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Home My WebLink About97-06329 .~ ~ ~ ~ '? .~ ~ ~ ! ~ , , ~ " " 'I d 1 ,I II " I" 'I " , , I, I, I" j) ;1 ;l ,.. 1 'I ;' , " ,'''i " ;'1 I' " " ,) l.lI " 'I , 'I " , Ii 'j I ,,, I '., jl , , I I q. , , 'i ..., , , ....) " t " c-.. , 0- " ~, " " " " , j" I, !" iI'; ,., " ,I " -:' ~.)~ wI.,} .C)(') " , " " , , ',I '" , , , ' , I,', , ~ '1 ' )'. {k(' d(}ptl 1/1:14t!'!' ~ .:ll'f .;.J;.-!l.."tf!,/ 1';7 , ~fi" '-.n~"/ , . /2, ,? 71 rri' i'~~~ "'~'!-<f:f#<' ........ q ~~ ,? , .'1 " " I, , q H ii ;' , " , , I,', Jl'.,' HANNAH ADKINS, IN THE COURT or CONNON PLEAS CUMBERLAND COUNTY, JilmNNSYLV.ANI~ NO, 97 - ~329 CIVIL TmRN ptJ\,INTIrr v, GARY EDWARD ADKINS, OEll'lIlNDANT IN OI"ORCIIl PRAECIPE TO TRANSMIT RECORD To the ProthonotarYI Transmit the recor.d, together with the following information, to the Court for the entr.y of a divorce decreel 1. Ground for divorce I irretrievable breakdown under Section 3301(c) of the Divorce Code. 2; Date and manner of service of the complaintl On December 4, 1997, Acceptance of Service by Defendant. 3., Date of execution of the affidavit of consent required'by Section 3301(c) of the Divor,ce Code: By Plaintiff"October 28, 1999; By Defendant, October 28, 1999. " 4. Related claims pending: None 5, , Date Plaintiff' 5 Waiver, of Notice in ~ 3301 (c) divorce , , was filed with the Prothonotary on October 28, 1999. Date Defendanr,'s Waiver. of Notice in ~ 3301(0)' divorce was filed with th~ Prothonotary on October 28, 1999. 7hm.M~. 41U Tl10mas D. Gould, Esquire " Attorney For Plaintiff, ' " ' ',- en il; ..:1 ~ . j', ,::: ~1:' ,,', r',.t" , ('1",; , ,. tI ~ j '~ . , ."., " .., 'j.r: (,) ;~-j 1:11 " l.",=) : rii 'I_ .- ,.l,;~ " ;:." :ilr.iJ ..1. dILl. "':', ,} , fl. I:) '., C;j ( , ' , , , , , , d , 1,.- 'I ",1 ," I,',; '0 .J ,,:, "", J.,; fl,' I,.' ~;. ~ 'rl. ! J ~:.I , 'i,:, I' ;'I""l('!,) l.::U.. /.: ,} oJ ~ j .... ~ 1 .~ .,~ r~ ~ " 'o:t "H ~c;:...,~ e. '^ ~ - I IIJ' q' {~.r 11.,," \o::t.. ,1)1 ,-1. ~ I'j' [,-' i' I' (,l ~ I ; l. ~ ,Q 'i..:l 1..,) 'J' <Co:) ~ l_.\ ~ '.' .'" ~..::) ..... r~ en itl -~-~--- ~_.~__~_t-------~~ ~-~-_.-..;._. ,i " ...; ,.. .... ~ P ..11 ~. '-'Xi - ''l;,t" r-J -...u I""- ..... Q rl ~ ,(,1 ~ '~ ~ ~ ,_;..u.n. -~! o ...J :J ,"g~8R ~j ~ II! it III l . 't In 'l ItClVl~~ o (.J ~ P r) ~u)~IflIii~ , ~ ~ ~,~ ~ o N ~ J: oJ} I- w.....~_ .....---- ----......-.---......- ,. ,I .. HANNAH ADKINS, I IN THE COURT OF COMMON PLEAS I'LAINTIFF I CUMBERLANDCOUNT~, PENNSYLVANIA I ,NO. 97 - G32.1 v. I CIVIL Tl!:RM I GARlC EDWARD ADKINS, I IN DIVORCE DEFENDANT I COMPLAINT UNDER SECTION 3301(0) OR 3301(d) OF THE DIVORCE CODE IN DIVORCE 1. The Plaintiff is Hannah Adkins who resides at 351 Stumpstown Road, Mechanicsburg I Cumberland County, l'ennsylvania 17055. 2. The ,Defendant is Gary Edward Adkins who resides at 6318 Forrest Ddve, Mechan,icsburg, Cumberland County I Pennsylvania 17055. 3. ,'rhe l'laintiff and Defendant have been bona fide residents of the Commonwealth of pennsylvani~ for at least six months immediately prior to the filing of this Complaint. 4. The Plaintiff and Defendant were married on December 11, 1976 in Suffolk CountYI New York. 5. There have been no prior actions of divorce or annulment between the parties in this or any other jurisdiction. 6. The marriage is irretrievably broken. 7. The Defendant is not a member of the Armed Services of the United States or any of its Allies. 8. The Plaintiff has been advised that counseling is available and that she may have the right to request that tne Court require the parties to participate in counseling, -. 9. The Plaintiff requests this Honorab~e court to enter a decree in divorce. " ~m'l.vJb. &,.(/ Thomas D. Gould Attorney for Plaintiff I.D. # 36508 2 East Main Street 'Shiremaostown, PA 17011 (717) 731-1461 Fax 761-1974 I verify that the statements made in this Complaint 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. '" ~l' 1fI:'t..nAI(LiL ~ >/i:'~'1G1 Hannah Adkins Date:_~ , ' >. ,n' '.. fr; I", "/, .. ~', .' j.,. oo r') ~~..O! 1,/ , I"~ , , , ;;r; , (, " '''-. f"j ,I,' I;';) , , .,;...... , .. , " J,I./ i.1 , , 1.1: " ~ , , , "'\ I (. "11 , .J " " ',; " \1 ~ .W ~h tr- (t: I,; " 1.-, .. i:', ~II ~ , I !:'J , " ~:; f'" ' , l;" I.~ i ,I, " t,'o ui 1.1)/ , I '" ~ . l\J I:j', , , I.t I, I," l'Iri ( , I ( ,_~ " I 1.:.; " ,'h ,I l.) m u , , HANNAH ADKINS, Plaint::I.tf v.. IN TUII COURT Oil' CCHION PLIIAS Oil' cMmlllRLl\ND COtlN'rY I PlIINNSYLVANIA NO. 97-6329 CIVIL TIIRM 'I GARY lIlDWAlW ADKINS I Defendant: IN DIVORCIll KaJYER OF NOTIcm OF INTENTION TO REOUEST IllNTRY OF A DIVORCII DmCRIIlm UNDmR ,SIICTION 3301101 OF THm DIVORCII CODm 1. I consent to the entry of a final decree without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I ,will. not be divorced until a divorce decree is entered by the court and that a copy of the,decree ,will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are subject to the penalties of 18 Pa, C.S. Section 4904 relating to unsworn falsification to authorities. DATED: ' / () J;;.. 'i? /99 ( I H1~~ a~' Hannah Adlc:l.n. I ',I, , " ,I .~ fr.: r' /J,I( " , fl.lJ I~'j , , C'l 1..,1 "':1' \'; (.oJ (' , ' :1.: .... " , It I I,: I " ~ 1:-::' ~'" I, " , <.1 ';-1 U, 01 , 1111/ II". ,I r: ,) ',' , ' , , HANNAH ADKINS, PUUNTXFF IN THE COURT OF COMMON PLEAS Cm-mER.LJ\ND COUNTY, PENNSYLVANIA NO. 97 - 63,)," CIVIL TERM IN DIVOllCE v. GARY EDWARD ADKINS, 'DEl"ENDANT ACCEPTANCE OF SERVICE I I Guy Edward Adkins I accept service of ,the, Complaint In Divorce in the above captioned matter. Dated: 7'J ec..r~..v,,\ ~ Qr 4-rJ '1. '17 ~ Gary Edwa d Adkins 4 ~ (l! ...clE:" ~...4r' _ ~ r)ft' Mechanicsburg, PA 17055 DEFENDANT &S) ,~ hurV!::.f- f)"./v~ " ", ,.1 , " " HMNM' I\PKINS, Plaintiff , , I I , , , I IN '1'118 COUll'!' Ol" COMMON 1'1,1;;1\6 Ol" CUMO~:IH,I\Nf) COLJN'I'Y, r~,NNS'iLV^NII\ CIVIL ACTION - LAW NO. 97 - 6n') CIVIC, 19 IN, IHVOllCf:, VB. GI\IlY 1;;DWI\RD I\DKINB, Defendant S'~ ^'!:\!!L!HillE!~: p/\'r1;;r I\C'1't V.J~I'n;~ I 12/30/.28 " , _ecg!lo~nic Cl?illll!.,.Ult~.li'-rl.~Ldj,J:'..~.c.till.....f.or.c.P.r.e.tr.J.LllB' LLf},'11 ~ '. ~~1(:, ~L~\~\~L):;'..f.).._t~~..,J..S~L,~.._:_~-, ;,..-... ./" ~\6.ji._.._ )JftQ,l~h?!6JJ!t4..:){2.LkQL!--b~&1L,~.\---, ~,;:rf),~~I11' cl ,a ~~.. ~ 7::,':', /..,tl'(''''/,'f..I,('','4\t. /L',l."I,- ~.'f,U._lifl fci~-;"I\r .L~'-.LXl ,.. ,,:"!..,[iA'-!:).IIJ )"::.-C{!/j..!U ,~/..1 (";-,,,,) H~. . ''f;7'"-;. I 0. 7>r II,' I ,', "tt; .'", ( " i ,fri}I,'I"" ,I ,/ ), '1 ~,,,,,I/J)II,tI /{7~',\: I, t~~/l, ;{.J"I,.,..,,), " "'~ Ii /1 ,'J/i ~ ....':.._ L.._,-..~ ;~'__t;jI'L:!:_...'....~_,(Vj...J..."!L~'.O'n,-,L!~L/.J.:..L'_!..J:c.!....JL I...) V"t (I.e. , ' r'l) 1,It .. l~ ,.1 G..~ ".r"'/; ,I, ,1/"/1.,11,(-:'" \.I,lllJllt/,!11 (/I.:.,112"I'_f. ((((A( j;" .' ,.,., (.I .r". ",/1/"",,,1:(,, tlo'!'1 /,t, , .A ", I ,1.1t./l}t!Lt,l,.(,! --~~---~~~-- -.;;:'I(II-'~~-' ~-:--:')~,;:T-~;' -l,c~";-:-;:~l---::;'!t7:-,[;C'l~i'_':_2";:-7i-;-'i~;'\~~- ;Zl~~-.;- -~1 .--, /J ,,,/.,. In, J,/J",/ "C?I-".,: 1),1/-",'.1~"'r1"( -~-----_.. JlJ4('i;"~1-;'~'( tlFl'~~";';;:;' O:~/,.;.~;;;~~~,[~.., ../11 ~/~_ /JW.~ ,C'tlf:,:-v~'-:!:.~...:_,.. ". ',_____1____ , , u" ..... .__.___....."'T"_~. ".-.--. ._.__.._~-..._,. ~... , " , , ~k OFFICE OF DIVORCE MASTER CUMUEfllAND COUNTY COURT OF COMMON I'I.EA6 9 Nonh HonovQr 61rool Corllslo, PA 17013 (717) 240',6535 I. Robert IlIcker, II Divorce Mesler Treel olD Collfer all Ice MBneger/Reporlet We.t Shore 697.0371 Ex!. 6535 January 12, 1999 Thomas D. Gould, Esquire 2 East Main street shiremanstown, PA, 17011 Gregory R. Reed, Esquire 2423 North Third street Harrisburg, PA 17110 REI Hannah Adkins vs. Gary Edward Adkins No. 97 - 6329 civil In Divoroe Oear Mr. Gould and Mr. Reedl I I received a copy of an answer and counterclaim filed on behalf of the Defendant. The counterclaim raised the economic issue of equitable distribution. Consequently I since an economic claim has been raised in the action, I am going to proceed on the basis that grounds for divorce are not an issue and direct the filing of pre-trial statements. In accordance with P.R.C.P. 1920.33(b) I am directing each counsel to file a pre-trial statement on or before Monday, February 1, 1999. Upon receipt of the pre-trial statements, I will immediately schedule a pre-hearing conference with counsel to discuss the issues and, if necessary I schedule a hearing. Very truly yours, E. Robert Elicker. II Divorce Master NOTE: Sanctions for failure to file the pre-trial statements are set forth in subdivision (c) and (d) of Rule 1920.33. THE ORIGINAL PRE-TRIAL STATEMENT SHOULD BE FILED IN THE MASTER'S OFFICE AND A COPY SENT DIRECTLY TO OPPOSING COUNSEL " HANNAH ADKINS, I ,IN THE COURT O~ CCMMON P~EAS OF " Plaintiff I CUMBERLAND COUNTY, PENNSYLVANIA I CIVI~ ACTION - LAW VB, I I I NO" 97 - 6329 CIVIL GARY EDWARD ADKINS, I Defendant I IN OIVORCE NOTICE OF PRE-HEARING CONFERENCE TO I, Thomas O. GQuld Gregory R. Reed I Counsel for Plaintiff I Counsel for Defendant A pre-hearing oonference has been scheduled at the 1 Office of the Divorce Master, 9 North Hanover street I carlisle, Pennsylvania, on the 5th day of May, 1999, at 9:30 a.m., at which time we will review the pre-trial statements previously filed by oounael, define issues; identify witnesses, eKplore the possibility of settlement and, if necessary, soh'edule, a hearing. Very truly yours, Date of Notice: 2/15/99 E. Robert Elicker, II Divorce Master 'I 2 EAST MAIN GTlTEET SIIIRI'MANIITOWN,"~ 17011 'lfiOffttlS''.D. qOllra ArrOf/NEY AT ~AW 171717:II.UOI fAX 701,1074 , , January 31, 1999 E. Robert E:Ucker, rr Office ,of the Divorce Master 9 North Hanover Street Carlisle, PA 1,7013 " Re: Adkins v. Adkins No. 97-6329 CIVIL In Divorce Dca r Mr. El.icker: Enclosed please Hnd 1;'1aJ,nUff's pre-trial statements. I look forward to your pre-hearing confar~nce. ' Ver.y truly youvs/ ~/).~ Thomas D. Gould enr::losure ce. Grogory R. Rued, Esquire Hanl1ah Adkins' " " I, , Ii 'I I' ,I} ;! ~ ';I , J...-............-_,...;.-.._.~~.~~.............-~,.........:.....__.._.._-~__,~t-........;.. 'I! ;,...~. ~! " 0' ...J ::> , 0 o ~ ~ " ~cn ~ it 10 ~ci~~~~ , ?l U) ~ iii ~ i- :i <t: ~ ~ ~ " ~ I[ N ~ o - I: iJi I- II, -, ',( " I, 'I '" .. .' " , , . LAW OfFICE \,)1' THOMAS 0 GOULD " I J,-', /-'f 'I I/~( '? '. ), (.. 4./..-~< . i."r""'..J . Arr(Jlnl~Y~-, ^I LAW 2 !:N?Jr ,..lAIN ~'illHTI ;iHIIH H^~hl{)';'''~l, I'^ 1/1.111 /1/ /-'1 I..\fil HANNAH ADKINS, IN THe COURT or COHMON PLmlS CUMBlIlro..ANP COUNTY; PlIiNNSYLVANIA NO. 97 - 6329 CIVIL TlIlRH PLAINTIFr v. GARY EOWARD ADKINS, Olllll'lllNDANT ;IN DIVORCE PRE-TRIAL STATlIlMENT On behalf of PlaintHf, 8squire, does hereby file the consideration of the court: Hannah Adkins, Thomas D. 'Gould, following pre-trial statement for 1. Marital Assets: assets of the parties. Attached is a listing of the marital 2. Expert Witnesses: Conrad M. Siegol, or one of his actuaries, to provide an opinion as to the net value of the Plaintiffls Federal pension. Mr. Siegel's report will be provided upon its completion. 3. available witnesses amend the Lay Witnesses: Based on the limited information made by Defendant, Plaintiff does not intend to present any ot[ler than the parties. Plaintiff reserves the right to witness list as additional information becomes available. 4. The following is a list of the exhibits to be entered into evJ.dence: a. Income tax returns for the last ten years. b. Pensionappraisah c. Marital home appraisal; if necessary. d'. Personal property appraJ.sal, if dispu'ted. e. Credit card invoices related to Defendant' s business for the past 5 years. f. Joint financial account information for' ~ast 5 years. ! MArU'I'M. PHOP8R'l'Y PLAINTIFF LISTS ALL MARITAL PROPERTY IN WHICH 8lTH8H OR BOTH SPOUS8SHlW8 A Lk~()AI. OH EQUI'I'ABI.8 IN'I'EI~EST INPIVIPUALI.Y OR WITH ANY OTH8R PIiJRSON AS OF 'l':'I~l PA'I'E b~' S8PARA'l'ION OF 'l'H8 PAH'l'I8S (pecember 1996)1 DESCHIP'!'ION OF PROPElR'l'Y , NAMES OF ALL OWNERS VALUE VALUATION DATE ADDIT IONAL INFORMATION LIENS OR ' ENCUMBRANCES In~M NO. 1 I'l'8M NO, 2 Milrital Home 351 Stumpstown Rd Mechunicsburg, PA 1993 ~'ord van 103,000 miles Hannah & Gary AdkIns Hannah & Gar~ Adkins $118,400.00 $7,400.00 August 1998 May 1998 Purchased in 9/90 for $93,000.00. Since 12/96 Wife has' Made al,l. payments In 'p,ossession of Hannah Adkins , Mortgage Payoff $90,000.00 at separation $87,000.00 Current pay~off Nbne " DE:SCRI 1?'l'rON Oli' I?ROI?I!:R'l'Y NAME:S Oli' ALL OWNERS VALUE VALUATION DA'fE: ADDITIONAL INIi'O~MATION LIE:NS OR ' E:NCUMBRANCE:S DE:SCRIPTION Oli' I?ROI?E:RTY ['l'li:M NO. :2 n'E:M NO. 5 1900 li'ord 'l'ruck ChQcking Account I?NC Ha'nnah & Gary Adkins 'Hannah Adkins $2,000.00 $700.00 January 1999 January 1999 In possession of ~ary Adkins OpQned after Separation None N/A I'l'E:M NO. 6 ITE:M NO. 9 Saving~ Beet - PNC, Term Life Ins w/E:R 'I , NAME:S Or' Hannah Adkins Hannah Adkins ALL OWNERS , VALUE: $2,500.00 $60,000.00 VALUATION January 1999 January 1999 DATE:' ADDITIONAL Opened after No eash'value INIi'ORMATION separation , LIE:NS Ort N/A N/A E:NCUMBRANCE:S INCOME AND EXPENSE STATEMENT OF IIANNA II AIJI{ INS SSN 116 ,~_, 62~jlJ DRW DATE 12/31/90 THIS STATEMENT MUST BE FILLED OUT (II you are sell.employed or II yov are salaried by a business or which you are owner In whole or In part, yov must also fill oul the Supplementl' Income Slltlment which appears on the lasl page or Ihls l"come Ind Expense Stat.mlnt.) , INCOME (al WagesI6.'ary FAA /IBG Int Airport Middletown PA Employer & Address / JobTIt/elDescrlpllon IIlrway 'l'ransportat ion System Special ist Pay PeriOd (weekly, bl.weskly, monthly) 8i -WoeltJ. y , GroslS Pay per Pay Period ..".........................".................,..................................'....,..............u,.......... $ 2.4, 20.04 Payroll Deducllons: Federal Withholding 1'..........,....$ Social Security .t""~.~...!r.H,r..t;1....S Local Wage T8X ..........................$ Slate Income Tax .......................$ Retlrftment ..........'.......................,$ Health Insurance .............."...."..$ Other (specllylG.};'.Q.IIJri...I..1.f.u,$ Thri rt Say tn.g~...P..l.a.ll,$ La bo r Un i Ol)....R.~~~.".......$ 374.38 35.09 24.20 67.76 1 fi 1 .111 fiq.fifi 24.111 11 'I. 24 26.59 Net Pay per Pay Period ......................................................................................................................... $ 1 . 2 '7 1 . .1~ , (b) Other Income Inlerest/Dlvldends ......................5 PenslonlAnnvlty .........................$ Social Securlly ...........................5 Renta/Royallles ..........................$ Expense Account .......................5 Glfts............,................................5 Unomployment Compensation .$ Workmo~'s Compensation ........$. Tolal, Other Income .......................$ Week Year Month S $ S $ S $ S $ $ $ S $ S $ $ $ $ $ INCOME ANO EXPENSE STATEMENT OF 1..,lIy 111I11'" IlIlImtnll made In Ihls lneo.... Ind Ea""nl' Sill.. menl Ir. Uut and correcl.. undtflland lhal J.IN Ilatem.nll "",In , I.. mid. IUbjtcl 10 I". .....111.. 01 '8 PI.C,S, 4804 ,.lIl1ng 10 unlwo.n 1IIIIIIc.ollon \0 lulhofltltl, 0..., l7" '''Intltl or Dtr.ndIni PROPERTY OWNED Checking Accounts ..,..,..- Descrlpllon. PNC Ollnlt lI.tuI 600.00 Owner,hlp' H W J 5' 5 5 5 5 S 5 S S S S S S --- ---- ,..."" PNC Oanlt --.- 2~1I00.00 Savlngl5 Accounts H"f""" ....,...... --- Credit Union ,.."............111 --- ...H,......'..."II ---.. Stocks/Bonds ".."..,,,.....,, "'"""',,,,,," J:Jl ;::scumpstown Road. Aeal Estale ""'....II.IIHtIt'" ........."'......".. Macnanlcaburg, PA 17055 --- . --- 110,1I00.0<L-... __ ---- Other ....'''11......'111''''...,.'.'. ---. .,............1,.,.............. --- Total, Property ......"..'.'.,....., ---- INSURANCE Compeny Policy No. cover.ge' H W C Hospital ",,,.,........,........... Medical .......,."...'............. HeallhIAccldenl............., Health Amadea (HMO) Dlsablllly Income ............ Other (dentel, elc,).......... (' H . Husband, W . Wife, J . Jolnl, C . Child) --- --- 11,;t;n,;?t;.<1 Q1 --- --- --- SUPPLEMENTAL INCOME STATEMENT A. This form mV$t be filled out by a person who (check one): _ (1) operales a buslneu or practices a profession; or __ (2) Is e member of a partnership or lolnt venlure; or _ (3) Is a shareholder In and Is salaried by a closed corporation or similar entity. B, Allach to this slatement a copy 01 the following documents rel,tlng to the bvslnen, prolesslon, partnership. lolnt venture, corporation or similar entity, ' (11 the most recent Federellncoma Tax Retum, and (2) the mas I recent Prollt and Loss Statement. C. Name and Address of bV$lnen: Telephone Number D. Name and Address (If dllterent than C) of accountant, conlroller or other person In charge olllnenclal records: E. (1) Annual income trom business ,.........................................~.................................................. S (2) How often Is income received? ...................................................,.................1....................... $ (3) Grosl Inco"" per pay period ................................................................................................ S_ (..) Ne' Incom. per PlY period ................,........................... ...................................................... S (5) $pecl'lc deductions If any ...........................................................................................:......~. S 0",,,,..,,, STATEMENT OF EARNINGS AND LEAVE I'l1go lSSSS III "I ~ "'~ filII" , flJl liP End O"l~ SCO 61> nil ST Fl l).nRIII! A'QlJlaf OT.Norm OT'T,." 2n 12 119 1811 07 101 174 51 12 10 E SO I ~S, 00 2S,Sl 2S,25 4~,22 , 1 EA 000 83EK ADKINS, HANNAH 6264 , EARNINGS AND DEDUCTIONS C~rr"nl Poy Period ' I AdJ~llm.nt I Blwkly Tolol Oe1cflplion I HrI.IM1nl "-mount I Oel,CrJptfon I Hrl I MJn I Amount I In,J.dOl Adj -R~~W~~~;rr----'f8-8g 2a9H~ ,_Wlg,,1l.O- 2l20.04 II .24 I-GRlISS - , ;c12Q...OA- --6nilHWH ; arM -&~9~~e~ -- t:-~a -rm.:MAtj?RA~~A ,~ ~.g. -aH-*~91. I ~:iI9~ '-ai+~~k j~ --mo~E9]lTSS ) ~~H~ .....AllClMJOmL O..Q!) _rOIAl.-QEQU~LlONS 1',48 69 t I 41l_.Jl.lL_ - N!T~PAV >>>>>>>>>>>>>>>>>>>>>> 12'U..3- YCAB-ID-D~~~ANCLDaDUCltcNs GdU 6~~~' M~~t-Jlllm~~6--~~~~ ~~-07%-S.tA~T#H-- STAX-OEClll'iJI:IDW11I.lIl1ll'rl>A I. TAXO HM1>ilNl'A , CiHI TSP-FUNCG-AMr T5P-FUNO-C"'AMr Tspu~nm- - '767.3:1 6:1119.49 _li3..L..1~ 1799.16 -'.ti6 , 80 t!l.\l.lL.JlQ .3tOO ~~g A'CCllMUt:ATIVE1NFCR/ofATlOfr - RETIREMENT T5P 66 '.o.:L;l2 18912.86 . I.fAYE-INFORMATION ~~~~T YR EA~NcibP u:mW_~~~~~'ggO u~n - SgO -i~~1!""-\1S!9 L~~E 7eH~E _-5lJ:K 4 00 00 60t 30 10 0 t 9490 ~o OTHER INfilBMAIllltj -bU~ -OTH EXM~ll.I.lW , vrn' , . tV' ". "" ,.AWARE OF FRAUO. WASTE AND ABUSE IN WLCALI. fa HOTLINE. FTS B -.368.. toI6.! OR TOI.I.FREE '..800"424-9071. - " , f--__ - - - ...." ,...., , ,...-,,, "Htl'l '" ...... lIrun" ",II/,q flt"l'f"UII{ lJ .11" I",.. ". In AQIUU~IAfIU" . OFFIOE OF DIVORCE MASTI!!R CUMLlERLANP COUNTY COURT OF COMMON PLEAS o Nonh Hanover Stroot Carlisle, PA 17013 (717) 240.6535 E. Robert IlIcker, II Divorce Mutor Treel .10 Colver Olllce Monoge/lReporter We.t Shore 697.0371 Ext. 6535 April 6, 1999 Thomas D. Gould, Esquire 2 East Main street shiremanstown, PA 17011 Gregory R. Reed, Esquire ~423 North Third street Harrisburg, PA 17110 REI Hannah Adkins vs. Gary Edward Adkins No. 97 M 6329 civil In Divoroe Dear Mr. Gould and Mr. Reedl A pre-hearing conferenc~ has been scheduled for the above referenced oaBe in my office on Wednesday I May 5/ 1999, at 9130 a.m. Because I have to go out of town that day I need to leave in the morning. I was wondering if we could start tqe pl:'e-hearing c,)llfarence at 8:30 a.m. Pleaso call and confirm that the 8:30 a.m. start time is aoceptable which wouln allow us to cqmplete our busi~ess by 10:00 a.m. Thank you for your consideration in,regard to this request for the time change. Very truly yours/ E. Robert Elicker, II Divorce Master IIMN^I' MlI( INH, PloIntiff IN 'rHE COUll'1' OJ!' COMMON PLEAS O~' CUMBERLAND COUN~Y, PENNSYLVANIA NO. 97 - (j329 vs. GI\IW, EDWl\Il[1 1\111<11'16" Defendant CIVIL ACTION - LAW IN DIVORCE ORDER I\NIL NOTICE SET'rING nEARING '1'01 Hannah AdkIns , Plaintiff 'rhomaa D. Gould , Counsel for Plaintiff Gory Edward Adkins , Defendant Gregory R. Reed , Counsel for Defendant, You are directed to appear for a hearing to take testimony on the outstanding issues in the above captioned divorce p~oceedings at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania on the 28th _ day of October ,1999, at 9100 a.m., ut which place and time you will be given the opportunity to present witnesses and exhibits in support of your case. Pres iden t .Judge Pate of Order and NQticel ~!ln!99 BYI Divorce Master lr YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FOR'l'H ,BELOW TO FIND OUT WHEHE YOU CAN GET LEGAL HELP. CUMm:llJ:ANI.l COllN';'Y BAn AHSOC IAT ION 2 J,lIIEWfY AVENUE CM1LlSLE, PA 1701:\ 'I'EJ,I':PlIONE ("I J '/) 249- J 1 (,(, . HANNAH ADKINS, t IN THE COURT OF COMMON PLEAS PLAINTIIIF t CUMBERLAND COUNTY, I I'ENNSYLVANIA I v. I NO. 97.6329 CIVIL TERM I . GARY EDWARD ADKINS, t IN DIVORCE . . DEFENDANT I \>EFENDANT'S ANSWER AND COUNTERCl.AIM l. Admitted. 2. Admitted. 3. Admitted. " 4. Admitted. S. Admitted. 6. Admitted. 7. Admitted. 8, Admitted. 'I 9. Admitted. ' , WHEREFORE; Defendant requests this Honorable Court to enter a Final Decree in Divorce. COUNTERCLAIM Claim for Equitable IlIstrlbutlon of Martial Property 10, Paragraphs 1 through 9 inclusive of Defendant's Answers to Complaint are incorporated herein by refer7nce as though fully set forth herein. 11. Plaintiff and Defendal1t;joinlly and severally, possess various items of both , real and personal marital property which are subject to equitable distribution by the Court. ~ WHEREFORE, Defendunt requests your Honorable Court to enter a decree equitably diijtrlbuting all properly, real and penonal. owned by the partleij hereto und lor ijuch further rollef Qij lhe Court may deem proper. " I. D"'hS(/f2!I , &.~~ Attomey for Defendunt 2423 North Third Street Hamijburg. P A 17110 , (717) 238-0434 ,I " I 1 . " . , 1:-,:: , " I' J'" ill IJ() nr:/; :-~ hi ;1;1(1" etHlc;'.!i.l; /"(1'", _ '~. Id ;' - Ji.'I_!{-l'ty IL\,',':r'-;v\ , I' ., , '_I " " HANNAH ADKINS, Plaintiff IN THm COURT or CONHON PLmAS or ctlHEIlllRLAND C'OUN'l'Y, PlllNNSnNANIA VIS. GARY BD~ ADKXNS, Defendant NO. 97-6329 CIVIL term IN DIVORClIl STIPULATION 011' FAR'rr8S AND COflNS8I. A) Plaintiff: Name, address, age, occupation Hannah Adkins (Salamonl DOB 09/29/57 (4~1 NY 351 Stumpstown Road 81ectronic Technician MechanicsburQ.FA 17055 Defendant: Name, address, age, occupation Gary ~dward Adkins DOB 08/01/54 (451 IN 63]8 Irorrest Drive Construction MechanicsburQ. FA 17055 B) When tl)e method of service of the complaint has been by registered (certified) mail: . Service by Acceptance of Service C) Date and place of marriage: December 11, 1976 ~uffolk County" NY D) Both parties have resided in I?ennsylvania for the past 25 y~ars. HANNAH AOKINS I Plaintiff IN THIll COURT OD' CCHtON PLEAS OD' CUNBlBRLAND COUN'l'Y, PmNNSYLV1INXA V8. 1 , I ,I 1 t 1 I,: GARY BDWAl'lD AOKINS I Defendant NO, 97-6329 CIVIL term IN DIVORClB ,/ ,! I STIPULATION or PARTIES AND COUN9EL A) PI&intiffl Name, aedress, age, occupatIon Hannah Adkins (Salamon) DOB 09/29/57 (42) NY 351 Stum9stown Road Electronic Technician , Mechanicsbur9.PA 17055 Defendant t , , Name, address, age, occupation Gary Edward Adkins DOB 08/01/54 (45) IN 6318 Forrest Drive Construction Mechanicsburq. PA 17055 B) When the method of service of the complaint has been by registered (c~~tified) mail: Service by Acceptance of Service C) Date and place of marr.iag~l December 11, 1976 Suffolk County, NY D) Both p~rties have resided in Pennsy1 yania for the pas't 25 years. voluntary deduotion for the Thrift sAvings Plan III the amount of $115.24. The retirement deduotion as r.lhown on 11111' pay stub is mandatory. Wife does not have any hllalth problems. She does ourrently provide medioal ilifluranoe ooverage for the family. Husband is 44 years of age and residerl .1t 6316 Forrest Urive, Meohaniosburg, penneylvania. He l~ a high sohool graduate, has an assooiates degree, and i\'~cording to oounsel for wife is one semester short of havinq II baohelor/s degree. He ourrently works construct!Qn as a super intendent for LObar, Ino., and takes home \1"'Jkly $551.00. According to wife's counslll, husband if! being treated for prostrate canoer. upon the entry of a divorce deoree, husband's medical insuranoe benefits will terminate through wife's employer. Husband will be entitled to, however, pick up a COBRA benefit through wife's llJnllloyer. We do need to know the cost of that benefit to IIlIBband. The parties own real estate at 351 stumpstown Road, Mechanicsburg, Pennsylvania, where wife L\ ~urrently residing. Wife has an appraisal which was done Ly a reill estate appraiser showing a market value of $118,uuO.OO. Husband b~lieves the market value is $125,000.OlJ, and his oounsel has indioated that he will probably have the property appraised by hi!) own appraiser. The MilBter did indicate that if there is no more than a 5 percrmt deviation between the two expert values he would do an aVlll:age. Otherwise, we would need to hear the testimony at both experts. The house is subject to a mortgage in i'ilvor of Dsr Finanoial with an approximate payoff of $87,000,00. The monthly payment is $763.00 which includes taxes ,II1d insurance. Wife would like to stay in the home, if she Qan afford to do so, and counsel will have to deter~line how they may want to fashion an equitable distribution to allow wife to retain the premises. otherwise, the house should be listed for sale, and the parties can share the costs of sale. Wife has a retirement plan through thll federal government, and two years of her employment was before marriage which will have to be considered in the' valuation. The Master has indicated that if there are not '''Iough offsetting assets to account for the value of til" pensiull represented by husband's interest, then we will I."we to do the dietributicm by a Qualified Domestic RelatiulHJ Ordel'. 1\ deferred distribution method is not favored unl"u~ there Ill. no way to fashion an equituble distribution by "lfsettiny assets. Counsel will have to determine whether or not tll'" equitable distribution can be accomplished thrmlyh an oflHDt or whethel' we need to apply a deferred distribut Lon and thll\: decision will determine whether or not they need to have tho pensio" income valued. Wife also has an interest in a Thrift uavings Vlan through her employment, which has a value as shu\'II\ on' tho.> pretrial statement of $21,000.00. Mr. Gould indioated thOl there is a loan against the account, and he is ,/Ulng to provide that lnformation so we so we know what '11'3 net VIll\l" is in the Thrift Savings Plan as of the date of lleparati()n. The parties own a 1993 Ford Arrowstar, and a lY88' Ford 150 pickup truck. Counsel agree with the values placed on the vehicles by the parties as stated in the pretrial statement, $7,400.00 for the Ford Arrowstar and $2,000.00 for the pickup truck. However, if the values no ad to be adjusted because of the length of time that has passed from the separation to the date of hearing, then coullsol will have the right to make those adjustments. With respect to the household tangibl,' persona I property, counsel are not going .to use any valUUR in the equitable distribution computation for the propul'ty retained by each of the parties. Counsel have indicated that the parties ~re satisfied with the distribution of tile tangible personal property. Husband's counsel has also pointed out that husband disagrees with wife's assessment of his lack of contributions to the accumulation of the marital ustate, and his position is that he did make contributions tu the financial. life of the marriage and the accumulat I 'HI of assets. wife is making an issue about husband'>> lack 01 industry during the marriage in providing income to the family. Wife is making an issue about husband'u failure to contribute to the accumulation of marital assets, her feeling being that she had to work at a position that eal'ned most of the income for the family, while husband apparently tried to make a living working in the construct Lon industry. To tie it in with this argument is an issue that wife raLuou based on debt which she claims she helped pay of! around separation resulting from husband's seH-employw'llt as .\ IN THE COURT OW COMMON PLmAS OW CUMBmRLAND COUNTY, PENNSYLVANIA HANNAH AOI(INS I CIVIL ACTION - LAW Plaintiff v, NO. 97-6329 CIVIL GARY ECHARD MI<INS , Defendant IN DIVORCE Datel ~~/917 Gr~~ R'; Reed, Esquire ,-'--'---~- Attorney for Defendant 2423 North 'l'hird street, Harrisburg, PA 17110 (717) 238-0434 Attorney I.P. 23705 pc: ThomaS E. Gould, Esquire , " IIANNAII AI>I":INS, l'I.AIN'l'Uo'F t IN 'I'III~ COUltT OF COMMON I)U:AS t CUMmml.AND COUNTY, r III~NNSYLVANIA I I NO. 97.6329 CIVIL, T1mM v. GAIW EDWAltD ADI":INS, t IN UIVOltCE DEFI~NDAN'1' I Il1WENDAN'I"S A~m ANU COUNTImCI.AIM L Admilled, 2. Admllllld. 3. Admllled, I' 4, Admitted, 5, Admitted. 6. Admitted, 7" Admittcd. 8. Admlttcd. 9. Admitted, WHEREFORE, Defendant rcquests this Honorable Court to enter aFinal Decn:e in Divorce, ,COUNTERCLAIM Claim for E<Jultnhle Illstrlhutloll of Martlnll)roperty 10, Paragraphs I through 9 inclusive of Dcfendnnt's AnslVersto COl11plaintare inc6rporuted herein hy referencc as lhough fully sel forth herein, II. Plaintiff and Defendllllt; joinlly IInd severally, possess various hems ofbolh real and personal marital property which ore subjcclto equitahle distrihution by the Court, 'I WIIElWFOJW, LJelimdulll reLluesls youI' IILJlloruhle ('oUl'llo clltel'U deerue equlluhly dlstrlhutlllg ull propurty, reuluml persollul, oWlled hy the purtles hel'eto IIllLllilr sueh 1\lrther relief us the Court Ilmy deem pl'Llper. ~~. - --.. Gregory It R >d, squire Auomey for Delimdullt 2423 North Third Street Harrisburg. P ^ 17110 (717) 238-0434 , Date: '4/~ " 'I , I " '" ,1/ , AND NOW, this , 1 , CEJR'rIFICA'l'8 OF ~[;JR~ ~day of January, 1999, I, Gregory R. Reed, Esquire, Attorney for Defendant, do hereby certify that I have this day served by ~irst class mail a copy of the attached Answer and Counterclaim to the following address I Office of Divorce Master E. Robert Elicker, II' 9 North Hanover Street carlisle, PA 17013 Thomas E. Gould, Esquire 2 East Main Stre~t Shiremanstown, PA 17011 ~~ Gregory R. Reed, Esquire Attorney for D~fendant .2423 North Third Street, Harrisburg, Pennsylvania 17110 (717) 238-0434 Attorney 1.0. 23705 , ' " '7f- . ,. Ci I' ...)~ " Z\ \',1 ", l.' ~::-J , ~ 0) I' I-c, ~ )- ~ \i I , <) $ \:1 I () CC '~ , ,"\ , I ' , y ~ ."- ~ b,. " 1,' 9r/17(}rr gc, !J(,IIIt! .Ath:)frtttY'JI llJ~ ,/!'n N Thil" $, . i'f""'.b'IIO, PA 11110 (7171230'0434 FQ' (7171230'8469 Curt Long Prothonotary I Counhouse Square Carlisle, P A 17013-3387 Re: Adkins v. Adkins No. 94-3583 Dear Mr, Long: January 28, 1999 Enclosed please find the original of Defendant's Pre-Trial Statement. Please file the same forthwith. GRR/cj>>, Enclosure pc: E., Robert Elicker, II, Esquire Thomas D. Goald, Esquire I' or' '" , ", '.' , I ,'I '. .';'1 '/,"-'1-\:,< ; I !,'ut' , __, ._(~i; 1" 'I. 'i- i:.j'ifi~f 'H'<i'.iC':Qi , ~j'\!l_ -'/-~-~i q-' . ,- _', ;j;t:lhj',J , I' , ,q'!;litl~;' , ..,.,:-,-I~J,' , ,_,)rl~' I . . ,,;n(l,lN ,.:;\';,'.;w, " 'i,ll'-pj, . IN T~E COURT OF COMMON PLmASE OF CuMBERLAND COUNTY. PENNSYLVANI~ Hannah Adkins plail~tiff CIVIL ACTION - LAW v. I I I I I I I CJ7~ ~ ~ NO. *-3*a- Gary Edward Adkins Defendant IN DIVORClll DlllFENDANT'S PRE.TRIAL STATlllMENI 1. LIST OF ASSETS: Plaintiffs Inventory und Appraisement Is attached hereto, marked Exhibit "A" and lncorpllruted herein by reference, 2. EXPERT WITNESSES: Ted Long- Pension Appraiser Real Estate appraisers ifvalue ciulIlot be agree upon. 3. LAY WITNESSES: (I) Defendant (Ii) Plaintiff as on cross examination 4. EXHIBITS: Income tax retums for 1993,1994,1995,1996 and 1997 and Plaintiff's Pension. Plan documentation, a copy of which is attached hereto and incorporated herein by reference, S. PLAINTIFF'S INCOME AND EXPENSES: A copy of Plaintiff's Income and Expense Statement are attached hereto, marked Exhibit "B" and incorporated herein by reference, 6, V AWE OF PENSION OR RETIREMENT BENEFITS: Sell~opy of Plaintiff's Income anu El'pense Statement. 7, COUNSEL FEES: Plaintiff's counsel has to date lnvesteu 12 hours In this mailer at the rate of $150.00 per hour. If this matter proceeds to the Master's Heuring Plaintiff's counsel anticipates a minimam of IS additional hours. 8. MARITAL DEBTS: , Mortgage on martial residence, approximately $87,000.00. 9. PLAINTIFF'S PROPOSED RESOLUTION: a) Sale of real estate with 50150 division of marital property, net proceeds going to Defendant. b) Transfer of ownership of Plaintiff's Thrift Savings Plan to Defendant. c), Ownership of 1992 Ford Aerostar retained by Plaintiff, d) Ownership of 1988 Ford F ISO pick up retained by Defendant. e) I Household fumiture and fumishings divided equally, t) The balance of Defendant's claim. g) Defendant to receive the balance of his share of the martial property in the form of a QDRO for the Plaintiff's FAA Retirement Plan, ,lot" Q~A"?/~f G~ ~-=- Attomey for Defendant 2423 North Third Street Harrisburg, P A 17110 (717) 238-0434 Attomey I.D, No. 23705 .. " . IN THE COURT 011' COMMON PLmAS 011' COMBlllRLAND COUN'l'Y, PlllNNSYLVANIA v. , I CIVIL ACTION - LAW I I I NO. 97-6329 I I I IN DIVORCE HANNAH AD1':INS, Plaintiff GARY mDWARD AD1':INS, Defendant INVlllN'l'ORY AND APPRAISEMEN'l' 011' GARY mDWARD ADKINS Plaintiff files the following inventory and appraisement of all property owned o~ possessed by either party at the time this action was commenced and all property transferred within the preceding three years, Plaintiff verifies that the statements made in this inventory and appraisement are true and correct. Defendant understands that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. Date: ~II//'~L , ..- ?~o.~ ~Qwa..J Q),\~ Gary Edw d Adkins >~ r' , I c: ; , . , UI , , , - .~', " i , , , , - " ,. c: , '. , ,- , , :' '-. ~~~',~d /fA" .. AssmTS OF PAR1Ims Plaintiff marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. If an item has been appraised, a copy of the appraisal report is attached. (Xl 1. Real Property (X) 2. Motor Vehicles (Mobile Home) 3. Stocks, bonds, securities and options 4. Certificates of Deposit (Xl 5. Checking accounts, cash (X) 6. Savings accounts, money market and savings certificates () 7. Contents of safe deposit boxes (I 8. Trusts () 9. Life insurance policies (indicates face value, cash ,surrender value and current beneficiaries) ( I 10. ( I 1l. ( I 12, ( I 13.. ( I 14, ( ) 15, Annuities Gifts Inheritance , Patents, copyrights, inventions, royalties Personal property outside the home Businesses (list all owners, including percentage of ownership, and officer/director positions held by a party with company) ( ) 16, Employment termination benefits - severance pay, workmen's compensation claim/award . 'MARITAL PROPERTY Defendant lists 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 commended: ITEM NAMES O~ DAT:&! Oil' mll1UB DESCRIPT;ON Oil' PROPERTY ALL OWNERS ACOU:tSITION 1. Residence - 351 Stumpstown Road J?la.lntif f and Mechanicsburg, J?A Defendant $125,000.00 less mortgage $87,000.00 2 . 1992 Ford Areostar $7,400.00 J?laintiff and Defendant 2. 1988 Ford F150 Pickup $2,000.00 Plaintiff and I Defendant 6, U.S. Department of Transportation J?laintiff' Thrift Savings Plan ($21,000.00) 19. FAA Retirement $122,166.96 J?laintiff 25. Contents of Home $ 10,000.00 J?laintiff and Defendant NON MARITAL PROPERTY :ttem No. DescriDtionof Pro~~ Reason for Exclusion 5, Checking Account-Financial Trust ($400.00) 6, Savings Account-Financial Trust ($1,200.00) ,Post Separation Post Separation LIABILI'l'IES Plaintiff marks on the lists all liabilities of either or both spouses alone or with any, person as of the date this action was commencedt 1'm:J DESCRIPTION NAMES or ALL NUMBmR or LIABILI'l"l CREDITORS l2U..~ AMO\'1N'L' 24, Home Mortgage BSI Financial plaintiff and $88,000.00 Defendant (estimate) ~ER'1'IFICATE OF SERVICE AND NOW, this U~ day of December, 1998, I, Grego,ry R. Reed, Esquire, 'Attorney for Plaintiff, do hereby certify that I have served by first class mail a copy of the attached Plaintiff's Income and Expense Statement and Inventory and Appraisement this day to the following address: Thomas E. Gould, Esquire 2 East Main Street Shireman".,., ~~ Gregpry~. Reed, Esquire Attorney for Plaintiff 2423 North Third Street Harrisburg, Pennsylvania 17110 . (717) 238-0434 Attorney I.D. No. 23705 , IN THE COURT 0' COMMON PLmAS 0' CUMBERLAND COUNTY. PENNSYLVANIA HANNAH ADKINS , I CXVJ:L ACUON - r..AW Plaintiff I I V. I NO. 97-6329 I GARY EDWARD ADKINS, I Defendant I IN DIVORCE DEFENDANT'S INCOME AND EXPENSE STATEMENT. FEDERAL INCOME TAX RETURN AND PAY STUBS AS REOUIRED UNDER ROLE 1920.31 I hereby file the Statement of Income and E.:qJenses, Tax Return and Pay Stubs as Required Under Rule 1920,31 and verify that the information therein containe~ is true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Date: ~II~/~J_ , ~ ~~~~ Gary Ed rd Adkins ~ (...., ~ " - I ...j " '; :.~ , " .. " : , 11 , , , ., .. _I l'x~; b;+ 'I f)' , ~NCOME AND EXPENSm STATmMmNT Ql GARY mOWARD AORXNS , :rNCO~ STATmMmNT, , Employer: NidState, ,Inc. Address : Type of Work: Construction Superintendent Pay Period (weekly, bi-weekly, etc,): WeeklY Gross Pay per Pay Period: 686.00 Net Pay per Pay Period: 466.80 EXPENSE STATEMEN'l' ~lIlKLY , MONTHLY lJIARL Y Home: Rent $650.00 Utilities ~OO.OO Insurance: 'I Automobile , , 52.00 Automobile: Fuel Repairs 200.00 . License and Registration Personal: Miscellaneous , 100.00 Clothing and shoes: 50.,00 Food: 375.00 Barber 10.00 Entertainment: 25.00 Gifts: , 25.00 Legal Fees " , 150.0Q. TOTAL AVERAGE MONTHLY EXPENSES 1,837.00 aSI Financial-Home Mortgage PROE'ERTY OWNED: 'I ' I3Ar.ANCI!I OWl!lD $67,000.00 (Estimate) DI!ISCRIIi'TION VALt1I!I OWNER Checking Account Financial Trust. $ 700.00 H Savings Account Financial , Trust 4,200.00 H Real Est.at.e , 351 Stumps town Road 125,000.00 H & W Mechanicsburg, PA Insurance provided by Employ~r , " !;, , ' ""j .".'1:.:~'~' ;:.~,... ~:. .\:./',r:''''i~,'~;'/: ;"..,': I ' , , I. " .. '" <' .I,<,/","';.';>':'~'.til': ~I;j ,'" ,', , .,t;. . ,.'r_ lei :,1", \, .' . 'r.,',> ,...,: ,.1 ",'t:r;.t~, ,_.p.~~I~'t~!I~ir",'., "'~":'P"r:.II:t~.':.t~ ,\t.".r~ :,.;' ):h. , " . .. r ".- - .1,;' " ".,:.,... i :' " . . '" , , . -", " " ,'. t,' t ~ ,~t.', ':', I ,,' ,'-': ,', "~~,' :.' . . , -, , I" I 'I' ~,.' " - P l ! r ' ., .; "r .' ". -. \' ,I I .. I . I \.. .~' 't . t:'"t'l.",r~' ..tf h~,pl'l tr.nIJ~'j h.f\>r1j"'fl.l :r~,f::"rir~". t_, ":.l,; ''''.:,1... I;,.} . .:' !', t.:.;y. .,~:.' ,1;, '~ ,'.l ,":;, t, I ' ;1 i" )., ,,"', " .' ,',. ,',' . EMPL. I (945) GARY E. ADKINS ..GROSS.. ..OTHER.. CURRENT : 686.00 0.00 Y-T-D: 2,606.80 0.00 .FEDERAL. ...FICA... CURRENT : 76.65 52.48 Y-T-D :, 286.02 199.43 GARN SAVING CURRENT : 0.00 0.00 Y-T-D: 0.00 0,00 BONDS HOSP CURRENT : 0.00 0.00 Y-T-D: 0.00 0.00 .';' . ':," '," I," ZM"~. r (945) CURY.. ADmlS ex.'1 onoo ..TOTAL.. 686.00 2,606.80 ..STATE... 19.21 73.00 UNIONS 64.00 243.20 XFEDTX 0.00 0.00 '. 'I' " . , ' ,'" '" .. CK. ~: 09l.47 PERIOD ENDING: :e.14798 ....NET.... 466.80 1,7,79.08 ..... RATE BREAKDOWN ....... SOURS RATE P.n..Y 40.00 at $17.150 686.00 . OTHER PAYl 0.00 ..LOCAL.. 6.86 26.07 ............~....~....*=a~ TOTAL GROSS I 686.00 OWAY 0.00 0.00 OPT 0.00 0.00 'f H.....'. "'" ,.....;:. '" >,' , , ..r:1 ,'., ,walCD IUOma. lo/ll/" 9100 HC01l3 40.00 lATH II: $1'7.150 0't1I:I:A PAri --GROSS.. ..01111I\.. ..TO'l'AL.. ...lnn'... ...... 1lA'1'1 BUAIDON'N ..... 'AY ...,00 .1 n.'" lU.tI n.n , ~',u.7t ';" ,;~,- CU1lI.INTI cae .QQ 0.00 1'-T-D," 1,'20.10 0.00 'U.OO J.,)20,1I0 :~nD~'" ...no.-. ctI'Ill.IN"t'l' .~~: ''1'.15 ":~'\'- T-T-DI '~.:1:.:~;-O,.J7 .~. ..~:i~~~~..-~- .,.... Ct1RJl!N'l'L ')'--':0.00 /'. . r,: - _'. . t-T-DI'~;:r':~ 0.00 . ,'f":,\:';"";f.'::':'" ..,', 'I;;~~;'''''~~'~' ':-:"'. ,-"- " ~.: IIOIfDS . .. CtJ1UlKNT I ',. . II ~oo Y-1'-DI 0.00 ..STAn.. 7.... 'OIItCHS '.~ ',..00 .-\..-~~, 11. ..20 .'. .-., .. '......, ':;'!'1~ ".'- I " )..0.00, ",,"',.0.00 ,..... '~ . IAvtIlO 0.00 .0.00 Ion .0.00 H 0.00 ,. t:,,:~~"- " "".10 1,nz.:U ..LOCAL.. ',If U,2l WAY 0.00 0.00 .r '.. Ol"l' . 0.00 0,00 TOTAL GROSS I ...................~...... 0,00 ',' Ir '~. ... ., ,,'. .".t... '" ' ~,;,.",::, . :,'l . .., '.., " . ";'..' '.~" 10" , . ..... '. '........."I~!Jfo..~{.,~~.t;,.t ~t:..:.' ....00 " .-.'~:.:,..t~r~:t~~ ;~ '. . . . ~ ' ,-'~,.,._::r:(\<~~;;.~~,.,.~,~ '. ~ , " .... .",\ ,,' J ".,1;.;... , .; \ ~ '..:..,i:.::;:J~;,::h~,;::,:~.:. , . '.~.. :,t.~;'...lr..":,,,,:,'lr!f:l.t~t'.'!;:.:~.:'~.'.' .' . '..'I ..",,,,,,,,.,..~.,"" ....,.~.',._, . '':~t::;\ ,\::'~''''I..' Pi''''',' '....'JJ.. II'. .'. ,,:':"~iJ~;;;., .. ~!i"i-f=i~~ /''', i'~~'::~';1vJrrrj~' ff!... .'\ib';;'~;"'::' :-.... ,.":!~~.:..,;A.i.':,,~iJ'.::.r.:.1,~'1~.. ./ i.t;.~,;.Y.,_\ .. ':" .~..~..J.l:.V.:_'fJ;~~^4l.."!"';!J''C..!;./.1'1.,.....'!'1'.:-..... . -.;:;::.:~i~~:'t(~e~~~\:~,.,_: ""--~.oT;,......':,"'Y.'!$liIt.~;....~." ,,: '?~~:.Fj:{l~i(?:~'~r~?;?t~.':. .,' ,.' ",,,* .,._,. . :t.",~.!i41': " :~.~.., " ,;:;;'<t;:i;:~~}f::,;~\i~l;~&f:;ij:i:\\{;k::c'\'~j:~",>,'1\.zi(l~[;fit~~1;t~;,.y/' 0;;> .....i':.., ..... ;.~'i~:'~:,j ;!t.. ~~hlt, ,.. ,.... ....-; 'It-h"\)-,::,1'" .:" 0( ,: '. :.'\ :.',"~.. ':' ',;', ~;.:, ;;.~'t.". ".'. .~I.:~..t ~?fu$i1i':F;,,~::~~';:J:. j,~:;~.., .:. ' .; '.('".:''' :y;~".;..~>"r:/ :':"".:, ," ", .:~,,;: "$I.,~..;t'", .;,', .:.:. -'f" ....:..:..7,.. ..' ".'. ::'..,....,~ 1....,I.."..,~,..~ .w.....~.-;\I.':<< "', ...:' . (" . , 'r;.r.- ". "If: .....' ./'" ,J< '1:-: . " . . ....'.... '!,.' , : -t.,.. .J/, t" If' .~' ..j ,~"",t.'~.,:~r -, ,",," , :1" " ,r .-..... :.,1, .', .pO "'_~.", ___... , ~,...--- -- ,., 0035 -- GARY E. ADKINS .~ la, ... . , SIIAM -- APR 19,1998 -..... ~lIa APR 25,1998 5 01 EARNINGS ,.., APR 29, 1998 TA.."aS ,-~ SALARY - .... - -.. 550.00 FICA MEDFICA FED WTIl PA TOTAL $ 660.00 TOTAL $ ~, 0035 -- GARY E. ADKINS ~ - ... ~, SIIAM -- APR 26.1998 -..... _ra. ..,.,. MAY 2.1998 S 01 EARNINGS TA.."aS ,-- MAY 5,1998 ...... 442.56-7495 -~ SALARY - .... - --- 575.00 FICA MEDFICA FED WTB PA "T t. ". . ,. TOTAL $ 676,00 TOTAL $ '. ". '. '.-;."-. 'f, "I,,' t " '" "-..," '.' :/":... ''';,.:,1., " . ..' i': ". " .' I,H , ,/I! r~ .' .\' .1'.H':"'o ,., [.' "', '" """,/, ...... 442-55.7496 - 40.30 9.43 92.57 18.20 . ,..-." ,.. .....-.- SHA.\>mOCK DEVELOPMENT, INC. 24' W, EDISON RD. SUITE lIQ MISHAWAKA, IN 46m DEDUCTIONS YEAR TO DATE -- SAYINGS MED ICAL -. 100.00 3S.59 -- GROSS FICA MEDFlCA FED WTN STATE MEDICAL - lt050,OO 685.10 150.23 1573.59 309.40 622.03 1~0.60 TOTAL $ 136,59 ....~ ~IIU I ~-....352,91 - 41.85 9.78 99.57 18.90 f.....,_._ SHA.\>mOCK DEVELOPMENT, INC. 24' W, EDISON RD. SUITE lI0 MISHAWAKA.IN 46m .DEDUCTIONS ,. :'<'YEAR TO DATE - - -- - SAYINGS 100.00 GROSS 11725.00 MEDICAL 36.59 FICA 726.95 MEOFlCA , '. 170,01 FED WTB 1573.25 STATE 328,30 MEDICAL 858.82 170,10 TOTAL $ 136.59 -~ ... ""'''368,31 , ' -- '.-.. .-. ",.---- '. " :'. ,.... ....:;:;','~);:<~.~'~[~~j:;!}~S~:~":;;i;;:;:\;:,~i:;~i:"';';;\:::!':~i,r/:i;;,t::"';(~'~'~'~~l:!;y1j:,.. .' r.l"""\'~II),,,,,,,,,"-~''''''t>''qllr.'''''',,' f ," "........ .:.~ "''t'"'':''' t. ":' , ",.': ':. l.>.t <;1"'\.";" ; :4 If, i~~!:::'i~~::~i..'~.;:..i~'\ ", ,"\' : ,:, ~ " . ",:,', ..:;.-~. ': J' ,I" .;. ".,' .. ~~:;.. , . .;t.~ :',:",",;" . 'I :.hi:.. " . . !...:;...... '.' , '. .1, I.",.",: ," " , ',. f,". '. ~ I , . ' , , ,"" , ", ...,' , ,.!';' ".' I' "',' . . p. . I 1 . . I ','/' ..'" '1' ' .. ,.,I"".I'~"i.'./",., ' II,." .H" "rl..I"'l (C'," '" ';I'l '~r' .,'" ,. , ~tl "~'H" ,'j" :!;: . :, ';;l i; I i :,,~~P~I','~ '.':'/ ':1 /!:~ I;r,/~ .'Jj..:I~::';,'i,\'l ":, ,,:, r..;: . , .-1 1'(,/ \ ' ~ I If :1" . t rd. :~~ dllt' J I~'t n'irt't~.-,~;~lr~H.f;'i~.., ~I "", , . " . I'.., . 'I,'" ':.. .. .,' ",".~' .,., '., .. .. ,~. ,",', '.,',/,,'. '. .',',' I , 'j, " , I.r,," '.-."',0'"' .., , '''', .,\t;tr,. .." , , I ....._.._..____......._..._,...~.., , ~*_4_4""> ~. - 0035 GARY E. AOKINS U.' .4 ... ...., - SHAM 442.64.7494 -- ... .. .... MAY 3.199B MAY 9,t99B S 01 MAY 13,t99B EARNINGS T A:'{ES - - ... - -- .- SALARY 676.00 FICA 41,85 MEDFlCA 9.19 FEO 11TH 99.57 PA IB.90 t__._ SHA.,;mOCK DEVELOPMENT, INC. 245 W. EDISON ltD. sum 110 M1SHAWAKA, IN 46545 DEDllC1'IONS "YEARTO DATE --- SAVINGS MEDICAL -'" 100.00 36.59 - GROSS FtCA MEDFtCA FED 11TH STATE MEDICAL -, 12400.00 148.80 1/9.80 1112.83 341.20 695.21 TOTAL $ 676,00 TOTAL $ ...~ ioU"" ............368 , 30 170,11 TOTAL $ 136.59 , '. ,'.: " " .....'*. ' ~. 0035 -- GARY.E. ADKINS '--.- SHAMROCK DEVELOPMENT, INC. 245 W, EDISON RD. SUITE 110 MISHAWAKA.IN 46545 " (DEDU~ON.S' ",;:,"M'.!<\~YE.. ",oCT. 0" "DATE \",0....1' ,p.,..,,~[.,j;..: ~,..." ~ .. ... .... ..... 442.56.1496 SHAM -- _.. 1M 0. w.f MAY 16.1998 S 01 'EA'n..m.rG S";:',M!""",,::':,'.,,: . ~:1,U.-' :.0<",..,:;:"...:",.',;..1" -.. MAY 20,1998 MAY 10,1998 .,:',."TAXES, '''.,'' ", >; ~ :~'.\V ~,,:-" :.- I " ,'. .(.':';- - SALARY - - - -- 675.00 FICA MEDFICA FEO 11TH PA - 41.85 SAVINGS 9.79 MEDICAL 99.57 1S.90 -'" 100.00 35.59 - GROSS FICA MEDFICA FED 11TH STATE MEDICAL - 13075,00 810.55 189.59 1812 .40 366,10 731.80 , :.' ~::' . ' ~.. .. . .' ,,_ 4.~ TOTAL -- .... -368,30 $ 675,00 TOTAL $ 170,11 TOTAL $ 136.59 -'_._~---"~----'-",:",---'- " 1 , . :. . '.: " '.:'.'r .,.,,,:, :,;. ~:. '.i ;:':'.:, ::':.' ,:. t, .;r.' 1:..:.(.: t' ~\'., t' ':: ;: .:: <:,..:,.: ."( ';" ',' r 'rt', ': . I. . ;.', :(:;.:...::' ..r' '"::::'~''r:..''' , , ..:, .t~.:<'""...'..~.....: I,,: i .\ :11','f*lfr,'r"ll';'\'I"I', ("lo\t...,t..III"tr,I.I',t t,.; 'I ill,.I.!..: 1../.'111'" i"'..'i1..::'''.l'.....tt.JJ.!I't: I~' 1,1 't. '. .. . ' 4 . . : ... : -to l ./1 t . ,0.1'1' " ,~ ' ,t ':' I 1'.1 It,', J' , '" .', I I '.' I ' ' .1 't '\, J I I , f . L I :t. '.1:.' f . 'I: .' , " .; .." ,.~. , ,Iii': I'."l!d,: ,'1\ "1't'P "f '.,"1'1011' ~'I,'r" 1'>1'1 "lot>.,!:.: .. I., t, t "1'!" ',t;....:. .,t:.;. ..... ,'l~ ,'.I (~::' ' :, .,:~.;)}/;~~r:;:~~~/:I;,?~.;i:{::~~W:;:/~:,~~:'~:,~:<;:,'~::,:':: :::::!,.::,~,'::::;,:i:..: ,;,::' :.,:,';": ',-: :.::~:.: ,:,::::',' ~";'i':-.;/\:;~,':,/,~:~~;'~::,:--:,:::" " . ,I .. ..':: ...,:;.. ,~;1~:1'(~., I: ."!, :~;:~;g.,~' ~i: .&,~~(:;/~ V'~'~:: ;:~:' :'~I},I:'~ ~: ....~: ~(..,~:. ..:\... J.., . I . ;;.., .', ,.#,'!. ~.(: ;.< (~~ f~'t'~"I~~"'!'/I~': ....~.~':J.~,. '.' ,0 ., . _..'.- ---... ,< j' " ." " '. ' ..," , , , , ',' ' , '/':, ',,', , " ,', ',.',' ", " ',': ,I' d, '~.' ' J" . . I' '" .f I" 'I '''',. II, '..' ',f "tr"', I , & ,~ ',' ", ' '~I "1\' "Ill,',fl"~'t,y 'i~,rtt'..j,~'r-!;t'!o"':"""TI'I"r r I'f,r.,.' .rll~.rt' rr.......l\, {"lllth-.'Hfll..r- ,', ~" ~1,t,~"1 ht"'t.I\! '''::'I''I,''~I'..t "'I'""" -old, ":' ,:"It.., ,"" " ',.' .' .q,'t."". . ", , ;,' ,". ~",ht .,.' " "., . ",. . " , , , ":."":,' ~. "'-' ,...,~...-..._----- ---" ~. -- 0035 IIARY E. ADKINS - ... ... -, SIIAM -.. .... .. .. MAY 17,1998 MAY 23,1998 S 01 , 'EARNINGS' - - w. - -- SALARY 075,00 FICA MEDFlCA FED WTII PA --.~.- SIIAl\-ffiOCK DEVELOPl'rlENl', INC. 245 W. EDISON RD. SUITE 110 MISRA W AKA. IN 46545 ..... 442.55.7495 -.. MA'/ 27,t998 TAXES, d' .,.. · ,DEDUCTIONS ':.:\,:,;., YEAR: TO DATE - - 41.85 SAVINGS 9.79 MEDICAL 99.57 lB.90 -, too,OO 35.59. - GIlOSS FICA MEOFICA FED I/TJI STATE MEDICAL --. 13750.00 852.50 t99,3B 1971,97 385.00 75B.39 TOTAL $ 675,00 TOTAL $ 170,11 TOTAL $ .... "'M. ".""368.30 136.59 ., '". " <'.;"." ;." "':"'.';,':;",,-, ~, 0035 -- GARY E. ADKINS ~_..- SIIAl\IROCK DEVELOPMENT, INC. 245 W. EDISON RD, SUITE 110 MISHAWAKA, IN 46545 ~ .. - -, ~ SIIAM 442-56.7496 -.. MAY 24,1998 -... ... "'" ...,., MAY 30.199B S ot ..,jEARNINGS:.;.S!.;!i.\;:+>i,L:,."., -.. JUN 3.199B : TAXES, ' " <::DEDUCTIONS :+;~0i;~V:'YEARTODATE --- SALARY -- ... - ........ -. --- - - - 675.00 FICA 41.85 SAVINGS 100.00 GIlOSS 14425.00 "', MEDFlCA 9.7B MEDICAL 35.59 FICA B94.35 FED \/TH 99.57 MEDnCA 209,15 PA lB,90 FtD \/TH 2071.54 STATE 403.90 MEDICAL 804.9U ',' TOTAL $ "'M 675,00 TOTAL $ 170.10 TOTAL $ "'M' .......368.31 136,59 "'.. .. " I I',' " " " .. '. .,..0>;1 ',' I , ;.... ,," '" ":",,,' ,:,;:',:',,:>;,,:'... ;,,:/'I'.~,,'~(:, '1,',,\ ':':":""'~I"'::'" '", ': ',.,,::.'j.." :"',,:, ..~ r." If '1.".1, it .' ~./,'..' '(',~t 'l~ '; "I. "Iri' ~j,lri'.li[."~"" :.\;,./.' ,'t. r /,!,": I ,/ t :',!t' h" t r I ."., I. \,tf ,..Ilj ,tHi'I'.'H~t'_'i~ , ' :' :'. / ,._:...~ ,,+., ,'i'..; 1..1. . ':;1, ':',i,'.:, .L,~~;:',/;"I, ", .::~.i',:' ~ "'.: 't' ';' ,"'" ,',' \' ,_. ", / ''',.': :1: ":7' >, .' ... . I' '. ',' f,i .'. '/ . EARNINGS ''';''-''' TA.XES DEDUCTIONS' YEAR. TO DATE : i ~:""" .' - .... ... -, -- - - -- - - SALARY 675.00 FICA 41.85 SAY INGS 100.00 GROSS 15100.00 :I MEDFlCA 9.79 MED ltAL 35.59 FICA 936.20 " FED 11TH 99.57 MEDFlCA 218.95 PA 18.90 FED WTH 2171.11 ~ STATE 422,80 MEDICAL 841.57 ;',. !;~.\~ : " .V ,....,>'j. ..-.......,...- '-".-.-.. , ....-.. ...."...--....-.......-.. -~....._-....__..,.... ~, 0035 -- IlARV E. ADKINS r__._ SHA.vmOCK DEVELOPMENT, INC. 24' W. llDISON RD. SlJITE 110 MLSHAWAKA,IN 46'4' ... .... ... -, ..... 442.65.7495 SHAM -- HAY JI.1998 --.. -.. ,..,., JUN 6.t998 S 01 -- JUN 10,1998 TOTAL $ 676,00 TOTAL $ -~ 170,11 TOTAL $ .n"" """'368,30 136.69 ... .' I, . w' ~, ;.,' ."'" .. Ui035 I GARY-E. ADKINS ... ..... '--....... SHAMROCK DEVELOPMENT, INC. 24' W. !!DISON RO, SlJITE 110 MLSHA W AKA, IN .u;'4S ... *. ..... SHAM 442.55.7495 -- - -~ .. - ~ JUN 13.1998 S 01 -- JUN 17.1998 JUN 7.1998 I ,iEARNINGS;.'V;V,.'.." ' ",TAXES 'DEDUCTIONS:>:;):,:!.YEARTODATE -- SALARY TOTAL $ 170,11 TOTAL $ -~ 136: 69 676,00 TOTAL $ ..~. U.l.,I"l,uJ6B.:30 .,' :'. '. g:.'.~,t";;:;~;';;:i:;,~;}1~~;::Lr~iJ;;~[;~:;(t~;~?l:"1;)";~:"~];i;'t~~~1t~:{" : " ~.; :: " .; " " <'.... 11,' , " "' . ,..-'/ -, \, ',." .,' :,.":.",,',' .,,,',-d '", : '"" "':':'','.' ":\'''i,, .:::':<; : i'\",::; "';';:':;:',:,:.'. '':;l':'" :" II;:',' ,::/'-" ':;;"; ,';, OJ)..:,,:_ I .....;' :~!"' ,I':-"li:;~ ~"~i~"l /':~I t~;' MJ r,:,l r f~'~ i \~i"~\i ~;.}N :',',1 r' ..,~,~I,l;ll:r~~I,I~~t,t~!t~:';i, ':~ J; -'t~ 'i;, .r .t+:-,.:;I:l,: ,':~ I,l; '1,' /.....';,1 "',l.r ,~'., !',r ( .' ". :',~' ',': . ~ .: . '.', '. t " ' . ":;,', .l": ,.',.... II" , ',' I.' .;.... ....l ',', t .-\... ", ,'., -. .", .., ", .' ,.; 'I ,- .. , , .' ' ,'," ;.'- t," . L ,"""!i',lfp,' '..' "t;., I.t'd fr!,l 'Jr~~)r''''''~; ,. ,.. , .~'. -.~ \ ',:-p,f,'- ~..' "'., ....'.,,-",; t. f" . , . , , '." " " ' --.---- ~, -- 0035 GARY E. ADKINS - - - -, ..... SIIAH 442-50-7495 -- -- .. .... .. JUN 14,1996 JUN ZO, t998 S 01 JUN 2h t998 EARNINGS ,TA.XES . ~,......-. SHAMROCK DEVELOPMENT, INC. 24' W.I!DISON RO, SlIlTI! tlO MISHAWAKA, IN 46'4S - - .... - - - - - - - SALARY 675.00 FICA 41.85 SAVINGS tOO.OO GROSS t6450.00 HEDFlCA 9.79 MED tCAL 36.69 FtCA 1019.90 FED WTII 99.57 MEDFlCA 238.53 PA 18.90 FED IITll 2370,Z5 STATE 460.60 MEDICAL 914.75 .'! DEDUCTIONS' YEAR TO ' DATE TOTAL $ 675.00 TOTAL $ 170,11 TOTAL $ 136.59 -.. - , -368,30 ......'.h..'. . "._ , . 'L. ': ;:'. ~. ~,: ",' ,~.",:..';;.~...',.,'.':,..,":';~,'~..,:~,.','.,.,'.",::':'. ;".' '. " '..!;',;~':',~~~!; .,.. ;:.'.... . , , ;.- " 'r' ~'., ; .", "'.", "".,;- , . ~. 0035 -- GARY E. ADKINS ~ ... - -, ...... 442-56-7496 ~_.- SHAMROCK DEVELOPMENl" INC. 245 W. I!DLSot~'RO, St1ITl! 110 MISHAWAKA,IN 46.545 'DE"D' u"""'ONS:,'...'..lF:Xji?!:\\YE'in'....o.. ..'D' "TE \J......&..A' ,1,-._<1:''''''<''0''_ ~,4 . It. SIIAH -- JUN 21.1996 -.... ...- ..,.,. JUN 27,1998 S 01 EARNINGS c' :';"',- '::;';-;.. -.. JUL 1,1998 ''',T' ... V1:'S'"", "." ~-.-.._..,. h-c.-.,: - - .... - - - - - - - SALARY . 675.00 FICA 41.85 SAVINGS 100.00 GROSS 171Z5.00 , MEDFlCA 9.78 MEDICAL 36.59 FICA ' . . 1061.75 '.., FED 11TH 99.51 MEDFlCA ,,' .. 248.31 PA 18,90 FtIlIITII ~ ," 2469.BZ STATE 479,50 MEDICAL 951.34 .'.... TOTAL $ 675,00 TOTAL $ 170,10 TOTAL S 136,59 -.. _M. .-368,31 -- I I " " ,', ,., .. . .' . " . . I{",< ;';;:;~);<;,];,:Ji;~!:~':,;:?:,i':'l:,i:J'~:}I!,:; ::t:I..:':::':;;~;;;~:l,~g;;,:f:~:< 0( . _ , ......'~'l'".1:.:..:," ;;..t....q..i~ ...... '..:....~r"....~~....t,-c.~..I'I~::. ~.~ J. "r";"",l.j'!.i"";"':::~'" ~.L~"x..~:fJ:,.\...~..:t.uv."'~:"-f~ . ' . ',' ........~'. "'~ ,....... ..... '..-:; # 'f .,.. ~ ,.' ~". .. -~: '" I" ..,. ,.f, . , ~ ...... ." ,.~r " .....'.~ ",: " " .1 ,',;, ' j"":' , ,~: lit" , '. " '. " .' .,\'" .'. ,:,',l'.! "l.; : ;'. ;",'..' t, '. " ,"'" ',' . ,'. I, I r I! I. t ,~II, '! . to , J f " " I" , I", ' ,., It ,., ~,~"llit"i'tr;":~"n+i"l'.";'i.',:",'-1 ;'i.I,'~',,,..'I,1 ~l."t >f:;'~,',;".n,":" j'r""'I. ,,",'" :. ~', .., .' '" .... .' . ro, " .'1": '~,::..' '~' .," . ' . ;"', .,' . " ~.. ;. ' i.1 ,,' 1 n, .:. r. . .' '. ',fl, ~ " , , ' . 'I if' '.";,. . ; '. ~' . ','" II ~ .' '1 'It >l r, ,I _;,1. f\ '''....,. : .".1 '.' .' . ~ . r ~ . t' . " ..... .'-"-' ......- .~.......~.':..',. .--.. .......'.....'_.._-~.........._...................._--...,...- . ....- '. . -_.............' ,.. -- 0035 OARY E. ADkiNS '"' ... - -, SHAM -.. ... ... .. JUN 2D,t998 JUL 4,1998 S 01 'EARNINGS " ..... 442.64.749 ... JUL 8.t998 TAXES '__t,- SHA.~mOCK DEVELOPl\1IE~n\ INC. 24' W. EDISON RD. . SUITE tlO MISHA W AKA. IN 46'45 -~ SALARY - .... DEDUCTIONS' "'YEAR TO DATE " - .. ' 475,00 .f.. . , ,. . - FICA MEDFlCA FED WTIl PA - , ~ 41.85 - '9.79 99.57 18.90 - - -- - SAVINGS too.oo GROSS 17800.00 MEDICAL 34.59 FtCA 1103 .40 MEDFICA 258.10 FED IITII m9.39 STArE 498.40 MED CAL 981.93 " .'. . ...,.... TOTAL $ 676,00 TOTAL $ 170,11 TOTAL $ 136,69 -.. ...., .........""368 ' 30 - ,.. " '1: . .> ',:,'~ r~,:.><.~.:.; ":. . ",. .... , ~, -- 0035 OARY E. ADkINS ~ .... - -, SHAM -- -- ... .. -- JUL 5.1998 JUL 11.1998 S 01 ~, . ..... 442.54.7494 -- JUL 15.1998 ~_.- SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE 110 MISHAWAKA.IN 4654' .'~.<, >:';?:::;:{:r:~t'EARN:INGS;;Wf~:}M::;:::J<f:.:'; ...,....;. ,"".' TA.ns '.,tt;:};.~ .DEDUCTIONS.',![):<ri',m;:YEARTO DATE -- - ... - - - - - - - SALARY ,675.00 FICA ," 41.85 SAVtNGS ,tOO.OO GROSS t8475.00 HEOFlCA " 9.79 HEDlrAL 36.59 FICA 1145.45 FED 11TH ' 99.57 " MEDFlCA 247.89 " ".. PA 18.90 FED wm 2448.94 STATE 517.30 MEDICAL 1024,52 " TOTAL $ 676.00 TOTAL $ 170 ,11 TOTAL $ 136,59 -.. ..... .."."J68, .10 ,-.,.. -...-,-- _..~._-.-- .----......--..--...-" -- .'---.----.. i.. " "::: .. ,'.: ",., ,,::,,:,' :::"'''':''''':":'':;,.':,1,,.':'' ::', ::::,::;,:>,,:., ",J "."":,, :"',":',:,:',;: ,,"''';:''''',':,'','', l :: '::. ..'; :. l:i:"':..:,;.::~,I\..~: ("';:'.:! ,,'It, ,:It':',II'r}:;'I''::.~:'t::':, ;..:.r",';":l'ill.::l., 1'),\, '/ I" f.; I.:,: "'1' 'I I."f1'''t>I;!:'j1t''f',' .1:r'r':';'t,::r"lt:. 1',lltl..., ' )..:. ....... . , ,: .-t., .1 ..' ,.". ,.' .... I" , ',. . '... I, ",1 l'I.1 ,. . I j' ~ 'j I.. , ., ,'l' , : ..>J,. .', I ;:.; .r '1.1,., \'. .rl 1.:1 ".!. r t" ,. (. 'j," . l 'l' t '~' ."r: t" ".t . '1' \.. It. !, .. I.: I. . , .,,: . .' II t.l. :'~ ,. v, ,. I . I ,.1, " . . I <, ::i.:'.<::,:::: >.',~::::; ::~~",,:;::~';;~;:~:~:~:;,~'r(::~:<('::;:,:,:: ":';:::'. :'" :',',::, ,",':, :;' ,.' ::. :.', . ,',:' ':, " ::~. :::':::,':,l.{:; :':)\/ I ,:,:' ' ~..."".."" '!"''''''', "-,,,'<'~J'.i/"'\""'! . ",.,.,..., . _",...'\',,"~~,:.'~",.,',.. ' ' ~ ....::. .~.. :;.. ....j..;..:t~ S:.: ,,^,'..:, ,"r..:;: 'i.~".~;'~,"':i'l::. .':','., ,'.' ~'''''':'''''}f ~,,:.; :,:' J.. .;.: "..;. ''''~: ;',;~~;r.. ~':'\...<'--t':tl~f'l~ 1 '/ C, ~ 'Ii t..: . : :~::"I'l'~::' ;."':; ~'~'o{:'?!~~;::>:";':..,,~'..:'r'-:~~~;;:h',~I.;':,!,":t:':.I:' ~il.. .;..: . ."r~~f:.:1 Jf.;'~J,.' I. ':'.~: ,_ :', .~~~::(.'1f":',j ~v.:..r;.J ~~!I't-";t; ,,'1jf~4fi"JI'~:;,~:,;.; -t.~ "I"' - , , ,. " . '., ,'" ".";"1 t.. ,'." ", " ';', "1/'" 'I,',':: J:' ,"';' :' ",; 'r,o"':; ': ,',p.~. .,l"",~: ' ., 'I~i'\' " ','::': ',.,~ ',' ,.:: ~"::"'.: '., .'/;. ..;t:,,'.~I:/,,,:-,., i~' ' . 'I ~,.If":~ :~/:,r~:iIY\'+:; ,. ::~'::: ::,it.I.~I~~;.::'li~'::.~L~ '~}.(;~t:'~;:~A:f\:f~!~.::~I?,I,tf",~:,'r,.: ~..~:,~:t'~}:,?:.<tr;" '~.It,~ I; 'll,.~:: ::~',":"~ ~~~q :n.'.l~'rti! .'~'~I:.I'~:~:I.I; l' , <: " "; ,.," , ' , , .... , ,', , , . .., - .....,...t_ 0035 IIARY E. ADKINS SHMmOCK DEVELOPMENT, INC. - ... - ..., ..... 24' W. EDISON RD. SIIAH 442.55.7495 sum 110 - -- .... -- MISHAWAKA, IN oMm JUL 12. 199B JUL 18,t098 S 01 JUL 22,1998 EARNINGS, " TA."(ES DEDUCTIONS YEAR: TO DATE -- SAU\RY - ... - -- 575 .00 FICA MEDFlCA FED WTII PA - 41.85 9.79 99.57 18.90 - SAVINGS MEDICAL - 100.00 36.59 - GROSS FICA MEDFICA FED \/T1l STATE MEDICAL - 19150.00 1187.30 277.58 2768.53 536.20 1061.ll TOTAL $ 675,00 TOTAL $ 170,11 TOTAL $ 136.59 -.. ..... -'.......368,30 .~ ,;::: ::.':~~~. .,":.', .;.....,.. , , "\N 'f' " f" '. I' '; - ... 0035 -- IIARY E. ADKINS ~ .. - ..., ~ '---- SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD, SUITE 110 MISHAWAKA.IN 46.m SIlAH 442.56-7496 -- JUL t9.199B '-... ...,. ~ JUL 25.1098 S Ot -- JUL 29,1998 ",(!:: EARNINGS "}i,'.'>',,:, "', ,TAXES" ,,"{DEDUCTlONS'i,i'1;iKbwEARTODATE - - - ... -- -- - - -. - - SAU\RY 675.00 FICA 41.85 SAVINGS 100.00 GROSS , ,19825.00 ", " . "':~"" MEDFICA 9.78 MEDICAL 36.59 FICA . , " t229.15 .. FED WTH 99.57 MEDFICA " 287.46 PA 18.90 FED\/T1l ' , 2868.10 STArE 555.10 MEDICAL 1097.70 ..... TOTAL $ 675,00 TOTAL 5 170,10 TOTAL $ 136,59 -.. ...... "'''''368,31 ...-...._..~._-----...- --_.....---...:-----_._-_._~-.- >It' ,.:.1 ", ,:". " , ;,i.:..';'; ::'::', ": ,~ ' , .. ',;,~' . ,""',:;::'.,,'y' ..,.. ""',:',:,";':,": ;'..', ..!':,:,," ,,':.,:,' ,/ .." ,;,,::{i"':-"i:.' :':"" r~l .;'t"~"~I,..,1 .,r.II.~.,t""~l,..,;',I,;, ,1.,/'lpr:{',~tl~r,J.:....~,t'!'~'}'T;-,~;lr Jr, t'1,r.",,' _I"~.tfp":rlp,.., lqJ"",Plrld.J.'h~...:'", /". .' :.~:}:/'\ ./: ,..;. ~,\;. :f::,:...,~~",:rrr.t>::. t'.;::.:,,~~~::',l,:'-:, :~.I,.,:;.'f',.',.:'.:':"':"',."";",'~I,,,:; .' ,'..,',', '::', ",.1""'\"::','_",' ".' P.. 'I' ", , ',;.':"-':; -..-.-.... .~.-...._-.__..'..;..._'". -..:" , "M"___.o...-,. .., 0035 -- GARY E. ADKINS ~_.- , SHMffiOCK DEVELOPMEN1\ INC. 243 W. EDISON RD. SUl'l'E tlO M1SHAWAKA,IN 46545 ~ ... - ..., ...... 442.55.7495 SIlAM -- JUL 25.1998 ,...... 1M loa .,., AUG l.t998 S 01 ... AUG 5,t998 ,',i";;""EARNlN GS', ':,/,'.:..!",' """';':"""" , TA.US" ,',DEDUCTIONS .YEAR TO DATE - SALARY - - - -.. 575.00 FICA MEOFICA FED WTIl PA - - - - - 41.85 SAVINGS 100.00 GROSS 20500.00 9.79 MEDICAL 35.59 FICA t271.00 99.57 McDFlCA 297.25 18.90 F!Il1/T1I 2957,07 STATE 574.00 MEDtCAL 1134.29 TOTAL $ 675.00 TOTAL $ ..... 170.11 TOTAL $ ..... "'-361],30 136.59 ,~ ':":' l' '.'. '. " I I, "'., , ~ .:. ;,~" .::'p.': " '....:'... ~ '. '.. ."; .\. , , ,;' ',r' ',' , 10'035 I GARY E, ADKINS ~_.- SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD, ' SUITE 110 MISHAWAKA, IN 46545 ~ ... ,-' I~- II ;';;-55.7495 I AUG'12.1998 'TAXES':' "iDEDUCfIONS !:"o<:-,'.YEAR: 'IO'DA TE - SHAM I AuG 2.199~1 AuG 8,1998 [J >EARNINGS ~.'ir}?f:.:';::t:.'i. - - - - -- - -- - - - SALARY 575.00 FtCA 41,85 SAVINGS 100.00 GROSS ~1l/5.00 MEOFlCA 9.79 MEDICAL 35.59 FICA tll2 .80 FED WTH 99.57 MEDFlCA JO/.04 PA 18.90 FEDI/TII JOG7.24 STATE 592.90 MEDICAL ll/O.IIO I TOTAL $ 675.00 TOTAL $ '.... 170.11 TOTAL $ ., ..........36a ' 30 136,59 ....., --,.__ .".............M..._......_. ..-.. ' . . '.. ...-. ...."--,, .'._. ....."".. .., ..,. .-.. .~..... "" " ,~ ..... '-, _... ''''H''''..., , ~1j:t~~~~~~r!;~~I~~r!i~[~~f;~~<~j~~~fer~i;:;;r,"':;>'c:.;r,'il'J:;l,i:::t,:::; ". .'t' ,I '1 .' I ,I.' " ." . . . ',',,1,1: " ' " ",' ",' '.>',.' ,~'. :" ' , I';'?~' " ;'.: ':~'t:~:">~: : ,,,,,~,,, :'r',:rd:, '?t(\:t ;~::: ':/<-;i:\ '~/:"':'r '';>> . ,tli ii, ,',;:.~.. '\ ..~'~ /"/,:";[,,,:' ~<I'.. ,~~' -; i', ' '. ,~,' J I "., ~.t' , I',,' ~" .,r" I, .f, " ',I L..,"ll t'\'~"~'I~ l.~Jil~f,.t;~'I~ ,tJ fl.>~;~'rl' ,: 'r f r "t.r.-. '~, , , ~,;t'f.1 {',uf [. 'II r" :.... II ~~ rJ .,'11 I tkf. .l.lh~,...[~. (', , :~!t.;"l'"""','l_:'lf.'rr~"'_ir,I./I~/'lt.f..lj,,,._fl.t,"', :1 ".t ~.ill:'\,~,,'.'I,"'~,l.,t";.':t."", :.,. , ,'I '7"1,,;" "!,'I' .....f . _' , I. ''''1,'''''' "'.'.j..:' "..' '.. ',.. ,,". "-". "'. . . ". I. d '. .' . ;' ....,.,1.".',; ,'. , --,--_..~-_.. ~ ... ... .., ..... 442.56-7496 ~""t_ SHA.'t1ROCK DEVELOP.lHENT, INC. 24' W. EDISON RD, SUITE llO MISRA W AKA. IN 4654' ~, 0035 - GAilY E. ADKINS SHAH -~ Aua 9,1998 - ~.. Aua 15.t990 S ot -.. Aua t9.1998 EARNINGS',.k!.)'.;;iL'" . ,TAXES , 'DEDUcrrONSh'!~)~N:;'YEARTODATE - - ... - - - - - - - SALARY 575.00 FICA 41.85 SAV INGS 100.00 GROSS 21850.00 HEDFlCA 9.79 MEDICAL 36.59 FlCA 1354.70 FEDWTII 99.57 MEDFlCA 315.83 PA t8.90 FED 11TH 3166.81 STATE 6U.80 MEDICAL 1207.47 I TOTAL $ 675.00 TOTAL $ 170,11 TOTAL $ 1~6,59 -- ""MO ~ ...........368,30 ._-..l.. , " , t ~ .... I ~. 0035 -- GARY E. ADKINS ~_.