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Home My WebLink About06-01-06 (2) , --.J 15056041169 REV -1500 EX (06-05) ~~ciRaverue Bl.reaJ ci IrdviduaI Taxes FQ8a<~1 H:rTisblJg, ~ 17128-(0)1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year a I ()(O File Number IX),? q Date of Birth 251-48-0036 01202006 Decedent's Last Name Suffix Decedent's First Name SAUSSAMAN BEATRICE MI B (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW !Xl 1. Original Return D 4. Limited Estate IX] 6. Decedent Died Testate (Attach Copy of Will) D 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach Copy of Trust) D 10. Spousal Poverty Credit (date of death D 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D D 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ALLEN W. SAUSSAMAN, JR. Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address ,-....) .-:-::> :::'::'J u....... City or Post Office State ZIP Code OA~ FILED -~ '., f~ c::> =.i:J -- ~~ )" b :~ f'l -If () . rn 781 LANCASTER AVENUE Second line of address ::"::i# ENOLA PA 17025 w w Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG T OF PERS RESPONSIBLE FOR FILING RETURN DATE 05 -/1 06 ADDRESS 781 LANCASTER AVENUE, ENOLA, PA 17025 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041169 15056041169 --.J ---I 15056042160 REV-1500 EX Decedent's Name: BEATRICE B SAUSSAMAN RECAPITULATION 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) D Separate Billing Requested. . . . . .. 7. 8. Total Gross Assets (total Lines 1 - 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . . . . . . . . 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .. . . . . . . . . . . . .. 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 11. 12. Net Value of Estate (Line 8 minus Line 11). . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . .. 13. 14. Net Value Subjectto Tax (Line 12 minus Line 13). .. " . .. . .. . .. . . .. . .. ... 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0_ 16. Amount of Line 14 taxable at lineal rate x .0~5 17. Amount of Line 14 taxable at sibling rate x .12 18. Amount of Line 14 taxable at collateral rate x .15 15. 7,642.26 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042160 Decedent's Social Security Number 251-48-0036 151,000.00 0.00 0.00 0.00 35,386.81 0.00 0.00 186,386.81 12,264.35 4,294.54 16,558.89 169,827.92 0.00 169,827.92 0.00 0.00 0.00 0.00 7,652.26 IXI 15056042160 ---I REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 0 6 - 0 7 9 DECEDENT'S NAME BEATRICE B. SAUSSAMAN STREET ADDRESS 205 THIRD STREET CITY -\ STATE I ZIP SUMMERDALE PA 17093 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 7,652.26 7.500.00 375.00 Total Credits (A + B + C) (2) 7,875.00 3. Interest/Penalty if applicable D. Interest E. Penalty 7,875.00 TotallnterestlPenalty (D + E) (3) 4. If Line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 232.74 B. Enter the total of line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. \Xl 0 b. retain the right to designate who shall use the property transferred or its income: . . . . . . . . . . . . . . . . . . ., 0 ~ c. retain a reversionary interest; or ......................"...,............................. 0 ~ d. receive the promise for life of either payments, benefits or care? ..........,.................,... 