank and CoreSllll'l F,r,l Penn.ylvanil B.nk~
Hamilton Bank . Now Jersev Nallonal Bank . Co,aState. Bank 01 Delaware. N A . Phil.dllphlllnllfnallonal Bank
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..tate of GUY R. S.elt.
Sept.aber 20, 1'94
Page 2
&CCOUII'l' ~.I
&CCOUII'l' 110 I
'l'X'l'LII1
Savin9.
5"'50-03890
GUY R. S.elt.
G. Raymond Smelt.,
5/12/S7
$10,70,.03
415.415
$10,755.49
Jr.
DAD OPIDIBDI
DOD "..,....110.1
ACCIlVllD DI'l'I
'l'O'faL I
10.. Xlft'. 1'0.1
We tru.t that we have been
of assistance to you in this matter.
Sincerely,
~~~ature
COI G. Raymond smelt., Jr., Executor
/.d
IN REPLY REFER TO:
IIAIISARA EDWARDS TEL 121fi.!l7:J.<\6111
GOVERNMENTsEmncesDEPT.
Fe: OHIQ2.1()o16
P. O. BOX 6867
PHILADELPHIA, PA 19101
r:::";;
Smeltz, Guy R.
ITEM
NUMBER
A. Fun.ral Exp.nsesl
1.
.
.
uv.Ult ... V.eIJ
B.
A.
C.
'1.
2.
3.
A.
5.
6.
7.
8.
< ~ .
~
COMMOHWIAlYH O. 'INHlYlYANIA
INHUlTANCI we _maN
IIIIDINT DICIDINT
$CHEDULI H
FUNERAL EXPENSES,
ADMINISTRATIVE com AND
MISCELLANEOUS EXPENSES
PI.a.. Print or T
DESCRIPTION
AMOUNT
Groff Funeral Services
Funera 1 1 unch
Funeral flowers
$7,220
125
19
1.
Admlnllt,atl... Casfst
"'nonol Rap,....ntatM Comml..lon.
Sodol Sacvrlty Numb., 01 "'nonol R.p....ntatl",,:
Y.or Comml..lon. paid
2.
A"omey Fa..
150
Kluxen & Newcomer
3. Family Exempllon
Claimant Relatlon.hlp
Add,.... 01 Clalm~nf at d.e.d.nt'. d.oth
St,..., Add,....
City
Stat.
Zip Cod.
Probata Fa..
25
MI.e.llan.au. Exp.nsesl
Waggoner, Frutiger and Daub, CPA's Estate Tax Services
1,250
TOTAL (AI.o .nlor on IIn. 9, Recapitulation)
III mo.. .pae. I. nHd.d, In..rt addlflanalsh.." 0' sam. sl...)
S B,7B9
lh'
"'Ulll"II~II' .
CQMMONWUU" Of "NN'''.NI4
.......llANCI \U I"UIH
"'lOIN' OfCIOI"'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES AND LIENS
PI,o'l Print or T
PILI NUMB lit
n TIOP
Guy R. Smeltz
ITIM
NUMBllt
DISCRIPTION
AMOUNT
2.
VISA, Balance
Bell of Pa., Final Balance
$ 302.11
10.64
1.
TOTAL (Aho onlor on IIn. 10, Rocopllulollon)
(II more 'pac. II n"d.d, ins.rt oddiliona' .huts 01 .ame sI,..)
$ 312.75
- I
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COMMONWIAUH Of "NM,nVANIA
.......,ANCI1A1 UTUtH
__I
SCHEDULE J
BENEFICIARIES
ISTATI O.
PILI HUMIIER
Guy R. Smeltz
.
ITIM
HUMBIR
HAMI AND ADDRISS O' BINEflCIARY
RILAnOHSHIP
AMOUNT OR
SHARI O' ISTATI
A. Ta.abll 10quIIIII
I.
G. Raymond Smeltz, Jr.
15 Round Hill Road
Camp Hill, PA 17011
Kenneth E. Smeltz
210 So. School Lane
Lancaster, PA 17603
son
50%
2.
son
50%
\TIM
HUMIER
NAME AND ADDRESS OF BENEFICIARY
AMOUNT OR
SHARI O' ESTATE
I. Chorlloblo and Go.ornmlnlal BlqU11I1l
I.