- SHMffiOCK DEVELOPMENT, INC. 24' W,l!OlSON RD, SUITE llO MISRAWAKA, IN 46545 ;I~ ... .., I ;.;z-56-749S __ ...... 1Il4.... .,.., 0..... AUG 16.1998 Aua 22 .1998 SOL AUG 26,1998 , ,', "<,"'EA~G$;2';?/iith;\;:iij\,;:;ii}TAxES.;; ',..,1' :,. .. ..." ,-,"',;;P"'i_"":",i?' '''.-'.. ":.... _.' " ;,DEDUcrIONS',.Mt&t)iiG.YEAR:TODATE - - ... -- - - - - - - SALARY 575.00 FtCA 41.85 SAV INGS 100.00 GROSS 22525.00 MEDFlCA 9.78 MEDICAL 36.59 FICA 1395.55 FED WTH 99.57 MEIlFtCA 325,61 PA 18.90 FED 11TH 3266,38 STATE 630.70 MEDICAL 1244,06 TOTAL $ 675,00 TOTAL $ 170,10 TOTAL $ 136.59 -- ""w UUJ.uJ68.31 ._.....~ .-- . " i;;;;g~~~ij~~~~~~l~~;\;,'I~",t;;},;,;,;,::;;::;,::r}'t:':~~:;,"(';;1~{11!~:':,~' .:'. ;. ': . ',.:!~; - r:. . i ~ !.. ;,.', :'~ t\:' ... 0035 ~ .... SIlAM _. AUG 23,1998 -- SALARY TOTAL .., 0035 ~ w. SIlAM I AliG 30,1998 -- SALARY 11 TOTAL ,,' I, " I , . > ',., '; > , >1',',lf':, ',',' " , It. t .~II f ' . J,' 'I I, " , ' I r , , ,. I ~ iI, \ ' ,.) , .' ,,, i ! t' ,I ~ I., ,~., I u ~, . tH' , , tft' ) I,', ~:,'.I'~.~.'Jf~,II.:J1 ""~I\.' 'l I r'.,.'I" '. "'"",," , . 1"','"1'>."'"",, ,', , '. ," '.', '. " " .'. I' .", ,_ ,.,", f" .,' ,';..f" ",I..,' f.., I," ".I'f' ....' Jf -111"'_-:\" ..;,i' , ..I, I t"lf h, t r Ii'" ~tt' " ,,,.,! I r I, "J,I H~..'i', f (' " ,- .', . .. ,-' .. - '- ". :, . I I ~ '. " I j ..',; . . ;, ", ,', ....,...- SHAi,;mOCK DEVELOPMENT, INC. 24~ W. EDISON RD. S l11'l1! II 0 MISHAWAKA.IN 46~4~ ,. ,. ...... l " . .; ';~': t .: ., . : . t " " ' "".'." . "" :::1' .',: '. '" ,--.-. 17"__.,...._____....,~_....~~______ DEDUCTIONS, -- SAVINGS -- 100.00 -- GARY E. ADKINS ... ..., 442.16.7496 -- .. AUG 29,1998 S 01 -. SEP 2,t998 , TA."mS $ 676,00 TOTAL $ 170,11 TOTAL $ 100,00 :, ,"'".",. ..nTO DATE ..,'.:.~".-,,_..~ -' -- = GROSS 2J200.00 FICA t438.40 MEDFICA 336.40 FED Will 3366.96 STATE 549.50 MEDICAL 1244,05 -.. ..... ...........404,89 "EARNINGSi' " .,' ~_.- SHAMROCK DEVELOPMENT, INC. 24~ W. EDISON RD. Sl11'l1! no MISHAWAKA. IN 4654~ }DEDUc:rIONsiii'h;n(VYEARTO',DATE $ 676,00 TOTAL $ 170,11 TOTAl, $ 100,OO - - - -.moo - -- -- - - .,' , ",,675.00 FtCA 41.85 SAVINGS 100,00 GROSS , 23876.00 '\ MEDFtCA 9.79 FICA 1480.25 FED WTII 99.57 MEDFlCA 345.19 " ,,~t. ' PA 18.90 FED WTH 3455.52 STATE 658,50 MEDICAL 1244.06 .' ',' -', ~.::/ ':..,~:,':::::~.\;;:~~~;~::':,~;~.~; ~ ~";'I , :.: ,. Itt>. ..t~,.t . t: ):t(.. :.,. - -.moo FtCA HEDFtCA FED Wilt PA - 41,85 9.79 99.57 18.90 675.00 " , " -- GARY E. ADKINS - - -.. ..~ .-.....404.89 ..., 442.16.7496 I SeP 5.1998 "EARNINGS ... ..... S 01 _. SEP 9,1998 '........."...,.............-....~~.t......W"~.A..~UA_..~ '~..I" ~.,...A"';/~.~~....._..........:~..4,.",."".....__'l1>_~~... .. .u .'1 .. .........w......-...lol... .' . -,' . .",.-..' :::;;::';:\it~~.,<,;". ": :':, "',:,:-,<:.'T.AXESI ',.',' '/,;,;:'{ '~'l... . " " ,I I" t ." ,:,1 , , I , .'h '-'t' \,' I '" ",! '1_' ,\ ,\ ,",' .', ',..", ' . ',"',., , "',,, i, I ~.\ 1'1' '!'" , ~", ,...',~r'I';"j,IHJ/,':'~II',",~,.o!_/~1 '1,.-,. ,f,:,H: I 'tr t'~l r.' ,11':11'1. "':'II'I'~r)"'.. -.'-~'t~,''''q~I..t.;~f'l'"n,..' ..,','r~""d, ,',-,," , . ~ . " 'i. ... ,'I' -.!..... n' " ','" .,'.', -.,' .', . ..'," ' '.' f " " I . . :',, 1- ,",,"'-' ,,' ,',':""'rl".'" -'.j . " ,. I" It : I ',' I'~' I t: ". ""'II' 'l,.q!,LII~, II'dll.r,,;...llr'..'I~ ,:.'. . _I, '. ~" :. "t .': 'I '... t'""" ., , : , I" " t', " , " ',', .....-. .... ----.-....-...-..---...-...-- ---- t'" __ " . ~, -- 0035 GMY E. ADkINS ~ - ... ..., SIlAH -- -- ..... SEP O,lg98 SEP 12,t998 5 OL EARNINGS - - ... - SALARY 575.00 -- 442-60.7490 '--.- SlIAL'rlROCK DEVELOPME..'IT, INC. 245 W, EDISON RD. SUITE 110 , MISHAWAKA. rN 46545 -.. SEP to,t998 .TAXES: . DEDUCl'IONS'l'\.(/,i'IYEARTODATE - FICA MEDFICA FED WTII PA - n.86 9,79 99.67 tB.90 - - - SAVINGS tOO.OO GRDSS 24550,00 Flr.A 1522.10 MEDFtCA 365.98 FED IITII 3565.09 STATE 087,40 MEDICAL 1244.06 TOTAL $ -- ..... ..............404.89 676,00 TOTAL $ 170,11 TOTAL $ 100,00 '-,";--' / ';' . " , '. . '.... ~!.. ~, 0035 -- GARY E. ADKINS ~_.- SHAMROCK DEVELOPMENT, INC. 245 W, EDISON RD. SUITE 1I0 MISHA W AKA. rN 46545 '>) DEDUCTIONS; ff0,&\){'f,';!'\lEAR,TODATE '" - SIIA.... ..., -- - 442.56.749 ,-- ..... 1M'" lNWf .-_ SEP 19.1998 S 01 SEP 23,1998 . "E'ARNlN' , GS' '"''In,..",:,,,.',.''':'':''' "'AXE. S., ,:\.. . :;.: -', "/:~:;Eji1:ti_:\!,:::::::,:.i,;_i,:::":):::,;,L&, ';':';'/.,-;:. SEP 13,1998 - SALARY - ... - - - - - - - 760.00 FtCA " 46.50 SAVINGS 100.00 1lIl0SS 25300,00 MEDFlCA 10,87 FtCA 1568.60 FED WTH 120.57 MEDFICA 366,85 PA 21.00 FED 11TH 3685.66 STATE 708.40 MEDICAL 1244.06 TOTAL $ 760.00 TOTAL $ -- ..., ......'451.06 198,94 TOTAL $ 100,00 --_...-._. -----.-. -'._-". .-----.........--- . " : , , ," "','r,;p, , " . 'II " " '; ,\'1' l, ::1'1 .,); t' ,1'-' .' '>". 'I" , . ,'I"'('t' 'I "I.,II'~I':\""t,~/I~llt,l,j~lltr.,..ll'\''''I''''.' ",f " I.' t: I.., '.t(:. dl.(' .1, .,J. Ii, 'I "..ll 'r' " . I ", " . ''I' " ','." H ," ~ ,,, , .. ,." " ,. '",,',,; I,,'. i(:', I' ,i' 'Hr., "'1("" "I,! _.tli,';';>, ~ ,.,.1 \"tll, " l.../f;r\' ,-'lit rd'ptit~I..,~. /". .' '....' ", "",...'~:' 'I,' "" \ ,'~,'. I; .,','>, " , ....". '" .. _._.......-._--.-.....~......_------...-..., ,~.- .... -- 0035 GARY E. ADKINS - - - .... ...., SIIAH 442.55.74~5 - -- .. ... SEP 20,l99B SEP 25,t99B S 01 SEP 30.199B EARNINGS , TA."aS , - - WI -. - - SAl.J\RY 750.00 FICA 45.50 MEDFlCA to.BB FED WTIl 120.57 PA 21.00 TOTAl.. $ 760,00 TOTAL $ 198,96 TOTAL $ 100,00 -... "M. ,I,"~Rj,u451. OS '''- ",' 't" " I ',' ., , ','I' ',', ..., 0035 -- GARY E. ADKINS ~ - - ..., ...., 442.56.7496 SIIAH -... SEP 27.199B -.... ..... ...,..., OCT 3.199B S 01 "',EARNINGS'h);';ij'W;{)', ...... OCT 7,I99B ",TAXES, - .- SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD. surrn 110 MISHAWAKA, IN 46545 DEDUC'l'[ONS'~ "; ',YEAR TO DATE - - - - SAVINGS tOO.OO GROSS 26060,00 FICA 1515.10 MEDFlCA 377 .73 FED WTII 3B06.23 STATE 729.-\0 MEDICAL t244.06 ~_.- SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD. SUITE 110 MISHAWAKA, IN 46545 , ,DEDUCTION'S>{i);\(;,'[.:,\YEAR 'IODATE - - - - -'" - - - - 750,00 FtCA 46.50 SAVINGS 100.00 GROSS 26BOO.00 MEDFICA to.B7 FICA ,. 1661.60 FED WTIl 120.57 MEDFtCA 3BB,60 PA 21.00 FED WTH 3926.BO STATE 750.40 MEDtCAL " 1244.06 ,.. " - SAl.J\RY TOTAL $ 750,00 TOTAL $ 198,94 TOTAL $ 100.00 -- '..M............451. o6l -"'-"'-.-'- ...--------., --...--....-.-............. ..........---.---...---:- ........ ,. i~ '.,..." ""':';::"":';;':',:':11:'1 ,..r :..;:.:.;>'::..,,'.::'::':~".::,:,:.~.' ,:," ..:," ::""':','::,~~",>,:,":;/:'..:..'''' [,"'r. ,"r, ".,.' ,.,."I'I"':""..::..\,'q"';r:~":t''''I,,'II. 'ifl""'III~':"I, 1'.:1",' 'lifl,lflll '1.'''::I.,:~Ii'I'''I.W''':':l,:'''.i.l~:h.,t.,t'::I':' . !.... ., 1:.;'[.1'11.: ,~:"'II: "r "','1"1' 1,'1:1",11,:".1."'" "I:'::-I~"".\t ~' ': t.,,' I" -',""')1:1.:.1.:1 .."I', ,',...r-..,:,t ':'II",~: .:.. ':,", ", ',I 1<1','. ~'~I~J' I"', ':II,I~I ,,} "111,'1 .,)',.,,>1,1. .,'f ~.I:'r..1 ....,. '"J"'::.. "." .""" :"1 ".,. .' ':..... I "..:1'1' ..': i:. ~. , : ~~:'." ,~::, . :'~:~;~~~/:~~;:<:~~.;:~;:~'~;~:.~r:';;~:\~~;:::::::;) (~:,:,:,,",,/;.'/:::,: :.:,:: ~;, :',:,,::',::~::: ,,:;'; :~)::' :'~:':.;:.,,;:';,~:;'~;:;~:,;:'~~:~::,:!;~,.r~:::',~;;:~J;~:::,:::' : . ' ~ ,',..... ~ O(.''''f .n,!, ''7~..~..J..~,:vC.~. ...~, \ ":':': ..' ,," ...'.,..Y"'~i"I.,J:.. .: ' .' t .~.,. "'1 ,\ 'l'\!r..~"'r!... .tI...=.V:1r".:!..;til..l....,~;:.., '" 1 ., .".'1'.,.1' - ,.,~ t', "'- . ,- .~ ~. ' ..,").. .......,., '......' ." ,I.... ~'. . .'''' .r.... '.. ," '~....'.',," I, ,',' '.,' ", ;,!~:::~r)(\'~/i'~~~:'~:~~( .'''' , .' ' .. -' . I . i . ,. ~.. . . . .' ~ ' '" . ' . , ' , , ': .,' ',', . .:',,'. ',' .",' ,I ';1 .,'.."',' '. .., '" ... ;., '". '.' .' ,'~ ,"> . !.' . '.. I '~ '.. ..'. t'.> , .,' '. . "I...l.f'/I!..,.tl.r..~)",,!;...J ,'1"'1."."0.,'-,1" "'."jl.:.~,.,:,..'1"'H"""-,lt, ....,..,. "~'-Ir ".,'I,If.1,.'- .: ,', , 1-' I ~ ,J -IT"" i,~I,~ ,..' It rlll",.Ji,lt.~",.._,t t\ ~''''' I. r'~' t. r'l't~'~" \.t!.ll'.t,t b. -I rl1 J{" 1.)1:" ",lIl.rd '1.~1Ih.,1 (t. :1; . "~::':l t I ~\~I' ,I '," I; t:~~ :_. II,'. f. ";..f." II . .',"'r ~'.,l..~t, ,.>"r:' '1". .' ':., I,' . " .r':' ; .' ..'" . -.~ ,":.", ", ,', 'I,. ",' ~'...... - I, .'. " '. . ,-. . " .'" . " ",', , ",', ',.....,. ",' ,. ",,;..',,1';1 ," ,', , , ", , . '......._..._......._........_-_.._....'..~ _..,---- EMPL.: (945) OARY E. ADKINS CK.~1 09380 ..GROSS.. ..O'l'HER.. ..TOTAL.. ...NET.... CURRENT : 666.00 0.00 686,00 479.60 Y-T-Dl 5,213.60 0.00 5,213.60 3,578.97 .FEDERAL. ...FICA.. ..STATE.. ..LOCAL.. CURRENT : 76.65 52.46 19.21 6.66 Y-T-D: 572.04 398.66 145.99 52.14 OARN SAVING ONIONS UWAY CURREN'l' : 0.00 0.00 51.20 0.00 "i-T-D: 0.00 0.00 465.60 0.00 BONDS HOSP XFEDTX OPT CURRENT : 0.00 0.00 0.00 0.00 Y-T-D: 0.00 0.00 0.00 0.00 ,', .-. h " ':~<ir3,i: :;:::: " .. , .:...:~',. .: "~',~, '-I. . ", 'T'~'- ..'d '. ~ t ~ t ~I:-,i~'.t'\ r.,'. . . I . .:/t:'~.~~;:.~;.I:, 7.:,~,,'},r,:;,:,/,.,'.,.:,,:~~~, ,:', ::':t~:. ," c-. :I~ '<r:''': (1451 aur I.ADmS ;:~.: ::~~,~~.~t!'.,.~I:I, . :?::~;~.~S~';,\ .. . .-o:acss.. ,...oTDIR.. . ..TO'rAL.. 121"[..1 CU1UUEH'1'1 {)Z3.20 0.00 ,~-..U3.20, 'l'''T-Cl ''i; 14:1.:,0 0..00 _ _:' J,.~.:I.."o ..i~~~~::....:,;:.~,.~:':~ I '~":::f:".r:. ::: . f' "'" .racllALa ...'lC,\oo..... ....1TATJl.. J ,\ I I 'I CI1l'.IlIllrr, T-T.DI . ::-.,:,\"..23 "J"''' . 411.140 n.n .', 33.05 '~"I' 213..0" :~~" "107.51 '-';::':.~'" IAvtNa \;~... tnrIOIIS ,. ..-'.',~,;" ", . , . ;0.00 J'.';':r' .....0 , O~oo...5~t':i!lo.40 ~ .!it~t"l:' ..,;. - IDS~. ,'t'\xmrrx 0.00' :1;. :.0.00 ,'. , 0.00 ....',:::,... 0.00 ..... RATI DUAmQNII ....... 'BOllRS .:: lATa' '. 'tAr , , , ,.n.oo .t..11~~~~1i.54..~0 ..,.t ':.. ' <,;;~;;g;;~l:.?~:<_:._, ' . .00 .~ ..~.. .101'1, ~.a74 .40,' . ,i~:.>I..,:-:-'~4 . .. " ,'.. OTBDPAY, '.-r,r.~<..o.ctO.,:;\~:.l.~,... .:....:,..~.~." , ' """.' .. '; ,,;::.. .~: ';:: ,.; ..' ..-..=;~f:,~~n;i;;: ;'j.j~w~"".:Hi~?'j':'~:,>..;"~,, .,~" ,'.:'.', "': '-:~.' .....',~., ". ......'l{~.I.~..,~.,..~:'If~ ',' - . .: ':.~ ". :..:..~~;j'~'~C ~/.::~~~:;\ ~~:~'f~f,<:~~,:"..t.' ~..~t: .':\," , : "';:'i't~' '.I~".. . It;t ;...'rW:'J....t{'J.... '. .~ J, " :; ;~;~:,'i~,~,:;!", '" ~~; ~ ~'dt::,r " , .. I':'~ '.': '. ~~'l-o'.; , .. . .,":;J .' .... .. i:~,";,,7:1 Of' '." '.!. ...' .\ '" , ~ ' "... ~. ~ .;1, " l;lI:.l. on7~ ",'.tl, '.l~":"lt:': ...m.... ,Io.n .2,.~:l.1.7 ~~;?f.~::. -t.OCAL.. "0;:: ~.:_2;l. '.:,'n.u. ., ";~': ':~" ' '1 UNAI ,', ...'. .., ,,~.~: 0.00 ,tl'~;' , ,',. ,1 o.~o , " .';,..'. ,':..on ..0.00 ',' 0.00' ", , .. :"',,:;':;q:' . E'ERIOD END I.o."lG I J9.~e)8 ~.... ~TE B~OWN .~~QQ HOURS RATE PAY 32.00 at:: $17.150 548.80 OTHER I?AYI 137.20 ........................aa TOTAL GROSS: 686.00 .... .:" . . . ""~' .,.., ..GAJUf t't1PJtIN't', "r';~io' 00' 1-1'.DI '.~~;~'" 0:'00 c:vIUt!lII', y.-r.c, 'ICIIIlS 0.00 0.00 '" " "t.' . '. I ~... ,,' .... " ,.~:, ''':00 SUQIHO. 11/.5/11 .. ~ I " ','-- .-----...-..>:.. ".-..-~>:_.. "'"~._."-'--"-"'7- .. " 1"1 '; . ! ;, ~ . .' 9275 ,. '.:.... ' . .. '.~ :' . . ":" 1 ,:' .; ..;,::.' !'~:" :: . ,:,,: :~. \:~:.: f.i~~I: ~.,':'~:.::~. :1; : ;.~:.,;//;:::.:: ~ ',:': .':' ".:"I'~:'~~:';I:>::< ;.:.~ >::.; :1: .~~: ;:;/:~\:',( ,.1 ::'>';'~.:, <.;;./:.,: :.:::::::, :.:..:. , :1,:" '. .... ~.Il:'o( ..,;t,'tn". ..,....,'It'L.lr..'.t.ll,dtl, I,I"..!,"L;:"I'I 1....t..I".I,li....'I-:.."tl".~~t.,:J,',...,.,,,..:,t',. ",' ~\ .. :::,~'" .' n .~,: .:i~:":I' '. I "'-; , '.1..'; .:(:~,;':;:I:;~.. .1,'. .. ,!. II '.j"', =..' : ~., ,~:. .::' :" ,I,..! " r : I : ", 11:/1 .: r'lll 'f'l 'f. ~, I. ! I '.' : :'1 .~; " ,I.: .~: :, I . t, .1. . t .. :. .:, . ':' " 'r I ~:..J;, . . ..... !o "', : "':' .,~ ~'''~' .' 'I )1 ~'r"'\ ....,: ;''':: ,.".1 . ."l.r .... r" b I " '\- I ".' I ~ .';:- t ..1 . :":": ..' ~"'.: ,.:' t ~ I' .. . , ;i;::: ,/,'.,:, ';:':',:~;:i::ff~/:r..' >}:;i~:?i&'!;~:~)~:'<)~; ;;;\ :;>:' .';:,~..' :-::;(:;;\,)' :.:: ~,\ ~ ~ t:.:~'A~j;~;~::;~;j~;~ff;~<i ;if:ii :;"'~::' , " 't';. ~ J-' "": ,~, 'f:.:-':':. :or:-. lo~:i:~"(' "'"t',:" '~'~':.~~;;:~.: ;..... ~.l.___ ":::"~i:'~' : II ~ -(0:. .... "--:';"(.~~~I' ;:.. ".~'. :~;:~ ..:..,' ii'! f:t~ ,I :~:. . ~~~. ~ -:~ 4:~~~il;?1:'" '~' G.."~' ; '."'.": '('",'.. "-f.i. "'~:'':' .. :'~:: "j ~;.: ~?:1~";' ;..r,rl,;..::..:....~::-.o(O.;~:'.;t:: ~:::.,:> '::, ;I::::' 'I~-i~: t~J;}:;f.~,.~.? .~Il.~" {; ;J>( :".... f.: ~i!f~:"~:,~ .1 ~.'" :1 ~ ., lit ,~ ., - i . ';' . .:t . .. :.. .... . .; .I Clly, ""''' " ..it 'lilli, 'W', &II1lI :1' ...., It "1; "h,. "fll'" ...,...,... .."It. "'t" ~t-rr G ;;;;;;;i;nUal .. 00 1'l~ WI", SJ 10 ~o 10 Ihil hlno? , al.cUon Clmpl'~n' 1/ lolnl rllVln. 40" vo~r ooo~" 'Nonl S3 10 0 10 Ih.. IuM? . 1 S'nU'1 2 Murll4 ""n~ /Olnt r,Mn (Iv,n " only ona hlO IneofTl4) :] -.a""UIiIiIl' '....,.11 filII,", r",,, ..h.,', 'e~ ......, 1111111_"" "",, ~ 4 HUd 0' hOUllhol" (With qUalifying Q.flon), (S.'lug. t2.) It lit. 'lI'Ii'",,,, ""'11'11" ''''1' Il:vt""Yllll' ''''''"l1n, .,,,ttI/UtI"'I',lIlfll."',.. ... FlJrm pol';O I , lJ,. .. ,~. ,. S J '.U'I, I el....,. l. _II. 11 ",''' I "'11' -. "'.,lU. I FIling Status (5.. pa~1 '2./ ell"". only an. bait. E.1omptlons (5.. p.;o '3,) II Mil" I""',a UUIIUII" "..n;,u, Incame .\l'lac:'1 c.,py 3 0' your Form. W-2, W-ICl, illlO 10Q9.~ h.r.. Ir you did not ;'1 I W-2, Slo p,;, IS. I!nda... but do not ,1l't~c..,. your paymenr InCl P~ymenc 'tQllC:'\er. See P",I 32. AdjUSlmenls to Income C.a1l1/on: See 11\S111.tC".Jons....... ... Adl. Gr. Incom, 1040 lj..s'.~i~ di~fdl~;r .i;~~~~.T~ ~r~R'a tu rn ""~..."I'...,.,OIt'f ..."1. ""U"'''IIIII'O''I, 1996 I "H '/I, ~IH J'It,-OIL II. I,,.,,, ""., 'h YU"I "~'"' ,1"'.'"41" .11 0"", "4, 'U'.':CI" YOlJf IQcl., UCUl1ry no. .,..,...::.. -7 Q tSpOIJU" loc/.' ucurlr'! no. , .. c:, ..I) c:. For PnvI"', A.I .nO P'P_""or1C A_O~.Uon Act NOtlCI, ... QI ,,7, Yu No X ...~.., '''"11'~, .....'II'IIU "',,'It'III, Gl_~.': " ,,""lltlll''', I.."'.." Itrll ~'I'I' .ltrf ,01111,1 :3..)fN,:1'./ MO~'U'"'' 35t ....toll. ""01 O:,'t'C~III; ...,.,,~ ,"lI"t1'''&ltOI''''~'IU "'''1141 ~o..., "'II"', 5 5, l.XJ OUIII~ln wldOw'orl with 400,nol", on,ld 'vr, 100uo_ 01.0 "'9 I, IS.. 0000 '3,) Vourll" II your PI/OM (or oomlOne .Ioe) e." ClllIm yo~ II a eop.nelne on hi, or hl~ No. or ..... ...,....,.., .. II.< rellJln, 00 not onlOK l><lK f.. BUI bl OU" 10 Cheek box on IIn, l3b, pg, 2. "'. II b S~ou... I . . . , . , . . I , . I I . . . O d I I I,oU'''UIlI'IIOIt,1 I I" flI.,II,"r. C,. N..., Y"" C 'p.n ,nt.ll: ucunt'i'"um'lr,ttuIII ""t1'"'''I_II~'" ,.w"'"", "'1I0llllUlo CII,fi'"11,/ft'I.,n".III' '" 'U.,... U"I,. _ r:,~lIfuo,'"' WII'I ');'rMC'!':'~:" A.D!<!t>rS kl6l-H -748a !SON I l2 ';I"'~,"r" ~~~~ ~~~~~ I~g:~;:~~;~ g;gg~~~~ I g r,:~~~Ji:',:;~::~. I 1 I ..g. "I I I I I -L . ---.:- - OnOlllllln., "" h 1l1lt,nlltUUO\lI_ d It ~Dij' "UlcllIllIlI'tllvl "III ,0'" ~UI" CI.lm.'o U ~Oll' lIuoIlG.nf\lIl"".lI'''''U'.""m,"l, I"'UII.,. . iOtal number 0' UlmaDO"S' elalmed. ' 7 WagA'. 'lIilllll4, .po, .Ie, alt." ''''''''twor , 7 I 8 a Tlleabl. InlOI.ot Inoeme (I" pag. lei. Anao., 5enaoulo a " ovor $~ 8a I b iu..t.,mptlnl.,tIIlll. "'" tll. :)ON"l"IIIctuOl Oil Nil' I.. . 8b I IWil:ili!:i 9 Olvloono Ineome, AM,en Sen.Oul. 311 0'" $.00 9 10 T""=I' '"I1.Inco, cr.dlto, or oN.OlS 01 11010 ,no loe~ 'nco"" t"lI4 (I" Psg. If) . 10 I 11 Alimony rlOtlvod 11 I 12 B~sln...lneo""or(loo'). Mach SenoduloCorC.ez . 121 13 Ca='lsI ~lIn or ~a...), "requ~,o. anaoll Senodul. 0 (... PI~O If) 13 I 14 01/101 ~lins or ~ouul, Anleh Fonn .717 141 1Sa TOIsl IRA allllibudon. llSal b T...bl.amounll.......'71 15bl 16a illlA'''"'',", & UUIIIIIIU [T6al b i'uabl, amount,... u,o tn l6b' 17 ~.nI" rlllur.to, rOY'I"., plIlnmnlpo, 5 oorpor.don..InJ.lS, Ole. ANlICh Sohee~le a 171 18 FlITT1lnooma or (Iou), An.<:I1 Son.oul. F . 181 19 Un.mploYfTI4nl oomoonUdon (... pig. '1). 19 20a 50oilll.oounty benenlS 120a I b T..a=l. amounlll.. ..,. .., 20bl 21 Ol/1er Inooma, 21 I 22 Aad amaunrs ,nOwn In tit nanf ::olumn for lines 7 t"'auo", 21. This is '/Our totallncomelll.f 22 230 Your IRA O.dUCllon (I" ~Iga , I) 23al b S=olae', IRA d'd~edon (I" pig. '1) . 23b1 24 Moving ..p.n.... Anlell "ann 3103 or 31C:l-': . 241 2S Ono-hllf 0' sell-.",ploymenlllle. 2S I 28 S'If-em~loy,o he~tn InllJ"ne, dlldUClIon (I" =.e. :11./ 281 27 Keogn & .d lImoloy.d sa,' .I.n., " sa,' "'OCK O. ,r 27 I 23 P,nllly on uny 'Mlne"wsl 0' ..'In;. 2B I 29 Alimony pliO, FllOJp"nr. SSN '" 29 I "'UtllI,"It". ""1""011 ~,. II lit ... =5 832 , 5 - 30 Ace: tines ~a Ituoue" 29, rh831t 118 'Jour fobl oJcHuscm_nts . 31 Suarract lI". :]0 rrom line 22. nus is 'lour oJdlusted roS$ Incom. U. - -, 170 Sa,084 1815 Fonn 1_ pog. t '.:~ "~ 7',1 -. r. ',~ ~ '~ ,'t "'; ~ .~ 5 ~ ,... ,1; :'~ ii, i~ .' ~ :.1: ~, ~, - t,', f ..1 ~ '" I I ..~ "... ~.~ ~~ ,J '.'':' '" :'! '. IH' FQlIl1 IColO ~'I E & ~J-- TJX campU- tJ,lo~ 1~""lJ.a~' :JI '\; ';1: " .: .~ .1)"" wanl NtASIO \o;\l" your tv, I" p3;' l' Cladlts ,s..o.g. I') Olhar Taxas (SoH plgQ ~,I Paymenls AnaCh Forms W.2. W'IG, .no 1C<J9..R on lI'I4I front. Retund or AmQunt You Owe "111111 :z H.~tl'l,~!~ ~,c!<:nJS :12 ,t.I11()unl 'ram IIn.. J1 (1~llilSl.t1 gll:UJ Incor..' , . . . . j . , . . J3a Chll<:k ,':OVoowotol.!! 0' 0100,0 Bllndl O'~ooo.. will.!! 01 Oldll,O Blind, AOd tn. nornO.r "00'" ohlKk.o '00'. .no .ntar Ih. lolll h.,. ~ ~~a b " yoor o.,.nl (or ,o",..n. .,.., "n clllrn you II I dlp.nolnl. cno<:~ n.". ~ ~~b , c" you u. m,rn.. hllnq "PII'I~y 'nd your ,pouu 111m II. d.du,aonl ~ . ~c " ' Qr YQlJ U, I duQI"'IG!UO lJi.n, IQ' p4gQ 23 Inl1l;"eck hlll~, , . ,. <oj! 1,lj'lt'l t,.mllld dlducllon.lrom Boh.dul. A.lln. 1.. OR } .'" ,," ~4 !nlll SUnd.rd dlducUon .hown o.low 101 youllIUnq III,"', hili )'I........ "'1"" lh. ~,.IM. ". ,",n.., _, ,'11'1" U I. fl", ,.", 11""1"'" '"lInl''' tt ,I\~ lIlU'''''' n.. ~II 1'1' I 'f'II,,,,"U'.'UIIIIIlIl'lt,UfO, ,1'111' .rg.r . Slngl..Sl,Ooo . H.,d 01 hOUUhOld.$5,71lQ ., I I 01 . Mllnld IIIlng Jointly or CUlIlMng Wldow(")-SQ,I~ ~4 your. . Momld nnng '"Plllllly-~,a70 I~I::'II':I: ~5 Suov.ctlln. H Irom IIn. 01. . ~5 ~6 IIl1nl 02 I. Sn.010 or I.... mulllply s,z,SOQ by 111. 1011l numblt ot Illornp~onl d.......d On IIn. ,". II IIn. 02 I. o'.r S4M2!. ...Ihl work.hiNl on pI,. 24 lor Ih. 1I'I100nllo .nlll . ~6 ~7 TUlbl.lnoom.. GubVlot IIn. 04 Irom IIn. l4, IIl1n. 00 I. 1TlO1I1I1.n IIn. OS, Inllr -0.. . ~7 ~6 '1'... Cho<:k II Irom: BlliJr.. '1'1011, bOT" R.I. Sen.c:ulu. a OCOPllol Olin r"wol1< IhHLardO ,,,,..,UI.,.....'.141, Allu"u'It,h,,..,,I.,mt'IUI4 ~ . 09 ,lddlllonal I..... ChO<:lc IIlrom: aD F<lrm 4.70 100 Form 4.72 . 40 Aod IIn., 04 Ind O. 41 Crlclllor Child & d.p.nd.nl '01. "p.n.... An.oh Form 1" 42 ClIOlt lor 111. .Idlllty or Ih. dlubl.O, ,In.oh Soh.dul. R 43 Folllgn I.. erlolt. M.en Form 111. . . . . . . 44 Clh.r 011011. (I'" ~" lS). ChecK II 110m a(] Form 0.00 bJ Form ~14' CUForm 040ldO Form 44 45 APd IIn.. 41 Uuou,h ... 46 SUbl"C: Iln. 4S Irom Iln. ~. II IIn. 44 I. mor. Ihln IIn. ~. 'nlll -0. 47 SIII-.rnploy"...nl'.., AnlCh Son.eul. SE. . 48 AHern.DVt minImum 11X. Attlch F<=rm e:z.s,. . . . . . . . . . . . 4~ Rec.t.erurtta.xIl,Cheelclffrom: aO,,,,",ul bO",,,.,..., cO ,,,,,,un. 50 Sec!1l .ecunty .nd 1.1'010"'"1"" On lip Inco"," not r.pon..lo Imploy.r, An". 'or,. "I'. 51 '1'.. on qualln.d 1I111.",.nl plan.. Inolueln, IFIA., 1I1.0ullld, Inlch Form 40Z. 52 Ao.anc. .,rn.d InCQ",. ClIOII p.ym.nts Irom Form W'2 5~ Hou.lhold ornploy"'.nll..... Anaon SOh..ul. H . 54 Add IIn., 44 Ihrouoh SO, Thill. your 'otol tAl . 55 56 57 ) 0801. 1 1 .;'! . ~ ~a . 09 40 I 11:!I!~!I!llil ;I'liilll 11:1"11'1111: :j;I!I!rl 1:,,1111111 I,t .. 45 46 471 48 491 50 I 511 521 S~ 541 1:li'i!n! 11'1"11'1' '1['111 1'111111 f~I' i~~[ I NO ~~~ill II ~~~,I~l 61 52 , 8~ i~i!l~ . 85 41 42 4~ 5,119 . ~ ,1' 9 j 41J .~ - A -- .....~::' -"'''Il"c~,". a. ...,tlll'l'14. If "'y" ~"'" ,10''''1'''10'', 11'1"11. "U 55 I 10S5 ..~ ,.. p,y","nlJ .ne arnounlllllpllod 110m 1GS4 '.lUm 56 I ~med Income cndlt. Arulll 51"'''\111 IIC II .,," "111" q~.Il'"", Ili!IIII!!I!I;! amlca. NOflU_UI. ..,".. t"'OIll'l'III,"'" ., I !l1.!!I!::: an. ,.,.. ~ 57 Amounl pile Wltl1 Form AaU (ellt.ns'on raquut) 58 r......oo....CI,lnly,lIto.ll"r"ta...,',.,II.IClf'..1I.0.'ZI . . . 59 at,.,., ...".,,"tJ. CntllllU ',om aD..,,,,, ,.u b 0 .rorl'll ''13' 80 Add IIn.. sa !hrOUOh ilO. Thu. II' 'lOur totol o.vm.nts IIl1n. 51 IS more lI1an IIn. 54. 'Uo~.ct IInl 54 ~om IIn. '1. iImlunt you OVe.~PAIC Amounl 01 IIn. ~ you w.nl RIlFUNC!C TO YOU Amount 01 IIn. ~ to b<I APPU!C TO YOUR lU4 !$T. TAX ~ 84 tf II", .'i, 11I," titan 1/1'11 ".'\llv.nll",., ,,.'" w",... 'fIUI i, '1'1, AMOUNT YOU OWl!. F<lr elllils on nOW. 10 p.y.lncludlng using Form 11l4O-V. P.yment Vouen.r. ... p.g.~. 86 :onrn.lC<l tl>< c.n.,IV Is... .... 031. Also InClud. on II.. 55 166 I Q 3 58 59 60 61 82 63 64 65 ~' ~ ~ Ilil:lllillllU:t:ihllJilliil:llt:li':lltil\(!I:IIII:I: lilll !'~I'IIi'!; ::tl ~ VQII'.II"Atl.i,. ~ ~f - ::M::JLOY::D "..uu', ,~..t1I" St"='E~.V!SO~ I..... II I ~."'Ot.'ft' rx1 I r",,", SIJQ\U"'''O''.hltI. I' j't"'''l\Irrt, aCTI1 "'tat IUJ". ""u.,.,.. )..'--.J ,"~".tll" , --:l.....f' 0. Y'" ""' J""'I"t,",(Q,-,o...,. ~ K-r t'"tl",,,,atO'f'ClI6ItCl ">.J 100".. 7 0 NE'tI ""..",I", UrCI" llCUntV "a. %111:0" ?\ 17070 1995 F<lrm 1040 pogo a llA SQiECULES Me '(1".,;1 lQ.lO) Sc/1udule A - Itemized Deductions 1 .a "'~I 7'" M ,~ 1995 ~ Anoeh 10 F.rm 1010, (Oeho~ijloe II 0" bukl "M'.h"",nl ~ SOl '""''''.00"0 tor 5.hodijl.. A ."d e IF.rm 10.01. Soculn.. No, 07 Your .001"IO.U',1'/ "umbor -..74 'r.'/ ...... .,....., ," ,-'t~_.I"''''I.1 ---r ...",..10"" ..~ .........,.-- .,. .0":,," 'J . IV .... ''''r...~ ..l'l '(".;, ~'r' ::: ' ";;:;~;'.nl 'O~ nOllndudl "pon"""mOij'''. or plld by omlrl. -... I M.dl.~ .n. .onlll "ponu. (uo P'io A-I) . ..... :z '~II' u".~"1 '''''' ,.,'" '0'0, II", U 7. ~ J MulUply IInl 2 Ib<lVI by 7,m (,071) , c.-.... . Suo.0.lllnI3 'rom 11"" I, If IIno 31, morl Ihl" 11M I, ""'er"', 5 ""0 'nd 10.11 'nc:omo iIllII . . R.II 111110 1&lI.' ('01 p.go "'3) . 7 p",~"1I propony I.... . 01"01""" UIII'/P' ,,,. l1!1Oijnl ~ STM 07 tAd. IInll 5 1hr0ij n 1 . 10 " ,~. .' ,A .l'.~t , ' :~ i!i',!;,!,J: /",,.,,, " -'~I:' I :':'1111 IJI~Jili~ 1)::':1:1' ,.1,;[_., 'II" I!" 3 1"";1'1 oIlilll" 4 I rliliilil" 1 I ",11'1'1 ~,'I; 1'1'11 7 ,111,,11 ::nlllil)~ I'I"[ ,'III'Ii:: . JI;,1.iI11 , 10 /:IM:il'!i ~ /llllli I!~ 1!1:1!li/I!! /"1111:: 11!li,I'lil ,II III II!i'IIII'il ,,1,111111;, I'd, '. II Ill/IIlli!! f'!i'II/11 12 :1"1,/,111 'tllll;/ 11"111 13 !I!rl~;fl,: II I"l 1IIIIniilil '11:'i'II'11 1:lIU"IJi I!II"W IS 7 ""Iii 11'l'u'~'" 1'111 'i'~ ",III Ili~;lllllil I. 17 II !Ii ~ II! : i i 18 7- .!..~ :"J .'; ..~ ~t; ~ ~'.;1 ::'\: ;;,i. B "f. l~ -. '" ..'. ,in ," t,!:. ::::- '...,.. ,..i ." !, .. ~. ~ .., :.r. "_i4 :.... .... S ;3 :1 ;.J' ,"" 1 1- :..: '-.I> - !! i -. T....'1w ~~ ~ _A'I,) - -..1 'r....PI~ ~.m. ""Mf',IIIUI'''' lilt IIOIIt" ""nUII rov tI, '0"" IOU f ..../11. "'.,'.....htl.'..I".t'...I1.." ~'ll ,It'''''' IOU. I' '10111I1, Uti ,.,..,,',.II'l...,,''''\I.II,.\,IlJ,'lI,.,.''.III.I'......;..)'''..".wl~U ..,,,,,', "'''''II'''''D'~''' ''''1 M' 1""U. . . . . . . ~ ;,oqo A.Z.) "'to, 12 """'n~ I'OWnt I' "" IJ QICl,le'::I.. 14 c''ll>IO Clu11'f 15 treu m.:lclI 11 .;rt U1d gell I btnent tofrt.," 17 P-.;'A-l, 11 Polnls nol "pon.. 10 you on Form lell, SIt P';' A-3 lor Ipldll lilli' InvOIlmOnllnll"SL II "oul.ld. ,n..n Form .sez. (S.. pl;1 A-3,) Add IInOl '0 InlOij n 13 7 2 Gins by .:uh or check. II YOij m'.1 .ny ;Ih 01 S2eo or more. '" pogl A'3. . Clnor lIlan by c:u" or .hllCk, II any gin 01 S2ilO or mo,", "" P"i" "'3. lIovor $.lCO, YOij MUS" 'M,on Form 4213 Corryov" trom prior yoar . AOd nnOlIS '"lOij "'7 c..u"1'f 'nd !!!.ttt Lou.. 11 Joo i!.<;lonu. 20 and M.'l OIlIer ww:.Il~n.ou.s l)equc12onl iii:ilnii :1111,/,1'11 II,illl, 20 21 liliil!~ 22 n Im~l!ilill :IS CUijll1\r or tnoM losslool, AMI.h Form .SU, IS" o. . A-4,) UnrounOijll.a amploy" "oonsoo -/00 ~Ivll. union duos, job odijC>bo". 110, ~ rlqijlre.. YQij MUST ,n,oh Form 210S or 2101-U, (S.. ~Igl A-S.) ~ CSoo 0.;' A.S I., h:)et\SU 10 "","0: .110,) 21 ,,"" preplflbon I"s . 22 ClIllr "OO"SOO - 1",,"stmonL Sl/. ..oosrt b<l.. lie. UII l'Jpo .n. l1!1Oijnr . . ~ t 2:1 24 :IS 2S Otn.r 27 ~u.".ou. O""'-J.n, ~ "-nIq", O""ctl... Ad. 11110130 lIltougn 22 . In'., &M'lI"l ''''11I ","It 10.0, ~". 11 MWboly IIno 20 'b<lVt by 2'~ (,02) . SuOuaClllno 2S from IIno 2:1, It IInl 251, moro 1Il1" IIno 2:1. .nlor -c- ClIllr -Irom 1111 on p'go ".S, WSl;YPI an. lIITlllijnl ~ . 24 I 21 Is Form 104O.lIn. 32. ovor SI",7CO '0'" 1.57,350 " mamod IIUng 200.,lIl1y)1 NO. VOijr d'Oijctlo" Is nOllllM.., Acallll ,"""unlS In Ino fl1 "gm ::alumn tor Ilnls 4 lIl,ou.n 27, ,\IIQ, 'MI" on F."" 104O.lIno Jo, Il'lol.vgor of Ill", omoijnl or your "IMOara decij.bon, ~ Yes. Your deduction m3V ~ I["",,ed. S.. aloe A-' 'or It'l. .1I'T1Ounr ~o ,mer. P'lQ'f".Ncrk Reduction Ac:l NoUc:e, s.. Form 1040 In.tNcUQnL IIA J ~' 2. " ,.; /'illll"I'I'II"II'II"I'IIIlI'II':';""I'IIIII,,,III,'I':',I,'I/:H,"" ,f::i'i!Ji) hi:, J II:; II :lr~::;!;li'll!!i i!!I!:!~~,:i; ,:i:i~ r::i:I:1 'i'l S."oclul. A (Form 1040) 19S5 SOiEOULE C (1;1m1 lOol~) Profit or Loss From BlIslness (Sol_ Pr.p,lol.r.Mlp) P'r1I1."Mlp., ,.Inl .'nl~r... 01... 01".111I. f.rm lOll. illarll"',"1 IQAO .rF."" 10AI. ~ S..ln'INolI.n. '.r Sch.d,,11 e,F.,,,, 10AOl. .m...._..09 0..111 ...~nrf n"mb., (SSN) 422-56-701. ~.; B l!.Ill" pnn.IPI' ~..ln"l .... (... P'i' c..) ~n 41 4 o empl.Y" ID n"mb" (I!IN), If ,nv Qf.I' ,"II. '......u", ~ .. ~n..h I. ~., 1995 ,- l r ., , ': " ~A ~ ':\:1 'r1 ~ ", ., ~:i -. '~ "'\ ~1 ,j; ~~ ~ - ~"...".''"'''' _ --....1_1. 'f ...... d ~.., - .............,.. :..\ ': . '~_.:. or prol.lIl.n,lncl..'ni pr..",t .r lll'i'" (,.. P'io C -') A~c..,~- ,~ ~,.-,.,? II no IIpll.1I ~ullin..' nlm..I".. ~lInK, c:: ..........,..JIT"4. _ ">tV :l:K:~IS c. .,. ~~ Id.....lln'""olni .ull. or r..m no,) ~ << _ ~ ~,I oHl... 11.11 .no ZIP .ed. Cl"f. '11:-".,..... , ,""",'''''''l ".,.In.dl (I) Cm (l) Accru41 ~ ~I' .m'. 0 0 Low,",.f ...1 0 Olh" (.nlOh (':;1 C... Mt 'ooly 01 a ._ ...."'1 ,n"n,ory: (I) C~1l (l) .r mlll1c.1 (0) ..ollnlo.n) (4)~ .ntell.o, "'p IIn. H) H w..",." 'ny .n,ni,'n d.I.m'inlni qu,"un... e.'I.I,.r .lIuan.n. bllW"n oo.nlni &I1d clo'lng In.,nI01'(111"".." IltllCl1 ~lJJ\jDQ" . . ~."'" t . . 10 '." .. '" :>4 1"" '/NI,"lIly pll1lclo,"'ln thl op".oon or thl. b~.ln... ouring lU37 11'/110,"" P'i' c.a I.r lima on I..... J ,., Y'elJ ,1'3" Ii 'If It 'I'll "" d"", "k t'l Part I Income , ar... rlCa,ol. or ,II... C,uUonllf Ihll In,om. w.. rtpon.d 10 y.u.n Form W-a Ind the 'SIINtOI'( 0 wr'CllOy..' cox on tnll lorm WU 4nICKldl .11 pl;1 C-Z and d1~1< her' . . . . . , ... 2; ~1Il\lrnl .and ,a,UOWlt'lCII . < . l s..~..<t IIna 2lronllln" , , Co., 'I ,oo~. 'ol~ (Irom IInl ~ on pa.. 21 s a".. proll~ Subv.<t IIn. '~.m IInl l I Cln" Inc,ml, Incl"olng F'd"aI Ind 1l.1t ,,,ollnl qr iIJ.. t.. cr.~lt.r r.lunQ ("" p.g. C.2) T O,oss Income AC:d IIn ,5 Ind Part" Excenses. enllr "cln.., lor b".inl" UOI 01 our home onion IIn.lO, · ~.'''''''In. . 2 0 19 P,n"on .no prol/l-,ntr1n. ,lln, It , aa~ ~aclS Ir.m .41a, or 20 Rlnl or I.... (... pig. C-')I 1.;:":1:::1 "rllell (SeI' ,;:1119' C-3) , . V'I'Uel", lIl,cftln'''''llllll 'O"lalll'''l 201 '0 C., 'no tnJck ..oonSf. b OUlIr ~"aln.1SO proPlny , lO~ I (,.. pago ColI 10 21 R.palrs ,no mllnl.nonco lf " CoJr1"'mulon$ .and "aflS. 11 22 I"UII"(/I"lno'Il,l11l4 tt1 11I111111'. 12 Il Coolouon . fa :r.I r.... and llconu" 23 IJ C.arlldaUon and section '7; 24 Trav'4 m"I" &II, "'I.rt&ln""nu '~:!ii:I::! '.=ens. dedUCtion (nOf Induded I Trl"ll . t 24a In PI11II1) (... po., C-3) . 13 b M.II. In~.n 14 EmplOY" bln,n, progllllN 1tr1llnmen~ (Ot/'lll' tJ'lan on line 19) . 14 0 tn,., 10"'.' Un, IS In'.".nco (Olh.' In&l1 nllltl1) IS . 2 z., ""'''''' l' Inl.,esc ':ll'[Jill:1 3:';~~!~r f... u. ,',~I .Mongl,. (plld 1.0&11".110.). 151 d SUClI'OClnn. 2"OIrom IIn. alb. lid b ethar , lib as UWld.... as 17 L~aJ o1nd .orollils~lonlJ 24 W.g8l11...."'aIQ\t''''.n'Clldllll . 28 ,,,,"'.. . 17 a7 O'nlr '.O.nsll (~om IIn. If.n ~ CMCltxOllns. . . . . ,. 260 OIQ' 2' . . . II r..., "o'nl" bolOrt ....ns.. 10' .u"nlll "Sf of home, Add IInlt 5 Inro~gn 27 in eOI~mn" . 2S r,nlOilVo ~ront (lolSO). S"b.1Cl IIn. as ~.m IIn. 1 .', . so e....ns.. lor b".ln... USf or yo"r home. AIl..n Fonn 5129 II Nit p,on! 0' (Io..~ S"bll'ICl Un. 30 lrem IIno ~. 0"" orol/l. .mlr on Fonn f040."n, 12. lno ALSO on Scltod"l, Sl!.lIno a (1lIMOI'( employ...., ". ~a;. C-,), ElIII.. In" tnJ"'. .nlllf on Fonn '041, IInl 2. 'II 1 lOIS, you MUSi ~o an to IInl 32. 3:Z II 'IOY nl\/t ... IOU. cheek lne ':'OlC tnaz duc.'1bes your iml'S1l"nenr In Itlll .1C':J'Jny (see .cag. C-5). 'II 'Iou cneckld J::l, .nlll' !".l~u an Form HUG, IIn_ 12, and ALSO .,n .$4:hltch.lle Sa. line 2 ('''ilJIQry ,mOIOV"', ," PI;' C,,), !>III..."O tnJIIS. .n,,,, on Fonn 1041, IIn. J. -.....!!1 'IOU cnllCKed J2~, vou MUS7 ,nacn Form 81". IlG, ita134rwOtk ReducUon Act Notha. ... Form 1QoCO I"struc:tfons. 2.407 v.. No 1 l , 0 , I 5 5 1 7<;,220 715 ., 20 00 7 ~ 'of; ~ ~ !V- It,< L ..:4;t i ',~ ,~ t; ,j! G()'J ... 4 20 1, aoo 15 ~:? 3 2: ,)7 . .;; 21 '''H:I .29 . lO I }lJ } 021 8 AU ''''''''1''''''' I' &1 "'.... 32b Som, ,n"..,"",,, I' 1'101 un,.. ... ScnldUI, C (Fonn '(40) '995 -;i I ,.. , ~'. I t'~ ." it:, /1::' .{:; ii 1- t ~ .:;\ eT. ,. II<: 'i; .. ",. .. ii 11 t: ~ :.1 ~ ,,.,.., ,<:-,OIISl~ ...........' " ......d UN Plqa 2 - - ......-~ r:- .... . ............ :; ~I' CQst 0' Goods Sold (I" gig, <HI .......:1"/ .1 ~f'/IMlog 0/ yur. II 41n4ll01 Irom IUI yurl clollng Inv,nIOl'/, In.eh opl.nlUon Q:I ::a "",auus I... <:\lll 0' IIlms wllhor,.." ler pl"on,~ UII . :u ~ c..... " I.oor, Co OOllnCluOI IIJII'f pliO 10 yourllll " >> M.u.,&JI Jl14 INpnllU , ' " a. :III %1 elf., aQdlO I a7 ~4d 11"11 JJ Ihrough 37 . , a. a 2-:1 )II " . :It ""I"lory II lno 01 y"r . al '" Co.! 0' oodl lold. Subll'lo! IInl a9 Irom IInl aD, Inllr Ihl /llull hl/l 1"0 on 01 I I. IInl .. ,"0 a a Pvt IV Information on Yllur e cle, CO",OIlII IIlII 011I QN~V il r,OU UI Clllmlng elf or fNC.~ 1X0lnUI on 11"1 10 1110 Itl nOI IIculrae 10 ml Form ..eu lor Ihll bUllnl", S.. 11I1 InlfNoOO"1 lor 1"1 q on pagl C.J 10 IIno lutll you myll mi. U Q When 010 you pl.OI your VlhlClI In llrulel lor bu.lnm PUrpOIl.? (11'101lIh, dky. Y"lt) ~ 01 Ill' 10.oJ n"moll 01 mlllI you orovI your vlnloll Ounng 19$5, 1"lIr IIl1 numcII 01 ""III 01..01..93 you UIIO your VIllldl 'or. . Bu"oes. 143 2 a b Commyoog Q 00 you (or your ,pOUII) h.vI 1I10lllll VlhlClI lvllil.OI., lor pl"onlll u.e? . ... Was your Vlhloll lVllillOl1 'or UII dUnng on.ouiy nOU"? .as , 00 you hevI IvlolOOI 10 lIUPPOrt your 010U0'.100? . b II ..,..... I. the .vloeoo. 'Nn"lo? , ,Part Y:,::i Other Expenses. U" Olio.. bull"es. "0'''11' "ollooluo.o 0" II".. S-26 or 11"1 JO, o Olher l~3 ~/~a No No No Vas Vas Vas VI' S"'-~!.L. t:~.N'D "'00 S 8010 . "abl oth.r uoenus. 5nl8r hi'. Ind Qn ~IQI 1. An. 21 I I I "II co II. ~ cay. Ill"" "paU ."1.., '1,&1', &114 ::f' '0111, I' ~IJlI ",~. ,to,,,,,, IIII1"u, Iil".'" II, Mr~1 /~ Pruld.nllo' It. 00 you wlnl $:110 go 10 1111. IUno? , EI.oUon Campaign' II. olnl,elUm do.. ounoOU.e wlnl $110 0 10 1111. IUno? FIling Status 1 51ngla 2 MllTiad nllnglolnl rlMn (Ivln II only one had Inoome) a Ma",.., 'l~/l' UIJIIU, "t\lm, 111I" fDO~.t'. 41$,.. UO~'I ".UI"'m' II".. ... 4 He,a 0' hQua,nold rNiUl qUaJltylng P'rlO"). (S..lnab\JcdonlS,) 1'1/1. OI,l&U,."", ~"IO" ". ,,,U4 'III nOI you, ~.o.n<l.nt. ,nl.,llIlIohl/l,',,.II1'I,I,..,,. .. Cu~llvln wIOOW/""Hllh oeoonoln! oMilo I lit .oou.. Olld ~19 1.IS..ln.lnJo~on.,1 Your..II.1I your po/enl (or lOlT1lOn. IllI) o.n, d. 41m you U a d.p.no.nl on hi. or h'; IO., ./1.... k bo U'UId ,n'I tAX rGtwn, do not ehee .lC 61 " I I . I . , I " ~o .. -L. b Spou.s,.. I . . . . . . . , , I . . . I I No, or 10111 C Dlp.ndentsl 121 t)'Q./l",nrIIQI;lII. t31 Q'Q,n4.nr. I.' Q, <I ~~W'" ,n 'e I' mati cr'lI1,l. I.Clolntyl'lUm'.,,lr br,lmll, '1'.UIt.nlO 10 YOI,j O. lI\1u III . . U Cll~'It/l'm. loutn.,"t ClumIUIIIII"nlnlt. o"r"om, .'lv'4'#flln,.. _3 1II'It ,n . .utIt411",fc;TrMOTHY ADK:NS 12 .~14n.tlhl""'.11l yO""ll'!O'W~o'n In'tN';lllm.. SHENN AOK!NS ? orIlUI&Uonl'" c::C!:S AD' ~~S ? ..,.," FrJlm Q,JCIJ t L:Ib~1 ~ u.. ~ In,IA5 8 Iu,., I Oln,,- I- ......., tot III'''' C p"ltf " 0' I,D', . Ch""k only one bol(. E.xompllons Income A~.on Copy 601 your FoIll\'lW-2, w-aa, Md lC9~-R her., It you Old not gOlo W-2, ... 1M IIn. 7 InsatJc:tions. Pleue s.nd any payrnenl lIplt.lelv 'Hlll1 Form 104(J-V, So. 1I1.lIn. 62' In'llIJo:Iano, Adjusted Gross Income "l/n011 i. under t/9,4SS I (unoor S.UOQ " a cnllO olon'l 11v. ""In you), .... tnl Iln. S. INlrucltons. 1040 On"'ln"nl 01 1/" r"uu'r _..1,'11,,"'" J"nnll' hrv,,, U.S. Indlvldua Income Tax Return 00 AOO Iln.. ~a I"rougn 2'J 31 SubQ'3ct rlne JO /rem rln. Z2. n,l:) r, 'lCur adlu.tted qroM! Income ,~~r Pnvacy Act and Pap.rwonc RoducUon Aol /lo~o., .... p'gl 7, P."IIt..,U,J&Jt, I-Qu, JI,IIU,<I"ln"'""u'h ,"hl" YQllf'I"lrlAm..."lIllHlJll I' ljlunI/UW", 1114"n'.IIIII".",. "'",mb.' 'fN LUI"""" ~ HOlrl,i"",.U 5 6a d rOloJ number "' ..emoaon. OIOJmed , 7 WBS". l4l1ll0.. ~p" '10, An.on Form(.) W-Z '''11 ',ullllv-IJ4 ""1...."1." tI.ot.'n II,., IIIUI, :" QMq"~D, tUI-l0lA Your '001" Uourlly no, 4 ?-5 - 0\9- Spol,lu.a loclal ucurll'/ no, 110-50-.250\ For h,IO In "ndlng IIn. InllllJo:on., ... p4g0' a and 3 In th. booklo~ Yu No '( 1996 I "n., 1"'41114 ."t",,, 8 a Tilubl.lnlel4oL An.oh S~Moul. a " over $ol(IO , b Tax-ex.mpt Inl"..L CON'; Inolud. on IIn. 9. . 9 Olvlolno Income. AII.on Soneoul. 6 II over,$4<:O 10 r"".'bll relund', creOllS, or off.alS 0' lI.I' IIJ1d 10031 Incom.I.... (...In.llIJo~on'J 11 Allmonv,,,,,elved 12 6usln...lncom. or 00111, AUlICh SonlOul. C or c.ez 10 Copllal gain or 0011), II ,equlred. '~.oh SOhldul1 C , 14 01l11t ;41", or (loll4ll1Jl, A~.oh Form il797 15 TOloJ IRA OI'01bu~on. 11sa' b roxobl. emountc...I"'1 18a Totllll"Ulll,.,.s.."IlUilt,. 16al b ia.lCllbI8l1mOuntC.ul"It.1 17a Rlntal real Ul.I., roy4l.0" portnl"hlp.. S cqrporaaon',llIJ.lS. .to, AlleOh Sohldull E 18 FlIJ1TIlncome or Oou). Alleoh llchadul. F 19 Un.mploym.nl compln"~on 20a Sodal 'llO\Jrtty blntllts 120a' 21 Oll1er Income. , . 8bl b Taxlbl. amcunrc...i/l,t.l - , 22 AOd emounl3ln 111. lor nOnl column lor IInl. 7 tnrou n Z1, Thill. 'lour 10tlllnooml 20a Your IRA o.ouo:on (...In.INcaon.1 2~al 20b SPOUII', IRA d.duotl~n (...In.llIJo:Ion.) 20bl 24 Moving ..p.n..., Moen Form 1900 or 19O:J-F , 24 , 25 Cne-hlll 01 SlII..",ploymenll4X, Anooh Sch.dul. SE 25 1 26 Salt-omployed M4Ill1 inMOllO. d.duo:lon (1I.ln,LI, 26 I 27 KlOgn do lell .",ployao Se.' plen.. II SEP, ohaclc ~ 0 27 26 Ponalty on ..rly ,.1IhOrowal 01 1..lng, 28 I 29 Alimony paid, Roc:pi.nr. SSN ~ 29 /'l"I.lt.:I1ICk."'f ""II. IIftUl'ltI4I'1An;IYQll' u. .'flIIIIC""ut"'lonlJ, E 71 8al ;: Hl!J ~ HII 9 10 I 111 121 101 14 1Sbl 16bl 17 18 19 20bl O"a'''''.''I,Ol'lU I101.,HtrU lOllY" _ A.04"umo". 1"1'''4 on Q"..Uo.... II- .5 234 (3,9321 21 ~ 221 I'I/Iiil 1111!il 1,lli!!i! I11I11II1II 1111/1'11 !I'.I!I.II! Illill,111 ,'II!I 00 ~ 311 , 302 o I'crm 1040 (lOSe, fu r' fD III I ~ : I . I I . * ~ '. I I . ,J. I . I II i . I . I III FlJm1 liNQ (1 ~Olll r.A ?.'( E TlU Compu- lallon II you w.n! 1M IRS 10 "9U" you, ,.., S84 111. I/n.37 InllO'\jcdonll. .- Credits Other Taxos Payments An.ch Forms W-2, W-ZG, .no 10SS-R on lI1alronL Refund S.nO II ri9ht to you, bankl See inst ilnd nl/ in dOb, c. Il1d O. Amount Vou Owe Sign He,e Keeo a coov at tn13 fGlUrn tor 'JOUf record3. Paid P,eparer's Use Only u. Pl0" 2 & H.:..mflH ADKnrS I 'U')-c;~:74% 32 ,\/l1QlH1f from Un.. ~ I (111ju1I1IIJJ ~rQlSlS I"~omlt~. . ... . . . . I . . . . 0.2. Ii 1 :] 0 :2 03a ChlJ<k '~OYouw... I~ 0' 010.,0 Sl/nOI OSPOO" WU"" 0' 010",0 Sl/nO, I :ij":i AOd tnQ numbo, 01 bo.u ohOl<.a. abdv. .nO .nl.r 111. lorlll hGr.. . . . ~ 300 L " ,i" blt'loo u. mun.. I/I/n9 sopu~I.,y ano your spoun II.lrJ:.. d.duceons 0' ",";, yoo ,II. . Ou.HI.",. IIlI.n, ...In.lI1Jcuon. .no ch...~ h.re . . . , . ~ 33bO :;;:::;'; tl.mlUO O.Ooollon. ~om SOh.dUI, A.I/n. 2S, Oil } iili,;I,: 04 Enll' 5, bndorO O.doollon shown b.low 10' yoo, nllng 110"'.. S'''' '" ....... li'I,:' "I U'lG ."y ... ,,, II"" ~~lO" QR 'OlnlO'" C&II clAIm YOli" l ; 1;1:11': '/If';lfr JUI'''''''', '1t''',lllIlt\IlHIO,U 10 /In.. ~'U' III1HI..,. U"UO:U", ' 1!1:'.'!il~ 01 . . Sln;lo-S~,CCO . MlIII1o<l nllng lolnlly or CUlllltylng ...lcow(er)-U,7CO 34 yo on . H..<I 01 hoosoholel-~,aco . Mon1.0 nllng uPIIIOIGlY-$:l,2eO ;: !";":u as .sU~l1lct IIn..34 Iram Un.. J2 I , . . , , , , , , , . I , . . as 36 II IIno a2 10 SSS.~7S 0' 1110, m~l~ply S2,eSO by 111. 10loJ num!:.r 01 ".mp~on. cJlIlm.<l on l!t:,:ili~ IIn. '0, II IIn. 22 I. 0." SSS,~7~. ..0 111. ...ol1<oh"lln Ih. illOL 10' 111. lmOUnllO onler, . 36 :I 7 TIlI.!:I. Inoom.. SUb~.ctlln. 3S fl'om IIno as. II IIn. 28 10 more Ihll1 IIno as. .nl" 00_ . 3 7 38 T~ S..ln.lI1Jc~ono. ChICk " lorlll Inolu~" any IIllC ~om I 0 'orm(s) 1181 ~ :lil'I~!il!, b I J Form ..sn, , , . . . . . . . . . . . . . . . ~ 38 39 Crodll lor ohllel4. ooponOonlo,,, op.n..., Anoch Form 2441 39 I ':!jili11Ii 40 C'.dll tor 111. ,'Oorly 0' lno elIUbl... Anach SchoOol. R. . 40 I Illiill!II" 41 'o,ol;n ,ax or.OIL An.ch Form 1118. . . . . . . 41 I 'II I'iil I' 42 Olho,. Check Illrom . 8 Form aeco b 0 Form e:JGS l:i;:!:iiW 11'111" o 0 'orm seal d '~rm (.pllCity) 42 ::;I:iI:IJi 43 Add IInl5 3.!1ll'lrough 42 I . . . . . , . . , , . . . . . , 43 44 Sob~'cllln. 01:] ',om line 2e, II ilne 01:] 10 mo,olhon IIn. 3S, onter -oJ-. . , . . ~ 44 45 SIIII-,.mploymenr fl1X. A"3Cn S..:necuhJ SE . , . . , . I , , , , I 45 46 Allern.~v. mlnlmom I... An.on Form 52'1 , . . . . . . . . . . . 46 47 SocJlIIllCllhl'/ ano MOdle.re I.. on ~P Incom. nOI IOpon.d to .mploy"....... '''''' "1' . 47 48 Tax on oulllln.O rearomonr pl.ns, Including IRAo. It ,oculroO, un'ch Form sa29 . , 'I 48 1 49 AO.,noo urn.d Inoomo ""dll _.ym.nt. I,om 'orm W-2. . , . . . . . . 49 I 60 HOO"hoIO .mploym.nlllllCo.. Macn Sch.elUI. H. .. ....... 50 I 51 Adellln.. "'Ih,oooh eo. illl. 'l'IOU' tol.1ll.1x . . ,. .,..,. ~ 51 52 F.derllJ Inoomol.. wllhhllO ~om Form. w.~ .no lCSG . . 52 I , 0 27n lii,il/:I':II 53 ISSS OIL lax p.ym.n15 .n<llJ1100nl applleo Irom lSGe roMn , 53 '1:111 1':1 54 !.1m.d Incom. cr.dlL "ltUl1 S'n.~ul. lIe if .,OU ~''i. a 411111'Y1no Iliil!III'11 II'iii'lllll :~':."',O"~UI' 'U"'~ 1IIII0llftl a,"Ollll' P I , ~llll:i I'ill,i 'II II! ., 11,11' NO 55 Amoom plIlO ....lIh Form 44ee ("Ienolon ,.oueor). . . . 55 i I' III I 11:111111 56 1"II..a'ocitJa'lNr,ry.lIf~AAT"'lu'""U'".ld(,,,jn.t.1 . . . . 56 11111"1 57 Orll., :I'1m'''Ut en'CSlu"rCSM a 0 '01'" 2~' b 0 ""'" '13' 57 I !11111,iU 56 AOO IInu ~2 Ih,oooh 37. Th... IIQ 'IOU' tol.1l .avm.nts.. ,.,.. 58 59 l'U".U1,mo"lnanlluSI..llottar:tllu5l'lOmUuU.Th..III"umoulltyau O'laRPAIO . . . 59 60a AmoQnIOllln.eS'/ou'.enIR!FUNCECTOVCU, . . .,....,' . . .,....,. . .. 600 b A""Q oum.., I I I I I I I I I 10 T,.e: I I ChOl<klnq I I S"lng. ,ill'i'I'''I/'!",'II'/ d........."'.., I I I I I I I I I I I I I I I I I ..1 "''''0I,lll,UII".1'10U'''''1 ~IIOTOYOUAIH'UT1J",IATlOT.u: ...161 I II!"III[I),'II'I j'lI".tll',"O" ItlMII", U. ."IUtao,:I". U IrOM U".II. 1'1'1"1'111. AMOUNT YOU OWE!. !IJIlIII. For 011"," on how 10 p.y anO o.e Form 104Q-V, 0" ',,",",cUono . . . . . . ~ 62 11:IIIIIIIIII!il!~I!li(~~:IIIIIIIIIII!lllilll[il:llil!1liilillliiWil! 61 62 63 Es~m.r.o lax oonllllV, AI.o Indod. on II". i% . .183 I u""., lu"a.e.. 0' U'I"ty, I dtclU,ltla,l "a..,. ''''''1".4 In" '.N'" 'nrl UllOmDlIIVl"O ..nUlIl.. and '"II"'lfIlI, Mil to In, lI..t d my""........,. &fI" tt.II.,. I".y u. !N', 04"ect,.&I'Id COIIIOIII.. ~"Ilfne" IJ' ''''''''(01'''' U'llIII,UDAY")" ~.~ 0" .vI 11"01"""'''' ., ."'tlhll' p,.,,,,,, ,'u My ..nowI'd,.. ~ YOU'.1911.N'. ~ 10'" 1011. 10al. !o?- ~ t<:::.(,'{ !":~r:urc!,u. S2:<'/!C:;;S, , 7~Q ~R:DG2 STRE2T ~r=:'tl C\J~3EP.~'fD !?i\ 5110....'..."'..114'.. 1'1'JIII'''l\H'',10T~ lI'I..al'lon. 1'1104"'" ~ _ ~ 'IQ""'M' 1/fli 1,,""".""IIU',.II'. UIII'''.,"IIIO''''I1I&f111 ,dd,... LJI, kif "'11I.,1f'..OCl&&'.ClJntV"a. 7 . II'" 23 -2 37~77? 1:1":.011. 17Q70 lQS8 Form 1040 P.g. 2 13,4'79 47 A?3 12 750 35,073 5,2';'_ 5,2.;~ 5,26'~ 10,270 5 009 5 009 - J~h i SCHEOULEO A&!3 (Foml 1040) Schedule A ~ ItlJmlzad Daductlons r GM3Nq 1~"J~ (Gohedule B ,. on b,ok) 1996 ~~'Ohm.n' .. A\t1<h '0 Form 10'0. .. S..'n"l\JoUon. lor Sohedlll.. A .nd B IForm 10'01. S..uon., No, 07 Your .0<111 ...umy numo.r 14~? -';;-7~q~ 1':':1::1;: 1'!}I:!i]11 'i',hiilill 4 i:I.I:ll1I'1 iiii!il!III!: 111'11;1'1 9<; r:[:I;lu:1 I . . , , . . . . . , . . . . . t 9 286 liii:il!lil:! liiill!.i!I!I,1 :I",;III'II'II"'IIIIII! :ii',il'l ""'1111 1:1:!lllIII 1I':iil~:li: I,: :11 ~ II: I ' I". III, I I . . I . I . . . 14 III ~ '! 'II' t I li:IIII'IIII: 11,11111 ,',1001,1' ""II 1'11111',1 ,11,,1111.1 "hhlil I . . . . , . . . . 1. Olg.,.",.nlotlh,r,..,ury tllllf~.il "'_'''~' ~h~'lIt I'" l'UITI'''I'"Q''"''''~'1'''' 10.i0 fi,l.?.'( MedlOlI and CenUI e..p.nsu E I;. H~rN;1.:-i ~KnIS C.uUonl Co nOllnolud, ,'pon.u '''mburUd or pAid by OlnOrl. 1 M'dloAl and d'/IIAI ..p,nlll (u. p'~o f-'),' . . . . :I 1"""',"'~"lf"""""1'I'I "~'4lu".n , .1 2: ~ MulUply IIno Z Ib<lV. by M'I. (,07') , , . . . , , 4 3ublra.,lIno 3 ~om 11M I, "llno 31, 1M" th,n IInl I Imor -Q- . tS SllIle I/1d locoJ lncom.luu , ~ ~ ~ . . . . . o R..J 01'410 lUll (III pogo A-Z) , , . . . . . . T Per50naJ propeny tI.lles .' . . , . . . . . . . Olh.r lUll, UIIIYP' ,"d lIIl10unl .. STATEMENT ,. 1 9 Add IInll 5 Ihrouoh O. . , 10 II 1::;U,lll; 1 I'I" ' Ii, ~) III Ii, ~ (5.. p.g. A-I.) 5 5 7 ,111:111111 . 2 <;91 t 10~ T.... Vou P,'d 1 991 10 lilllll'illl'l lil[II:111 111!llii ili,(i III "IJ., 11 Intorut YO" F,'d (G.. p'g. A-Z.) I'tOfn,/fIOr1,'UII",,'lIllIIlI UIIII'''QortUllIyouo"".,m 1011. . /'10m' "'otI9&'II'''''UIIIO(1I01"1O fa .,Oij Oil ,,,,,.,, 10tt. I' Uhllo In, IImlllt '10m w/lom 'fO" DI"911fln' "IIm't ,.. U9'....I"'i "1O..IItl, p.run'./l&m'IIUIIII')'I"9110,,&IUIUO'... , . . . . . . .. Nol.: 12 Pe"onlll lmere5t III nol 1~ dlOuoUbll, 14 0111.0 10 Charily IS It you m.do 15 a ~Itt ilnd f.OI' b.nlrl, or It. sae 17 p.go ,1-3. 15 Fo'ml nOll'ponod 10 you on Form 'cso. Soo pago ,1-3 lor speclaJ Nit. . . , . . . . . . , InvoSllnon'lmor..~ II "qul"d, In40n Form .S5Z. (Goo pag' A"3,) . . , . . . . . . . . Add lInoll 10 throuc:h 13 . . . . . . . . 12 I~ 9 2% Ili[il'ilill'll 1"1,,::1111 . IS . 111!i:;:~:11 , I 17 Oll~ by cuh dr .hO<:k, "you mo. I Iny gin 01 '250 or 1M". ... page A"3. . . . . I , I . . . . . . . Omor men by cllllh dr cneck. II ,ny gin 01 '250 or more. "" pago A-3. "ovor ~CO, you MUST 4U40h I'1lrm OZII3. . C.vryover from prior yut I . . . . . . . . . Add !InGlS 15 throuqh 17 . . . . . I . 200 '00 C..ullly .nd Thin Lo.... 19 Job e..penloa 20 Ind Mcat O1nor Mlsc.lIan.oua O.ducUDn~ C..uoll'l or In.~ 1.151011. An,on Form .oa., IS.. 0400 A-',) . Unrl,mburUd Imploy.. "pon,," -lOb ~4v.'. unldn dUll, lOb oduc,UOn,lIo. "required, you MUGT In40n Form 21Q6 dr Zloa-a (5.. pig. A-a,) .. liilll!'III!i! ,111'1"1" ",1111 ZO Z1 - ~llllll~~ :12 2:1 Ililiillllll as 19 il:,I;III"'!'I:ii ("III' 11"1 iillil!!11 illll:ml '1'1" 1111i!1I !llll!I'1 Ili!lll! !mlllli Z5 ~'I'III'I'II 111101 u:cll! %1 (5.. pa~1 A-' tor 8.1lpenoGS fo dl.UC' norl.) 21 TiLle preparaQon '.ea _ . . . . . . . . :12 Othor ..ponlll -1"'"UTlfn~ 11I1. dOPOl'1 b<l., 010. Uat tYpe and amount. . . . . .... :12 Z4 25 20 Omor %1 Mllcldlilnlous OlductJonl To'" I'.",'zed O.ducUons Add IInll ZO I/Irou~n 2Z , . . '. ' :4 I' . . . . . Int".mo",,,'t,,m'o,,,, I040,I".U . .1 4 Mu'~p'Y IInl Za .cov. by 2!~ (,02). , . . . . . , . Sub~4C1l1n. 25 from IIn.2:I. "lIn. ZS 111M'" Ih.n Ilnl 2:1, .ntor -Q- . Cmor . ~om lilt on p.g. A-a, Uallypo and ~unl . 2. II Formt04Q. ilno 32. OVII" 'T,~eo (OvAr ~am' ,I m4tT1od ~lIn9 separ"IIYI? NO. Your do.u<:t!on 10 nOlllmtod. Add lho ~un~ In I/Illar ngnt COlumn ldr IIn.. . mrou~h %7, AIJo. In lor on Form 1040. 11M 34, ml targer 01 mi. """un' or your 'landard dldu<:':lon, _ YES. Your d/fduct!on mav be Ilmrted. 'ee 011C;' A..~ for rhe ,unotHH 10 linter, For PlpOlWGrk AoduotJon Aot NoUo.. I.. I'1lnn I~ Inall'llotJonl, IU } . %1 11 <\ 79 11@llill@ilillil!!ii::1;liil!l!i!lilllliliililllliii!iiilill!l!i',!:I,:1 Scnedull A (Porm I~) 1996 V"', - SCHEDULE C (Form 1040) Profit or Loss From Business (501. Proprl.lo"hlp) ~ P.rtn."hlp'.lolnl v.nluru. .to,. mu.l MI. Form 1015. ~ Atuoh to Form 10.0 or Form 1041. ~ e,,'n.lNoUon. 'or eoh.dUI 0 IForm 10401. l~'::=:.:'~., 09 5..,.1 "OUrlly numb., (5~N) 442-s.;-7oI95 BEnt., prlnolpll bU"n..,. ,Od. (II' P'i. C.t) ~., 01 , 01 D Emplov" ID numb., (5IN). It .ny 0.\111 H"......'l"'. 1996 011I.,111'I....10' lilt r'U'~N tlll""AI "''f.II!J' ~"'1I1f. ," Nili" 0' p,opnllor G~~'C I:' ~ N A PMclpill bu.ln... or prol...lon, Inel~.lng prod~elor 1I",'e. (... pig. Cot) ON ?AC OR C Bu,'no.. nlm., I' no 'Oporll. b~llin... nlllTl..I..,. bl.nk. R.t AD l'N' ! eu.in... Idd,.,. Qncl~.'ng .~II. or room no,l ~ Clrl, lown or ooat .Hleo, 1111. Ind ZIP COd. F AceounUng m.thod: (') '( Cuh 35l STUME'STOWN - ~ :\or oIccNoI ROAD 7 Olh.r (.poelly) ~ G Old you 'malorlollv pllUclp"e' In lh. oparaaon Ollhl. b~.ln... during '8'671' "No,"." pig. C'2 10' nml on 101lll's . asl y.. 0 No ~O H If you '1llfted or aeQ~lrsd Ihls bualnsl4 during 1088. ehee:< h.r. li,Part Ii: Income 1 Gro,. ,...Ig" or .01.., CauUonl1f II1lslneom. 'HU reporled 10 you on F.rm 'N-2 and 1M 'StsMor/ 0 1 63,Ql2 employes" OX on that form WIl$ checked, see paGe C-2 and checK here . , , , . . ... 2 Ro""ns .nd .1I0waneo. . . . , . . . . . . . . . . . . . . . . . 2 3 Su.~.elllne 2 Irom line 1 . . . . , . . . , . . . . . . . . . . . . 3 ~3 5' , 4 C.'l ., g.Od. sold (Irom line 42 .n page 2) . . . . . . . . . . . . . , . , 4 Q, 345 5 Gro.. pro"~ Subuocllln. 4 'rom IIno 3 . . . . . , . . . . . . . . . . . 5 , 2 ,.7 . Clhar Ineom., Ineluelng Fsdarol .nd 1I.le gOGollns or hJollox credU or rshJnd (lie p.ge C'2) . , . 8 7 Gross 'ncom." Add IIna. " and" . . , . . , . . . . . . . . . . . ~ 7 l' 'iS7 [I Part II" Extlens~s, Ent.r ..o.nu.lor bUdln... ~.e 0' '/C~r home onlv on IIn. 30. 8 Advertl.lng . . . . . 8 3 400 " pen.lon and pront-shlll1ng plan. 19 9 Bad doblO Irom sol.. or %0 Rent or lo~o (.e. p.g. C.41: !!::!ilUII .o""co. ('00 pogo C'3) . . 9 I 'l'I'IIl:I".ITI&cllliltl'Y,lItd IQUlo",.nl %00 10 CM .nd I1\Jck expen." b Olher bu.ln..,. propectV . . 20b (... page C-3) . . . . 10 5 659 21 Repolrs ana'molnl.nane. . . %1 11 Comml..lon. .nd ,.... . . II :u SIIDPU..(notlllclulI.d I" Pan till. . :u 12 Oeplodon , . . . . . 1% 23 TU.S and IIc.n.es. , . . :tI '3 Oepred.Uon .nd ,ocaon 179 %4 r'..../lI, m..."and 'nlfrUlnm,nt: ijl'1"'" "tw!:1I o,p.ns. dedUedon (nOllnclUded . Travel . , . . . . . 24. In PIII1II1) (.0. p.ge C'3) . . to b Mlall'and en 14 Employ.. b.nenr progrlllTlS I IttToInmanl (olher lhan on line 19) . . . 14 C Ilu.,50".0'""' 15 In.urance (other lhan h.lIlh) , 15 475 24I1,utlj.CrtIO 18 Interose: ijil:jiq!i! a"'~tAQ,O" r (.,. .,,~, III pI"",.4 8 Mortgage (plld 10 banks, tiC,) . 188 d SubUoClllne 201C Irom I/n. 2'd . %Cd b Clhor . . . . . . . 18h :IS UUllaes . . . . . . :15 4,351 17 l"'JaI and pl'<1l...'onll %8 Wagls(I.u .",,,IIIY,"'"' ClteU", . 2d sel\flClIs . . . . . 17 , 2014 %7 Olh.r "p.ns.s (Irom IIn. 018 on 18 CttlCB GXOenS8 18 3'0 Q.ql 2\ 27 ",n . " . . . . . . 28 TObl ."".n... bllore e'pln... 101 ~u.ln_ u.. 01 hom., Add lines 8 Ihrough 27 In col~mns . . ~ 28 , " 9 ~9 ientadv. prOnl (1011I), SUb~'Cllln. 28 ~om I/ne 7 . . . . . . . . . . . . . 29 { 2\ 30 exc.""o. lor business ~st 0' yout homa. Anleh Fonn 8829 , . . . . . . . . . . 30 01 N.t pro III Ot (tOila), Sl/b~.Clllns 30 ~om I/nd 29. "1 a p'o"~ .nler 00 Form 1000.lln. 12, and AWlO on Soh.dul. Se. IInl 2 (Ol.WIOI'{ .moloy...., } (1,932) ,eo oage C-5), e.w.. iII1d Il'1Jsrs, .ntaron Form 'Q41,lIn. 3, 31 Oil a loss, '{OU MUST go on to IIn. 32. 3~ It 'IOU h,.ve a I..., Choek 111. be, 1Il0, desClib.. '/Our Inves_nlln this "",","y (," plI<Je C'5), ." you Checked 320. .ntStll1llolO on Form IQ4O, IIn. 12. and AWlO on ScIlodull SI!, IIn. 2 ("",UtOI'{ .mOIOV..... ,ee PII<J. C-5), E:llares and ""'10. .nler on Form 1041.lInl 0, ." '/Cu Checked 32h, 'IOU MUST .nach Porm 81~. For PtptFWork R on Ad Node 323 [X] AIII""..,m'IW"'":U. } 32b 0 :Io""'Il'f..tm.nll.nllt at"'" I :, , , , , , ,. illll I .~h4f(tJll) C (FrJrm IQlo\01 1001' Nilml(" G;.,,?Y E AOKrNS Part III Cost at Goods Sold ,... o.q. C.II :l:J MIIMd('1 Ulld 10 Low", 01 eO'1 Of~lr (I".e~ va/u. dOling Invlnlo"!: (.10 CO'I (biD ormlll1<ol (0'0 "pllnauon) 34 W~ I/1tr" .ny e~.ng.ln d.l.rmlnlng qu.noa... eo. 10, or volu.dona b.lW..n opining .nd do.lng Inv.nlorf711 "Y.... .n4e~ .'Plill1.aon . 531'4 - 442 ..5'; ..749~ Po1r;,. 2 ~ No 42 Co.t or good. abld. Subtract IIn. 41 frcm IIn. '0. Bnt.rll1. r..ull ~.,. and on P.g. f. IIn. 4 42 51 . 34.1- iW,R,~!J::,nt1;:1 Information on Your Vehicle. Compl.I.II1I. Port ONLY It you ar. claiming ear or rruck "p.n... on IIn. 10 Il1d Il. nol ,"qulr.d to m. Form ~e210r 1111. bu.ln.,., See 111. In.llUcdon, 'or IIn. 13 on pig. C-O 10 Md oUllI ',ou mUll nle. ~ . 0 V.. 3. Inv.ntory .1 b"9lnnlng 01 y.II, It ctiff.'lnllrom lilt "III" do.lng Inv.nlor" In.ch "pl.n.don , 04'1 3. Purch.... lei. call o//tomo wfll1dr.wn 'or p....nal ua. . 01 37 c.w ., I.bor, 00 nollnclude aaluy paid 10 yours." , 37 31 M.t.nal. .nd IlJppllu , . . as , 39 OI/1.r co.t. . . . 3S '0 Add IIno. 3a II1roogh 3S . . , . . . 40 41 "w.nlory Itlnd 01 y.1I . . . 41 ~ When did you pltc. your v.~lclo In 111II,e. lor bual~O~ PUIllO...? (monlh. dlY. YII/) ~ 0 1- 0 1. - 8 8 44 or 1/1. 10lal numb" 01 mU.. you 'drove your v.~lelo during laal, .nl.r lI1e numb., 01 mil.. you ulld your v.~iel. Ion a Bu.lnes. 18.256 o CIMr b Commuung 45 00 you (or your IpOU..) h.ve 1II101~.r v.nlel. avallabl. lor p.rsonal u.e1 41 'N~ your v.~lde Ivallabl. lor u.. dunng oil-duty hours? 47 a 00 you h.v. I'Ild.nc. 10 IlJpport your daeucuon? b It "Y.... I. t~. I'Ildone. wrin.n? 'i!1 Palt',""::1 Oth er Ex enses. U.t b.low bu.ln... a'OlntOS nOllndud.d on IIn.. .-21 or IIn. 00. V.. V.a VIS V.. SMALL l-l'..ANO 4.1 r4~1 ottl., 4rp.n.... !!nrer t1.,. and on 0 . 1, line r! ... 9,004 No No No No so ~ . 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II 1"1"1111"1\1'''' 1-'14",11111"""","IIIIUI , C .,....,.., H H"Tll,"II'''' ~U/lI''Il ~ JS~ 1t:2...... t cay, 10...n 0' 1I11.l0Illn, ,tat'l U'. :1" nil', 1'1'" "'_. """,,,,.."11,'""" 10, ..ld.nU.1 '" Ct{. , r ' r: 7 .odon C.mp.19n \. 00 yaij 'HII1I>> to go 10 0111IUn01 , .." . '0\ ., If .101,1 roMn, aall vaijr laaijll \V,n"~ 10 010 1lI111U,d1. 1 Slngll 2 MlIl1ld nll,glalnt '11U1I1 (IVln II only ani hid IMa",l) :I Nun.. n."'....u""l\I',..IIlIII ."un', Uti ..Q"', hlllnam. ".,., ,. 4 HUd 01 hQijllhala ('HIUI ~ijlllf'/I,g pI/1an).(SII plgo 10,) """''''~'9."..,1,,,''1' "''''10'' ....,.",c .lIt.,U.lll.hll.'I""".""..... QijlllMn wldOW('" 'HIUI dlClnalnl child ( IIllaOUII dlod .'9 .ISlt CI 0 10,' Yourult.1t yaijr pliant (or 10",tolnt .llt) cen clllm you U I dlptndanl On hie or h'} N., .".... ,It..... ." taxt.turn, do n-~tctu,ck bOICe. . . . . . , . . ., IAMtllII ;g;L E --:- I.au"l"", AQ:UNS _ 1."'''&1"' ~"".!~rS ,tU', ",~11'I1 lul 1Q\lf U,II 11&"1' &/1II'lIlllal &;.10.1 th.It'S ,. ".lon, For h.lp In IIndln9l1n- In,INedOnl, ... p.goc 2 ona 31n 111. boo~I.~ V.. No "'Ill '::UUl'lq ~..' ....ullot.tlLI'I..youru. ~"..,uCt .,'\It ,,111"4. "'11" :he<:. only O. ~o)t. 5 -611 2 b m SpOijl' - . . , . , . . . . , , . . . . . . . Nil. ""'011' C a.pond.nlll ~l:,~.1I ."II"""'''U 1110,,,''''''111'1 l:lIO..."u"r. .,1111111111 _"'I lll~'lllI'I!I' UUIllJl\l IGOll.'CNnty"lollflur ,.11011"''''''0 yolol O\l!~~:" .'1'11" ""I.' ~4~ -L I,,,,QIItll&l'lI" 'i'TWl.,;-t;OV rNS io.n-"/4~7~8 ~(lN l.L . SI4I'lc:ltu.......lln ~~~~. 10-':;-' - 74 - a,:; 7 'Qb!i"-""''''~ ~ou 0101.10 IIII"U ",Q'l'Ic:1l"II, SHENNA -12 ,uoUIUI'I 1183-n-S).2: ,..u&,.1l1 -- ..,II&Q,IO, rLE:<IS ,nll.ur::.t"''''R 11 I I O'''I'IUl'ltlll'I tit I "ot ."t".. "Oil' ___ ,1,44"1,1"''''' \ \ ",.,,..,,, d Talll numcor or ",macana cllllrr.d . . . . . . . . . . . . . . . tl".. .now." Cj Income 7 w.~", 11111111, CPI, .le. Anlc, Farm(l) 'N-2 7 82,7"/8 6 a T..,cl.lnler"L Anlch sch.dull B " required . . :1 Bbl' . . . . . . 801 63 Atuoh b T......mpllnl.reIL 00 NOT Inclijdl On IInl eo. . ir:lm!~!\~ Copy 8 0' your 9 Olvlcend I,ca",e. Mech ScMdule a II required . . . . . , . . . . . 9 Form. W'2, W-20. ,nd 10 TUle11 'IIU,CI. ctlcllJ, or 0""11 01 slele IlI1d lacllll,cp",o 1""" (111I pa~o '2) . . . 101 ' s; 1099-R hor., 11 ,Illmony roc.lvod . . . . . . . . . , . . . . . . . . 11 I' you did nal 12 8u,I,,,,,,I,ca,,,0 or Qou). Anech SChedule C ar C.I!Z . . . . . . . . . 12 gel. W-'Z. 13 C'llilol gllln or Qau). Alleeh Scnldijlo 0 . . . , . . . . . . . . . 13 ... p.~e 12- 14 0111.. gllnl or (loUIS), Anech ?orm 4797 14 . . . . . . . , . . . . 150 TalllllRA dlllllbijdans \ 1501 b TillCeblo amounti... .... 'SI 15bl EnolOll, but do 16a rOWlIIIIIIO".llll,,\lIlI.. 16al b TillClble amoijnll....... ISI 16b "". anloh. lilY 17 Rentll rell ..we, roylillQl. partnlr4nlpl. S caJ1loredone, 1l'U11lI. 110. Aneeh SoMdijlt It . 17 ,,.ymOnL ~ 18 pum I,ca",. or Qau). Aaeeh 5ch.dult F . . . . . . . . . . . . 18 plUSEI ual Form l040'V, 19 Unll1'ploymtnl corrp.nSldan . . . . . . . . . . . . . . . 19 20a Sac:IIIIOCU/11'f bon,"1lI120al b raxobllt 3J11Qu"lIUU'" '" 20b - 21 om" I,como. 21 - 22 ACd !he arnounlJ In tholat non' oOlu"'n lor 'Inel 7 throuon 21, Thilll 'lour tatolln.om- ~ 221 83027 Adlusted 23 IRA dedUcaon (s.. psgt 18) . . . . . . . 231 ~1!\I\\\ Gross 24 M.dlalllllvtnll' oc<OU,1 dlducdan, AlllICh Form ~ . 24 Income 25 Movl,g "PI",". Atl1ch I'<lrm 3903 or ~903-F . . . 2! tl\\\\\\\, 26 Cnt-hall 0' SllHrrploymo,1 tax. AlllIah SahodUlo S! . 26 27 s..,.omploy.d h.~UllnlurIll1C. dlducdon (s.. pagl , 7J. 27\ II line 32 i. und.r 26 I(jQgn .nd so;l'OII'oloyld SI!P II1d 91MPU plane . . 261 "I S2'J.2'JO (under 29 P.nllty on urty 'NlO1drswlll .t lIving. . . . . , 291 i:ll~i ,\i\ S3,no II . cn,ld 300 AlImony plld, b ~"",pl"r, SSN ~ 30al 111111111 did not live 'NltJ1 '1"li\:\1 you\. SM ElC in.~ .1'111::1" on p'~. 2', 31 ,ldd Iln.. Z1l11roug' 30a . . . , . . . . . . . . . 31 32 SUQnct line 31 tram line 22. This is 'lour 3.dlulSted aroS,J, '"com. ~I 32\ 81 017 I'<lrm 104d ('997) For Prlva<,/ A<1 and P'p.rwo", RlducUon Acl Node.. .... pS9- 30. u- ,- ,." 1. i. I. ;. Q I. . :. j'l'ljlml!Joll'(l;ii'", a;>?.'( r: .-, :~.~trll,W 1>,f)K~II" . JJ ",IWI"'I trf.Un iJflll J:1 (JdjUGltliJ -;(0/1:1 ff1t:lJlnll), I . . . . . . 04a CIIOCI' It:OVouw"o ~~ ,,, 014,,0 611n41 05POU.. '... 8S or ola.r,O 611n4, AoJ4 I~O nume.r 01 ""0' C~""'O. obo'. .n4 """ 111. !QI<J ~U,. , . ~ 340 b " )"., ". m4lT1u. ~lIna ,up"olOly ono your .pou,. Illmizu dl4ucaon, or yo', Qt" . du,HIOIll' <Jlu", ,.u po~. 18 .no C~"". n,," tllm'lOIi dodu.Uonl Irom 54nldul. A, IInl Z8, OR 05 En I" BUndard dldu.Uon '~OWn 00'0'11 lor .'ou, NUng IIOIllI, 0'''.. IJlQ .... III' rOI4 ."...'" lily ..w,1t IIno "4." .,um."". l.r'J,r CAn~", )'Olol U. 411t11I1U"t. 01 0 Slngl.-S', tDQ 0 M4IT11d nllng iolnlly or Ou~ltylng w!dOw(ar)-S8.ICQ youn 0 HOld or nouaohOld-SS,ODQ . Montod nnng ,lp"""ly-SIl,~Q 36 BUO~lIllllln. 35 trQm IIn. 03 . . I . , . 07 I/llnl 30 II SllQ,ICO 0' I..., muloply S2.880 by 111010101 number or o.lmpOonl clalmod on IIno Dd. I/llnl 30 10 0'" SIQ,PCO, ...1111 WO"'hUIOn pogl tD 10'1111 omountto on I" 06 TllI.blo'neomo. Bub~,,' IIno 37 ~om IIno 38, II IIno 071a mo"lI1an 11M 38, Inlor-<l- 09 TllC. S.. 00 110. cnee. II.ny:.. ~om on Form',) U,. b Form '9'/'% . ~ 40 C/.OII 10' ahlld & dlplnd.nl Cillo ..p.n.... AnllCn FOrm Z..., 40 41 Cloolllo, 1I1..IOonyo, 1110 dlublod. An..h Sanodul. R. 41 42 AdopOon c:rldl~ A"lI:h Form 88.'l9. .. 42 40 Fo..lgnl""c:rldl~ Anll:nForml"8 . ,. . . .. 40 44 Olnor, cnllCk II ~om 18 Form 08CO b 0 Form Il:IP8 Iliiilllil:ll e 0 Form 8ll0, d Form (opll<lty) 44 45 Add IInoo 4(J 1I1,0ugn 44 . 46 SuO~'clllnl '" trQm IInl 39, Ill1no 'Slo mor. Ihon :inl 30, ,nlor -c- . 47 S.lf-.mploymlntt"". Anoen Scnldulo SE 46 AIIernoUvo minimum I"", Mo~n Form a2~t 49 SocloJ seeunlY ond Mldlcllle I"" an op Incom. nOI r.poned to .mplayer. Amoo '"m '131 " 50 Tax on quall~ed "Uroment pions Oncludlng IMo) and MSA., Anacn Form ~320 II required. 51 Ad,ance OII,nld Inaam. areoll peymenl4 Irom Form(sl 'N-Z 52 Houllnold employment t""lI, Mlcn Scnedul. H. 53 Add Ilnoo '.I~rou ~~:l. Thlo Is 'lour tol4l tax , 54 F.OD'oJ Incomll"" 'NllI1nlld Iram Forms W-2 and 1098 54 55 '997 os~ IlIJ< paymlnt! end ",,"un! epplled from IS9a rollJrn 55 56a e.med Income c"dl~ .moo h~..".IIC" va, 'm '''Ill'''''. [1:'1.11111'111 011114. b HQntulat' '&IUd l"aom'l.mount ~ I I !I Jill ...ty.. ~ 56a 57 Amounl paid 'HltI1 i'<lrm <IlI8S (roquesllor o><t.nslon) .. 57 58 bi:u"OdAJucuntyM4ARTAtaaW1tn".14('''1I'Q,:M. . . . 58 59 Ot""uym,nu,C:hulll",olfl' 0"1,,11I1.,1 b D'o,"''''~' 59 60 Add IInos ~'. S&, ~e.. ~7, ~a, and ~8, These 311 "aur lotalo. menta , 61 It 11111 .0 I' mGrI UIU. II'" U. '''!lUUI'ln, U 'rOm n", '0, Thill. ul.lInol.tn,you ~VERPAIO 62a Amount 01 IIn. a, ou wenl ReFUNDeD TO YOU . b.............. 0 3 3 0 I 71 2 0 ~o ~'/lll: X Cheekln d 1.(1;01'"''''',"'''' 0 1 7 7 63 "mollnt " tin." .,.,.., ...lIlt ~Jro '1'0 YOUR II.' ISTlUAnO TAX ... 63 I 64 It Il,,, 131. IfIOrt '"11I U". to, IUOlrlat~I/l' .0 'rom Iln, 13. rill' 11 tll' AMOUNT YOU owe.. Far dewi<l en ~ow 10 plY. s.. pa~1 Z7 Tax Compu- tallon II 'IOU 'Ha'" InIIRS 10 "gura your w,ne pa~1 10, Credlls Othe, Taxes Payments Anecn FCl1NW-:l. W-ZQ, anO 1009-R on Inelra"L Refund Have it dlr""ay deposltld' S.. p .gl Z9 and nil '" 820, c, an~ d, Amount You Owe Sign Here Keeo . copy at trllS return tor your re..:ord3. Paid Preparer's Use Only U~ 1 ~ SoJ'Ilngs 65 .sOml..d till( a.nallY, ,0.1.0 InclUOo on IIn. tl4 . ,165 I . 4 · 33 , , ~ ~ ~ P'Jq.2 --7'49'" e3,Q27 o 1 =- , Q , 21 11111' lillll 64 111111!llillllllll!i~llllll!illiillllllll!llllllllllillil!IIIIII!III!1111!:11 . ~ ~ 'I'ourfIQ",nu. ~ YqUrQlZlNlllao" Urt"t, ;J,,,,IUU or III"ury,1 dutil' lnlll /I.." u.a"llM'cI Uti, UNtn Iltd &CCGtllu"'tI"9 lon,,,"1...&IId ,umrft,nu. "'It to t". OUI 0' 1ft" 11"0"..4131 &lid blll.t, III.., U. Q"\l', ~r"ot. &lId =,"pl.", O.clU&Qon 0' PIIIIII.,(OI"" fnlll tI,IOly."ll DUtd on aJllt,'or,uaotl ot "''licit 11,..11., /lu Ill., IUUIWltdQ', , 0111 ;;;;;;:; u9""tu", 1'1011'" "turn, Barl1 ,"''''' ~14lt. 0111 ElROJ::CT MANAGER Soo",'" oC=.tOlDon ....C.-m1'....~~N' .......,.""'1 ~ 'UJII'tlUt , '"'''''''''''"'(0''1 I' Ult""'"llO.,. 4dllr... 01" y :,nrA1 AJ:. ER1f:....~S 8RrDGE STR<:'~T CUMB ERr. '10 'IC o IIN t1"~d. - 8-33H 74. 77 is 7070 il II II , I. SCHEDULES ,o\&B Schedule A '~ Itemi;:ed Deductions OMII ,~o '~'I-r.QN (Form 1040) , , ,1997, (Sohldull B I. on b"Ok) OUIUI/lllllllJ' II" rr...u,"" 5.. 'n,l",oUonl 'or SohlduJ.. A and B IForm 10~01. Anllehmonl I"IUII,I ~ '~'I1t;. S..r"t11U " AltI.h 10 Form 1040, .. 5.<:Illnal No. 07 N.m~II"'o""lI"jf'l,m IQAt) 'lour 100101 ..aurlly num~., r:;l,~" '" I'- H'l.NNAt1 1).1'11<1';:.1>: Lo1" -~';.749" Mlol..1 C."lIonl Co nOllnoludl ..non.., ralmourlld or paid by Olh"". 1:1,I:i"ii~ 1" lillll, Ind 1 M.dlcal J/ld dlnlll I~plnl" (UI P'9~1-1) " . , . , . 1 An~ -il';: li'l: Olnl.1l 2 Inllf linG""' ,,,'" '.''" 10&0, IIn' U . , 2 83 027 li,':iit:1 I''';; 111'i' .: 2'7 :11'j ill:!1 I!,)cp,nu. 3 MUIUply IInl 2 .boVI by 7,m (,071) . . . . . . . . 3 "III, lid. 1o,li! . SUbll'o:!!!nl 31Tom IInl I. I' IInl 31, mort man IIn. ,. ,nler -03. . . . . , . . . 4 0 TUII You 5 51"11 and laalll Inooml lUll , . . . . . . . . . 5 , A ~~ '11i:1 !Ii:li P.ld 0 Rill IIIIIIIUI' ("" Pl91 A-2) . . . . . . . . . 0 1 ~ll Q ,:1;: '1'1', T p.,.onlll propol1'( IUU T 'I'd 'II" (5., . . . . . . . . . . . I'" il!:11 I Other tuu, UIIl'fPI ilOd iIIl10unl .. Ilii!i:illl~ ("I po~. A-2.) (II 5 It :,1, , Add IInlllihrauoh a . . . . . . . , . . . . . . . . . . . . 4.SS8 - 7,4<;7- 1l1hlrut 10 1'10,.,. mort;.;.IIII"U' "" polnU ""4"11I11 ~Oij lOll '"m IOU, . . . 10 ili1iii!(' Vou Paid 11 HQm. monqlq.lllllf'UIIQI'UQnU 10 'f01,l01l""'" ,all. tf",l" 10'11'1. '11'1111111 Itlf'''" '10m wll.'" 'f4U "411qlll 111.11411I', ,n uq."'-I.".. .fl4.. u"n (5.. IIIf.QII'."IIII'.IG.IICU)'f","0.,U,4UI'''1 , ~ , , , , . .. 1111111!lill p.~e A-2.) , iil,lill!!l ,ii II i ",11.11111 I![III Nollr 11 il,!,il Pet90naJ 12 Palnll no! r.pon.d 10 you on Form loaa. S.. p09. A-3 '111:11'11 InloreS( liS ,or .p'c:l1Il ",101 . . , . . . . . . . , . . 12 I I,d, nol 13 Inv.'Im'nllnl.r..~ If ,.qulred. a~aah Form '952. (5.. I",:lilllll d.duccbl., 11'111'11 pog' A-3,) , . . , . . . . . . . , . , 13 !:lliI:.I:1 I. Add IInll 10 throuon 13 , . . . . . . . . . . . . . . . . . 14 7 4!;7 Gltu 10 liiil:!III!il H:II' I" ('I' II Charity 15 Gilts by COSh or cneok. II you mod. J/lY gm .1 5250 or more, .... 1'1' Ilill "1'\0 ,1'1'1 page A-3, . . . . . . . , . . . . , . . IS 11111 11'11 II you mad. II OIl1.r lJ1an by c:lSh or cheok, If any gl~ 01 $250 or mor.. 11111I1111I1 11'11 [1111 a g,n and 11/1 Pcot a bononl ,.. pag' A-3. Vou MUST .naan Form 025:111 ov.r "00 . . . 10 I[i' 1'1 illll or I~ a.. IT Canyover ~om prior YII/ IT l:iill p.ge A-3, . . . . . . . . . . . 18 Add IInl' 15ihrouoh 17 , . , . . . , . , . , . . . . la ,nn C..ually Ind mert ~o.... 19 Ca.ullll'l or Ih,lIlo..II'), An.ch Form .a.., (S.. pao. A-',) . , . . . . . . , 19 Job I!xpen,a. 20 Unrelmbu,..d employ.. "pin,., -100 lI'oveI. union 11!!il~1111 If I! III and Moot dU." job .c11.Icatton, eta, Vou MUST allaCh Form 210a II Olher or 210a-EZ I' required, (5... page A-',) .. IIII !