0 ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 0 lXI 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? , . . .. 0 lXI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 !XI IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. 99116(a)(1.1.)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. 99116(a)(1.1 )(ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ESTATE OF BEATRICE B. SAUSSAMAN 21-06-079 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchange between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. SCHEDULE A REAL ESTATE ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 151,000.00 205 THIRD STREET SUMMERDALE, PA 17093 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 151,000.00 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ESTATE OF BEATRICE B. SAUSSAMAN FILE NUMBER 21-06-079 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 2 3 4 DESCRIPTION VALUE AT DATE OF DEATH 21,225.79 1,682.41 11,569.50 909.11 PNC NATIONWIDE PNC AMERICHOICE TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 35,386.81 REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ESTATE OF BEATRICE B. SAUSSAMAN Debts of decedent must be reported on Schedule I. FILE NUMBER 21-06-079 ITEM NUMBER DESCRIPTION AMOUNT A. FUNDERAL EXPENSES: 1. RICHARDSON FUNERAL 5,245.00 FUNERAL LUNCHEON AND CHURCH B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Add ress City State - ZIP Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State - ZIP Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. See attached sheet 7,019.35 TOTAL (Also enter on line 9, Recapitulation) $ 12,264.35 (If more space is needed, insert additional sheets of the same size) ESTATE OF BEATRICE B. SAUSSAMAN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Patriot News $161.16 Law Journal $ 75.00 Short Certificate - stamps $ 99.32 Wolfe & Shearer - appraiser $250.00 Jon Saussaman - advertise $ 51.50 Enola Borough - sewer $115.00 East Pennsboro - real estate taxes $337.96 PP&L $ 38.77 PA Am. Water $ 18.64 Jane Biddle, Tax Preparation $ 40.00 Internal Revenue Service - 2005 tax $263.00 Susquehanna Medicine $124.00 Maronetta Miller $200.00 123702. I 4/28/06 -1- REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ESTATE OF BEATRICE B. SAUSSAMAN FILE NUMBER 21-06-079 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE DESCRIPTION OF DEATH ITEM NUMBER 1. 2. 3 . 4. 5. 6 . 7. 8 . 9. 10. 11. JON SAUSSAMAN VERIZON ATT VERIZON ENOLA SEWER-TRASH NATIONWIDE-HOMEOWNERS PA AM. WATER PPL SENTINEL BEVERLY HEALTH SOCIAL SECURITY 65.00 168.45 149.63 167.29 126.50 413.00 47.15 56.53 107.99 1,105.00 1,888.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4,294.54 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES FILE NUMBER 21-06-079 ESTATE OF ESTATE OF BEATRICE B. SAUSSAMAN RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAMEAND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1. ALLEN W. SAUSSAMAN SON 1/4 RESIDUE 2. DEBORAH A. MARTZ DAUGHTER 1/4 RESIDUE 3. JOAN L. EICHELBERGER DAUGHTER 1/4 RESIDUE 4 . JON R. SAUSSAMAN SON 1/4 RESIDUE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) o PNCBAN< 040 ENOLA (108) 235 NORTH ENOLA ROAD ENOLA PA 17025 Cashbox 04 * Deposit Multi/Mix 11:10 FEB212006 Account Number 5004147598 Tran Amount $909. 