TOTAL CHARITABLE AND GOVERNMENTAL 8EQUESTS IAho onlor on IIno 13, Rocopllulollonl S
(If mo.. .poco 10 o..dod, lOll" addlllaool .hool. of ,amo .1101
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LAST WILL AND TESTAMENT
OP
GUY R, SMELTZ
~
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I, GUY R. SMELTZ, of the Clty of Lencaster, County of
Lancaster and Commonwealth of Penneylvania, declare thle to be
my laet Wl11 and Teetament and hereby revoke all former Wl1let
ITEM 1. I dlrect the payment out of my eetate of the
expenees of my last 111nees, funeral and burlal.
ITEM 2. All estate and lnherltance taxes which may
become peyable by reaeon of my death wlth reapect to any property
comprlelng my gross estate for tax purpoees, whether or not such
property paeees under thls my Wl11 and whether Pederal or State,
wlth any lnterest or penalty aeeeseed thereon, shall be pald
out of the prlnclpal of my eetate, Juet as lf euch taxee were
my debtsl and no pereon ehall be requlred to refund or to relmburse
any part thereof. Taxee on future lntereete and remalnders may
be prepald.
ITEM 3. I glve, devlee and bequeath all the rest,
reeldue and remalnder of my eetate, of whatsoever nature and
whereeoever eltuate, wlth the rlght to accept the aerne ln klnd,
abeolutely and ln fee elmple, to my wlfe, MINNIE A. SMELTZ, or
her helrs or aeslgne,
ITEM 4, Should my wlfe predeceaee me, I glve, devlse
and bequeath the eald resldue to my lseue, per etlrpee.
ITEM 5. I nomlnate, constltute and appolnt my wlfe,
MINNIE A. SMELTZ, executrlx under thle my lest Wl11 and Testament.
Should she predeceaee me, fall to quallfy or cease to actl then I
nominate, constltute and appolnt my eone, a. RAYMOND SMELTZ, JR.
and KENNETH E. SMELTZ, or the eurvlvor of them, executore under
thle my laet Wl11 and Teetament ln her etead. Should both of them
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predeoeale me, rail to qualiry or ollse to aotl then I nominate,
oonatitute and appoint my oldest living grendohild rrom esoh or my
laid two sons to eerve together ae exeoutore in the stead or my
sane or the survivor or them,
ITEM 6. No exeoutor Ihell be required to furnish bond
in any Jurildiotion ror any realon.
EXECUTED THIS I/J 7'H day or 'J".... ""/
, 1979.
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Signed, aealed, pUblilhed and deolered by the Ibove
Teatator, OUY R. SMELTZ, ae and ror hie lalt Will Ind Teltament,
in the prlsenoe or UI, who, at hil requelt, in hie prelenoe, and
in the presenoe or eaoh other, have hereunto eubeoribed our
nlmes al witneleel thereto.
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We, auy R. Smeltz , K. L. Shirk, Jr,
,snd Barbara L. Reiet , the Testetor/
Testetrix and the witneseee, respectively, whose names are signed
to the ettached or foregoing instrument, being first duly affirmed,
do hereby declare to the undersigned authority that the Teetator/
Testatrix signed and executed the inetrument as his/her last
Will and that he/she hsd signed willingly, and that he/ehe executed
it as his/her frae and VOluntary act for the purpoees therein
expreased, and that each of the witnessee, in the preeence and
hearing of the Testator/Testatrix, eigned the Will as witnea~ and
that to the best of our knowledge, the Teatator/Teatatrix wae at
that time eighteen (18) yeare of age or older, of eound mind and
under no conetraint or undue influence.
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COMMONWEALTH OP PENNSYLVANIA
COUNTY OP LANCASTER
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SUbscribed, affirmed to and
acknowledged before me by
, the aforesaid Testator/
Testatrix, end witnese~~
reepect~~h1e 10
day of , 1971.
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RECEIVED FROM.
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ACN
ASSESSMENT P:'
CONTROL 11;,I
NUM8ER
AMOUNT
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WAGGONER TJ MOTlW C
3310 MARKET 9T.
101
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CAMP HILL PA 17011
'010 HI"
ESTATE INfORMATION.
