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Home My WebLink About98-03564 J .., .:s o ~ t) ~ \J '" ~ o Cj 1\ ~ I I I \ t t I \. !~ I, n i~ i l~ ld' I "-J ! t' \c) ..1 l'n: , . JI , < Il .; "j , ~i ""I j ~ ~1 ""."..\ "'.'",;' :,..... . ...'.-, " , " , ,..... " ... ...-, . ~:t-:."':.:" -.:+:...:+:.'.:+:,' ':..' -:+;.~,,~..:~. .:+:. .:+:. -:.:. .:+~. .:.:. -:+:. ':+:. -:+:. -:+:. .:+;. ,:.:'-:",-:.;.::.:.;~::-:.:.:.~..:.,;.:.:. .:.:.-:.:.:.:.:<:.:.:<:-;~ ~ -...-- ----~..- ------..-...- .... ----...-..... ,'. ~ , ~ ~ ? ~ ,', ~ ~ ~ ~.~ ~ '.' ~ :< ~ ... ~ ~.~ ~ ',0 ~ ~.~ ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY STATE OF t;1f ~l^~ 1~,;;;'~J;~;: \""~"'.?"'I-- " ,.--.{"---;;", PENNA, ~ ,', ~ ~ ......SANDRAR. GOUSE PLAINTIFF 98-3564 2001 ['; (). .....,....,.... 19 Vpr'-;U:i ~ '.' ,.... ..................-,..... HOWARD CURTIS GOUSE DEFENDANT ,', ~ A ~ ~.~ ~ ~.~ ~ ~J ~ ~.~ "'Ii ~ ~.) t', ~ .., ~ ~ ~'; ~ .' ~ ~.~ ~ ~-'~ ~ ~-: ,', ~ ,', ~ ,'. DECREE IN DIVORCE AND NOW, ' . , , . , .Q 0t.~. ~.cJ.. , ,~ . .. " .B ,'?-~t?.I. it is ordered and decreed that ...... .S.~~.~~~. .~?~~~. . . . , . . . . . , . , . . . , . . , , . . . " plaintiff, and.........."... ,l;Iq~~!\P .GVR~I,S, 9.Q1)!,.I~...,.....,..,..... defendant, are divorced from the bonds of matrimony, The court retoins j'.Jrisdiction of the following claims which have been raised of record in this action for which a final order has not yet been entered; .........,.....,.... 'QDRO forplaintifffrol11 Defel1dant'sTeaIilsfe'rsRetir'ehlellt'Fiuid' ....",..,...........,...,.............. ,... ,........,... *. ~'; l, ~ ~ ~ ~.~ Dy Thc,5?rt:/? /r} nJ.. VVw Fe O~, L.. Allc'tV d . , '" Prothonotary ~ ~.~ ~ ',' ~ ~ :;( ~ ~ ---..-;..... ---.........-._---......-...-..-..-...-.~---~------~-_._.~_. ~~~~---~._~~*~~~*~***~ ~ '.' ~ ,'~ ~ ~ '.~ ~ ~.~ ,', ~ ~ ~ ~.~ ~.; ~ ~ ~.~ ~ c'~ *- ~.~ ~ '.' !.~ ~ ~.~ ~ ~.~ ~ .~ ~ ~.~ ~ ~.~ ,;., ~ C ~ ~.~ ~ ~'j ~ ~'1 ~ ~ '.' ,; ~ ~.~ ~ '.' ~ ~ ~ ~ ~ ~ ..... J. * e ~ ~ '.' -~----.----~---~~.) ~ ,.:.:.' .:.;..~o;. {~;. :.:.;.'.:+;. .:.;. .:+:. .:+:,.:+:.. ." : "-' ). , , Plaintiff Sandra R. Gouse v, Defendant Howard Curtis Gouse In The Court Of Common Pleas Of Cumberland County, Pennsylvania Docket No, 98-3564 In Divorce QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, this 3 r J..cJay of () Xl, U ,200\, based on the findings set forth below in items one through five, IT IS HEREBY ORDERED, ADJUDGED AND DECREED in items six through \wenty-one: 1, Parties: The parties hereto were husband and wife, and a divorce action is in this Court at the above number, This Court has persol1al jurisdiction over the parties. The parties were married on June 13, 1964, 2, Participant Information: The name, last known address, social security number, and date of birth of the plan "Participant" are: Name: Howard Curtis Gouse ("Participant") Address: 400 Adams Street Ex!., Enola, Pel1nsylvania 17025 Social Security Number: #207-34-5450 Birth Date: February 2, 1946 3, Alternate Payee Information: The name, last known address, social security l1umber, and date of birth of the "Alternate Payee" are: Name: Sandra R. Gouse ("Alternate Payee") Address: 16 Poplar Street, Wormleysburg, Pennsylvania 17043 Social Security Number: #172-36-2034 Birth Date: January 25,1947 The Al,ternate Payee shall have the duty to notify the plan administrator in writing of any changes in her mailing address subsequent to the el1try of this Order. 4, Plan Name: The name of the Plan to which this Order applies is the Cel1tral Pennsylvania Teamsters Retirement Income Plan (hereinafter referred to as "Plan"). Any changes in Plan Administrator, Plal1 Sponsor, or name of the Plan shall not affect Alternate Payee's rights as stipulated under this Order. 5, Effect of This Order as a Qualified Domestic Relations Order: This Order creates and recognizes the existence of an Alternate Payee's right to receive a portion of the Participant's benefits payable under an employer-sponsored pension plan that is qualified under Section 401 of the Il1ternal Revenue Code (the "Code") and the Employee Retirement Income Security Act of 1974 ("ERISA"), It is intended to constitute a Qualified Domestic Relations Order ("QDRO") under Section 414 (p) of the Code and Section 206(d)(3) of ERISA and the Retirement Equity Act of 1984, P.L.98-397 DRAFTED: 9/11/01 07-16-01-145-2176Q . ' . -. . .!.' ~ .,: , . -..... ) . 6, Pursuant to State Domestic Relations Law: This Order is entered pursuant to the authmity granted in the applicable domestic relations laws of Pennsylvania, 7, For Provisions of Marital Property Rights: This Order relates to the provisiol1 of marital property rights as a result of the Order of Divorce between the Participant and the Alternate Payee. S, Amount of Alternate Payee's Benefit: This Order assigns to the Alternate Payee an amount equal to Sixty Thousand Dollars ($60,000,00) of the Participal1t's Total Account Balance accumulated under the Retirement Income Plan, All benefits payable under the Defined Benefit Plan shall remain the sole property of the Participant. The Alternate Payee's portion of the beneffts described above shall be allocated on a prorata basis from all of the accounts and/or investmel1t funds mail1tained under the Plan on behalf of the Participant. Such benefits shall also be segregated and separately maintained in a nonforfeitable Account(s) established on behalf of the Alternate Payee. This Account(s) will initially be established in the same fund mix percentages as the Participant maintains in his account. 9, Commencement Date and Form of Payment to Alternate Payee: If the Alternate Payee so elects, her benefits shall be paid to her as soon as administratively feasible following the date this Order is approved as a QDRO by the Plan Administrator, or at the earliest date permitted under the terms of the Plan or Section 414(p) of the Internal Revenue Code, if later. Benefits will be payable to the Alternate Payee in any form or permissible option otherwise available to participants under the terms of the Plan other than a joint and sUNivor annuity with respect to the Alternate Payee's subsequent spouse. Such payment options available to the Alternate Payee shall include, but will not be limited, to a single lump-sum cash payment. 10. Alternate Payee's Rights and Privileges: On and after the date that this Order is deemed to be a Qualified Domestic Relations Order, but before the Alternate Payee receives her total distribution under the Plan, the Alternate Payee shall be entitled to all of the rights al1d election privileges that are afforded to Plan beneficiaries, including, but not limited to, the rules regarding the right to designate a beneficiary for death benefit purposes only to the extent permitted under the provisions of the Plan. 11. Death of Alternate Payee: In the event of the Alternate Payee's death prior to her receiving the full amount of benefits called for under this Order and under the benefft optiol1 chosen by the Alternate Payee, such Alternate Payee's beneficiary(ies), as designated on the appropriate form provided by the Plan Administrator (or in the absence of a beneficiary desigl1ation, her estate), shall receive the remainder of any unpaid beneffts under the terms of this Order. 12, Death of Participant: In the event that the Participant dies prior to the establishment of separate account(s) in the name of the Alternate Payee, such Alternate Payee shall be treated as the sUNiving spouse of the Participant for any death benefits payable under the Plan to the extent of the full amount of her benefits as called for under Paragraph 8 of this Order. Should the Participant predecease the Alternate Payee after the new account(s) have been established on her behalf, such Participant's death shall in no way affect the Alternate Payee's right to the portion of her benefits as stipulated hereil1. 13, Savings Clause: This Order is not intended, and shall not be construed in such a manner as to require the Plan: DRAFTED: 9/11/01 07-16-01-145-2176Q ,I . """-.,". ~ ~ . . (a) (b) (c) to provide any type or form of benefit option not otherwise provided under the terms of the Plan; to require the Plan to provide increased benefits determined on the basis of actuarial value; to require the payment of any benefits to the Alternate Payee which are required to be paid to another alternate payee under another order that was previously deemed to be a ODRO; or to make any payment or take any action which is inconsistent with any federal or state law, rule, regulation or applicable judicial decision, (d) 14, Certification of Necessary Information: All payments made pursuant to this Order shall be conditioned on the certification by the Alternate Payee and the Participant to the Plan Administrator of such information as the Plan Administrator may reasonably require from such parties to make the necessary calculation of the benefit amounts cOl1tained herein. 15, Continued Qualified Status of Order: It is the il1tention of the parties that this ODRO cOl1tinue to qualify as a aDRO under Section 414(p) of the Il1ternal Revenue Code, as it may be amended from time to time, al1d that the Plan Admil1istrator shall reserve the right to reconfirm the qualified status of the Order at the time benefits become payable hereul1der. 16. Tax Treatment of Distributions Made Under This Order: For purposes of Sections 402(a)(1) and 72 of the Internal Revenue Code, any Alternate Payee who is the spouse or former spouse of the Participant shall be treated as the distributee of any distribution or payments made to the Alternate Payee under the terms of this Order, and as such, will be required to pay the appropriate federal income taxes on such distribution. 17, Constructive Receipt: In the event that the Plan Trustee inadvertently pays to the Participant allY benefits that are assigl1ed to the Alternate Payee pursuant to the terms of this Order, the Participal1t shall immediately reimburse the Alternate Payee to the extent that the Participal1t has received such benefit payments, and shall forthwith pay such amounts so received directly to the Alternate Payee within ten (10) days of receipt. In the event that the Plan Trustee inadvertently pays to the Alternate Payee any benefits that are to remain the sole property of the Participant pursuant to the terms of this Order, the Alternate Payee shall immediately reimburse the Participant to the extent that the Alternate Payee has received such benefit payments, and shall forthwith pay such amounts so received directly to the Participant within ten (10) days of receipt. 18, Effect of Plan Termination: In the event of a Plan termination, the Alternate Payee shall be entitled to receive her portion of the Participant's bel1efits as stipulated herein in accordance with the Plal1's termil1ation provisions for participants and beneficiaries. 19. Continued Jurisdiction: The Court shall retain jurisdiction with respect to this Order to the extent required to maintain its qualified status and the original intent of the parties as stipulated herein. The Court shall also retain jurisdiction to enter such further orders as are necessary to enforce the assignment of benefits to the Alternate Payee as set forth herein, including, but not limited to, the recharacterization thereof as a division of benefits under another plan, as applicable, or to make an award of disability benefits that may become payable under the Plan, if applicable, or to make an award of spousal DRAFTED: 9/11/01 07-16-01-145-2176Q I . ., Prothonotary on April 6, 2001. Inasmuch as Mr. Gause's affidavit and waiver were not filed within thirty days of the date of signing, Mr. Gause is going to have to re-execute an affidavit and waiver and file those with the Prothonotary within seven days of today's date. Mrs. Gause has not yet signed and filed an affidavit of consent or waiver of notice of intention to request entry of divorce decree; however, her counsel indicated that he will file those documents on her behalf within seven days of today's date. After considerable negotiations today, the Master has been advised that the parties have reached a settlement with regard to all of the outstanding economic issues. An agreement is going to be placed on the record in the presence of the parties. The agreement as placed on the record will be considered the substantive agreement of the parties not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription, The agreement is going to be transcribed and sent to counsel to review for typographical errors, correction of typographical errors will be made and then the parties will be asked to affix their signatures affirming the terms of settlement as stated on the record at this time. In any event, when the parties leave the hearing room today they are bound by the terms of settlement as stated on the record even though there may not be a subsequent signing of ., . , the agreement affirming the terms of settlement at a later time. Upon the Master receiving a completed agreement, he will prepare an order vacating his appointment and counsel will then be able to file a praecipe transmitting the record to the Court requesting a final decree in divorce. Mr. Dougherty. MR. DOUGHERTY: 1. The marital residence located at 400 Adams Street Extended, Enola, Pennsylvania, will be transferred to husband. Wife will execute a deed transferring said interest to the husband within sixty (60) days of today's date. Husband will agree to pay wife the amount of $67,000.00 made payable by certified or cashier's check also to be delivered within sixty (60) days. 2. Husband agrees to transfer to wife his interest in the retirement income plan in the amount of $60,000.00, Wife shall be responsible for preparing a QDRO to be submitted to the Teamsters pension plan to be reviewed and approved by the plan and by the Court of Common Pleas. 3. Husband will transfer to wife his one-third interest in the cabin located in Tioga County. 4. With regard to transferring the interest of both the marital residence and the cabin in Tioga County it is agreed between the parties that husband will deliver to his counsel a certified or cashier's check in the amount of $67,000.00 along with a deed conveying his one-third interest in the cabin in Tioga County, at which time husband's attorney will contact wife's attorney and husband's attorney will deliver to wife's attorney the aforementioned certified or cashier's check along with the aforementioned deed and wife's attorney will deliver to husband's attorney a deed conveying wife's interest in the marital residence to husband. The transactions regarding the Tioga County cabin and the marital real estate and payment of money shall occur within sixty (60) days of today's date. 5, Wife agrees to withdraw her claims for alimony and counsel fees. " . . " 6, Wife shall retain her interest in the Provident Mutual Insurance policy, No. 2432326. Husband shall maintain his interest in the Ohio National Financial Services policy, No. 823116, 7, All other personal items not specifically distributed pursuant to this agreement shall remain in the possession of that party retaining them as of the date of that agreement. 8, Wife will agree to return to husband personal papers, including his GED certificate, Husband will return to wife the clock previously identified as well as wife's mother's armoire and the three brooches included therein, 9. Husband shall retain all interest in tools, materials, and equipment utilized for his taxidermy business. Wife shall retain all interest in tools, materials and equipment utilized in her beauty shop, Wife shall remove all tools, materials and equipment in the beauty shop on or before the date of delivery of the deed set forth herein. Wife shall provide husband with 24 hours notice of when she intends to remove the aforementioned items from the beauty shop. 10, 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 relationship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the other, and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. MR. OWEN: Would you state for the record your name? MRS, GOUSE: Sandra Ruth Gause. MR. OWEN: And your current address? MRS. GOUSE: 16 Poplar Street, Wormleysburg. MR. OWEN: Mrs. Gause, you have been present today in the Master's office here in Carlisle for the last several hours; is that correct? MRS. GOUSE: Yes. MR. OWEN: You've been present in this room for the last ten to fifteen minutes as the agreement has been dictated to the court reporter; is that correct? MRS. GOUSE: Yes. MR. OWEN, Having heard the terms that have been dictated, do you understand the terms as they were read? MRS. GOUSE, Yes. MR. OWEN: Do you agree to accept those terms and be bound by them even though the document itself will not be typed today or ready for signature? MRS. GOUSE: Yes. (A discussion was held off the record.) MR. DOUGHERTY: With regard to the cabin in Tioga County, wife agrees that husband shall no longer be responsible for payment of the mortgage following transfer of the deed and wife agrees to payoff the balance of the mortgage within thirty (30) days of receipt of the $67,000.00 certified or cashier's check. THE MASTER: Mrs, Gause, have you heard the addendum to the agreement? MRS. GOUSE: Yes. THE MASTER: Do you understand what has been stated regarding the mortgage? MRS. GOUSE: Yes; that I have to pay the mortgage off when I get my money. THE MAS'I'ER: Yes. Do you understand that? MRS. GOUSE: Yes. THE MASTER: Are you agreeable to do that? MRS. GaUSE: Yes. MR, DOUGHERTY: Please state your name. MR. GOUSE: Howard Curtis Gause. MR, DOUGHERTY: Mr. Gause, have you been present during my representation of the agreement between yourself and Mrs. Gause regarding the equitable distribution? MR. GOUSE, Yes, I have. MR. DOUGHERTY: Do you understand the terms of the equitable distribution? MR. GOUSE: Yes. MR. DOUGHERTY: Are you in agreement with the terms of the equitable distribution? MR. GOUSE: Yes. THE MASTER: You understand that you are ~~~i~l~W!.[~..)~lW~i;~f"~.i!;:'\!!-f"i,;"""r':"Y';"L" ',., .. ,'",,' ,.", <;"" ""''''', " ,','"".'..."",.:'.""",',.. .,'.;._:,:,.,.!..:,'.".'~.',~"~'"._,,_(,,'},_:..:'<...:::,"!:~:.'tl\i,..;,'~~fr'.',,'.'.'j,).;),,'i;:.-:'?J~1:{~~:~~!'....4! '~' ~ '".\::if~;~~~k~,~~j~~:;::;=.::c.::::~~::~j_:::,::_.;:~:.~:~::~~;"~:G~':::,DDnGlcl;B.~:'Ouian;:~:::'.'::' .--_:" -. ;":~~.;--=--; - ~~' --.- ~-.-.:: ':'. ~ '-t~=-:- ...;~~-;:,,:;- ;:::';'T,:;:,..t:.~J: i::.ff~~i;~sti:;tl\.,~~,jri;':);;; ;'dJ,j;~ i: ~;j..;,..; "fl '.0 i'COUN8I!LOR;AHAW "/? f-<... '. j:;J': ,.. '-,'--": ~'" c:'C ;;; 7";';I'aJ;~'!,i ;~;;{;~,._~.~-,;:~t'.,1kt,I~~,,-',:~\~\~'i;'\~ ~2i:v'1 (e-~ ~111'r ~ --'1''' DR'.-rf),' ~ 'D"; ,,' ,. , ' ','\ ,,', ~,:, "~,;-;J/~l~;~i, "" ~'~il~)' ....,.. · '. . ~:t.=.. . . .' ...' ,;:j;~l~ :i;i:.';!iW0~\}.':\;"~,<:r, , '.' \ ":"i.;T~i:~';\.}~y), :,j SANDRA R. GOUSE PLAINTIFF vs. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA C/8 - .31;10 'f : NO.' CIVIL TERM HOWARD CURTIS GOUSE DEFENDANT : CIVIL ACTION -LAW : IN D[VORCE NOTICE TO DEFEND AND CLAIM RIGHTS YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take prompt actiol1, You are warned that if you fail to do so, the case may proceed without you and a decree of divorce or annulment may be entered agail1st you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rig:,ts important to you, including custody or visitation of your children. When the grounds for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage coul1seling. A list of marriage counselors is avail- able in the office of the Prothonotary at: CUMBERLAND COUNTY COURTHOUSE. Carlisle. Pennsylvania 17013 IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PERSONAL PROPERTY. LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE O~ ANNULMENT IS GRANTED. YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR T~LEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, GO'lrt...A€I'l'tinirtratsl, TI,;,J I"luul /L j! Cumberlal1d County 8sI:lft1geUGe .8ttl~ jF.T.iOjtz..f\o1 Carlisle, Pennsylval1ia 17013 cJ... Iv {lM'{L.1 /11k.- Telephone: I 218 II$(! /, cJ-LfC{- -J/&(;, ~ . N ~ ,is lr. .. lJ.,p ~ ;?~ u"?"- O&.~. ~:~ :r.: (..)~ "- $ IllS.' n-:.j ',.0 n~ G,- N ,:L Cr:'~: l ,0.. [fiffi . L. ~," W r'.' fJ.la... .. cr. ~ ,~ c:> :::> 0 Co) - " ::I:l ,;,... :... ;I> 'J,';:', .- "';"")~::~'8' :' ;(:h~\~ ~." ;;'~. , t '~ ",.5 - =: ;' '..511' 8;;1Zo " .'~ , Z 8 en SI \: ,,:, N ' ~< "'i ,o-j, n c ~ ,> 0 'I: , ""..!.., ~ ,,(') ., ...' Cl>Ul 1 _ .. ......., , ,'.. "~'''" J;k~{~\N; " " .(") ,;{:~.;.r;i:i ',":.',: 00 0 :I" :I" ~ Z t:l n r:; ~ tl '0 n :xl" .~ ~ . 8 G'l ~' H <: 0 Ul en c:: . ,00' 0 G'l t'.l ":l 0 c:: 00. tl Ul '0 ~, (I) i:':I I-' Hl . $lJ. <: (I) .... 'H" J:l ::l ",~' 0.' rt",', , III ....,' , ,J:l 'HI rt HI . ,:~..:' '...-.....'., H,O',C::Z <:."':3:".. H',:."b:l'i-3 I:"'~~'~ '> I-'t;:l.:rtl 'C"lw~'n I-3IU1Z'O ,H en t:l c::: , O'..."i":xl z:::, n',8 ,'n.o,:," I'....~O ~'~:t-3~ ,Zl...h~n " ,r..,,:,..,..O S.~:.'~'~ ',<:'1",t'.l:O oa..zz ,.\,:~i;':;,\'Z,;l;.'! ,n,'...:I"'O :"::ij::;~ .~._-~..:..-~.-::~~ SANDRA R. GOUSE PLAINTIFF IN THE COURT OF COMMON PLEAS CUMBERL^ND COUNTY, PENNA. VS. No. 3564 CIV[L TERM 1998 HOWARD CURTIS GOUSE DEFENDANT CIV[L ACT[ON - LA W [N DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301(c) OF THE D[VORCE CODE I. I consent to the entry of a final dcercc of divorce 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 affidavi t are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Date: July 16,2001 >... I.1J [t" ~: .,~ (-; I';' ~~.. ;'1 r) .. ~ .'i ( ; ('J ~~ 'r'. ~.."! ,) .', .. I .. '.... :,} '<< ;j , I ,-, ~ '.If\ ; _J;::: ::::,: I'" ,-. .lr~j ~":j :/)0:" "'-'" C.) ::5 u ~1 ~, !;; In (Xl 1004 ..~. ~ 8 ~' < ~'? ~ Ul ~ !;' " ':,',:~Ii~~ ~ ~ ' , ,~.. UJ z - rn "l <~':':"r!,tj,olo3 (5 .'..,ro ;<:UlOO M Coli )' ~ '" '..', co' Z:o 0 IJl ;', '. ," ,:; '" i:I: .- .~tII, ..., ':. :~ -.I'; '~' ':'(_i~.':",'o- . ,_,-.,'1--" -_ ,.". ; .', 'I'Q , ,.i ,'::,':". ',,,-:, .. _~+'1 "-" '. ;~ , ",.:'.i/.....~'ki~-~,~,:... tI: fIl' ~ ~ ~' Z t:l >::I ~, H t:l I:l ~ (l ::0 c:: . H ::0 ~ ~ G'l 'H <l 0 ,l;j fIl IJl c:: fIl. G'l ,trJ ~ 0 . c:: tl fIl to fIl !D trJ t-' ~ Hl . PJ !D I"' ~ ;J ::s Pi r1' ,. jlJ 1-" ;J H>' rt H> , . . " ''" .- :~ '. . . ~ ';" ... ',' " SANDRA R. GOUSE, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. Plaintiff, vs. No. 98-3564 Civil Term HOWARD CURTIS GOUSE, Defendant. CIVIL ACTION - DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on July 25, 1998. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. ~4904 relating to unsworn falsification to authorities. Dated: 7J/ j h ~/ 2Jcnv--,~ c- ~Q HOWARD CURTIS GOUSE ,.. ','-,"..... ""-......- --- '.. to ...... i;,D C ['C j::~ .' al c; ,~~ w~ " , " .. '~~)>'.., ,- :~~ >- " ; ,-. ~) ~,~':i . I:': .;~ ~.~: .') lLl "J :-l.. ;.'~ '1.1'. ::J ; " ::) (;] ~' ~ i!! ,",(Xl = OlD 0 ., CO ~ z $. t'"' . . 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','2:C:l,1'-i ,OC:: 2:, . iii' ~: 'iD t-" tIi' ,,~.,O).:tJ:j.:.~,:. , l'lC ",' ,~~~r; .."'2:,C:: ":.'t::l,,~:; nn..,,;, ,H,O 0, '~lt~, '..; "~" ':tJ:j'~',::.l::s:,;, ~"cl'O ".:~~\ ..,2: "d, \:fi:i~~~ CERTIFICATE OF SERVICE AND NOW, this III day of July, 2001, I, John B. Dougherty, Esquire, attorney for Defendant, Howard Curtis Gouse, hereby certify that I served the within WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(c) OF THE DIVORCE CODE this day by depositing the same in the United States mail, postage prepaid, in the post office at Harrisburg, Pennsylvania, addressed to: By First Class Mail: Donald B. Owen, Esquire 708 North Front Street P. O. Box 146 W ormleysburg, P A 17043 E. Robert Elicker, II, Esquire Office of Divorce Master Cumberland Court of Common Pleas 9 North Hanover Street Carlisle, PA 17013 By: '1-1vL ~. ~'$JJ ~ff JOHN B. D' GHE Y SANDRA R. GOUS E, Plaintiff IN THE COURT OF COMl-ION PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs, NO, 98 - 3564 CIVIL ! HOWARD CURTIS GOUSE, Defendant IN DIVORCE TO: Donald B, Owen Attorney for Plaintiff John B. Dougherty Attorney for Defendant DATE: Monday, October 2, 2000 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. OR IF DISCOVERY IS NOT COMPLETE: (a) Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions, Mr. Owen and Mr. Dougherty, Attorneys at Law 22 January 2001 Page 2 equitable distribution is a matter to be heard by the Master. I am going to allow counsel two weeks to raise any economic claims which they wish to raise in the action after which I will issue a directive for the filing of pretrial statements. If no economic claims are raised, I will then ask the Court to vacate my appointment. Very truly yours, E. Robert Elicker, II Divorce Master ... " 'r'C " >- o.(U ~. " :0; C. .' ~ ..' Z. '.:,' 0 r. 5~t; U3" (; ~.' ~c: f-) .:;~ --0 ... "'::.. r'. or. O~ (""1:-:.1 '. (j.,p; -",,,~ .; ".. " 'Ot:l>'3~ n 2: tll ..'..~ '. ":l tol,O ~ 0 0 ~~~~. H ~ 1:"' \0 ~.. CXl . t:I~1il 0 > I l4 w n <: l>:', ','H tIl":l U1 ~ rn '. ,", , <>'3 H '" "." O~ 2: 0 01> ,G1 " l>:' ~O 2: H 0" n >'3 n tIl 'd, 'toltll H I, 1-" .tIl , tol al &1 <: CO) tol, nn, t:I 1-" 0 . 010'3 H ,... d ,t:lHOO ~ t:I tIl 'tolO":l":l >'3 (1) tol '2: " (1) 111' . . ,> H n ~ (1) ~t:I~ tol ::s p. OHtol III ,~~.~ ::So .' '. C'll>:' H <T, ....... . -no, ',,,:., '.", tol = :";',' " r..: '", 'f;::: ,'" ..." ,., , ,,' ~,"1 , " "i q; .1' ' t"" . , ,U,!.,'",' ~W.,:~}; '" " 1t(\, " t,......"-".. i';:~,~~'" ~. , f'~i~i::,'~ .~ .{." f~,;:;,:':,~::::)':".:;:,",:'; LAW OfPfCU IRA H, WEINSTOCK, P,C. SUIT< 100 800 N, SECOND SI >EfT HARRISBURG, Pf.NN5YU'ANIA 17102 TEUPHONE' /7,17) 23R'1657 ,~ SANDRA R, GOUSE, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA, Plaintiff, VS, No, 98-3564 Civil Term HOWARD CURTIS GOUSE, Defendant. CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 330l(c) OF THE DIVORCE CODE 1, I consent to the entry of a final decree of divorce 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 lIoderstand that false statements herein are made subject to the penalties of 18 Pa,C,S, S4904 relating to unsworn falsification to authorities, Dated: 1- "1 (/" () / [ .- I ) , 1 ( .-,' ,n , .', .L7'''./]'f.V.'1d vU.....l.v~ _/~,v~... HOWARD CURTIS GOUSE ~iZ~~'(~:.:;';';\" ," nl:/2.:~::';.""'" ~., ' ~".:; . " , ,;, i'I'! _ ,-:,>" .~' :', "--',,,-, ,,;,',"i', i:~~::::X,i::V.;.'., . . .~,~',((:,',: ' . LAW OfPICE.\ IRA H, WEINSTOCK. P,C. SUITE 100 800 N. SECDND SlRUT HARRIIIURG. PENNSYI,VANIA 17102 TEL1PHON!' 1717) 23/1,1657 ,~ ,",... , , ,', - 1j)'--"-~~lVl!liCia'" _~!~_~"WfllltUll P"" - SANDRA R. GOUSE, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. Plaintiff, vs, No, 98-3564 Civil Term HOWARD CURTIS GOUSE, Defendant. CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301(c) OF THE DIVORCE CODE 1, I consent to the entry of a final decree of divorce 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 COirect, I understand that false statements herein are made subject to the penalties of 18 Pa,C,S. ~4904 relating to unsworn falsification to authorities, Dated: 7-! b-O/ . ( _2~)c~, HOWARD CURTIS GOUSE .~._-_........,.". ...... ....~--...,. CERTIFICATE OF SERVICE AND NOW, this ut... day of July, 2001, I, John B, Dougherty, Esquire, attorney for Defendant, Howard Curtis Gouse, hereby certify that I served the within WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(c) OF THE DIVORCE CODE this day by depositing the same in the United States mail, postage prepaid, in the post office at Harrisburg, Pennsylvania, addressed to: By First Class Mail: Donald B, Owen, Esquire 708 North Front Street p, 0, Box 146 Wormleysburg, PA 17043 E, Robert Elicker, II, Esquire Office of Divorce Master Cumberland Court of Common Pleas 9 North Hanover Street Carlisle, PA 17013 By: fAt 3 ~ . JOHN' B, D GHE Y LAW OmcES IRA H, WEINSTOCK. P,C, SUIT!, 100 800 N, SECDND StREET HARRI'BURG, PtNN'YI,VANIA 17102 -, , -. T[LEPHON[: 1717) 231\01667 ,~ '.' . SANDRA R, GOUSE, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA, Plaintiff, vs, No, 98-3564 Civil Term HOWARD CURTIS GOUSE, Defendant. CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REOUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301(c) OF THE DIVORCE CODE 1, I consent to the entry of a final decree of divorce 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 made subject to the penalties of 18 Pa.C,S, ~4904 relating to unsworn falsification to authorities, Dated: 7-! b-O/ . f _~)c~, HOWARD CURTIS GOUSE CERTIFICATE OF SERVICE AND NOW, this ut... day of July, 2001, I, John B, Dougherty, Esquire, attorney for Defendant, Howard Curtis Gouse, hereby certify that I served the within WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(c) OF THE DIVORCE CODE this day by depositing the same in the United States mail, postage prepaid, in the post office at Harrisburg, Pennsylvania, addressed to: By First Class Mail: Donald B. Owen, Esquire 708 North Front Street P. O. Box 146 Wormleysburg, PA 17043 E. Robert Elicker, II, Esquire Office of Divorce Master Cumberland Court of Common Pleas 9 North Hanover Street Carlisle, PA 17013 By: fiio3 ~ JOHN' B, D GHE - Y ,~:.. fr: ':".'~? ';'l.)J{"J. 0"'. TcJf! ',-l-~: , (,p<;", Qt... ,",\ c'- .,,,'.'. .:lC ,~ ...0 I :g: '.:,-=.c. ~' :::><l: 9::t, .,l,;,J ..1_ , Cl?3 ?,; in '''lZ =j--'" 'tn(iJ rno.. :"~ '::J <..) == . ". . i"';',, :', n 2: tll H 0 0 < ';l:l H '.~, 1:"' \0 CXl ~ I W c' 1-3 U1 H '" ~ 01> () I 1-" ,<: t:l 1-', H 1:-', <: ,;, t:I' ~ (1) (1) 111" n ~' (1) tol ::s '~', Pl ::s rt, .. " 'J,_ " , , if " " ;'",' :.;.~, . CERTIFICATE OF SERVICE AND NOW, this 51h day of April, 2001, I, John B, Dougherty, Esquire, attorney for Plaintiff, hereby certify that I servcd the within AFFIDAVIT OF CONSENT this day by depositing the same in the Unitcd States mail, postage prcpaid, in the post office at Harrisburg, Pennsylvania, addressed to: By First Class Mail: Donald B. Owen, Esquire 708 N. Front Street P,O. Box 146 Wornlelysburg, PA 17043 E, Robert Elicker, II, Esquire Office of Divorce Master Cumbedand Court of Co mill on Pleas 9 North Hanover Street Carlisle, PAl 70 13 BY: ~ SANDRA R. GOUSE, Plaintiff vs, HOWARD CURTIS GOUSE, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO, 3564 CIVIL TERM 1998 : CIVIL ACTION - LAW : IN DIVORCE AMENDED COMPLAINT IN DIVORCE COUNT I Reauest for a fault divorce under 3301 (a) (6) of the Divorce Code 9, The prior paragraphs of this complaint are incorporated herein by reference thereto, 10. Defendant has offered such indignitiGs to the plaintiff, who is the innocent and injured spouse, as to render the Plaintiff's condition burdensome and intolerable, 11. This action is not collusive, 12, Plaintiff has been advised of the availability of counseling and that plaintiff and defendant have the right to request the Court to require the parties to participate in such counseling, WHEREFORE, Plaintiff respectfully requests that the Court enter a Decree in Divorce, pursuant to 3301 (a) (6) of the Divorce Code. Count II Request for Equitable Distribution of Marital Property Under 3104 and 3502 (a) of the Divorce Code 13, The prior paragraphs of this complaint are incorporated herein by reference thereto. 14, Plaintiff and Defendant have acquired property, both real and personal during their marriage from the date of said marriage until the date of their separation, 15, Plaintiff and defendant have been unable to agree as to an equitable distribution of said property, WHEREFORE, Plaintiff respectfully requests the court to equitably distribute the marital property of the parties, pursuant to 3104 and 3502 (a) of the Divorce Code, '\",:;;:,: .".', "'..,," "..,'.. t:I t:ln 2: lJl t>J HH 0 0 t:j <:<: ,~ OH Z l>:lt" \0 tl ~:J> co' t:I ~ I Z n w n <: >'3 >'3 U1 ~ , H '" en 0 01> >'3 Z H ;g n tIl ,.., tol <: CO) I f;; ,... t:I 0 1-3 '..... CD c: :a :;: HI tIl 'H 1-3 CD tol ~ H CD ::J . t" Z 'i 0.' a AI' ::J rt . t i t ~Cll 'Ioj "II III 0 '""I ::z: c: 0 . F')'<~ ,'.'~ ~ W~ r ';"""'::)/"'"' ~ ~ 0 i!." 'i~ ~"~ _ 00 ~ <:i~~g~a ;~~j~~; ~ ~ I ~ ,t,;,;,:~,'~:,::;.t:,~~:.:l,';,_':;,>,::';._.,: ,..(;:.:; ~:^:: ':;. <:: . __ _~ , , .. ,_ ".~" ""t.,::: ~;::_'_:-.\,,';: "', 1.:- " 'tI' ',..." 'lll" ,1-'.' ::S.. 2.i HI "~." " II. ASSETS OF THE PARTIES Dcfcndant has prcviously filcd an invcntory rcgarding thc asscts at issuc. In addition, the Dcfendant has attachcd a sprcadshcct with thc marital assets and there proposed valucs as ofthc datc of separation, May 25,1998, or as close as possiblc thcreto, III, EXPERT WITNESSES None, IV, FACT WITNESSES Howard Gouse will testify regarding the property at issue, Wife's contributions to thc marriagc and Wife's marital infidelity, Ron Erb will testify regarding the Wife's marital infidelity, Bob Bankes will be called on as cross-examination to be questioned regarding Wife's marital infidelity, V, LIST OF EXHIBITS A, Appraisal of the marital home dated 12/16/99 valuing the property at $110,000,00; B, Statement from Harris Bank regarding husband's savings account valued at $13,037,39 as of May 29,1998; C, Copy of wife's bankbook from Dauphin Deposit for the period of May 20, 1996 through August 19,1999; D. Statement from Provident Mutual Insurance Company regarding cash value of wife's life insurance policy, Total policy value is $1,886,73; 2 E,Statcmcnt from Ohio National Financial Scrviccs rcgarding Husband's life insurancc policy, Thc nct cash valuc as orOctobcr 16, 1999 is $5,839,85; F. A letter from Ccntral Pennsylvania Tcamstcrs Pension Fund dated October 5, 1999 addressed to Husband outlining the amount of Husband's Retiremcnt Income Plan as of June 30, 1998, Said balance was $69,894.39; G. Kclly Blue Book Retail Report on 1983 Ford Pickup F-150 Shortbed valued at $3,660,00; H, Kelly Blue Book Retail Report on 1994 Ford Aerostar Cargo Van valued at $9,095.00; 1. Statement from Husband's Dauphin Deposit checking account showing a balance of$269,53 as of May 22,1998; and 1. Letter from First Union dated January 12, 2000 regarding the payoff amount for the loan on the cabin as or May 25, 1998 valued at $9,026.48, VI. GROSS INCOME Husband's Federal Tax Return for the year 1999 indicates a gross income of $33,024,00 which is derived mainly from his employment as a dockworker for ABF Frcight Systems, Inc, A copy of Defendant's 2000 Federal Income Tax Return will be provided, VII. DEFENDANT'S EXPENSES Defendant has previously filed an Income and Expense Statement. 3 VII. PENSION AND RETIREMENT BENEFITS Husbund has both u Rctircmcnt Incomc Plun und Dcfincd Bcnefit Plan through thc Ccntral Pcnnsylvania Tcumslcrs Pension Fund, Thc Dcfincd Bcnefit Plan providcs a monthly paymcnt of$316,97 payablc to the Defcndant at upon rctircmcnt. Thc Rctirement Income Plan is valucd at $69,894.39 as of Junc 30, 1998. VIII. MARITAL DEBT Thc only marital dcbt at issuc is thc loan with Firsl Union for the cubin, As of May 25, 1998 there was $9,026,48 owed on thc property. IX. PROPOSED RESOLUTION OF ECONOMIC ISSUES Husband proposes that he remain in possession of the marital home and pay wife 55% of the equity as of the date of separation, Husband will also agree to a QDRO directing payment to Wife in the amount of 55% of the value of both the Defined Benefit Plan and the Retirement Income Plnn as of the date of separation, Husband agrees to give Wife the cabin and its furnishings, thc gravesites und Wife may retain the Provident Mutual Insurance Policy, Husband will retain his Ohio National Insurance Policy, The parties will retain the personal items currently in their possession with the exception of the gun reloader, 30.06 carbine and 30,06 rifle, and Husband's GED certificate and personal papers which will be returned to Husband. Husband will not agree to an award of alimony or attorney's fees, 4 ::j 0" III '" III <II ollo Cool 0' III ....0 0' III ... m 3: - - i!;'~~ -_. -~.__. -- Iii - ~~ -- 1---. 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(Il1alltlldd,v.o.vorltbuolloldV1lut,) INCtCATEDVALUUYCOST APPROACH.. .... - 1 COnlIr\ICIIonWIII1IlIy II 0 N....Q/WIITGlIIyPIlIO."" Wl/IlIllyCMfIlJtEapifn " 'wndWI~" hUttdtd....lletnt.....oI~,.. .......lIldproQ\Wf.,~ iItIlfNt 0Cll'If1dl1t1d1llH nhll'ltt1'It .IM~'" Tht~kdId.' .rto!II IuIf.mtnI,. ~ IMIktt ftKlln to Ihott 111M cit ~ VIftM~ bMWttn t1e1Rlbfed Ind CIllI'I'JC*IbII P""J*'1tI. .. .lgnIflam Ilem In "'I compar.bll pl1lf*tY ft .upltflllr Of motI 'IYOU" Ihan. H tlll:llkl~..'" H ~ 1l1'A1d1. hit NdtK:Ind N IndIctltd ~1l"'1 at f\btId: U. tlgnll\c:ant h.m k1 tM ~ lit 1nfttb'1o. I... """..... ""'. ....""itol.lIIlOO1y. 111M l.l..........~_.....""'.lUlgllol hllcII.. .......01'" "")Id" IIEM SUBJECT COUl'AllASlE NO, I COMPARAIllE NO.2 COMPARABLE NO, ~ ams s e r, L ncoln Or. 1970 Randall Rd. Enola Sbur Hili Enola es miles l . OXIm 10 "" PrIU kelOlOl.U.,A111 .,.SourCl U.UE !llIUS1NEHI8 11., or Flnanc1rt9 once~.'~ II. 01 8oJ.mm' DC.1Ion ~lIVIlw ' ,,., andA IIfCmllrlllllcn none , su orbal1 , .2 ac....ave ranc -' ave r c -aYe.- ears goo ,- ,.... I.....' w.' " 3 '2 ,_ 150 ,Fl.'-2 par a : , u f. '+7 , su ur an 01 aC.~Bve anch - ave r, Yln-ave 30i ears a~e li . Till_ It&fllll .... 6 I 3' . 10 S, fl. u 100l 500 000 o 0 " non G ca r a r . enclosed porch s \0 rm s WDO stDye . B-nDne ' car cr t.'+ . 00 , , " ,+1.500 I I I none similar ,I re ace d';, ; 500 :1 ". 4 500 t 109,500 .' DESCRIPTion none none suburban .21 ac.-ave ranch - ave r c -ave.' years 900 Tdlll ,......1.. I , 5 I S ,fl,' +1,000 suburban . 5 aC.-ave ranc - aye br.&v n-ave 30 \ ears Dod '-2.000 - ,000 6 ' 3 1232 fu I art. 500 10l1ll1~111IN1 5 I _ -1,5'30 1075 ,FL' +3 000 full-exp. : art. fin.' + 50 , , fi n. I + G BB-nDne ' car att OF HA - C A' -1 500 1 car cr t, +1 000 r nDne +" ,500 + 1 ,500 none similar fire lace similar 500 fire lace 500 500 $109,300 500 1'110.400 :~~::ft:::=~~'=~~~1 --'--'-"TMO:'.iiioiiiiiirt'Muii~~;-"---'''''-' _: 10,000 1lIs 'IlJoIsII k modi :1 "ilia" DlIOOjld III lit,. DlelaIIGIIt, IntptcIooIII CCI1<it'ooI hlld beow, 0 compt.llo, pel ~'"' I1Id spoelncllklnl, C<1l1JMn1.I11dCondllonsciUl>IlIIIlII:T a n Its resent condition. The boaut shop was lnc u e as v ng sana ys S IS 0 es a S an as 1ng p'rlce onl ., T e,market a roach best a ralsal method for evaluat- . lno this tYee of orooertv an or whlc t e most re a e a a s laval Ie. This l!JlI"'lIlls bul<l upon~; !blJvlltqul"m,"~, !It CI<1I",~kln. coollngonll1ld IImII1no OlIIdIlion.. .nd Milko! V.I" 0,0,1110, Ih,' ... 11.,1<1 In g FmHA. HUO &1.. VA 1oIIIiJdlo,', , _ FII.JdIMIICF00\l419~IN. 7M8)/FIMIeMItFtIm tl104S\llIY, 718e)11dllll1chr( 19 0 .'Iochld, I(iYt}ESTlAATEMIlAMTVAlIJE,ASDmIll,Ol'11t!Bt8ECTPIlOI'fmYASOf 12-16-99 II-'obol \ 10,000 , 11\'(') ,,"l1y:lh.i ,olh. b~SI. {OU'llcndYolI<IOllndbtU,'lht ,..lIlnd dill .110 h...ln ar,'ru. andeo"..'; '''''1 {w'lp.rsonallyln,poei'O ,,,' ,ublocl p"parly. OOI,,,,,E.!tJeand OUI, lIfld h m D a," ltMlerliJrlnspoc1lon 01 >.11 eompsraNlt Iftln cUed In this fepott: and IhlllI lwltj h!lvo no undlScloJodlntllre91,prosenl 0' Plo,pocllvo Ihe,.I" I A ,I,~ I ^",.I,arlll ,..."", :~~.. ':L- 11&\,... "w.... .~.""" ,.__, 0 Old 0 Did /lo' . ~. ,. ....- IncnRd P"wulv . / I '. " of:,':'" , :';;~!1' . :....,. /~\:.~~: . ',,',\ ~;: -i- , ,~ l 15-DEC-1999 15tlo~47 ================================== >>1 Single Family BOOK Format Status S~TT Sub-Type SF City CAMP HILL LP$ 112900 SO:UNION CLD:08/24/99 FIN:CASH MT: 31 SP$ 109900 +-------------------------------------------------------------------+ I 3535 LINCOLN DR Area 006 MLS # 10011999 I I Mun HAM~D~N Dev HOLLYWOOD Sch CUMB I I Dir W ON MARK~T, R/36TH ST, R/LINCOLN, I I I I TotSqFt 1232 Source PUBLIC * No Stories: 1,0 I I LotSz 10BX84 Acr 0,21 Lot SqFt I I StyleRANcH ExtBRICK ConstFRAME YrBlt+/- 0000 I I Bsmt FULL,FINISHED* ?rk ATT,l CAR GAR >>Firep1 01 I +--------------------------------+----------------------------------+ I >>Br 3 >>Bth:F 1 H I #Rms 6 ITax 1386 Yr 98/99 Fee I I Lvl-Bth:F M H +------------______________________+ I LvI Apx. Sz I.v1 Apx. Sz I ApI DISHWASHER, DIS~OSAL I I LR M 15X11 MBR M 13X12'6 10thRm FAMILY ROOM I I DR M 10'9X9 BRi M 10XII IHeat ZONED, GAS, HOT WATER I I FR L 34'7X21 BR2 M 9XIO ICool WINDOW UNIT(S) War Y I I DEN BR3 IIntF ELEC. STOVE CONNECTION,EL* I I KIT M 10'9XI0'9 BR4 IwtSw PUBLIC SEWER,~UBLIC WATER I +--------------------~-----------+----------------------------------+ I ALL BRICK RANCH ON CORNER LOT, LIVING ROOM WITH STONE FIRE- I I PLACE, COUNTRY KITCHEN, lIALJ' BATH OFF MASTER. STAIN~D WOOD- I I WORK & HARDWooD FLOORS. R~ClmTLY FINISH~D LOW~R L~V~L. 2 I I ZON~ GAS HEAT, LARG~ WORKSHC~, R~S~RV~D: LIGHT ABOV~ POOL I I TABLE, I I I +-------------------------------------------------------------------+ I Sh CALL LIST* Bsh CALL LIST* LBx FRONT * La D~TW~1 761-1910 I I SAC 3.0 BAC 3.0 OAC TLC LT ~RS I I LA BITTING, PAT 697-2554 I I LA OW I ILA voicemail 214-9249 email pat@detweiler.com I +-------------------------------------------------------------------+ L 'r' il(;- ...... . ,r,::." )",'.. 'I' ,~ .l , lS-DEC-1999 15:10:41 ================================== #5 Sihgle Family BOOK Format status SETT Sub-Type SF City ENOLA LP$ 109900 SO:RMREAL CLD:08/20/99 FIN: MT: 49 SP$ 108800 +----~--------------------~-----------------------------------------+ I 1970 RANDALL RD Area 006 MLS # 10042734 I I Mun HAMPDEN Dev GLENDA CREST Sch CUMB I I Dir W/ WERTZVILLE RD IRT 644) L/ RANDALL RD (ACROSS FROM WESTBUR I I 1 I TotSqFt 1075 Source PUBLIC * No Stories: 1.0 1 I LotSz 89 X 170 Acr 0.35 Lot SqFt 151301 I StyleRANCH EKtBRICK,VINYL C9nstFRAME YrB1t+/- 0000 I I Bsmt F.XPOSF.O/WAT,KO* Prk PVD DR,ATT, CARPORT #Fi reo1 01 I +---~----------------------------+----------------------------------+ I #Br 3 #Bth:F 2 H 1 #Rms 7 ITax 953 Yr 98-99 Fee I I Lv1-Bth:F M,L H M +__________________________________+ I LvI Apx.Sz LvI Apx. Sz IApl RANGE, DISHWASHER, DISPOSAL., * I I LR ,M 14X15.4 MBR M 9,2X14.1010thRm FAMILY ROOM, BREAKFAST NO* I I DR" ~Rl' 1 Heat li'OltCEb AIR, OIL I I FR t l1x23.6' BR2 M 11.2X11.7ICool CENTRAL AIR,CEILING* War N I I DEN 81n M 7 ,10Xll. 61 IntF FTRF.PT.ACF: HISF:RT. SOME WIN* I I KIT M 9X16,6 BR4 L 11.9X17,31Wtsw PUBLIC SEWER,PUBLIC WATER I +--------------------------------+----------------------------------+ I WELL MAINTAINED NEUTRAL 3 BR RANCH 2 1/2 BATHS, FINISHED I I BASEMENT,FR+BR4 LR, WOODBURNING FP,CARPORT,WALK OUT BASMNT. I I LARGE LEVEL LOT WITH STORAGE SHED.NF:W CPT JAN 99. ROOF I I 4/95, 3 CEILING FANS. TO REMAIN: DW,STOVE,DISP,FRIG,FP GLASS I I ENCLOSURE, CURTAINS, MINIS EXCEPT MBR & BR 2, 3 CEILING FANS I I SilEO, ENTERTNMNT UNIT, BSKTBL HOOP/RSVD MICRO, WID, SWNGST, SD, W I +-----------------------------------~-------------------------------+ I Sh CALL LIST* Bsh CALL LIST* LBx CPLB-S* LO C21PI 737-6113 I SAC 3.5 BAC 3,5 OAC TLC LT ERS I LA THOMAS, SUSAN II, 761-5442 I LA OW I LA voicemail 558-5487 em,lil I +-------------------------------------------------------------------+ ----.--------.-------..-.-----."-,--...--. " ~ Dauphin Deposit Bcm~ HOWARD C GOUS" 400 AD!\MS ST EXT F.:NOLf, PA ! 7025 DATE PAGE 22 B MAGICARD HOLDERS ARE NOT SURCHARGED AT OUR ATNS. CONTACT A BRANCIf TODAY OR CALL 1 800-ANYTIME TO APPLY, " SUMMA.RY FOR ACCOUNT 49-37846-5 PREVIOUS BALANCE 05-12-98 5 DEPOSITS AND CREDITS 22 CHECKS AND DEBITS CURRENT BALANCE STATEMENT END DATE 508, 66 1,583.50 1,499,80 592,36 06-10-9B "- .-' ----=::::::::::-- - ~ ............._,~.':;..::::-._..- :';'~-;";'~'M"_ CHf:CKS CHECK # DA TE 610 05-18 615' 05-19 617' 06-03 618 05-20 619 05-21 620 05-22 621 05-27 622 05-22 , DENOTES GAP AMOUNT 24.34 200,00 100,00 48,43 47,70 100,00 62,85 153,68 IN CHECK SEQUENCE CHECK I DA 1'E C23 05 -20 624 05 -22 625 05-22 626 05 -2B 627 06-01 62B 06-03 629 06-03 NUMBERS TOTAL /lUM['iiR OE' CHECKS 22 MISCELLANEOUS PRIME OE' LIE'E CLASSIC sac SEC NUMBER INTEREST RATE AS OE' 06-10-98 1998 INTEREST PAID YTD ANNUAL PERCENTAGE YIELD EARNED PO S l' E 0 AMOUNT CHECK # DATE 119.4~ 630 D6-01 75,00 631 06-03 70.49 632 06-02 57. '13 633 06-08 39.70 634 06-08 130.51 635 06-10 125.71 63B' 06-10 TOTAL CHECKS PAID DEBITS AND CREDITS 06-10-90 ,. 355? 49378465 CY 8 32 207-34 -5450 1.000% 2,53 1,026% AMOUNT .14,61 6,99 B,82 10.00 56,83 3B,OO 9.22 1,499,BO DATE AMOUNT DESCRIPT ION 06-10 ,35 + INTEREST PAYMENT DEPOS ITS P 0 S l' E 0 DATE IlNOUNT DA'I'E A/ofOUN't DATE AMOUNT 05-15 600.00 05-29 295,00 06-0B 430.75 05-26 257,40 o A I L Y 8 A L A N C E S U M /of A R Y DATE BA LANCE DATE BALANCE DATE BALANCE 05-15 1,IOB,66 05.22 269,53 06-01 647,34 05-18 I,OB4,32 05-26 526,93 06-02 638,52 05-19 B84,32 05-27 ./64,08 06-03 275.31 05-20 716,40 05-28 406, 65 06-08 639,23 05-21 668,70 05-29 701,65 06-10 592,36 In case of errors or questions concerning Electronic Translers or your A 1M card, please call1.80Q.ANYTIME (1-800-269.8463). For hearing Impaired service call1.80Q.621.20e8. ~ ,.......,......... . ~~8n~~ N ........ ~ w ........... Y"",,Ww\oIw ............... ................ ~~~i~~ )J.. :nu: .........,............. 000000 t~~~~::. W"':V.'HfIJ OCDw.nllt . ~~~~~~ }.., ~"IOID\A\O 0 .0ClOO 0 E W~NNN ~ ~ 160'" ~ .", ~ , . 0... ," -:::::t:::- ,'., ~ ~ !' ~ ....\DWw\..llJl '/ W\oIQ"'ao -otJeOQO (' u.....oooo 0 " tIIwoooo t ; (""' "-") en ~ .........~ "",,NNl\I .. .. .. ... "'''''0-''&0''... ~ WOww...,.. ~~:':':'~ U'OW:..rWu WO\D\o14\O ""Ut..,c".u o "H. iOTH,/I ...w......'" ....N!JI'~'" ",..---- ~n~~~ III ..~ ;j~IQQ~ ~I..aa~ ~ oi~t:lr-i "'''' ~~ , "H "i.J ., N .. .. " , '" ~ ACCr',' WITH " , ' ~:").. NO \ I :' ,''- =r DAfE r AMOUNT/CODE 1-- ~A,1.A~CE ~LlEn 1'10 -; 227JAN98 ..*_-30!).l)!) W *.*2,830.56 3615 3 . 5 11 FEB98 ** u '300. on 6 ,13').5/, 3615 , 1 : 3HAR98 **.uI50.00 ~2 98C).56 3615 10 9HAR98 **-"100.00 0 "*~1,081).5ti 42',6 " 1230HAR98 """75.00 0 ***3,155.56 4246 PLEASE INFORM US OF ANY, '1 \ , I I 1. CHANGE OF ADDRESS 13 21APR98 """60.00 W **'3,095.56 4439 \. 15 llMAY9B ""-'95.00 15 17 16 29MAY98 .. -. _2.)1). 00 . 19 20 21 lJUN9B ......23.59 ,014.154662 2229JUN9B .....180.0.) ,W "-2,83".154662 L 28JUL98 ....$101)~.OO W -"$2'13".15 4439 23 I 2. Dauphin Deposit Bank and Trust Company SAVINGS DEPARTMENT NoncE-This bOQl\ .hould till proSDnlad nIl"" bank allollst om. In each veal to thai" mil,. be po.lOO, tho lnlotbll enlftrotJ !Iud 11\0 bBloncIJ .hown. In m~k'no wllhdlillVl<lls. .lwaYII pres,,"l your pass.boOk-we dDCIlne lopoJ'unltl,s you do CODES: 0 - o.pollt W - WUhdrllW.1 1-ll\llu..' . , " IN ACCT, WITH ~~:\ OAT~ - ~''''O'~N;:;;;;:;O~[ ....,~^'^;,;.;' "=1 TEU,t;;';~o L E!/.AUG9B ''''SJ,34.mr-l:rU-flP'(iI,n..'15--''(;(;2_ '2 L E!4SEP9B ....~bO(I,OO /) "'~i!6')').15 21'.2 ' 3 19UCT9B .....$50.1)1) W H"H!Ci:;I'.15 ,,1.39 4 5 18NOV9B o .....tf.'fw.Of '''1<'3'-'''.15 ***'$650.~~W * '$1650.15 .....~19.32 ""1669.~7 ......50.00 0 "'.,719.41 ....~600.1)1) W...,"HI19...'7 · "'$100,00 I. ....".11'1.'.1 PLEASE: INFORM US OF ANY 7 E!7NOV9B OtDEC98 to L 06JAN99 L IIMAR99 05APR99 o 9 tt 12 CHANGE OF ADDRE:SS 13 21 Af'R99 ..... tno, Ill) ()...., "7".10'1 I' L 01MAY99: ''''''5')0.00 D "HIS;I'!,'.I 14 15 IOHAY99 ....HUI).I)l) D "HIt,'!'!",,, 10 L 17MAY99 ......6'I.tJl) ....1/,:.17.".1 I L E!IMAY~9 ""$500.04 D '.'$2139.51 t1 I 10 2BMIIV99 *'''~13l),')~ W "'$1989,;'1 19 20 L OlJUN99 .....,!(II'.')') 21 15', f~_1 :~~rl\ l S /' 013 014449 '\,. Qfy) (1(11.11)('" 15/. OJ8lJI5 1'5'. I.Ij/tlJ', 13', I.' J ",'~'F~ " I ~,(, 'II ;;'.';9 , 1:1', 1,)13"".6 t St, 1,.1P.2~: ~I'J 13', "l:n,n 013 014923, 13'. PI'; 11 i. · .. · .1; I ': , 9:1 , .. '21m? 5 I Ii;', ')I 6f~ I P. H",2'.I!",I. I", I :;1. ',Ii"E6!,:~ j , I bauphlh Deposit eiiiik!il;'d Trust Company --, ' SA V'NGS DEPARTMENT I NOllC!_ThIt booII'ho~d be "","I'd" "', bank., 1..., "',n In 9,101, y,"'" "",n m'r ", r"I'd, Ih','"1"".1 enl.r.d l!Ind Ifl9 bllr.neA ~how", In mAld/lg 'MlhdrnwFtr!', "rwn~\ I"r{l~nrll ~OUf PAsf:.boo~-.wn doc "" '0 P/lr lJI1~n you do, COO!~: 0 - Dt>ptI." W _ WllhdrllYltl r._ tllhH".1 22 OlJUN99 03JUN99 f)f.l!-*lf'f;'...I).r)(1 I .*"~21':It).'ttl \oJ 23 24 (U.'I) iii. If."}' 111 " It IN ACCT. Willi NO, ~ ~, , 2 3 4 5, 6 1 6 9 to " I~ D"TE AMOUNT/COOE 19AUG99 ,*..~I>("),I"'J ~196.1.A;~~F.-_. . W ",1I..toL'_A!)."" '( ~ --~~U.;'~-N(). I';)', ,,,tJ,(I!r.' c~ '\, PLEASE INFORM US OF ANY CHANGE OF ADDRESS . . . t3 14 IS 18 17 18 t9 20 21 22 23 24 ~ Dauphin Deposit Bank and Trust Company SAVINGS DEPARTMENT NotlCI-Thll book ,hollld be pro~&f11ild IllhIs blnk ,IIeUI OIlC' In u.ch yoe! 10 !hAt 11 mAY hfI poO;llld, Iho lnlo,eel enllijd &.nd Ihll blll..ttellhown. In mllkll'l9 Wlthdrawnl., I\I'lfnyR prMIH11 your pM~,bnok-W9 deeMne to pey urH~ you do. COD!9~ n-lltpollll W_Wlll1dl~wftl 1_lnIfHt'~1 The Ohio National Life Insurance Company OhiD National Life Assurance Corpo~ation . ~~ Ohio National _. Financial Services. Post Office IIox 237 Cincinn'ti, Ohio 45201.0237 Telephone: 513.794,6100 ., HOWARD C GOUSE 400 ADAMS ST ENOLA PA 17025 FrDm: Angel, r Weeks Individual Insurance Services Date: 10-2S.99 Insured: I-IowaI'd C GDuse .J In response to your recent inquiry, pie",," refer tu items checked below (disregard items /lot checked): [81 CASH VALUE INFORMATION: Refund Refund Less Net Net Policy Effective Guaranteed Dividend Prepaid Loan Existing Cash Death Number Date Value Value Premium Interest Lo,n Value Benefit 823116 10-16-99 $2,490,62 $3,339,29 $9,98 $0,00 $0,00 $S,B39,85 $8,939.00 o PREMIUM INFORMATION: PDlicy Number Premium Paid To Amount MDde of Payment Loan Interest Paid To Amount Outstanding Loan o DIVIDEND V ALVES: Policy Number Effective Date Dividend Option Total Accumulations Paid-Up Additional Ins, Cash Value of Paid- U p Additional Ins, o A policy profile is enclosed to provide projected cash value and dividend information, Dividends arc based on the current scale unless stated otherwise; lhey are not guaranteed, Outstanding policy loans may not be reflected on the prDfile(s), Please review it carefully and contact us or your representative if you have any questions. [81 Your agent is: Jack E Snavely II Ph,No, 717-737-3)63 ' Remarks: cc: Jack E Snavely U/22S3-105 PLEASE KEEP US INFORMED OF ANY ADDRESS CHANGE Form 88 Rev. 7/97 ~ r- -- ~\ C' '1\ ~ ~ ~ ~) =i -'V 0 0"1>> ci> 0" I>> III .. 0 r, I>> w 0 C' I>> N ... m ;!: -~ -=-.- 'It - - - -~-_.- -- --, -, "f~:r II~ f ~I 0 ~ &> ~ W ~- "O- il: G'l g~ "01r./>. if - :r <D '" -, '" 0 iiI ~ 8 1.:' '^ -,I :'l ~ ~~ s:l-f:l c C' !!. c Ej' " S' < ::> -. !:'J ~ m ;\ II c <D -< =. i III t~ 5. Ul ~ 'C"Tl .. a. a. a . III cE i .. 0 ~ < tIl => llOl 0 fi' cB . III a CD m =I -- 3 :u ~ ~. [(Ii r [~ => :r m~ S' ~ i: a. "Tl ir c8 -':r 0 lJl ... =>f!} => -. m- Ol 0 ~ c 'lil=> g ... l': '" ~m => c i' 0 z VI - => a c ,C iii' ::I - fit - ~ 2: - f=-- - -- -- - c - - - - . 5 :J :J '< :J 3: lJ 0 0 m 0 m t. .. Z \II 0 ::I ;:; m :I a. r ~ 0 z 1.., 0 3: l: c: c. 1 .. ::r ;!: ~ j m ~ \\: z ~ .. 0 :I - - -- -- -- - m - - --, ..-- ~ a. I/J z ~ 0 z [, tJ Ei' , ;!: " 5 " Ul :J :J :J :J :J :l> ~ 0 . 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'- -, -- - ..=_~- -- -, -, - - - -, .r ~ 0 ~ co 0 ~\ b b '" 0 ~~ Ol 0 ~ 0 - 0 r' r rP co . a> -~ ~ ~ 8 ~~ 8 0 8 0 "- " ~ (' I:: t L ~ !i,'^:'~~ C' .[;\ ~~\'.x, I\\.., ~] (' ~ ~\ q, 10\ '-., ~ t> L ._._...:...-.--~-_.._. '.. ~ I , ~ _'-0...,,1 I ~' ~ o 0' III d ~Sf?;~ ~ ~~m ~ 1Il ~;; ~ iii ~ ~ V' -- '1:',.1, Jz "!:\ '-'>. ~ "" ~, v\ '" CD <0 Co '" <0 '" CD ~II T r o 1: ~ 1.._ ;;- r -~~ ~ ~ ~ . '" co ~ f ~ r ( '1\ o , r '" 8 8 ~ !; ...c;:~ ~ - ~ l: L~ ~~ -CURRICULUM VITAE- K imherley Garrison Pension Appraisers, !nc, was formed in 19R9. Ms, Cnrrison joined the Finn in IllllH. Pension Apprnisers, Inc, specializes in determining the present value of defined pension benefits for equitable distribution purposes, and assists nttorneys nnd individuals in the preparation of Qualified Domestic Relntions Orders, Atthe present time, the company actively does business in :17 states and Washington, D,C. Since beginning her employment, Ms. Garrison has determined the present vnlul' for equitable distribution purposes of over 2,000 pensions, and assisted in drnfting domestic relations orders, Ms. Garrison has worked with a/l types of plans, including qualified plans which fall under the rules and regulations of the Employee Retirement Income Security Act (ERISA), state and locnl governmentnl plans, the Military Retirement System, both the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FEI<S), nnd the l<ailrond f<etirement System, . Education: Bachelor of Science, .I~nuary '1993 Allentown College of SI. Francis de Sales Center Valley, Pennsylvania Court Testimony: Massachusetts (probate and Family Court) New York (Supreme Court) Oklahoma (District Court, Domestic Division) Pennsylvania (Court of Common Pleas) AI- 'I $P~ W n-,J-C>..'S ~l' .?-- I <-Is " .., r t, ( ~ r '\:~r. . ~ J iii ~,~ ~,i:f,J n i'l' V J: I 1 ~ ' r: 11'-".' t J ~ 'I' \ : \' .., ~~l '. :~ .; i '" t. 7::) q ~" " l'I i:,i,j 1" I , , ~.' , 'i"'; 1.';( IVl. ',fi,t! d. , .. -CURRICULUM VITAE- Theodore 1(, Long, J 1', In 1975 Mr, Long formed Industriill ComnlL'rciillll1vesll1ll'l1ts COlllpill1Y which, lip until '1983, WilS exclusively involved in the eVilluiltiol1 ill1d ilpprilising of commerciill investment reill estilte, Inl9R.1 the scope of Industriill Commerciill Investments business WilS expi'lnded to include the Actui'lrii'll Determilwtion of the Present Value of Defined Pension Benefits for Equitilble Distribution I>urposes, These services include the determiniltion of the present vi'llue of (1) Level Annuities, (2) Vilrii'lble Annuities, (.1) Increi'lsing ilnd Decrei'lsing Annuities ilnd (4) Deferred Annuities, In 1989 Mr. Long formed Pension Appmisers, Ine., which speciillizes in determining the present value of defined pension benefits for equiti'lble distribution purposes. At the present time, the compi'lny actively does business in .17 Sti'ltes and Wi'lshington D,C. Educiltion: University of Richmond, Richmond, Virgin'ii'l Mi'lster of Commerce Degree - June 1968 Lebanon Valley College, Annville, Pennsylvaniil Bachelor of Science Degree in Business ilnd Economics - June '1966 Publici'ltion: "Actuarial Determination of the Present Value of Pension Benefits for Equitilble Distribution" Lectu res: Court Testimony: eenns.ylYania Connecticut (Sllperior Court) Kentucky (Circuit Court) Maine (District Court) Maryland (Circuit Court) Michigan (Circuit Court) New Jersey (Superior Court) New York (Supreme Court) Ohio (Court of Common Pleils) Pennsylvilniil (Court of Common Pleils) Virginia (Generi'll District Court) Berks County Bill' Association Butler County Bill' Association Delaware County Bar Associiltion 8(0.:1 W I ---r-i-Ls.<;:, J <;/-S . ~ . >, I t.. ,'j .0' j, ,I . l ';:1 ; , [,:',\1 . ;; ~ i !',' , :"',\,,,:\ '['! :,') , ..' ., ",'1 ~, \i, "~:"~1 . i:.I,l "Ilj .: ':,I',ij I' . .~. ' :,/:, ....:, .~ ",'~"9 1 '.Vt,'P '!J~;i !j'i',h ' . ~t, ~ :;~ ""1 : ~ ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE STRAWBE:RRY SOUARE: HARRISBURG, PA.1712a'IIOO THE: SE:CRE:TARY , , i , i I I I I I I , I March 21, 2001 (717) 783-3680 MS SANDRA R GOUSE 16 POPULAR ST WORMLEYSBURG PA 17043 Dear Ms, Gouse: This is to confirm your transfer from Wage Imaging Operator Trainee, permanent part-time position, to Imaging Operator Trainee, permanent salary position, in the Bureau of Imaging and Document Management, Imaging Support and Banking Operations Division, at a biweekly salary of $721,50, effective March 19, 2001, You will continue to serve the remainder of your initial 180 calendar day probationary period, which began on December 14, 2000. You will also continue to serve the remainder of your twelve month training period, Upon satisfactory completion of this training, you will be promoted to the Imaging Operator classification at Pay Range 3, Please accept my best wishes for success in your new position, Sincerely, 1T~~~'~Oh Larry p, Williams Secretary of Revenue ).'r ,/ -\- ~ rLPlJ'i\f{'j ,...---c--\ ,..- ,..dr".. _ --. , '-0~ COMMONWEALTH OF PA - EMPLOYE STATEMENT PAY PERIOD ENDING, 02-02-01 PAY DATE: 02-16-01 YT', 091801120000 DEPT: OIB CDC: 02010 EMP', 505972 POS', OB8293 SSN: 172-36-203. B/U, AI PAY RANGE, 02 STEP: I LEVEL: 00 REVENUE IMG/DOC-SPRT /BNKG OP SANDRA R GDUSE 16 POPULAR ST WDRMLEYSBURG PA 17043 : STATE PATD BENEFITS HEALTH BENEFITS CAPITAL BLUE CROSS ANN MED HOSP RET EMP HLTH PROG IREHP) LIFE INSURANCE HORKERS COMP SOCIAL SECURITY MEDICARE RETIREMENT STATE EHPLOYES RET SYS 190.00 116,01 .95 I3,5B 44,73 10.46 4.40 SERVICE CREDIT: STATEMENT o YR 4 PP HOURS,',' PP EMD BREAKOOHN GNOSS EARN HOURS> 02-02-01 REG-MAGE 75.00 RATE, ' 9.62 pp ,END, ',: ,'," "LEAYE USAGE REPORTED BALANCE LAST STATEMENT ACCRUAL THIS PP LY REPORTED THIS PP ADJUSTMENTS BALANCE THIS STMT ,':AMMUAL'" : ' 2.44 2.03 .00 .00 4,47 'PERSON...,l:' .00 .00 .00 .00 .00 5,45 3.75 .00 .00 9.20 MESSAGE CENTER: LOCAL HAGE TAX COUNTY/MUNICIPALITY: CUMBERLAND COUNTY FHT TAX GROSS: 6B5,42 GROSS EARMINGS 721,50 1,767.69 MINUS DEDUCTIONS FED HTH TX S 00 B7.51 190,70 soe SEe TX 6.20000% 44,73 109.59 SOC SEC/MED TX 1. 45000% 10,46 25.63 STATE HTH TX PA 2.80000% 20,20 49,49 LOC HG TX-RES PA 21 934 1.00000% 7,22 17,6B REI P/U CON SlATE EMP 5.00000% 36.08 8B,3B FAIR SH FEE ArSCME - 13 2545 7,22 17.6B FED HTH TX-ADD 5,00 20,00 NET EARNINGS: PLUS REIMBURSEHENTS 503,OB 0, 3 , : ' TOTAL C1iECK AMOUNT .. ,GROSS' ',' 721,50 , TOTAL GROSS,'EARNINGS,:,T1US PAY,:' ,:' "',$",:' :0"',721;50',0' GENERAL NONSUPV EHP MILITARY DAYS CREDIT DATE 26 CREDIT DAYS o CREDIT DAYS 02-02-01 HORMLEYSBURG BORO *5 \\ILf.>1 J'fl ((15 I,.) c~ - ID o m e)C-1 . . COMMONWEALTH OF PA - EMPLOYE STATEMENT ,"" n.v "' Iv... ,. n,.. GROSS EARNINGS 792.75 4,058,'0 PAV PERIOD ENDING, 03-30-01 PAV DATE' 04-12-01 MINUS DEDUCTIONS VII, 091801360000 DEPT, 018 CDC, 02010 FED MIM TX S 00 97,67 569,99 SOC SEC TX 6,20000% 49,15 301.24 EHPI, 505972 POSI, 111896 SSH' 172-36-2034 SOC SEC/MED TX 1,45000% 11.49 70,44 B/U, Al PAV RAHGE, 02 STEP, I LEVEL, 00 SlATE HIM TX PA 2,80000% 22,20 136.05 REVEHUE IMG/DOC-SPRI/8NKG OP LOC HG IX-RES PA 21 936 I. 00000% 7,93 48.61 RET P/U CON SlATE EHP 5,00000% 39.66 262,96 FAIR SN FEE AFSCHE - 13 2545 7.22 66.56 FED HIN TX-ADD 5,00 60.00 SANDRA R GOUSE 16 POPULAR ST WORMLEVSBURG PA 17043 NET EARNINGS, 552,65 '$TATE PAID 8ENEFITS . . . PLUS RE1HBURSEMEHTS MEAL TN BENEFITS CAPITAL BLUE CROSS 190.00 AHN HED NOSP RET EMP NLTM PROG (REMP) 116.01 LI FE INSURANCE ,95 HORKERS COHP 14.92 ~:iDCtAt S~CUftl1'( 4'}.15 MEDICARE 11.49 RETlREMENI STATE EHPLOVES REI SVS 4.83 IUIAL "Alt"A1D BENEF..S $ 3.,.3, PAID LEAVESTATEME.NT .... ..;;:- '..... lOT AL CMECK AHOUHT . . . .......,..$ .552,45. .,>,' SERVICE CREDIT' o VR 8 PP PPEND LEAVE USAGE REPORTED ( ......., ...... HOURS . ..... PP END BREAKDOHNGROSS EARN MOURS ... I... RATE. · .. . GROSS 03-30-01 ... . 75.00 9,62 721.50 <- IV'-'u-v, SH DIF-REG~ 75.00 ,95 71. 25 ,. r--- ~- , TOTAh' GROSSEARNINGSTHIS~AV,' ' '.,$(. 792;75; ,., t; , " ..( PERSONAL .... ...".. '\ ... \\ BALANCE LAST STATEMENT 10.56 20.45 7.50 GEIIERAL NOHSUPV 66 CREDIT DAVS ACCRUAL TMI S PP 2,03 3,75 ,00 LV REPORTED THIS PP ,00 .00 .00 EMP NILITARV DAVS o CREDIT DAYS ADJUSTMENTS .00 ,00 .00 CREDIT DATE 03-30-01 BALAHCE TMIS STMT 12,59 24.20 7,50 ~ \",.. MESSAGE CENTER, LOCAL NAGE TAX COUNTV/MUNICIPALITV, CUMBERLAND COUNTY }"m"" ~o FNT TAX GROSS, 753,11 ~j(JI..' tJAcd 6\3L~. ~60~~ J.{' ~~0KJf) ~ " 5r->cd\M.E ~ . 0 . GOVERNOR'S COUNCIL onl'hysiml Fill/(~s llnd Sports , H- ' . . . '.~ . -, '," '. Creat Pennsylvania Workout . , . I. "f... , ... . '. ~, '" I . .' " . .,...., ' "'" . . , I ,~' ,: .' Keep Pennsylvania on the MOVE! Statewide Events Governor Ridge has proclaimed May 200 I as "Great Pennsylvania Workout Month" and May 9,2001 as "Great Pennsylvania Workout Day." Aprl130-May 4 Minutes Across Pennsylvania May 9 Events are held throughout the Commonwealth to promote physical activity and to improve the health and well-being of all Pennsylvanians. Great PA Workout Day May 14-May 18 Diabetes and Physical Activity Awareness Pennsylvanians who are interested in participating in statewide events should contact the District Health Office at 1-877-PA HEALTH for details and registration information for local area events, May 21-May 25 Osteoporosis PreT1ention through Physical Activity and Healthy Eating 'er 5 a Day-for Better Health! For Your Health, For Your Community. ~MENTOF HEALTH Tom RjdJ:~, Gllvernor Robert S, Zimmermun, Jr.. ScrrcrafJ' of/feo/,II ,j 'j) :;'1'.,'" '1 '~ ;. j " if / " ,,',. '.',<'....... i .. ,~/ ;1 ;" , -.... ~i ~,;L:~ ;~)..','.~.,. " .., ;~j ~ f ':;; ',. ", ,,", ',. , '0- hi~' I ,1.~, [il],,' \'''' ))~i I' \" "<r i '~;, i::~ - , , ro,", 1 040 u:s~i~Ji:id~~II~'~~;~'T~;'n~turn __ 20U_l~) ror Ihe ear Jan I ,Dee 31 2000. or olhor la, ear Il, Iml111 ,2000, end,n Your Fir'l Na~ MI l.." '~MIII label ('I''' If'I""UC.II()II') Us. the IRS libel. Olllclwise. plo;ls'c Sllml or 'Vpo, Presldentlll ElecUon Clmpllgn ('5e.1I1,lruchon,.) Filing Status Chock only one box. Exemptions If 1TI00e than six dependents, see Instructions. Income A<<lch F ann. W.2 and W.2G hert. Also '<<Ich Fann(s) I099-R If tex wa. withheld, 11 vou did nol gel a W,2, see instructions. Enclose, but do nolallach,any payment. Also, ..1........0 use Fa;;;; I040-V, Adjusted Gross Income Ins 111" only - n,llIol ""11.. f~ ..1,W~ I/lltll\ "I,ll" -"-' '-'r-'-'-" ".' I 20 rMO Nt! 1!J.t~ nl)'~ You, SM." S.cUrfly ~ X Slnole Meriled filing lolnt return (even if on'v one had income) M'lriled fillnd sop,;rale relorn. EnlCf spouse's SSN above & full "amo hore ". . .. Hedd 01 hoLisChold (will' qualifying porson). (Soe inslruclions,) 11 Ihe qualifying person is a child bul not y;,;'--' dependoni. ehler this child's namo boro "," auaji I . widower with de ondent child ear S Duse died" . See inslluclrons. Yourself, I; your paronl (or someone else) can claim Vou as a dependent on his or her tax relurri, do not check box 6a ". , , ' . . , .. .. , , , .. . ' , , , . .. . , , , , .. , . , ' , . .. , , ' ~ No. 01 bOll.. ChKkflt 0" .... --Gaaod6b. .,.........,...,.............,.............- No.olyOUf chlldrenDn 6c who: .1I....d wllhyou . did not IIYe wtth you due 10 ~:~(~p. r------I K'It.tructJonS) .. L__.__. D.pend.nts on 6c not .",...d .bove Sand r a II a Joint Ret~n. SpoU'\,ft FlJsl Ho'me R .." Gallse lol..IN.1111l'! d Total mmOOr of exem lions claimed ......,......,...,..............,...............,...... 7 Wages. salaries. tips, elc, AIIach Fonn(s) W,2 ...'.. "......................,.,...... 7 ila taxable Interest. Attach Schedule B if required" ",. "",,'.', ,.."..,..,.,,'.,..', .' 8, b taic-exemptlnler.s!. Do not include on line Sa , , . , , ' . , ' , . , "I 8 b 11 Ordinary dlviderids, Attach Schedule B il required. . ' , ' " "."""""..,....'.'",..." 9 10 Taxable tefunds. credits. or offsets of stale and local Income la,os (see inslructions) """ 10 11 Alimony received"".,,,....,...........,,,......,.....,...,....,......,........... 11 12 Sui;lness Income lit Ooss). AUactl Schedule C or C,EZ " ,'.'""",."",...'",.,....' 12 13 Capillil gain or (loss). AIIach Schedule D if required. If nol required. check here, ,... .. 0 13 14 other gains or dosses), Attach Form 4797 ".,..."" '.",...",.""",...,.."...".... 14 15'TotaIIRAdlstribut'oris."".~ 'I b Taxable amounl (see Inslrs) ,. ISb hi' Total pensions &. annullies ,00= b Taxable amount (see Inslrs) .' 16b 11 Rental reai estate. royallies. partnershi"s. S corporations, trusls. elc, Attach Schedule E .. 17 18 Farm Incom;, Oi Ooss). Attach Schedul', F ........... ,.,.',...'....".,..,.,."..,'..... 18 19 lJnenijiloyment compensation '..',.....,." ,." ,.."..'"...,........... ,.,..,.',,'. ,. 19 2U SociilliciJrilj berielilL .. . , ~ I b Ta,able amount (see instrs)" 20 b 21 atMr iiii:i>me, L1sl type & amount (s.. inslrs) 21 ,22 Add the arriourits In the far right column forlln.s7thril -h-21,Thisis- ou~ loiiilncome~'; 22 23 IRA deduction (see Instructions) ,."""""...."",.,.... 23 2.4 studenlloari lriterest dedUction (see InslrucHons) . , , , , , . , , , .' 24 25 Medical saving's account deduction, Attach Form 8853 ...",. 25 26 Moving exjienses, Altach Form 3903 ..",...".,..',..,,'" 26 V Orie-hall oi sell,employment la" Attach Schedule SE"""., 27 2il self.employed health insurance deduction (see Instructions) " 28 29 Seli-employed SEP. SIMPLE. and qualified plans"., ",.",. 29 3lI Penaliy on eady withdrawal of savings ,.",...,.".,.,.",' 30 31' Allmoni paid b Reclplent's SSN , , . ' ;. 318 32 Add lines 23lhroU9h 3ia "....,,,,,,...,,,,,,........'..,..' .. .. . , . . . .. . .. .. . . .. ., 32 33 Subtract line 32 from line 22, This is our "d usted ross Income .""""...."",..,.. 33 BAA For Disclosure, Prlvlcy Act, and P8pi!rwOrl< Reduction Act Notice, see Instructions, FDlAOI12 11107100 ~ l..il;~-(I {-f' > / ,.J C ewe ltorne Add/est (number and ttrMO. II You HA....,., P.O. Am. St'e hl\truchon\ 16 poplar Street City, Town 01 Pott Office. II You Ua...., ~ rOU!IlJ" Add,!)s", See In\!lucllOll\ ApAtlnlfjn! No 510110 IIPCOIIIl PA ... Noti: Checkllig 'Yes' will not chanQe your la, or redlke your refund, ". 00 au or our souse If filin a oint return, want $3 10 0 to nus fund? ... ,.... .. 1 2 3 ~ 5 63 b SiJse ....,..,. .."... t DepMdont~: (2) Derendenl'S socia securrty number (3) Dependent's relationship to you (4) d l'IU.1lilymgdnld forctllld tal cre~M(~e iMlrudlOnS) First name last name \' r S) 172-36-2034 SroUM'S SM.I., SKUftty N.,"III" '-l--i;~p~rt;;li! 1 You must enter vow <;(1(1111 security numhe'(s) ;tllovf! N" [d' d .[~~] ,I-'-J I' 7.764, ---~2.2-:- Add numbe,.. . ~~"'::':'. . .. 208_:_ 7.994, 7,99'\, rorm 1040 (200.1) FOlm 1040 2000 Tax and Credits Standard L Deducllon fo,Mosl ""nple Single; "'.400 Head 01 household: $6.450 Marriedtilll19 loinlly: or Qualifying widow(er): $7.350 Married filino sepalalely: $3.675 Other Taxes Payments If you have a qualifying child, attach r Schedule EIC,I Refund Have it directly deposiled! See instructions ~nd liII in 67b. 67c, and 67d, Amount You Owe Sign Here Joint return? ::i~e instructions. Keep a copy for your records. Paid Preparer's Use Only 172-36-2034 P",,'2 . ~__~l~_'!~: sand r a R Gause 34 Amount from 111\0 33 (adlusled O'OSS income) ,'.','.'""","'" ' ' 35' Check if: 0 YoU wele 65/0Ider. 0 Blind: 0 Spouse was 65101del. 0 Blind, Add the numbel 01 bo,es c11<!cked above m,d enter Ihe lolal hele " "~ 35a b 11 yoU ale mallled Mino sep, arately and y Jur spouse itemizes deduclilll". ' [1 or you were a dual,stalus alien. see insHJCtions and check here, "" " ' ," 35b is Enter yout Ilerh~ddtdUcllons 'rom Sclledule A, line 28, 0' standard deduction shown on the lell. Bul see instructions Inlind your sland31d deduclion il you checkcd any box on line 358 or 35b 0' If someonl1 can claim you as a depondent """,.""" 37 sublracl line 36 Iriirh line ~ ,.', ,.."., "",., "."""..."..",,""',. "."" 38 11 liO' 34 Is $96,100 Iii leii, mulliply $2,800 by II1e tot,1 number of elemphon' claimed on hne 6d, If hne 34 Is over 196.700,IOOlt1!ioIltk,he<t In II1e InslructlOns ". the amount to enter""""",.,.,.,..,..,' 39 T'Xibl6lricome, Subtract lino 38 from line 37, II line 38 is more than line 37. entor .0, 40 tj, (,iOIMh,Hhid< II {oj la, Is Irom i 0 Form(sl8814 b 0 Form 4971 ,....,..,.,....,..,' .. ' 41 Allernatlve minimum lax, Attach Ferm 6251 ."...,...,...,.,."",.,",.," """ 42 Add tines 40 and 41 '..'", ,.'"". ,. "",.."....."..,',.., ",.'", ",.,.....',., 4i Foreign tax lildlt, Attach Form 1116 If required ,.""""", 43 44 Crodit lor cf1i1d 1,.J d,piooenl earo expenses, Mach Form 2441 ."",.", 44 45 Credil lor thi eld,;rly or the dlsabied. AIIach Schedule R ",., 45 .\6 EdUCation credits. Attach Form 8863 ",......,..,...,....,' 46 41 child la. cnidii (see Instructions) ...",.",.,.."....",.,' 47 4il Adoption credi!. Attach Form 8839 """,...' ,..'..',..',.. 48 49 olller, Check illrom.:, il 8 Form 3800 b 0 Form 8396 t 0 Fdrm 8801 d Form (specify) 49 sO AddIiOlis4illi<ou~hI9,The!'areyourtolalcr'dlts ....",..",...................., ..........' 50 51 sublract line 50 hom jlne 42, 11 line 50 is more thari line 42, enter ,0. .... . , , ' , . ' . , ' , . , ," 51 52 Sclf.emploimenl~dlt3ch Schedule SE ....,.........."......,......,..,......"......,...., 52 53 Social seCuiity lOll Medicare ta, on tip lo<ome not reporteO 10 employtr. Attach Form 4137 ' , , ' , , .. . .. ' , , ' , ., 53 54 nix on IRAs. blhei fellrement plans. and MSAs, Attach Form 5329 If required, . ' , . ' , . ' , . " 54 55 Advance earned IrlCome credit payments from Form(s) VI.2 .""",."..",.".,""",. 55 56 Household ~mplciyliiehllaxes, Attach Schedule H , . . . . .. .. , , . ' , . . . , , , ' , , ' . , , . , , ' . , ' , , ' .' 56 51 Add lineS 51,$, Thl. Ii our tolll IIx ,..,..' ................,...............,..........",.. 57 58 Federallricome tai withheld from Forms W,2 and 1099 ",.', 58 1 066, 59 200l estimaled Ial p;ym;ni> and amounl applied Irom 199'3 roturn ........ 59 60i \!:airieci lricollie d'dtl (E1C).., ....,' ".""......".,....,' 60a b Nenlaxable earned Income: amount" .. arid type," , 61 Excess soclalsicli;-ify -;'ii'd-RRTA la-;; ;;u,h'eid ("~ei,;sir"s) ,-: ,-: 61 62 Additional child ta, credit. Attach Form 8812 ,.....'"....',' 62 63 Amount paid ~~ r€qtiiSt lor ,it,nsion to fiI, (see Instructions) ",.".", 63 64 Other payments, Check If from, . ' , ' . 0 Form 2439 b 0 rorm4136,,,, , ,....."..,."..,.,.. ,..', ,., ".",., 64 65 Add lines 58, 59. 6Oa. and 61 through &\, These are your 10t.1 payments ..,.....,..., ,....',.,.. ......" ........,."...........,...... ,...,." 65 66 If line 65" 111010 than line 57, subtract IIn, 57 from line 65. ThI, " the amouni you overPaid , . , , , . , , . ' . , . , ,. 66 &73 AmOuriloilihe 66yoilwanl ritfundedioyoO .............. ,...,.""........ ,..,.,..... 678 .. b Routing number,. , , . , , , " c Type: 0 Checking 0 Savings " d Accouni iitJinber ...,.., 6ll AmOunt.' ii,! is yi,d Winl applied 10 your 2001 estimated Ii. ; , . . , . ,.;.. 68 69 II Itri. 57 is moreUian Hoe 65. subtract tine 65lrom line 57. This is the aniounl you .. -~ owe, For delailson hOW to pay. see Instructions....".......,...."........, ..,..,.., "" 70 Estlmaled \a, peiialtY, Also Include on lille 69...,.."..,..,. 70 ';'{;{ '";;,,,j, ,,'.:',;, ,'J' Unc\ot' P.l'flIlties of perjlry, I d&clare that I have examined th s return end accompanying schedules and sta\.emcnts. and 10 the best of my knowledQo and belief, tnlly are true.wrect, and eompleto. Declarallon of Jlleparer (other than taxpayer) Is based on all inf0mt3lion of vdlich preparer has an)' kncwoledQc. ., vOU'Slonalure Dale Your Occupation Daytime Phone Number FOlA0112 10130t00 . ' spouse's SlgnatUle.11 a lnl t'turn. ~ 36 37 4,400, 3 , 52,4~ .. 38 39 40 41 .. 42 2 800, 794." lL~." U.8., 118, 118. 184, 1 :>.50, 1113~. 1 132, uslSiQn. D.lle Beaut I ci an SpotM'S Occupation May \toe IRS discusS this return 'hith the pt'eparer shown below Y , (see instructions)? es Prtparef'S ssN Of PTIN Dale Prepafllf'S .. Signature ~ Film's Name (oryoosit sell.employed), Addt~, and ZIP Code Check if self.employed set -prepared [IN PlooM No, ~ Form 1040 (2000) 'Schedule C (Fo"n 1040) Profit or Loss from Business _~~~.~":"~"':~ (Sole Proprietorship) 2000 10 I>arin.",hlps, Joint venture., etc, must file Fonn 1065 or Fonn 1055-0, · Attach 10 Fomt 104ll or Fonn 1041, . S..lnslrucllons for Schedule C (Forl11 1040), 09 Sod'" Stcurlty Ht.mbt, (SSM) oi11ol1l"WIlI oIlf~ r,.~ury t,.Ip'nA' n....nllIlI Se'VQ (99) N.tInl'O"'It'lpllnW Sandra R Gouse A Punc"",,1 OIlIIM" Of PrOIMsiotl. lrddinQ ProdUct Of Selviclt (SH In.llllclion1) 172-36-2034 B fnter Cod. from In&tnxUonl Service: SlyllnR & CuttlnR Hair C [lu-.loeSS Name. II No Sep,ri,ale Dusinetl Name. leave blank. . 812112 o EmplG)"H ID NlI'nb.r (ElM), If Any E g~"~~~(ii\j'~i'f:&"l,~"'r~)~~.QQ. .M,!m_s_~V!1~t !~te.!1~ LO.!1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _", '" Enola, Pa, I7n5 ,. F Accounling melhOd: (1j IRI Cash (2) 0 Accrual ~ Olher (specify) . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ G Did you 'malill'ally parlicipale' In 11>8 dperal/on 01 Ihis business during 20001 If 'No.' see insfruclio". (or limilon losses, , " IRf Yes No H If ou slarled or ac uircd Ihis business durl 2000, check here" .. , " , .. .. , .. .. ' .. ' , .. , .. .. ' .. , .. .. , " " .. , .. .. .. , .. .. , " .., _ Part I Incoine Gross receipts or sales,CauUori: II this Income was reported 10 you on Form W,2 and 1I1e 'Slatulory employee' boic o~ lhal 'orm was checked. see the ins !ructions and check here. ' 2 Returns and allowances .',......:.;..............,.....,..".......... 3 Sublracl line 21rom line j ";......,.",.,...........",,,....., 4 Cosl of goods sold (from line 42 on pad;; 2) ,.....,..,..'".'.,..., " -0 4,}J.1..: 1 2 3 4 4 J}~-,- 5 Gross pronto Subtract line 4 (roni line:1 ..........,.."" . , , , , ' , , 6 Other income. including federal and state gasoline or luel tax credil or refund " 5 6 4.J).4.c 7 Gross Income, Add lines 5 and 6 .. , .. .. .. .. . , .. .. .. , .. ' , . .. . ' , , .. .. , , . , , .. , , , , . . , , , , , , , , .. , . , , . .. . 7 Part II Ex enses, Enler ex enses for business use of our home onion I",e 30, 8 Advertising.............,...... 8 19 Pension and profit.sharing plans, . ....... 19 9 Sad debls Irom sales or 20 Rent or lease (see inslrue/ions): services (see inslructions)...... 9 'Vehicles, mAchinery. and equipment...., 20a 10 Car and truck expenses (see instrs) "" 10 b Olher business property. , ",.,. '.....,.. 20b 11 Commissions and lees, , , , , , . .. 11 21 Repairs and mainlenance "" ,., 21 12 Oepletion......,.............. 12 22 Supplies (not included in Pari III) ........ 22 13 Depreciation and Section 23 Taxes and licenses ...".,."........... 23 179 expense deduction -, T I I d t ' I' (not included in Part III) Of rave, mea s, an enter alOmen . (see instructions) " .. .. .. .. .... 13 j Travel ...,........'"......,'..,......, 24. 14 Employee ooneiit programs b Meals and (olher than on line 19) """'" 14 enlertainmenl,....,.", . II. I: Enler nondeduclible 15 Insurance (olher than hea h) ." 15 amounl included on line 16 Interest: . 24b (see instruclions) " · Mortl'\!< (paid 10 banks, .Ie) .,.,.", l/;a d Subtractli"e 24< from line 24b ""'.",, 24d bOlher..........."..",......, 16b 25 Utilities,.""."".,..,....."."..,.., 25 17 Legal & prolesslonal services", 17 25. 26 Wages (less employment credils) ....",. 26 18 Officeex nse ..,......,...... 18 623. 27 Oiherol nses Iromline48on ai,,,...... 27 28 Total. .xpenses belore expenses for business use o( home. Add lines 8 Ihrough 27 in columns ,."".."",. 28 4,134, 73S, 1. 466. 3,926, 29 Tenlative proiil (lass), Sublraci line 2illrom line 7 ...,......."......,'....,.........,. "",..........,.. 29 30 Expenses fei bUSiness use of your hOme, A<<ach Fomi 8829 ..,'........ ' , , . . . . . . . . . .. , . , , .. , .. .. .. . , .. , ", 30 31 Net profll oi ~ci..). Subtract line 30 from tine 29, ;, If a profil, ,,,,ter on Fofiii 10401 Un. 12, and also on Schedule S1',llo. 2 (stalulory employees, see Instrucllons). Es ates and trusts, enler on Form 1""1, line 3. · II,a loss. you musl go !o line 32, 32 If you have a toss, check the boic tha! describes your investmenl hi this activity (see inslructions), · II you checked 32a. enter the idss on Fonn i04O,lIne 1;:, and also on Schedule SE, IIn. 2 (slalulory employees, see instrUctions). Estales and trusl!,. enler on Form 1041, line 3, 2tJg, } 20S. 31 . II you checked 32b. you must attach Forni 6198. BAA For Paperwork Reducllon Act lloUce, see Fonn 1040 InstruclionS, } D Some investment 32b is not at risk, Schedule C (Form 1040) 2000 O All inveslment IS 328 at risk. FDiZOlli 11121100 91.\5. 129, Schedule C D,m 1040 2000 Sandhi R GDuse 172 _ 36-2034 p,,!!!, 2 Part " Cost of Goods So d seu Insllucloe~ 33 Melhod(s) used 10 value closing liwenlorY: i LlCo';'-b~~;-;;;~;'I~;;;;';;k~'-;-O Olher (,'l1a~i'-;'-nr.;;'~II~';)'" , 34 ~~~e~~~I:~~ ~~gl~~~I~~~t,e.'~I,~'~~, ~U,~~liIl~~: cOSls, 0', v~'ua"ons. be,lw,een OpOlllng a'~f closlngin~,~~t~ry,?, ,,-,-~f~_lJ N~, 3S Inventory at beginning 0' year, II dirterenl 'rom 'asl ye.,,'s closing IIwenlo,y, alloch eXflJanalion . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 36 P,Ke hoses less cost 0' lIems withdrawn 'or personal use " 36 37 Cosl of labor, Do not Include any amounts paid 10 yoursell , , ,,,'...,, 37 38 Materials and supplies.. , , , .. , .. .. . , , , .. .. , , , , , , , , , , , , ................ 38 39 Olher costs..",......,......,...........,....,,,,.., ---..- ................ ....,..",,,..,,.. 39 40 Add lines 35 throUgh 39......,..,......"..,..,,,..,,,.. , . . . . . , . . . . . .................... ~ 41 Inventory al end of year ..............,,,,,,,.............., ......",........ ,......,..", """""" 41 ods Sold, subtract line 41 Ircirri line 40, Enter Ihe resull here and on a e I. line 4 """""""" 42 Irilohriiltloll tin You~ Vllhlcle. Complete this pari only if you a'e claiming car 0' Iluck expenses on line 10 and are nol required to file FOlm4562 fOI this business, See the inslrucflDns lor line 13 fa find auf jf you musl file, , 43 Whon did you place your vehicle In service /0' business purposes? (monlh. day, yeal) . ----------- 44 Of the lolal number 0; miies you drovti your vehicle dUling 2000. enler the number of miies you used your vehicle 'or: a Business _ _ _ _ _ _ _ _ _ _ _ h Commuting _ _ _ _ _ _ _ _ _ _ _ cOllier _ _ _ _ _ _ _ _ _ __ 4S Do you (or your spouSe) have another vehicle available for personal us.? ,...."..,",..,.."""""....""", ,.."DYes 0 No 46 Was your vehicle available lor lise durlrig oif'duly hou,s? ,,' , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,DYes [lNo "DYes [lNo 47 a Do you have evidence to suppori your deduciion? , , , , , , , , , , ................................................... b If 'Yes: is the evidence lYfitleh? ,..,..........,......"""..,.., , , , , , , .. , .. , , , , , , , , , .. " , , , , , , , .. . , , , .. , , , , , , , , .. .. Part V Other Ex enses. List below business ex enses not included on lines 8 _ 26 or line 30, No 1~~~It~_~~2~WE~S~~~~~~~__________________________________ Jb~~_____________________________________________________ ~~~~f~~g~~_______________________________________________ 780, 664, 22, ------~-------------------------------------------------- --------------------------------------------------------_. --------------------------------------------------------- --------------------------------------------------------- --------------------------------------------------------_. 48 Tolal olhor expenses, Enter here and on page I, line 27 '" ...........,.................................. 48 1,46(" Schedule C (Form 1040) 2000 ForZOl12 0612.3100 If I" d , I '" , I ~ ' \ I, ~, \ t. p , I (1",( '/' ',' I:.,: 1':'\'."1 j ,.<i, I' ,.J., 1". 'I tJ . ! 'I 1','1 : 1 ' '. ,I,. , '\, !>:~ , (. .:,--:;;:.~ I EX 0 RS R A 0 FS S FY 0 SC 21250 PN 717-728-1775 lC 8106 .00 4 208.00 ' ' 7 .00 , .! 10 .00 , ....J , ,.IlL~AsE , DO NOT USE VdUR LABEL 0000114017 2000 PA.40 Page 1 of 2 ~."...._-... ......-..___4..__..._...,. 172-36-2034 GO GOUSE SANDRA R 16 POPLAR STREET WORMLEVSBURG PA 17043 LA 8113;00 2 22 . DO 5 .00 8 :00 11 8336; 00 lB 3 6 9 12 67.00 ,DO .00 11336.00 233.00 ..., .....,-....~..w.~..__......~. ,,_ ............_ .... ---------------------------------------------------------------------. Please fold page along Ihis hne Local'nlonniU.n, Enlei where you lived as of 12/31/00, School District: Eas t Pennsboro School Code: 21250 Counly: Cumberland Municipalily: Eas t Pennsboro Extension, check Ihis box. Amended Return, check Ihis box, Fiscal Vear Flier, check Ihis box, Residency Status, (Chech the coired box' R X Resident NR Nonresident P Part. Yea; Ri,;:ldOril From: To: Type Flier. (Check only one box) S X Single J Married. Filing Jolnlly M Married, Filing Separately F Flnal D Deceased Date of dealtl 1a Gross compensalion. irom PA Schedule W,2S. or your Forms W.2 or olher slalemenls, 1. 1 b Unreimbursed employee bUSiness e'Penses. Irom PA Schedule UE .."",..,.""" 1 b 1 c Nel compenSalion. Subl"jc!line i b Iroin line 1 a ....".."....,.."....,,,,,....,,,.., 1 c 2 Inlerest income, Complete and .,!Ociose PA Schedule A if over $2.500 ,".""""",'. 2 3 Dividend Income, Compiel. and entlose pA Schedule B /I over $2.500 .,'.'"'."".,, 3 4 Net income or 16ss /rom !tie bperation'ol business. profession. or farin .",'.""."", 4 5 Net gain or loss /rom the Slile. exchange, or dlsposllion of properly, . . . . , , , , . . . , , . , . , . . , . , , , , , . 5 6 Nel income or loss Irom r"iiis, ioyallies, palen Is. or copyrights, . . , , , . , , , , , , . . . , . ' , , . , , , , , , . ' . , 6 7 Estaie or trusllncome, Complele and eriClose PA Schedule J .........."........,... , . . , , . ' , , 7 8 Gambling and lottery winnings.. , .. , ... .. , " . .. .. .. . .. . , . , . , . . .. .. .. .. , .. , , . , , , . . . , , ' .. , , . . , 8 9 Tot.ol perinsylvanli talcibie Inconili, Add bnly the Posilive income amounts from lines lc. 2. 3, 4, 5, 6, 7, and 8, Dei iioUdd any lossesreported on lines 4, 5, or 6 ......"..."" " , " , " .. ' , 9 10 ContribuiJoni 18 YoU, Miidic.!l Sllvin/jii Account See lhe 'nsiruellons """"""" "" '.., 10 11 AdJusted Pennsylliani. lixable income. Subtract line 10 from line 9 ,.,.".",....".,...., 11 12 Pennsylvanl8!.ii< lIiblllty,llulllply IInli jj by 2.8% (0,028). Also enter on line 13, page 2 "'" '" 12 PAIA0412 11116100 8, 173 ,00 67.00 8,106,00 22.00 ,00 208.00 ,00 .00 .00 .00 8,336,00 ,00 8,336.00 233 .00 @ 0000114017 ---J L tc FC CD ~ CD 0000114017 L ~ .;':''.'~ .. '"'" 13 Total Pennilylvlirili fj" 1I06l1lly, .. , Enler your lax liability from line 12 on page 1 ..,......".".",..."..,.." ",'.,. """"" 13 t4 Total Pennsyiv.nla l.ii ~tlihO'd,lnirri '1/.2, J>A Sd..;dule W,2S, or your Forms W,2. or olher slalemen~ , 14 15 Credit from v6Ui im Pennsylvania IriCome Tax Relurn :"" 15 16 2000 estimated Installment payments ',.,'",.,..",.""., 16 17 2000 exlenslon ~aymenl ..,..,.: '.. ,....,.,.."...,....,., 17 18 Nonresident iax withheld on youi piA Sdiedule(s) NRK,I " .,. ill 19 TOlalestlm.tedp.yme;;I~.ndcfed1~,Addlines 15,16. 17,and18 ....,",."."..,...""" 19 Tax Forgiveness Credit. CDmplele lines 2Oa, 2Ob, 21, and 22, Read Instructions, 20. Filing SlattiS: XUnmar,led dr Mparilled Married Deceased,..." """"" '."" 20a 20b Dependents, Part B, 11",,2, PA Schedule SP '.... ,.."..,..."............,."",.",....", 20b 21 Tolal eligibilliy Income, Part C. line 11, PA Schedule SP " . , ' , , , , .. . , . .. . . , .. . , . , . , .. .. , , . , '" 21 22 Tax Forgiveness Crl!dit ;"om Part b, Iliie 16. PA Schedule SP '" ,..,",....",.".,..,.",.", 22 23 Tolal credit lor taxes paid to othe; slales or countries, Enclose your PA Schedule G or RK.I ,,", 23 24 Pennsylvani. Employtiientlricenuve p;ymenb Cridil Enclose your PA Schedule W, RK.I or NRK.l " ' , , , , . , , , , ' . , . " 24 25 Pennsylvania Jobs Cr~lion Tax Credillron; eildosed c.rtificate or pA Schedule IlK,! or NRK,' """',..""."" 25 26 ~ln~~~~ ~~~!~r~~~r~~I~~ ,I~,~~~'~~~ ,~~~ ,~~~~I,t: ,fr~~ e.~'~~~. ~:rtilic~,le. ~~ , . , , , . , , '. 26 21 ~"~'A'~~~~~,~~~~lct t%f.f~~I~~,~I,:~~,~~~:t:.~~~,e~~i~..,~~ ~.e,~ifi,c,~I:."."""".,..,. 27 28 Toia' PiyiiieiilSind ci'edtls. Add firies 14. 19 and 22 through 27 ......"...", ',..,..,,'. , "', 28 29 Tax Du., If line Iii is more than 11",,28, enier the difference here,...,. ,....,'.,'.,.. "'....,, 29 30 Overpaymenllf 11",,28 Is inc,e lhah llrill i3. enle, the differente heie """.",...,...",.:.,' 30 31 Refund - amoUnt 01 line 30 you waril as a chl!ck rnalll!d to you, , , . , . . , . . . . . , , , , . , , , , Re'und 31 32 Credit - amolJO! 61 Ii"" 30 you ilia;;1 at a ciedit t6 your 2001 estlriialed lax account """""" 32 33 DonaHon '- ariiount olUne 30 yoU wanllo donate 10 the Vllld Resource ConservlltlOI1 Furid ..,. 33 ~ Donallon - ainOiJIll 0/ liliil30 yOU Wanlfo dOhate to the 0.$, olyirijilt Commlilee, pA Division" 34 35 Donallon - amount 01 line 30 you lVaHI to donate 10 the O''lJllri DoiiO, Awareness Trost Fund. ., 35 36 Donalfon - amOunt of line 30 YOll wanllo donale to ihe Kc\/'OelVlelriAlii Memonal, Inc "'" , . . '. 36 37 Donation - ariiOUnl iil lihil30 YDll Wantlo donate to Breast and Cervltil C..ncer Ile....rch '.". 37 The toial 0; lines 31 Ikiiluh 117 niusl 'oatllrie 30, ~fr:g~~~ ~:~IJe~ ~~!hat '.<we) ~~ examined this ~urn, fnclud1no all ecx:ompanylng sche<lules and slalements, and 10 the best of my (our) belief they Your Signabn Dale Yoor Occop3llon ...J 0000214015 . '''..-......-... ...'".......,.......~. ...,..~~........._, GOUSE SANDRA 13 233.00 14 1b ;00 17 19 ;00 20A 21 a33b.OO 22 24 ;00 25 27 ;00 2/\ 3D ~3.00 31 33 .00 3lj 3b .00 37 R 01 229.00 .00 47.00 .00 27b.OO 43.00 .[]o .[]O . ~ ~._--.__....__......_........., "~"-' SPOUSO'I 51QllItur. if Filma JoIntly ....- 0Ic....,."'Y N_, "",",'_ T_.) Pleparer or Company Name (please prinl) Dille '# Signature of lhe Prepare. (optional) Self-Prepared L 0000.214015 PAlA0412 11/16100 2000 PA-40 Page 2 of 2 172-3b-2034 15 11\ 20B 23 2b 29 32 35 DO .00 .00 .00 .00 SPOuse's Occupation Dale L .00 .00 .O[] .[]O .00 ,00 .00 233 ,00 229 ,00 ,00 01 00 8,336.00 47.00 .00 ,00 .00 .00 .00 276 ,00 .00 43.VO 43.00 .00 .00 ,00 .00 .00 .00 Beauti c i an i't ':'j Telephone Number 0000214015 --' ....J pA SchedUlli Ue: Allowable Employee lJuSlhess Expenses ~~:t.lf,.~"'l'Jr0l~vm.t " 2000 N...TWt 1)/ "'pI",,' CIaImInQ EJpenset: Sandra R Gousl! t'.1I1Plov't", N.vne: Deoartment o~ Revenue I)nctlbf Ihe Out.es of h Job In IM1id1 YOlllnwred TIltH E.~f1se\: Clerk Part A. Employee Busllt~ss I;IlPeh6es. Clullon, Vou may 1101 ~e Ilnil4 0' Form 2106 or Form 2106El. Vou musl itomile Ihese e'penses in ParI G of this schadul.. Vehicle experi"" slancWd ",lIilll.;b ratb. ' Filing lip, If yoU dci riol iliA Foim2106 b; :illi6Ez. enler your lolal business miles mlloooe rale ' ' ,Ehler the resull on fine I. 1 Enter lhe amoun! fidmyour Ferril:ii66 or line 1 of Form 2t06EZ.."""" VehIcle expenses. Actuiil Iriivol tin<! mllellge e;penses, 2 Enter the amoUnt trom idlJf I'orriI2106. Make the followlno adjuslments .'", ""....',.. ," 3 Add back the IncluSldn amount, tlit~ adjUstmen! does not apply for Pennsylvania purposes, . , . ' , , . , , , . , . , 4 Depreclalion, VOU m.ylJi~ any aem;iillly accepted method. If nol USing your Form 2106. enler your depreclaliori e,pense.~,r1d tomprele line 5 ".."...""......""..".."".... ..'"",".."",'" 4 5 Depreclallon methcXf ,,;.i,;:...c.. \:,' 6 AdUlt trjllei Ii\d ffilla,GS i.jilin"_ to; I'enn.ylvonla purpo..., Total lines 2. 3. and 4 .'".,.",.. .', 6 7 Parking fees, toils. ilnd IransiloHiltion, Ehler lhe amount from your Form 2106 or Form 2106EZ..,."",., ,7 8 Away from home overnlQhl. Eriter IIi<l llii1cilinl irom your Form 2106 or Form 2106EZ "'" "",'. ,.". "" 8 9 Meals and en!iirtairimenl expenses, Enter lhe amount from your Foriil 2106 or Form 21 O6EZ .,.'",.',," 9 10 Totafex'nseSlorPilrlA. Add lines I of Gand 7. 8. and 9 """",,,,, ".",,,, '" "" ".... ".... ". 10 Part B, D re Em 10 ee Bli!llnllS~ Ex llnses. 11 Union due..lisl Uiiion name(s) arid amounl(s) paid, Enter total. Altach additional sheets, if needed. N,meal union(s) lnd jniOun~l\ ..,..! MsHe 12 Worlc clethis inil Ohllolms. Required es il condition 01 employmenl and not suitable for everyday use, Description.."..,,, ". 13 Smlll 1001. iiid $uppllil, ReqUired as Ii condition at employmenl and not provided by your employer. Descfiption ......... ;;; 14 Professlon.lllcense i..., mlipiactfc6lriStirii\Ce. and ndollty bond premiums, Required as a condition of your employmonl Descrlplion .."".."., ' 14 15 Tolalex "nses lerPirlS, Add lihes tt. 12. 13. and 14..",.."..,........",,,....,,,,,,,,,,,........ 15 Part C, Office or Wo' rei Ex 'nses, Vou musl an.wer Alllhree ueslions or Ihe de arlmenl will disallow our ex enses. Cl Does your employer reqUire YOll to maintain a suilable work area away from lhe employer's premises? , . , . C1 1 Ves ar~ C2 Is Ihls work area \110 prlnelpal place where you perform the duties of your employment? ". , , . . , , , . , , , , , . , C2 1 Ve. 2 N. C3 Do you use this work aloa,tegula,iy and e,eluslvely 10 per'orm the duties of your employment? ",."."" C3 1 Ves ~ N. If you answer veslo AillhrOli qlJeslionS. continUe, If you answered No to Ahy quesli.n. you may no! claim at home e'penses, Actuat office ilr wort. ltil/lii,lelias. En\!ir expenses 'or the enllre year .rid then calculate Ihe business portion, a Depreciallon expeiis~(OOiiieoWriefSoiijy) ,.."., ..,...,..',.... ,....". ..",,,,,,,,,.',, ". ...."""... a bReal estate laxe. ........' ,:,........ ,.. ..,..",..,,,...' ,....,...,., ,,,..,,,,,..,,,, ..".,,,,.., ".... b cMorlgaoe Inlerest (homeowners only) ,..""".""""".. ,.."....".' ..,..:"" "". ".'" ,...."...., c d Ulililies .....",...............,....,............,......,...."...."."".."...."......,.."',....,, d e Property insurance, "..;;,..:. ......."..."",..',,, ",,,..,....,, '" ....",.. '.... ,,,,.,,,,,,,,,,.. e I Property mainlenar1Cil, lleiiilze iii! type & aml., maintenance .,penses I,'tuned '.' I g Other apportionabl. el;ierisi!, lleinlie fhil type to ami .1 these expenses ., g hRenl (renters Dnly) '..:.', ,:"". ,;,;,...,."......",...."........, '" ""....,,,.,, ,,,,,....,, '...., h I Total. Add lines a Ihrolilh H. Enter tHe total here, .. . .. .' .,.....,.....,.,,,..,,,,,.,,.,,,,.....,,,.. ,. . " I I Business percenlaQ9 01 properly. bivide the total square ft'olage of your work area by the total square foolaoe of your enllre properly, Round to 2 decimal places,......,...." ". ,,,....,, ".., ".,....". ....,. I Ie Apportioned e,penses, MuHiply line I by the percentage on Ii"e i . ,....". "......",,,,, ,,,,,,,,,,'.,..... Ie I Total office supplies, lI.mize supplies you purchased e,c1uslvely lor lJse In your office or work area .,.. Total I 16 Totolexperiseslorl>iHC, Add lines k and I..,.,,"...."..""....".. ""'..',,. ,,,,, "......,.,... 16 0001714013 orflCIAl tJ5f 0'4.V Soc...ISnflJlltty'lllm~': 172-3G-20H [ml,hl'fIIn,AcIctlllu [fIl(l~'" r,.IIIl.;111O Number: 18 5''--~r_<?.9_~)!QQ.d_5JI.c_CJS 23-2172299 mp!ovt'fS l!lellhofle 1I111tM!,: "83-3019 and mulliply by the 'ederal standard 2 3 11 ~.7..., 12 13 --- -J ------ ..' 67, % L 0001714013 PAI^,412 11116/00 00D1714013 --.J . ....J PA Schedule Uti Allowable Em. ployeEl Business Ex2ellses PA.olA!IOOIOO' 000 PA OEPARlflEtIJ' c# REVENuE I .. 0001814011 OffICIAL USE "lflL'f N,lrM 01 '..PAyef Clalm"'IO Elptmes: Sandra R Gouse Part 0, Moving Expense~. . Enter lhe nOOlber 01 miles from your old home to YOlU now workplaco .' ' , . , , ' , , , b Enlor 1M number oi miles from youl Did homo to your old wor kplaco " c Subkact line b Irom line j .od .nlir the dlff,r,nce " , " , , . , . . ' , , , , . . , . . , . . .. . . , " " .. . ' , ' , If line c Is 50 miles or more, cDnlinue, If nol alloast 50 miles, IOU may not claim moving expenses, 17 Transportation upilhSe$ In movlhO household goodS and personal effeels "" ' , ",." ' ,.' 17 18 Travel. meals, arid looolrid ilx~eHSes IMlng Iho aclual move from your old homo to your new homo 18 19 Tol.,..pirise$/or Part D, Add ilneii 17 and 18 ,..',.,...,'........,....',..,.'.'.'"'.'".'..,,..," 19 Part E, Educatloh!;:xl>enses, You must answer AIf Ihree queslions or 1110 doparlrnenl will disallow X?ur exponses, E1 Old your employer or a law require thai you oblaln Ihls educ,ollon to relaln your present posilion or job? "..., ,0 1 Yes If you answer Yes, conlinue, il you answ~i !lcl, you may not claim ..ducillion expenses, E2 Did you need this educatlDn to meellhe entry level or minimum requlremenls 10 oblain your job? ""'...',, , '8 Yes E3 Will this .dueallon prOgrdm or cduiUl 01 study qualify you for a new business or profession? "".,.".'""" 1 Yes If you answer No 10 bolh OJ,,sliDns. c/jntlhti<i, II you answer Ves 10 either queslion. you may not claim educalion expenses. 20 Name of college. university 01 edJcallDnallnslllutlon 21 Course of sludy 22 Tuillon or i..s . , " . . , , . , , .. , .. .. .. , , .. .. , .. ' , , , , .. , , , " .. . ' . , , .. .. ' . , , " , ' , , , .. , 22 23 Course materials",.." ,.... "..,......""""..,..'""..,,, ".. "......" ".' 23 24 Travel e.pilOse. ",,,:,, . , " , :;1.. , .. " .. .. .. , .. .. .. " .. , " . .. , " .. " " .. .. " .. 24 25 Totale.rises'dr piil ii. Add lines 22. 23. and 24 ",.....'.......'"......."..".'," 25 Part F. De recl6tfotl Eil nse~. Do I10t include vehicles usa Part A and office or work area use Pari C e. enses. (I) Description 01 properly, (Ill eost or (c) Depreciallon (d) Depreciation (e) Secllon 179 . oloor basis method deduction expense StlCllI' ~t>(U"fy N'""!ll" 172-36-2034 I miles mile" miles -~ 0 2 No B 2 No 2 No b c ..~ (I) EJcpen:;;;-! Add (d) + (C)J 26 Tolalex" hseSloH'lIrl F. Add colunin I...."..,.... ,....",.. ...'......"".,.."..'.'..., ,,,... '..' 26 Part G, Mlscellart~oUs Ex hses.ltemize \he and amount of ur additional e. nses. Includin e. enses trom Form 2100 or Form 2100El, a '",.~., a b b c d c d e . " " .'. e 27 Tolat mlse"lllineous ex "~"s lorl"tt Q, Add lines a itiro he.....",,,,,,,,,,,....,,,....,..,,,,,.. 27 Total.llowabloi penris vinli em' d ee aUSlhoS. e. 'nses. You must also accounl for reimbursemenls. If an . 28 Total eXll<inses, Add lines 10, 15; 16, 19.25.26. and 27 ....,........"",,,,,,,..,, ".....,,,,,,,,,,,, 28 67, 29 lIelmbursemenl.. ~nter reimbursements thai your employer did ~ol report as la.able wages on your Form W,2 .....".,..,..,....;.."..,,,,,....,,,,..,..,,,......,....,,.,,,,..,.,,,.,,,,,,...... 29 30 Net..penseorii!lm~iJf~morit..,;......,,,,,,,,,..,,....,,,..,,..,,,,..,..,,,......,...."",...." 30 67, tllln. 28 Is More ",an line 29, enler the difference on line 30 and include on line 1 b. unreimbursed employee business e.penses, on your PA-40, If IIn. 291. Marti than IIno 28, enler tlie difference on line 30 and Include the excess on line la, gross Pennsylvania compensation. on your PA,40, L 0001&14011 PA1A1412 l1f161OO 0001814011 -..J '- ,-~ Wage Statelt1ent Summary L ?A ScIood.... W.2S <09,00). 2000 , A. DEPARTMENT rjF nt.\'tMJE Of r ICI^!, 1,',",',_ ()I ,I . ;:'~~'r':S'~-:~~::;'"'~"~ r..n.l~n: ---------,.,--...- ~;.;'~~~,:,;;;~: ,- Instr~ctfonL Instoad of subrniturlQ your Form(s) W.2. or photocoplcs. you m;y-r.l1lm tt;""~-;;-;~'~Y-;;~on t)Clow. Keep your o;~in.1iF~;;;I~: W.2. ImportanL Your Pennsylvania compcnsaUon may 00 different from your ledewl wages. Caution. If you belrevo Iha! a Pennsylvania Drnollfll on your Form W.21s Incorrect, you must submit YOU( aclual Form W.2 With a wutlcn p.xpianahon from your employer. You must submit olher statements'Of amounts you arb repot't!no 85 compensation on your Pe'~~Jva~a tax return. _ ,,_ InformlUon 'rom tach Font! W.2. Humber of Fonn(s W.2 a Employer Idenliflcation Number Irom Federal wages from box I box B , 2_ 23-2172299 2 3 4 5 ...2.. .. 7 Total ............ ./,..... '.. '... ......... '."...."...,... ::~&:~~~,"cf'riE~ Interest and Dividend Income Nilme(~) as StlCM'n on YOt" Penl'lsylvanta Ta. Return: -1 0001211jQ14 " aU need more s aco, au may photocopy IIllS schedule or prepare your own schedule in this '(JIm.1!. c 'nclud.,,,, 101.11 on lille I. (d) Include Ihe tol..' on [11I'14 Pennsylvania taxable Pennsylvania laIC compensatron from bOle 17 withheld 'rom box 18 7 764, $ 8,173, $ 229, S------ 's' .00 nol include I" $ - $ wllhhold 10 "011'01 .- $ 'tal. or country 'n ~ column (d) T $ '$ T --S . 00 not mclude 10(;1/ Income Ln: withheld III column (d). s C.utlon, Tho Oep,,' ment (eser~es the right 10 require your actual For ,W,2, 2000 Socl<ll Ser.ulOly Numbel: Sandra R Gouse 172-36-2034 " you need more space you may photocopy these schedules orJ'rcP31e YOUl own schedules in tillS formal. Caution. Federal and Pennsylvania rules for taxable inlercsl and diVIdend income are different. Rea ,he Insll1lctlons. Filing lips, "elll.e, your Pennsylvania inleresl income or dividend income is $2,500 or less, you do not heed to submit a schedule. If either your inlerest income or dividend income is more than $2,500. you must submil a schedule, ' ',' ' Fllln~ opllons: ' , 1 You can submil a copy 01 your iederal schedUle, or you can lusl enter your lederal inleresl income andlor dividend income, Tho department car'! verify the amounts you repartee on your federal income tax return. 2 Otherwise, fist the name of each payer and (he amount of Penllsylvanra interest and dividend income you received in 2000. M Si:liadule A - Pennsyivahla taxable Interest Income Filing 0 lion 1, Enter lhe amount from our leaeral Schedule B Form 1040 or Schedule I orm 1000A ,'..,." , $ 22, Fllln 0 lion 2. Penns Ivania taxable Inlerestlncomc. Read lhe InswcUons. 2 Tolal Pennsyllliida .tixible Ii;!.fi!st llicoiiiil, Add the amounls above and entei online 2 of your ' Penns fvania tax return .;...i. ....'..J..Lt~,1i...-;.............. ...... ......... ... ......,......,... .....,'. ..... 2 $ iiA Si:litidlile B - Perinsylvarihl Taxable Dividend Ihcome FlIln 0 Uon' 1, Enler the amolJnl from out federal Schedule B orm 1040 or Schedule I orm 1040A ""'.,,, , Fllln 0 lion 2. Penns Ivania taxable dividend Income. Read Ihe Inswctlons. 22. 2 Total PennsylvAnia tiXabU dlllldend lricome, Add the amounts above and enler on line 3 of your Penns Ivania lax relurn ..,.. ..,.... .." ........"..".. ..,..,........,........,,,'..'.... ......,...... 2 S Important Caplllll galri dlslrlbullons lire dividend Income for Pennsylvania purposes, even though you report them on Schedule D for federal purposes, L 0001214014 PA1A 1501 11116/00 0001214014 ~ pA 5chC!duld C Plont 01 LoU tfi:lillIlUlIH,;d 6f p",f.sslon (Sole Proprleto/shlp) , ~~~~8J; RtIJEMt, Allach to Form pA..40. p,l..1;i; 01 pA,,\j HarM 01 Owner " Sl'OM'l on PtnmyN.an1a r.. Retum Sandra R Gouse "", .... A Main business actlvlly i> Service: Stylinp; & Cult In B Business name" s~ndra R GoUse D Business address (mmOOr and Mreet) 400 Adam5 Street Extens t on Cily. slate and ZIP tooti .. Eiio\<I, pa:--- --- - - -- - -- - - - - -170'2-5- - - -- E Method(s) used to value closlolO lrivenhiry, check the appropriale box: (1) L J Cost (2) 0 LoWe. 01 cosl or market (3) II other (if other, allach explanation) r Accounting method. check the dppropilalti box: (1) ~J Cash (2) 0 Accrual (3)1 I Olher (specify) . G Was there arTj charigl! In deteritllnlno ijlJanlllles, costs, or valuations between opening and closing Inventory? , ' II 'Ves' alllich explanation, H Did oudedl.d.. ensesloi an Dfficii In Qur home? .,......",...."",.,...,."",.,."...."....,...,',.". Part I Irlcotitli ,;I:':""(;~"'.I!i.~"'iHr,ljW"Ii".,," "-' . , ' , I.Grossreceiptsolsale~ ....,................,......, ,..,,,,,,,,...., 1. bReturnsandall.wances .......,....,....",..".., .. ....,..,.... lb cBatance(suIJlrad line lbIrDmline tal ..,.. ,..,..' , ..,.. ,.......... ......,.. ,..........,.... 1c 2 Cost of goods sold aridfoftiperations (Schedule C,l. line 8) ,.......... ' , .. ,.. , ..' .. ....' ....,........ , 2 3 Gross proM (subtract tine'2 i,omllne lc) ..,.. " . .... ".. ' .. ' ,.. ,... ..,.... ..,.. .. ' ,'" ..... ",...... ,.. .. 3 4 other income (aliach schOdulel'nch~~ Interest from accounls receivable. business cllOcking accounls and other business accounts. Also nclUde sales of operational assels, See Instruction booklets, , ' , , , , . . , , , . , . ' . . ' 4 5 Total income add lines:! iind4 ...........,.. ..'"......,,,' ......,....... ......."" ,..........' ".... 5 Part II Dedtlttlcj"s"i,!~(;.~~~~Wl~R?~~~;J":~~~;;I',;, hi,., ,:1 H'~" ';'r > . ,.', ,. 1.'..,', 6 Advertising .............................. ,~.; 7 Amortization............................. o Bad debts Irom sales o~ services ",.',.,.' 9 Bank charges .............,..,........,.., 10 Car and truck expenses""...,....,....., 32 Olher expenses (specify): II CommissIons ............................ · .!-~l!n_d.!:Y..J?c-~'=-eErrln.8-~-_. 12 Depletion ....,..............,..,..,:..... b Phone 13 Depreciation (explain In Schedule (:,2) .. . .. c ]I ~ ~( ~ ~ aJ- g ~ 5= = = = = = = = = : 14 Dues and publications.... ,;......,..,.... d 15 ~;;'ff~';;~~.~~~~~~~~~~,~t~I,~~~:..,.. : - - - - - - - - - - -- - - - -- -. ,16 Freight (nol'llicitidedonSchOduleC;lj,.." 9 = = = = = = = == = = = = = = = = =: 17 Insurance........:,:..........,;......." H 18 Interest on bUsiness Indebtedness ,;:;"... 1 19 Laundry and c1eanlnQ : .. , ; . .. .. . .. ..: ; .. .. I 20 Legal and proiesslonal teivlces ".":",,, 2 5 . k 21 Office.suppiles ..,:,..:....,.......::,.... 623. I ------------------' 22 Pension ind proiit,sl\irinQ \lI!ns rot employee; ,;.... ii1 - - - - - - - - - - - - - - - - - - ' 23 Postage ................,;..,............ Ii ------------------' 24 RentonbusinessplDpei'lY ;..:....,;...... Ii ------------------' 25 Repairs,......,....:....,....,........,.. p 26 Supplies (not included on scoodule C.\) '" 945. q ==== === == == = == = == =: Z7 Taxes ..................;;..;............ 129.; 28 Telephone............................,.. 33 R~~c; ;xpe;;s~; by li,; \~t;1 b~l~e-;~ 29 T I nd t! I ' I credits claimed (for example. rave a en er a nmen ",.,..,.,,:,..., Employment Incentive Payments 30 Utilities,..,..,,,......, I .. .. , .. .... , . .. .. 738 . Credit on the PA.40 ......,.. .. . .. .. .. 34 Total deduCtions add amounts In cotumns for lines 6 thro h 32r and deduct line 33 ",.."",.".",.",.. 34 35 Net rolil or loss subtract line 34 from line 5 , Enter total here and on the PA lax return. , , . . , . , , , . , , . , , . , . .' 35 0003114014 * Cf'I~l~!;.~j~r._~.,1l t 20 .Q!!. Schedule C ",. .~ Ol'l'nc,'s 801':iAI Sl!(lll"ty NUl'llM' 172-36-2034 : roduct or sclvlce . C f,'lIp.'~' hll'nlilll".1Ihon 'lurnhl!f 172-36-2034 (' .. c Ve. No --'-'..' x 4 134. .,!,1}4,;, 4, q,~_, 4,134, '" ' ': ' " 31 Wages ................................ 780, 664, 22, ------------------. ------------------. ------------------. ------------------. ------------------. 3 926, 208, L 0003114014 PAIZ0612 11116100 0003114014 ....J .~ I'A schedule c PA.oCC09.00, ' ',~", PA OEPAAMJo/f 01' IlEvtNUE 0003214012 L 5o(1.1I$f!f;UlI'Y Numhf!' Of'r'C~^.~I!1L~~! ____J ....L ____..' ......_.. 2e 3 4 S 6 7 8 1 Life or rate Dcprccinholl for this VCi'3( ~1Nt 01 P'OCHMtll'll as 5t-toWn 00 t>enM~"1ri t"i Relurn :"udra R GaUse, , I Schedule C-' .:;; CdM of GilOds Sold and/or Operations 1 Invenlory atlieglnlllnij 01 year (if diffeient from lasl year's c1o'ing in\lanlory, altaeh e,planalion) , 2. Purchases.....:....... ,..,.,."... ......, , " . ....,..,,, ,~J b Cosl of Itams \\4thdrawn lof personal uSe ..'"", " ",,,.,,,.,,, I.2Jil c Balance (sublrad line 2b 'rani line 2a' . , .. , , , , , . . , , , , ' , , , . ' . , , . , , , , ' , , .. .. .. ' , , , , , , ' 3 Cost ollabcr (do nollliCliJdii salary paid to yourself) , , .. .. , . . , , .. , , " , , . . , , , . .. 4 Malerlals and 5Upplle~~:.... ..,..,....... ".... ,..",............,......"..".. "" S Olhercosts(allachscheduliij ..,,'........,.... '..'....,......,........ '...." 6 Add lines 1. 20. j, 4, arid 5 ..,..,..,......., ,.. .. ......... .., ...., 7 Inventoryalendolyear .......,,,.......,.... ......,..,,,,,,,......, 8 Cosloi oOds sold and/or oeralion. "sub/raclline 7 from line 6 . Enter here and on Pari I, line 2 .."."., ~ Schedule C.2 ~ :Dll ti!l:latlClI1..'j~.:[,i',;, Descrlplion 01 properly. ' . bal. ,.' , acqulri,(l . ;..., (a) . . (hI .'.. (c) 1 Tolal addiliorlal firsl.year depreclalion (do not include in Items bolow) 2 Olher deprcCiallon: Buildings ....", .....', ,,,,. Furniture arid fixlures "".. Transportation eqUipment " Machinery & olh eqUipment Olh (speciiy) .;. .: .. .. -' .. _ 172-36-2034 Cosl or other basis Depreciation allowed or allowable In prior years MelllOd of computing depreciation (I) (g) (d) (e) 3 S Balance sublraclline4 ~cini iine 3', Enier here and on Part II. line 13......,....."..,......."......,.... 5 Si:he iile ~3:!; IisIHltfdffilatldl1):,.;." ;",.o"-,<^,""..i;.';,,.,:,.' ' ".,~'" If you incur any oi the expenses deseriood ileiii\Y. elller the amounl of lhe expense and describe lhe kinds of costs incUrred and the business purpose, . .". ,."".,>.,' ' Expense," ---------------- ---------------- ----------------. ---------------- ---------------- ----------------- ---------------- ---------------- ---------------- ---------------- 3 Totals"","""'" ':."., ":",, ,,::,;. .........................:............. .,. . 4 Depreciation claimed hi Schedule c,j :,:"....,."",......,., ..,..,....,'. ..,.. ,.... '"'''''' :'"..",... 4 A Entertainment facility (boat. resort, tanch. ele) B Living accommodationS (except employees on business) C Vacations for yoursell. ~otlr employees, or their families, L 0003214012 PAlZ0612 11116100 0003214012 Amount $ S $ . M sdt41tfuh! S" : ....J SJll!cl~1 Tax Fotlllvehlis~ Credit PA.olOWC09.ool, , PA DEPAAlMEN'T OF RE~ . H.tme .." Shown on Vow Ptnnspanl.t T._ Return: Sandra R GoUse SPO!M" NMnIt (.....n if 1tI1nQ M9',.I.Iy1: [J[J[J1.114[J16 2000 on ICIAl. ll!;E O'l Y SlXi,.1 S~ClI'lty Numbflr: - 172-36-2034 -- Spouse', Socii'll Se~UI'llv t;'llllbcw P.rt A. T FlIe",;r Taw ~o. lven'". Unmarried, C1leeJ< this boi al'd !he Unmlrrl!d or Separaled 00. on PA,40, line 20.1, Also ,he<k the 'pplOp"'I. box b<!low Ih,t d",,,be. your ,ltu,llon, B SlllQle, Unmarried on December 31. 2000, AI5D, check Ihl5 box If divorced, SlllQle end claimed lis a dependent on my parent~. PA Schedule SP, Enler your parents' social security numbers and names. SSN: Name: ssN: Name: ~ Seporltlid. C~~ ihls box and the Unmarried or Separate' I box on PA40. line 20a if you are separated pu<suanllo a wrillen agreemenl, or married, but sepllialed and IIvlno aparl for lhe lasl six mOrllhs of 2000, B Dece6sed. cheCk lhis box il filing lei, a decedent. AlsD, chc'ck the Deceased box on PA,40, line 20a, , M.med. Check this box and too Married box on PA.40. Iir~ 2Oa, Also check Ihe appropriate bDX below U",I describes your siluation, ~ Married and Claiming tax Forgiveness together with my spouse. Married and fillnO separate Penrisylv'II1i. lax relurns, Enter spouse's social securily number and name above, Married wilh a spouse who Is Ii dependent Dn his or her PMentS' PA Schedule SP, Enler spouse's parents' SSNs and names, ssN: ,; ,.' " Name: SSN: Name: o Marriici IIfIh i lpouie who i. a d~ndenl on the federal income tn return of another person, Enler the SSN ,nd n'm. of the person "aiming your .pou.., SSN: Name: ' o Separated and living apart (rom my spouse. but for less lhan six monlhs of 2000, Enter spouse's SSN and name above, Part B, De 'ncleft! Chlldi-Oil.llrilvlcU 'II iii. Inlonnillon lor each de nclanl child, AUach .ddlUon.1 sheels If needed. 1 Dependenl's Name A e Relallonshl SSN Total Income Important: Only claim a child lhat you claim as your dependent on your federal income tax return, 2 Number of aepOOdenlS for PA Schedule SP. Enter on PA-40, line 2Ob, , .. .. . , , , , ' , .. " .. .. , , , , , .. .. , , , .. , .. , , , .. , 2 P.rt C. Eligibility lricame. If filillQ as Unmarried. Separaled. or for a Decedenl. use the You, Income column, If filing as Married. use 100 YoUr Income and Spouse Income columns, Add Ihe lotals and use the Joint income lotal. " I Your Income =:J Spouse Income ~ j PA laxable income /rom your pA..w"......,..,,,, j 8,336.0 0 Report income lhalls riOt taxable lor Pennsylvania purposes on lines 2 thro h 10, See the instructions, 2 Nonlaxable Interest, dividends. and ~alns , , , , , , , , , ' 2 3 Alimony,,,, ".... ,.... ..,...., ,,'.......... ..,.. 