11 Cash Amount $0.00 W/S 10 WWSH1083 Sequence Number 00281 Batch 303 This deposit or paYlent is accepted subject to verification and to the rules and regulations of this bank. Deposits lay not be avaUable for iuediate withdrawal. Receipt should be held until verified with your stBtelent. o PNCBAN< 040 HAMPDEN (117) 4242 CARLISLE PIKE . C'AMP HILL PA 11011 Cashbox 01 * Deposit Check 10:14 MAR 14 2006 Account Number Tran Amount 5004147598 $21 J 225 .79 WIS IO.WWSHl171 Sequence Number 00021 Batch 401 This deposit or Ply.ent is Iccepted subiect to verification and to the rules and regulations of this bank. Deposits lay not be lIvlIilllble for i..ediste withdrallal. Receipt should be held until verified III th your stlltelent. ," Received 11/10/2004 09:21AM in 01 :28 on line [15] for 3068 * Pg 2/4 ,ov 10 04 09~5Be Tom Conrad (717) 2B5-0720 p.2 I office addr'us of rht: wit. 1933S. " L5..& J'LZ,;:,.."..,J ($ , :>s. Jr. DJ;.J:D - .... ROO E Po T ..r_ZL~U.~I\.L"""""""T. ~". REOORDER OF OEEOS .~ CUMBE~LANO COUNTY-PA ) ~ ,,; - ;~, ( l;' .'. .~. ,~_I \. ")"r__ 1fiqi5 ~.e.eb:92 ~~.~ ~l RI') 11 '37 C ---==-" ('_-.'/") day of -JffII ,-..:.-.'" ~"'I, ....... RINF.TY-TWO <~99~) BEN ~. ~~A~nXCE OAVaSAMAN. Wldoy. o~ S~mme~~A~a. ~&nt Pennobor. Tovn.h1p~ Cumber1~nd Coun~Y7 ~Gnn~y1v&n~&~ here1n~rter rer.rrwd t.o o.~ "CnANTOn" -^ND~ idtll seal, AL~EN w. ~AUaC^M^N, In.. D~nOn^)l (nee: CAUGSAMAN) MARTZ; JOAN ~~Tlce: GAunSAMAN} ;B:l.CHl!;LH.I!;Rli.l';R; .Ud .,JON ll. bAUb~.AMJ\.I.'I, "A!I Join't Tenantl!l .t.I:t~U THE IlICU'J,' OF s'UnVXV'ORsJ.t:r.~I"' b.~~:tn';'fie"r 1."C 1':0"1:' 1:' e d 't 0 "l'J .. c;; n AlIl"l'XF:r." ./ ~'Wl'tMESSETH. "rh<<t [n consIderation ot ONE ($~. 00) DOLL.I\~ IJLnd. N&.turD.~ Love ,t' o."nd ^:ft:e ct:Lon ------------------------------------------ IDI>Kd'rl ~"'d paid. the receipt whereQf is hereby acknowledged. the said g.-antol' i" ~nvey to the said granleq, , do e:2 hCl'eby gl'.;l ~. ""h.--; ~ or p~~e~1(s) or ~and ~~tua~e ~n ~8~~~crdB1c. To~n"h1p or En~~ Pwnnnboro. CUMbQr~~n4 County, '.- J'cnn!Jy1va.n~A. bound..d and cloDor1"b.,a r.l.1'I 1'01.10W'b. 'to wi.t: ~~ ~> wrillcn. nROINNXNO ~b ~ poin~ on thQ WOO~ "lC~ 01' ~hird a~rr~~ .~..,t the Northeo.s-t. corner 01: t.hllJ d:tv~d:inl: 1i.ne be~'Wecn Lot!! Nos. ":'~ 81 il.t'ld 82 on t.he hercinr;a.rtr.:-r mont:loned P1a.n. Zlnj,d pOint a1:Jo "..:.''be1ng ninety (90) :feQ'~ North or the Nor'thvcst corner ot' '1'h1rd 8tr~et And a ~~xteen (16) fft~t wide ~llcy; ~UENCE in a. we:Jterl.~ ~411."o~tlon Glong ft_ld dividing 11nc between Lot~ Non. 61 o.nd 32. .. on.~ hu.ndr.,d, ...k'lCl tJixty (1.60) {'eet to eo sixt.een (16) r..1: ",:ide alloy; TrrENC~ in B north~r1y d~Toctlon ~l.on~ tb~ cR~tcrn ~~nQ . or said ~1~oy. one hundr.d and ~wenty (120) ~eet 'to a po~nt on \the divldln~ 1~n~ bc~w~en Lot~ No~. 85 and 86 on th~ hftr~inar~cr .en"tionc:d p1a.n; TJlJ':nCE ~n all elUJ borl.y (U.r.c t;lon al.on(S llJtl.id 41vlding 11no. one hundr~4 ~ix~y (100) ~~et to & po~nt on the lI~lSt oidQ ot Thir<l Gtrec'" i THENCE ~J.onlZ "thQ DIUIO 1n 1.1. ::Iou.thcx-l.y direetion, one hundrG~ "twenty (120) ree~ "to G po~nt. ~he p~~c. l>vlj:o;W35 r/.C.E 579 I. ~cl Book ? "'--' ;78 / /" f ~v / :10, 10 0... , ~.'" 1,... . , , : , I . . ;: ; :! !. . ~. ,: ; !~ .1. I. . I~~ : . 'i::: . I .~ I' Received 11/10/2004 09:21AM in OS; S8a Tom Conrad 01 :28 on line r15J for 3068 * Pg 3/4 (717J 285-0720 P.3 ~=- .~ ~:.,.:... ;: ;.: o-r B1l;QXNNING. ... . ~ , , . .. '- n~'INC Lot.". If,>%!. 82, Ij~. 04 aod 85, Sect.ioo """.11\ the P1an or S~m~erdAle. 5414 p1an b~1ng r~co~aQd ~n P1~n Book 1, P.8~ 4~. and h~vlns ~rect~d theroon on Lo~ No. 83. A two ~nd onc-hAlr ~tory CrA~e Owo1~ip~ house, knovp APd numbered AD 205 ~h1.d SLrce~. Summbrda1u. P~nnoy~v~n1a.. \.ll.lu~W35 r:,~[ IH:i'ING TUB SAME' PARCELS or l.a.nd vhS-ch the Orl1n-tor. B. U~ATRtcm SAUGnAMAN. ~nd her bu~b~n~. ALLEN W. SAUSSAMAN, roceivod by d~Cld :trom ALL1=lN W. ~All:Jl3AM^N' 1J IDu1.hur. ~ARAH O. SAUSOAMAN. WidOW. on -the 28th d~y or ^pri~ 1960. n~ v~l.l mQro ~~l1y appo~r o~ rocord. &n recorded in the Cumber~~nd Co~n-ty Courthou:!o.;). t\",cok'dc:r o~ Dccdn Ot;1'1co. 111 Deed Dook "U", V01. l~. Page 2177. AS re~orl1ed on thu 11.t1'\ d4J.Y o~ MAY ),,960. ^1.L~N 'IN. SA p4J.uDad Q.way on 21day oX Apri1 1992. D. U~^rR1C~ ~~USUAMAN. Cr~ntor. h~~oby reaervoa ~or her.:<e1.!' A. "L:tl'~E ~~'1'AT1!:" .1.n1..t)r~o't.. 'rIns IS A (;OJfVE~ANCE FXlOM MO'I'.lJ:r;:n to CJlILDR1!:N an(\. .0 .u~h T"K~HVOk~. ~X~M~T VhO~ VENNOYLVANIA HE^LT~ ~RANSFER TAX. 580 on" A ". .:L n ~!.n.n Dook. :1..',. ... ~vo And. orcd II.S Oran1:;or. USSAMAl'f. SARAH O. ,,1.11 J'Qo~Ct nd Coun~y "U". Vol.. 1.9. ALLEN W. SAUSS ~ e:rvea tor .d at! ouoh ~s. ~'SFER TAX. Received 11/10/2004 09:21AM in 01:28 on line [15] for 3068 * Pg 4/4 04 OSs5Ba Tom Conrad (717J 285-0720 p.4 will ~p~ci.1\1ly WARRAN'r ANI) r:'-OREVfiR, DnFfiND th~ pt'opcrty ~ IN WITNuSS WHEREOF, sl'Iid SI'(\Il'('tf hn ~ here\l ."..., set }1 " r h:Uld :t nd lOcal . the ~ 4 ~~'J9_' 7~.c......ue:'''.4__ [.ern'. .~.. ~~~fc'lr"'gf~~'A:M'A'~""'-"""" Vo' . . .. .. . . . .. . . .. . . .. . .. , , . . .. . . , . . . . . . . . . . . .. . . .. . . .. . . . . . '" 1$1'111 I . . . __... _' .. . ... . .. ..... . . .. . . .. . .. .... . . . .. . ..... ..., . ..... [jJ..t J .. ... ... . .. . . . .. . . .. . . .. . . . . . . .. . .. .. .. .. ...... . .. , . " .... .. ($,,"IJ . ..,..... . .. . .......... .., . ..... ...., . .. ... . .., , .. .. .... .. . . [$~.(1 .. .. .. .. . . ... . . . ~ . . . . .. . .. . . . . .. . .. . _ . . .. . .. . , .. . .. . .. . . .. .. [$....1 ) i: CElt'rXFXCATE OF/n~JDENCE . .... Jlf~' 'f:.~~~ - . ~~. I hereby cer\~ry. thlU the prccl5c residence of tllC.glllW\t .., herein is ;U~~Wl<:'\ . .' ,\'(~~C ,.\--t~ GU~...lt h1'l",-S' ~ (. ..1 ,_:.' -h> '\3 .:i~t~:=t (r.. C4..- ;5;:::..... ~~ '-"'. -+J~J,..... ::.. ..,.. ".:.' .. . .. . .. :. ., L ...... .-. .. . .... .. .... ........ ". -oM 20:-- 1... ./1.....'( .~? oJ . :3 .__ ..-"--- ^'U"""T'" ^,,~~ t... (;'....,.... ~>' .')\. "'. ~"",,,.(.""S;.Q. ( 1:). J (, ,_ .~ - Yo B~x 1'3 '3 ..-...-....... } ..- S~~, ~. ie.n<lcrsigncd officer. personAlly I\rp~i\r~d ". lltutlllhll ,,1 J1'C'II"1l'llh111I1i" COMD1';RJ~I\N'P m .................. ......... .... -~ ..5 <.l;\y of . toht: t.'l 19 l~ before me n. no~~ry pu'!:>3.:l,e. D. nE^TRIC~ SI\USSAMAN. Widov Wom~n.' whose nnme 1. co ~ubsetibad to the within executed the ~nmc foJ' th~ p\lrp<>><> therein f~:(;~:~~~~~i1j ;..~ :' t!' ~~nl~.'J rr ~~~~. .,:~:() . ~$ . " G :. ',' . ~iSte,.., ........\- ..J..h;h;..."~J1tt1.p.~.~ .... .~~.:i."c'c"' ---I ';".\C'~'i,."" I t"'~:Ei;~~~t~~~:1~:.~~~:~F?,:.; . ":"'j MtII.t.c't. p~~~~'I~;;; t)!'r1cie.l Commis~ion nlCl'ircl .... ./.l l'l-.Ihik.... ....,. hereunto JOel my h:II'ld :and . ~ ~.( !l .~~)..&:~. .... ... IN WITNSSS WH 1'1RI!OI'. J hnve UvU~ Wi 5 r,..~t 581.