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II
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el-1994-1013
B9N 173-03-9969
CUMBERLAND
REGISTER OF WILLS
m TOTAL AMOUNT PAID $1 . S?7. 94
RECEIVED B~
MARV C. LEWI
REGISTER OF WILLS
REMARKS
G. RAYMOND SMELTZ, JR.
SEAL
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v1V01547 EX AFP 112-94*
COMMONWEALTH Of PENNSYLVANIA
DEPAAtH[Nt or RElJtNU[
IURtAU OF INDIVIDUAL TAXEI
orPT. n0601
HAARIIIURG. PA 17ua-06D1
;r;- / -10
cI
ACN
101
NOTICE OF INHERITANCE TAK
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT Of TAK
FILE NO.
DATE OF DEATH 03-19-94 COUNTY CUMBERLAND
NOTE I TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS FORM WITH YOUR TAX
PAYMENT TO THE REOISTER OF WILLS. MAKE CHECK PAYABLE TO "REOISTER Of WILLS, AGENT"
REMIT PAYMENT TO:
,
,
TIMOTHY C WAGGONER
WAGGONER ETAL
3310 MARKET ST
CAMP HILL PA 17011
;';
DATE
02-15-95
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
A.ount He.Ht.d
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ....
iil'v: i5'4"riif-AFP-iiii:94Y-iliifici--ci,n-NHiiiifAiici-YAX-jiPPR'AisiH€tn-.--,\[.i."ciiiAiici-iiri----------- - -----
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SMELTZ GUY R FILE NO. Zl 94-1013 ACN 101 DATE OZ-15-95
APPROVED DEDUCTIONS AND EXEMPTIONSt
8,789.00
9. FUn.~.l Exp.n.../AdM. COlts/HiIC. Expan... ISch.dul. HJ (9)
10. Oabt.'Hortg,ga Liabiliti../Llana (Sch.dul. II 1101 312.75
II. Totol Doductlonl 111)
12. Hat Value of Tax R.turn (121
IS, Charitable/Goyern..nt.l aequa.t, ISch.dule ~) CIS)
1~. ...t V.lu. of Eat.t. Subject to T'M: (4)
NOTEt If an aBBeBBmBnt waB iBBued previouBly, 1ineB 14, 15 and/or 16, 17 and 18 will
reflect figuree thet include the total of abl returns aBBeBBed to date.
ASSESSMENT OF TAXt
15. A.ount of Lin. 14 .t Spou..l rat. 115)
16. Aaount of Lin. 14 taxabl. .t Lin..l/CI... A rat. 1161
17. A.ount of Lin. 14 t.xabl. .t Collataral/CI... 8 rat. (17)
18. Principal Tax Du.
TAK RETURN WASI I X I ACCEPTED AS FILEO
R!SERVATION CONCERNING FUTURE INTEREST 0 SEE REVERSE
APPRAISED VALUE OF RETURN BASED ONt ORIGINAL
1. R..1 Eat.t. ISch.dul. A) 11)
2. Stock. and Bond. ISchedul. B) (2)
5. Clo..ly Held Stock/Partner.hip Intar..t (Sch.dule C) (5)
4. HortDaDe./Not.. Rec.lvabl. (Schedule D) (4)
i. C.sh/Bank D.po.ltl/Hi.c. Parlonal Prop.rty ISchedul. EJ Ii)
6. Jointly Owned Proparty ISchedule FJ 16J
7. Tr.n.far' (Schedule 0) 17J
8. Total A...t.
TAX CREDITS I
PAYMENT
DATE
lZ-06-94
DISCOUNT 1+)
INTEREST 1-)
RECEIPT
NUMBER
MM913Z53
.00
I CHANGED
.00
.00
.00
.00
.00
40 .400.71
.00
IS)
40 ,400.71
q .101 71i
31.298.96
.00
31.298.96
.00
31, 298.96
.00
K'OO.
K.06.
K .15.
IlS)
.00
1,877 . 94
.00
1 ,877 . 94
AMOUNT PAID
1,877.94
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
.,:
1,877.94
.00
.00
.00
. IF rAID AFTER DATE INOICATEO, SEE REVEHSE
FOR CALCULATION Of AOOITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN U, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREon" ICRI, YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS..