HomeMy WebLinkAbout97-00887
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COM~~~tiI'W~llI'pP.llll!11l1cr~ANIA
HANRIS~5~h,\t~~'I8,O&Q \
/5-;"/1- ,;;}
r.prf:A.\~S~ D8AlH AP18f1IU/J1!l,' UH8ClK HUflf,
INHIRITANCII TAX AITURN Ji.g'i ~MA OllIS(llAIME~._-
RII81PIINT DI!OIlDIINT PILI NUMBIA
(TO III PI~IID IN DUP~IOATe
Hi
II
I
IDDlUINHIAP
RODurt
DATa OP 08ATH DATS OF BIRTH
09!03j1997 11/03/1913
(lOU coon
OBCsCSNI'S COMP.Eln AOORESS
62 Llnqu Ilrlvu, Lot 12
MochunloHDur6' PA 170~~
OSCoOSNT'S NAMS I.ART, PIAST. ANC
NIHHu!.
SOOIA. SECURITY NIIMBnR
207.07-6362
M,
(IOUIlI GumDurlllnd
liP APPPoAa,elsuflVIVINO SPOUSS'S NAMs (,AST,PIASI AND MIOO.UINIIIA.) SOOlA' IISClURITY NUMPeR
21.97-<)667
Y AR
PSA
AMOUNT RC081VSO (IIUE INSTRUClTlON8,
0.00
1. Orlolnal Relurn
4, Llmllad Ealsl.
!
I
(~)
13 ,526 ,Ill.
a, Bupplemenlsl Return ~. Remelnder Relurn
4n, Fulurelnlereet Complomlae (fol dalu 01 death prior 10 la.I3,Sa)
(for dat.. 01 dealh slIer 12-,a,aa) COh Pedarlll esllll. Ts. Return Raqulred
[Xl e, Decedenl Died T..18Ie 07, Deced.nl Malnlalned a Llvlno Truel ~~. TOlal~mbsr 0 Deposll Boxos
(AlI80h co 01 WilD (AUach a copy 01 Truat) ..ft. " '
ALL CCARIBPC PINCI ANP CPNPIPINTIAL TAX INFORMATION 8HOULD BI DIAIlCTlD T(lI" ~ '
NAMa COMPl.SHi ~^Il.INa ^ppnUB6 ~I ;e \-1; ~l~
.lnmuB Il, Hu hOB IRWIN, MoKNIGH'r & HU~~~p ,", /~.;
muPHoNsNUMB8R 60 Wust Pomfrq~' StroD' .....: ';!
1 -2/9- 3 3 C rUBlo P 'l. .01.3 "U -
" Re.1 Ealale Sohedule A iii
20 Slooka and Bonds ISohedule B) (2) rt
3, Cl08Bly Held Slook/P.rtnelshlp Inleleal (Sch.dule 0) (3) None
4, Mo~gagas and Nole, Receivable (Sohedule 0) (4) - Nono
&, Caah, a,nk Depoalls & Mlacallaneoua Pelaonal Properly (Bch. a) (e) 2 ,39'/. 98
eo JolnUyOwnedPrope~y(SoheduleF} (e) 167,353.76
7, T,.nal.rs (Sohedule 0) (Sohedula l) (7) Non!!
&, Tala I OrouAu'IS (Iolal Linea 1'7)
9. Funeral a.pense" Admlnlslratlve Coala, Mlscellanaoua .
, Expenus (Sohedule H)
10, Oebla, Morlgage LI.blllllea, Liens (Sohedule Il
11. Tolal Deduction. (lolsl Linea 9 & 10)
12, Nel V.lua 01 aslate (Line a minus Line' 1)
13. ChRtllable and Oovernl1)enlal aeque.la (Schedule J)
14, Nel Value Bub eollo Te. (Llnela mlnua~lne 13)
1&. S\)oua81 Tranalela (lor datea 01 dealh aller 6.30-94)
See Instructions 'or Applloable percenlage on paga 2.
(Include value~.lrom Schedule K or Sohedule M.)
le, Amounl 01 line 14 18xable .16% lale
(Include values from Schedul. K or Schedule M,)
17. Amounl 01 Line 14Ia.able.1 16% rata
(Inolude values Irom Bchedule K or Sohedule M,)
18, Prlnolp.lla. duO (Add lax from line 16, 16 and 11.)
19, Credlls/Sp poverlY PlloI Paymehla Ol.counl Inlereol
0,00 + 8 ,600,00 ; 1/52.63 0.00
20, If ~Ine 1911 rOSIer Ihen Llha18, enl" the dlllerenc. on line 20, This 1.lhe OVBAPAYMaNT,
IB 0 Cheok he,. If ou.ra ra u..Un n 'Itund 01 our oyar . manl,
21, II Line 161s gre.le/than Line 19, enler Iho dlll"'.c. on ~lne21, Thla 1.lhe TAX PUll.
A, anler Ihe InlO"al on the balance due on Line 21A.
B. anle, Ihe tolal 01 Line 21 and 21A on line alS. This la Ihe BALANCB PUB,
nke C eok P abl 10' ,I,'r of I' A an
.. .. BIl BUlla TO AN8WBA A~L QUB8TION8 ON MQIl2 ANO TC RICHIOK MATH · ..
.rpent IUIO. PI' tlly\'ClUtt I .VUlClmM ,,. u;n, nc ng.cl;omp.oyogIC' UIII!'ldlll.,em.ntt.,IndlotMbIBIOfl'!'YknOW18dgundbellel,lllllrult,
COIr.ClaM compleltt, declare thlt all t.., 88tll_ hlllltentepOfled II HUI marklt v.IUD, Oecla,atlon 01 plepller olher than the pelton., ,opralentallve I. billed on,alllnfolmlltol'l 01
whll"pl.p.'.rh....nyknowleda.. ., ...... "
91GNATlJA8 OP PERnON RS9PONSlb.PPOR F"ING RETURN Curol. ^. LlndRoy OATE
3 JryhnR DrIve
Miicil;niiicisb'ur - - - 'p,,' - -nb-55 -, - - -, -. - -, -.".
IRWIN McKNIGHT & HUGHgS
60 WORt Pcmfroc Serooe
cariY:iin','-PA"-i'tb"f:i--'- -" -.' ..,,- -,..,- - - -.-.
(10)
2,68/1,67
(1&)
.!hQQ X
(le)
153,540,66 X .06'
~
(17)
0.00 X .16 '
'I
w
CO
(8)
~
(11)
(12)-
(13)
(14)
,
(le)
(19)
(20)
(21)
(21A)
(21B)
a
169,751.7/1
16 ,21.1. 06
153 I 51t(}. 66
Nono
l.53 ,5/10 , 66
0,00
9,212. "'1_
0.00
9,212./1/,
9,052.63
'0.00
159.81
0.00
159.81-
_~ -.iff. <}f
OATU '
1, 'U//?8
Form (~8V. 1.9~)
RaV. 1608 a~ . (11-11)
COMI1JIIIlm4\<QMhYAN1A
80HIDUl.II"
...Bobort M. Nissa!. SS// 207-07.6362 09/03/1997
JOlnt'en.nt(.)!
.A,
NAMI
Carol A. Lindsoy
ADDRU8 .
--:l:lohna I)d va
Moohunicsburl.l, PA 1.7055
10
Cynthia I,indso)'
1652 'I'dndle Road
Garllslo, PA !.7013
21.97,0887
RILATION8HIP TO DIOBDINT
duul.lht,(u:
I.Irandohlld
0,
Oonise A, Ur\daey
212 Mtn', View Torraool 200lgrandchlld
Dovor, PA 1.7315
ITBM LITTRR oAT. , TOTAL VALVB 0100'8 DOLLARVALUB OP
PO MADB DB80RIPTION OP PROPI"TY
NUMIIR Ti~lrJT JOINT OP A881T 'I,INT. DBCIDINTINTlRI8T
1. A 01./1996 Membors United Foderal 30,000.00 50,00r. '15,000,00
Credit Union, (/1.02/,2
2 A 1.2/1993 PNG Brokerage (Investors 51,1.69,83 50.00r. 25,5811.92
Trllllt Government Fund)
3 B 01./1.996 Members United Federal 15,000.00 50.00r. 7,500.00
Credit Union, (/1.02113
I. C 01/1996 Members United Federal 15,000.00 50.00r. 7,500,00'
Crodi t Union ,(/102MI
5 A 02/1996 Membors United Faderal 30,000.00 50.00r. 15,000.00
Credit Union (/10268 ,
6 11 02/1996 Members ,United Federel 5,000.00 50,00r. 2,500.00
Gredit Union, (/10269
7 C 02/1996 Members United Federal 5,000.00 50.00r. 2,500.00
Credit Union, (/10270
8 11/1995 "
A Membors United Fedoral 4,000.00 50.00r. 2,000.00
Credit Union, (/10188
9 A 10/1979 PNC Bank, N,A, , cheokina 18,538,71 50 ,oar. 9.269,,36
acctl (/5070089293
10 A , 1.2/1990 ' Franklin Templeton Growth 1.60,998.96 50.00r. 80,1.99,118
Fund. A/G (/101. .1842716579
, ,
TOTAL (AIIO Inter on line 6. Reoapltulatlo'!l. 167,353,76
Jolntly"owned property:
i/
(II more space 18 needed, Inu,t addltlonl! ehelle of .erne .I/.e.)
Copyright {tl \9t~ 'DIm 1I0ftW'" only CPSyeleml. Inc, '-,
Form 1100 9chedule P (Rey, 12.88)
COpy
LAS7' WILL AND TESTAMENT
I, ROBERT M. NISSEL, of Mechanlcsbur!l, Cumberland County, Pennsylvanln, being
of sound mind, disposing memory and full legal age, do hereby mnke, publish and declare this to '.
be my Last Will and Testament, hereby revoking all WlIIs and Codicils heretofore made by me,
QIDf;, I direct my Executor or Executrix, as the case may be, to pay all of my debts, '
funeral and administrative expenses as soon as convenient after my decease, Furthermore, I
direct that all state, Inheritance, succession and other death taxes Imposed or payable by reason of
my death and Interest and penalties thereon with respect to all property composing of my gross
estate for death tax purposes, whether or not. such property. passes under this WllI, shall be paid
by the Executor or Executrix of my estate,
twQ. My Executor ~r EMcutrlx may, at his or her discretion, compromise claims,
borrow money. retain property for such length of time as he or she may deem proper; tease and
sell property for such prices, on such tertns, at publlc or private sallls, as he or she may deem
proper; and Invest estate property and Income without restriction to legal Investments unless
" '
otherwise provided hereunder, I authorize III\d empower my Executor or Executrix to sell any
., realty and/or pera.\lnalty owned by me at my death and not specifically devised or beq\leathed
,
herein, "I public of private sale or sllles and to give goodnnd sufficient deeds lmd/or bllls of sale
therefor, In fee simple, as 1 could do If living, My Executor or Executrix hf authorlzed III\d
empowered to engage in any business In which 1 m~y be engaged at my death, for such period of
time after my death as seems ,,'xpedlent to said Exec.utor or Executrix.
HAKI OHICK PAYAB~B AND RIHIT PAYHINT TOI
REGIaTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT A~CNO THIS LINI .... RI!AIN ~CWIR PORTION FOR YCUR RIOORDS ~
~W: 1Ili'f'I'l/"~fr'lf."r &,:nY"il&Yioi""o ''mAiliif~iJ'cl'i"Y'\i!"'ii\5'~~Aiil'M\f.Il't";"~tt"6'Q~iJ'cl'i'b1f'''''"''''""""''"
DI8ALLOWA 01 OF DIDUOTIOHs AND ASSBSIHINT OP 1A~
IITATI OF NISSI!L ROBI!RT M FI~I NO. 21 97'0887 AON 101 DATI 07-1Il"1998
TAX RPTURN WABI (X) ACCIPTID AB PILID () CHANOBD
RISIRVATION OONOIRN~NO FUTURB IHTIRB8T . 811 RIVIRIB
APPRAXIID VALUI OP RBTURN BASID ONI ORIGINAL RETURN
1. R..l I.tata IBah.dul. A)
8. Itook. and Bond. IBoh.dula BI
8, Cla.alv Hald Itook/Partner.hip Int.ra.t IBahadul, CI
~. Hartlale./Nota. Rao.iyabl. (Soh.dula D)
8, Cllh/B.nk Depolitl/Hho,p.raanll Prop.rt~ (loh'dUla II
6. ~intlv Dwnad Prop.rtv (Sah.dul. P)
7, Tr.n.fare (Sah.dule 0)
8. Total A...t.
APPROVID DBDUOTION8 AND IlClHPTIONSI
9, pun.ral IMp.n.../AdM, Coatl/Hho, IMpen.a. llahadula H) (9)
10. D.bh/Hart...e LhbiUU../Li.n. (Bahedull II (10) ~ .684.61
11 , . Total D'duaUon. nll .