~I 111111 MlsccUanlllous FORM 2105 2,983 20 ., QS3 1I111i"1 Dflducdona 21 Tax propl/auon I_ . . . . . . . . . . . . 21 III (5.1 22 Oll1er "plnsn .I""..tmln~ ..I. depo.lt bOll, Ita, U,t ill II pag. A-5 lor l'fPI ond amount . . . . , ... 'illl IX!::Iensts to UNrON DUES 651) Ll dOdUC! hlr..) 22 ,:;~n - , 63' 2:1 Add linn 20 ihrou9n 22 . . . :1 ~4 " . ~J . . . 22 24 I""rlmolllll'rom'o,,,, 1O-4O,II",U , 027 Ililllllllll :zs Multtply IInl 24 obov, by 2% (,021 . . . . . . . . . :zs 1 &;ii1 ' III1I 2S Subtroct ~nt :zs from nnl 2:1, It line 25 ;a more tnon Ilnl 23, Int.. -03- , . , . , . 2S 1,972 Other 2T 01l11r. 110m 11.1 on' p.gl A-5. U'Il'fPt and ,amount .. ~1!11111111 Ml!lIcIUaneous Oeducdon!ll 2T To.., 21 I. Form 1040, line 3.:1, avor 1121,200 (OVIr Seo,ilOO " mamld n~ng IIpor.reIY)?' Itemized NO, Vour dlductton :. nOllln>tod, Add 1118 3Il1Ounta In Ihl lor r1<jnt column J Dlllducdons 'or IIn.. 4111rou9h 2T, ,lIIId, Inltt on Form 1040, lin, 25, thl larger 0' ~ 2. 14 <;l7 thlo amount or 'lour "and...d dlOuctton, !l!1111 1IIIIIIIIIIi:IIII'll!i'lrll'II'II'I"I'III'i:llliliillll'1IIi"'1 ves. Your deductlon may oe 11m rod. SH oaqe A-5 lor the JIT'lOunt to I1nter, I,! .1i',I:li!I!,III,IIIII,IIIII'lllllli!!!'I.::'1 For Pap.Mor1C Reduction Act Not;lce, N. Form t04U IntO'1Jcdons. u. Soltedull A (Form '040) 1997 ,ll I .. I . I III :. , -, S..:hq(juhJIS ,laB If'Jnr1 10oll)) IllIJ7 Nillr,U(5) ~tVJwn on FlJfm 1ColQ, 01101111 Inll,,,.m. &/III UI;I.I","llnlyn"/1l~"I' Il'Iq.." '" 111'" .'4'. GA.~.'{ F. &' !"-,~NN;"H P..DKrNS ' ., Schedule B~lntare6t and Dividend Income OMBNo.le4~'~07" P>qq2 Your lIocll1' ,U";lJrtt'1 n1Jmb.r H:2 -%-7'!'9'7 .AtuclImant S.':uonco No. 06 8 Add 111. lIIl10unlll on IIno 5 . . . . 8 7 CiIjlllal galn dl4lJ1buaons. I!nrer hero ond on 'SonOdulo o. 7 11'111111'11 8 NonlllCobIOdI'lI1buaons. (S..lholns~ lor Form 10All. IIno 0.) 8 l ~ 9 Addlln.. 71nd 8 . 9 10 SUbUCl Ilno g /rem IIno 8, anl.nn"osult ner. and on ""rm '040.lIn. g. . 10 You must complol' Ulls P4ll1! you (0) nod over SolOO 01 InlerllSl or dlvldondl; (bl hoc a torolgn lCCOun~ or (01 rocllvld 0 clmbudon /rem, or wero , grlnlor 01, or 1 ",anl1l(or 10. I tore.,n 1I1J'~' 11a At any ilmo dul1ng '907. did you navo on InlollSt In or I slgnowr. or ol/1er ~lI1or1lY over 1 IInandlll lOCOunt In 0 10l8lgn oounay, SIlen .. I 'oIl/1K accoun~ IIOClJnUOI ac.oun~ or Olhllf' IInondll tCCounl'? 5.. pog. 13-2 lor ..olodons and IIl1ng I8C11llremonllllor ""rm TO F 00-22" . . b II "Y.... onler Ulo n.",o 01 1I1010relgn eounay . 12 Ounng lU7, old you roc II" I <1I,lJ1buaon ~om, or wer. 'IOu Ulo granter of, or "'1II""ror ro. I fo,lI n tnJsl111 "Y.... 'IOU mav nlvo 10 IIlolorm 3520 or 928, So. 00 . B-Z For POp.MOrl< Roouoll<n Ael Nod.o, ,.. Form 1040 Inl,",ollon.. irA Part I Intorest Income (5'0 pag., 12 and 6-1.) Nololll you ,o.olvod 0 ""rm lCOO-INT, I'<lnn 1000-010, '" INb'OlUlO "tlll,mtnt tram a brokerl~' nrm, IISIlJ10 IIrm'o nl1m' IS the pay" and enler tnl tala! Inllr81C shown on thai: toml. Part II Dividend Income (Se. po~.. 12 ono 13-1.) Nohl! ;r you receIved a Form 1099...0IV, or substltutl sralemen[ from a brok'''g. linn. list Ulo Itun's name as mo PlYor and onler 111. tolal dlvloond. shown on that lorm. Part III Foreign Accounts and Trusts (5" p.go 13-2.) No.., II "ou hoo over $olOO In lo..bl.'n,er"llncom~, 'ou 1T1Im also ~omol.'o Pitt III. 1 l..l~1 nama~' Q4ylt,.lf any tn/,rult III rQm 15.' dr-I nllnc:eQ mort9~Q. Ina tnQ buyer us.d Ulo proport'/ .. ! p."onal r",osne., ,.. plgo a-I . d lI.t 11111 Inloreol ",,~ Aioo InoW Ulot buyofl .odlll ..eunly numll... and a dr... "'mounc . M 'T o - 6 1 2 AOd Ulo amounlO on IIno 1 . . . 3 e.,dudoblolnt.,..lon ,,11.s EE U,S, o.vlngs bondOlsS1Jed an" 1880 ~om Form S8,5. IIno 14, You MUST oneeh Fonn S81510 Form 10All , . . 4 5ub~..t Iln. 3 ~om IIno :z. En lor lno r..ult h.ro and on ""nn 10All. IIno So . ote' If '/0 ha.d dlillr .i 0 In QSlJ d \ll~ ne! 3"dl r 'JIMr dlsmbuttcn on steel< . ow rru t 31 5 u.t nsmo 01 poy." Ineludo grollO dlvld.nds ond/or olher eJlll1buUons on "oCk here, Any .apllnl gnln dllll1lludon' .no nonlll.Xebl. dlslJ1~uaons will b. doduClod on IIn.. 7 and S, . 2 3 o 4 ,. malllre ~1rttll "mount 63 5 V.. No l~llillll~ Ilill!ill~lil 111111111111111!li'II'I,I'1 11,11,1.11 JI,llj,: . Sohodulo IS (Form 1040) 1 n7 '. . q . :. I"'''" 21 q6 Employee Business Expenses ~ IS.." .'p.".t,'nlllrt.u;UQnl, , , 1997 o I1NQ,II"'.'1I1' a.lUII"'......' Uu rll"'Ij'~ IIH.'IIIlII1...."ta'.,..''=. YQlI,IlAln. ~ AlI..h 10 'orm 1000, .lltlc"""nt SUlillICI "fQ, 5~ qoll'''''UIII'' "''''IQft ~qij I"C'.J"U ..../I... G."<P.'( Ii: .~Df'ur'" IPart II Employee BUlSlnulS e~penlSQlS Bnd Ro/mburlSQmonts U"r STEP 1 Enter Your ~pensQS Column A 01J1., Than Mull Ind !nltnaJnm.nl Column B MIll'lI1d I!nllllllnm'nl 1 VlIhle.!. '~p.nll' tram line 22 or line 20 , .... . t' , 2 PlII1<ln~ I.... lrlll., .nd ~'n.ponIOdn, Including 7aJn. bU" "0,. IJ1UI did nollnvd'vl dv.mlght ~,v.1 or cO/1VT1uMg 10 Ind Irom Wdrll . . . o Trlvel "'p"nel whlll IW'y 110m homo overnight. Including lOdging. Ilrplln.. cor rentll, Itc. 00 nollncludo m.Il, and InllnWnmlnl . . . 4 Buolnu. "' pinel' nOllnoludld on IInoo I IJ1rough l. 00 nollncludo muJIt and tntfJrtaJom.nt . , .. .... ... :i;IIIIIIII;1 i!P:II':I'::'I,iill:l:'i:'~:llill!li;llii:'Y'i'" I I' I ,1:1 '1111fll "~!III II'~ lihl: '1';1' ,'111" I :111111:11 ;'iI111:I!i"" 111,'lllli::III!liil:::::I:":'1 11I1II 11111111, I: 1111' ~,!': I;" I , I, 11'11 11111'11:::1': 'III,'I'I::!'I,', 111:IIMIIII,I!,lli!I!,. 1I:!II,:!:I:i'!,!!: 5 1!!III!I!iii!ili!liliiilllillllllllilllllllllll!il!I;I!W:Iii lliiillllllll I ~ II! I! II i I! i 1 2 o 4 5 Molls sM ,nlonaJnmont ..pon." (...'nOINOOonl) 6 Totol upons". In COlumn A, sdd IInls I IJ1rougn 4 snd onler !ho r.oUlL In Column a, .nter 1J1. amounllrllm IInl 5. . . , . 4 7~1) 6 a 71S() . . Nol.: It you 'Nero nol relmbursld tor any upon..oln Slip'. Iklp IIno 7 Me onter !hI amounllrom IInl 5 on Ilno S. STEP 2 Enter Reimbursements Recelvod From Your F.mployer tor E~penSQs Usted In STEP 1 7 Emer amounts your Imployor gavI 'IOU thOl 'Nero not reponod Id you In bO, 1 or Form W-2. Includl any amounl roponod "nder co do "\.'In bo. 10 or vour Form W.Z (...lnOlNo:ono) . 1 ",'I'IF, II' I Ilh' 11111'1' 77 !1!!Hlili,i 7 7 640 . , , STEP 0 FIgure Expenses To Oeduct on Schedule A (Form 1040) a Subll'IClllnl 7 irom IIno a, . I) a 4.120 , . . Not.: It both columns or IInl 5 UI zoro. SlOp hero. It Column A Is IISlIthon zsro. repon 1110 amount ..Inoomo on Form '040, IIno 7, 9 In Column A. Inler 1110 l1T\Clunl ~om IInl 5, In Column a, rnulOply 1110 lIIT10unt Oil IIno a by 50'4 (,.\0). It oIlJ1oroolumn Is zero or less, Intor .0(1- In that column.. ..... 9 . . . 10 Add !hI amoun~ on IInl 9 or boll1 column" and omor 1J11 rcnal h.,... AI.o. onllr thl lotll on Schldul. A (Form 1040), IInl ZO. (FI..buls Ilat. or looal govlrnm.nt otlldolS, ~aJl".d plrlomUng artIs~, II1d Individuals 'Nlth dlubIllO..: S".lI1o'nsll'lJOlIon, tor spedlll 1Il1.. on wtlera to tnrer the total.) . . . .. . , For Paplrwot1t Roduc:t1on Act NOUOI, ,..In"ll'IJoUonl. IU ~ 10 , . ,/'Jrm 2106 (1997) D Q I I . FoJfm 21ClJ It!)U7) ~ I ;, I . Part II V~hlcl<l E~ qn~u IS." '""NeD.n. 10 1nd ~uI whiCh """~"O '011'101$10,) Sdcllon altnqralln'ormallon (01 'I.hlel. I 11 Enlor thq <1l1lQ '/IJhIC!Q 'Nd$ pl4C'Jd in lJIfrm:1I I , 11 ,.. '..' 1~ f.IJI ",,1'5 'I.hlelo w.. dn,"n dUMg 19~7 . , 12 , 13 B""no.., mll05lncl"dOd on llno 12 . , 13 H porC'"1 0' bU'ln.u "", OlvldO Iln. 13 ;y Ilno 12 . 14 15 Avorogo dolly ro"nd Il1p ccmmullng dl.lonco. , 15 ,. C.rrJT'Ullng mllu Ineludod on IIno 12 . ,. 11 elMr 11'1,105, Add lines 13 ..,a '5 >1111 lubllOClIll. IOIIIJ ~om IIno 12 , 17 16 00 you (or your IPOU'" hov. lnolJ1or 'IIhl<l. 4v"loel.lor p,"on,' purpoGO.? . II y.ur o",ploy" provld.d you wllJ1 . vehlel., I. p,,,,onllJ uoo during on-dul'J hou/1 p.rmlhld? 0 VOl 0 No 15 P~.s.u (b) V.n'd. ~ o ",,1..1 n"l.. I ",,1.. mlltJ!I III ~:. mi.. mtllll , mi.. I rrlhlll mllu mllu IJMQ . lliJves ~a 00 you hove ovld.ne. 10 .upport your d.ducllon? . , , miNot ~'ppllool:lO llilves ONO 21 11''\'..,.1. Ih. ovldonco wl1h.n? . Secllon B - Standard Mileage Rale (U.. IhlllltC'On only I' you own 1Il...hlel,,1 :a M',luplY IIn. 13 by 31.8 c.nil (,315). Enlor 1M ".ult hll. llI1a on IIn. I,(RurolJ mill CO"I.".... ~~~~ . n Section C - ctual Ex ens as {ol V.hlcl. I Ibl V.hlel. 2 23 ~:~~~:~,o~;:.ep~". vehlde . 2:l liI'i!iiili:!~I:ii:~iliil::::iiilili!I!lli!lllllii!!:!111;!li~:I!:1 li!ii!:i!l!i!li~jii;IIIIII!,I::illl!II!I',!!:,ii.:!i!;i!i:l!llli!l;i 24a Veh,el' renlol~ . . 24a 1:~I;illllllllllln!il':i!II~II'I!II':I:H!III b IncluGlan .uncunt (see fnsll'UcCQns) . 24b 'il.!i11lli Ii ~ ,1'<i!,I;;,Jii!r!;'i11~:1 c Sut:O'llct line 24b tram Uno 24a . '24e 'III, ,:,!: I',.: tl:Ii'IIIIIII': ,1111. 'II 'i:: ':1'1' I 'I III, I I, 'I I, ~ I '1111'1111' , 25 V.:lJue 01 employer-provided 1,1, '11;'11:111""';1111'11 '1'11"1:1,:111'111,';1111, 'I,'" 1'''''11111'11'"'1'1'1''111''111'' veh,ele (oppU.. only If 100l~ 01 i":'11 "li'I:III,IIIIIII" 1'1[11:,11 to; :!I :,I,:II'!II ,i annual leaso vl1lue was Included 11111,1 11,1, ' 11,1 'II' I' It l'll'lli 11;'11 , " I" 1111 I' II I on Form W-Z--U8 h1IStrJCCOllIS) . I I'll II 111'111 ,II I, , "III'I:I:';'I',II!I' I I Add IInee 23. 2~, lII1a 2' , "'1'1'" 1'1111'111111' Mul~ply IIh. 25 by Ill. pereenl.g. ,"1111'111' 'I' I' 'II 'I'll on line, 4 1'1111:1111 1'1' 2a OeprllCioaon. Enler amount ~om liliil'lilll'!I: III 11III' Une:JO below., 28 111:j ,lljl II1'1 25 Ada line. 21 .na 29, enler IOliIJ "III l'IIIII,!1111;:I'I'I!I' liI,' II 1'1'11'''1''''111' III here .1lld on line 1 . 29 i I I I'" ,III I I 1'1' Section D - Depreciation of Vehicles (U"Il1,..""lIon onlv II 'IOU own lhe ..nlelo,1 {al Venlele t I li!;illii!illl!lllillllll!lllllli!ll!il:':!III! !llii!~:illllllifli!!I!II!llil:II!llllili!i::1 l!il:!lliil:II:!ill:!iii!%lli!II'iIi!lil::illlllli!ili!l!:1:1:1;! lil!i!lii!i1ji!ii1il!ililillii!lilll!li!!liW!i!!il!i!!II!lilllll! Ilill!11 I'll I" 2S 27 '. 30 emer cc~t or OIh.r besl. (.ee I".~e;on~) 30 I 31 emar amount 0' .odon 11!J ;- aeducaon (~.. In'lnJcaone) . 3t 3'2 Mulaply IIn. 30 by nn.,4 (.... In~~C1lon. " you eIltCted 111. .",,;on , 79 deduedon) . 32 '. :13 enler doprocto;on moll1od II1d percenlag. (ooe In'lIUC1loh') :l3 34 Mulaply Iln. 3'2 by Ill. pereehlog. I. Olt IIn. 33 (seoln'lIUedon.) 34 :IS Add Iln.. 31 .nd 34 . :l5 '. 3S Enter 111. limit ~om 111. tabl.ln 111. IIn. 3S In'lIUe~on~ . l. 31 Mulaply IIn. 35 by 111. ~''''enl'g. on line 14 31 3e emer 111. .mall.r of IIn. 35 or IIh' l7, AIoo enlllr II1Is J/11OUht on IIn. 29 o1bovlt l8 19:'" No li:'W"I":I'lli"I':I!IIJiiL1:ll"'1 . ~ , ;' " I' I : !, Ii iI i I !, : I ! Ii' d :' )1.1",.,:, 1:!Vd'I':"1 !i'!':'I,~II:I. - (bI'I.n,co 2 l'III'I!llilillltlliilllii!: It 111:llt'II~'I; /1;:,111111;11:111111; !I!ili~:,!h ~,'i :h ,li'd;d,.!II.,I, ," I Illi'I!I'llllllilll'IIII'IIIIIIIII'IIIII!!,;'!I,;I,: ,',I,II"III,I!I,II...ld,I"d'" 11""""",1."1"',,,11'11' , 11111.,lil:I::I::':',llli:,'!I:.i'.:I::I!llil:'I'II"1Ili'I!I!i:i'I'!.I!II!!:li:11i 111.11!!!l::ii:,!:!:::i'jl!II!I!ii:i1ii!IIII!II" ''',''''nll''.'llfl'';il'l '11'1 ! 111'i"III,;.!',I,:, '!"II:'iH"" 11:lall ,:' ,11;,II:IIIII!II!II'i:::illllllll,III:I'!I'II'III:1 :111;'I"':i,11I.1I'1 1,.,,1,.1 ':1111"11',' i '11 11o?i L " '," I,ll I' I,III!'IIIIIIII:II:II'I!IIIIII'IIIII!IIII:IIIII;II!:I:II1:1 Ilmull!!i!:illllllllll!111 1"1.; ,;",,,.11"":, ,',I,ill',IJ'I,,,,,,,,,,,,',,, II",,;,.;I_I,I,>!,I ;,1, I.!II IIIH,ili'!IIII!:I'II'II'I'!ii!ll:i':'lli'I!~:1 bl.;'I!UI11:f:':il%l:.li,I",,; -- ;~ 1.r":~:: .:,,'1 :.. '.. : 1~. I _ ,;.', _d ~: : .10:, :.-:..., "'I " I ~.~ 't~ '~:'''j ~f .: .. ,"1,,- J ",_ 3:, I,_~ ,... :~:."::;:",,:\~'j !>I. :," J]I ;_;:':,.::." :~";I,I:;"':/"'l::: . 3,1 f . ~ ...~. :'i . ': ''''~' '" "'" "" ',.. '-','" , . ~ . : : .;:. .', ::!: . I'; 1:, 't -'" I~' ,.' I ':,,','.<;.~F;:,.;:.':::...:,:.. ".l .. ~I J :'" to: . - ~.f ,.' ,.:\' -'-, , '1_ ~': . ,,-/ .:: ~H .. "-'- . I, '.. .~.. '"'' . J"':. .~.;: \,~."'. ';'::1. "" ""'"'1 .',". :....;';t"I' -'-.... '- ... ~..' I ~ ", 1,- " . , ", r., .- " , .;, I- .' ,. " 'I '" . .' ,- .,-. '. ., .. ".'If , I,U ." '....; .1-\ ~. -' 11_~' 'j'. "", '. , ,. ." i. 1-, ..... " :.1.. '. 'N", '.. ~ . "::''':''''':", I. ",. ,,' , ' ~.' it' ", ", " - .\.,'......,: 'I_i,..,: ~.'I' .: ,r .": 'I.~..~.h\ '':-1"'' f ''I':'':. ._,'. , ,. II !, '~:'1 . , " '1. ~.'.. .oj'r : . '," ~;,. i'.' : ."t.'.liJf d ~_~ 0\1"1\ '-. I a.~n: "'''1 " ":Ill' j''':I.J '.'PIO:" . I'II~.. . ~.....,." " ':""~ '.\.,"/1', .ro,." " "'i I'f,. ,'''''' , '~H~ . . '1"", to '... "... "!,:.t'I '''Cif '" t ~1.lq ':""''"'' 'I,,,,:..,,, , .,~ It ::..e.... "'" '..~ : J, ,. 1,'lift :"'.fIJl 'JI,i ':r :.Ill ';') ",... : ":IJII '... "",'1 ,,:,:~,I~ "~~Igo..,. ~-;;;-~-;:."',."." 111111,. " V'I1I,1 UI""IM",Il) "I..a '.U '.I\1"',.a "'<;II'l'"1:1 1(.,,,UJI(tJ0I1 "...,q'''''DIJ''O'lnytJu,'r/lI''''CQ'''I..'tUl.l1t L l""1"I.lJ.rOt,aIJrI,', .; For "MPLCYEE'~ RECOROS 'Io10't:" 10 Em,,'o .,,,. rt,'","ut I ^,.a~II, ~U', 3In"~"'a, ,J<)J 5: "oJ.....!),) J,jllCO.a'U"'lntY"'I'1" ." ~~ J ,"'I"IUI, ...qu illq ~1I1 " .. "VOIC,1l.itnOlf S.~4'J5 J 2 21 ","',"IIII,.a4''''..,I.IIO..I'';04. ~:;,t~CC:-: DE'lZtO!?M:::m:, ~5 :1. S!J!3CN RO, ::-=: l!. 'J .. j:......;N.;X..~, I~T 45545 'HU'HC.aIIIClml'l't1l1mOlf ,P.::':.7 f '~~ .',nlll"'lIIt, .aOO'UII lIto..1 ;~4' ~...r! :: .3....::<:N:: H S :CREST DP.:'IZ 'C:";.l.ll!CSaIJRG, filA 17055 UUc~nry ~1I' II "lIo~11O tip. I I '''q''O'.l.a~I'IQ 1I1&11, ,"UIIIWlun",t.. ,~.t/.. '4' 00' 11 liMO'., tmlllOy.. ..ICU.JlII!, 'r'I'IQI't '"'' t..~~ '.D. rpp~l ,0 ,vR hr. t-'1~I'""It.lr. ',=,. I "'sUII '..qu, ~aa. fie. """'"m. I" COO" "'''. '''.'''' "fetoYl'lI.an...uJtAllm."t 1997 l,:..,.,....II~'"ll.I.l..II.,,'..,' J ::2 5 .1~ IJ4(.1.aIIlC..."'y 't. .....11111.,.. , "... " I~TC . ''''11'1&1'1(1 c..C uym'"l rt'l't'd, ""D. JIiOfQW 1"'s~I""CO"': '2.- f' I.JCAJI"C4m, '2. " ,.. ~.. ) "' p~ I....... I,,; r- (',t; ,I , 1 V.' ' " l' fY- ';, ,. C~) ~ !. C'" , I" I l, " , I , I l' I' ) 1...) " , , , , , I' I' ',' , , I' BALANcm owmo 'I BSI Financial-Home Mortgage PROPERTY OWNEDt $87,000.00 (Estimate) omSCRIPTXON YA!IIDll OWNlllR Checking Account Financial Trust $ 700.00 H Savings Account ' II Financial Trust 4,200.00 H Real Estate ,,, 351 Stumpstown Road 125,000.00 H & W Mechanicsburg, PA Insurance Provided by Employer , , 'I I I " '~ . ' ,j" I' '." ,. . "f<; I .~ '. ," -"'. .,.-....... ......-......-_............._._...--~-.. ... EMPL.I (945) GARY E. ADKINS CK.lh 09147 ...GROSS... ..OTHER... ...TOTAL.. ...NET.... CURRENT I 686.00 0.00 686.00 466.80 Y-T-DI 2,606.80 0.00 2,606,80 1,779,08 .FEDERAL. ....FICA... ..STATE... ..LOCAL.... CURRENTI 76.65 52.48 19.21 6.86 Y-T-DI 286.02 199.43 73.00 26.07 GARN SAVING UNIONS UWAY CURRENT I 0.00 0,00 64.00 0,00 Y-T-DI 0.00 0,00 243.20 0.00 BONDS HOSP XFEDTX OPT CURRENT I 0.00 0.00 0.00 0.00 Y-T-DI 0.00 0.00 0.00 0,00 ______...-_.n.-.______.,.____ ._ EHPL. I ('''1 aMY B. NlKIHS CK,', onoo ..051.098.. ..0TJDIJl.. ...TOT,\L.. ....NI'l'... CURRINT , , U6.00 0.00 C".OO 4U.IO Y'T-C, l.,nD.eo 0,00 1.120..0 1,)12.:21 .PlDIRAL. ...,ICA.. ..STATI.. ..LOCAL.. CUllRSlIT , 1I.n 52.48 n.n .." Y-T-D. 20',.)1 lU.1!J n." It.a> OARN SAVINO UNIONS WAY CURRINT I 0.00 0.00 ".00 0.00 Y.T-D, 0,00 0.00 171.20 0.00 BONDS R05' XnI7I'X OPT CURRINTI 0.00 0.00 0.00 0.00 Y"T-CI 1),00 ",00 0.00 0.00 _._-~----_.-. PI"OD IHDIHO, 10/25/" ..... RAT. DRIAJa)OWlf ..... HOURS RATS 40.00 at $17,110 OTlIIR PAY I PAY 6U.ao 0.00 .......................... TOTAL OROS81 ,u.oo " ,I ':.,.-".,:,' "I','::',": ,; il ;',;.' f ~ : " , .' ;',' ,.'., . '.' . i....:;, '" ; " ,..". , , PERIOD ENDING I :9.14798 ..... RATE BREAKDOWN .==..= HOURS RATE PAY 40.00 at $17.150 686.00 OTHER PAY I 0.00 .a....~~...........R..._~A TOTAL GROSSI 686,00 ..,' 9100 ',\ I. ,'I, ' ; .- ~.. ~..-.......--.- : :1 , , . .,..,.",1;' -"'1 , , . .'1 ._l.';".:"':'!?;":!~-<' .;.. , . ," .., -.- 0036 GARY E. ADK1~S H' 1., ..., ,.... .., SIIAM 442.66.1496 -~ . ... ,-- API! IOJ,I99a API! 26,1998 S 01 APR 29,1990 EARNINGS TAXES ,...,.... ..... ~. --, .....,.",.. _u, SALAlIY 560.00 FICA 40.30 MEDFlCA 9.43 FED WTlI 92.61 PA l8.2Q TOTAL $ 650,00 TOTAL $ 160,50 TOTAL $ 136,69 ,-. 'H~I .........352,91 ,., 0035 -.- GARY E. ADKI~S I., ,., ...,., ...., ...., SIIAM 442-66.1496 -~ APR 26.1998 ~"""" Wll.. ...rort MAY 2,1998 S 01 ,-- MAY 6,1998 TAXES EARNINGS ~......" SALARY -.. ~. -... 615.00 -,.". FICA HEOF I CA FED WTIl PA _0' 41.85 9.18 99.51 18.90 TOTAL $ 675,00 TOTAL $ 170,10 TOTAL $ , .. .'. '.' .--___.~___..~__.u. ~ t , , , ;- :.,,':, ',I, "".<:!',:::j:,:--': , '.' :" 1.,..;.:.','...,',',.,' " :::;t,_':"(If..'.':: , , .:; " " 'L.t';, -; ,.,:,- ,',,' ,. , ,',-, , It!'" '''1'.' '--'- SHAMROCK DEVELOPMENT, INC. ' 24~ W, eDISON RD. SUITllllO MISHAWAKA, IN 465H DEDUCTIONS YEAR TO DATE ..". -.. 1_'''''_ #,No'" SAYINGS 100.00 GROSS 11050.00 MEDICAL 36.59 FICA 685.10 MEOFICA 160.2J FED WTIl 1613.69 STAJE 309.40 HEDICAL 622.03 r_..a_ ' SHAMROCK DEVELOPMENT, INC. 24~ W, EDISON RD. SUITE 110 MISHAWAKA, IN 46545 , ' DEDUCTIONS YEAR TO DATE lIUI'U't.. SAVINGS HEOICAL _WI 100.00 36.69 -..... GROSS FICA HEOFlCA FEO WTII STATE MEDICAL --. 1lI25,OO 126.95 110.01 1613.26 328.30 658,62 136.59 ,-- .n,., ........368,31 ',' " t t, 'I ;_,', i:.' , I I "hi _I , ~ ,-, -- 0036 GARV E. ADKINS ,-" .., .., '..., SIIAH 442-66-1490 .. .. . .., .- HAY J,I098 HAV 0,1908 S 01 MAY lJ,I098 EARNINGS TAXES _'Ir\). _u ..., w.., ,-,..~. *.,., SA LAllY 616.00 FICA 41.86 MEDFtCA 9.79 FED WTIl 99.67 PA 18.90 TOTAL $ 675,00 TOTAL $ 170.11 TOTAL $ 136,59 ,_. -- 0035 GARY Eo ADKINS ,'" ~, .., ,..., ..... SIIAH 442-56-1496 ~0.1098 I -- ..... kIWI ,-.. HAY 16,1998 S 01 MAY 20,1998 EARNINGS TAXES _'l."'~ .... ... w... ~"'. - S,~LARY 675.00 FICA 41.85 MEDFICA 9.79 FED WTIl 99.57 PA 18.90 TOTAL $ 675.00 TOTAL $ 170;11 TOTAL $ 136,59 -~ "'., .......368.30 ,'. .,', ;'.,' ,,';..:, '..", ,,' "': '1'1" ,t, 't.,.,1<. '/,':.': ," I"",,, ,-.........,- SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE tlO MISHAWAKA, IN 46'4' , DEDUCTIONS YEAR TO DATE ......,). W.., -.... w.., SAVINGS 100.00 GROSS 12400.00 MEDICAL 36.69 FICA 768.80 MEDFlCA 179.80 FED WTIl 1772.83 STATE 347.20 MEDICAL 695.21 ,.... ..,,,,, .......368,30 ~._.- SHAMROCK DEVELOPMENT, INC. 24' W, EDISON RD, SUtTE 110 MISHAWAKA, IN 46'4' DEDUCTIONS YEAR TO DATE ....... - - - SAVINGS 100.00 GROSS 13075.00 MEDtCAL 36.59 FICA 810.65 MEDFlCA 189.59 FED WTII 1872,40 STATE 366.10 MEDICAL 731.80 .. -...~. .__...",-, .. ..-, ....,.,. '."'.,,";L", "" " ,', h >, : ,',' ; ,', I' , ; ~ . .., ... 0036 QARY E. ADKINS .., .., 'w SI/AM 442.66.1495 -- . ,., ... MAY 17,I99Q MAY 23,1098 S 01 MAY 27,1998 EARNINGS ' TAXES .-"n... .... ... ..... "',m_ .."' S~LA'lY 676.00 fICA 41.8U MEDflCA 9.70 fED WT/I 99.67 PA 16.90 TOTAL $ 675,00 TOTAL $ 170,11 TOTAL $ 136,59 ..... "n~r ............368,30 ,.. 0035 -- GARY E. ADKINS I'.' IJ., .... ,.., ...., SI/AM ~ MAY 24.1998 442.56.7496 I r:1AYio,1998 EARNINGS ... ~ """" S 01 ..... JUN 3.1998 TAXES -- SALARY - ... MMIIrf '''It'IQI 676.00 fICA MEDflCA fED WTI/ PA -, 41,85 9.78 99.57 18,90 TOTAL $ 675,00 TOTAL $ 170,10 TOTAL $ 136,59 ..... "If""" ........368,31 " ,',I, '. ' ... . .-........-,...". '."H".~__' .. .. ,...,... .........,,.. SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD, SUIT!! ttO MISHA W AKA, IN 46545 DEDUCTIONS YEAR TO DATE .......- -.. ...... ....... SAVINGS 100.00 DROSS 13750.00 MEDICAL 36,59 fICA 852.50 MEDflCA 199.38 fED wnf 1971.97 STATE 385.00 MED I CAI. 766.39 , ... ..- _._- 0-' ,- .__,__._ _.~._. .._.., .....u.., ~_.- SHAMROCK DEVELOPMENT, INC. 245 W, EDISON RD. SUITE tlO MISHA W AKA, IN 46545 DEDUCTIONS YEAR TO DATE --- SAVINGS MEDICAL - 100,00 36.59 - GROSS fICA , MEOflCA fED WTI/ STATE MEDICAL ....... 14425,00 894.35 209.16 2071.54 403.9Q 604,98 -.--.-.............. ....-...."...._H......_.e..._. . '.. " ,.,' ....., ", o' :0",." '.':: ",: ,.;,,' ,"", 'I: ',,",,:,.:': .' .';'.. ... . .... ...-.... "..~..... , .' t'..;' ~. " '; , ''''.,'' ,,!.' .',""', " .'. " ',-:.. . " ;.. "T., . , . "- 0036 GARY E. ADKINS Il' .., .., ,..., .. SIIAII 442.66-7496 - ... .... HAY 3l,t908 JUN 6,1998 S 01 JUN 10,1998 EARNINGS TAXES -..... .... ... ..... FICA" ...... SALARY 676.00 41,86 MEOFICA 9.79 FED WIll 99.67 PA 18.90 TOTAl, $ 676,00 TOTAL $ 170.11 TOTAL $ 136,59 ...~ Ion"" -**368,30 " .' !l!d'", I....~..- SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD, SUITE ItO MISHAWAKA, IN 46545 DEDUCTIONS YEAR TO DATE. -..... ..... ....... -- SAVlHGS 100.00 GROSS 16100.00 MEOICAL 36.69 FICA 936.20 MEOFICA 218.95 FEOWIII 217t.ll STAlE 422,80 MEOICAL 841.57 ___..__,..._..._k'~"''''_'"''''''''~''._~'''_''__' ",__ ..._. .....__._.__... .__.~_. w.... ".,_.._.._.__~_~ ,__,.,.",... . ~. -- ,,___a_ 0035 GARY E. AOKINS SHAMROCK DEVELOPMENT, INC. h, .., ...., ,.., ...., 245 W. EDISON RD, SHAH 442.55.7496 SUlTa 110 -.. -- .. .. .... ..... MISHAWAKA,IN 46545 JUN 7. t998 JUN 13,1998 S 01 JUN 17,1998 EARNINGS TAXES DEDUCTIONS YEAR 10 DATE -..... .... ~. -- -- *.., _11m_ ..... -- ..... SALARY 675.00 FICA 41,85 SAVINGS 100.00 GROSS 15775.00 MEOFICA 9,79 MEDICAL 36.59 FICA 978.05 FED Will 99.57 MEDFICA 228.74 PA 18.90 FED WIH 2270,58 STATE 441,70 MEDICAL 878,16 TOTAL 675.00 TOTAL $ 170.11 TOTAL $ 136.59 ,..... -~. -*368,30 $ . "-'-~"-",,-_. .... .~-~... ~,_'-' ......r~'.--;---...... ~._~ --. ._-_......._.--.-..~.--._- ..,~-~...-.. ',';,,; .' , ~, . ,~ '. : . .' . ( I . to .':',:, I , H .; . ~, ,', ,,;:"-' . ~ " ,,' : .... :l ,: "'.t." :.,.,.,;;' .. \, '. .t,' " . , , , ,'to ., , . ',;' ," .....-'..'.".. ''''.._n'''~''',."""",,,,,,,,,,,.,, . ',...".....--...--..-...... . ~, 0036 aARY E, ADKJNS r., ..., ..., ,.., slim -.. - . "" JUtI 14,1998 JUN 20,t998 S Ot EARNINGS TAXES '*',",.. ..., ~" -... """""1 SALARY 675,00 FICA MEDFICA FED WTlt PA '- - SJlAMltOCK DEVELOPMENT, INC. 245 W, EDISON RD, SUITE 110 M1SHAWAKA,1N 46'45 DEDUCTIONS , YEAR TO DATE -, ""'..,.. .... ..-.. ~.., 41,06 SAVINGS 100.00 GROSS \5460.00 9.79 MEDICAL 36.69 FICA \019.90 99.67 MEDFICA 238,63 18.90 FED WTII 2370.26 STArE 460.50 MEDICAL 914,76 TOTAL $ 676.00 TOTAL $ ,... L70,l1 TOTAL $ L36.69 _"III' .......368,30 '.4_. .._'.._._...,.._...____...._ , I ~, -~ r__..._ 0035 GARY E. ADKINS SHAMROCK DEVELOPMENT, INC. t44 ..., ...., -, ~~. 24' W. EDISON RD. Sil^"l 442-55-7495 SUITE lIO -.. -- ..... ."" -.. MISHAWAKA, IN 4654' JUN 21.1998 JUN 27, \998 S 0\ JUl \,1990 EARNJNGS TAXES DEDUCTIONS YEAR TO DATE -- .... ~. - ....... - -- ...... -- - SALARY 575:00 FICA 41.85 SAVINGS 100.00 GROSS 17125.00 MEDFICA 9.70 MEDICAL 36.59 FICA 1051.76 , FED WTII 99.67 MEDFICA 248.31 PA 10.90 FED WTII 2469.02 STATE 479.60 MEDJCAl 961,34 TOTAL $ -. 170,10 TOTAL $ L36,59 m., ".......368,31 675,00 TOTAL $ ., .......,.,., ,....... -..,.-" :'." . t. ' ;, ; ~ :, '1 '. '. ," ,.- I. .,", ".:':;:1 I', I,t,"',, ' ;:.:,,11,: ,. ',,'.,: " '." ".-, ",' I,: :: ':,.".:': ',f ; ,;1' i. ,~ ; ',' .':' ' \ \ .:,:: 1,'.:';1"', ". 0036 ,-,, ~, SIIAM ,-... JUN 20,1990 _.~ SAI.ARY TOTAL ~, 0035 r" .., SIIAM -... JUL 5.1990 - SAU\RY TOTAL . ' - GARY E. ADKINS ., .w, JUL 4,t990 sot EARNINGS .... ... $ -- GARY E, ADKINS "'" ~, ;.... . , ' ,.' TAXES ..... 41.05 9.79 00.57 10.90 ':, .' "", I_~.. ,.. SHAMROCK DEVELOPMENT, INC. 24S W. EDISON RD. SUIT!! 110 MISHAWAKA. IN 46S4S DEDUCTIONS YEAR TO DATE .....".. -- -..... -. ~AVINGS 100.00 GROSS 17000.00 MEDICAL 35.59 FICA 1103,60 MEDF I CA 250.10 FEU WTII 2560.39 STATE 490.40 MEDICAL 9B7.93 675,00 TOTAL $ 170,11 T01rAL $ 136,59 "...,.., .....". m.oo FlCA MEDFlCA FED WTII PA EARNINGS ,....... . ~ ...m JUL 11.199B SOL - .... $ ....., -- 575.00 FICA MEDFICA FED WTlI PA ~ 442.55.7495 ,- JUL 15,1000 1'AXES ... ..... "n,., .......368 30 r__._ SHAMROCK DEVELOPMENT, INC. 24S W.EDISON RD, , SUITE ltO MISHAWAKA, IN 46S4S DEDUCTIONS ....., -- 41.85 SAVINGS 9.79 MEDICAL 90,57 18.90 YEAR TO DATE -- ....... 100.00 GROSS 36,59 FICA MEDFICA FED WTII STATE MEDl CAL -- 18475,00 1145,45 257 .89 2568.05 517.30 1024.52 ;1 . :" I'"~ ~. " 675,00 TOTAL $ -- 170,11 TOTAL $ 136,59 ""11I1 .........368,30 >',1, "l,:I,.,'.il' ' " " I- '. :",:' ::,-." 'I'.' ....: - .......,...-.-.....,' " , , :'~:: ',I'" I- ,', .:' ", ... , ~ ~ ." , ' L " '\".' _....... ".,. ....,.. .._-".... ...........-.....--..-,.--......_____........._._....._ , 1 .., - 0035 GARY E, ADkINS h, .., .., ...., SIIAM -- - .. JUL 12,1990 JUL IB, t990 S 01 EARNINGS -.- SALARY TOTAL .., 0035 .., a.l SIIAM I jUi:" 19.1990 -- SALARY TOTAL .'1:: ',"',' ,'1..... .... .... /IiIIaUtt _""'NI 575.00 FICA MEDFICA FED WTlt PA $ ...., 442.55.7495 ,..... JUL 22,t990 TAXES ...., 41.05 9.79 99.57 10.90 '--."" SHAMROCK DEVELOPMENT, lNC, 24' W,EDISON RD. SUITE 110 MISHAWAKA, IN 46545 DEDUCTIONS YEAR TO DATE ........ ..... -..... ..... SAVINGS 100.00 GROSS t9150.00 MEDICAL 35.59 FICA llB7 . 30 MEDFlCA 277.60 FED WTlI 276B.53 STATE 6J6.2o MEDICAL t051.ll 676,00 TOTAL $' 170,11 TOTAL $ 136,,69 -- GARY E. ADkiNS o.a, <lIIU ..-...... 1M ~m JUL 25.199B S 01 EARNINGS .... ... ..... -- 575.00 FICA MEDFICA FED WTH PA $ " 442.56.7495 ,.... JUL 29,I99B TAXES 676.00 TOTAL $ 170,10 TOTAL $ 136,69 " " .. ,..I ......................-.. ..... 41,05 9.7B 99.57 IB,90 -- IIn"., .......368,30 r__._ SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD. SUITE 110 MISHAWAKA, IN 46'45 DEDUCTIONS -- SAVINGS MEDICAL ..... 100.00 36.59 '...,...... ',' :. ,.; "" :.,:'. """, YEAR TO DATE -- GROSS FICA ' MEDFICA FED WTIl STATE MEDICAL ..... 19B25.0D 1229,15 2B7.46 2B6B,lD 555.10 1097.70 ,..- ~., ..........368 , 31 , , .' '. . ;; "".,' !~'i.' ",', , . ~'. . . r .' . .' ,"r,. .., - , 0035 GARV E. ADKINS ...., .., - ,.. SIlAH -.. .. JUL 25,19911 AUG l.t99B S 01 EARNINGS --.. .... ... - SALARY 575.00 TOTAL $ 675.00 TOTAL $ 170,11 TOTAL $ 136,59 ,.... ..P....., *....***.368.30 , . .. 442. 5.7495 ,.. AUG 5,199B TAXES "'''Im.. NMIIt FICA 41.B5 MEDFICA 9.79 FED WrII 99.57 PA lB.90 ... -- 0035 GARY E. ADKINS f~ fa, - -, -, SIlAH 442.56.7496 I AuG 2.1991l 1-- .... .... ..... AUG B.199B S 01 AUG 12.199B EARNINGS TAXES ~ .... .... - - ..... SALARY 675.00 FICA 41.B5 MEOFlCA 9.79 FED WTII 99.57 PA lB.90 TOTAL $ 675.00 TOTAL $ 170,11 TOTAL $ 136,59 I' :.1' ,,' ..',': ',,", , . ,,).' ,';1' I. ", ,I . .. .......... -... . .. .... _ ,... .__...r._..." ., . . r..,. _ II-. SHAMROCK DEVELOPMENT, INC. 245 W. EDISON RD. SUITE 110 MISHAWAKA. IN 46$45 DEDUCTIONS YEAR TO DATE ....... ...., ........ -... SAVINGS 100.00 GROSS 20500.00 MED I CAL 36.59 FICA 1271.00 MEDFICA 297.25 FED Will 2957.57 STATE 574.00 MEDICAL 1134.29 r_"-t_ SHAMROCK DEVELOPMENT, INC. 245 W, EDISON RD, SUITE 110 MISHAWAKA,IN 46545 DEDUCTIONS YEAR TO DATE ....- - ........ -- SAVINGS 100.00 GROSS 21175,00 MEDICAL 36.59 FICA 1J12.B5 MEDFICA 307.04 FED WIll 3067.24 STATE 592.90 MEDICAL 1I70.B8 -.. ..... *1"*.......368,30 :' " '. :....:'\' .' '" ,,~ : . " " I:' "'" ."~' ..., -- 0035 GARY E. ADKINS l'.' ,., .. .w, SIIAH ..... ... AUG 9,1990 AU~ IS ,t090 S Gl EARNINGS 1""""_ .... ... ...., FICA.... SALARY 675.GO MEDFICA FED WTII PA TOTAL $ 675,00 TOTAL $ 170,11 TOTAL $ 136.59 ..... "'., *******368,30 [J035 --- GARY E. ADKINS h' IMI ... ..., SIIAH ..... AUG 16,1990 .-.... ... P,.. .."" AUG 22.1990 SOL EARNIN~, _.~ SALARY .... ... TOTAL $ 675,00 TOTAL $ ..... 170,10 TOTAL $ 136.59 ..... ..........368,31 ). -", ...., 442.56. 496 ,..... AUG 19.1990 TAXES '''d, . --. ...- ..., -.-'.- ..,...........................,."..., r_".._ SHAMROCK DEVELOP1\iENT, INC. 24' W. IlDISON RD, SUITE 110 MISHAWAKA, IN 46,~4' DEDUCTIONS YEAR TO DATE ...., ....,.. _u, ........ ..... 41.06 SAVINGS tOO.OO GROSS 2186G.OG 9.79 MEDICAL 35.69 FICA 1364.70 99.57 MEDF I CA 316.83 10.90 FED WTII 3166.01 STATE 611.80 MED I CAL 1207.47 ..... 442-66-7495 .-.. AUG 26, t998 TAXES ,-..---..-.,...-..- - . ..' ~ . . .... . . ~ ~ .. ~.......~.....-.------.......---'_...~...._----. .-. -_. ~-.- SHAMROCK DEVELOPMENT, INC. 245 W, EDISON RD. SUITE 110 MISHAWAKA,IN 46545 DEDUCTIONS YEAR TO DATE ...., -~ 676.00 FICA MEDFICA FED WTII PA ..... ........ 41.85 SAVINGS 9.70 MEDICAL 99.67 18,90 ..... ,,- . '". . .~.. ,,-, '" . .. . . .. __,. ,0' '.n . . "', .. . '.. 'i '. :.': '.':..' "I', -- -- 100.00 GROSS 36.69 FICA MEDFtCA FED WTII STATE MEDICAL ..... 22525.00 1396.55 326,51 3266.38 630.10 t244.06 "' .. .......'".._.-...........~--,----_.,.._. "1,1" ,:'.:....,. , I "'.1 "" ., '. . '"'.Ii, .. .., - 0035 GARV E. ADKINS ,., ., ... ,.. 511 442.56. 496 -.. ,. . AIIG 23,1998 AIIG 29,t990 S 01 SEP 2,1998 EARNINGS TAXES ~'"'. .... ~. ...... .'1'1_ - SALAltV 615.00 FICA 41.85 MEDFICA 9.79 FED WTIt 99.57 PA 18.90 TOTAL $ 676.00 TOTAL $ 170.11 TOTAL $ 100,00 I " I . ; ~ '...'.' , .........~.._...._....,.-... 1~1ItoII ,.. SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE tlO MISHAWi\KA,IN 46'4' DEDUCTIONS YEAR TO DATE .,..". - -- -, SAYIIIGS tOO.OO GROSS 23200.00 FICA 1438.40 MEDFlCA 336.40 FED WTII 3365.95 STATE 549.60 MEOICAL 1244.06 ..... _If"'" -...*404.89 _. ... "r"'''''.' .,.... .....M.. ..,..".'..~~.,._.~_.~_.. ...,__.._"..._.____M~.___._ _~.._. ... -- 0035 GARV E, ADKIIIS ,., ., ... -, ..... SIIAH 442.56.7490 -.. -- .... .... -.. AUG 30,1998 SEP 5,1998 S 01 SEP 9,1998 EARNINGS TAXES ~ ... ~. ...... --- - SALARV 075.00 FICA 41.85 MEDFICA 9.79 FED WTH 99.67 PA 18.90 ~-.- SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. StJlTE 110 MISHAWi\KA, IN 46'4' DEDUCTIONS YEAR TO DATE -..... - - - SAVIIIGS 100,00 GROSS 23875.00 FICA t480.25 MEOFICA 346,19 FEO 11TH 3465.52 STATE 668,50 ~EOJCAL 1244,06 TOTAL $ 675.00 TOTAL $ 170.11 TOTAL $ 100.00 ..,........, -.. ..... .....-404,89 . '."~ . .""_....../.-t~....,~..'...".....,,;,..,..., ,,.~. , <C'.. '.:'. ."" ".,... '. ,.,., . . . ~ ,,,,. .,'." '." . I.. ... I..,.....,. '... ........ :'..~.,'," ,.j ._ " , :."', ,;,',..:. . '.. ,", . ;".;' ....' .... ,"' "'1.;' , . ",.:" """.":!..::': ,. 0035 '" . Sit SEP 5.1998 ....... SALARY TOTAL ~, 0035 too, ..., SItAH -- SEP 13 .1998 -..... SALARY TOTAL ",':' "", .' - GARY E. ADKINS ...... ,.", SEP 12,1998 S Ot EARNINGS -- ... ~I ...... ........ 575.00 FICA MEOFICA FED WTlt PA $ , 442.55-7495 , SEP 15.1998 TAXES -'" 41.85 9.79 99.57 18.90 676,00 TOTAL $ 170.11 TOTAL $ 100,00 ,.... Iln.., **......**404,89 -- GARY E. ADKINS lloIa' ""', _.... ....... IfI,1"IIT SEP 19,1998 S 01 EARNINGS -- ... ," ,""1' '........".,.,. SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE 110 MISHAWAKA, IN 46'4' DEDUCTIONS YEAR TO DATE ...,. ...... -- ..., SAVINGS tOO.OO GROSS 24550.00 FICA 1522.10 MEDFICA 355.08 FED WTlt 3555,09 STATE 587.40 MEDICAL 1244.06 ----~--_.._.._.