3 4 Insurance proceedS ahd inheiihirices ,.... .. , , , , '" 4 5 Gifts. awards, and prizes, ;..";,:",,..,....,..,.. 5 6' Noniesidentlncoine,,,,::,....,,',..,....,........ 6 , Nontaxable mlliiary lricome. Do riot liiciUde combal pay,.... ..'.., ..,..".., ..""...."..., 8 Nontaxable g~in /rom the !;ale 01 d iiislderice """ 9 Nonl,axable edUcational asslslance . : : , , , , , . , , , , , , , 10 Cash receipts. lor personal pUrpeises,lrom ouiside your home ........".."..........,......"..", 10 11 Total E1lglblllty I..come, Add lines i through 10, Enler on PA40. tine 21 .........,,,......,,,...... lj Part D, Calculatirig YoUr fA" FiitghleiiU!. 12 Pennsylvania lax liabilitY /rom yOlit ~A-40. line 13 "".,..,......,.........."",'....'".",,,....... 12 13 Less resident cfeditlriiin yolir pA~, line 23 '...."..",,,,,....',,,,,..,..,,,,,,,,,,,,,..,,,'..,,.., 13 14 Net Pennsylvania tax liability, subliad line 13 from line 12 ",....,..'"" ,..""" "..""",..",.... 14 IS percentaqe 01 tax forgiveness USing your dependents from Part B. lIne 2 and your eligibility Income from Part C, line 11 ....'..",.., ...,..,..'", ..,..""..,..""" 0.20 Enter the decimal. 16 T.. ~orglveriiss l:~dll Multiply linti jo\ by the decimal from line is, Enler on PA,40. line 22 """",,'. 16 I 47 D 0, , 8 9 If filing as, Unmarried or Sep.rlIed or (or a Decedenl, use Eligibility Income Table " If filing as Mamed use Eligibility Income Table 2, Total 8 336, Tolal Joint Incong L 233'~ 233. L [J00111401b PAIA2901 11116100 [J[J[]111401b .....J . , ~ ,-' V1 o '" III '1.{j[ EI 0 ... }D"Q OJ 'uJE.:<j at ~ . ~. Ul G') ~rtg 'U 1Il !" .... -.J o l:- t..> ",' ".;,. . '.,~". " ~ '" '" ., . "' " o n ~ '" W. ii '" < ~ N o o o "T1 Z :::- r :D ~ :D Z "T1 o :D ~ :DO ZO m'O 0-< Z n o s: m ~ ;: '~ " " ..'~_~t!... m " " , to 'l;; " ~ ,!: " , ';,Il " " . U } ,.. " ". . ~ ',.. " '" " " i.1 . , 'i~ , , , .. " .' " ::::.. . (j , .' r I.{ II" ~ " " f.: ~ ~> ;~i '1'1_ , " ,nn' ,. " U ~ ."u ... ~l~ .' , f, 'c, ~. u ~ U ".., . ,nln U . V "11 1111 " -, '" "'-j it gi: '" z , I . .. , ~ ' , . -, '" .> ' r ~l: , ~ ~~: ~ J ,~, ~~ "", n 9- ,1)1 .. <,' , , ,; , " p' n. " n " , r 'n ~ ~ ~ ~l ,', i . , . "'1 . ; < '. ~,~ . ~ 2 ,~ ~ :~ ..,- '. -, CU "' " . " fi )orJI " ~ S 9- ~ ". ,f, 'nm .> " ,. " .< , " l 7. .' ~ o. ,,, ~ '" , th '" . ;:: ~;l '" ;" , " [j,~ .l , " '" w" 9 ~ . :n c < .. " m . u n " .. .., " " . . ," <, c V V 0; .'; ~ n r . ~ " .. . . .. - " " " ~ ~I , , , . .. .. "' " 0 0 " " " " '..... " ...... ,~ . 6 " n < .. " I ~'B .;. .. '" ;:: ~ u n no .. ~ ~. 'j :).. l:{ ..~~." .---...'.-.-.-. ..2.- -L .~. ~ ;.." .. ~ :: .~ ~ :j:'~ ,:,9. ~ .: f~ ~ 'F~ IT I: ,~ .. ~ p~ i'~~ l f, ~ ~ :~ ~ . i:, \".. ...~: III o I! ~ x :i.. ~ -" ~.:.lffi ~m..1I~..! ~. r: I~'! ~~ ~ 5 i t. i~ ~ ~6 ~. ~ i. ~ ~6 ~ '-:-;a '~Fn i ~ i~ ~ fi;~ rl :;. '~ I~ ~ ~~ ~ .!:?: ~ 9. ~ ~ ~~ 'J~; v: . ~ ~ '. ~ ~ ~ ~ ~Jl ~. ~m l ~ n ~~ 0 ~_~ ... ~ :2 ~;z;. ~ ',6 ~, ~: ~i € ~i. E,~ eo,... (.1 J,' ift: ~ ::! ,:, >~'.; 'I~ .. ::' , ";" "; ,( ! :".; .'.. ..:.::~ 1; : . : /:~ .; ), ~l~:; ~ " " ... :. < , ,Y ,.. :~ " . '~ ~ t, I, " ~ " ... ,,' " '1 r ~ '" .. " ~ '" ~ :i "' I, m z f. '" ... .. \ << , , '" " " .. ~ ~ c ~: ~ u [ . ~ , E .,',. _.+._~. '" ~~ ~<~. - f..b. ;:,ff ~0 'ii' ~,~ Sf~ ~j~I".'~ 1'(,. ."" ~., 1 ~ ~.;~ ~1' ~ ~l ~ :.; I , ,h } : ',', IV IP , ~ ,I !i{' ',,, t c" ) " 1 t --'~'J, 1'<' n" C014170 28254-620-07197-0 2UUU.s.s 1.1': II H ,.... . 'film. DepanniAM.'! iiI \lill Tr4ldAU/y ~ Inlethal IfdVOtlUII SIIHllc6 ~ PHILADELPHiA! ~A 1~255 Dnlo 0' thlo notico: AUG, 28, 2000 Taxpnyer Idonllfylng Numbor 172- 36 - 2 0 3'0 Form: 10'00 TaxPorlod: DEC. 31, I??? FDr ao.lolnnce YDU may cnllu. al: 1-800-829-8815 1..IIII.I...II.I...i..I.III..I...,II.IIIII,IIII.,,1111,.,.1111,1 CALLER ID: 9358:0 SANDRA R GOUSE 16 POpLAR ST , WORMLEVSBURG pA 17043-1357162 , < I", '. .... WE CHANGED YOUR ACCOUNT 28222-127-36742-0 AS VOU,REQUESTi:Di UE CHANGED YOUR ACCOUNT FOR 1999 TO CORRECT YOUR EARNED INCOME CREDIT. 11= YDU HAVE ANV bUESTIONS, PLEASE CALL US AT TfIE NUMBER LISTED ABOVE. ',:' " STATEMENT OF ACCOUNT ACCOUNT BAlANci:' BEFORE ,tHIS CHANGE CREDItADbEtl ~" bi"E~ A~OUNt;Td DE REFUUDED TO YOU IF , VOU.DWE,NO,bTHE~UTAXES OR OTHER DEBTS WE ARE REQ IRED TO COLLECT YOU ~AYl"AVEdALkEAbv..RECEIVED THIS CHECK, IT TO BE HAl ED T YOU; UnLESS THERE ARE OTHER YOUR REFUND. . ", NONE $98.00CR $98.00 IF NOT, PLEASE ALLOW 2 WEEKS FOR HATTERS PENDING WHICH COULD POSTPONE r '0',. RETURN THIS ~ART lO USWlTH.YOURCHECK OR INQUIRY YOUR TELEPHO E NUMBER .' .' oEST TIME TO CALL ( ) REFUND AMOUNT.., ... .".",. ,.. ""..$98,00 8,559 28222127367420 1 ;509 ' ". 192 172362034 WL oood 30 0 199912 21B INTERNAL REVENUE SERVICE PHILADELPHIA; PA ,19255 SANDRA R GOUSE 16 POPLAR ST WORMLEYSBURG PA 17043-1357162 i" I , ' 11II1II.llIlIi,I,i,I'il.I,li,i,1 2a254-620-071~7-0 . \ 1.1,11I11.11I,111,1.1.1.1.11.111,.11I111.".1111.11,1111..1.11 PAGE 1 172-36-2034 " - - TAX 10 NUI1BER - SANDRA R GOUSE - - PO BOX 101 ENOLA, PA 17025-0101 '" ALLFIAST BANK 52-0312840 FOAMERLV KNOWN AS FIRST NATL BANK OF MO EIN NUI.8ER 25 SOUTH CHARLES STREET BALTIMORE, 110 21201-3330 - iIPoAtANt TAX ~ DOClKIfT 1-800-533-4630 15950 FllRIt 1ll99- 2llT ' , -- --, ' 2llllO IIflEllEST Il<<:cK: COI'Y D (OMB NO,l545-01121 FOR ~~ STATEMENT -SAViNGS--'" --- -------,-- - n -- -8-700-41.0-0374088- ___ __ __ n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _n _ _ _ _ _ _ _ __ _ _ _ _ ___ _u _._ IRS REPO!lT1NG IlA/'E IRS REPORT1NG m. SRNDRA R GOUSE SANDRR R GOUSE 172-36-2034 1 - INTEREST i~COHE Not INCLUOEO iN ITEM 3 2 - ERRL V WITHDRRWAL PENALTY 3 - INTEREST.O~ U.S. SRVINGS BONos a TREAS, OBLIGATIONS 4 - FEIlEIW. DtOII TAX wmRUI 5 - INVESTHENT EXPENSES 6 - FOREIGN TAX PAID , , 7 - FOREIGN coutlTRV OR U. S. ~OSSESSION $22,02 $0.00 $0.00 $0.00 $0,00 $0,00 , Thill Ij Irnpoihlnt tlllllnldhiilillon and Is being furnished to Ihe Internel Revenue Service. "YDU are required to file a relurn, Ii negllglince penilty or olher unction may be Imposed on you" Ihls Income I. taxable and the IRS detor. mlnei thil ~ hat not been leported. Instructions/or Illiclplinl " Ilem 1,- ShDWlllnterest paid 10 yoUdUflng ihe calendar year by the payer, This dDes nDt Include Interest shown In Item 3, "YDU receive a Form 1099-INT fDr Interest paid Dn a tax-exempt DbllgallDn, see the InstrucllDns fDr YDur Income lax return, . .' Ilem 2,- ShDwslnliresl Dr prinCipal lofleli"d because Df early withdrawal of lime savings, YDU may deduct this Dn the -Penalty on early withdrawal bl tillVlhiW line Df Form 1040, , Item 3,- ShDWS Intefesl 00 U,S" SMilnlls Bonds, Treasury bills, Treasury bDnds. and Treasury nDtes, This may Dr may not be all taxable. SOd Pub, SSO, Invesiment Income and Expenses, This Interest Is exempt frDm state and locallncDme laxes. Thill Intir"! " Iiiltlricludea In Itein 1, Item 4,- ShDwi backup withholding. I~or example. perSDns nDt furnishing their taxpayer IdentlflcallDn number tD the payer be- come subject t~ b;iC,k~p w!t!)hJi!dlng at a 31% rate" See Form W-9, Requ~st for Taxpayer Identification NU",ber and Cert~~catlon,.lor Inlt!rmAlib~ on, backup WlthhDldlng, Include this amount Dn your Incom~ lex return as tax withheld. Item S.- Any ,amou~! sh?wri Is YDurtshlir!l Df I~vestment expenses of a single-class R~MIC, If YDU file FDrm 1040, YDU may deduct these expenses Dn the 'Otner expenses" line of Schedule A (FDrm 1040) subject tD the 2% limit. This amDunt Is Included 'Inltem,l, . . , .. Item 6,- ShDWS fDrelgri tax paid. YolI may be able to claim this tax as a deductlDn or a credit Dn YDur Form 1040, See YDur Form 1040 Instrucllons, Nomlnees,- If this fDrm Inchides ariiounts belonging tD anDther person, YDU are cDnsldered a nDmlnee recipient. You must file FDrm 1099-INT fDr each."' the other owners shDwlng the IncDme allDcable tD each, YDU must alsD furnish a Form 1099-INT tD each Dr the Dther Dwners,. ~lIeForrn(s) 1099-INT with FDrm 1096, ,A,nnual Summary and Transmittal Dr U,S, InformallDn Returns. with the Internal RevenUe Service Center fDr YDur area, On each Form 1099-INT, list YDurself as the "payer" and the Dther owner as the 'recipient: On Form 1096; lis! yourself as the 'flier: A husband or wife Is nDt required to file a nominee return tD ShDW amDunts Dwned by the other, , I3illing for Sandra R, Gousc, 5/28/98 Initial consultation 2,0 hours $200 6/ I 9/98 prcpal'lltion of divorcc complainl 2,() hours $20C!f t= 6/20/98 officc visil/updatc/ sign complaint 1.0 hours $1 OO#-=-,: S'&l 6/25/98 Trip to Carlislc to filc divorcc complaint Send copy (0 dcfcndant with covcr Icllcr 2,5 hours $259t 7S'O 7/13/98 Confcrencc with clicnt to prcparc hcr lor support hearing on 7/14, 1,0 hours $100f;.:::;-: /r,s-tJ 7/14/98 tclecon with clicn( following hcaring 15 min, $25 t? ~.t 5' 8/25/98 officc visit; updatc situation; discuss my conversations with husband's support attorney, who will not reprcscnt defendant in divorce action, Sharc defendant's lettcrs to me; discuss strategy and possiblc solutions 2,0 holll's $20~ ___ Ic7 ) 9/19/98 prepare letter to defendant with proposal lor resolving equitable distribution of economic issues, 2,0 hours $200 If ,.- 1/24/99 conference with client; defendant refuses to (2...7) secure counsel; options and cost of forcing issue with Master discussed; second lellcr to defendant urging him to seclll'e counsel 2,0 hours $200 8/26/99 Meeting with client regarding defcndant's ~of"1) request to reduce spousal support based on his time off work because of injury, Prepare for and attend support hearing in Carlisle, 4,0 hours $400 '$., .--- 10/27/99 Conference with client following my receipt of d'-7~ letter from Jack Dougherty Esq, indicating representation of defendant. I3egin to discuss request for information regarding money from mother's estate, 1,0 hour $IOQ ---" "(91 :, /" 11/24/99 Prepare letter to J. Dougherty outlining a settlement plan 2,0 hours $200 'd I 7)---- -::0"' g- C6.J~:s6L ~,..... ({ I c.(l2.- 1 J :/ I ~ \\1 I ~. , iM ! l~ '~ ,,/ ,.11"\ W' I' ~ l, ; ii II I; I!: '; L., ...._.'f , ~. ~ ) " ., 2/26/00 Mccting with.l. Doughcrty to scc ifwc can find coml11on ground on cconomic issucs 1.5 hours 4/28/00 prcparc and attcnd 4-way confcrcncc with partics and J. Doughcrty, 3.5 hours 5/1 thru 6/25 Flurry of activity to try to work out plaintin's ability to obtainl1lortgagc loan @ MN13; anothcr spousal support hcaring on 5/30; 1ll1l11CroUS phonc convcrsations with c1icnt and Doughcrty trying to find that common ground in rcsponsc to latcst countcroffer ITom dcfcndant. 7.5 hours 7/28/00 prcparation of Icttcr rcsponding to countcroffcr 1,0 hour 9/23/00 Confercncc with c1icnt 0,5 hours 9/29/00 Defcndant's lawycr filcs for appointmcnt of Mastcr; Objcctions lodgcd primarily bccause discovcry as to Pcnsion and scvcral othcr itcms not complcted 0,5 hours 10/12/00 rcccive information 11'om Doughcrty on $10,000 pcrsonal injury scttfcmcnt and dcfcndant's invcntory and appraiscment; rcvicw samc with c1icnt and insrtruct her how to preparc hcr own, 2,5 hours 10/17/00 Reccive information from Pcnsion Appraisers Inc. following discussions with thcm; rcvicw with client and scnd copies to Doughcrty aileI' telccon with Pension Appraisers sceking clarification; advanced fec for appraisal ($195) 2,0 hours 2/5/0 I Preparation of amcnded complaint in divorcc; filc same on Fcbruary 6, 3,0 hours 4/5/01 Rcceive notice of prc trial statcmcnts duc 5/4; confcrencc with client on possible cxpenses and timclincs; submitncw proposal on 4/22; rcjected by dcfendant. 2.0 hours 4/30 -5/1 Preparc prctrial statemcnt 8,0 hours f11turc Anticipatcd timc in prcparing for and attcnding prc trial hcaring and preparing clicnt for and attcnding Mastcr's hearing 16 hours C0v~-;E:' L tG.-CS (? .J ,(L. $15? t.j., 3.) ;- $350 '7_ c.1J I $750 1ft $1003, It 3 $50 J, f,), -;,--- .- ...- ~ z..~ ~ -- 3 ) 7') I $50 f; .~, 6 C'CJ $250 :P '$\;-S?J , $395 '-1 ;). 1- ~ / $300 1Tf, US $200 5f,14 ':J~ $ 800 tJ .;- 7 r )- f r'i $1600 1231' I 'I c. :I .-- j ~ ~_......~... ~:!l~:!ln~ NNN""'NN~ ...-""'....-.... Wl.JWI",q""W .................... ........--... ~::~~~ lk ~nn~ .......................... 000000 ~~~~~~ W"':\I~""N O<lOwlnl"QI ,,(;,..,j, ,"j' 'l'" ~~~~~~ .,.;. " . t ~ " ';'",.' ..p~\O\O\D\O ;:i':',: " 'itt' " " :'; ',l~.,...: ~\, y'.~~ ! '.~!: ?:,i;" "11"'- iJrL" . " QOOOo i'ji'jNNN , .....CI'\ ." eft"'.. "::::t:::: ~ 'T (' ~' ..,'./ !I' ....l.OW..,~~ '~~g~gg \..~OOOO W!,DQOao .. )j:':,/ . :~; :; , ; .~'.; , , ',' ~.' ;" ~ ". J. I,,~ ~. '~ '":.~ ;~i):r . '--/) ;".;~:', . ,'.... ~ ~ .;-....106\001.. ..wNNf\,J . .. ... .. NWO<oleJ'lW WOW",...,... ..Qoo,I........~ ..,.. .. U'I0Y:",WW WQ\,Q\I)\O\D lIlU,,,",lJIIw OO'l.CDUt ...W......U' n::~~=:! u~n~ ~alegl ' ~J::;..!l::-; a/il... ::I(1j liStJl ,,~ 1)1.) o '" ~ t ~q V t'-Y\-w ~J \ .ssJO I' \-\~A~ SNI,)r{S -~ 13, l(j)ji. 3j '}- .... " o E ~ 0.... b..' o f. ~ ;~:;' THings stolen and hid for 2 years. JEWELERY BOX & CONTENTS Jewelery box is a free stnnding walnut cabinet Approx. 100 pair of various styles and sizes /:/1/-.?/2 '~9S 3 pr, of diamond studs (I-~ carat) 1 heart nec~lace of diamonds 1 pr. b1ac'< onyx 1 pr, pearl and diamond earrings gold chains assorted sizes and value, includes 2 herring hone, 1-18 carat gold I 74 cara~, gold ruby and diamond heart ring rnby and diamond hearl: necklace watches (1) diamond watch qf my mother,s opal earrins and ring 1:0 mal;ch emerald earrings garnet birthstone ring and earrings assorted Avon rings, bracelts and necl<laces, chains 1 (1~) carat diamond cocktail ring Orand mother,s lapel watch..still works Great-Grand father,s magnifying glass in a leather case also a jeweler,s magnifying glass Various pins and snch kids made for Mother.s Day gifts 5 Silver dollars from the 1700 and 1800 given to me by My Father Kennedy ~s Reciepts, credit cards and' pin numbers Pearls and differnt chains 'Keys for chest lockets s i 1 ver Grand Mother.s costnme jawerey 4 sets of beads and pearls odds anel ends This all was reported stolen May 29, 1998 to East Pennsb ora Police. As well as the other items taken from my bedroom the night Mr. Gouse decided to move me out, OTHER ITEMS ,also reported (". ,/.../ ifY _PSS <- <.. (.. <- 19 inch color T.V. ..... ",..St:.ero system..~,jJqpE'.5 shadow box with grandmothers thi~'~es angels, etc.,.. t.arge ~Talnut pendelen ~lall clock Collage of pictures of family present and past, small one out Of. my room, all Mottle and Father and Grandparents, and my family pictures ? Videos of my Mother and childern and GrandchildreAV, ,. He has bee holding for leverage to get what He wants ont of diver-roe. Iwant liLt. back. I -:\1=' l ( f ~fu::6{) 60s-SJUJ'Tld,.,) < 5,,<:, I -rc-o'V'-. J:X='G, Q<s ~- 1 u()V t 5 ('\6J~ ~~fr~[:[~;{;;,~." :};"-:;?7~"S.,;.::,7;;:::'7:":,:;:~ :: I~j,; > h3,n.j.:~~,;,L:":,'J:;(:' ~ '.S;.. ~ ~~0j::ln;.t:;;'d:;\":~:\~;"'Q,. ,,~', ," ~~ J,J-.',,,.,,,,..... 8 - ,.' ..' Q Z ."....".rr.-i~",..:c', '--W5e ,:i::,;:~.",;Ij:?:: . a.. . o:::i " ,.,.~".'i'H..',.r.)o -,,>. ~:~V~,";:::'~,..',\,:l u: ':0; :a- ~ ~:\'J,'~-.:.,:~.'-.fal,Q.. N: ,c.:.1Z ,\~;,.:::\'~G, 0... ,r.r:z /~:~;X~:;:~;~.l~'~~r;p:;~;~' ~:' _,~~ ,',.""",.. 'l:5 ',0 ::> ~\~{&> 0 " ; ~ , : f~~'~~"~' ~ ,,)i,:(,~:Z! ~ ;,,:J ~> ~ ,. c, ",z ,p . " 't1l ~ ~,'::~J:~ ;~~~ .~.. {~.I-.'" ~ 0 0 ~ O!I 1,;:Y'~ <~ m 0 8 :.'[I>"~:Z: ' i},(,~ '), ~ ::> . (') {~,j '/~U1'" '::::;' '~ ,,-T, ;'" ~ 'r(5- .. li~;~~,"~. . , ~'~ t:ln 2: tll H~ 0 0 ~H , ~ ~~ l>:ll:"' \0 [;l> ,CXl i~ I l4 w n ~' ,U1 liJ" "..H H '" t:I S,' fi 01> (1) >'3 <: 'tI, " Hl, H , ,... H n ,g, tIl lll' d ; I .....: '....._:' "",'~'.', <: p. S ::s ' 5 1-" III rt "' ,... ::s d. "I-" <T tIl 111,' 0 >'3 . tol 111 '. l>:l H (I) . . ,',fo< 2: 11 I:l l ",\ .\ INVENTORY ANI> APPRAISEMENT ASSETS OF PAIUIES Defendants marks on the list bclow those itcms applicable to the case at bar and itemizes the assets on thc following pagcs. (x) I. Real property (x) 2. Motor vchicles ( ) 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 (indicate lace value, cash surrcnder value and currcnt beneficiaries) ( ) 10, Annuities (x) II. Gifts (x) 12. Inheritances ( ) 13, Patents, copyrights, inventions, royalties (x) 14, Personal property outsidc the home (x) 15, Businesses (list all owncrs, including percentage of ownership, and officer/director positions held by a party with company) ( ) 16, Employmcnt tcrmination bcncfits-scvcrancc pay, workman claim award ( ) 17, Profit-sharing plans (x) 18, Pcnsion plans (indicatc cmploycc contribution and date plan vcsts) ( ) 19. Retircment plans, Individual Rctircmcnt Accounts ( ) 20, Disability payments ( ) 21. Litigation claims (maturcd and umnatun:d) ( ) 22. Military/V.A. benefits ( ) 23, Education benefits (x) 24, Debts due, including loans, mortgages held (x) 25. Household furnishings and pcrsonalty (include as a total category and attach itemized list if distribution of such assets is in dispute) ( ) 26, Other ::j C' III 0> III en 4> w C1' III NO C' III ... m ;C 'It ,-, - ~.,.- rf?~ -- ------ --- '-, ---. _.n -- -, ~'~] ,- -, -- '- ,-- &fJ: tIl nJ: 0 ::J 0 ::J tIl ;t.... 1l~ 3: Gl !iQ ;U III ::J' c: ::J' 0 CD 0 - CD CO -, CO 0 iiI CD < c: ~iD: < ~g- lI: ::J a ::J 0 a 'R Sl-CXl - c: C' e!. 0 OJ' g. 5' CD CD 0 c: w 0 < ::J -, ~ ;t. m c: '" ~ ,.. ld.., .. CD -< :, m en <0 ::J 30"+0 <0 -'::J ~ 0 '" '0.., 0.0. 0 '" 0. 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'0 '0 CD '0 '" Co 0 0 0 0 0 0 0 ':C. 0 0 0 0 0 0 0 i::> i::> i::> i::> i::> 0 i::> '" 0 0 0 0 0 0 0 CD '- - - - - I- - OJ N OJ N N OJ N CIO ~ Ol Ul " .. _'u~ --- ,- ~'-'--- -, -,- ._"---- -- -l @ Q~ 0 ~ Z 0 r- 0'b':!13: 0 - 0 [ 0 .., iaO -l I 1Il )>0 :r ::J OJ ~iil ::\. ID iil l1> :I )> s.3 .., - ;:;: .. c: ClC r- O~ C o :r 0 !!. 3 :!.I~ f/) ....OJ L )> ..- ID - OJ ::J l1> 0 :J: 8 " C" ~ a. .., ::J am iii' .. g OJ l1> .. iil ::J a -- ----- -- - - ----- 1-, -- -, L-_ - - - 1--,- ::l 0 '" ;;:; '" ID CX> N '" rh N , ill '" "0 <0 0 N <0 0 '" '" 0 :.. CX> 0 CX> 0 0 0 - 0 0 0 ITEMIZATION OF 1I0USEHOLD GOODS AND FUI{NISIIINGS Item I, Bedroom Sct 2, Sct of Lumps givcn as Christmas Prcscnts in a roximatcl 1993 3. Drcsser and Ni 'ht Stand 4, Sewin' Machinc 5. 2 Televisions 6, Entertainment Ccnter 7, Hutch 8. Anti ue Brass Bed 9. Air Conditioner 10, Gas Generator II. Leaf Blower 12. End Tables and Coffee Tables 13, Curtains 14, All Dishes, Pots and Pans 15. Silverware 16. Bread maker 17. Gun Reloader Kit 18, Two Guns from Husbands Father (Rifle and Carbine 19. Husbands Personal Records Purty llnd I'ossession Wile Wile Disputed Ycs Ycs Wifc Ycs Wile No Wile Yes Wile Yes Wife Ycs Wile Yes Wife Yes Husband Yes Wife Yes Wile Yes Wife Yes Wife Yes Wife Yes Wife Yes Wife Yes Wife Yes Wife Yes ,1 I I I I I I I I I i i I I I o.,p.,IOIIIIlI(11 .'" ".'.WY - r.,I",rWtIH,.....,M'Il r..,,,,,,,, I ForO: 1 040 u.s. Indlvlduallncomo Tax_RoJ!:!tJ~l~~~___ _~__~-,!!~ICOo~~!!-,!!"""'n'''..,,,., For Ul0 oor Jlln 1.l)cc 31, 1!YJ9. or OUIQl lax em bel Innl" . 1m, C"IJH1( . rOMONo.I!MOO74 MI You, Socl., s.curtty "Urtl~, S~rldr~ ,____. R GOllse 172-36-2034 ii I JDint fl."'"" !iJlOllU'" "" "amll .-- ;.;t.. .i~-;jTI;.",~;..---.-n_._- ----.-.-...--------- spou.... SlH;I.1 S.clutt)' HlIlrnk, d Total number of exem tions claimed ......... 7 Wages, salaries, tips, etc. Attach Form(s) W.2 8e Texeble interest. Attach Schedule 8 if required, b Tax.exempt interest. Do not include on line 8n 9 Ordinary dividends. Attach Schedule B if required, , '"'' " , , . , , , "" , , , " , , ' , " , 10 Taxable rcrunds, credits, or orfsets or stalo and local income taxes (see instructions) '1 Alimony received .................,... .. .. . .. . ....... . .. . . .. . . ..... . . . . . 12 Business Incomo or (loss). Att::lch Schedule C or C.EZ. . ..... . . . .. . . . . . , , ,. 15 Capital gaIn or (loss), Attach Schedule D if required. If not required, check here. . . . ~ 0 14 Othflt' gains or (losses). Attacl, Form 4797 . , . ,,' "" , ., ,." 15. Total IRA dis~lbuUons ",', ~.I I b Taxable amount (see instrs) " 160 Tol.1 pensions & annuities ,~ b Taxable amount (see instrs) ., 17 Rental real eSlate, royalties, partnerships, S corpora lions, ~usts, etc, AlIach Schedule E " 18 Farm Income or (loss). Attach Schedule F """",,,,,,.,,,,,,,, , , , , " """ , , ... , " , 19 Unemployment compensation "" , , , , , 208 Social seeurily oonefils ..... ~ 21 Other income, 1I,ttypo & amounl (,ee ins~') 22 Add the amounts In the far rl ht column ;orlines 'i throu- h 21.1h'5 Is our totellncome - ~ 23 IRA deduction (see instructions) " , " " , " " " " " , , " " '" 23 24 Sludent loan Interest deducllon (see Instrucllons) , " . " , ,," 24 25 Medical savIngs account deduclfon. Attach Form 8853 . .. . . .. 25 26 Moving expenses, Attach Form 3903" . , "" """ , " 26 'Z1 One.half of self.employmentlax, Alfach Schedule SE "". 'Z1 28 Selt.employed henllh Insurance deducllon (see instructions) . 28 29 Keogh and self.employed SEP am! SIMPLE piano, , . , , . , , " 29 30 Penalty on emly withdrawal of savings. 30 31 a Alimony raid b RC'(:ipicnl's SSN . .. 31 a 32 Add lines 1ltllfolfgh ll, " 32 33 Subtract tine 32 Irol11 line 22, Tilis Is oUI.d'usted ros5Income"""""",."""," 33 BAA For DlsclQ<;ure, Prlvecy Act, ond Peperwork Reduction Act Notice, see Instructions. FDIM112 11116199 Labol . (9_1,."w(ti,),.,,) U,..lhe IRS libel. OtJlcrwt5o. plenso pllnt or typo. Protl<Mnt111 Et.cIJon c.mpalgn ~~.....,) rUIng SlatUI Cht<:k oriy one box, Exemptions If more than six dependents, See Instructions. Income AUech Copy B of your Forms W-2 .nd W-2G h.re. Also e!tech Form(s) 109!J-R If lax WIS withheld. " you cIId not get e W'2, Ie. Instructioris. EncIOS., but do not stop e, eny payment. Also, pleaso use Fonn 1000-V. Adjusted Gross Income ... Imporbntl r You must enter your social security number(s) above. 17043-1357 Y051 No Not"a,,,~.. X 'Yet' WIll not chal1Q. - your taw 01 '.wt:. YOU' ,,,lund. Wormle sbur ht.. Do you wallt $3 10 go 10 ttlls fund? .. '" . . . . . " II n oInt return. does our S ouso want $3 10 (0 to Ihls fund? ........ . . . 1 Slngl. 2 MarrIed nllng Joint roturn (oven If only Olll1llild Income) S MlW"led tillno separale roturn. Enter SpOll!>!!'S SgN above & full tlCIITlC here ~ .. Hend of household (WiUl qlmlUylng por~on). (See Instructions.) If the qualifying person Is il chllc1 but not your dopendonf, enter this child's nnmo he'''. .. 5 Qualt I widower with de endent child ear rouse died" 19 eo Instructions. 68 YourseU. It your parent (or someone else) can claim you as a dependent on his or 1- ~~:.~~:. r--l herlaxrctUfTl,donotctleckbox6a. "" ..... .. . .... .. e..nd6b ...L--!J b.D Spouse... ............ ,..... ... ....,....... ....,. .........:.'......- ~~i:~!no:~ (2) Dependent's (3) Dependent 5 (4) " .c whot CJ c Dependent9: social security relationship QU3tifyinl;j child 0 liVid number to YOLl fOf t~Ud bll >MIll YOlt ..,. credIt (""11 . dldaotll"lI Instructions) w1lh you d.. to divorce or 'IIP. L:J _,.lIon(." Inltrllctfoll.) ., Dtpend'"lt on 6c not r--t :::,,:d. . . . . . . L--.J Add Rumbtr. ."'-rtdon ..",....... ...........,.. ..,....,.,.. Unt..bentt Y('IO." r1",NlnI" II",,,. Add,,,,,t (nl.lmbotr and \,....t) II Yl~, 11~~II;1 PO IInl. ~II" r'I\lmd"lII\ AI'"lr""f11 rjn 16 Popl~r Street ____ City, Twon or POlt OfficII II VN JI"..." II rorlliql! Alld,.\\. 5.., 1,,\1'"(11011\ St...,. llr CNJ. PA ---11) First name Last name ......................... ...",....,'~ .."",'.. ib 'T~~~;,~~,;;~~,;i (~~~'i~~'l;~):: 7 8e 34. 9 10 11 12 13 14 15b 16b 17 18 19 lOb 21 22 7 262. 1 359. 8 65S, 96. 96. 8 5S9. Form 1040 (1999) '0111I 1041l (1999) rax and -:redits Sl,ndord L O.ductlon lor Mo.1 - P"'plo SIIIt; \~, li"d of : hOllse'lOld: I $6,350 MMlled lill"" 10lnhx 0< OJ'hfy1"9 ~er): .....,Ied fltIng ""....t.ry: $3,600 Othor Taxos ?ayments Refund Hav, II dlreclly deposlledl See instrucUons and 1111 In 66b, 66c, .nd 66<1, IImount You Owe ;/gn iere olnl rolurn? :ee Instructions. :eep a copy )f your records. 'aid 'rep'arer's Iso Only Un~" "n.II,,, 0/ P"/Uoy, , d",,,. U"" h." ...mm,d ,,,. ..!urn .nd "'om,'n~n. "'>odor.. m'd '~"m'nts 'nd to U.. be., 01 my "","Iod,. 'nd be,..I, '''y ,.. IN.. 'nnoo', .nd <om,i,'" D.d"'';on 01 ,.."", (0'''' '''01 ~'"y..) i, b",d on .11 in'..m.';o~ 01 whkh ,..,.... h.. .ny kn~'''',., Your 5Igl1:1I1.". Dalf1 Your Oecupation Daytime T.lephone k Number (optional) ... Be~lJtician ~ 5,,,,,",. Si,n,'", II. Joint n",,,,, 0.., Mu,' Si,n O"n S,,,,,"'. O'~','';on j:;'::,A~~~iXi~Xf';tii/~,:&~~~~ Sandra R GOllse 34 Amounl 'rom ljne 33 (;,dj1l5!mJ qro:i:; IIlCnllll!) 3!:ia Chnck II: 0 You wmu G!;/oldf:'r, [] nrnlll; [I Sp()U~O Wil:-, G~j/olcJcl. Add the numbN of hm(f!!i checkerl nbovro O1nd en 1m 11m lo!"ll1mn . b If you ore married Iilirl<.J $epmntely ilnd your ~,pOIJr,U IletllizC5 dcduclloll5 0 or you wero il dunl.slnfu5llhcl1, !;CC IfI~,lrlJctI01l5 rm<l chnck here... ',.... ~ 35b 36 Enter your itemized doducllons trorn SChr}(JIJII? ^, IIrm 28, Or sflmdard doductlon shown on tho loll. But sac inr.lrlJr.tlons to flllel YOUI !ilanrl;u (J deduction II you dmckod nny box on lillo 3~n Of 35b or " !iornf'!OIlf! C.1f1 c:lnilll you ;'15 iI dnnf'!llelcnt '!1 SublrncllirlO 36 Irom lino 3t1 38 Illino 34 Is $9<1,97501 lcss, rnulliply $7,150 by Ihe 10tJI rlum~cr 01 e~r.mplions clilimoo on line (;d. If lino 34 is over S94,915, sre lhe worksheel in Ihe insllllehons 101 lhe illnounllo r,nlr.1 . .. .. .. . . . , . . ... . , , 39 Taxabl.lncome. Suhlrncllino:18 flO/IllirlQ 37. It line 38 is moro II1e1l1 line 37, OilIer .0, 40 TIl (see inshs). Ole<:k if :InY 1,1. it horn a 0 fOlm(s)?RH b 0 form 4972 , . . . 41 CredIt fOf child and dependenl e31e l!lpCnSl!S AII:w:h form 2~41 41 4.2 CredIt tor lho cldrrly or Ul0 (jjsablcd. ^t1i1ch Schedule R . 42 <I! Child I.. Clodll (see In'~tJcIJo''s) , 43 44 EWe.tlon aodils. Allnch Form B863 44 '" Adoption aedlt. Attncl' Form 8839., _ 45 oM Forolgn r... Cledrt. Alloch Form /11611 required , .. ""'" 46 41 Other. Check It trom... BForm 3800 b Ororl1\ B396 cO Form 8801 d Form (specify) 47 48 Add linel lllhrough 47, These 're)1lur lob' crodll. "',.,"'".""""""""",,,,,,,,,,,,,, 48 49 Sub~aclllne 48 from line 40, It line 48 is more tllan line 40, enter ,0, """.""""", ~ 49 50 S,".,mplojll1eo"", AII,ch Schedule SE , , ' , . , . , . . . , , , , , , , , , , , , . , " " , " , , , , , " , , " , , , , , , , '" 50 51 Alternative minimum lax. Minch Farm 6251 . . . . . . . . , . , . . . , . " . . .. . . , . " . . . . . . . . . . , . . .. 51 52 Social security and Medieme li1~ on lip income not repolled 10 employer. Allach rarm 4131 ..,..."....,.... 52 53 Tax on IRAs, other retirement pltlflS, and MSAs. Attac/1 Form 5329 if required,.,......,.. 53 54 Advance earned Income credit payments from Form(s) W.2 ..."...,...,....."....,... 54 59 Household employment laxes. Allacl1 Scl1edule H , , , " . , , . , " , , , , , , , ", , , , , , , , " , " '" 55 56 Add lines 49.55, This is )1lur toto"" , , , , , , , , , " , " , " " , , , , , , " , " " , , " , , " " , " " , " ... ~ 56 5] Federal Income tax witl1held from Forms W.2 and 1099 . ., . 57 58 1999 eslimaled lax ptl)Tllenls and t1mounl applied flom 1998 ralurn ., . . . . ,. 58 59. Euned Incom. credit. Alloch Schedule EIC if)1lu h,ve, qU'liIyinQ child, b Nontaxable earned income: amount .. and type ~ 59. 6ll Addltlonalchiidla;C;ediI.AllactJF;rmSsI2:,-:::::" 60 61 Amounl paidwilh requesllor extcnsion 10 file (see inslfucliol1s) . . .. . , . . . 61 62 Excess social security and RRT A tax withheld (see Inslrs) ,., 62 63 Other payments, Check II f,om . , , , ,. 0 Form 2439 b 0 Form 4136 """"""""""". .""...."",, 63 64 Add lines 57, 58, 59a, and 60 through 53. These are your total payments ."..,.,.,.....,.,............"..,..",....,."""."".".,.,., ~ 65 tf line 64 is more lhan line 56, subtract line 56 "0m line 64. This is the amount you Qverp.3ld ...,...,.,...., 660 AmDunl o!line 65 you wanl Refunded to You, , " ", " , . , , , , " ", "" " , , " ", , , ", , ~ ~ b Roullng number ",.", ~ c Type: 0 Checking 0 Savings ... dAccount number.".", I 07 Amounl olline 65)1lu wool Appll.d 10 Vour 2000 Elllm,led Tll "" ", ~I 07 I 172-36-2034 I~J[JI""I, r}4.- . .... 35aL 36 .~ 38 39 .,,~~- 64 65 66. 68 It line 56 Is more Ihan line 64, subtraclline 64 from line 56, This Is the Amount You Owe. For details on how to pay, see instructions.,....,.,., '1"" ,..."...,.......,.. 69 Estimated tax penaltv. Also include on line 68 """."""./ 69 ~ 68 ;~~;I}.;.i:,f~:~;'i::~'~;;;J ,i,~~{:; }~J;.:,1,i;?~t!g 41g. PI~Plrer's lrrrr. SJqn:llUlI ,. Fhm'sNArnl! (oryoUlsif slIlr'lImployt'd) and Addr.ss D~I" Prllp:uaf's SSN or PTlN ~ Sel f-prepared - Check Ifserf.ernployed ErN ZIP Code rolAOll:c' II/15m Form 1040 (1999) Paoo 2 8_,';;59-!- 4 300. 4,259. 2 750. I,S09. 227. 227. 192. 419. Profit or Loss fro/11 Business 01.10 fI,. ''''50014 (Solo I'roorloto"hlp) 1999 . Pllltm1r'lhlp5, Jolnl VPl1tWtt'I, ele. IIlust"'. rOl," 10G5 or Fann 1065-B. 09 . Atlllch to Form 1040 or Form 1041. .. Se., Instructlons for Sch.dule C (Form 1040). Soclll SIClfrlt1 Humbe, ISBN) ~chodulo C (F ann 1040) O.ptrlmlnlollh" r,lInury 1111111",11 n'''lrlHI SeNin (99) Nalllln'flmp,I,,1ot S~ndr~ R GOll-.se ^ P,I"~jplll Butln"t t)r P'n!Iluinfl. InchnJuIQ ""nduct", ~"'"'''' (v.. ""trll'I"'I'~1 --..- ---"-..--... ~ - .... ..--.----.--.--. _2erv 1 C~-ll!.!1LUl!JJJ_rl!'>...!.!.<l,1 ~._ C (JU\lnlt" 'bm., II No Sf'I':""'" fl'I\lml\l NAill,., Lila"" Ilr;",~ ... -'-'-'-_'___h__.~_____ 172-36-2034 B r,.t., Cod, ',fWft ""trvdon, - 812112 o Em~oy., ID Humb., ([IN)." A., --.--------------. - E D"""...Add"..(I"'~"..uil.~'''''n''o) -400 ^d~ms Street Extension _ Citro T~" or rt>\l Ollic". !\t"",. .\ 11I~ Coo'" E no 1 a ~ --P-a~" ." il '0.25- - _ _ _ .. _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F Accounting melhod: (1) f2J Cash (2) QA,;,rllal <3lU OUler (ooecify) _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ __ G Old you 'moterially participale' in Il1e operation of It"o blloineos during 1999? "'No,' see instructions for hmil on looses", IRf V.. H " au started or ac ulred this business durin 1999, cl1eck l1ere . , , ", "'" , , , ", , , , , , .., , "" , , ", , " " , , , .., ." "" ~ Part I:',::", In como Gross Income. Add tines 5 and 6 " " , " " " " , , , , , , , " " , " , , , , , " , , " " .. , , , , , " .. , " , , , " " " " , ,," 7 enses for business Use of our home onIon line 30. B 19 Pension and protit.sllarlng plans .. 20 Rent or lease (see Instructions): 9 a Vehicles, machinery, and equipment. 10 b Clner business property. . . . . . .... 11 21 Repairs and maintenance . . . . . . . 12 22 Supplies (not included in Part III) '" , 23 Taxes and licenses:............. 24 Travel, me~ls. and entertainment: 13 a Travel ......................... 14 Employee benefit programs b Moais and (other than on line t9) . . . . '. 14 entertainment ......... 1 1 c Enler nondeductible S Insurance (oll1er Ihan healll1) , " S amounllnciuded on line 16 Interest: 24b (see inslrUctions) " - Mollgage (paid 10 banks, elc) , ' , , 16_ d Sublraclline 24c from tine 24b """"" 24d bather" .. '" "" " , , , , , , " , " 16b 25 Utililies",..,."""",.."",,,,,,.., 25 17 Legal & professional services " 17 26 Wages (less employment credits) , , , , , , '. 26 18 Office ex ense..."....,...", 18 Z7 Olherexpcn"s (Irom Iin, 48 on page 2) """'" Z7 28 Tot_loxponses before expenses for business use of horne. Add lines 8 Ihrough 27 In columns ",.,."",," 28 1 Gross receIpts or sales. Caution: If t/lis income W;l.S rcpmled to you Of! Form W.211f!d the 'S/atu/ory employee' box Of! Ihnl form was cJJecl1ed. see life ins(wclloflS and c/leck Ilele . 2 Returns and allowances "" . . . . . . . . . . . . . . . . . . . . . 3 Subtract line 2 from Une 1 ......... . . . . . . . . . . . . . . . . . . . . . 4 Cost of goods sold (from line 42 on page 2) '''0 5 Gross profit. Sublractline 4 from line 3 , , 6 OttlCr Income, InCludIng federal and slate g;)Sollno or fuel tilX credit or refund. . . 9 Bad dobts from sales or servIces (see Instructions) 10 Car and huck expenses (,ee inslrs) 11 CommIssions and fees 12 Depletion""" 13 Depreciation and Section 179 expense deduction (not included In Part /II) (see Instructions) .......... 29 Tentative protlt (loss), Sublractllne 28 from line 7 . ""'" '" , " ''',,' """ . ""'''' SO Expenses for business Use o( your home, A/lach Form 8829 , , , , , , ""'" , " , " , , , " , 31 Not prol/l or (loss). Sublraclline 30 from line 29. · If a profit, enter on Fonn 1040, line 12, and _Iso on Schedul. SE, IIno 2 (stalutory employees, see instrUCtions). Estates and trusts. enter on f arm 1041, lino 3. . If a loss. you must go on to line 32. 32 If you have a loss. ct,eck the box that describes your invcolmenl in this acllvily (see inslrucllons). · If you checked 32a, enter the loss on Fa,", 1040, line 12, and also on Schedule SE, line 2 (statutory employees, see instrUctions). Estates and trusts. onler on Form 1041, line 3. """'" 29 SO · If you checked 32b, you must atlach Fom,6198. BAA For Paperwork Reduction Act Notico, seo fonn 1040 Instructions. ,} ]- rollOll2 10121199 1 2 3 4 5 010 S,010 5 6 5,010 5 010 19 20_ 2lJb 21 22 23 1 29S 24_ 646 1 710 3 651 1 359 31 1 359 i " :, i [i I I I O All investment Is 32 _ at risk, Some investment 32 b is not at risk. Schedule C (Form 1040) 199 i ,i r', r .>chodulo SE (Forrnl040) Solf-Employment Tax OMO "0. 1545.0074 ~ Soo In~trllr.lIol1!i lot Schodulo SE (rorm 1040). 1999 17 Depmlmelllor VIII t'lta">l.JlY Int.mOlI n'VII'IJ' Servin (99) N.III. t111"""0f1 ....Ilh S.t'.lmpIOYnM"lln('o",,, (.t 'I."..... 1'1'1 r !'II III lmo) .. AHlleh 10 Form 1040. Social $ocurity Number 01 Per~ol1 willi Soll.Employmont Il1como. 172- 36 -2034 S~ndr~ R Gouse Who Must Fllo Schodulo SE You must file Scl1edulo SE it: . You hod net comings from solr,olllploymonl from olhor Hum church C'!/Ilployno incorno (Iino 4 of Short SchedLJlo SE or Uno 4c of Long Schedule SE) 01 $400 or moro, Or . YOtlllfld church employee income 01 $108.28 or Illore. Incorne from services you performod ilS a minister Or tJ member of a religious order Is nol church employee income. See Instruction!;. Nofe: Even;f you /fad t1 (ass or a smnf( amount of income from self. employment. II may IJe to YOIl' benefit to file Schedule SE and use e/tlfer 'opllonal melllcd' In Pmt " o( Long SCI,edulc SE See In:;lfIICllo(J!i Excepllon: If your only self. employment Income was trom emnings as a minister, member of a religious order. or Christian Science praclltloner, Ind you filed Form 4J61 and receIved IRS approval not to be lal(cd on those earnIngs, do not fila Schedulo SE. Instead, wrlle 'Exempt- Form 4351' on pOlin 1040. line 50, May I Use Short Schedule SE or Must I Uso Long Schodulo SEl Old You Receive Woges or Tips In 19991 Jyes No Are you a minister, member at a religious order, or Yos Chrislian Science practitioner who received IRS approval not to be taxed on earnlr'lgs from these sources. but you owe self-employment tax on other earnings? No Was Ule total of your wages and tips subject to social security or railroad retirement tax plus_your net earnings from self. employment more than $72,600? Are you using one of the optional methods to figure your net earnings (see Instructions)? No Did you receive lips subject to social security or MedIcare lme (hal you did nol report to your employer? No No Old you receive church employee Income reported on Form W.2 0' $108.28 or more? No You Moy Use Short Schedule SE Below You Must Use long Schedule SE Section A - Short Schedule SE. Cautton: Read nbove 10 see if you can use Shorl Sclredu/e SF Net farm prollt or (loss) Irom Schedule F, line 35, and larm parlnerships, Sclledule K.l (Form 1065), ~el~."".""""""""""""""""",.."."" 1 2 Net prolil or (loss) from Schedule C, line 31; Schedule C,EZ, line 3; Schedule 1(.1 (Form 1055), line 15a (other than 'arming); and Schedule 1(.1 (Form 1055'8), box 9. Ministers and members 01 religrous orders, see Instructions for amounts to report on this lino. Sce Inslrucllons for othcr income to report ............... 3 Comblnellnesland2 ""'"'' """"""" ""',.,'''""""..""""""" 4 Nt ell earnings from seU-employment. Multiply line 3 by 92,35% (,9235), U less Ihan $400, do not file t 1 s schedule; you do not owe self.employmentlal(. , . . . . , . " . . . . . . . . . . . . . . . . . . ... . ..... . . . . . . . . . .. . . . . ~ 5 Sell-(lmployment t8X. If the amount on line 41s: · $72,600 or less, multiply Hne 11 by 15.3% (.153). Enter IlIe result tlere and on Form 1040,IIn9 SO. o More than $72,600, rnulliply line 4 by 2,9% (,029), 11'011, a(ld $9.002.40 to llle resull, Enter the total here and on Form 10ilO,line 50. . 6 Deduction for one.half of 5olf-e-mployment tax. Multiply line 5 by 50% (.5). I Entor Ihe result hero and on Form 1040,lIne 27 """"""""'''''''''''''' 6 I BM For Paperwor\( Reducllon Act Nollco, see Forni 1040 Instrucllons. 2 3 4 I'''' 5 96. ,...,J Schedule SE (Form 1040) 199 rDIA1IOl 11110199 1 35 . 1 359. 1 255. Yes S,1f1dr~ R Gouse 16 Popl~r Street Wormleysbllrg, PA 170~3-1)57 1999 U, S. INDIVIDUAL INCO~IE lAX RETURN SU~I~lARY Adjusted Gross Income Tox<lb I e Income Tot~l Tax Total P~yments P~yment Due IRS Effective T<lX Ratc $ $ $ $ $ 8,SS9 1,509 419 o 419 27.77 % " INSTRUCTIONS FOR ELECTRONIC FILING If you'rc filing electronically, plcase refer to the Electronic Filing Instructions on the ElectronIc Filing Form for det~iled step by step instructions. INSTRUCTIONS FOR MAILING YOUR RETURN Your federal Form 1040 shows ~ tax due of $419. Include a check or money order for this amount, p~yable to the United States Treasury. Write YOllr social security number and '1999 Form 1040' on the check. Enclose it with your return, but do not staple. Please m~il your return to the following IRS address postm~rked by Mond~y. April 17, 2000. Internal Revenue Service Center Philadelphia, PA 1925S-0002 Be sure to sign and date your return and include the Rroper amount of postage on the envelope, KEEP TillS PAGE FOR YOUR RECORDS - - DO NOT ~IAIL. ~ 'l'lOOL13003 1999 P A-40 Page 1 012 L 172-36-2034 GO EX 0 RS R GOUSE SANDRA R A 0 FS S FY 0 16 POPLAR STREET SC 21250 WORMLEYS8URG PA 170lj3 PN 717-728-1775 1A .00 18 .00 1C .00 2 34.00 3 .00 4 1359 .00 5 .00 6 .00 7 .00 8 .00 9 1393 .00 10 .00 11 1393.00 12 39.00 ---------------------------------------------------------------------, Please fold p;Jge along ltlis line Local Inform otten. Enter where you lived as of 12/31/99, School District: East Pennsboro School Code: 21250 County: Cumbe r I and Municipality: East Pennsboro Residency Stotus. (Check the correct box) R X Reslden' NR Nonresident P Part-Vear Resident From: To: Extension, ctleck this box, Amended Return, check this box. F1~cal Year Flier, check this box. Type Flier. (Clleck only one box) 5 X SIngle J Married, Filing Jolnlly M Married, Filing Separately F Final o Deceased Dale at death 1. Gross compensation, from PA Schedule W.2S, or your Forms W.2 or olher statements. . 1 b Unreimbursed employee business expenses, from PA SChedule UE 1 c Net compensation. Subtract line I b from line 1 a , , , , . . . . . . . . . . . . 2 interest income, Complete and enclose PA Schedule A if Over $2,500 3 Dividend income, Complete and enclose PA Schedule B if over $2,500 4 Net income or loss from the operation of business. profession, or farm 5 Net gain or loss 'rom tile sale, eXchange, or disposition of properly 6 Net income or loss from rents, royalties, patents, or copyrights ."............ 7 Estate or trust Income. Complete and enclose PA Schedule J, 8 Gambling and lottery winnings, , " , , " , " , " , " . , , , , .......... ................ ............ 9 Total gross Pennsylvanlo toxoblelncome. Add oniy IIle posilive income amounts tram lines Ie, 2,3, 4, 5, 6, 7, and 8, Do not odd any losses reporled on lines 4, 5, or 6 ",..,',.,.,."",,,, 10 Contributions to Your Medical SavIngs Account. See tile Instructions 11 Adjusled Pennsylvonlo loxable Income. Sublraclline 10 trollllil1o 9 ......... .............. 12 Pennsylvonla tax Iiablllly. Mulllply line 11 by 2.8% (0.028). Also onlor on lI"e 13, pago 2 ................... f'AIA0412 l0t'06199 L EC FC CD ITIJIo OJ 9900113003 10 .00 1b .00 1c .00 2 34.00 3 ,ad 4 1,359.00 S .00 6 ..00 7 .00 8 .00 9 1,393 .00 10 .00 11 1,393.00 12 39.0c@ 9900113003 -J '1'100213001 L 1999 P A-40 Page 2 of 2 SANDRA R 172-36-2034 3'1.00 111 .00 15 .00 .00 17 .00 18 .00 .00 20A 01 208 00 8655 .00 22 4.00 23 .00 .00 25 .00 26 .00 .00 28 4.00 29 35.00 .00 31 .00 32 .00 .00 34 .00 35 .00 .00 37 .00 -' liOUSE 13 16 19 21 24 27 30 33 36 13 Tala' Pennsylvania tox liability. Enter your tax liability from line 12 on page 1 , , " " , , " 14 Tolal Pennsylvania 'ax wilhheld, ham W,2, P^ Schetlule W,2S, or your rorms W,2or olher stalemenls , , . 15 Credit from your 199B Pennsylvania Income lax Relurn 15 16 1999 estimated Installment payments. 16 17 1999 extension payment ,.. 17 18 Nonresident tax withhold on your PA Schodlllo(s) Nru<.1 18 19 Tolalesllmaled payments and credits. Add linos 15, 16, 17, and 18 Tax Forgiveness Credit. Complete lines 20a. 2Ob. 21. and 22, Read instrucllons, lOa Filing Status: X Unmarried or separated Married Deceased lOa lOb Dependenls. Pari B, line 2. PA Schedule SP , 20b 21 Total eligibility Income, Part C, line II, PA Schedule SP 21 22 Tax Forgiveness Credll from Part D, line 16. PA Sclledule SP " 22 23 Total credit for taxes paid to oll1er slates or countries, Enclose your PA Schedule Gar RI<.1 '" 23 24 Pennsylvania Employmenllncenliv. Pa~n'''I' Oedit. Enclose your PA S,hetl"l. W, RK.I or NRK.I ' , , ' , ' , , , " 24 is Pennsylvania Jobs Creation Tax Credit, horn encloslld cCllilicale or PA Schedulo RK.l or tmK.l ..........,... 2S 26 ~tts~r,~~~l: ~K.it~l~R~.)C~~I~r~~ .l~l~~s~r.~~~~ ~~.x. ~~~~~t.' ,f~~~ .e.~~I~~~.d. ~~~~i~i~~~~ .~r.... ...... 26 'lJ Pennsylvania Research and Development Tax Credit, Irorn enclosed certificate or PA Schedule RI<.\ or NRI<.1 ",,' , , " , , '" , " . , " , , , """ " , , , , , , , , " , V 28 Total Payment.. and Credits. Add lines 14, 19 and 22 through 27 '" '" "'" ,,',"'" 28 29 Tax Due. If line 1315 more than line 28. enter tile difference here......... . .... 29 30 Ovorpayment. If line 28 is more Ihan line 13, enter tile difference here. . .. . . .. . 30 31 Rofund - amount of line 30 you wont as a check mailed to YOll . . . . . . . . . . . . . . . . . . . . . Refund 31 32 Credit - amount of line 30 you want as a credit to your 2000 estimated account. .. . . . . . , " .. .. 32 33 Donation - amount of line 30 you want 10 donate to the Wild Rosource Conservation Fund ,... 33 34 Denallon - amount of line 30 you want 10 donate to the U.S. Olyrnplc CommlUee. PA Division,. 34 35 Donation - Dmounl of line 30 you want 10 donate to the Organ Donor Awareness Trust Fund .. 35 36 Donation - amount of line 30 you want 10 donate to Ihe KorOlllNletll!lm Memorial, Inc, , , . . . , , ., 3G ~ Donation - amount of line 30 you want 10 donate to Broast and Cervical CllIncer ResGZlrch , . , .. '51 The tolal a. lines 3l through OT musl equal line 30. Under penalties of perjury, I (w.) decl:IIf'" !lal r (we) h:llye e...mitled Ihis relUln, incklding 1111 aCCOll1pllnyir1Q schfKlules and statements, ..nd to l11e best or my (our) belief l11ey .te we, correct, and comple\e. . Yoor Signature Oi'ltlJ Yoor OccupAtion 13 14 .00 .00 .00 .00 19 39.00 .00 .00 01 00 8,655 .00 4.00 .00 .00 .00 .00 .00 4.00 35.00 .00 .00 .00 .00 .00 .00 .00 .pO Spouso', Slgnalurfl il Filil19 JoinUy Oat" Spouse's Oceupftlion P(eparer or eompany nairn!, 0111er than toupaye,(s) P,e-parer or Com~lImy Nlme (please p,int) Onle T elt!phone Number Sigmllure oflt1e PI~roalf'( (orohon:ll) Self-Prepared L 9900213001 F'^'A(l.112 IOI!)(jt99 9900213001 Beautician -.J --' PA-40.C (9.98) '* '17031],3010 L AUach to Form PA.40, PA.65 or PA-41 U.ml 01 Pf(lp,illtOI ... Shown on Pflnn'y",."il ,.- n..lulIl Coml11onwoalth 01 Pennsylvania Profit or Loss from Business or Profession 1999 Schodule C f"A OCf"AntMEUT OF REVENUE !'\nt:..1 Secwlty 14mTl!>.r 01 Propri.lot S~ndra R Gouse 172-36-2034 A Main business actlvily_" Serv 1 ce: St.YJ...!J:!!L!LCut t Ul__..!.protl.uct oL~~~v~so_~__ , a Ouslness name to- S Cl nd r ~ R Gou 5 C [C h-parl' Id'llllllication Number o Business address (number alld slrool)jQQ.JlQ'!"!..5._?t,Jg~t_E~t..e!.1~i..o.[1__________ 172-36-2034 City, slale and ZIP code "EIlOI~, P~. 1702S ____ E Method(s) used to value closing Inventory, Cllp.ck tile nppropriale !lox: (1) rJ Cost (2) [I Lower of cost or mmket (3)IJ Other (If olher. aUach explallalion) F Accounting maUlod. check ltlC npprorrialr. box: (1) IRl Cash (2) [) Accrual (3)[) Olher <specify) . G Was there any change in determining qw:mlities. costs or valuations between opelling and closing inventory? " 'Yes' attach explanation, HOld ou deduct ex anses for an offlco in our tlOrTlO? ............" ..".. ".... , . .. , . .. . . "" . . . .... . . ,.... . . . ,.. ... . art. t "eotn.~~!n:-,/.t:~I;;~.:;~;/,,"::' "....~,:..;..~:\.';t/':'-''''.;'.''':'.'' ...'. .;'.,::" .d.' i.' 1 a Gross receipts or sales ...............,.. . . . . . . . . . , . b Returns and allowances, . . c Balance (subtract line lb tram line lal ,." 2 Cas I of goods sold and/or oper"lions (Schedule C, 1, line 8) , , . , ' 3 Gross profit (subtract line 2 from line I c) , ' , , , c c Ve. No x ~:;F*l"'" " 1b .. '" S,OIO. 1c 2 3 5 010. S 010. 4 aUmr income (attach sctledule) include interest from accounts receivable, business checking accounls and other business accounts. Also include sales of operational assets. See instruction booklets ,................ 4 5 Totallncome add lines 3 and 4) ..",,,,,,,,,,,,,..,,, , , " " "" , , " , .. , ' , , " , .. , , , , , , "." 5 Pait II~De' ili:tidl'ig:ii','. ':' , .' " ", .." ",,;;',')''''_':'::''.'-"'' 6 Advertising"",,,,,,,,,, 7 Amortization.....,.,....... 8 Bad debts from sales or services. . 9 Bank charges ,..,,,, 10 Car and truck expenses .. . . . . . . . . . 11 Commissions,.. 12 Depletion.""""",.. 13 Depreciation (explain in Sche(lule C,2) .' . . 14 Dues and publications. . .. . . .. . 5 010. 31 Wages 32 OlllOr expenses (specily)' · ..!-~I!'l9iY_J<_~te'?Q.i...Il.lU~___, b .!'bQ.ll_e_ _ _ _ _ _ _ __ __ __ _, c ll~IJ.IU!J.aJg~s_ __ __ __ _ _, 682. 908. 120. d 15 ~~N~~~ ~.e.~~f.i~ ~~~~~~~~ ~.t~~~ .t~l.a.~ . ; - - - - - - - - - - - - - - - -. - - . 16 Freight (nollncluded on Schedule C.ll g _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . 17 Insurance......................,.. h 18 Interest on business indebtedness, , , , , I 19 Laundry and cleaning "'''''',,'' J 20 Legal and professIonal services. . . . k 21 Otfice supplies ..",,,,,,,,,,, I 22 Pension and profit. sharing pli1ns for employees .,..,. . m 23 Postage .""""""" n 24 Rent on business property. . . . . . . . 0 25 Repairs"",,,,,,,, p _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , 26 Supplies (nolincludedonScl1eduleC.I) 1295, q __________________, Z7 Taxes..."................ r ------------------. 28 Telephone ..,..,........... . . . . . . . . , . 33 Reduce expenses by the total business 29 Travel and entertainment. , . . . . . . . . . E~~II~~~gt~~C~~rti~;~~enls 30 Utilities"",,,....,,,,,,,,,,,,,,..,,,,,, 646. Credll on the P,\,40 "",,'"'''''''' 34 Total deductions (add amounls in colL/mns for lines 6lllrough 32r) and deduct line 33.....",............. ~ 34 35 Net profit or 1055 (subtract line 34 flam line 5), Enler tolfll hore flnd on !he nppropriale line of Pennsylvanlo tax return. , . ., , ". . . . . . ., '_':":":"':"'~'_:_:"":"':~~:":':':_7.~":".'.':":":':"':":.':~:"':''':'':''':'~:'''' . . . ... . . .. . ... , .. . . . ,.. ". ,. 35 3 651. 1,359. L 9703113[J:L0 P^17.061? 11112199 9703113010 ---I ---1 Schedule C '1703213018 L ,,^ DErllmMENT or nr;VE~lIJt N.me 01 rroprletor.. G1mwn en Penn.ylvltl1r. Tllr nfllUfI1 Sandra R Gouse I SChiidule en'''' Cost of Goods Sold alld/or O~raUon!l SodJtI 5..curlty Numlllt, " - ---___._4_. .. .,.,"", ."." " .,',' .' I.'."'; " ,',-.1 . , Invontory at begInning Of Yf!nr (It dllfcront fr(lrll lnsl year's closing Inventory, attach explanation) 1 28 Purchasos... .. ~ b COst of Items wilhdrawn tor personal use " , 2b c Balance (subtract line 2b from line 2a) .,.. .......... '... . . . . . . . ..,..... .... "." 2c 3 Cost of labor (do not Inclucfe salary paid 10 yourself) . """'" '. ............ ............ . . . . . . . , .... 3 4 Materials and supplies '" .., .... '... '" .... ". "." ." "'''', .... ........ 4 5 Olher costs (allach schedule) ,.. ..... .... ..... ". ....... ..... ...... ....., " " .... ...... ...... 5 6 Add lines 1, 2c, 3, 4 and 5.." " .. .. ..,. ...... ." "" ... .......... ...., .... . . . . . . . " 6 - 7 Inventory at end of year ..... ", .... .... ........... " " '" ..... ........ '" ........ . . . . . . . ", ...... " 7 8 Cost of goods sold andlor opera lions (sub~act line 7 from line 6), Enter here and On Part I, line 2 . . . . . . . . . ~ 8 ISl:/jed 'a~2!~rH)cIDretl.Uoll iI",;,,:.' ;;;",~,.'i:o'.' ," I ' .... . .. ,',', ',;,,,,,,,, .. ;:\:.: ~:;;~lj';:':;r ;:;,:,,< ::,'1.; ,;~.\;;.~~;: ',. :~...'. ;:.:: 'I.:: ~!;,.; ~~Ji::~!~~r:"!:::l161l~g.f~1 Oesc"pllon 01 property Date Cost or Depreciation Melhod 01 Lite Oepreclallon la, allowed or allowable computing 0' acquired oUler basis In prior years depreciation rate this yea, (e) (b) (c) (d) (e) (I) (g) 1 Total additional first.year depreclallon (do not Include in Hems below) 2 Olhe, dep,eclalion: Buildings . . . . . . . . . . . . ..... Furniture end fixtures ...... Transportation equipment " Machinery & oth equipment Oth (speCify) _ _ _ _ _ _ _ ----------------. ----------------. ----------------. ----------------. ----------------. ----------------.- . ---------------- ---------------- ----------------. ----------------. 3 Totats . . . . . . . . . . . . . . . . . . . . . . '" .... "'" .. ..... ....................... ....... 3 4 Depreciation claimed In Schedule C.! ......... ...... ................ .............. ............. ........ 4 5 8alanc.lsub~actline 41rom IIn. 3). Enter here and on Port II, Iin. 13", ......."""..,.",."". ".,," 5 ~i'idUIIl,iC~g,;i::!i .. "/iilli_hlfoffililtlllfiJ<,,';;,,:Ji(,I",:,.:";..,i "" '.,', ,:'",.:;>"',:''i.';'{;',;'C',''.Ti:,;':..:,>;::ee,'',',:;,,i,;:;'";.:',,,;:,'::' r'"..';i:'.,(+:':.;:C'!{: i,':),\Wij;M~IDM:I~ , " I......,.. 172"36-2034 ""I""""""",y, r ,.' j.: "1" :,\i'. )~~ '..J';"}\'P'+,JJ" If you Incur anY,Of the expenses described below, enter the amount of the expense and describe the kinds of costs Incurred and the busIness purpose. . A Entertainment lacility (boat, resort, ranch. etc) Ex enses Amount B Living accommodations (except employees on business) $ C Vacations for yourself, your employees or their families. $ $ L 9703213018 P^'Z0612 10/19/99 9703213018 - S~ndr~ Jl Gouse C Social S.ctJrltyNl I I I,,' f'. l ('r\( .1 ' !~ ,!l iI" ~ i '~; : .... \ r. ,"~' I '\1 j, if~<~ I ,,,,,~ , ,ii' !.' i ....<....... ''" " --" PA Schedule SP '1'101113010 I f!~~~\~~~to~~~i,~u~nc_ss :~~(li~_J_~~L__,_____~ ;:IlI,"_ a, (.,hown on YOlJr r"IlI,,,.,lvnni,,, flU n",hull' " SP/)l,l,,', tlllll11'1 (..~.." if 'ihlll~ ~"plllll'.ly)' ------.------.. 172-36-21 SpOUM'. Soclll B .Part A. TY'p'e FII.r for Tex F~lv~"-,___ ou,;;;;;U'.d, a,eck thi, box 'nd Ihe IInrn.1Itiml or S'n,lI,'crJ h" nn I'A,~O, Ii", 20,1. A,,, ch"k !he 'nplopri," box below !h,! de,cribel )lJUI ,ilualion, B Sinqle. Unmmrled on December 31, 1999, CllCi.k this hox H divorced. Single nnd clnimcd liS n dependent on my pfllcnls' P^ Schedule SP, Enler your parenls' social security numbers tlnd naf SSN: Nome: SSN: Name: IRI S.p.rat.d. Check this box and !he Unmarried or Se.parated box on PA.40, line 200 it yeu are separated pursuant to a v.rillen e( married, but separated and living t'lpmllor the la~.l sIx months 011999. B Deceased. Check this box if filing for a deccdenl. ^Iso, check 1110 Dccc(lsed box on line 20a of your PA.40. Marrlod. Check this box and the Mmrlod box on PA.40, lino 200. Also check the appropriate box below thDt descrlbos your sltue B Married and claiming Tax Forgiveness together wlIh my spouse. Married and filIng separale Pennsylv<1nla lax relurns. Enlor spouse's social security number and name above. Married with a SnOU5p. who Is (I denendcnl on his or her parents' P^ Schedule SP. Enter spouse's parents' SSNs and nan SSN: NOllie: SSN: Narne: o Married with a 'pouse who i, a dependenl on Ihe led",1 income lax relurn 01 another person, Enler Ihe SSN ond nam. of th. per,on claiming jlIUr 'pou,. SSN: Name: o Separated and living apart frOIll my spouse. but lor less Ihan six menU,s 01 1999, Enter spouse's SSN and name above, Pert B. O. endent Children. Provld. .11 tho Inform.llon for eech de .ndenl child. Att.ch eddlllonel sh.ets If needed. 1 Dependent's Name ~ Relationship SSN Total income Importent: OJ child that YOt your depende federal Income 2 Number of dependents for PA Schedule SP, EllIer on PA.40, line 2Ob".""",...""""",..",."""",... Part C. Eligibility Income. If filing (]s Unmarried, Separated, or for a Decedent, Use tile Your Income column. It filing as Married, use the Your Income and SpolJse Income columns. Add the totals and use the Joint Income total. Your Income Spouse Income PA taxable income from your PA-40 ,', 1 1 393. Report income that Is not taxable for Pennsylvania purposes on lines 2 throu h 10. See tile instructions. 2 Nontaxable interest, dividends, and gains 2 0 . 3 Alimony,,,,,,,,,,. 3 7 262. 4 Insurance proceeds and Inheritances 4 5 Gifts, awards, and prizes ..,....... 5 6 Nonresidentincome,..""""",..,,,,,,, 6 7 Nonlaxable military income, Do not include cembat pay '" , .. , , , , " , , " , " , , " , " , , 7 8 Nontaxable gain from the sale of a residence 8 9 Nontaxable educational assistance .. 9 10 Cash receIpts, for personal purposes, from outside your home,,,,,,,, """"'"'''''''''' 10 11 Tole' E"glblll~ Income. Add lines 1 lilrougll 10, Enter on PA. 0, line 21 """""""""'" 11 Part D. Calcullltlng Your Tax Forgiveness. 12 Pennsylvania lax liability from your P^.,1O, line 13 . 13 Less re5jd~nt credit from your P^.40, line 23 14 Net Pennsylvania lax liability. Subtract line 13 frornline 12 2 II filII Unmer S.pen ror. Do lIseEII Income IIflllr Marrie ElIglbl/lb Tebl Total 8 6SS. Tolal Joint Ir 15 Perccnla9c of tax forgiveness using your c1encndcnls flom Pmt B, line 2 and your eligibility Income from Pmt C, line 11 ...... ". . . . . .. .................... 16 Tax Forglvenoss Crodit, Multiply line lit hy HIP. (Ir.cimallrom lino 15. Enter on P^.40, line 22 """""""" 12 13 14 .'............ 0.10 16 L 9901113010 PAIA2l}()! 10119/99 9901113010 .-- --- ....1'1<;' flll'l N''''~; l^"a.:h ~""'" ~:.'t""!hr.. Ilf I 11"" f1""""""I\II,'rllIlH>/1'~' -~~ ...f" W') f^,"'II/f;'l ,';"t'I'II'" li'I"~IIl"'III"" II ~..._-,.__. -. -..----..'---.- 5 TOIAI. I AXIIOI.F r:llrtNFI) "'CW,IF nFrOnF, '11' r "!InrI! S '1 ,,~<:,..,) UI{lM .'in r n.lI'l OYI.IHsr C^II<lUIII'<::lmn'.11 ~ 07"'" ,^'^"" "M"IFO "rr''''E l/in r",,,,,,/, 1)1""",,,,, ,.. o""..,,.r,,,,,,,,.., ",,",,',", ^""", .""....""0 O~""'"'''' 6 NET I.OSS roOM !-iF.! ".EMfllQV[:[) OU!WJES!>, I'tlOrr:SSlllN, on rAIlI.I 11l~1t LJn" a 'or nilI' N", PrOM,;) (Mlnr.h Arl',op,inl.. illS r:""..."",,,-:) 7 SUDJDl11t ''';I/Mnef till" r. llIlmllllf'~) If LF~~ IIIMI7rllfl. nllr" 1/"110 8. NET flnonr fnOM snr.F.MrI.OYf:(} OUSlflESS, F'110n:S~JON. 011 ''''IP.! ,tJ~n lkm () 100nllv tJN I o~~"~1 IAtr.1f.h A"'Ullflllilll' 'II!:: rod,,,,".,...;) ~ TOTAL TAXAnl r: ~M1Nr/) J~~CW.lF 1\Pl/l tJFr rn(lrl/~ 11I"d r In.. ; ill!" nl 10 TAX UADllITY I~~ or lIrlE 9 (M"I'ipIV Iln" 9 hVllll II. cnml1S A EflJEnIOIAll~;.TAXWI"lIrF.IUOYFMf'LOYfll. D. ENrEn QUAf1IU1LY "AYMENlS MADE 10 ""5 UUnt:M' ~:;t"H":.hh"l.":",N .O(:I':hJU:'l~h[.Iil'JijllTl"'I.U.:.IJ.___ I~ IF LINE IIC IS LAnOEn IIIAtII.lNF 10, ENTen 1lf:f!JtI/J Ill/I; "F/lr- (II Los, 111,'11 $1 nfl. FUI", 7r'II1 1:1 IF 1 IN!; IO'S lAf1(lCII HIMIIIrIF. 11(;. PAY IJNI'AlIIIJ^IM/I'f: IlV Af'IUI 1'; fll t(l~~ 111;", .,: Illn. rnlf'l l"1fl1 101 ADO INTr::f1r:ST Atl!) ('F"AUY or I~~ rf'11 MQIHI, or UHF 1:1 ArH'fl A"1l1l l!i 15 PAY BALANCE DUe WlTIllIIIS nETUnN (llll" 13 plu, lh,,, H) ",11.1.""",\ ^r",,,,,,,, --mrr '",v"",11" '''"iW;;iiiTIii".,,,, ,^m^" """IV CUlmENT ~Mll.rNO ^iii.iiiE~~---lifffijjl"i1f:'F.^Kir^SiiFi:O\"'T-- ",,____. ,;~~'~L_;';=~~'-~(;;"=l~;] TAXPAYER'S COpy 1999 FINAL RETURN FOR EARNED INCOME TAX Wr:ST^O FORM 5:11 mEV. 11/!1c)) ",:: .:: .;: .;:-:! ::. -;. ':: ~~. ';: ~;: .;: ~" -'~ t. (' I: J.' \'1 II /Il'l S.~1:nl~n ri '"(l!ft.:,. l.IIlX J q 1 J;' ."(1f..~ "" J 'II)')', '", II 1 ---.-..--.... ------.----.--...-.. ... --- .---------. - '" --..........--....---. ....- -. -- .. '.- .-. 011lnp1 ~ , , " ~'3 L;'(I,c:>O n 6 /~..J.:Fl. ()c:,~ , , .h~: 00 , 10 /.J,~? " -0- " " /" -1' J..3 1<, 15 10 I IlHF.rIEf/CE No. :t.. 1 .'~ .1-~' ~ n "so OUFlRCCOFloS,,,olc..,r "'''T rOU"RE A RESroC/n OF: () ~;" F r ~ "IN :~nn r(1 TW P --.'_'_'n__.__.. I -'''.------.-------1 -/ _ . :1.~'eIllCJlt 1'01' \' l'ar -,fI'!I ANt) rEOEf1^L I,n, NO. uOHN HANCOCK MUTUAL CLAIM SERVICES X-5 JOHN HANCOCK PLACE, PO BOX III BOSTON, MA 02117-0111 -cuiITOMim--.- ..'------,-.-.-, SERVICE PNONE. 1-800-732-5543 FEBEriiCO'.j':"14146 6 0 '-12068304 1.0 NO. ACCOWH NUMlJen ACCOUNT TYPE * * * 1999 1099-INT, LIFE INS.C C5288 7-9006889 PLEASE ADVISE INCORRECT. ADDRESS IN US IMMEDIATELY IF CORRECTIONS AND UPPER LEFT HAND THE TAX ID INQUIRIES CORNER. PLEASE NUMBER SHOWN BELOW IST'~"""~ SHOULD BE FORWARDED TO THE INCLUDE COpy OF THIS"1099 ALL THE TAXe..m1l..1.QJ!O. '....r.w .- . '........ .~. .-..., C:"J'r"'''~'''''''''''_'I...t''ll c."'..'..h........_.u.,.." C..",II.'.."."......._"...'.III (...,..,....,.. -"....._- C..,II ...".",....,.....,..",,,, lot'.OIU.C"",..,.........-._.. ,.... ...'(.(0"..'.........- '.., ,....(...,..,..,....._..', 10.....(...,..,..11_......_., '''''('('''''_'..0.0... '." I.....C...,..,......_.... 1999 CUSTOMER NAME, AnORess SA/lOnA GnOUSE 16 POrLAn ST WOnMLEYSBUAG, rA 17043-1357 IRS DESCRIPTION INTEREST INCOME * INTEREST INCOME IRS BOX' * * 1 AMOUNT U:'l ...,~......~.~ 172-36-2034 For Form 1099.8, OIV. INT, MISe nlld 010: This IlIlmporlDnt IlIlt InformaUon and 11lI being rurnlllhed In the Inlernol Revenue S. If you II'" rllqulled 10 fill! A telulU, n l1egUgonel! pennlly or OlhtH sAncllon mllY be Impolled on you Illhl. Income I. ta.abl. ar IllS dolnrmlnos Ihntll hits nol lIol'lI "'porled. .Form IO!!!! 010: ThIs lIlny nol tm Ihe COrrflclllgllre 10 report on your Income I". return. Seo Inlll'llcllonlJ below. Arc lIl1i..II'IICI" '.III"~"". ~., , 0;0...... .....'." r ,..~., ., ".'''''' '''., e. .,,, I'" '. ....'U'......,r....'.11',.I"....'. 'r"'''".. -.., ~"-' '. ."".., .,. ~,.- ,. ,..' "". '."'. "'''"ot .'.. .'I,~'~ ,,"~ In 1 .J...... .'...".. 1'( '., ,./.". '" r ~"h. '''.' ,,_, .....,,,., ~.'''', II, ,""..,.. ,,,,,.. "'1',"". " r,,~ ~~ I~,~',"..."'~f,,.. 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',".,,':,,~ ,~" .;;/ ...!~'l~"~~;',:.:,:, ~, ('~, ,":J ':~';, "~ ',.~ ,;, ,..;.. ..,";" '(I'.' ,:' .'lr , {,;;';"(r.N~!:s- ,__",1 - III the COUI" of' COflllllOIl "'eas of' CU~I/lEnL^N() COUII'Y, I'cllllsylvallia Pholle: (7 J 7) 2"0-6225 "O~IE,~T1C 1lJ.:t.,ITlflNS I'.fl. /lOX .1211, CAIlUSI",:, I'A, 17111.1 FlIx: (717) 240-6248 MIIRCU 7, '-000 Payee Nallle: SIINDRII R, GaUSE Payor Nallle: HONARD C. GaUSE: /'ACSES Melllber NUlllber: 2604100058 PACSES Case Number: 280100151 Olher Slale II) Number: "'1''''' ''''",: M' I'IIIT"S,,"""""1'1' 11I"" jlll'hr"e lhe I'ACSES C",'e NII"'''er. S'atefllellt of' Yearl ' I'a IIICII(S f'OI' Individnal Case SANDAA R. GaUSE 16 pOPULAR ST WORMLEYSBURG PA 17043-1357_16 Dear SANDRA R, GaUSE Court records indicate Ihat a 10lal of $ 6,086.78 \Vas paid dnring 1999 . TOlal paid for: Family Support (Spouse/Child/renD $ Child(ren) Support $ Spousal Support/Alirnony Pendente Lile/Alimony $ Medical SuPPort $ Fees $ 0.00 0.00 -&'056-.-4-:t -,) ~ It ~ , ~ 0,00 30.36 TOlalPaid on All Obligations: $ "'67O~a, };l7;;) _ ,," Sincerely, ACCOUNTING OFFICE '.----- ~' "~---- - .-- -- 101111111.1110,00010101,1,1111,00,1111011",111111",,11,01011 SntlORR R GOUSE POBOX 101 ENOLA, PA 17025-0101 PAGE I 172-3/ TAX ID - IHPORTIlHT TflX RETURN IJOCUHENT RLLFIRST BANK 52-03: FORHERL Y KNOWN AS FIRST NATL BANK OF MO EIN NI 25 SOUTH CIIRRLES STREET BALTIHORE, MO 21201-3330 1-8DO-533-Q630 FORH 1099- INT (mm tiC .15115~Ql12) 1999 INTEREST INCOME COPY B F~ PF.ClPIEHT RETAIL-CIIECKING------------------------__00I06_3380_4_----------------------------------------------------- IRS REPORTI/IG NAI1E IRS REPORTIIIG T' SANDRA R GOUSE SANORA R GOUSE 172-36-203Q 1 - INTEREST INCOME NOT INCLuoeo IN ITEH 3 2 - EARLY WITHORAWAL PENALTY 3 - INTEREST ON U.S. SAVINGS BONOS B TREAS. OBLIGATIONS 4 - FEDERAL INCOME TflX WIlHHELO 5 - INVESTMENT EXPENSES 6 - FOREIGN TAX PAID 7 - FOREIGN COUNTRY OR U.S. POSSESSION $1.18 $0.00 $0.00 $0.00 $0.00 $0.00 . This Is Important tax Informallon and Is being furnished to the Internal Revenue Service. If you are required to f a return, a negligence penalty or other sanction may be Imposed on you If this Income Is taxable and the IRS det. mines that It has not been reported, Instructions for Recipient Item 1.- Shows Inlerest paid to you during the calendar year by the payer. This does not Include Interest shown In Item 3. If you receive a Form 1099-INT for Interest paid on a tax-exempt obllgallon, please see the Instrucllons for your come tax return. Item 2.- Shows Interest or principal forfeited because of early w!lhdrawal of time savings. You may deduct this on the 'Per on early w!lhdrawal of savings' line of Form 1040, !lem 3., Shows Interest on V,S, Savings Bonds, Treasury bills, Treasury bonds, and Treasury notes. This mayor may not alllaxable. See Pub. 550, Investment Income and Expenses, This Interest Is exempl from state and local Income ta This Intereslls not Included In Item 1. Item 4.- Shows backup w!lhholdlng, For example. persons not furnishing their taxpayer Idenllflcallon number to the payer come subject to backup withholding at a 31% rate, See Form W.9, Raquest for Taxpayer Identification Number al Certification, for Informatton on backup withholding. Include this amount on your Income tax return as tax wlthher !lem 5.- Any amount shown Is your share of Investment expenses of a single-class REMIC, If you file Form 1040, you may de these expenses on the 'Other expenses'lIne of Schedule A (Form 1040) subJect to the 2% IImll. This amount Is Incll In !lem 1. . Item 6.- Shows foreign tax paid. You may be able to claim this tax as a deduction or a credit on your Form 1040. See your F 1040 Instrucllons. Nomlnees._ If your Federalldentlflcatton number Is shown on this fonn and the form Includes amounts belonging to another person, y' are considered a nominee recipient. You must file Form 1099-INT for each of the other owners showing the Income alloca to each. You must also furnish a Form 1099-INT to each of the other owners. File Form(s) 1099-INT with Form 1096, Anl1l Summary and Transmittal of V,S, Informallon Returns, with the Internal Revenue Service Center for your area, On each f 1099-INT. list yourself as the 'payer' and the other owner as the 'recipient: On Form 1096, list yourself as the 'flier.' A band or wife Is not required to file a nominee return to show amounts owned by the other, -- 1,"111",111,,,,,1,1,1,1,11,,,,,,1111"",,1111",11,""11,1 SnllDRA R GOUSE PO BOX 101 ENOLA, PA 17025-0101 IHPORTAHT TAX RETURN OOCUHENT FORIt 1099-00 luMY NO.1545-01121 1999 INTEREST lHCOHE pnGE I 172-36-, TnX 10 NI ALLFIRST BRllK 52-03121 FORMER LV KNOWN AS FIRST NATL BANK OF HO EIN NUHI 25 SOUTH CUARLES STREET BALTIHORE, HO 21201-3330 1-800-S33-Q630 COPY B rcn :mCIPmff STATEHENT-SAUINGS------------------------B_700_460_0374099---------------------______________________________ IRS REPORTING NAHE IRS REPORTING TIll SANORR R GOUSE SANDRA R GOUSE 172-36-2034 1 - INTEREST INCOME NOT INCLUOEO IN ITEM 3 2 - EARLV WITHORAWAL PENALTV 3 - INTEREST ON U.S. SAUINGS BONOS B TREAS. OBLIGATIONS 4 - FEDERAL INCOHE TAX WITHHElD 5 - INUESTMENT EXPENSES 6 - FOREIGN TAX PAlO 7 - FOREIGN COUNTRY OR U.S. POSSESSION $21.37 $0.00 $0.00 $0.00 $0.00 $0.00 . This Is Important tax Information and Is helng furnished to the Internal Revenue Service. 11 you are required to 11I1 a return, a negligence penalty or other sanction may he Imposed on you If this Income Is taxable and the IRS deter- mines that It has not been reported. Instructions lor Recipient Item 1.- Shows Inlerest paid to you during the calendar year by the payer. This does nol Include interesl shown In Item 3. If you receive a Form 1099.INT for Interest paid on i1 lax-exempt obligation, please see the instructions for your In come tax return. Item 2.- Shows Interesl or principal forleUed because of early wllhdrawal of time savings, You may deduct lhls on Ihe 'Penal on early wllhdrawal of savings' line of Form 1040, Item 3.- Shows Interest on U.S. Savings Bonds, Treasury bills, Treasury bonds, and Treasury notes. This mayor may not bE all taxable. See Pub. 550, Investment Income and Expenses. This interest is exempt from state and local Income taxE This Interest Is not Included In Item 1. Item 4.- Shows backup withholding, For example, persons nol furnishing their taxpayer idenWlcation number to the payer b' corne subject to backup withholding at a 31 % rale. See Form W-9, Request for Taxpayer Identlflcatton Number and Ct!1 tlflccdlull, tor Information on backup wl~hhold!ng. !r.:!udc thl~ :?:mour.t on your InrnmD. ta'( return as tax withheld, Item 5.. Any amount shown Is your share of Inveslment expenses of a single-class REMIC, If you file Form 1040, you may dedi Ihese expenses on the 'Other expenses' line of Schedule A (Form 1040) subjeclto lhe 2% limit, This am~unt Is Includ in Item 1. Item 6.- Shows foreign lax paid, You may be able 10 claim this tax as a deducllon or a credit on your Form 1040, See your FOI 1040 instructions, Nomlnees._ If your Federal identification number is shown on this form and the form includes amounts belonging 10 anolher person, you are considered a nominee recipient. You must file Form 1099-INT lor each or the other owners showIng the Income allocabl to each. You must also furnish a Form 1099.INT 10 each of the other owners. File Form(s) 1099-1NT with Form 1096, Annua Summary and Transmittal or u.s. Information Relurns, witl11he Internal Revenue Service Center for your area. On each Fa 1099-INT, list yoursell as the -payer- and the other owner as the "recipienV On Form 1096, lisl yoursell as the 'flier: A hi band or wife is not required 10 file a nominee return 10 show ;lITlounls owned by Ihe other. 36 . :17 JO ).,j/ or (I \ t)l\il, II E Xfc. N;)f::..S ~_._------_.._.._.._-......- -t;,f",,~ (), 1 /"""'"'''' "", ",, ."sq/ucl R"q 1? I 1/ , 6'~ LC-s:.C II 1l2I?/fMJII7NN r 7 I?..e -Z: N t;'- /;: E. X/V'.:s. ;DR. VI Jof r.s \5 me cI/~/N.L , ~,G (S/Jol:J ,-.. ~.J.... ( 177/7)/ll! ) . _ 7DIVe... (V/70 p) , : C)~e , (m,?lmy) C E'L L --Ph,-' me. GRS ::r l11u;::e: c:..T/ () ..J .71?q.:r VloU"/9 L/ C6lUr'CS ~~~~,,;z}/?~ ~X6S ,\SIlO/? CX,oEIlAJG 19 ____I r ,L,il..AJe/.'1f.,S 211 * d. Qfi.oc ER/~S , 1 21 k.. ." 'Or H:fl3SorV/f.t!. L/?-rt 22 .".' ,~\JuRc..\) 2 3 ~ ,. " 6 7 o 9 III II 12 13 15 17 23 2~ 25 26 27 20 29 30 31 32 33 3~ 35 '/ .. f/9L. ~'/-;t . '-'-'[d IP/11s p--!1?etfe. 3rt '111 .. ~ "f' II T I \' l~ !lo. 1!'1l.1 : ': I 1'1'1 ) .1 '- u /. "sO I~ () I"c 0 If'j'cic %' () - 1111/0 . ((10 t o _ c'l 0 , 10 '0 -7\ - l 0 110 0 0 -, , /- ~(} ,- "" j) IL c:,( , ", II , .. ,.., , , ... II , ,:] ~ , II , :1 , , U7 .... _....".~ .---...-- - , -, t, I.(~ ( P^ -- , - h_ h- I I , .. . - - - .. .. - .. .. -, - -. .-.- , , .. ,- , - - .. - - , '- .--. -I - -, , ,-- , .., -. .. , " h ,- ,- .. 1- 0 , _'_U - " - I, .. ,- -I- ; II -. 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(, I' '1 17 !, rLF^nr: CQtllM';f Yn,,,, nH" OVrll rr "ll~ 11/1If: I!'; r/l(~O"/1rr:1 II'; ~1>l!ll "11//111111I, rt.ft'I.(IYFnWIII. II^VF 10 r.\Jn'-'IT 1!1F: connF:'CT (MIl: IN wn"'NO, Ir Vall I/^VF All'" rllrrl(~lIl'Y Itl nn'^ltlllllll'll"l ItH"""'AII",, "J r-^~r 1'(HI,M:1 '(pun Inr.^l U1HO~J Fllt~r/lF~~ AOEt" I I 7. lAST CONTnlnUflNG EMfllOYEn rOlon TO. '? /11/ n ",1 1 1 I A. l^ST CONTnlnUTlOU INCLUOF.O. I : to..SrOUSE'S INFO: tlM-'F. or !H'OU:;F. I "'""'M!E OF srOIl". J / ;;> Co/'. 7 1 . 11, '1O",,,^l nETlnEMENT DAlE. 1 (() f / ('''(11 , 1111" IS '"lll"SI I.'~y [,1' (, ~f.,'r.'IIII(!!.Ul\'I:JC yr!IIP. ';71H BlllIIIUdY IINtl: !Ill' G1.1'1!'U,11nN 1:1 I'; YUln:; 1.'1 ';["Vle!. INt.tUI.J1N,: M LEASl 1 YF^'!S or: 1,c,f':PVlr:r lit; II'! /lCIIVI' 1'''',IlCr''~,'''1 "UP'" I'IM', H I\fJf1/11I' I. ' , " 1\ I., ~f.' ~ ,.t I,. I f.! r r; I f1(1(' K r. p!.In) flFI: . 0 f! '~ q. rLMJ AT. lire ",In f'l1 l' , 191J'i ~oc. ~EC, "0, Dr SPOUSE, 1 T?- }r,-2 014 Ir Yf'll ^"F ',Hmurll Ilr,., In''tll~, nr f,lJnlAIIIFl.1 r'I.F^SF. lJSF. 'liE F.NClO~F.f) GARn I;? ANNUAL OEtlEFIT ^CCnUAL. '1 T. '~(I JlII~ l~ fill: AMOUNt F^mlFn F.^,~II Yr^11 YOU wnnKFI'^, 1 r^~l IOll/lIUltrll'. r In/lp.F RI'NrTl I M:rnU/\1 !. r;. f.) 0 13. Esi'M^'ED NDnM^'. rENSlotl-l 70 t. 7 () f'lIt; ^~0l"'1 l!'l "" eSTIM^TE ONL V of FJWiMii. ['rF. Nsitm;/iiiiJ1l1l I I ^'1I1 ~llflVIVCln. F^nl Y. flr:rrnnrn (1tl VFf,'Ftl I., YEA" IN WIIICil ^CCnUF.T> nFtH:r1T!; AnE VF.!>TFD- I 'n'~; " , 1:'- j :j CM.END^" CnEDIT senvlGF. VF.Str:n RENF.rlT ^CCnUED ) ':1 YE~nS ~!OU~_S. YEAI1S YF.MlS _Y_~~!l~ ~~NEFITS ,'I .' 111 I ~ 7<; ):X:<X ..n 16:n ! I) 71, G tl "r, J I .. I, I 1'177 G 23't'1 t 1 1.0 27.% "I 1970 r. :: J/t2 , I I . (1 7.1.'16 191'1 I! ::~rl(, I I /. u n.% 19r11 H ;~.1711 I 1 .'] . (~6 1 '?f.li 11 ? (,Ir.; J I 1.0 2T.9~ 1982 II n 117 J 1 I.r) 2 7. '1(. 98~ I Ir?,;,,:; I I I. U 27. 'lE- 1'10'1 1 19(.3 I I I.:) 32.96 I Q!1li , ?n-,', J I 1.0 1?.. q(, In ,,~ If' If) I rl ?7n./f? I "If: ('ltllP^' IlI"H'I'~YIV^tll" "'^rt'~"~l'~; f'W"rtrttFtlf ItleDHI PtAN '('~)'.i f~I'P''''H; ';,ner:, WY1IIl (';f; I tic;, "" I')", In ~~ 1\ II. I tI': ^ OIHn f, '-; ".11. 11'Il( I'i:'i" ft' ."I( tll;. "^ I ')ci 1 ?,. ''\??:' 1')')/, MUll'''' '''Piny'! II"""" SI,,'r:.fH'>JI ,1/01/'>7 GOUSf; f(CfW^f1U C I, 00 ^ I> ^,.., r, !i' r: x f rNOL^ p^ 1 10~'i SOCiAL !lECUf1I'Y- ? U 7 - .J I, -.~; 'I !l n l. IJ I q f II I) ^ f r. -- ;: / 0 2. / (, , J 2. SPOUSe NAMe. - '3^Nnn^ l~tIU5[ ..1. 51'IHJSL: Ulf1tll 11^Il:. 1/;!!i/(ll (.. SPUUSE StlCll\L ~;ECUf?1 tY ~1I). _. 17~-' 1/-;'1) 1/, 5. 1?["POnfEO VAIl: IIr H1PF: - 'j/I':>/Tti (,. V~, S r l: I) S I A IUS - 1 (' U '; v l: S IF, t.l 7. ESI II~AIEU NIHlIlAL I1EI IflE~tr:r1l UAT!' - OJ/OI/?OIl_J n. DflAILS 1)1' F,""LflYr:1l CnN1f1lllllllr.HJS "'JSTr:1) In YfI\Jrl ACCUUNT FIll! IIIf. YEAr? lrJ')~ f'-I^, Wl'."r r1rcr-lvr:f> 'IV ?/IO/')T, F HPLf.lYF.' 11 "IHJ III PU r O'? "DUllS PAIU I III AL DlILLAIlS .--------------------------------------------.--------------------...--------------- A<1KANSAS (lESI FflEIGIII SYS InC J^r~..Qti 00 230.80 AIlKANSAS UESI rPEIGIII SYS nlc FCU. ,96 J 2 U 382.00 APKANSAS IJESI F"EIGllr SYs INC p.1I\n. .?ti 12 'J 302.08 ^f1K ANSAS nEST F"LIGII! SVS Inc APn.,Q6 1:16 i,I,7.56 Ar?KANSAS OE S I FPEIGIII SYs IJIC ~IAY. .9(> I It I, It 8 7.I'lJ Ar?KANSAS lIESI r PE: I Gill SYS INC JUN.,96 IOf. 622.131. AIlKANSAS (JEST rflE I Gill SYS INC JIlL.. DO 1 J(j 1'60.J6 AI'lKANSAS IJESI r PI'. I GII r SYs n,c AUG..<)6 1/,1, I, U7.44 Ar>KANSAS DESI F flr: I Gill SYS n,c SE.P., ?ti I fJ" 622.84 AflKANSAS IJESI F 11[: I GII r SYs IJ,IC OC T., 96 130 "'50.36 AIlKANSAS neST Frll'IGIII SVs INC NOV',?6 12 J 1'16. J6 AflKANSAS flESI FI'1: Ila'f SYS Inc OFC.,()(i 11,/, I, U 7. 4 I~ Ifl. OF:vrLOP'-1r:r--Jf fll ^CCIJt1UI. ^Ir:11 ^C(~IHJt,Jl "^I ^"H:r ,-rHlf.f 1?/05 '11 11'/',',", : I). L^ll~ CrJr--ITnll-1l1'lrH-JS/^nJt.I~fr.":N'c_; '(11 f'nfVtrJUS Vt:rd1S- '11 f ^-L . . .'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... '" I, 95.60 117.'1\ A. ACCOUNT UALANCE AS r;r- 1?/_1I/1'~')~; _ r,1. C:Or~TRI(JUf tor.J~. rn:Cr'Vf.() D\JPI"'I(j 1""', '. c. NET f:.^nNIN(j~; nDllt;l) (Junl~J(i 1')'.J~l .. 1>. ^CCOlHJf fl^'-^t>JCI... ^'.; 11F I;'/.II/l')')ri _ .11,.. 905. ')6 !j, ,,95,60 5,ljf\9.60 Iff). 071. or, · I Nt:LlJIJF 5 N9 11. ~t'NNU^LtZEO f1I\TE or rH:JtJnN I:^11NI:P IlN 1111, rnT..\L f:lJNO ron lQQ(, "I(,.? 'Y. , r ( Nr;JI[: NEI EMHIINI;S Ar?E' ACrUAl.l.Y CIlUIIJr'tl IU YOUr? ACCUUNI !lA5[1) llN lIUARTEnlY PAIl'S UF 'lE.I1HlN. IIIr-.r>rrr:lIl1: 11115 IlAll' CANtlOI ur: USEU III vEnlTY IIIE "NfOT f:Ar?NINGS AIJIJEIJ" A"lIUNI AIlOV,.. YOUr, ACCfJU~11 f1Al.AI,ICE SHOWN AIIOV!' 1<; SUBJECT 1(1 1\f)()lflnt-ll;,'>1:LI;lll1rJS ^t.JI) CflfH"rC;flflNS. ( I ~\ V~ '\ \ 1 ) I (', /, \ ~\\ -0C ~ "0 \Y, \I II \ \) I~ ~\. il I I. .scLl C\)~rn1' L 2 A. Ht>lIlE, 3 \3.c'r-lbi~ 4 C,GRRV.:-S 5 6...~~. mOTOR \fc.h,e,L 7 o .3. -:i;C)c.K-s ) 9 "..n..' €.R.T,P,c-n1"c.. de.. 10 . he.cK II\) q (-l ce.' j II I :~ ..~~_m. 5~D i rD1 -5 Fl~c- -, , 14 SR~S ckp. 8c,x - 15 16 .",. iRu...s-t:.s 17 :9 -..- - Jl~S IN~. 19 20 :~ roltu.:-h't,s :: '~~,,-~-- n :QR-lSI\) Ts \ I, 23 (\') 24 ',~,,'~\~ ._ ~esO{UfjL7kop, 25 .. _. OLLi.ad s Ho m iJ 26 27 ~".,] _' ..' Bu-.$/ Ill.ss-S 29 ___; . ElTtp t....6y /J}EllJl 29 30 ' '-~.:-.0_ :il;; ,c J,L W(/?/2~ I 31 n ~:=7.: 7?ciiuoi /<J"j 33 34 '~'~'[ ,:- . ,~?flf[:c.;1)eJr I. )1 _ 5 . 35 , I " 1.5./?.6 / ~I "'-t 36 ) 37""[- ',;-I-ICjJ?T/<.') rJ .0 [).f). ,; c.~ -17-'1 R-LJ QI0, 30.;t. j. , _ k. CA 116 J "Z&:JU 40 :J9. ' I. b '_ .. " -.. .,,,, "Cf.0 - 7-.5 F ~ I' "I' T 1\' l' II,..I';n.1 '''1111\1'; _ II~I__! 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" -' ~ ' f~~}~};_:{:'<;, f~" ::'. ~gfXs_!\: . . i~i;~-~!,.'i "I. r(;~;-::':< ". ~ r- .!;2......_,~ ..:2 ~~l:$..~~!i-,}..~:'-.:.,,~--~'~('") .~: "::::'" .l;f:g{~.'1'~~~,. 'EC ~?:.:'>':",i.:, ,9 (\ i......' "",' j, 'c'.jr."" . <0' ~~~"":~~ j f.,t,; ">:. ~ ,gt '0;>' 3~ 'o::z 1.ILO (1)0.. ~ :::> (J ,.!,f,(",:h' 3:.< " . ... ~ ...; ',:. " . ;~/i~~':\l~' , . " t'X::~:::.<= 8.<' ...." 'z"', ,",Z" <; ~ ,;..t:;,~,>,./ -~~;':>P~"'-~ tr.I,,~>', Ht"~':~/I'::I ~~-Z',~' , "-",, '0"' "0 ,..}~ '\:;:'~:'f,/:- "Z:i5'cn;.'.,' ," ."<" ",.,," """0'-,' :9" .y: I,;:: I\) :':i' <"~'" ,:.. "n " ';""";~""'>'~:' 0 C a~ ~n 2: = l ',', '~'," ~~ 0 I . !~ 01-1 ~I:"' \0, ~. ~> co :~.' I ' , ~ w ..'.~ ,".~ V1 . gjrn 1-1 C'\ 0 oIlo ~ 1-3 .<l "h:l8 .'., 'i:'J 21 CD 1-1 f-l..,J . 1-31-1 n HI rn III ", Cl ' '21 I "", CD . "", , rn n' <l' ::s 8 i:li:~ ~ ~' "". 'c. i-' ~ Cl "~. :e: rn ' HI,'" ~: ... rt " i:'J HI 1-1 CD . .' , ' 21 8 , , .;,' ,.\':,:'-~(' .~:: " . INCOME EMPLOYER A.B,F. Freight Systems ADDRESS P.O. Box 1925 New Kingston, PA 17072 { SOCIAL SECURITY NUMBER 207-34-5450 PA Y PERIOD Weekly GROSS PAY PER PERIOD $766.80 Itemized Payroll Deductions: Federal Withholding Social Security Local Wage Tax State Income Tax State Unemployment Tax Savings Bond Credit Union Life Insurance & Health Other Support $ 96.41 47.54 7.67 21.47 11.12 107.88 NET PAY PER PAY PERIOD $ 474.71 OTHER INCOME Weekly Monthly Yearly (Fill in appropriate one) Interest $ 9.25 Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Compo Workmen's Compo Public Assistance Other TOTAL $ 9.25 $ $ TOTAL INCOME $ 483.96 DeclaratIon Control Number jDCN!L [[1],1 -~[]41{= ~J~I -~-CI-CLJ -[[] IRS US!! Onlv. . Do no! wrlle ot stap'Ie In Ihl~ Sfllle!! Use tho IRS 'abel. Otherwise, please prlnlor type, Your fir5t name and Initial HOWARD C u.s. Individual Income Tax Declaration for an IRS e- file Return For the year January 1 - December 31. 1999 .,. See Instrucllons. Last name GOUSE OMBNo, 1545-0936 Form 8453 i]@99 DepnrlrnronlolllleffllnUlY n "rnltR II nUf! IV L A B E L tl E R E If a JoInt relurn, spouse's first name and Inlllal last name Your social security number 207-34-5450 Spouse's social secur"y no, Home address(number and slreel).1fyou have a P.O. box, see Instrucllons. 400 ADAMS ST EXT City. town or post office, slate, and ZIP code ENOLA PA 17025 ApI. no, A. IMPORTANTI A. You must enler _your SSN(s) above, Telephone number (optional) I Part I I Tax Return Information (VVhole dollars only) 1 Tolallncome (Form 1040, line 22; Form 1040A.llne 14; Form 1040EZ, line 4) . 2 Tolallax (Form 1040, line 56; Form 1040A, line 34; Form 1040EZ, line 10), 3 Federal Income lax withheld (Form 1040, line 57; Form 1 040A, line 35; Form 1040EZ, line 7) 4 Refund (Form 1040, line 66a; Form 1040A, line 41a; Form 1040EZ.llnc lla) , ri Amount ouowe Form 1040 line68'Form1040A Iine43'Form1040EZ line 12 Part II Declaration of Tax a er 51 nonl afterPartllscom leted, I consent that my refund be directly deposlled as desIgnated in the electronIc portion of my 1999 Federal Income lax return. If I have flied elolnl return, thlslsan Irrevocable appointment of the other spouse as an agent to receive the refund. I do not want direct deposit of my refund or I am not receiving a refund. 1 2 3 4 5 33,024 2,939 3,473- 534 b~ cO I authorize the U.S. Treasury and lis desIgnated Flnanclal Agents to Initiate an ACH debit (automatic withdrawal) entry to my financlallnslllutlon account Indicated for payment of my federal taxes owed, and my financlallnstnuUon to debit the entry to rT:1Y account. ThIs authorization Is to remain In full force and effect unlll the U.S. Treasury's FInancIal Agents receIve notHicatlon from me oHhe termination. To revoke thIs payment authorization, I must contact the U.S. Treasury Financial Agent at1. 888- 353. 4537 no later than 2 business days prior to the payment (settlement) date, I also authorize the financlallnsltullonslnvolved In the processlng of my electronIc payment of taxes to receive confidential Information necessary to answer Inquiries and resolve Issues related to my payment. If I have filed a balance due return, I understand that Ifthe IRS does not receive full and timely payment of my tax lIabll~y,1 will remaIn liable for the tax liability and all applicable Interest and penalties. If I have filed a JoInt Federa! and state tax return and there Is an error on my state return, I understand my Federal return will be rejected. Under penaUlesofperjury,1 declare that the Information I have given my ERa and the amounts In Part I above agree with the amountson the correspondIng lines of the electronic portion of my 1999 Federal Income tax return. To the best of my knowledge and belief, my return Is true, correct, and complete,l consent to my ERa sending my return, this declaration, and accompanying schedules and statements to the IRS. I also consent to the IRS sendIng my ERa andlor transmItter an acknowledgement of receipt of transmission and an IndIcation of whether or not my return Is accepted, and, lfrejected, the reason(s) forthe rejection, and, If 1 am applying for a refund anticlpation loan or similar product, an Indication of a refund offset. If the processing of my relurn or refund Is delayed,! authorize the IRS to disclose to my ERO and/ortransmitter the reason(s) for the delay, or when the refund was sent. Sign ~ COPY ONLY -.J______ ~COPY ON~Y , I Here ,. Your slgnaturo Date r Spou'ie's slgn3lUle. II aJoint return, 80Hl must llgn 03tO I Part 11I1 Declaration of Electronic Return Originator (ERO) and Paid Preparer (See Instructions,) I declare that! have reviewed the above taxpayer's return and that the entrleson Form 8453 are complete and correct to !Ile best of my knowledge. H I om onlya collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return, TIle taxpayer will have sIgned this form before I submit the return. I wHl give the taxpayer a copy of all forms and Information to be filed with the IRS, and have followed all other requirements In Pub. 1345, Handbook for Electronic Return Originators of Individual Income Tax Returns. If I am also the Paid Pre parer ,under penalUesofperjury I declare that I have examined the above taxpayer's return and accompanying schedules and statements, and to the best ormy knowledge and benef, they are true, correct, and complete. This Paid Pre parer declaration Is based on all Information of whIch I have any knowledge. ERO' ~;Z (Y 1& I Date ~heCklf . 5 .' also paid ERO S siQnature ;k.-t<A--<- Ct :A~A 02/22 /2000 ~arer Ijg Use Flrm'sname'(oryours ~H AND R BLOCK ani ~~I~Jd~c~yed) 413 NORTH ENOLA ENOLA" PA Check I ERa's SSN or PTIN II self- 01 emloed _ . EIN 25-1820203 ~P~~ 17025-0000 Under penalties 01 perjury, I declare th3t t h;:!ve eXl'Imined the above t3~payer'5 f!'lurn and accompl'Inying SChlldul"5 3nd 5tatpment!l, and In thl! blllll 01 my knowllldgll and bell"I, they are true, correct, 3nd comptete. This declaration Is b35ed on alllnfnrmatlon 01 whkh I have any knowlpdgo ~ I Date Pre parer's Paid si nature Preparer's Firm'sname(oryours ~ Ifsell- employed) Use Only and address KBA For Paperwork Reduction Act Notice, see lnstrucllons, Check ] PrepArcr's 5SN or PTIN Ilself. 