18. HltValu. of TalC Return (181
18. Charitable/OOY.r~antal Bequ..t.) Non-.laatad 9118 Tru.t. (Boh.dule JI (181
l~. Hit V.1Ull of Baht. Bub~.at to T'M llql 163,540.66
NOTII . Xf an ........Ilt. Will :l...u.d pr.v:l.ljIu,lY, 1:I.n.. 14, 11 .nd/ol' 16, 17 .nd 18 Id.ll
I'.n.ot f:Lgul''' th.t :l.nolude the t01:l1 of 6IJ" .l'l'turn. .......d to. d.t...
AI8188HINT OP TAlC I
11, AMount of Lin. lq at Ipou.al rlt. 1111
16. Aaount of Line l~ talCabl. It Lin..l/cle.. A rata (16)
17, AMount of Line lq taMable et c"lleterel/Cle.. B rete un
18. Prinoipel TIM Due
TAlC ORBDlnl
PAYHINT
DATI
-11
04-29-1998
1(;'.lll._.I.~
BURIAU OP INDIVIDUAL TAKPI
IlCllEMllAHCE lAM DIVl8lDH
IlEP1, 210601
IlAMMISIURO, PA 1711.-0101
ODHHONWIALYH OP PINNIYLVANIA
DIPARTHINT OP RIVINUI
NOTICE OP INHBRITANCI TAK
APPRAIIBHINT, ALLOWANCE DR DIBALLOWANCB
OF DIDUCTI0NI AND ABBIBBHINT OF TAK
JAME5 D HUGHES ESQ
IRWIN MCKNIGHT AND HUGH
60 W POHFRET ST
CARLISLE PA 11013
DATI
18TATI OF
DATI OP DIATH
FILl NUHIIR
OOUNTY
AON
07-15-1998
NISSEL
09"03-1997
2197-0887
CUHBERLAND
101
A"ount R'111ted
(1)
(8)
(8)
(~)
(8)
161
(7)
100
.00
.00
.00
2.397.98
167.383.76
iOO
(81
13,626. ~1
.00 X,OO.
163,540.66 X ,06.
.4~' X ,16.,
(181
RICUPT
NUHBIR
DlICOUNT 1+)
INTIRIIT/PIN PAID (-)
AHOUNT pAlO
AA27000
.
,00
I .
169,111.
TOTAL TAX ORIDIT
IALANOI OP TAlC DUI
INTIRI8T AND FIN.
TOTAL DUI
rY
*
UNU,,,'Ultt.m
ROBERT
M
NOTI: To inlur. prap.r
or_dit to ~our .oaount,
lub"it the upp.r portion
of tht. fori with vaur
teM PIYllnt.
169.761. 74
" .", . na
lS3,6~0.66
.00
,00
9,212.44
,00
9,212.44
9,212,44
.00
.00
,00
lC IF PAID AFTeR DATI INDICATBD, BII RIVIRI.
POR CALCULATION OF ADDItIONAL INTERIIT,
'( IF TOTAL DUI 18 LIBS THAN 81, NO PAYNINT II RIQUIRED.
IF TOTAL OUI 18 RBFLECTlO AB A "CREon" (CR), yoU HAY BE DUE
A RIFUND. BIE ROVERBE SlOP. OF THIB FORH FOR INBTRUOTIDNS.)
'0 ;~q
1"'\ \,~~
I{,I 'j Ui
~...... \)
tp, :
)
\til
....
~ ,I
:\)
,.9
~ ~a
I
I
I
j
I
il,:
.,J"
C.. 'r"
~~
'18~'V~llQltI ~.j.j.. of .....Cltnj. dvlno on or I>Ifo.. O"IIll.r Il, 19ea .. If IIIV lUIuro Inl....1 In Ih. ..1.1. I' Ir""""'r.d
. In po.....lon ~r onl~Vllnl 1.01...., (..II.j.r.11 ~.nefl.I'rl.. .f IhO d...~1 .fl.r tho ..pl..llon .f onv .,111. f.r
lif' Dr for ~..r'J the COIIonw..'th her.bv 'kpr...l~r.,.ry...thl rJaht ~~ appr,l.. and,...... tr.n,'.r !nh.rlt~. TIXit
.tthl l~fUl 01'" . (..U,I'roll "U. .n IIIV .uoh fulur. IMor..l.