----, ........", ~- 750.00 FICA MEDFICA ' FED WTIt PA $ ..... 442-55.7496 ,.... SEP 23.1998 TAXES -.....---. ,-.- -..-.. -------..- -,-----_. ~_.- SHAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE 110 MISHAWAKA, IN 46'4' DEDUCTIONS YEAR TO DATE ...... -- 46.50 SAVINGS 10,87 120.57 21.00 760.00 TOTAL $ 198,94 TOTAL $ 100.00 -.. "',., 0"""451.06 " -,",..-1-, , ~ ; .... -." ".,.., -",,''''-'''', ". ./1 ',',' , I ...... -- tOO.OO GROSS FICA MEDFICA FED WTIt STATE MEDICAL ...... 25300,00 1558.60 356.85 3685.66 708.40 1244.06 '... woO.._ i. .~._......-......." ........ .......'..... 0> ... ., , ;'.; '.i."".,' , ,'.. It....' M' -... 0036 IlARY E. ADKtNS ,~ , ..., ...., ...., SIIAH 442.66-1496 -... -... ..... .., ,... SEI' 20.1998 SEP 26,1998 S ot SEP 30,1998 EARNINGS TAXES -,.... - .., --, ...,....... --, SALARY 160.00 FICA 46.60 ME9FlCA 10.88 FED WTH 120.61 PA 21.00 TOTAL $ .., 0035 -... GARY E. ADKINS r." ., ""', ('1M' SIIAH -... SEP 21.1998 750.00 TOTAL $ 1'" :....,' ,.........- SflAMROCK DEVELOPMENT, INC. 24' W. EDISON RD. SUITE 110 MISHAWAKA, IN 46545 DEDUCTIONS YEAR TO DATE 1-""'. -.., .,""-- ~, SAVINGS 100.00 GROSS 26060.00 FICA 1616.10 MEDFICA 371,13 FED WTlt 3806.23 STATE 129.40 MEDICAL 1244,06 198,95 TOTAL $ tOO.OO ...... -_..~- ..... 442-66-1496 _..... ""~ _f'Wf OCT 3.1998 SOL EARNINGS' TAXES -- SALARY - ~ TOTAL $ . . I' " . ..' .-.. OCT 1,1998 ,."., ..,- 750.00 FICA MEOFICA FEO WTlI PA Ion.., ..........451,05 _... ._--_.~------ -.. - ._, ~_.- SHAMROCK DEVELOPMENT, INC. 245 W. EOlSON RD. SUITE tlO MISHAWAKA, IN 46545 DEDUCTIONS YEAR '}'O DATE ~ -....,.. 46.50 SAVINGS 10.81 120,57 21.00 - 26600.00 1651.60 368.60 3926.80 750,40 1244.06 750.00 TOTAL $ - - 100.00 GROSS FICA MFOFICA FED ifill STATE MEDICAL t98,94 TOTAL $ 100,00 -.. ...... .........451. 06 .',..; . , r" ' ...' , ,.:' ~ ;.' "'. ",' ,i. .... ,..,.,..;.' ".: ',l :: i, . ,'lr,; " , /; t'l ~ '\_'~" ) , 'It ." .1' ..t, ," " .' "~I,' t.. '. ' i',I, ""_""'_"'0-' ,.. .....,,-.-..-..... EMPL. I (945) GARY I!) , ADKINS CK.lh 09380 PlilRIOD ENOINClI 19 Cl:<9 ep 8 ..GROSS.. ..OTHER.. ..TOTAL.. ...NET... ..... RATE BREAKDOWN ..... CURRENT I 666.00 0.00 686.00 479.60 HOURS RATE PAY Y-T-D: 5,213.60 0.00 5,213.60 3,576.97 32.00 at $17.150 548,80 OTHER PAY I 137.20 .FEDERAL. .....FICA.. ...STA'l'E... ..LOCAL... .....................~...~ CURRENT I 76.65 52.48 19.21 6.86 TO'l'AL GROSS I 686.00 Y-T-D: 572.04 398.86 145.99 52.14 GARN SAVING UNIONS UWAY CURRENT : 0.00 0.00 51.20 0.00 Y-T-D: 0.00 0.00 465.60 0.00 BONDS HOSP XFEDTX OPT CURRENT: 0.00 0.00 0.00 0.00 " Y-T-D: 0.00 0.00 0.00 0.00 - ~-_.~~:.... o-~.~.-____._.___.. ,.l', IHPlI.1 (045) llAAY I, ADJtlHS elC... 01275 nRlOD INDINO l 11/15/" ..aROliS.. ..00000R.. ..TOTAL.. ...HaT... ..... RATa 8RIAkDOWH ..... CURIUlNT , 821.20 0.00 82).20 5'-2.91 HOURS RATll PAY Y.T-DI l,8U.CO 0,00 3,8U.U 2,U2.57 32.00 It 017.150 548,80 8,00 at 034.300 27' .40 ."BDIIML. ....ICA.. ..STAn.. ..LOCAL.. OTHIR PAY, 0.00 CURRBNT I t1.2J ..,.. 21,0$ 8.23 ........."................ Y-T-DI 4111.74 aU.90 107.57 38.42 TOTAL OROSSI ' 123,20 "NUl IAVINO UHIONB UlIAY CURRaNT 1 0.00 0.00 ",10 0.00 Y"T-OI 0.00 0.00 350.40 0.00 DONDS HOSP XPlDTX OPT ClTRRINTI 0.00 0.00 0.00 0.00 Y.T-CI 0.00 0',00 0;00 0.00 9275 .. ','.' ~,-..--~....-, '.' *... ':-'," "'" '.." ... . i , ' ',-, ' 'It :':, .' ,;1', to "; "~to 'i": I:. '," 1'.;" , " " " ~ ":'.' ':. "';:', .,:i'!:1I (', ;t~'::," r.':': .ilt'. ", ., t'I',: ",:, .:;:' ~ ., , = 1 ~ ., 'f -- ~ . .. . I ..11 I .. I- ,. . I F,,", 1040 0":' , , v.. . ,., ., I ~;r', I ';P"" , ...If - ....11 I ,,,I" . "'yat. I FIling Status 15..0',. '2,) Chl1Ck only ono :JQ)(, E.~empllons (5., P'.' 'J,) U"'I2I' l~." 1" UU"HII'. '''H;''I, Income ,\nole,' C"Py S ~I you, Forms W"'2. W"20, ana 'OOg-~ Mr.. II you did nOI ;81 .1 W"2. see P'O. 'l, EI1CIOSf, 'out dO not .1naen, your piymtnt and Polymenl vQl.lc~er. SH pog. J2, AdjuSlments to Income ClUlIon: Sit InatJ"lJC:,ons..,,,,, ... Adr. ar, Income U:S':i~di~ld~~f'i;~~~~'T~'~"R'eturn' 1995 ,1'".'/1'," '-I.." qIUl/UOO /101 ./'It 01 "101, '/1111', ,ou" ," C"'-I. ~o, 11".0)1J" VOLJr 10Clll IIcurlty no. ? spou.... ,ocl.1 .ecurlty no. 4 For P,IVlOY A.t Ind Plp.rwo,k R.duoUon A.I NoUu,... :I .7. Y.I No 'JI '""'"JIIl,oOU, 1I,,,U,lfU,,,'tll HI' """",11 "'q~' "/11 ".",. '"' ./IIIIt1 I.UIII,"'" C,ly, IIw"".oll'''''..mll.III' 11"""1 It row ",.",,,,,,,,,,,,,,"",,,,, III ~ ",..Id.nllo' Il. Do you wlnl $310 90 10 Ihllluno? . E'ectlon C,mp.lgn r II olnl IIluln, doOl OUI IDOU" w.nl 53 10 010 Ihl./un07 . Slng'a Morrl.d III1n9 lolnl liMn (.ven II only ona hid Ineom.) M"'III 'I~II' HUIII""II'''' '"111 III III u', UN ...... '1,111"..",. "".,.. Held 01 hou"hold (wilh oUllltyln9 I)",on). (S., R.ge , 2,) n I'" 'lI'Ii'Y'''' '''''",~" ./t.lo '1I11'101.,o~' O'III"U"l. 11I1111'" '"II",~."" ""., ~ 111,""""II'",'''lIa... '''..III"...~.,/III,.1 ~." 1I1/1l' 140/1'11""'111 ",',ll, 1 2 o 4 5 5a ~ol" ':""~I"I 'Yu. ..II"OI,/I'"D,.,OIl''''1 .',..~.. .,I~' "'111111, Ou.II"'ln ""oowl., ""Ih d.o.no.nl Child ( r, IDOUI. dl.d ~, I I. IS.. d' .'3,) Your.., " II you, Plllnl (01 lom.one 1110) din dlllm,you .. I o.p.no.nl on nl. or nI1'.," "... . . '1'1'''1410111& I... llturn, do nol dheek C'J' I., aul b. .ur. 10 .hlek bo' on IIn. 23b. pg. 2, .'", b Sou.. I I I . . . . . I , I I I . . I . . C 0 d h I I liIU""", a "'I" I.. 10'"""11 I I. II NI.., .,011' 'pin .n",,1 "CII"I.,II~II'l'cr. If ,.,,, ,,11110"''''1111''011 11I..1111'0 III '"110'11I 0" h (111''''11'11I'1.''111'11I' 111'111. ." ..,. I.. ,!v: "0"" .I'I,~ , -7 -7' 10 -7. 67 o .7? 2 .." U ..~':'~ d II row' '"1111"011'1 tin .,111,,,,, Dwl', It"lIItO u .,0101' on."O'/llwn,,,.. 0".'1" 'lI'''IIIlIIt, I,~,n "'" .. e TOIIJ number 01 ell.mobon. claimed. 7 Wlges, ull1l... up., 'IC. An..." 'orllllJIW., 8 a T..lbl,'nl"Ullneomo (... p.g. '~). An.en Sen.dull a " o..r S"oo b Tu....mpt'"""t1I... u" 'II. OO~ITI""UO' '"1'/11.. . ab I 9 DI.ld.nd Ineol"". M.cn SCN.OUII B II 0'" S"oo 10 TUlb11 "fund., er.oll.. 01 oN"I. 01 ,:JII Ind local Income 1"'" (II' pig. ,~) . 11 Allmeny IIe.,..d ' 12 BU.ln.lllneom. 01 (101$1, An.Ch Scn'dul~ C 0' c.ez , 10 C'PIIIl glln 0' (1011). If I.qullld, In.en 5eN.oull 0 (... pig. , I) 14 OIN" g.lnl or (IOUOI), AM.eh Form "707 15a TOIIlIRAol.U1bullonl l15al b T...bl..mounll........', l6a 1'0111 ""'IOI'I,l'''''1I1I11I 16al b "axable amountr... DIll' '11 17 Rlnlll ,..I 11111', 10yllllll, p."n".n,p., 5 eOlporoUonl, lIIJ.lS, lie, AnleN $eh.oul. E 18 Farm Income or ~o..,). An.en SeNldul1 F 19 Un.mployment comPlnllDon (... pig. , G) . 20a Soelll ..."lity binlnl. 120al 21 Olh" Income, 22 Add .mour"~ .nown.n lar n nr column for linll 7,"rou 20a You, IRA d.dueUon (... Pig, '01 b 5POUII'.IRA o.Ouetlon (I" pig. '0) 24 MOVIng ..p.n.... An.eN Form JG03 or 3G03-F . 25 On..nlll 01 .1I1-employment IU. 26 S.II-.mcloy,o h..llh In.Ulln.1 d.duellon (... o~ 21). 27 KlOgn & "" employ.d sap Plln., If SEP en.., U. . 28 P.nlJty OM ''''y WlINOrawlJ 01 $tvlng. 29 Alimony clld. ~"'P'.nrl SSN ~ 00 31 ',.:ilJ\: '9 10 11 121 10 14 15bl 15bl 17 18 19 b T.J<ldl.emount'....... 'II 20b 21 I N 21. Thl. I. 'ou' totlllnoom. 01 22 ;~~I 'iiill![:III,.:::i 24 Illi 'I~ 111':'1" 25 7 11,11'111':: d".II;:, 26 I ,:~I:::':'i.1 27 ;11'11011';1:1 "1",1-' 28 'llIII.111 29 ;.::llil:~. 1,.'::11:' ~'30 ~I 01 Add Iln." ~~. InfQuQn ,9. ThelSl ,sri 'Jour toulad uJtm>tntl . SUOfnClllnl 30 'rom lin. ;22, ThIS '8 'Jour Idlu.l.d roulncome II- -L. .11~t(I""I",O\,l -L Irlon'thw. .'1" .,.........IOlllvO'.. o~ ...."Ilon II.. U"uI C'''/I''I'II' 0".' IIU,/ll11.0100n_ 7 8a AU /110111I'01" '''11110 Oil II,. lIl' ~ 5 2 407 7 'GG5 Form '040 o.g. , f. f 'f. ~ .~ l , Felt'!l\;:':'" ~'" ::: & Ji.;N~I.;;'( ADKrNS ~ J~ An\()l.InllrQmllnQ31(laQI\JI$IQdgr~nj"C0n"l4) " , . 'I , . , . . . t , fa" 33a C~.ck II;OYo.".ro I~ 0' 010.,0 Blind: OSpO.iO "IS as 0' OldO"o Blind, COJT1PU~ Aoo thO n.m!:.r 01 bo... .~I/<:'.d .bov. .nd ,mor l~o 10111I ~o'o . . . . 33 ~ 1'11011 b II yo., pltonl (0' .omeon. oleo) ..n .1.lm yo. IS e dopend.nl, oheck ho". . 33bEr' " '. ~ C II yo. I/O m.nl.d IlIIng ..parol.ly .nd yo.r .po.lt IlomllOl dod"ollon. . 33c I', 'i", or you ." . dl,llll-5IaIO$ ~lIent IQ' polgO 23 and ehfck he", , . , . I,,' "! t'omlUd d.d..llon. Irom SChod"', A, IIno 2e, OR J ," ,I 34 Enlo, St.lIld"d d.d.ollon 'hown 0.10" 0' yo"r IIlIng '"1"., o.'lf >"IV .h",.. I .h,' the 1II, b4..,n WI" ):1,60' II, lOll ,." t:l IlJ 11'11' rOil' ,1'"4''' '1'll,ICllln~ It )'Oll ",.._to ".ISt, . i' !1::lir:' I yOIl' ,,-nu,., U~~1l10"1. lito, ill j'hll' "'g" . Slnglo-U,eQQ . HOld 01 ~0...hold.$S,71lQ " il4 ~~ r. · Marrl.d IllIng lolnlly 0' O"ell/ylng w'dow(er)-U,11lQ , , · , · Mlrrl.d IIlIng IIpIIII.IY.$.1,:!7S li!ili':I,',. as Subll.eI1l"'t~""omnn.32, , , . . . , , , , , . . , , . , 05 36 If IIno 121. SU,02S 0' I.... mu/llplV $2,6<.'0 bV lholole! n.mb., 01 ...mpllonl olelm.d on IIno I~, If IIno l211 over see,02s, no lho work.h"1 on p.go U lor lho omo."llo .nlor. , 36 37 "aubl.lnoomo. a.bU'.lllno le I,om IIn. lS, If IIno oe II mq,o Ihln IIno os. .nlll -0-. . 37 38 Tax, Cho.k IIlroml a~Tax TAOlo, bOTax RAlo Soh.~",OI, a OC.P'laI Gain Tax Wor\< Ihe41,or dO 'Drill 1I111'uu;, ."" "11I'''''1. '''11I 'ltllll'I"" ... e 39 AdolllonAII""ol, C~ook 1I1,0m: aD Form ~e70 bO Form ~$72. . . 40 Add lints 34 and 38 I . I I . I I . I I . I . I I . .... 41 Credlllo, ohlld & doponoonlo". up.n~OI, Anaoh Form 2<<1 41 42 Crodlt lor Iho o'do,IV or 1M OIOlblod, Medh Sohod"lo R . 42 43 Foreign I.. o'odl~ Maoh Form 1111 . . . , . . 43 44 Olho, oroolle (.eo ~o 21), C~'Ok Illrom aD Form l800 t(] Form uee au Form eeoldO Fo,m 44 45 Add lines 41lhrough 4". , . . . . . If. . I . .. .. 46 S.OtrAolllno ~5 I,om IIn. ~o, IIlIno '5 I. morolhln IIn. 40, .nlor -0- .,.. ~ 47 S.lt"em~loyment tAX. A"o1Ch SChedule sa.. I I . I . . . . . , . 48 Alternative minimum lax, Af1aCh Form 52S1. I , fl. . . . I I . 49 Aec.1pfurelaxes,Checlclflrom: aO,o,,,,,u, bO-ormull eO '0'",112.. 50 Soolal ....nly Anll Modlo". IIll on tip InoOrNI not ropon.d 10 omployer. AI"" ...." Ir , 51 Tax on q.a1l11od roUrerNInl plane,ln.l.olng 1M., If reo"lred, '"oo~ Fo,m 502$. . . 52 Advance Il1I'nedlncom4 credit paymenls tram Form W-2 I . . . . . . . 53 HO"lo~old omploymonll""OI, Anaoh 5o~eo.1O H . , . . . . . . . . 54 Ado IInOl ~e Ihrouoh S~, Thle 10 vou, '01011.10 . .. ..,. ., ~ 55 56 57 ,'l ';~ "j' ';') ,~~'9' ;J I ~ " {;' .. .' ~ : .1)"OU wanl ~",,'AS to ~rlJ~our ....., ,.. p'go 2' :j, ,.;, to \ Credits " ), :. Is.. p.go 24) Olher Taxes 15.. p.go 2~,1 Paymenls Attach Form3 W"2, W.2.G. ilna 1O'J9-R on IN fronl Retund or Amount You Owe SIgn Here Paid PrepareI' 5 u.. Only .U""I,num'U..'11lIl,14, "'"1'11'0,".0""1.11019,'''141 "U 55 , ees Ol~ IIlI paYrNInta Ind amo.nl .ppllod Irom , ee- return 56 Earned Income credlL 4nun Sclluvl.lrc: I' yOIl""'" II IIlll"'Y'"' l'ili!i~iil:1 "'lid, NOlll'''III, ..tlt'dl"cotllllamOlln1 .. I !:I~I'i::i:1 '"ClI)'OI .. 57 58 Amo"nt plld wllh Form ~eee ('lIIonl'On roq"OII! .. 58 59 ._n.. 1O;J,lltCu';ly,a"c1 ""U tAl .ll/lIUllll... p.,. Ul . . . 59 60 Qu", iU\lIII,"U, CIl,O II "om a 0 'o,m 14U b 0.0,,,. "31 eo 61 Add IIn.. 5S Ih'O.gh eo, Thoeo Ire vo", 101.11 plvmonts , ,. , , 62 If IIno 8' II morolhln IIno 64, ouOueolllno Soll,om IIno 8', Amount VOU OVERPAID 63 Amo"nl ollln. 82 yo. w.nt REFUNDED TO YOU , . . . . . . . . 64 Amo"nt 01 IIno 82 to b. APPLIED TO YOUR U$8 eST. TAX ~~ i 65 11 Ii", Ullma'tln.nU", 'I, UDVllJflill, 'lltom hn, 101. filii""'" AMOUNT YOU OWl!. For dotl,l. on how to ply,lnclUdlng "ling Form 'O_O~V. PlYrNInl Vouoner, e.. pegol2. 168 I 9 083 66 51I1m...o Ie. o.n.IIV I'" o.g. l~l, Aleo Includo on IIno 85 piJlJiJ 2 ?2-5'::.749':: 32 58 OR,.:L .. .. ~ 38 39 40 li:!I:I:IIII;: 1'1'[1' 11'lilli:I!:i !id!!ill:, 1"III,:I!' 45 46 . 47 . 48 , 49 . 50 , 61 , 52 53 54 I i II i i ~ : i I! i: JIIII!I:'lli 111,'1 iilii'!i:I!1 1IIIIIIIIil1'I 111,1111' 1/"'" 61 62 63 lil1iir:iU Lld::!:1 . 65 11 448 ,u: 6' I: 12 500 '4 131: <: "q .'; 119- c; 11 q '40 5,4;9 NO 00' -,- ':;:4- , ':::'4 I!::!:I'I !ii.li,I:'"I:':ii!'d";: 1"',1"',",'. U~O., 0'''''111''01 OIt/lIt.,. I UOII', Inall "I'" IIUIII'tII trill '1111'" .no UlOlftll&tlIMIIU/luulu aMIIt.al'"""'", '"0 10 "" 0'" 0' ",~ '"OWIIllO' Ind 0.11." In.., 1t,INI, 1O',eot, *1'10 GOm"I.II. O.IIIa'a1lon of onU"'llUn"tn." ta'a'Y"I" ,u.d an 11111'1'0'11I.110" 01 w",," IH'''''' IIu lily 11I'I'WI'40" ~ 'follr "II"lfij" 0.1. Your o.4Vllbon ~ SOOll....,IQIIIIIH..IIJOln"II'''II,IICTHlllw....'n. e.l. ""'It,,,,, ~'--I '1"1111", , -l.. ""'.II,/ft'IO'1111.1" ~ II..II-.....OIOy.III."' 101l'u. 7 0 ~ NE'1l CtrMBERtAND ?~ ... !.I. No. ZljI:OOt :'7070 '99S Form 'o~o p.g. 2 r 'S01EOULE~ MB (1onn 10.101 (S.hodulo a I. on book) Schedule A - Itemized Deductions ,-" - c-cM t........... ;. .1 T......y~ ,..,d All'.h",,,nl ~ 511.. InalrUcUqns lor Schedul., A and a (Form 1040). 6oo;uQnell No, 07 Vour .0.1.1 u.urlly numbor 2-5 -7 "" An",l;h 10 Fl)rm 10.&0, /"IQII'I,mOfl;&.,IIIII'UIU4 1lOIltlllIlUrl.. II yO\l on 1'.,", 10'1" /"IolI'I,/flo,III,.IIIII""IIOI'"OMlII 11.,01;011"'", lOll. l'Ulllol/l. 0"'''' U,m wIlOrll,,'1l Do"tnlUI'I'lQ"", ,....",..1.114 ,,,.'" Hut ,tfUrI""'II'II,II'l'lllIYIIIOIIO",,,,U"'" . I . , I I Polnl5 nol r.pon.<l 10 you on Form '.e8, See pege A.a lor 5po<:l.1 "'115 Invutmllnl Inleru~ II requlrod, eMeh Form ~e'2, (See p.g. A-a,) Add IIn.5 '0 Ihrough 1a ams by eUh or eheek, II you mede .ny gin 0112.0 or mo,., 50. p.g. A-a.. Olh.r lI1.n by euh or eho<:k. II eny g,n 0' 12ilO or mor.. 50. p.g. A-a, II over s.\OO, you MUST In.eh Form 8283 Cerryover Irom prior y.., . Add IInu " Ihrough 17 C"UIl or Ih.h loulesl, An.eh Form ~88~, ISee pe . A-',) Unrelmburud employee .,p,n",s '100 v.val. union dUes, job 'due'I,on, .Ie. II rlqulrod, you MUST sn.eh Fo,,,, 2'08 or 2108-ez. (S.. p.g. A-S,) ~ 21 Tax properluon Ie.. . 12 Cine, t)l",nlllS .. Investment. sate dll:OSlt bOlt. etc, type Ind amount . . III W.t I. 3 . . 7 . '0 1I'li'II;I!1 ~ IIII'!II' 1,111:111111" ,I':III!:' I,,:JIII;I, " 7 , . , ., 1"'- ~,,-q Add IIn.. 20 Ihrough 22 1","."'01l"1,,,,,,.I0,,,,,0.0,1I",U 24 12 13 1:'.1',11:- [I ['I:';! I' '1'''''1._. l' q '.. ..., -Ji .,'J; ,'Il ;.~ .,1 ~,~ iti , ~&l "0-.1 P~ld ~ ~"-tl MulUply IIn. 2~ lbovo OV ~\ (.02) Sub..elllne 251rom IIno 23. IIl1n, 25 i. moll Ihln 11M 23, .nl.r .0- Oln.r - from Ii., on p.go A-S. W.' !yp. .nd .",oun' ~ li,I.I::i::o 18 17 1"'.-11.' '!"':II"" 1'11"1" ,II:"II,!, ,I II<- "I,I!II,I;, 20 21 1'1'1"" '1"'.'1 '(I. Illillll"I:1 '''III'' 11:111:,1 22 23 IWill[I,,,1 25 21 I. Form 10<O,IIno 32, over SI14.7oo (over SS7,350,' momod "ling "PUIII/y)? NO, Your dooueUon ,I. nOlllmnod, Add Iho amoun" 'n Iho ler ngnl edlumn lor Iln.. 4 lh,ougn 27, Al.o, Ont", on Form' 040. IIno 34, Ih. lerg" or lhl' amounr or your at."aard dtaUCbon. ,..., Y!S. Your dOdUe110n m.v ..limned, S.. 00 0 A,S lor Iho .mount loonier, Pln4I"'Nork RldlJctlon Act NoUCI, ... Form 104Q In.tructJonL CU ~ ,,' _1 '.', JIklI.: 12 """"",1 If''.>>'lt$1IS 00' 13 QeOJC"J:IIf. ,4 CJtu to Clwlly IS l'fOU m.1de 18 I il" Jnd 9011 btlnenr kY 11. 'I!~ 17 P.... "-J. IB ..' '.~ .,. Ii:. ~I: J ,~ :1. ;-4 .j J .~ .\:: t't C.ulJalty and Theft Lauts 19 Joo !xpenlt' 20 In4 Malt Cl1lI" J.n..acellilneous ~UCUQns r30t :Jllit ,1.-' for ~nsGS IQ otc:IJct '''or..) 23 24 25 25 0...., 21 ~lIan'oul o.....u. n I To", ......Ilt<j ~ctIonl l~ OMe NO I~'~.C<l74 1995 4 11'1"1'11' 1'1" II:,I'I!;!;I ':ill'l,' Li {<iL 1III,tlll '"I''' "'1'1" lll:!I!llli; 1 1',jl,'1 1"['11,:1,, hl'I"!' II,q" hl'l! l:i'lh~', "1'1,'" Ilil'l" I,!'II.I "1-' ,liil;H I:'I':'!'!:: I:ill;%! tlii:l!ii!1 I '~i Iii " II ' ; i ~, ,I 1",,11' ''''-'' I!: i ,; ~ : "..11,,111, 14 I 1'1;; I:!, lilll'l<, 11;1[I~h ,;[II'il'( ;i:'I'ij'li, I"III'I!'" H:lllllllli Ij"III[,' ',:[:!I,:I 18 7 5 7 19 1',',11'1 1.,111' 'iiill,'!, 1'11'111[11, 1!llllill'll 1'1',11'1'1'1 "II" '1"11'1" lilill:II,111 11!11!11;li, II!II,:);I il:ll' 1111I 1::1::111 28 11'1:1:1111'lii\ 111I1.lli, 27 21 , I'I"!I'I'"II'I':<"'"'' '11'1"11"'(111"11"11""" 1"II[['[I',IIII!I,II:',II::t"I/II.,II'II"'I'III"I'I.11'.11111"'>1. ,;I,;,II'"q,yl; . ':':',!:"i'l ,1;1,.;1" '+1. I,;, Sohedule A I'orm 10401 "" Prollt or Loss From BusIness lSol. Pr.p,I.lanhlpl ~ P.rtn."hlp'.lalnl ..nlu,... .10" mu.llIl. 'orm 1011, AUUI\""f11 ~ Much 10 Form 10lO or F.rm 1041, ., S.. In.lrucllon. 'or Soh.d,l. C (Farm 10'0), It""" _., 01- S.ol.1 ..curily number (SSN) 422-56-74% B Enler prlnclp.1 bu.II,... o.d. I'" p.;e C") ~n , 4 D Employ.r ID number (EINI, II .ny a .1 v..d 10 0 0 I,ower 01 CO'I 0 Olh" (.".ch [;SJ 00.. nOI'~PIY (II V.. N. =:'."9,""mary: (1) Call (2) or mark., (3) O,pl.nIUOn) (I) cn.ck.o, I Ip IInl H) " W" lI'OI' .ny cn.ng.ln oOI"mlnln; qU.nUUI., cOIII,.r vllulUOlI1 b4lW..n op.nlng .nd CIOlln; InVlnloryll1 "V..,. """Ch __=~,t)(M , . . . . . . . . . , . , . . . . . . , . . . , . . . . - I :>d I"u '1Nlln.lly p.nlclpllI'ln lh. operlUon o/tnll bUlln... during lGU111'No.' ... p";. C'210r 1Im11 On 10.... . , . X J rt ~IJ fun.d 0'" r,atf 'hili bUlllnulI dllrl"t1 ,0118 t!:nIMK "er. . , , . . , I I . , I I . . . . . ..,1 I Pert I Inaome I Gre" rt<"g" or 5111.. C.ullonllllhlllncom. w.. r~ponld 10 you On Form W~2 Ind Ih. 'SI'l1IIory 0 1 76 220 ttr'Ql4y.... Olf on tn'l 'orm WI' chlCked, I" pig. -a and check he" . I ',. I I . 'It 2 j:\.l\ltns .1nd allowlne.. . . , . . . . . . , . . . . . . . . . , . 2 2 s"b.aclllno 2 Iram IIn., , , 3 76 220 . . . . . . . . . . . . . , . . . . . . . eoll 01 gOOd..old (from IIn. 10 on p';, 2) . . . . , . . , . . . . . , . . 4 58.620_ I Clr... proll~ Sub.'Cllln. . from IIn. 2 . . . , , . . . . . . . . . . . . S 17 600 I Clner Incom., Including Fooorll Ind 1111. ~IIOlln' or lull I.. credll or r.lund (... pi;. C'2) . . . . . 7 Clro.. Incom. AOd IIno. , .nd 0 . . . . . . . . . , . . . . . . . .., 7 17,600 I Part II Expenses. Enlll ....n...'or bUlln... u.. 01 your ham. onlv.n line 30, . Adverttslng . . . . . I 3,5:20 IG P.nllon onO pront..nonn; Olin I IG t aid debt' Itom 11I1.11 or 20 R.nl 0' I.... (... o.g. C.II: ;,1:,., ..",Ic.. (I" p.g. C-3) . , G . v.,,,,,.., """"1"1''1. '114 UWI'I'I'1I1 20. 10 Car Ina truck up.nll" b Olnar bu.ln... pr.Plny . , 20b (... p.g_ C'3) . . . . 10 4 296 21 R.pal" and motlnl,nance , , 21 , \I C-'mmlsolons and f.... . , " 22 '1I,.II..11I0I1IICI1I4.4,,,..,,,III), . 22 12 0.Cl18110n , . , . . . 12 23 T...II .nd IIc.nlll. . , . 2J 13 C,creeJaUon and sftCtion 'i'9 21 r"..I,I'IIIII., '"4 1"I.ru,I11l,"U 1'..::,11" '.Pfnse Olduction (not Ineludld . TII"I . . . . . . I 24. In Pon III) (II' p.g. C'3) , , 13 b Mul. .nd .n 14 EmQloytt bln,nt pragrllN "n.lnmtn~ (.Inor Ih.n on IIn. , 0) . " . 14 C 1"1.' so-,. "1111' 'I InlUllnC. (olhar lh.n n..nh) IS I H2 UD'IIDlntIO , . II Im.rut: 1,1 ih~iil ~:,~I~!:r ,u. aMong.;. (P'ld 10 b.nk., .IC,) . '11 d Suo.,cllln. aoc 'rom Iln. 2'b . 24d b OlJ1or , . . . , . ,Ib 2S UUllb.L . . . . . . 2S 4,620 17 ~"'ill 'nd orOlu.IDnll 21 W'9"/lu, ""'lI"~/!I'1II crull.1 . 21 Stf\fICII . . . 17 :2~C:; 27 olner "P.n... (from IIn. '1 on I~ ernc. OltOlnll' . 11 ~.." D'O' 21 . . . . . . 27 1,800 U TOIII up.n..1 bolO'. "P.n..1 lor Ou.lnll. UII 0' home, Add IIn'l Ilnrougn a7 ,n oOlumn. . . .., 21 '.5 , <13 It T.n"DVI prOl,r (lOll), Sub..Cllln. 211rom IIn. 7, . , . . . . . . . . . . 2' :2 407 lO ElfQ,nSI, tor bUlln... us. of your home, AttiC,' PClnn ..2. 30 . . . , . . . . . . . . II Nil p,afll .r (lOll). Sub..Clllng 30 Irom IIn. 21, 'If. arOfit .nllr on F.rm 10'0.lIn. 12. .nd ALSO on Sah.dul. Sl!.lIn. 2 (lIIl1.11ory .mploY"I, } :2.407 10. o.g. C'3), EIlIIII .nd tNOlI, .nlor on Form ,,,,,lIn. 3. 31 SQiEOULE C (1 <)m1 , OlO) ~r*'.""'~"" ==~I.,.,.t." -..-...d~ft;( .. .....""15 ~'lI Y E ,..........,,:.; '.r p,ol..IIOn, Ineludlng proouel or ..""c. (... P'O' C'" .. "t"CJC" 1),,'11 ,.....,.."AC7CP, I ""'. . , _ Ir no IOparall bUllnu. n.m., .... bl.nk, C "'-'.'.' ~ ",..,.~ ...- w..... (Incluo;ng lull. Dr ,oom no,) ~ Ie..., ....n QI .011 o'fiCI. 11.11 .nd ZIP COd' , ~"'ro; .,.,.Incd: (1) Cuh (2) Accnal (3) ";'~ " " " -~-: "'t , ,t* ~ ~ ., ,;;I -, 'f~ .\,,~, !'1 ':/1 'I: J" - ~ i .r .1. ,~ t '+~ ~ ~, r 0" . I..., you MUST go on 10 IIn. 32. 12 "10U nau. . ,au, cnock In. box In'l d.lCI1bo. you, in..."""nlln Inll ICl1V'1'/ (III p.g. C.$), 'If ~ou Cntclc.d ~2', Inllr 1"'1011 on Fonn 10.0,11", 12, ,and ALSO on Sc""dull Set 111'1' 2 I"""lory .mDloV..... 1M P.gl C.$), E.lIIU .nd QU,", .nl.r on ~onn '''',lIn. 3. -- 'II 'IOU <:nlCIUld 3:21). 'IOU MUST .tn.en Form 1191. ~o, P~D'l"W'ork R'cU,lI:tJon Act Nolle.. ,., Porm '0410 In.wotton.. u. e"'I ",. 1.".lQI. 1995 } 3U B "'11'"\1411""1111' "n... 32b So Ill. Ill_II'",,", I' "01 11nu, Scn.dul. C (Form '0.0) 1115 'f ~ 'I ~ ?~ i~l .r.l " .',j .,-..,.. ~ ":,,,., .~,J.:lIJII~ " "~J' '*......1 :.':; '"~Ii) ~.l:\' F ;....~:~. ,( ;\j~1f1 hi' C051 of Goods Sold ..i~ ".. :':/ xa ..,.1 '''',~ l: ,.. " '"... Page 2 S6N 422-5';-74% (10. P'go c-.) .....wy .1 ~..IMlog 01 y"r. II 0111."01 Irom 1051 y",'. olo.log InvenlolY, .Haoh .~planaIJon 33 """".... '." cool 0' II.m. ..lIhOrll'm lor p."onal u.. . 34 5B 620 )I;' :, ., 1",' :..~.l. ~, c.:.l ,r """,, 00 OOlloclud. "lolY p,IO 10 you,..II . . . . . . . . , , . . 35 ~ \l.lI.tlI&J1 .In" supplies . . . . . . , , , . , . , . , . . . , 05 ;01 J1 Clrcr COSIO . . , . . . . . . . . . . , . . , . . . . . 37 ~'d 11000 33 !hrough 37 . . , , . . . . . . . , . , , . . . . 3. , ;01 , , )f In....nIQry at end of YQDr . . . . . . . , . , . . . . , . . . . 35 5B.620 ." k' 'I" l~,\ ~~~ '~J' r;~ ,', ", >'! OIl Cool 01 ooodo oold, Sub~'clllo. 391rom IIn. 35, em" Ih. ,..ull h.,. and on ..g. ',lIn. 4. . 40 5 B , 62 9 Part IV Informallon on Your Vehicle. Camp,." Ihl5 .anON~V " y.u a/O ol,lmlng Oll/'.' Iroc~ ....nu..n IIn. ,0100 are n.1 '.qulr.O I. m. Form 4552 I.r Ihl. bu.ln..., S.. Ih.lnll",oll.n. I.r IIn. , 3 on .ag. C-3 I. noo aU11I you mu" 01.. ~ .; t' (,' t d,': t ':. f.: " if , , " lr ,. '^' " " " Wnen 010 you .18c. your I'.hlcl. In .."Ic. 'or bu.ln.u .ur.....? (monlh, Q 01 lno lolal oumber ., mil.. y.u Olav. y.ur v.hld. dul1ng ,990, .nler lhe oay, y..r) l> 01-01-9,L oumber 0' milO5 y.u u..O your v.hlel. lor. o Olh.r , , 39' 0 . . . , . . . . V.. No . . . . . , . . V.. No . . . . . . . . V.. No . . , . . , , V.. No , Bu"o... 14 3 :0 0 b Commullog Q 00 you (or your ..ou..) hal'O 100!h" vlhle" .valllbl. lor per.onal u..? . .. 1'.. your vlhlcle Ivell..I. '.r u.. during oll-ouly ~.ur.? , . . . . olS ,I 00 you have evidence fO lupport your d'duc~on1 . . . . . . . o It "Yas: is the ovldence 'Nr1nsn? I . I. ... I I . Part V " Olher Expenses. U'I ~.IOW bu.lne.. ....nll. nOllneluolo on 110" 8-25 or 110. ~O. S~;:G H.~D TOOLS ~,800 , I , , .. " , . " , ,~ "o~1 Olh.r .xg_nt_". enter h.r. and on CtIQ' 1, tin. 27 ~. 1 800 n. . u. .. . . \ F'Jml 1040 0"'. t Labol C VII A lI",IR$ IJ lUll, I OHlt/~ I. """', ... pi..,. I p//1' " or 1~1I" t Pr..ldenll,l It. Elecllon C,mp.lgn r FIling Status 1 2 ~ 4 Chock only one box, Exemptions Income Attach Copy B 01 your Forms W-2. W-20, 'ne! 10SS-R her., II you did nol gOI , W-2, .0. Ino line 7 Imnruction9, Pleas. send 'ny poym.nl 'opnt'toIY'HUh Form 104()-V, S.. Iho IIn. e20 Instructions. Adjusted G,oss Income II Iln. 31 Ie undor 12e,498 (und.r J9,8oo if a CI1lld aldn't tlve with 'IOU), ," the line :54 (n,,,ructlons. a,p"I,n,Il' ~t Ill' rtu'l,jty ..I"ltl/l~1 A'~"'ll' O,,~.u U.S. IndivIdual Income Tax Return 1996 "II ,lit ~I" J'Il, I-Qte.II, 11911, o)'oJIIlHt". ~U, 11.'1'" I" 'Y<!ltf '1,.1 II,U". .n~ 111111,1 ,.-" 1I"111Iy-,-Oq nol "'''1'''' lInf'l" Iht'ID'llt.:..-- d' OMB, Nq, 'US-Ill)" Vour 10010' ..cu,lly no, ~- - 4% Bpou.... loclol ..ourlly no, . ,.... I/''tlll I,UI"lt", G.I\R', E It '1<l1l11/,IY'''. IIlQ......'IIiU/l'm. ."41'1111.1 ADKINS I,IJlII'I1I' .apt,1'1l1 HQm"~d'U' S C,ly. lo""n orpoJl 0111.., Ill". 'lid ZIP 1104" II ,llIl h"\I'" to"'9" "dor,,,.,," P"9' II, 5 6e mo.lltllO.llrIIOCI,,1 IUlInlYlIlImlur,UbOf"III a.uml'" "", ",III.f. 61-74-74 8 1-74-8673 83-72-5123 ON U T'" E d Total number of ...menon, ololm.d . 7 Waga., aolorl.., np., otc. Att,ch Form(s) W-2 8 a Taxoblo Inlero.I, Anoch scnOdul. B if ov.r JolOO . b T..-uompllnle,e.L OOWl' Include on IIn. eo . 9 Olvld.nd Income. MaCh Sch.dul. B II ov.r SolOO 10 Taxabl. r.lunde, cradlt., or off..t. 0' alai. 'nd locllllncom. I",e. (aee In.tnJcnon.) 11 Alimony received 12 Bu.ln...lncom. or (10"), Anach Soh.dule C or C-EZ 13 Caplllll gain or (1000), II required, onoch SchedUI. 0 . 14 Olh.r glllne or (10....). Att,ch form 4797 , 15 TOIIllIRA dl.lrlbunon. ~ b r""oblOilmounl t". "",I 16a rn'" D'"~IOII' & .""1I111'~ IJ!!L b Taxable amount (u. illal,1 17a Ronlal r.al oOlet.. royalo.., partn.rohlp., S corporallon., tnJ,I., .10, Attoch Sch.dul. E 18 Form Income or (loa.). Anach Sch.dule F 19 Un.mploym.nl ~dmp.nl.oOn 20a SOCial oecurlly b.n.nlll I1Q!J 21 Olherlncome,_ 8b . b Taxable amount e... 111.1,1 22 Add amounla In th. lar rlohl column for line. 7 Ihrouoh 21. Thl. i. 'Io.rlolallnoomo 23a 'lour IRA doduollon (.ee In'tnJcoon.) 238 23b Spou..', IRA deducllon (,o.ln.tr\Jollon.) 23 24 Moving ..p.n..., Anlcn Fcrm OSOO 0' OSOO-F , 24 25 One-half of '.If-employment tax, Anoch Sch.dul. SE 25 26 S.II-.mploy.d h.alth Inourance d.duCllon ('''IMLI. 28 27 Keogn '" ,.11 employ.d SEe plan.. If SEP, check ~ 0 27 28 Ponally on early wllhdrswal Of oovlng. 28 29 Alimony paid. Reolel.n', SSN ~ 29 30 Add IIn.. 200 Ihrougn 29 31 Subl1l1ct line 30 from line 22. ThIs Is your ad usted ro..lncome For PrIvacy Act and Paperwork ReducUon Act Notlc.. !lee plge1. UA Fer holp I!lllndlng line InllNcnons, ..0 p.g.. 2 ond 3 In Iho booklet, V.. No 2 1 12 - 7 8a 1II,!I:illlll 9 10, 11 12 13 14 15b 16b 17 16 19 20b 21 ~ 22 1111'1'lil lillll !Il] 'II Ii 11111i! 11"11111 I!: Ii: 30 .. 31 NIU'fehIC~III9 ....... ....UIlOI chtllll' yQijf I.- "t'''14CI,Ol,l''''ijIlO, 0'0,"","1'011110 1I01Inl".c1Uov._ "4"/lU,"0'" ,"tlr'"011 IIII.'tOOV' ItJo b :< Sou.. o Ooponden"l II mort In." ". Hp.~4.nll. ('IFifll".m, loUflllm. .., '" "" .oT I MOTHY i/llltU.:1I01l1. SHENN ALE:<!S 00 you W'1ll $0 10 go 10 Ihl. lund? . , . If 8 clnl r.IUrn, do eo our seouo. wan I $~ 10 0 10 Ihll lund? Single Mlrrl.d IIIlng loint r.Mn (oven II only on. hod Incom.) MI,rl.., 1111"9 u,Oml, "Mil. ell,.r ,!)Qun', UN aGO'l', 11411 IIlfn. ""., ... HOIld 0' h~UlSllhQld (with qUlIlIlylng person), (SIl.lnstnJq:dono.) I' Ih. q\j~III~I"9 ,O.f.lIl'1ll.. c/lllo tulllot ~our "'lIlno.nl, "U.,lh,. Chlhl'."t~1 1'1"" ... OU811 In wldoWro,) with do .lId.nl cnlld ( OM ,eoue. dl.d ~'G . (S.eln.ll\lollon..) Vour.el'. If your porenl (or .om.one 011 e) o'n cl,lm you II a d.p.nd.n, on hlo or her N,. or ..... ClltlIucllln',. I'" roMn, do not ch.ck box e4 . "... -1- No. ,I ~014' mO,p,n",nr. ('" 0.0 cnl1411no"'C "'&1I0ll'/lllItO't014 mo. lIv," 1/1 '11II/101 ,ou~hom. 011'"'' wll/1 yOU -L -IIIOn'III\I,wltl'l ~Ol.l "u. 10 4lvOtc. Of"UrlUOIII.I' 11'11'14' 65 234 3 932) 3 6 3..Q.L Form 1040 (19ge) F<Jrm IO~c) /l'.l\}t31 P4q~ G'O'{ F & L('\NN,'\H ADKWS ,_, I 442 -5".74% ~--"'~2 A;nuunll,om IInu J I (adlu,lod aloulneomo,. . . . , . , . . . . '-:' .1 aa ' 61 302 ~~~pu- aaa Ch.uk ,1:Dyou...,. eHI 010.,0 BIIMI Depouu wooee 0' oldol,D Blind, ,I Ijl:.'i;:.1 M~ 1M numb" 01 bO", uhoukod abovo 'nd onlor 1M lolal hOIO, . . . ~ aall LJ:,,' C: lollon b II you ". morrlod IIlIng IOparo,oly and youl ,pou,oUomIIU' deduellona 01 "')1'11 you ale a duoHIOluI ollon, leeln,INoUon, Ind chick helo . . . , . ~ aabO I','!)!I'::: tlomlnq doducllone Irom Bulledulol A, IIn. 28, 0/1 } Iii/I 11<111 04 EllIer BtAndlrd do duo lion Ihown below or your IIlInO IIeluI, 0"" '" U"~14 11,11."""1.1 tho M~ l141lJn tin, UU, II OA urn"Ut, Un ,1,lm ~Cll,j U. : 1;1;1111' llarg., <l11I.nlt."",,, tilt l'lIlf\jClIQ"'I~ IIn4 riM lUll"'" "'41,1'111111, I'I!:::!": 0' 0 Slngle-HOOQ 0 Mlrrled IIlIno 10lnUv or au,lIlyln9 wldow(er)-18,700 a4 your: 0 Hood ot houleholo-I~,SOO 0 M,rrled IIllno up,roloIV-IJ,aeQ ,lii',I::,1 35 Subltlct line ~4 'ro", II". ~2 I , , I I . I I I I , , . I I , 05 36 II line 3211 $88,'17e or IUb, mulUply $~,e~O by Ihelolll number ol,umpllonl el~Il)'d on ,,:':,1:1:: 11M ed, II line a~ 10 over $68,47,$,100 Ihe wOIKlheelln Iholnll, 'or Ihe 'mounllo enlO, . , 06 07 Toxoblo Income. 5ublrocllln' a8 'rom IIno a8. IIlIno a811 more Ihon line ae, 'nler -0- . 37 06 TI~See InllNoUonl, Cheuk II 10111I Inoluilel onv ''''' Irom ,0 FOlm(l) 8814 lil'i""!, b I I Form 4972. " . I . I I . . I . I I . . . ~ 38 39 Creolllor ohlld & dopenden' cllle eXpen"I, Anloh Form ~441 09 ""'I'" I 40 Creolt lor Ihe elderly or tho dlubled, An.oh Sohodule /1, . 40 1'Ii.I!.::!lill 41 Foreign I"" credll, An.eh Form 1 " 8. . . . . . . 41':'111'1' 4a Olhar, Cheok IIlrom a 8 Fo,m a800 b 0 FOlm oaS8 ::i'I~.!:i:1 lil1ili'l!lii o 0 Form 8801 d Felm (Ipeclfy) 42 ,i:I\:I:.I: 43 AcJcJ linn ~a lhrough 42 I I . I . I I . I , . , , , , I I 40 44 Sublraelllne 4a rrom line J8, 1111118 40 10 moro Ihon line a8, enler -0-. . . . . .. 44 45 S~lf"employmGnr fl1.)(, . AttllCh SchGdUlo SI! . , I I I , . , I . . . 45 46 AlternaU~G mInimum tllX, Attach FQrm e2S1 , . I I , I I I , . I I 48 j 47 500111lleuulily and Medloaro I"" on Up Inoome nol leportoo 10 emplover, A"". 'Of."" . 47 46 Tax on oualllled rellremenl planl,lneludlng IRAI, II laqulled, anaeh FOlm ea~o . . . 46 49 Advance aarnl1d Incomo credit p4ymont, 'rom Form W~2, . I , I I I I . 49 50 Houlehold employmonlla.es, Anloh Schedula H. . , . , . . . , , . 50 51 Add llnal 4. Ihrouoh eo, Thilll 'lour totAl In , , . . . . . . , . . .. 51 52 Feoerallncome,,,,,..llhheldllomFormlW-21ndl00S . . 52 10 270 1''11'1 50 lS00 all, I"" paymenll and amouniepplled Irom lOGe relurn , 50 ii!ll,i~ilili, 54 Earntd 'ncome credlL Anu" 'cntdult lie If yOIl n4~t.. 411"U,.,lng l'iii'I[llli1i !IIIII ;1 I I '11'111" '11111" cnllcJ. NQ",tuUlt ....tn'4Inqq",'l tIll0lltH . :,'I':iitlli !11"I:;;i In' t,,, .. 54' I!II':IIIIIII NO 55 Amounl plld 'Nllh Form 4880 (a'lenllon reouell). . . ,55 IIII[IIIHI 56 Ihu..u(I"I..IMlly...ncJAAU'.....IIr'lr'I.ldf....I/'IIf,1 . I . I 56 111:111111'1:lli 57 Of/It, "''f",.M., C",oll if "0'" a 0 "Ium 2"31 ,b 0 '0'''' 4131 57 i~iillll:iil 56 Add IInel ~2 Ihrouqh ~7, These are 'lour lotal plymenlA ..,.. .. 58 59 Utlnt UI'I'IIIU.I".."tln. 51, 'lI!Jltu.III". 51 ',om Iln.Sot, rtll'I.III,.mlllllllyolI OVERPAID . . . 59 600 Amounl ot line SO 'IOU 'NenlREFUNOEO TO YOU . . . .,....,. . , .,....,. . .. 600 b A"',,<umm I I I 1 I I I I I 10 Tvpe: 1 I Cheuklno I I SO'llnga !i!~'il:I!lil d A'''",<um,,, I I I I I I I I I I I I I I I I I I 1'lilr,I!11111 "ma~"t" Iln, ShOll ""."1 APpt.IID TO YOUR 1117 Ul1",ATlO TAX ~ I 61 111111. U II". 