0 em loyed _ j EIN ZIP code Forrn 84&3 (1990) Form 8453 (1999) FD8453D.jV 1.91 Department orlhe Treasury. Internal Revenue ServIce U;S. Individual Income Tax Return Form 1040 Label (See InstrucUons on page 18,) UsolholRS labol. Olherwlse, please prlnl orlype, Presldenlla! ~ Election Campaign Do you wanl $310 go 10 thIs fund? , . . See a a18. Ua olnlrelurn does ours ousewant$3to otolhlsfund? Filing Status 1 Single 2 Married filing Joint return (even Ir only one had Income) 3 X MarrIed filing separate rei urn. Enll'f \\POU~Il'\\ SS~l abov" and full nam.. h"",! ~ SANDRA GOUSE 4 Head o(household (with qualifying person), (See page 18,) Ifll1e qualifying person Isa child but notyourdependenl, enler lhis chlld'sn3me here. ... Quail In widower wllhde endentchUd ears ousedled ~ 19 ,See a e 18, Yourself, Jryour parent (or someone else) can claIm you as a dependent on hlsor her lax relurn, do not check box 6a b Souse, c Dependents: -WFlrslname 1l@99 n IRS Use Onl .. On nol w,illl 0" ~ Ie In I Forlhe earJan.l-0ec,31 1999 or other tax earbe Innln 1999 endln OMBNo, 1545.0074 Your social !lecurlty m~mber 207-34-5450 HOWARD C GOUSE 400 ADAMS ST EXT ENOLA, PA 17025 Spouse's socIal securHy number 172-36-2034 IMPORTANTI A. You must enler A. YQ.YLS~ll(&above. Ves No Note: Checking - 'Yes"wlllnol X change your lax or reduce ourrefund, Check only one box, Exemptions 6 6a } No.ofbolt!!l check.l!don . , 611nd6b , . No.ofyouf 4) i' qua1.chlldfl!non6c child for who: 1 last name (2) Dependent's socIal securit numbe (3) Dependent's relatronship to YOU .U'o'l!dwllhyou_ . dldnolltvewith youdUlllodivOfce Ofsepalalion (sI!ePll~e1g1 _ Dependenlson 6cnoll!nl1lled above Ifmore than sIx dependents, see page 19, d Tala! number or exem lions claimed Income 7 Wages, salaries, Ups, elc. Attach Form(s) W- 2 7 8a .Taxahle Interest. Allach Schedule B Irrequlred 8a AIIach b Tax- exempllnterest. 00 NOT Include on line 8a . 8b CopyBolyour 9 Ordinary dividends, AIIach Schedule B Irrequlred 9 Forms W- 2 and W- 2G here. 10 Taxable refunds, credlls, or onsets orslate and local Income taxes (see page 21) . 10 Also attach 11 Alimony receIved 11 Fonn 1099- R II 12 Business Income or (loss), Allach Schedule Cor C- EZ 12 tax was ~D wilhheld. 13 Capital gain or (loss), If Sch D not required, check here 13 14 Olhergainsor(losses), Attach Form 4797, , J b ~ax~bl~ a~nt : 14 If you did not 15a TolallRAdlslribullons , '~ 15b gel a W. 2, lGa Total pensions and annuities. 16a b Taxable amnt. 16b see page 20. 17 Rental real estate, royallies, partnershIps, S corporatlons,lrusls, etc, Attach Schedule E , 17 18 Farm Income or (loss). AUach Schedule F , 18 Enclose, butdo 19 Unemployment compensation. . , 19 not staple, any 20a SocIal security benefits , . ~I r b ~ax~bl~ amnt : 20b payment. Also, please use 21 Olller Income, List type and amount (see page 24) Form 1040- V, 21 22 Add the amounts In the far rl ht column ror lines 7 throu h21. This Is ourtotallncome .. 22 Adjusted 23 IRAdeducllon (see page 26) , 23 Gross 24 Student loan Interest deducUon (see page 26) . 24 Income 26 Medical savings account deduction. Altach Form 8853 26 26 MovIng expenses. Altach Form 3903 26 27 One- hair olself- employment tax. Attach Schedule SE 27 62. 28 Self. employed heallh Insurance deducllon (see page 28) 28 29 Keogh and self- employed SEP and SIMPLE plans, 29 30 Penartyon earlywlthdrawalorsavings . 30 31a Alimony paid b Recipient's SSN .. 172-36-2034 31a 7,854. 32 Add lines 23 Ihrough 31a 32 33 Subtract line 32 from line 22. ThIs Is our ad usled ross Income .., ,33 KBA For Disclosure, Privacy Act, and Paf'lerwork Reduction Act Notice, see page 54. Fonn 1040 (1999) FD1040-1V 1.25 Add numb",s ,~~~~f:go~~ II- 31,672. 481. 871. 33,024. c' Form 1040 1999 Tax and Credits Standard Deducllon for Mos. People Single: $4,300 Head of household: $6,350 Married filing Jointly or Qualifying wldow(er): $7,200 Merrled filing separately: $3,600 other Taxes Payments Refund Have it directly deposited I See page 48 and fill In 66b, 66c, and 66d. Amount You Owe Sign Here Joint return? See page 18. Keep a copy for your records. Paid Pre parer's Use Only K8A Form 1040 (1999) 55 Addllnes49throu h55,Thlsls ourtotallax . , 67 Federal Income taxwllhheld from Forms W. 2 and 1099 . 68 1999 estimated tax paymenls& amount applied from 1996 relurn. 59a Earned Income credit. Attach 5ch. EIC If you have a qualifying child b Nontaxable earned Income: amI. )io I and type .. 60 Additional child tax credit. Attach Form 6612 61 Amount paid with request for extension 10 file (see page 48) 52 Excesssoclalsecurllyend RRTAlaxwllhheld (see,Qj'ge48) , . 63 Olherpaymenls, Checklffrom a 0 Form 2439 bU Form 4136, 64 Add IInes57through63, These are aurtotal a ents, 65 Ifllne 64 Is more Ihan line 66. sublraclllne 56 from line 64, Thlslsthe amount you OVERPAID 66a Amounlofllne65youwantREFUNDEDTOYOU, , , , ' , , , , , , .. b Routing number I I" c Type: D_checklng 0 Savings ~ d Account number , ~ 67 Amt.ofllne65youwanIAPPLlEDT02000ESTIMATEDTAX ... W 68 If line 5615 more Ihan line 64, sublraclllne 64 from line 56, This Is the AMOUNT YOU OWE. Fordetallsonhowtopay,seepage49 . 69 Estimated tax Denaltv. Also Include on line 68 . Undor penaltlD!!; 01 perJury,1 dtlcl~relhal' ha....e examined this rotur" and accompanying schedule5 and statements, and 10 Ihe best of my knowledge and bellel, th~y ale !rue, correct, llnd complete. Decl~r~t1on or prep~rer (other lh ~n t~)Ip~yer) J!l b~!led on atllnformatlon of whIch pIe parer has any knowledge. Your sIgnature, Dale Your occupal1on Daytime telephone ~ number (optional) For Info Only -Do not fil OCK WORKER Spouse'sslgnalure, Ire)olnl relurn, BOTH musl sign, Spouse'soccupatlon For Info Onl -Do not fil Preparer's .... sl nature r Flrm'sname (or yours If self. employee) and address HOWARD C GOUSE 34 Amounl from line 33 (ndju!'tlcd oro!'.!'. Incorne) . . . , . . . . . . . 36a Check If: [I You were 65 or older, LI OlJnd; [I Spouse wns 65 or older, Add tile number of bOKoschecked above and elller Ille lolal here b If you are married filing separately nnd your SPOU5C Iternlzesdeductlonsor you were a dual. slalusallen, see png'! 3Qand check here (J 811n~ .... 35a ," 35b 0 3G Enter your itemIzed deductions from Schedule A, line 28, OR standnrd deducllon shown on the len. But see page 30 10 find your stnndard deducllon If you checked any bo)( on line 35a or 35b or If someone can claim YOll as a dependent 37 SUblraclllne36fromllne34, If line 341s $94,975 or less. multiply $2.750 by the lolal nl,lmber of exemptions claimed on II Ine 341s over $901,975, see the worksheet on page 31 for the amount to enter 39 Taxable Income. ubtmcl line 38 from line 37. If line 36 Is more than nne 37, enter. Q. 40 Tax. Check Ifany lax Isfrom aD Form(s)6614 bD Form4972 41 Credit for child and dependent care c)(penS(>s. Attach Form 201011. 42 Credit for the elderly or the disabled. Allach Schedule R 43 Child lax credll (see page 33), 44 Educallon credits. Allach Form 8863 45 Adoption credit. Ailach Form 6639 48 Forelgnta)(credlt.AllachForm 1116lfrequlred. . . . . 47 Olher. Check If from a 0 Form 3600 b 0 Form 6396 cO Form 6601 dO Form (specify) 48 Add Iines411hrough 47, 49 Subtrectline 48 from line 40, Ifline 48lsmore than line 40, enter- 0- , 50 Self. employment lax, AlIach Schedule SE 51 Alternallve minImum tax. Attach Form 6251 52 Social security and Medicare la)( on lip Income not reported to employer. Attach Form 4137 . 53 Ta)( on IRAs, other rellrement plans, and MSAs. Attach Form 5329 If required , 54 Advance earned Income credit payments from Form(s) W- 2 55 Household employment ta)(es. Attach Schedule H 38 41 42 43 44 ..iL ___ 46 47 57 58 .. 3,473. 59a 60 61 62 63 ',lll' Dale 2/22/00 h. HAND R BLOCK r ENOLA, PA FD1040.2Vl,25 207-34-5450 P. e2 ~_ 25,108. 36 3 600. 37 21,508. 38 ~9 18,758. .. 40 2, .. 48 49 50 51 52 53 54 55 2,816. 123. 56 2,939. ,~ 3,473. 534. 534. .. 64 65 66a .. 68 Preparer's SSN or PTlN EIN 25"'1820203 ZIPcode 17025-0000 Form 1040(1999) -<. u ..I<. .(., rr ~ w ~ w ~ S'~ ~ 0 ~ ~ ! ~ u: u: \\ w ~ ~ () '" '" I- Z W :; 0 ...J ::::l Z Z . < z C < U. Z > ~ w w h '" 0 z < U. 0 C 0 lD ~ " i:l: ~ ~ 0 II: '" III ~ I;; 1;1 0 0 u ::::l w J: n~ 0 J: W 8- . !; II: g ~ ~ W ~ .. 0 " II: ~ , 0 > -R! is .l.. ~~ ~ ~ ~ ~ ~ ~ altU . f '!! ~o o ii' i" ....... & ~ ltt~ \) w (fJ c:: a: ~ II. ~ ~ &J~ .J'. ~ ~ ~ ~ 2iO~o.. a1~.~ lei oj . ..: c 0) ~ ~ ~ u gQ) ~J~ ~~ ~ - ~ ~ ~ o;~ '* \) - ~ ~ ~ ~~ S il!. ~ g.'-' h~ g r w .. :\ " ;;. .\.;.w~ i3 ~ ~ :J ~:i rri5, fl~ (l)Z S' a~ S grr ~ rrO "'1J ~~ ~o ~ ~ '!! N ~~ irS ~ 2~ " w~ di a:~ ~ It ~;; ~ ffi ~g "-00 i!: 0 fj "-~ ~"O> ~~ a o.x ~ i' "O':! u _ >- " .. '" ~o o !!:D '" ;;:l, . , ~t;l. ~ 0 !i ~D ~ " ~ ~ '" rr " w ~ ~ w "-'" " 0,,- frl o. "->-0 W;; oili> 0 ,,- ~ w w "- i'!l'i u ffi!a~ rr"o 0 <'" ~ ~ z lHc~ w ~~ W "'" ~ ~ w 0 ~~~ ~i3a " in 0 . w ~&~ ~ ~ , ~ z rr :!! d ~ . ~ ~ S"-l ~ M .,; ~ i , . COMMONWEALTH OF PENNSYLVANIA) ) ss, COUNTYOFCUMDERLAND ) I vcrify that thc statcmcnls madc inlhc allachcd INCOME ANI> EXPENSE STATEMENT arc truc and corrcct. lundcrstand lhat liilsc statcmcnts hcrein arc madc subjcct to thc pcnaltics sct forth in 18 Pa. C. S, *4904 relaling to unsworn falsification to authoritics. DATED: ?'-1 cJ.- C/ cJ 7!~)6~ / HOWARD GOUSE ,.......,:,,~ CERTIFICATE OF SERVICE AND NOW, this 25th day of September, 2000, I, John B. Dougherty, Esquire, attomey for Plaintiff, hereby certify that [ served the within DEFENDANT'S INCOME AND EXPENSE SHEET Ihis day by depositing the same in the United States mail, postage prepaid, in the post office at Harrisburg, Pennsylvania, addressed to: By First Class Mail: Donald B. Owen, Esquire P,O. Box 416 Wormelysburg, PA 17043 Howard Gouse 400 Adams S!. Ex!. Enola, f' A 17025 n BY:~~~ 6 ~~ur HN B. DOUGHE Y .".,.".".,.."".,o..w.,..".... ), Crf'llER WITNESSES: Non~. 4. EX! IIIlITS: non~ nol allaclwd loth~ pr~-lrial slal~ll1~nl. '. 5. INCOivlE STATWvIENT: I'laintitrs cllrr~l1Ilcll~r of~ll1ploYIl1~nl with tlw COll1ll1onw~allh of P~nnsylvania and two r~ccnt pay sluhs ar~ allachcd aloug with thc plaintilrs 2000 incoll1c tax rctul'll, 6. EXPENSE STATEMENT: nonc 7, PENSION: Thc dcfendant's pcnsion has two parts 10 it. Thc CcntralPA Tcamstcrs Pcnsion Fund changcd from a Dcfined Bcncfit Plan as of Dccembcr 31, 1986, at which timc it bccamc a Dcfincd Contribution Plan, As pCI' thc allachcd information /romPcnsion Appraiscrs Inc., thc valuc of thc Dcfined Bcncfit portion, that is {rozcn, is $39, 565.88. Thc Dcfincd Contribution Plan, which bcgan on January I, 1987, as of Junc 30, 1998 (onc month atlcr datc of scparation) is $69, 894.39. In simplc tcrms, assuming that thc cquitablc distribution of thcsc two amounts wcrc to bc 50-50, plainti Ir s sharc would bc $54,730. I 4 plus her sharc of accumulatcd interest on thc Dcfincd Contribution Plan sincc date of scparation. 8, COUNSEL FEES: Dctailcd statement allached. 9. VALUATION ISSUES: (~) PlaintifTbelievcs th~t defendant had an account at Harris Savings Bank (account # 902131174) in thc ~mount 01'$13, 037 as of date of separation. The attached copy of the statement shows that the defendant withdrew $12,937.39 from that account on June 18, 1998. See line 6 (b) on plaintiffs annotated list of assets. Plaintiff operatcs a beauty salon from officc in marital rcsidence; defendant operates a taxidermy business from the home. Value of that business and ~1I equipment subject to valuation. Plaintiff has no interest in and does not seek to v~luc dcfend~nt's tools, hunting and camping equipment. I' 11 r If 'I I , ~ ii : , :~M . r~ !I " I ~ :i 10. MARITAL DEBTS: Mortgage on cabin in Tiog~ County which defendant proposes to remain responsible for and has made payments on since datc of sep~ration. I I. PROPOSED RESOLUTION OF ECONOMIC ISSUES: Plaintiff contends that the combined value of the parties as per list of assets is approximately $10,000 less than what it should be. Specifically, the amount of the defined benefit plan on line 16 is $39, 565.88 nol $30,000. And there is ~ failure to report the defendant's Harris savings account (# 902131 174); said account had a balance 01'$13,037.39 as of date of separalion. Furthermore the plaintiff contends that the $14,000 attributed to be a marital asset online 24 (money from the estate of the plaintiffs mother is not subject to distribution for purposes of equitable distribution. Distribution ofthc estate was madc bc/ore datc of separation and the $3,190 on " i" : i . , , I , I I i ! I "I , Iinc 6 of dcfcndant's lisl of asscts rcprcscnts thc balancc of thai $14,OOO.'I'hat brings thc total valuc of thc assets subjcctto cquitablc distributcd to $29X,563.1 X not $2X9.959.5X. Ikcausc of thc disparity in carning capacity and past rccord of cmploymcnt, plaintilT sinccrely belicvcs that alimony should bc part of any divorcc ordcr and that a 60-40 split of asscts in lill'or of thc plaintilT is appropriatc. Sixty pcrccnt 01'$298563.18 is $179,137. I. Plaintiff rcccives marital domicilc valucd at $110,000, Icss $10,000 which is thc cstimatcd diminution in valuc lor rcmoval of maturc trccs and shrubbcry by dcfcndant on Eastcr wcckcnd 2001. This conveyancc to ineludc all ofthc fumiturc and applianccs (valucd at $8.(00) in working condition. $5,000 to bc placcd in cscrow to guard againsl any dcstruction or sabotagc as husband vacatcs thc marital rcsidcncc whcrc he has bccn rcsiding sincc datc of scparation. Thc $5,000 in cscrow is justilicd givcn thc history of dcstruction and sabotagc to thc marital rcsidcncc and thc dclendant's tortious interfercncc with thc plaintirt"s bcauty shop, which is localcd thcrcin, ovcr thc last threc ycars. 2. Plaintiff to rcceivc thc $39,565,88 portion ofthc dcfendant's pcnsion (frozcn as of 12/31/86) known as thc dcfined bcncfit plan; dcfcndant to rctain his activc and growing portion ofthc dcfendant's rctircmcnt fund valucd at $69,894.39 as of datc of scparation. According to Pcnsion Appraiscr Inc. a QDRO can bc written to makc thc $39,565 payablc to thc plaintiff immediately. 3. Cash in the amount of$3,600 for plaintifl's onc-third share in a hunting cabin in Tioga County. The cabin has thrce owncrs, plaintift~ defendant and one of thcir sons; cabin valucd at $20,000 less a $9,000 mortgage balancc as of date of separation. 4. Parties retain respective motor vchicles. Wife's vehicle valued at $9,095. 5. Plaintiff to receive two insurancc policies with combincd c~sh surrender value of $8,305.96. 6. Wife to rcceivc jewclry valued by defcndant at $9,000. NOTE: Defendant has upon more than onc occasion told plaintiff he does not have this jewclry therefore, plaintiff has been unable to ascertain its value, if in f~ct it still is in possession of the defcndant. Plaintiff requests that defendant give said jewelry to his counsel when thc pre-trial conference occurs, List ofjcwelry as detailed by plaintiff accompanies the pre-trial statement plus a TV, a shadow box of knick-knacks, a wall clock, family pictures and videos. Total value of items in above numbered paragraphs = $177,565. J. .' 1" ~' , '~i ',I' " .~ "; '~ '~ I iI' .1""/(',1', : II ~ 1) 'Ild 'It! ' , c I ~f' (j r,- ?:" .';:J, f~:_;~ ~ :;"1 1.-:--, '.''J '.., J L~~ ~. ;~ ~-, -,' ( , /:' ~ ~. -.......,......~--~:..,. . ., ~ ;])'J1/ a 1,1 r!.1. OWl'/! COlJnselor.nt I.nIY l(Jll>>nXW*l<i;l.I~jl(X Ph~,~~>%f.JM new offfice: 708 North Front Str,.et, p, 0, Sox 416, Wormleysburg, PA, 17043 July 28, 2000 John S. Dougherty, Esq, Ira H. Weinstock, p.C. Suite 100 800 N, Second Street Harrisburg, PA 17102 Dear Jack: It has. been a while since I have communicated with you. I met with Sandy in late .June before taking a three week vacation. I had hoped to get this lelter out before July 1 but I did not and I have been catching up on everything since then, When I met with Sandy we reviewed all of the issues still unresolved, Sandy is frustrated by the situation to the point that she is considering discontinuing the divorce action. She is heavily in debt to me, with the very real possibility of having to spend thousands more as this situation seems destined to go to Bob Elicker. She is working two jobs, literally seven days a week, while living in one bedroom at her daughter's house, while Curt enjoys the run of the marital domicile and companionship and vacations and new vehicles etc, If we end up at the Master's hearing, be assured that we will be seeking more than a 50-50 split. You and I know that equitable distribution does not automatically mean 50-50. In this case 60-40 seems much more equitable. Here are the highlights of Sandy's final position, 1. $4,000,00 in counsel fees. 2. Sell the cabin...it has approx. $9,000 in equity, which divided among the three owners is $3,000 each, The cabin must be sold before the bank will lend money to Sandy to buyout Curt's interest (if any, in the marital domicile) as we do the math . and value the assets and adjust for a 60-40 split. 3. Sandy gets the house in exchange for Curt keeping his retirement(s), Sandy believes Curt has retirement benefits from Henkle and McCoy, (and/or thru ISEW) where he worked for for about 11 years, This is one of several areas where I will be "_4 .t'''"y',', :Jim, "aJ .AJ"i" "" J./i. S'o,/' in :J,,,J.. .At. .tin,oln " Central Pennsylvania Teamsters Pension Fund JOSEPH J. SAMOU:WICZ, Admlnlslralor BOARD OF TRUStEES: RON KISTLER, Chlllrman and Trusl.. TOM J, VENTURA, SOcI1llary and Trusl.. VINCENT R, DAGEN, TruII.d BARRY B. KRZYZEIVSI<I, TrulleiJ I MARTIN l. CULLEN, Asslslant Adminlstralor 1055 Spring Slr.." WYDmls,'ng. PA Mailing Addr.s", P. O. BD~ 15223 RORdlng, PA 19612-5223 Phon.: 810.320-5505 TOLL FREE IN PA 1.800.343.0138 TOLL FREE IN USA 1.800.331.0420 October 25, 1999 '4!,,'tlP..... Mr. Howard c. Goune snn 207-34-5450 400 Adams st. Ext. Enoll1. pA 17025 Deat' I1r. Goune: This is in reply to your inquiry regarding pennion information relative in thE! matter of a divorce. . Enclosed herewith please find a copy of your ESTIMATED Annual statl!meill: for thl! year ending 199B. You are vented in a pennion of' aPPro~lmal:ely $31S,g, per month. under the Defined Benefit Plan, which is payabl~ to YoU al: the age of 57. Urldl!t' l:h~ Defined Benefit Plan there in no lump num dltitHbtiHotL it you Want a p~'e"ent value computation. you must hire yoUr OWh acl:uary to make thin computation. pleaSe bl! advined that effective January 1, 1987 the Pennion Plan under which you are covered wae changed from a Defined Benefit Plan, l:o a ttel:irement Income Plan. An of June 30. 1998. your balance in yoUr ~el:iremeril: income Plan was $69/994.39; and an of June 30. 1999, the end of l:he tlecond quarter, your Retirement Income Plan has been credited with an amoUrtl: of $90.91~.11. 11.11 colltHhutions nubmitted to the Defined Benefit Plan, and Rel:irement tncom@ ~lan. were paid solely by contributing employers. Also enclosed herewith, please find a copy of the Amended and I!estiltetl l5eHI1l!d gi!nefit Plan. as well as a copy of the Amended and Reatal:ed Retlrem@nt Ihcome Plan documents. These documents contain the lal1gUage for both plans. At l:ha presenl: time, you have Sandra R. Gause, designated as your primary bellef1ciary with this Fund. If Ii change is necessary. plea;;e cioinplet!! thi! enclosed designation of beneficiary form according to l:he enclosed insl:rucl:ions. .. i .,f , , , Subj: Date: 10/4/20009:53:54 AM Central Daylight lime From: weinstock@supemet.com To: donowen71esq@aol.com Dear Don: I just wanted to follow up on the disco~ry issue, Regarding the IBEW retirement, Mr, Gouse informs me that he was not ~sted in that retirement plan and therefore there is no retirement. He indicated that he had receiled a letter to that effect and it was located in the filing cabinets that your client remoled from the marital home, The personal injury case was settled for $10,000 minus $300 in attomey's fees. We can prol1de ~rificalion of that if you wish, Finally, my client has adl1sed me that the only sal1ngs account at the time of separation was with Harris Bank, I ha~ asked my client to contact Harris to prol1de a statement regarding the amount in the account on the date of separation. if you wish to hire an actuary to get a \alue of the Defined Benefit Pian we will certainly cooperate, howeler. my client has indicated that he is not willing to contribute to that cost. It is our position that this benefit couid be dealt with on a percentage basis. It is my hope that we will hale the information regarding the sal1ngs account within a week and therefore hale this case ready for trial. Very truly yours, Jack Dougherty Headers Retum-Path: <weinstock@supemet.com> Receiwd: from rly-zc01.mx.aol.com (rly-zc01,mail.aol.com [172,31,33,1]) by air-zc02.mail.aol.com (v76J1,8) with ESMTP; Wed, 04 Oct 2000 10:53:54 -0400 Receiwd: fi'om maii012,maii.onemain.com (smtp-out001,onemain.com [63,208,208,71]) by rly-zc01.mx,aol.com (v75_b3,9) with ESMTP; Wed, 04 Oct 2000 10:53:26 -0400 Receiwd: (qmaiI4734 in\Oked fi'om network); 4 Oct 2000 14:53:19 -0000 Receiwd: fi'om systems,desllpemet.net (HELO mailman,endymion,com) ([204.249,184.20]) (enwlope-sender <weinstock@supemet.com>) by maiI012,maii.onemain,com (qmail-idap-1.03) with SMTP for <donowen71esq@aOi.com>; 4 Oct 2000 14:53:19 -0000 To: donowen71esq@aoi.com From: weinstock@supemet.com Subject: Date: Wed, 4 Oct 2000 10: 57: 54 -0500 X-Mailer. Endymion MailMan \Q,O Message-ID: <200010041053, LRJa09946@rly-zc01,mx,aoi.com> Wednesday, October 04, 2000 America Online: Donowen71esq Page: 1 Ph: 717-732-3552 DONALD B. OWEN Fax: 717-975-1706 ATTORNEY AT LAW 708 N. FRONT STREET P. O. BOX 416 WORMLEYSBURG,PENNSYLVA]ITA17043 e-mail: donowen71esq@aol.com October 12, 2000 E. Robert Elicker, Esq, Divorce Master 9 North Hanover Street Carlisle, PA 17013 In re: Gouse v. Gouse Docket # 98-3564 Dear Mr. Elicker: In my letter of October 6 and my response to the status of discovery and unresolved issues in the above captioned case, I neglected to mention the issue of counsel fees for the plaintiff, an issue clearly detailed in my July letter to defendant's counsel. My client has been unable to pay me anything since I took on the case for Mrs. Gouse, who has been a client of mine for other reasons a number of times over the years, Her bill is already over $2,000 and the time necessary to prepare for and go to the Masters hearing will add substantially to that total. Sincerely, d)~QdB((2 Donald B. Owen copyto:J. Dougherty "A lawyer's time and advice are his stock in trade." Abraham lincoln ",.' SANDRA R. GOUSE PLAINTIFF IN TIlE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. VS. No, 3564 CIVIL TERM 1998 HOWARD CURTIS GOUSE DEFENDANT CIVIL ACTION - LA W IN DIVORCE CERTIFICATE OF SERVICE I, Donald B. Owcn Esq. do hcrcby certify that on this datc, I served a truc and correct copy of the Pre-Trial Statcment, pursuant to Pennsylvania Rules of Court, Rule 1920.33 in the abovc captioned malleI' upon the following individual, by United States mail, first class, postage pre-paid, addressed as follows: John Dougherty Esq. attorney for the defendant Ira H. Weinstock P. C. Suite 100 800 North Second Strect Harrisburg, I' A 17102 Date: May 2,2001 ~~R(L Donald B. Owen Esq. Plainti rf s attorney Supreme Court 10 # 15508 P.O. Box 416 Wormleysbl1l'g PA 17043 (717) 732 3552 IRA H. WEINSTOCll WENDY D. Bowm J.-.sON M. WEINSTOCll JOlIN B. DoUOtlERTY JEFFREY R. Sellon LAW OFFICES IRA H. WEINS'.l'OCK, P. C. Sum, 100 800 N. S~:c.OND SmE~:T IlARIlISIlUIlO. f'I,NN~"YLVANIA I 7 102 ARc\ Co\)(~ 7 I 7 lJ.:J.EI'1I0N": 238-1657 ~ May 3. 2001 E. Robert Elicker, Esquire 9 North Hanover Street Carlisle, PA 17013 RE: Gouse v. Gouse No. 68-3564 Civil Dear Mr. Elicker: FAX: (717) 238'6691 E-MAIl. ADDREss wei nSlock.lawGverizon.nel Enclosed please find an original Defendant's Pre-Trial Statement regarding the above captioned matter. If you have any questions, do not hesitate to contact me. Very truly yours, L)ctf/?~ 6. t!b4A'~ MHN 8. DOUGHERTY '71 JBD:rln Enclosure: cc: Donald B. Owen, Esquire Howard Gouse -i",' :-;.2 ",-__"""'._'_'_W"r"""._~"~~ htA H. WmNSl'OGI< WENDY D. BO\\1I': JASON M. WEINSl'OGI< JOliN B. DoUGIIEH1Y JEFFREY R. SCHOn LAW OFFICES IRA H. WEINS'rOCK, P. C. SUlm 100 800 N. SECOND SmEET HARmSlJURG, PENNSa1YANIA I 7102 Am'" GOOE 71 7 ThLEPlloNr,= 238-1657 ..... FAX: (717) 238-6691 E-MAIL ADDREss wei nstock.la w@verizon.net May 3, 2001 Curt Long, Prothonotary Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 RE: Gouse v. Gouse No. 98-3564 Civil Dear Mr. Long: Enclosed please find an original and one (1) copy of the Defendant's Pre-Trial Statement regarding the above captioned malter. Please return the extra time stamped copy to me in the enclosed self addressed envelope. If you have any questions, do not hcsitate to contact me. Very truly yours, r1~, !h. LfJCtd{~ l$ZHN B. DOUGHERf{." ;r JBD:rln Enclosure cc: E. Robert Elicker, II, Esquire Donald B. Owen, Esquire Howard Gouse DONALD B, OWEN ATTORNEY AT LA W 717-732-3552 P.O, BOX416 WORMLEYSBURG, PENNSYLVANIA 17043 ;i ~II . ~' July 17,2001 E, Robcrt Elickcr, II Divorcc Master 9 North Hano\'cr Strcct Carlislc, PA 17013 In rc: Gousc v. Gousc / No 98 - 3564 Dcar Bob: Enclosed is the original of the agreement you sent to my office, Mrs. Gouse has signed it and I have witnessed her signature. As per your letter of July 13, you said you would forward the original to the defendant's attorney. I have also enclosed her Affidavit of Consent and her Waiver of Notice and have prepared a Praecipe to Transmit, once all of the other pieccs arc in plaec. '1 } I I I, . ,~ ~ .~ J ft." '1' ,t :,/:" .;1 \ " ' '" 'd Copy to: John B, Doughcrty Esq. u ^ lawycr1s'time and advice arc his stock in trade" Abrahnm Lincoln SANDRA R. GOUSE PLAINTWr IN TilE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. VS. No. 3564 CIVIL TERM 1998 HOWARD CURTIS GOUSE DEFENDANT CIVIL ACTION - LA W IN DIVORCE PRAECIPE TO TRANSMIT RECORD To thc Prothonotary: Plcasc transmit thc record, togcthcr with thc following information to thc Court for entry of a Divorcc Decrcc: 1. Ground for Divorce: Irretrievable breakdown under Scction3301@ofthc Divorce Code. 2. Date and manner ofscrvice ofthc complaint via certified mail, return receipt requested, addrcssce only, as per the attached rcceipts, certified number Z 592 917912 mailed on July 6, 1998 and delivered on July 9, 1998. 3. Date of execution of affidavit of consent rcquircd by Section 3301@ ofthc Divorce Code: by the plaintiff: July 16,2001; by the defendant: 2001. 4. Related claims pending: None. An agreement was reached on July 12,2001 while thc parties were at the Office of the Master for a scheduled hearing on equitable distribution, said agreement having becn subsequently prepared and executed by the partics hereto. Date: ~.Jd eO ,2001 c- Donald B. Owen Esq. Plaintiffs attorncy Supreme CourtlD # 15508 1',0. Box 416 Wormleysburg PA 17043 (717) 732 3552