PUllPO.. Of'
HOllOl1 To fUlfill jh. roqulrn.n" of 8.ollon 21'0 of Ih. Inhorltoil". .nd hl.l. To. A.I, ~ol II of I'''. '(11 p,'.
8.oUon 91'01,
PAVlItHTI
Pol..h I,hI t.P p.rjlon.f Ihl,Hollo. IIId '~III Wllh. ~our p.v..nl I. Ih. R.,I.I.r .f Hili. p.lnl.d on IhI ..y.... .Ido,
..11.... .oh.ok 0. ..n.v ..dor p.v.~I. 10' RSOlSTSR OF "I~L8, A~EHT . ,
I . , .
"MIl (ORlI A .'fund of . I.. orodlt, whl.h WOl nol ro""..I.( on Ih. T.. R.lurn...v b. ..""..I.d bv oo""I.U". III "Appllo.Uon
for "fund.of P,,,".~Iy,,"I. l!\herll.n.. II1d hl.l. TI'" CRIY-UU), Appll..Uon,.rt .v.llobl. .1 lho Offlo.
oflhlR.,I.t.. of Will., IIIV of lho II R.y.nu. OI.lrl.1 Offlo.., or bv o.lllno IhO ,p..111 24.hou.
In.Wlrlot ..rviol ~.r. for for.. order!ngl In Pinnlvlvenl. l-aOO~S6~..O.Ot out.ldlP.nn.~lyan1'-and
.IIhlnl....1 Horrhllllro,,1I C1I1) 181'8094. TOO'. (111) 111-nBl (1I...ln'I"".lr'd C1n1~1.
P8J10TlOHI,
, .
M~Porl~ In Inl....11101 ..U.f1od with tho 'PP.lhll.nl. .1I.w,,"., or'dh.llDwlll1O' of d""".U..,,, or ..........1
.f "'. Cll1OlucU". dh.ounl or Inl....tl .. .h..n on Ihh HoUo. 1U0I o~l.ol within' .I.W. (69) d.v, of ...dRt of
Ihh t<<IU.. bV',
'-W.ltt"" Prol,,1 to Ih. PA P.porl..nl of R.v.nu.. I.,rd of App..h, O.pt, '211011, Hor.loburo, p~ 11UI'lOll,
--.I.ollon'I. h.y. thO ..lIor d.l.roln.d .1 .Udlt of Ih. ....unl of lho p.,."",1 rop'''IIII.Uy., OR
.........1 to the orphWl" C~u,rt,' .
ADttIH
IITRATlYI . .. ,
CORRICTIONtI' 'lotUll .rrorl dl.oov.rad on thi. ..i.....nt .hoUld bi,.ddr....d In writing tal PA OiPtrt..nt of Rivenue,
IU.... of lndlvldu.1 T...., ATTN, P..I A.......nt R.vl.. Unll, Oopl. 110~01, H.rrl,~urg. PA 171Ie-069'
PhlI/1I (111) 1'1'6101. SO. p.g. I,of Ih. boolll.1 "In."u.llon. for l""orlt.no. T.. R.lu'n f.r . Rllld,,"1
Dooodonl" IRtlY-UOll f.r "" ",pUn'll.n of .dolnl'IroUy.l~ ..rrlolobl. or.oro, "
D1SCOUNTt" 11 ""~ t.. duo h p.ld within Ihr.. (S) o.IIIIdor l<>nlh. Oflor Ih. d..od.nl'. CltOlh, . f1v. Por.onl C6H) dhoounl of
lho I.. p.ld'l. .lloWld.
'PIW.ILTYI Tho UH tl' "",'IV non-Portl.IP'Il.n p.nlltv II o"",ul.d.n Ih' t.I" ,0f'th..I.. II1d Intor..1 .......d.1nd I10t
p.,~ blfo.. J""u,,V II, 1996, Ih. 11..1 d'V .lIor Iho .nd ., th' I.. "n..tv pori.., Thlo l1OI1.porUolp.llon
P....lt~ 10 IIlPllloblO In Ih, .... 'II1n.. ond In Ih. Ih. .... U.. Porl.d .. vou .Would IIPP..1 tho I.. IIId Int".1I
IhlI hi, bllI1 ......od. ..Indl.,t.d on thlo ,hOlI...