51 1'1'1I0,.1"1" 11/'1' U. '1I0t'Wtlu Sf "om IIn. II. TIIIII. tll. AMOUNT YOU OWe. liilll t! For del~II on how;' paV ond UIO Form I040-V. leelnllr\Jodone. , , , . . .. 6a liiilll!lliilll!!!II!!llii!I!:!!lillllll!!III!ilillill!1IlliI!Illillii!lilllll ~ r- II you wont 1M IRS 10 nguro your 1II.><,le.the IIno 37 InlllrucUonll, Credits Other Taxes Paymanls Anach Forms W-2, W-ZG, and 109S-A on Ihe Ironl, Refund Sono II rlghl to '{our bank! S.ao Insr, and 1111 In lOb, e, and d, Amount You Owe Sign ~Iere KeGO a ~OPV Qf thiS rorum lor '{our records. Paid Preparar's Usa Only ilU 61 62 63 ,160 I eldmeled 'ax oonel1'/, AllO Inolud' on line 12 . 13 479 47 823 " 750 35.073 C;,261 5.261 r.: 261 10 270 C; 009. 5,009 U"O., 1""111I.. 0' It"jll,y, I d.el",. 1/'1'11 /'I4Y' ...mlll.d t/'lllt,tU'" .nd .eClomlt..ny!/'Ig '011'11""" '"4 4"1'''''''11, '''cJ 10 tll, Oil' olllty InowltcJg.and D.U." fn.y ,,,,It\i., 00"101. .ul4 GomDI,I., QUI"I\IO" at l:!rlunl(OIIl., f/'l,n I,ID..,"'I. bu.d on'III~'4''''''110'' at willa" ~tlDI'" II" ,ny l"OWI.C1g.. ~ VOII' 'lg",.M. alt. Your OCCII1t41l0" ~ 5POIlIt'lllq"..Iuf., I' JClInlf.""n. aor", 11I1111'10'" 0111 1If101"", 'IQ"lfUrt ,''"..",..m.II'''IOII,. II "1'~.mPloytdl'"d tddf'" I<'=' 7~!j NE'I/ IIN I ZI,. ~ClcJ. !?,~, 94 17Q7!j '908 Form 1040 ooge 2 SCHEDULES A&EI (Form 10.10) ToIUII YOll P,ld (5., pao' A-I.) lnlerut You Paid (5', p'g' A-2.) Nola: 12 Personal IrHorOBt IS nol 13 a'ducUble. " GI/t.s 10 Chorlly 16 If you mad, 18 a girt and FcO! il bene III orll, sea 17 p'g' A-J, t8 Casualty ilnd Th.tt Losses 19 Job Expan... 20 and Most Other MIscellaneous OaducUon. 21 22 (5.. pag' A-' lor expenses fa deduct he..,) 23 2,' 28 28 Other 27 Mlse.llan.OUI Oeducllonl - TO"I It,nllzed OeducUons Schedule A - itemIzed Deductions (Sohadu'a B I. on baok' An,chm,nl ~ S.. In.trucllan. lor SChadu'.. A Ind B 'Porm 10'01, S'oUonco 110, 07 Your .001.1 "oUllly n'jmbar ~4?a6.'74aa p!I;:!I:jl, ,"111'1': !LI,!';;! :1;li'l,illll ,1'i,jl,II' 11..11" 4 i"'i!I'it'! 1111:I'lil!ill 'I 'Ii il,II'II:I'i 95 1"11:'1'1 ,I,,,,, . . . . I I I , . I . . , I 8 a iA~ ii,i!IJil.III'!I' 1:.II'!'.1 "1"1'1 1,'il:l! iii!iliilill I:'IIII!II ii!:I!I!II:1 .j!lll:mi' l:rll'w,1 14 iF""'I' 'II I'll!" ",I ill'" __ )'1:,11' 20n lilili'ii :11:,,'; :1:I;i;!!111 11111'11'11', 1..tlIL:I, 18 ~ MUOh t. Porm 1040, H4m' mOtI9'Q.lnt.rell,"d polll" "liar'"" 10 you '" "01'" 108. , , ~ /1om. mortg"9'ltU".J1~OI"QO'ttd to yOl,l 011 '0;1'011, II UltI 10 Ill' , PilItfOlI"o",...1l0myOl,tOOijgllllll.1l01ll1,_Up.g. -t.llo.nov,thU ""'011" Il.m., IO'"lllYIlllIlllJ,,'/I0 .Utll. . I ~ , I , . Polnt~ not ropo~od 10, you an Form 1000, Soo pago A-3 ror specl41 f\Jles I , , , , . , . . . Invo~rmenllnloroll, It reaulred, an,oh Form '002, (Sao page A"3.) I . . , , , , . I . I Add Ilne~ 10 IhroUOh 13. ....,. Olh. by c..h or oheck, It you mado ~ny gl" or S2~0 or more, ..e 1)490 A"3. I . I I . . I . . . . I . , Olhor Ihen by o..h or oheok, It .ny gl" 01 S2~0 or moro, .ee page A-O, 1I0VI,SOoo, you MUST anooh Farm 02~. , C.1fryover Irom prlor year. . I . . . . f . . AddUnest51hrouah17 .....,. I . C"uoll'/ or Ih." la..(e.), Mooh Form '00', (See pooe A-,,) . Unrolmbu"od employee expenses -job ~avel, union dues, lOb oduoollon, ote, It required. you MUST anaeh Form 2100 or 2100-ez, (S.e page A-,,) ~ Tax preparauon rees . . . . I I , . Other expense. - Invesrmsnt. sate depo.lt box. 010. type and llmOunt I . . . I ... U.t 1:1,1111:11, 1 1111111:11,,: Q 5 8 7 11111111il, . to ~ 11!llillll!1 11!I'rl/1Ir' ~! 111/11:,[ 11 12 t3 111'lilll;II!: 1,,,,111,,, 15 11''1'" ])1,11.:,,1 15 17 . . . ? , ~ q,- 1 'n~ 'I 10 . . " , , . , illiilllli! !,t:'i:'i" "'11"" :;'111'1101 "I'III'J 111,,111 iiiilililli 20 '1"1"'1 21 1111'1 'i :1111 II Iii! I1I11111 1IIIIi Ii II 22 II I 22 lillll 1IIIIIilllll 111111,11 25 . . . , . . . 28 - lillllllllll 27 28 I. Parm 1040, line 32, OV8I .117,080 (over SOU70 II mllll'led nllng s.porat.ly)? NO, Vour d'duonon,l, notllmll.d, Add Ih. ilIMunt.ln the'or nghloalumn lor IIn.. 41hrough 27, Also. enter On Form 1040, 11M 34, lhe I.rgar 01 thl, amount or your s,.ndord d.duonan, veSt Your deducnon may be IImlt.d, See Qaqe A..' lor the .unounf to linter, For Paperwork R.ducUon Aot Notle.. If' Form 1<<UO rnttruoUon.. UA. OUI""""I~' Ill' r"H~rr 1'ltfl~.1 ilU'I'''' hhlU IUJ 1'H"'IIII'"~*""n'1rm Iq.&Q GARY E f. U"M''''~lJ AnKUIS M.dlool CaUIlOnl 00 notlnolUQQ oponsOllllmbu,ud or psld by Olh.,l. .nd I Modlooland denial "p,nus (ue pago A-I). . . . , . a.nul 2 't1It","q~nl"II,"'O""IO"QIIl".n . ,~ Expan... 3 Multiply IIno a .boYo by 7,D\~ (,071) . . . . . . . . 4 SUblractllne 3/rom IIn. 1, II line Ols mo'Olh.n line 1, enllr -0- . 5 !:Slalo lInd IOClIllncome tlUl:8S , I . I , . . I I . l5 ROISI earBte IIJC.lS (aee pllge A-:Z) I . I I I t I I I 7 Perllon.l property 14)18' I . I . . . . . , . . 1 Qlhor IO"s, Ust type and OmoUhl ~ STATEMENT # 1 o Add lines ~ Ihrouah O. . . . . 10 If Add lines 20 through 22 .. ......,. Inter ","cUlle "0," "or," 1040,l1n_ .u . : I 24 I Mulnply IIno 2' above by 2.,l, (,02), . . . . . . . . Sub~aolllne 2~ Iram IIn. 22. It IIn. 2D I. more Ihen IIn. 22, 'hI.r -0- Olher - Irom list on pag. A-4, Ust tyP' .nd ilIMunl ~ J ~ 'eMS IIQ le'HlIJ7' _ 1996 , , qq, a ?REi ,no 21 1 , , 479 Irlllili!illililiilrl!iii::J1illllllllllllllilii!llllllii!iI11ili!lllllli:il!1 Seheclula A (Form 10aO) 1900 ...:a-.;. I I -. I fII " I I ~ ~ ~ f' ~ ~ -- I '. i I .. I , ~ SCHEDULE C (Form 10,10) OMII"lI),I5.'-I)O'" Profit or Loss From Business (Bol. proprlolorohlp) ~ Partnorohlpo, lolnt vonlur.., 010" muot fII. Form IOU. ~. .. F F I S "!lU'Ir"'"I ~ "It.o" to orm 1040 or orm 1041. ~ B.. nllruoUono 'or ohodulo C (F.rm 1040, s",..", No. 09 Soolol ..ourlly numb.r (BBNl 442-56-7496 nlor pr nolpol buoln..a codo (a.. p.g. C-e) ~ d 1 d o Empl.yer 10 numbor (EIN). " Iny 1996 C.g"tr'lll~1 ~Il/l! r,...l,II, 1~11I~~1 "'~'"\l' 1I~lc.II'1 N.llrd Q/ proprullor G R'{. D S A Pnnclp.1 bualno...r pr.'uslon,lncIUdlng producl or u,..,lc. (aa. p.ga ColI CONTRACTOR C eu,lne" nama, II no ,.p.ralo bu,lna" nom., 'oa" blonk. 9AR'{ ADKtNS CONTRACTOR E eu",no.. oddrosa (Including oullo or ,oom no,) ~ CIIY. fown.r 001 .lIlc., 11010 ond ZIP cod. F Ace.unung mnlhudl (I) Cuh ROAD 7 Olher (opoelry) ~ a Old you "m.l.rllllly pmclp'''''ln Ih. op.r.Uon .Ifhl. bu.ln... du,lng 100G?" "No,.... p.g. C-210r IImll on 10..81 . lli.l Va. 0 N. ~O H II you SIOrlod or .oqul,.d Ihlo bUllnou durl"g lOOe, choek ho,o I~ 11 nc e 1 Oro," ,ocolgll or sol8l, C.ull."1II Ihl. I"como wlS roponod 10 you on Fo,m w-z and Ih. "Statutory 0 63 512 ompIOVGQ" Oll on Iha.t form WOI checked, see page C-2 I2nd check ht3re I . I . I I , II-' 1 2 ~ot\Jrns and allowancos . . . . . . . . . . . . . . . . . . . . . 2 3 5ublt'.III,,,' 2 Irom llno, . . . . . . . . . . . . . . . . . . . . . 3 q ~12 4 C.,I ., gOOd' oold (Irom IIno 420" pogo 2) . . . . . . . . . . . . . . . 4 51 34.5 5 Oro.. prollL Subltoctllno' Ir.m IIno 3 . . . . . . . . .' . . . . . . . . 5 12.167 e Olher I"com.. i"CIUdl"g Fade,,1 .nd 11011 gOI.lIno .r ruoll"" c,edll or ,./und (0.. pogo e-2) . . . . G 7 QrolSS Incom." A,.jd lines ~ Ind 8 . . . . . . . . . . . . . . . . .~ 7 t, ,167 I Part II' Expenses. enr., o'oono.. lor bUSlnll. ueo 01 y.ur ham. onlv.n IIn. 30, e Ad,orti,l"g . . . . . 3 4.00 10 P.n.lon ond prollt-'hllll"g plan. 10 9 Bad debfS from 54l,.lI or 20 R."I or 1.00. (00. pogo e-4): ::::Iidi!l! .o",co. ('00 pogo e-3) . . 9 ~ V,hicl.., m.CIWtl'Y, 'nil ,qUIIl/ll"lt 201 10 C.J( 3nd tNck Q)lpenlS8S b Olhor bu.lnolo propertY . . 20b (,ee p.go e-3) . . . 10 5 659 21 Repaint and malnlenanco " . 21 II Commissions and lees. . , " 22 Suppll'.("otlnct"~'4In Part III). . 22 -- 12 Ooplell.n . 12 , 23 T""'I ond IIc.nlol, 23 , . . . . . . . , 13 Ooprocloll." o"d locll." 179 24 Trlll.', /11"1', 'n4 '''ltfUlnlll.nu 1,1'1'""(' I!iillll:, o,pen,. doducllon (n.linclud.d a Travel. . . . . 24a in PIU\ ill) (se. pogo e-3) . . 13 b Moal. .nd .n 14 empl.y.. bon.m progrlllN I.nal"m.nl (ol"er Ihon on IIn. 19) . 14 o rl1l"SO~I.o'tln. , . . 15 Inluronc. (.,h.r Ihon h.alth) . 15 47" Z.b ,ubl,atto l' Inleresl: lI::iWliiI t1mitlJ,to1r(l.. pIg.,,"- a Mong.g. Ipllld I. b.nk., alc.) . tGI d Subltoct IIn. 240 Ir.m IIn. 24b . 24d b Olher . . . . . . . tab 25 UIIIIII.. . . . " . 25 4. 351 17 ~ogal .nd pr.r..ol.nlll 2e Wage8(l... .moloYIn.At C"II[U) . 25 s~(\tlces . . ; . 17 '44 27 OtheIIKp.no.. (rrom "". 48 on II Ot1lce t!Kl:lenSe . '8 "" poaa 2) . . . . 27 1.SS0 . T...I upa"... b.'ora O'P."I.. ,., (Juolno.. u...1 homo. Add IIn.. a Ihrough 27in ..'um". , . . ~ 2' 16 099 1. Tonlallva prollr (I.ssl, Su~nctllno 28 tr.m "". 7 . . . . . . . . . . . 29 (3 -q-'2 \ 0 exoonoe. lor Quoino.. ue. .t your home. AnOCh Ferm e829 . . . . . . . . . 30 1 Not pr.1It .r (1."1. Suna,cllln. 30 Irom "". 20. 0111 proll!, .nl.r on F.rm 1040. "".,2. and ALSO.n Soh.dul. SI!. IIn. 2 (st.lUlIlry .mploy..... } 0 932) 'M oog. e-5), estlll. and trUsts, enter on Form l041.lIn. 3, 31 P rt I om 2 3 3 '" .,..., ./.u MUST g. on 10 line 32. 32 II y.u novo .1...., Choc. fho bo'lhot d8ICrllla. your Investme"lln fhi. .c:1lvity (... pog.e-5). .,t you cnoc'.d 32'. .nll' fh.lo... on Form 1000,lIn. 12. .nd A~SO." Soh.dul. Se.lln. 2 (SI.M.ry employ..s. 0.. pog. e-5), estol.. '"d ,,'W3. o"l.r on Form l041.lIn. 3. ." ',.u ~h"k.d 32b. v.u MUST '".Ch F.rm el... For P;ap4rwork At<tucUon Ac1 Node., 'eel Fonn 1040 InstnlcUons. i!A } 32_ [Xl AlIln'ol..''''.nll..HI..... 32b 0 So"'. ,n".",unt I' not .t".... Soh.dul. e (Form 1040) 19.0 ~~hllduhJ G Jf2!I!1 1l.J401 1 'J!,tJ NolH1t1(O) GA?Y "' ADl<tNS Part III Cool 0' Goodo Sold ca.. pogo C,,!) 33 MOlno~(') uood 10 Lowor 01 COol Olhor (.II.oh voleo ~lo'lng ""onlo,y: (0)0 COIl (~)O or mo,kel (.,O..plo"oUO") 34 W.~ 1M" ony ohongo I" <1olormlnlng quonllUIO, 00111, or voluollonl belWoe" ope"'"g .nd olollng I"Vonloty? It "YOII," ilt14ch Q>cpl4MlJOn I Pog.2 eell 442-51;-7496 -- . 0 v.. IJ] No 35 Inv.nlory " boglnnl"9 or yo", It dlltoronllrom lASt y..~o olollng I"vo"lory, ollaoh "plo"oUO" . 35 aG 37 3G ,,- 30 40 41 30 Purohes.llou ~ollo' 1I0mo wllhdr4W" tor pI/lone! UIO . . ., 37 Co,1 01 labor. 00 nOllnoludo sal.ry pold 10 yourloll . 30 Malon.lo .nd luppllol :39 OHler coallS I 40 Add ""01 31 Ihrough 30 41 I"vonlory at ond 01 year . . , " . 42 Co.t ot ood.oold. SuOlrOOIIl"o 41 rrom line 4(1. Enler tho reoull here 0"<1 on 0 0 t. ""0 4 . 42 51. 345 uRart I\{'I Intormal/Qn on Your Veh cle. Complele Ihls pan ONLV "you lite oloiml"g Ollt or l1uok oxpo"oe. on line 10 ."d sro nOI roqulred to me Form 4102 lor IlIla buolnell,' Seo Iho l"sltUoUons 'or ""0 13 on p.g. e-3 10 n"d out II you muot 1110, -- 43 Whon ~Id you plo,. your v.hlclo In oo,..,loe lor bual"oll purpolol? (monlh, doy, yurl ~ 01 - 0 1- a 8 44 01 Iho 10101 "Umbor 01 mllo. you drovo your vohlolo dunng 10~5, onlor Iho "umbor or mil.. you u.od your '/thlole 'or: a 8usll1oaG 18.256 b eommuU"g o Olhor 9.004 45 00 you (or your IpOUIO) h.vo onolhor vOhlole .vell.blo ror porso"1II UIO? 4e Wo. your vohlclo ~v.II'blo lor U.O during oN-dUty hours? 47 a Do you havo ovldonoo 10 luppon your doducllon? b II "'(01,' I. Iho evldo"oO w,inon? Part.", I Other Ex enses. WII bolow buolnlll oxoen.os "Ollnoludod on "".. e-ao or IIno 30, x V.. X V.. X V.. :< V., No No No No HAND TOOLS 5,L 4' Total other "xpens.,. enrer Mere IInd on Q e t, !lne 21 41 15-0 u. lIi'i 0 To -0. f11l_q wItt, Emplov..l, ,,-'. 1996 ?~:_~~b. ~eR"'L Tn rhl\J . 1~.,.\t"I\l;"'Il" I ....U..,I''1..4lI'l.. '01"'11, ,..UI.I'...."'. J" Il~,l' .. III Il'0,61 le7.IS le,'1 ,'hl' , -'11" .t..,......llt~ . -' Ill'" ("",,"11"', ~~ 2S' \6415 70 ,'IUII _t,.t tll' 1,.. ItIUI' lU .,"HUII! 12'0.61 Tl.~ If...lIl.r.',Ilt'''..U.,...,.Il...:,..... 1~1~0. Ho<l .1"001".0. IHt. 3ell MAHIT lUlU t,,"P HI". P~ 17011 1,....I.'..'..."ll..~"ly"II"'Itt' 4'z.l6.7'96 .11'Il1I1.'..'.II.II'I.,..."..,./I.:".... .. CAn I. ~OKIHI 3\1 IIU"PII~H ROID MltHAHltIIURO. P~ 170\\ .. . ." 'II '"1101111""0'1'11111 'tI'''''~ I'. '1,/1 '"" ."'IWO. III II StlIIUll" 'It .01\) 14 011'11' S\Jl 1.\7 'l ol~I..lfI. ..I I ~ n ,"10,.. I~'" , ,.,. , ~r!:~'.?:l!7.?---r"..----"..:.--- 'I SUit ("",,', Ul,l,. "5' H..t, I. .. "p I'"'' ,,, , . . 2~~__"___"_r___.."Jj~J~-- ""'D' ~l"'1\ . ---......--......- I' UII.I'II""" .. .." . _..........J!...:'--- .,m "".2 w.Q' '"0~" St'l.".,,., ~Ut." l'lt T"..1I7 -,I'. .. "'.....,, '. ""I'.'"'''''' "",",," A'.......""" 11.\ \Alii -pv C ,.or EMP'-OY~I:.'5 RaCORO.s ...alHIOIIIl,/Il\Otl 19\ , .......a,...I.I01.UII.'UI'II'. 1240.61 ""I 1996 0.... No, ,,,,,'-0001 ...rallft""" tAl .Iln"." I!T.9G oc'al..h'lly..... , MUll"" ..... ,"I \111 1240.6\ . l/lll'o~.r 11l.1II.,taO"..../I. :1. n.. . lAl~OR HOMI II"OOI"HO, IHC. 36" KARKIT SllllT tAMP Ht~~. P~ 17011 "'11'11'''1' ~.. 21"~1l70 n.~ . 1"'1111'1'''1 IOtl.1 Itcwr.tr "..."'0'" .:..:.2.16.7'96 1"'010.,... "."'....0"....". :U1UOt OART I. ~OKI HS JII STUMPST~N RO~O "ICHAHleISURO. P~ 17015 . ....,. ." I . . " "fOIlO....14h..II11ft I' U.,llt"I,,,.,.II' .., ,.. QtrW 1.\7 IVI -' , . I.' "1. ."'.. 10"'11,""'11." nun.",:.a" 0"/1'"111 h'lft"".lorIOIU .. .. '" I 11'1010.,.. '''1 . \0-.' t ...Q I 40. -r--------- --------------...--------- ~.... !"'O"'I ., "I. " 1"..".t It \,' I' ,,. ",., I t.. .......,.. , 'OCA I. .. ...... . ..1 ,.. L" - I' ... .__~___ 12'0," \2.':" -----r------------I ------------ ",w..) w'o..""..5I1lt"'''"' ::l..l,Olllltf".....'.,.IIlIS tl,ll.d,"'ahOIlI' :1'1"0 111'''1.",11 10 1".I,."'''allll....~\j. S,_u 1t-'1~UI v... 1996 0"0 N., ".,.'0" ,.". Ifilli'll' .. w.I~"'" 1e1.ge UI"..hlf....'U -. .1Ilo.1..~'t 1 ..t'''''''' 'II,II!".I fl.. I .II>4J170 ,.,u', ,.1 ""'1. IIIU" w.,.. ."1 I'. 1140.61 111I'1'1'''' "'''''111111''''.'''' II'.... IAT~OR HOHI RIMOOI~IHO. IHt. n.99 Jal' KARKIT ITRIIT tAIIP HI~~. P~ \7011 . .."I'~ .I~ ....I"lN"","WfIl." 441.\6.7496 . I/II,I~.,.." /1."'.,...,.....,,11I i'''.... OAR! I. IDKIHS )\1 IIUMpeTCWH ROAD ~ICH~H I CUU.O, P~ \ 7011 . ,,'/11'/1 Uti .,..1 'f\''ll'~ Itl ."'" '"' ItllII.IW.'. 11'1 .. U "'I"II'a. IOf'" U u' 0""' S\JI 1.17 ,"1I1'r'~ Ill'''' . .,.,.. II i'OI'fl''''IIl\lO/l -!~~ z.!:.'2".:~~ -. .~ - - - - - - ~2:o..:~l_ -t - --- - -':'!.::: -.. -' II "" ." """.\" ""."""".."., II '''''''IIIft'I'' , .. .., ..... I W .' .. .'I~ M, u. ~OC~~ 1240.61 \2.41 ------------ _._-----~--- -----------" ,.,,,,w-2 Wall ,"III Tn .'"'","'", 0..,- "1111 ,.".....'.,.. UlIS T'nl""'o'lIIallO,, I' ,""""'"1,",'"111"111'''/1'1 "...""". hNIU U'" 1U'ZI 1996 O,..IM. ,,"'.000' .0.1111"'011I. u.. .1'"Il,IG 1eT.9S "'PIO,.,..II'I', 21' 1643570 QI',' ,""'f1I)' ..... 1240.61 MIIIIU" .al" .". 1111 \240.61 Oc.ollllcwnl)' tu wI11l"..eI '1'4,<<:3 . MI"Uft",.W\'''''I'' n.99 lmpll,.,.. "..",..u."U.,'" :'. UOI TAT~OR HOI<I RlMool~tHO. INC. 3S1\ MARKII ST.IIT CAIlP Hl~~. PA 170" Imllloyn" ....., 11110I"1')1' "",., De' 4.I.U.T496 , I"'...r.... IIlm.....,.U.III' :l~ IOU OAIT I. AD~IHI HI STUMPSI~H ROAO , MICKANICSSU.O. P~ 17Qll i I i , o"",""'~..,,. .. f , . , ' I \" IIIOIIU,IIII.O 011" 1'2 ..,/lU"' W'. 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II'" I.;, ..., 73-0UBG7B lr'"I....,...I, ,,",.'11 'I '..I""......,. 52,011.44 1,753.74 , "".." ,'U 1:'"'11:''''''1,1''' "H'II'"',,,, I.. W,I"",,,II 50,012.10 IO,Oel.75 ....,. ,,.,,,,., w"H . 'UI" "...."1' ,.. w""",,1II II). "."... "",,"" ..I..hl......III II :'"]"" I' ~..."I. ...... '0 ""' w.,... "U. '11 .' HAMPDEN.PA 52.802.44 ,:.... w-2 WAOE ANO TAX STAT!MENr 1896 COPY B . To lit 'II.. ...1111 .",pIO,,"" 'lotU, T.., 1\1'1'1 C""l""nl 01 ''''. f,...IoI'''' 11111'''11 1I,,,,nl,l' .",,1" I"""" I Itl..., ""'-" .". "~I C... U,S. oer-ARTMeNT OF T~ANSPORTATION MIKE MONRONEY AeRONAUTICA~ CENTeR P.O, 80X 25800 IAMZ-5001 CKI.AHOMA elrf. OK 73 I a-48SA I.......'.. 'I. It., 11.0111111 I""....." II" ......,... Itllll', ...".. .". I.. C... 118 "50-U54 H~N~ ADKINS 31\ STUMPS TOliN RoAO M~CH~ICsBU~Cl. PA 17055 EA 011I1 It. ,..,.oaaa 'I"'" P!~N 1"""....,1'.1, :.It. n-08US75 \'1"" ""'fI. "11,111, 1111'..1"......,. 8l.8n,44 1.783,74 I .....,.., ,'U, Ol"t' CI",""UIIIIl I ",,'.1 "I~''''' h. W'I""'" 1.7 ~ "'It. ,,,\11111, W"" hll.1 lUWII" 'u W'I""'I' \ I ",,'""t W"., 'Il' 'III . "''','"' ,.. W.I""... 8 I 42 G20n,U 'II .;lIll '1,,11 .,"II"IIC I'. "'11111 ...../1. "",,...'..M,1I1 1.....Il'.ltl"'. HAMPDEN, PA , \ ,~,"II . . 10'."" Wit.., "II, II' :\ 52.002.4,\ - ~,,,I I"""" 'U 529.90 'O"M W.. WA g ANI'" "AX "':"A'i=M ~~ 1996 copy c . 110' .molo\l.... ,.CO'U OU."""III 01 ,". f''''''''\I 11'11"",. 1II.",."U' $,'VIII .......... It..., "'..,... I'" r.. ~... ~.S. Oe'A;;rMEIIIT OF r~"'N5PO~T,.rION MIKE MON~CNEY M"eNAUTlCA~ ceNTeR P 0, 90~ 25800 IAMZ-SOOI CKI.A"OMA CITY, OK 7312S-4gSA 1""",,"'1""" 73.QII.171 ,,,,"..,,ltl""" II""" ,11':" :... 1"'.1....' 11/11 HANNAH ADK I N5 3S 1 srUMPsTOIIN ROAD M!CHANICSBURCl, PA 17055 EA 118"SO-8254 0"'1"., lu,.oao. 't'l'" P!~N '73~'6'51&~175:' .... If SIIII ",un, f.U, III." Iuu 'Il"'" 'u G:.002,44 1.783.74 \ \ \' Wt,.., "II. 0111" ~''''I.''..tI'" I...,.. '"'"'" 'I' W,IIIII'IIII lO.OB1.75 51,U2,eo I "'lII h'~"no I.. WI''''''''' "'111 "Ill/I" WI,.. ",,""'1"""" '1l"'U \. ltlU'''" ,.. WIl""'" 1113,42 G2 ' 012. U 1)1 'C"ll 1"/1 ....".. l'~ 2 " ~.,,",. "."". HAMPDEN,PA 'I ""'1'" ,., 20.11" w...., ',... II' 2' ....111".."'..11 52.0n.U 8Zl1,II0 13. It''''I'' ___.../1' 1,-,,,,.,,.,,,,,,11\ ,. X iA':" M "'T 1996 COOl' t To a. II II to WHlI b'noIO"..'. SIf". Cll'l'. 0' 1.001. 1"001'1'I' f.. lII,I\J'" ~UIHm,n' 01 In, T'tII'uPI' 11111/1,.1 _'''I''U' S.,v.I:. ,.,"M W- .""1"'" '.. ..., '3.~U.." ,.....U..I "'I"" "1.,.11I .~.ll' :h.. ~,5, ~eOAnMENT OF T~ANSPORTArICN MIKe MON~OIllEY AE"OIllAUTIC"'\. eaNTE" P,O, 80~ 2seoo IAMZ-SOOI OK\.A"OMA CITY. OK 73:25-496A .....'...'1"."'..,...'... I"'.a" :... ,"'....... UN HANNAH ADKINS ~S' srUMPSTOIIN ROAO M!CHANICSBU~Cl. PA 17055 1,0. 118 -50-S2U 0""1 .... "..,.~oo~ It'IU. P!NN I....'.... I 'Ill. ..:. It., 73-0SU1l7S If 'UI. ""'1'" 'I". I'" 'I SIIII 'II..MI ,.. n,ilU." 1.783.74 Co.., .I '1'0 'I WI,U. "", lIl".. :,,,,,,"UIII~ : _.11I./" ,~""'. fl. ""11""'" $I,OG2.BO '0.081.7S ...111 .........1' "".,.. ""111,..,,"1' '" 'Nil""'" \ I .....,..'.",..11."..".. . ""....." 'f.. WII"""' 91~.42 G2, 092, U 84 11.,,11" .,e I J. "'~II' ,....III, 4""'11t"."..1I1 i""'" i .. ~:.w.:.c... .....' ,~.."'. . 829.11 11.....""..."'. HNO'DEN. PA :ro ~'U' "",.,.11, "", '" 11 U.U2,U :1'.. :)I,,,,""IM 01 "'II T,,,.ur l"t"n.1 ''''''In\JI .,,,,e. 1997 ,"$1/"1'"1..01)/1111 "',...,"II.III.lrt'..'IICH., ,I' OMII, Nil, IIU~"lJ'4 Vour oool.l..cu,11y "0. 4,\2 -515 -'74915 spou.." 100101 ...u,lly no, - 0-6 1040 CIll.,t,"~OlI .J/ tilt r, 1"'1" .. l/'It.,,,.I1 r"~.rl\l' ,.,'11(1 U,S, Jndlvldual Inco'T'e Tax Return " 111"1 ~ ..' J4I\, ,- '= 11:, 1', I 'J1'. ~, .,11'" ". ~.., . '11"'1111' ,,,".,"IJIII1 .-SiI;<'!i.'{ 1- Yo)lH Ijflt/l,""'I\~I"III.1 LUIJlI"" l,.ul/l&"'I HA~JNAH 114m..UIU' II '1I)I/'Illlt\llll, IIlq~I'" fir,llllm. .1l-lIIllU.t "'~I. /I. For hllp IlIlIndlno IInl 1IIIIrucUon., I" pOO" 2 I"d G In tho boo~I.L V.. No o City, lq',tjlt qlllQtt ~lIItl1. ,lilt, ~~ ZtPU~', If yQ\I ".n .10"1911 "4'''1,..' pl~' 10, 70 :r!MOTHY SHE:NNA . t.E'( S Enclose. but do not atto.Ch, any poymont, AIIO pl.UG USI Form 1040-V. II line 321. under $29,290 (undOr S9.nO iI . ch,ld did nolll__ wlll1 you), soo Ele InoL on pogo 21. d Total "umbor 01 1<0mgDO"' cl..mld . 7 woge., slllor1l1. Dpl, olc. AU.ch Form(l) W-2 B B T..abl.lnllr..L Auach SCheduleS I' roqulred b T......mptlnlOrelt, 00 NOT Includo on llno 00. Bb G Olvldl"d Inr.omO, Auoch Schodulo e "roqulrod . .' 10 Tll!loblo rolundl, ClOdllo, or 011101. 01 tlolO and 10Clll Incomo 1""0' (III pogo 121 . 11 Alimony roellvld 12 eUllhlU Incomo or (1010). Att.ch SchodUlo e or e-ez 13 e.pltal gal" or (lOll), Moch Schedulo 0 . 14 Olher Oal". or (10.0..). Attach Fo,m 4107 16a TOIIIIIM dlltrlbuDO"O ~ b Tll!loblo amounft." ,...,3, 1Ba Tot>"""'" u,""" ill![ , ~ b Tll!loblo amounl'....... III 17 R.nlal ,oal IltOIO. royIiDO.. p4l1"enl"ip" S corpOreDO"", ltUol', etc. Attach Schodulo a 1 B Farm I"como or (10'0). Attach SChldulo F 19 u"omploymO"ICOmponoaDon 20a SoclllllICunty bo"olllo ~ b Tll!loblo amounll..' ,..' \" 21 Olher Incomo, 6 Be b c I'4ott,ChlCl1II;'''t'U" 'WIII/lot 11'1&119' YOl,lt I.. OttlO\luyol,lrflIYl'ld. \IJ.G - 00 you w."l ~3 10 go 10 \hI. IU"d1 . It 4 olnl return, dOli OUIlPOUU wlnt 53 to 0 to I I. lund? slngll Married nll"g 101"1 relum (evl" It only 0"0 h4Q l"cOme) Ma"I.1S 11I11'19 ..Iwa" "hUI'I. Il'Ilar IPOUUI, UN "bOll'l MIII.m, It.". .. Hood ofllOUllhold (with qu~IIyI"O plr.o"). (eaa plgo 10,) \I "..uo"I~'IP""'" "hlld "".. y'" ....'.onl. '1'I1.,,"i'4~lh,..".m. ",,,. .. outll In widoW or) wllh dloGndont child ( OOllceUII diad ~10 ' ,leGO COqo 10,) Vourull.1t your parl"t (or 10mllOno 1110) 00" ,Itlm you II e dlpo"do"IO" hi. or hor llllC relllrn, do "01 chock bo~ Uo . NOto'bO'" \"lIIl1ldOI'l .~dttJ NOt 0' your I"'W'''"'U whO'. , '.UlI.owlt"'fO\l -L . ~ld/'lotl''1' wllh youl1u.IO,I'IOrc. 0,UIII,,1I41l tlllP'9.11) -L - ADKtNS ~. t N Ota,n'Unll,n ec nOl .ntlrto UOV' -- ~41I'1umu'D' ."I"'~ on 11,," abO'l' ~ 7 Ba \\!l.i\\I~\h 9 10 11 12 13 14 16b 18b 17 18 19 20b 778 63 18 - 22 23 24 25 28 27 2B 29 30B h 21, Thl.l. 23 24 25 28 27 28 29 30a 8 .027 Forni 1040 (1991) Add Iho amounl.ln Ihllar n hlCOlumrt for Iino. 7 Ih'oU 1M d.dUcbon (010 pogo 1G) Modlcli sovl"g. 4CCOU"t doducDon. Attach FOrni eaeJ Movl"9 o,ponee.. Attach Form 3903 or 3003-F . Onl-hllll ollolt-omploymont lalC. Attach schadUlo sa s.lt.omploy.d holilh 1".url"CO doduCDO" ('00 pogo '1). KllCgh 4nd solt-ImplOYld sap and SIMP~a plana Ponlil'f 0" lor1y wltndrowli or .~vl"g. Alimony paid, b RIClpllnr. SSN ~ our 101411noom. .. Q.U.. 31 Add IInl' ':3 Ih,ough 300 32 Suotn.t 11"0 31 'rom II no 22, Thlt iO your ad uotod -- -- For Privacy Act ."d Poporwork RoducUon Act NoU.'. ... pogo 3e. ro,. Inoom. n. .. fl'IJrrll le.!l) t'ij;"', P.qo 2 GAP,'{ E. r, '~.~,NN,\H AnKHI!; I ,4~-~r.-'/ol9" Tax :J:.J . ArtlQI,JIlI "0m line J2 (lIdJUlSIOl1 grolltllneQmJ)). : . , I I I . . . . . 33 R3 ()?7 Compu- 34a CI,o,k II:OVouworo G~ 0' Old"O ell"dl OSpouuwos e~ or oldor,D ell"d. IL : 11'1: tallon Add I~. numbor 01 bO'oo c~.cklo obovo .nd onler Iho 10111 h"o . . . . ~34B ) : ~ l' 'II: b II you or. m"rled IlIlnij 10p.,.lely a"d your IPOUIQ lI,mlzel deoucllono 0' ,1"llil you or. . duol-slotu. .110". III pogo 1 e and chock hor. . . . . . ~a4bO 1:''1''',11 111,1:111 as f"'l" "..",,"' om '~..~ ., ""' 'I' '" J 1111' ' E""r 1.0" erd doducUon Ihown 010 or your III "9 Ilalu., Do.... ii:lll1ll1li IhQ pit. I'll ~911 Cht4~.4 .n~ 1011 an Un. ).. tr II 9,um.qnt lors" UII ,111m ~aij '. I q'IIUUIII. I 14.517 01 a SI"gle-$4,1GO 0 Mlrnod IiIlng 10lnUy or oUulllyl"9 wldow(er)-$MOO 3S your; 0 Ho.d or houlOhold-U,oeo 0 Morn.d nllng IIpar.I.ly-s:l,410 II'll!llII,I: sa 510 II you wanl 36 SubVlctllne De I,om IIno 03 . . . . . . . . . . . . . . . . 36 Iho IRS 10 37 1111". 33 I. sao,oilO or 10", mUla,ly $2,6~0 by lho 101.1 numblr ot o.empUo". cle/mod on 1,:'illl,1111 "9u,o your 11"0 6d.,lIl1no 0311 ovor $00,000, III tho wo,klhoolon page 10 ror tho omou"llo O"W . 37 .259- 14)(.08' 38 Taxoblol"como. SubltoCIII"o 31 rrom ""'13hlf ""0 37/. moro lIt.nl]' 36, o"lor -0- 38 .260 plge 'D, . 39 Tax. SII 040010. Chock Ir any lax rrom 0 Forml.\ ee14 b Form 4012 . ~ 39 121 Credlte 40 Crodll ror child & depondonloaro O.pO""... Aaoch Form 2'41 40 I I III ~: I i II 41 etodll ror I~o alde~y or tho dill bled. Attach Schodulo R . . 41 Ilililllllll 42 AdopUon crodll, An.ch Form ee3o. . . . . . . . 42 43 Forolg" t.. crodll, Aaoch Form" 18 .. . . . . . 43 '1:lill:111 44 Olhor, Check IIlrom . 8 Form 3800 b 0 Form e3S1 1,I!I!Ii 1:11 c 0 Form eeOl d Form (.po.lly) 1'44 1111!llllil! 45 Add IInol 40 through 44 . . . . . . . . . . . . . . . . . 46 46 SublTOClllno 46 Irom IIno 30, II line 4510 mora thon IIno 39, ,nlor -0- . . . . . ~ 46 10 ", Other 47 SOIl-,mploymonll"". Aaoch Scnodulo SE . . . . . . . . . . . . 47 Toxes 46 Aller"'avo minimum I"", Anac~ Form 5261 . . . . . . . . . . . . 48 - 49 Soclllllecurlly and ModlcorolOJC 0" lip Incomo "01 raponod 10 employ or. """ 'OIm ,,1/ . 49 50 - Tax 0" quallned raUromonl planl (Includl"~ IRA.) .nd MSAI, Anoch Form 132G II roqulrod. 50 51 AOVO"CO earned I"come cradll payme"l, 'rom Form(s) W-2 . . . . . . . . 51 52 HouSOhOld omploymonlt""os. An.ch Schodulo H. . . . . . . . . . . 52 53 Add """0 46 I~'ough 62. Thl. Is your tolal \0)( . . . . . . , . . . ~ 53 10 121 Payments 54 Foderal l"cOmol" withhold Irom Forms W-2 and '000 . . 54 12 835 1!I'li'HI 55 1901011,1" p.ymonts a"d ,moU"loppllod Irom 100G roturn . 55 iilllll!1111 56a flam"d Income credit. Attld" 5c""IIIII. (ICI, yau I'tlI,lHQUIIII)'l"t 'I!IIIIIIIII IIIIHI'I! IIII!I,IIII ahlld. II NantuuI.'...,n,d I"com.: ,mount ~I I 11111111 111111111I1I Altoch I"dlyp. ~ 56a lil'llj' Form., W-2, 57 Amou"t paid wllh Form 40G8 (reque.t ror olClon.lo") . . . 57 111111111:1 W-20, '"d 56 r."u.aClllucunlYlnd ARl'AII.WIII'II'I.,dl...lUql"b' . . 56 illlllll111 '099-A on the Iront. 59 Oln"Q.....m.nu. CIIUKI' ',am I 0 '0''" Z.~O b . 'or"'4')f 59 I"I!,I,I:II 60 Add 11"01 64, 56, 6eo, 67, 68, on~ 6S, Th..o .ro yoUr total o.vmont.s . . . . . ~ 60 12.835 Retund 61 1111",'0 I' 11I0" Ill." Un. 53, ,ulllflCf 1111. U Irarn 11111 dO, 'I'hl,I,lh. '11I01,11'11 you OVERPAID . . 61 '.714 Have it 62a Amounl 01 ""0 el ou 1'10"1 ReFUNOEO TO VOU. . . . . . . . . . ~ 62a '.714 dlrecUy b A.o"~"m'" I 01 31 11 31 01 41 71 21 01 ~o r"oo: rXlehOCklno 'n'sovlng. ilillilili! doposlIedl 500 ~.go 2e d Accal,lnlllumll., I 0101011"'7101711171 I I I I I I I ,nd lI,n 02b, II11II111 c, and d. 63 Al1'Iaullt.,tt1Il.dl YOU 'II'.nr APpt.IIOTO YOUA tI'lunJ.lATlO TAX, ~ 6:5 ill 1 lilll Amount 64 I' Iln. U 1..,la" IIUIIII", eo, IUOltlet 111'1' dO 'rom 111'1' 13. Thl. il tll. AMOUNT YOU OWl!. You Owo For dotllll. 0" ~ow 10 pay, SII pogo 27 . . . . . . . . . . . . ~ 64 65 EsUmOlod lOX pan ally, AI.o '"clude on IIno G4 . . . . I!!.. I 11111!111111111111111111111111111:lllllllilillllllllll11!:I:III!lllilllll!!1 Sign Here Kooo . copy ot !his return for your recordS. \J"~.r .lIlIA_lllll. af 1I.'lury, I d.glart l"lt I "I~' ,,,,,,II,,.lIlIlhl. "turn &nd IcaalllOMytllQ Icntdulu &tId"Uttmt"tI,1It1l 1111/'11 DeU 0' my kltawlUQ' Ind lIlIfi,t, lhl" art tNt, Gortler, &nd campi. It. OICIMlUall at IIrtptrtr(alhll' thlll Ula'YlI"I' au.d ~n 'II Infarmlban ot which IlreD,ttf hu III~ ktlawltdQlI. ~ Your'lon.rutt 0111 Yaur cGCUUnon ~ SIIOuU'tllQnllu". lrjalntfllll'''. SOTH II'III.ltIO". 0,1. ~oou..'. ouuut!an '" ' 94 Paid Preparer's Use Only "',ur.,.. .... 'IQ""tur. " fl1rm'I/I.mt(a,y If ult".mlllaYII .lIdt... 01" C"tUU .Ilt..tmllla'f.d 'I I'" ZIP1ad. 7 t. r:' 710 BRtDGE: N W C )A i\ R v ':E o. II' II . i. I i. , I I ,- I- I- I t. I I. OMO No. la.a-007' P. ,,2 Vour ooolal uoWlty number 6-74% An..h",o"l 5.1UO".O NQ. 00 5dll)'JljhU A.ill IF'lfIll 1I','1)11IJ27 N.Ul"J{~) ~IHJW/l ~n FlJ,/Il It)''Q, o~ 11111 ,"llf "'111' Ill" 6l)~I~II'CijIl11"'jlll"" I' III.,wlt 011 111111/ 'hI', gM'{ r,; F, fquiNl\H Afll\UlS ' . Schedule B-Interest and Dividend Income 8 Add lhe omounlll 0" "". 0 . 8 7 Capitol goln dlotribuUo",. e"IOr hera .nd on S.hedul. O. 7 I111I1111111 8 N.nl"".bl. dlotribuUo"o, (500 Iho InoL ror Form 1040. IIn. 0,1 8 i 9 Add "".. 7 Ind e 9 10 SUb~O.1 IIno 0 Irom IIn. G, e"lor the relull IlOr. Ind on F.rm 1040, ""09. ~ 10 You muot .omplllo thl. port " you (I) hod over 5400 ollnl.reot .r dlvld.nd.; (b) hod 0 rorelg" .c.ounr, or (.) r....iv.d I dl.tribuUan from. or w.re I grel\lor ot, or I ~onl'or.r 10. I 10"lg" IlUIL ' 11 a At .ny UrtlI dUrl"g 1007, did you hovo on Inl.rolt In Qr 0 S1gnolUro or .Ihor luthOrlty OVor I "".n.lol ,..0u"lln . loreig" .0U"try, su.h '0 . bonk o...U"t, IICurliloo 1..OUnt, .r other ""oneill o...un17 5.. pig. a-a lor o...pIlO". o"d "ling requlremo"1lI ror Form TO F 00-22.1 b II "fa... ."tor Ih. "011100' 1/11 lorolgn eounlly ~ 12 OUrl"g 1887, did you r...olvo I dlotribuilo" rrom, or wor. y.u Ih. grlntor or, or ~onltoror 10. I l.r.1 n 1lU11? II "f..,' 'roU mov hOV.IO i11.lorm J020.r oaG, 5.. 01 . S-Z F.r P.perw.rk Rodu.U.n A.t H.Uoo. a.. F.rm 1040 InolruoUon.. !fA part I Inlor~el Incomo (500 P'OOIIZ '"05,1.1 N.III II you roco'VI. I Form 1000-INT, Fo,m 1000-010, or lIuballlulO Slllllment /(om II b(okarl~o nrm. "'llho/llm'l nllm841lhe P4YIJ( i1nd lInl.r 1"0 1.101 Inllroll sh.wn ." IhOl lorm, Part II Dividend Income (500 p.gls 12 ond B-1.I N.IO: Ily.u rocel\led a (form 'OOO-OIV, or lubsCMO sfalemont from a brokerage IIrm, 11111/10 nrm', name as Iho poyer ."d entor the tolal .Ivldo"dl shown on tha! lorm, Part III Foreign Accounts and Trusts (S.. pog. e-2,) N.lol II '101) hod o'lor ,4CO I" IllJCobl'llnlor"II,'o.",o, Y.I) mUll olo. ..m 1010 Port III, TWII n.mo ql poynr, II allY 1",,,,.'ilToJi9m. ,01l0r-lInoM'b m."o~e, 1M . buy., u!o~ 11111 P,opol1Y 01 I porIO"" ,"Id'r..o, soo pogo a-I 0 d 1I111hlo 11110(111 1101. All. IhQW Ihol buyo,'II..I,II.ou,11'/ "umber I"d 0 droOl Amount ,~ 1 - 2 A~d Iho lmounlo on llno I . 3 e..ludobl.I",ollll.n .erl.. ee U,S, 14vl"91 bO"dl'Muod Inor loao Irom Fo,m GelS, IIno 14, V.u MUST .n..h F.rm 101010 F.rm 10'Q . 4 SubItO.III"o 3 rrom ""0 2. enlor Iho rOlull horo ond 0" Fo,m 104Q, llno eo ~ N.lor II vou hod over 5000 In or. IV'dond ndl r IMr dl tnbull.nl.n I k' U u 1 'I 5 WII nome 01 p4yor. 1".lu~o grolO oivldondo o"dl.r olhor dlllt1buU.n. on 11..k horo, Any .Ipllol Olin dllltlbuUo"' Ind "O"'""obIO dl.ltlbullO"1 will bo dedU.lld ." linn 7 I"d e, ~ . 2 3 . 3 4 .m let P. III Am.unt 6 5 Val No . Ililiilllllllllllllllll Ilillllllllllllllllllllll Soh.dul. B (Form 1040) 1917 ~""11 21.06 Employee Business Expenses ~ s.. ,'p4nololn,l,ucUonl, 1997 , ,.j OMO No. IloU..IIQy O,g"tm'~IQ' nu r'U'III, r"I.,~.IAh'lllj,'h'''I<:' Y~\I' ~.'". ~ Altoch to Form 'O~o, AIIUltm,/l1 SUVI/I'lINlI,64 CnUPlllo" h, wru,,, ~Q'" '"CII"14 '.11I"'" GAP.\' t. rs Ipart II Employee Buslneu Expenses end Reimbursement,s STEP 1 Enter Your Expenses Column A OthGr Thin MOIl. and e"lono1"m'"1 Column B Mull and E"lln.l"monl 1 Vohlclo o'penoo Irom line 22 or II", 20 . . , . 2 Psrklng lIe., 10111, 'nd 1t1"lportoUon. Includl"Q ~II", bu., ele" thll did nOII"volvo ovornlghtltavel or eommullng 10 '"d Irom wor~ 3 rra,ol "PO"'O whllo ow.y Irom homo ovornlghl, I"cludlng lOdging, olrplo"o, eill' ronlol, ele, 00 not Includo mo.lllnd ontonolnm'"1 . 4 8u,lnoao O'PO"'U nOllncludod 0" IIno. , IhrQuqh 3, 00 "otlncludo muals and enlertlllnm,nt I . . 