lNTlRtllT1 'intorlll h Ohorllld 1>I,1""ln, wlth,II..1 d.~.f doli~qu.n.~. .r nln. (9) ..nlh. ,,"d one (I) d.v fro. IhI d.I..f
do.Ih, 10 IhO d'l. of p.v,.nl. T.... Ifhloh ~..".. d.IIIlq1J,nll>lforo J.nuor~ 1(1962 b.., Inh."1 .llho ..10 'ilf
.IM (6HI p"o,nl P.. IMUI o.lolllOl.d.1 . d.lIv rol. of .000164, All I.... Whl.hb.._ ~'lInquI"I'on '"" Ifl"
J""""v I, 1911 wUI b..r Inlorlllll . rot. whl.h wUl yorv frol ..l.ndor ~." j. .".nd" VII' with IhlI rolO
\lI1I1Ounolll bv Ih. PA DIII"I..nl .f R'V.nuI. Th. 'PPllo.bl. Inl""' rol.. f.r 19I1lhroullh 1'98 o.e:
DR
_ lnter.it Ait. Oa1h . Int.r..t hatnr Xur
tn'ir..t RU.
Dal1v Int.r.at ~'Gtor
19'2 10H ,0091~1
ItU 16H .ooom
l,e4 11H .000101
1'86 16H .000116
1916 IOH .000114
.-lnl....I I. o.loUI.11d .. f"IIOW"
INTBRBIIT . BALANDS D' TA" UHPAIO " NUNBSR OF DAYE DSUHqUBNT " DAI~YXHTBR"T FACTOR
--Anv Hollo. I..~ .fl.r jho I.. boO.... d'llnqU.nl will "fl.ol .n Inl.r'.I .'I.UI.jlo~ I. flfl.II1 (II) d.v.
blv.nd tho d.lt:.f lho ........nl. If p.v..nl I. I.d. ,f I" lho Inl....t ..lpul.llon d.,. 'blwn on lho
Hollo., IIIdlll....1 Inl"..11II1I ~'O'I.UI,I.d.
1961
1961-1991
1991
I99N99~
199B-1996
9X
IIH
9X
1X
'H
,000241
,000101
.000147
.000191
.000141
COMMONWIAI.TH 01' PlNNSYI.VANIA\
COUNTY 01' CUMIIRI.ANP J
..,
._~._..~ ...._.._.__.__... ..m__.__.9arol_.^,.,.. ~!.ntla.~y_ .__._.._____._...._._..._.nm__.
belnll duly aworn c.._._,..___ ~cccrdlnll to I~w, do pc", .~nd '~y, that ahe,..1!LJ;.\ll!,Jlll.l!.Ill!.tUIL_--....._.-
_.__~_.._~'--_..._..-.-..._....-_----~H 01 the E,hte 01.. Robert JL..JUaaol
I.te 01 ___ .13J.lY,Q.cll.pl:':l.ns..'l'ownahl,p. __~_.._._n" _.-.., Cumberlond County, Po., decu.ed ~nd thot the
within I, on In~e~tory modo by .m__.__~o!!'r.<!J...A,_.W:ndeey___ ..'-- _._...:mn__' the 'uld ElIecu~dll
o!the entire utoto 01 IOld decedent, con,htlnll .01 011 thopmonal prap'~rty and rullltah, except rul uhte ouhldo
the Commonwulth 01 Penn,yl~~nla, and thot tho Illlure' opposite uoh ltom 01 the In~entary nprDlent Itl, lair ~.Iue
01 01 the deh 01 decedont', death, .
~nd ,ubwlbed belare me,
98
n.t:} ~n.kL' -
Carol A, Lindaay,
_J:,Johl1.!!..Jlr~t'{,!L_____.___~.'~-
~
Nnl",lnl Bonl
,Inc" ""lin" I IJr.,whnll!lI., Noln,rv Public
c'nrllf\ln flnlfl, e(IIl\I,otll1l111 (/OLln~ 0
My Cnnlll, f'!...lon Exp\r(Jf~^uO. 111\ 1 0
Date 0 /POI~"'~~------' ---.-.QL----
PIV Month
._.M\!Ili1lmi9JllllU:.&,_l'A 11055
Add,,,,
1997
Vu,
INSTRUCTIONS
I. An Inventory mUtt be IlIed within three month, ~fter~ppolntment 01 pmanel repruentotlve,
2. A ,upplement Inventory mUtt be IlIed within thirty day' 01 dllOovery 01 additIonal alUh,
3. Addltlonol ,hoeh may be ethched II to petlonelty or ro~lty
4. S".Artlale IV, FldualerlOl Act 011949.
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