1"'1'1111"1""'1"1' "",I':'I'IIII""I'II"'II'II,Ii'l.1 : ~ 11"1 III'I! II: III:: '" : ,II i, i!!:, 1:1, : I: Ii:, I,:!:! : II' : II: Ii;:::: 1,,1'11111, 1,11,,11, ",I," ''''H''IIII"" ':!il'I'1I 1:::1/1'1' iiilll'IIII:I:;",1 1'llfl;lillll:i!:!!I:I![1 111:1[11 II11 ilil(ll I,ll! 11111 iillllilll III,JI::' "I' 1,1 5 li:lllll:il:!lli!lli:;!III'llj:lllill;III:1111Iil!111111!llli 1:lliillill 3 0 l'ili!,I:lll 1 2 (J 4 5 Mool, 'nd Onlono1"mo"ll'penlO' (lOol"ltruello"l) S Tol.11 "p.".... In eolun1ll A, add IIno. 1 Ih,ouqh 4 and o"tor Iho r"ult. In Column e, om., Ihe .mount rrom IIno' . <I 7.&.Q 6 <I 760 Nol.: II you woro "01 rolmburlOd ror ony O'po"lOlin Slop 1, Iklp ""0 7 ."d o"lor lh, I/nounl Irom 11110 G on IIno 8, STEP 2 Entor Reimbursements Received From Your Employer tor Expenses Listed In STEP 1 7 Enror .mou"IS your omployor Q'V' you thot wore not reportod 10 you '" bo' 1 0' Form W-2,/ncludo Iny amounl reportod undor codo "~'In bo, 13 or our Form W-2 (s.o InlltUctto"l) . I'",:', n"fil, 1'1'" "II "II 77'I',:!'I,1 7 7 40 STEP 3 Figure Expenses To Deduct on Schedule A (Form 1040) 8 Sublt,clllno 7 'rom IIno 8. . . '1,,111;111 ,.nl:ll! 'r iiliJlll' I) ;';!II!III .,1'"",1 1';1'111': ilil"1 i;:1111 I ~ ! ! IIII11I 6 Nolo: II bOlh columns 0111"0 e '10 lUro, SlOP More, It eolum" A 1010.. Ihon Uro. ropOrt tho .mounl 'ol"come on Form 10'0, llno 7. o .' . . " 9 In Column A. o"lor Iho omoU"1 'rom IIno 8, In Column e, mulUply Iho omoU"t on IIno 8 by '0\4 (,SO), " olthor column I. zoro or les$, enter ,,0.. In that column . . , 9 10 ~dd Iho amOU"13 on line ~ 0' bOlh columns and enler Iho tOlal horo, Allo. entor the tOlalon Schodul. A (Form 10~0). line 20. (Foo-boolo IIOte or 10co1 govornmont omclole. quallnod porformlng OrtlolO, and Inolviduo1s with dlsablllllos: 500 Iho Insll'UcUon. rOt Ipeclo1 nJI08 0" wnere to enter the total. For P'perwork R.duollon A.I Nollo.. ",. InetrucUon.. C CA ~ 10 Form 2106 (1007) iU F<J"T12'CIJfI~ . I'" . rP-art ]lli11clll Ex Ilnsos 15."lnsltlJ~1I0nII0 nnd Qui which 10e1l0l1S lu com 1.'0, SllcllorL~ -- Generallnrormal on a '1uhlclo 1 11 EI'ltJr IIlQ dalll 'ilJlllCIQ NJt,I plactd In OlIJf\tICQ , . I 'I 12 To"l mll.1 vohlell was ~IIVO" during 1001 . . 12 mil" 1J BUlIlnlllHl mlllflS 1,,~ludOJj an UnG l:l. . I ~ I 13 mllell 14 P."onl 01 bUlineu use, Olvldollno 13 by lint 12 . . 14 , 15 Avorogo dolly round IJ1p com",u~"G dlllonCt. . . , ,5 1111100 10 C.mmu~"g ",lIollnr.ludo~ 0" IIno 12 . . Ie mlloa 17 Olhar ".,Iea, Add linea 13 '"d 10 O"d lubl1aetlho tOlaJ ~om """ la . 17 11'1100 10 00 you (or your IpOUse) hav. ,"othlr v.hlclt avolllble'or perlonal pUlpono? . 19 If your omploy" provldod Y04 wllh a vohlcll, II pllsonol UIQ duII"g oil-duty hourI pormlnod? 0 VOG 0 No 20 00 you hovo ovldoMO 10 luppon your doduoUon? . . . 2\ If '",,01," 10 Iho ovldoneo wllnan? . Secllon B - Stan ard I ee e Rale (Ulllhla ucUon 0"1 II ou own tho vehlolo. 22 MullJply IIno 13 by 01.5 contI (.31GI. Enlor tltt reaull here and on IInt\, (Au rill ma" 00111"1, lie h'ISINr:~onll, . . I I Secllon C - Actun Ex ensee (I) '1ohirlo \ 23 0"011"0, 011, ropolro, vlhiclo I"''''"", ""1'11 :"" "'I' 'i,"1.1'11 'I'" I ',""' InllUfl2nClI, elo, . I" 23 1,';:ii:!:I:!:li!!li,!,II:i[:iilir:!:dll,,!,:lii:I'I'1 \':\ :Na Vehlclo renlllls . ,.. 2"011 I,',! 11'-1 "'LIII'II' :1'," ',111.1'1 l'I'"i,I',IIIIIII.IIIII,IIIII'lll,lh'II,'I' b Inelullo" .mount (lOG 1"lltlJcUonl) . 24b ' ". ."".' ,. ",' c Sublract Une iZ4b trom Une 244 I 244 I , I I1111 11:11"1'1,,' I' ,I :1'1, ,',;:1:, 1::I,;:II:li'llllli'; '11::::'::11' ',,' '.,1....1 'I I ' '111' 1111111 I I II '11'1":'111'1"'11111 i 1'111""1'1'1",, " 25 alu1 01 employor-proy dad 11'1 I' :'11,1 / 'I '~II,II"IIIII', :':11 1:1 ~111'::il:llilllll::!:'I:IIIIIII, I :11, ,1.':,"':'11,,: I"~ '.'enhn'ue.loll(eaoPI~I~1I010U:IYwl.rs' OI"OC~I~Udo~d . ,,' "I' ,:1,,1:":1'1'1' :11',,1,,11','1:'1,1: I' "":"'1 : ,I 1.!'i:)1 ;,::i"II/:'II: 'l'lhll 'l'l:rl~i ,~:!':l'hiL,,!,I, '4' T'" '" ,,' 1"\1111'<"1':"":1111 :I"II,II':I:'il"rI",il'; on Form W-2--leololltUcoonsj . 25 I': I '! ," :,'1111 '11,'11111' :':1':': I: I 1,111'" :.I,::!,II~::II': ,II:'I.I.,III:'I:IIII;IIII:III:!IIII:II:I>',.'.:,., 'I ' , I ' II I I I : I I lit I I '1'1' " I 'III'I'!! II ,I i ,d Ii' I - : 1'111. 1I1I 'ji I I ~ ,I, III 'I !, : I, 1 AddUnet23.24C',and2' 21 1""1' \11'lll' ,1' 111111:' 'II' ""!rl,,'II'~"'I'IIIII' '1'1111'11',1'1.1, Muloply IIno aa by IhG poroenllgo 11"1",:1" i "11',11111"111'111' 11,11'::'1 il"II'IIIIII'II, 111!11!!II::!1111:11!I'II: '11111111 ill.I'III!111I"I:.: on ""0 14 . .. 21 I "1""1 'I" ,II 'l'll:,i I, 11'1:":: ,"1'1'1" '"," "1','I'1i11111 I:"I!.: ',I 'I' ,:,.,1 '1"1 ,1,,1,,11, III I 1'1 '1'111111[11111 111,1::1'1,1-11 '1111!lrl;lil' II II 11:11'II':IIII'i"I,I'!;, 2S Oopr..lo~on. cr"lor omounllrom li:,I!, 1':'11 :::1 il,i:II!::' 1111!11',lilljl, [li'I':' I, :111111: 1,,11..111111: II 11::I',I',!'!,:I!':!:I!i" ""0 lB below 25 III' 1,.,I,I'III',"i 111'1' "11,',1" I" ""'II: 111"'I'I"h I' 1'1 ": ' "11,,:.1,,1' 20 ~:r~ '~n~ :~ I~;: 12S, .Enlor t011ll 29 !:I;II;II,I'I',:illl,!i:;I!I!:lill ill!:!! iiil:!!:!I;:I,:,! ::1 li!iIIIIIIIIUi'I:lllililllillliilili:ii:i:llil:;!i,!i:~:lli:t: Section 0 De reclellon 01 VehIcles IUIG IhlG loc~on 0"1 "VOll own I.\e vohlolo.' .) '1ehlclo , I' . '''I 11'11""1'1' ""'I ' 1";II;:il!)!I:I:,I!IIIIII:lli'l'I.'I; li:II:!!illiilli!ii,!ili1il!lilll!I!I!ilill:{ii'!il:li1,1::::I!:! . 2a Ib '1ohlcl. 2 11I11 I! III i I! II ~ Iii II I ! 1111: Iii i II! I: i i Iii i I II! I Ii: I: Ii::! I ~,' , 1 11\ 2e 21 (b) '1on,clo 2 3Q Enlor cost or olhor basis (0.. InlltUcllonl) ao 01 Enlor omounl 0' I..~on 119 deducUo" (1..lnsltUc~ono) . 31 32 MulOply IIno 00 by IInl '4 (000 InsltUctlonlll you eltclGd tho 1...00" 110 doduc~on) . 32 :l3 Enlor dop,eclltlon motltod and porconlage (I" InsltUo~o"s) 33 34 Mul~ply ""e 02 by Iht parconl'go on line 03 ('eoinsltUo~o"o) 34 35 Add lines 01 end 34 . 35 3e Emor tho limit rrom tlto tobloin Iho linG OG l"oltUCilono 07 Mul~ply line 3G by tho porconllgG 0" line 14 3e Enlor Iho sm.ller 0' IIno 05 or IIno 31, Aloo o"ter tltls amount on line 2B above UA "I: i:":"i'.I':1 ',:;,i,1!"i"1 1'li1i:I!,ii'l!i!(:::II'1 11"1."1"""1""'111'"1,1'1111',1111'1,,,111"'11"'1,I, I., ': i'" ~. ' :,', I , "'", , i:I" " ! ' , 'I , III .11 I . pag.. 2 b '1enlcle 2 mlloa mlleo \~ m,loa m,le mlloa Na 1U1{ Not ~Ippllcoblo . lliJvos DNa No , k " I~q::" ,1[1'1 ,I i 'Ii:,', i ;: I i I : II i i; ii,: 1 i ~ II' i,: : II Ij'.,::III:II,":II':III;II'"I!III:II ! '! 'tl!:!II;:'I'! :1:iAIiI 'I,ll; !ltl,I".IIII!!lllli!lli!I!I!iilili!!I::III;!II! ,,-_..~ 'C ., ,'I " I rll! :'-11 iH"i' ,_Ii; ,d I)', '\1 , '" '/' ~:, 1'1 __ _._ . ,-h .{' ','d' _,',_ ',_ , ",," /LAW OFPIr;~8'OF" ,(lREO,ORY,".. ~'ED , !~;\,}:;;,:",< :;'ir~~::t't~g'~i~~:r~~:"" i,: ;" A!I,\L!J,;I:_-~_)-- ".i.',,,\ - -' -', ' - ,'" .. - -; '; -d -;- '-\1'.1 If:',:;I')' ,~~'"~BU"OIPEN~BYLVANIi\,I711~ . ,; . '''!rl'!'!;?!LilV_ 1--. ,'1',',: (717) ~:s.0434}1 ';':';-\"'i':~;:-l, I I'j .o' I "I" 1;{:;;:/I,;:;:':i,.'," '",', " I ~';"':;':IVi,i".;c'.')':'J""L ( \ . ,. .\' ,.."- .,....'...."....'-. ,." . " ;"". IN THE COURT or COMMON PLEAS or CUMBERLAND COUNTY, PENNSYLVANIA HANNAH ADKINS, I CIVXL ACTION - :LAW plaintiff I I V. I NO. 97-6329 I GARY EDWARD ADKINS, I Defendant I IN DI'TORCE INVENTORY AND APPRAISEMENT or GARY EDWARD ADKXNS ?laintiff files the following inventory and appraisement of all property owned or possessed by either party at the time this action was commenced and all property transferred within the preceding ,three year~. ?laintiff verifies that the statements made in this inventory and appraisement are true and correct. Defendant understands that false statements herein are made subject to the penalties of 18 ?a. C.S. 54904 relating to unsworn falsification to authorities. Date: ~/(//"fTP_ , r -~c~ ~nw~~ Gary Edw d Adklns AssmTs or PARTIms ~laintiff, marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. If an item has been appraised, a copy of the appraisal report is attached. (X) 1. Real ~roperty (X) 2. Motor Vehicles (Mobile Home) 3. Stocks, bonds, securities and options 4. Certificates of Deposit (X) 5. Checking accounts, cash (X) 6. Savings accounts, money market and savings certificates ,7. Contents of safe deposit boxes 8~ Trusts 9. Life insurance policies (indicates face value, cash surrender value and current beneficiaries) Annuities ) 10. ) 11. I 12. ) 13. 14. 15. Gifts Inheritance ~atents, copyrights, inventions, royalties ~ersonal property outside the home Businesses (list'all owner~, including percentage of ownership. and officer/director positions held by a party with company) ( ) 16. Employment termination benefits - severance pay, workmen's compensation claim/award 17. 18. (X) 19. 20. 21. 22. 23. (X) 24. (X) 25. . Profit sharing plans , Pension J?lanlil (indicate employee contribution and date plan ~ests) , Retirement plans, Individual Retirement Accounts' Disability payments Litigation claims (matured and unmatured) Military/V.A. benefits Education benefits Debts due, including loa~s, mortgages held Household furnishings and personality (include as a total category and attach itemized list if distribution of such assets is in dispute ( ) 26. Other " ,'1 .1 , MARITAL PROPERTY Defendant lists all mad tal :;>roperty in which ei ther or both spouses have a legal or equitable interest individually or with any other person as of the date this action was commended; I.TI.M NAMIllS 01' J2.ATE 01' NUMBER DESCRIPTION 01' PROPERT~ ALL OWNlllRS ACOUISITI9N 1. Residence - 351 Stumps town Road Plaintif f and Mechanicsburg, PA Defendant $125/000.00 less mortgage $87/000.00 2. 1992 Ford Areostar $7/400.00 Plaintiff and Defendant 2 . 1988 Ford F150 Pickup $2/000.00 P1aintif f and Defendant 6. U.S. Department of Transportation P1aintif f' Thrift, Savings Plan ($21/000.00) 19. FAA Retirement $122/166.96 Plaintiff 25. Contents of Home $ 10/000.00 P1aintif f and Defendant NON MARIT~ PROPERiX Item No. D8soriDtion of PrODertv aeason for Exolusion 5. Checking Account-Financial Trust ($400.00) 6. Savings Account-Financial Trust ($1/200.00) Post separation Post Separation l ~A6T MA'N 6TAE~T 6H'R~MANGTOWN,PA 17011 'lfiomas'D. (joutif ArrORNIIYAnAW 17171 731'I~QI FAX 7el.I~7~ December 16, 1999 Gr~gor.y R. Reed, Eoquire 2423 N. Third Street Harrisburgt ~A 17110 ReI Adkins v. Adkins No. 97-6329 CtVIL TERM ;j.u.:.r Mr. Reed: , Enclo~ed is the Divorce Master's transcript for your a~d Mr.. Ad~ins' signature. You are to forward a full~ executed copy to th~ ~1(1ster. Once it is filed with the ProthonotHY ! can Hle the documents necessary to complete the divorce and prepare th'l QDRr,) far the TS~ and penslon. . ~lease contact me.if YOIl have any questio>\s. Sincerely, .~'l4D.~ Thomas D. GOlllrJ ce. E. Robert Elicker, It Hannah Adkllis ., " " HANNAH ADKINS PlaintIff IN Tllli: (;OUR'l' O~' COMMON PLIi:AS OF. CUMI3E:RLAND COUNTY, pmNNSYLVANIA NO. 97 - 6329 CIVIL, VS. GARY EDWARD ADKINS, Defendant IN DtVORCE: ORDEI\ OF COURT . ., ~ AND NOW,' this _~ day of 2000, the parties and counsp,l having entered into an 'agreement and stipula~ion resolving the economic issues on ,October 28, 1999, the date set for a Master's hearing, , the agreement and stipulation having been transcribed, and subsequently signed by the parties and counselr the ,appointment of the Master is vacated, and counsel can conclude the proceedings by the filing of a praecipe to , trans'mit the record with the affidavits of consent of the parties so that a final decree in divorce can be entered. BY THE COURT, cc: , Thomalj D. Gould . Attorney for Plaintiff GrelJory R. Reed Attorney. for Defendant ~~ . !-/.J'tJO. . RK~ P.J. :t ..~ . ~ II," '11 ~: " &.:; " lit' .. ,j-1 , -', I')"'; II' I' ~-,. I"" it; ;. ) ;.:i~ , l:t:J .~ I, I", ,'j "'I';j ... I' t I ',,) ,','" ',lie :':1 d ',) II " " [ claims were ralsod for alimony and counsel fOOB nnd costs. The parties wore mnrried on December 11, ~976, ~nd separated in late December 1996. They are the natural parents,of throe children. The two daughters are minors and they sharo time with both parents and the parents have joint custody. The son lives with the father and will be l6 years of ago on October 31, 1999. After negotiations this morning, the Master has been advised that the parties have reached an agreement with respect to the economic claim of equitable distribution. Counsel are going to place on the recordr in the presence of the parties,' the agreement. The agreement, as placed, on the record will be considered the substantive agreement of the parties not subject any changes or modifications except for correction of typographical errors which may be made during the transcription. After the agreement has been transcribed, the parties and cou~sel can review the document for typographical errors, make any correctio,ns as necessary" and then ,affix their signatures by way of affirmation of the terms of the agreement that are stated on the record at' this time. Even if the agreement is not signed by counsel and the parties, they will be bound by the terms of the agreement and there will be no substantive changes permitted after the parties and counsel leave the hearing room today. lIIarital home but th,1t dudflion will bu up to thu Plaintiff, Th(j Plaintiff will givo thu DLJfundant u note for $15,500.00 which will be placed againflt the marital reilidonce. There will be no interost on thill note. 3. Plaintiff will alllo pay to Defendant a po'rUon of her federal pension il(jt up throu~h a Qualified Domeiltic Relutions Order or 110mB other acceptabl(j means to the federal pension plan. The amount will be calculated by taking the Plaintiff's monthly benofit amount, multiplying that by 701, multiplying that number by a fraction which would have the numerator as 20 and the denominator as the number of years that the Plaintiff has qualified service and thon multiplyi,ng thut number by 50'1,. That numher w.lll reflect the portion of the amount that the Defendant is entitled to receive from Plaintiff I s federal pension. ,The Defendant"s portion, 'in the 'event of his death, will be paid to his designated benefi~iary. 4. The parties pr.eviously distributed between themselves the tangible household personal property and vehicles and the accounts of money representing intangible assets. Each party will retain the tangible and intangible personal property previously received as his or her sole and separate property free of any claims of the other party. 5. Husband shall transfer all interest he has in the marital home by fee simple deed or quitclaim deed to wife. Such transfer will be effective upon the receipt of the $15,500.00 previously mentioned. 6. The parties agree -that they w.i 11 execute any documents necessary to transfer the t.itle to either the home, vehicles, or any other personal property or real ~roperty that they ~ay'have consistent w.ith tnis agr.eement. 7. Pla.intiff's counsel will prepare a Qualified Domestic Relations Order for review by Defendant's counsel for the purpose of the transfer of the thrift sav.ings plan and th~ pension. ,8. Except as herein otherwise provided, each Party may 'dispose of his 'or her property in any way and each party hereby waives and relinquishes any and, all rights he or she may now have or hereafter acquire under the present or future laws of any jurisdiction. to share in the property or the estate of the other as a result of the marital relat.ionship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to ""k.. II 'I iI I 11/11, I; IllI Will I) t; thu othqr, and right t.o act as i1lhlllllijlltJ dl.,)/: III OX<tclIl.or In the other's estate. Each will ,II, ,1h,! I.U'IIIIIIlt 01 1.110 lltl1ul;' UXr3cutG, acknowledge, and dllllvul.' IIIlY iIIld i\ 11 I.lIutrllmontfl which may be necessary or i1dVIHilhLu to cnrry Lnto uEfoct this mutual waiver and rlll,ln'lIlLuh/llunt or .111 ,Huch .interest, rights, and claims. 'l'IW: MMl'n:l\: Mrs. Adkinsr have you been prlHlullt dlll: LIIV UW tltfltomont of the agreement on the record? Mf\~l. AlJl<rNs: Yes. '1'1 iii: MAS'n~l\: Po you understand the agreement nil rJtlltud on tho record? MI~S'.' ADKINS: Yes. 'l'IIE: MAS'l'ER: And it i6 your intention to rusolVe tHo equitable distributi~n claim pursuant to the , terma or the aqrupment as stated on the record? MRS. ADKINS: Yes, it is. 'rHE MAS'rEH: Do you understand that when you funve heio todaYr whether you siqn the agreement or notr you ore bOUhd, by th,<!l terms of LIte agreement? MRS. ADKINS: Yes, I do. THE: MASTER: Mr. Adkins, have you been proson~ during the s~atement of the ~greement? MR. ADKINS: Yes, I have. THE MASTER: Do you understand the te.J;'ms of thq agreemen,t? MR. ADKINS: Yes. THE MASTER: And do you want the terms'of the . . agreement as stated to be a final and full settlement of t~e , equitable distribution claim in this casa? MR, ADRINSI Yes, I do. nlE; MAs'rER~ And do you understand that when , you leave her~ todaYr whether or not you sign the agreement, you are bound by the terms of the agreement? MR. ADRINS~ Yes, I do. I acknowledge that t have read the abov~ stipulation and agreement, that I understand the terms qf settlement as set forth herein, and that by signing ~elow t ratify and affirm the agreement previously made and intend to bind myself to the settlement as a contract obligating . myself to the terms of settlement and subjecting myself to the methods and procedures of enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. , I WITNF.:SSI DATE: ~4#~,~~ Thomas D.Gould Attorney for Plaintiff ~~ G",o,k R"d . '_ Attorney for Defendant I J. -I$"- ~? , . '/'J /', fJ_ ' , J-fb...~lkJLl'C~,-,> Hannah Adkins I~ I ?'/0? VS, HI THE: COURT Of COM!>ION PLEiI.S Of CUMBERLAND COUNT'{, l?ENNS'ftNANtJl. NO. 97 ~ 6329 CtV!L HANNAH APKtNS, Plaintiff GARY EDWARD ADK!NS, Defendant !N D!VORCE THE: MASTERI Today is Thu~sday, Octob~~ 26, 1999, ,This is the date set fo~ a Maste~'s hea~ing i~ the above captioned divorce proceedings. P~esent a~e the Plaintiff; Hannah Adkins, and he~ counsel Thomas D. Gould, and the Defendant, Gary Edwa~d Adkins, and his counse: Gregory R. Reed. This action was commenced by the filing of a diverce complaint on NO'/ernbe~ ),4, 1997, ~aising g~ouncis for divorce of irret~ievable breakdown of the ma~riage. :he parties h~ve provided the Master with afiidavits of consent and waive~s of notice of intention to ~equest entry 0: divorce dec~ee which have been signed and dated today. The Master's office will file the affidavits and waivers. M~. Gould has also provided the Master with an a~eeptance of service 0 f the complaint in divorce signed by Nt. .ll.dkins. The Maste~'s'office will also file the acceptance of service of the complaint. The complaint did not raise any economic e~aimsl howeve~, on January 7, 1999, the Defendant husband filed an answe~ and counterclaim and in the counterclaim raised the economic issue of. equitable distribution. No claims were raised for al imony and counsel fees and coats. , The parties were married on Pecember 11, 1976, and separated in late Pecember 1996. They are the na~ura1 'parents of three children. Th'.! t'IIO daughters are minors and they share time with both parents and the parents have joint custody. The son liv'.!s with the father and will be 16 years 0 f age on October 31, 1999. After negotiations this morning, the, ~!aster has been advised that the parties have r'.!ached an agre'.!ment with respect to the economic claim of eqUitable distribution. Counsel are going to place on the record, in the presence of the parties, the agreement. The agreement as placed on the record will be considered the substantive agreement of the parties not subject any changes or modifications except for correction of typographical errors which may b~ made during the transcription. After 'the agreement has be~n transcribed, the parties and counsel can review the document for typographical errors, make any corrections as necessary, and'then affix their signatures by way of affirmation of the terms of the agreement that are st~ted on the record at this time. Even if the a7reement. is not signed by counsel and the parties, they will be bound by ~he terms of th~ agreeme~t and there will be no substantive changes permitted after the parties and counsel leave the hearing room today. Atce~ the ag~eemenc has been ~etu~ned to the Maste~'~ office, the Maste~ will prepare a~ ~rder vacating his appointmenc and counsel can p~epare a praecipe transmitting the reeo~d to the Court requesting the entry of I a final decree in divo~ee. Also, it is likely that. counsel, afte1." the statement of the agreement on the record, will have certain document~ that will have to be p~epa~ed in order to , , accomplish the te~ms of the settlement. If a Qualified Domestic Relations O~der is ~equi~ed, the Jrder can be J presented to the Cou~t at any time following the ent~y of a divo~ce decree fo~ finalization of the , terms of settlement with resP"lct to the pension a::d r.ollover of any monies from the thrift savings plan. Mr. Gould. MR. GOULD: The pa~ties have agreed in an effort to resolve the equitab:e distribution of the marital asset;sto the .fo'llowing: 1. The ~laintiff has agreed to pay the Defendant ,the sum of $10,000.00 from he~ thrift sa',ings plan' either by a Qualified Domestic Relations Order or some other acceptable means from the thrift savings plan that she has. The money from the thrift savings plan will be rolled into an account selected by husband for the transfer so as there is no tax consequence to the ?laintiff or to the Defendant if ~e so chooses to leave the money in th.e account. This transfer will be accomplished within thirty (30) days of today's date. . 2. In addition, the ~laintiff will pay the Defendant the sum of $15,500.00 within six months. It is anticipated that this money would be as a result of the sale of the marital home but that decLeion will be up to the Plaintiff. The E'laintiff will give the Defendant a not.e fo~ $l5,500.00 which will be placed against the marital residence, There will be no interest. on t.his note. 3. E'laintiff will also pay to Defendant a porti~n of her federal pension set up through a Qualifieq Domestic Relations Order or Bome other acceptable means t.o the federal pension plan. The amount will be calculated by taking the Plaintif"s monthly benefit amount, multiplying that by 70%, multiplying that number by a fraction which wouid have the numerator a~ 20 and t.he denominator as the number of years that .the Plaintiff has qualified service and then mUltiplying that number by 50~. Th"t number will reflect the portion of the amount t.hat the Defendant is entitled to receive from Plaintiff's federal pension, The Defendant.'s portion, in the event of his death, will be paid to his designated b~nefieiary. 4. The parties pJ:'eviou5ly distributed bet'/leen themselves the tangible household peJ:'50nal pJ:'operty and vehicles and the accounts of money J:'epresenting intangible assets. Each party will retain t.he tangible and intangible personal prope~ty pJ:'eviously received as'his or her sole and s,eparat.e pJ:'operty free of any claims of the other party. 5. Husband shall transfer all interest. he has in the , marital. home by fee simple deed OJ:' quitclaim deed to wife, Such transfeJ:' will be effective upon the J:'eceipt of the $15,500.00 previously mentioned. 6. The paJ:'ties agJ:'ee that. they will execute any documents necessary to tJ:'ansfer the title to eitheJ:' the home, vehicles, OJ:' any other peJ:'sonal propElJ:'ty OJ:' J:'eal pJ:'opeJ:'ty that they may have consist.ent With this agJ:'eement. 7. Plaintiff's counsel will pJ:'epare a Qualified Domestic Relations OJ:'deJ:' for review by Defendant' 5, counsel far the pUJ:'pose of the tJ:'ansfeJ:' of the thJ:'ift savings plan and. the pension. 8. Except as heJ:'ein otheJ:'wi~epJ:'ovided, each paJ:'ty may dispose of his OJ:' heJ:' ~ropeJ:'ty in any way and each par.ty heJ:'eby ,waives 'and J:'elinquishes any and all J:'ights he OJ:' she may now have or heJ:'eafteJ:' acquiJ:'El under the pJ:'esent OJ:' . fut.ure laws of any jurisdiction to share in the pJ:'operty OJ:' the estate of the other as a result of the marital ~elationship including without limitation, statutoJ:'Y allowance, widow's allowaneer right of intestacy, right to agreement as stated to be a final and full settlement of the equitable distribution claim in this case? MR. ADKINS I Yes, I do. THE MASTERI And do you understand that when you le~ve here today, whether or. not you sign the agreement, you ~re bound by the terms of the agreement? MR. ADKtNSI Yes, I do. , I acknowledge tha~ I have read the above stipulation and agreement, that I understand the terms of s.ttlement as set forth herein, and that by signing below I ratify and affirm the agreement previously made and intend to bind mY3elf to the settlement as a contract obligating myself to the terms ,of settlement and subjecting myself co the methods and procedures ef enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. WITNESS I PATEl ~.uP)_x!J_I/ Thomas D. Gould Attorney for ~laintiEE ~ f...."? ' .1-fJa..-......... t'l L,'- lA::k-~~ Hannah Adkins , 12-loS"- ,? Gregory R. Reed Attorney for Defendant Gary Edward Adkins . .., 6. 'l'ho Pilrt!.oB have Btl.puli.ltod lh'lt thu wltll!.n Ql.wllfl.od Rotiram~nt Honofits Order refLoctH their ilgroomdnl. Wm1R~:I:'OI~mr PlaintIff respecl:fuL Ly rotjl.losta that tllIH Honorablfl , Court enter tho wIthin Qual!.fLod Retiromont Donof!.ts Order. , ReBpoctfu~ly sl.lbmlttodl D<l ted -1./puL.2..'7;..JQJlJl. ~~~ 'l'homas D. Gould 2 East Main Stroet 'Shiremanstownr PA 170ll (717) 731-1461 r. D. /136508 ^~torney For PLaintiff VERIFICATION If Hannah ^dkin~1 hereby swear and affirm that the fa<:ts contained iri the foregoing Request for E:ntry of il QUaliqed , , Retirement Benefits Court Order are true and correct ilnd are ~ade subj ect to the penalties of 18 Pa. C. S. Sec. 4904 rela ting to unsworn fa~sification td authorities. Date:-i0'~}O() lp, ' ',' (" ('1 c'-.....,,"-t~~...,t Cl.v'<'l Hannah Adkins . APR 2 4 20~~ HANNAH AIlKI~~, li'eU t:ioner r I~'THm COURT or COMMO~ PLmAS CUNBIBRLl\NP COUNTY, PJllNNSYLV1\NIA ~o. 97~6329 CIVIL TIBRM VI. GARY IBDWARD APKINS, Relpondent CIVIL ACTION - ~W IN DIVORCPl QUALIrIIBD RmTt~NT BENErI~S ORDER 1. This Order is being entered in conjunction with a Pecree in Pivoreel the Court intends this Order to bea Qualified Retirement Benefits Court Order ("Q~BCO"). 2. This Order creates and recognizes the existence of the Alternate Payee' B right to rece~ve a portion of ,the Thrift Savings Plan (TSP) benefits payable with respect to the Participant. 3. This QRBCO relltes to the provision of marital property rights to the 'Alternate Payee as a result of ' a marital settlement agreement entered into by' the parties' on' October 28, 1999. A Decree in Divur~B was entered on February 2, 2000. 4. This QDRO applies ~othe Thiift SaVings ~lan account held for Hannah Adkins ("91an") by the Federal Retirement Thrift Investment Board and any successor thereto., Hannah Adkins ("Participant") is ,a Participant in the Plan. Gary Edward Adkins ("Alternate Payee") is the Alternate Payee for purposes of this QRBCO. 10. In the l;lvent that the 'Pflrticipllnt die/! prior to the eatablishment of ~ separate accoUnt Ln the name of the Alternate Payee, such Alti.lrnate Payeo shall be treated as thlil B1,Irviving apouse of the Participant for any death bGnefits payable under the Plan to the full extent of the full amount of his benef.its as called for under Paragraph 7 of thia Order. Should Participant predecease the Alternate Payee aner t.he new, flccount has been I established on his behalfr such Participant's death shall in no way affect Alternate Payee's right to' the portion or' his benef1ts as stipulated herein. 11. This Order is not intendedr and shall not be construed in such a manner as to require the Plan,to: a. provide any type,or form of berefit not otherwise provided under the terms of the Plan: 'j . I b. require the Plan to provide increased benefits; or c. require the payment of any benefits to 'the Alternate Payee that are roqui~ed to be paid to another alternate payee under another order that, was previously deemed to be a ORBCO, 12. ~ll payments made pur~uant to this Order shall be conditioned on the certification by the ,Alternate Payee and the Participant to the Plan Admlnistrator'of such information as the Plan Administrator may reaso,nably require from su'ch parti'es. 13. It 1.13 the intontl,on Qf, tho partlol3' that this ORBCO contlnue to qualHy al3 a ORBeO under !l U.B.C. !/B435(d) (1) (2) and section 8467, as it may be amended from time to time. 14. In the event that the Plan lnadvertently pays to the Participant any beneflts that are, al3sJ,gned to the Alternate Payee pursuant co ti.e' t"1rlll13 of thill QHElCur the Participant shall immediately reimburse the Alternate Payee to the extent tha~ she has recelved such benefit ,paymentsr and shall forthwith pay such amounts so received directly to the Alternate Payee within ten days , of receipt. 111 the event the Plan inadvertently pays to the Alternate Payee any benefits that are riot assignfld to him pursuant to the terms of this QRBCO, the Alternate Payee shall immediately reimburse the Par;tic,1.pant to toe extent he has received such ,benefit payments and shall forthwith pay such amount~ so received directly to the Participant within ten days of receipt. 15. In the event of a Plan terminationr the'Alternate Payee shall be ~ntltled to re~eive his portiun of Participant's benefits as stipulated herein in accordance' with the Plan's termination provisions for. participants and beneficiar.ies. , 16. 'The Alternate Payee assumes sole responsibility for the , tax consequences of the dicitribution under this QRBCO.; 17. The Plan Administrator shall piomptly notify the Participant and the Alternate Payee of the receipt of this QRBeO " ilnd StJilll. not ify thn Pilrttcipant and the ALtornate Payee of tho PIon' B procedllros for dot(Jrm1ntng the qualHIod. status of th1s QRBCO. The P~an AdminIstrator shall determIno the qualIfIed ~tatus of the QRBCO and shall notHv tho Pilrt.iclpant and .the Alternate Payee of the determInation wIthIn a reasonable perIbdof time after r.eceipt of this QRBCO. The Court retaIns judsd1ction over this matter as provided by , litw. We stipulate that the foregoing is our Agreement and requeit tha,t it be approved ',and entered as an Order of Court. \-8.:.~(,-- C1:l k':~'-" Hannah Adkins ' ))..In .-- L!{~ AdkJ.ns ADOPTED AND APPROVED AS AN ORDER BY 'l'HE CO R ': ftr'( ').tf , ~ J. '-I. ). I, - O() ?t'f~I\.J(.~:'; (fJlcL ...~) .tn-d' G;o--lL('L . b.. La.. 07,) 1v...1L(.~..c j{()J~,e..e.-