Loading...
HomeMy WebLinkAbout97-00959 I'ETITION H)R I'I{OIIATE 1I11d (;RANT <W LETTERS ~1-1~~?-'~9efL ~' /. ~11(1 Ll 11 No. I,,: I:',~/(/t(' II/ j//liil /,,, 't al.\'II kllllll'lI (1.\ jllilA'Y IIMI'II,d ____ .,' ,0('("'(1-\'('(1, Sodal S(,cllrity No. l>;' '(.' IV ,)~ '/J. X)('('''-I~:l-- Kl'gisler of Wills for Ihe C"llIlIY "I' u .u,,,. ill the t'1l11l11l01lWelllih 01 l'enllsylvilllill TI'" pel ili"ll "I' llie IlIllkrsiglled It'SPl'''1 fttlh' n:prt'Sl'llts I hal: VOlll Pl'litiolll'r('.), who i"','iHl' IX Yl'ar~ or uge, olllkiL'1' un the l'XL'l'U\(.'.I"~, ill I he 1",1 will "I' I ht' al1<lIl' thWlknl, daled .'" L Y I) 6' hi.. . ami codhil(,) dmed" ",,__u~.m.' ..., 11IImed "~~_, 19.c..._.__. ..-...._-_.....,...........-~-"..~---~ (~lall' tell'lalll rir('lltl\\lHlh'l", l',~ I l'nl1lll'iil! Illll, d~'i\lh ul \'\t'l'utDr. l'le.) D,.'eelllklll wa, dOllliciled ill dealli ill (lll.'.d.. hI.:~...J /111. ,{ _.... .".'."'.- coull.t~1 pen\\?,rIVllllia, with lifjt. . IIlElA~~Y "f1b'NNI~~~~2"I)r.JP: ,,('J.. 1/. ,g~/~I,":~!:~~:._I'// . lz:.~~ (lhl '\tll'\'I, (l\lllllll'l ;\1111 11111IH,'ipalil~-l l>eel'"dt'II,lhel /X.., yealS of age, died /1}Nt./l/bC";' //._____.",.... I 92.:-L_. Ill. fC'I'YCIl<,!IC /f'IJ/'lldl . ....... ."'''....-.------, I~'l'('pl <1\ lollow", del'l,th.'lll did 1l11llllilrry. \Va" IInllJivorl'cd and did not huve H child born or adopted Unl'r l''\cl'lIll111l of IhL' \\iUofkI'L'd for pWbalL': was 1I011hl' victim or a killing nnll was never ndjudkutcd IIlCOIllIWII'II': It) (;/(". ...------.,.....,."----.... DL'l'L'IHko\ at lkath OWIIl'd prnl1l'rly with L'sti11lHlcd values as follows: (If <lolllki"'d ill l'a.1 AIII",r,oll;>I properlY (If not dOllllcikd ill I'a.) I'l'l'\ollal properlY ill Pennsylvania (Ilnol dOlllkikd ill Pa,) Pi.'P'llIlU[ propcl'lY In ('OllIlIY Vallll' l',.j I'l'all.,...tall' ill I\'llll.~yh,allia _ ..' _ " .;! 1 . slllI"l"d ", foil"",,: ({,,(!'1 I), ,,)(, /',.,J(!I,d, I'Y"...J22L5Y'-:....,.""._____.__ $ _.J:J;QfCt/.) , oU $ $,. $ II'IILRI:nli<i'" pe,ill,,"er(sI r",pel'I!'lIily r~~,ll~,S\(S) tllC probale of Ihe IUSI will and eodlcil(s) plt'Sl'nlcd hl'l'l'with ill1<.lll1(' !lranl ol1L'ltl'rS__~~:-~-!/(I/.l/(;4!lrijL-r----_dd''''-'-'-'-- . , (It'\lal\l('nllH~; adrninhlrUliotl \".I,ll.; ll<hlllnlwalioll d<h,n,~',\.a.) I hi..' I'n II , , o ~: ~~ g:~ ~-~ /) , 7! ; /' 0/ "..-' / t2 ,-,-- t./ ,; ( ,.- L~ ~__,""'?rL....,:~'-: '''/ ~" (!jfl1l'lL;S I--;,{(",.,;;"rli:,~;,;;;) __ ?/- " '}<,;,'oc> 6,;/ y L>12_ . 1i(('J Ie' 1111!t;'//xlk'O) /1/ I e,i '/7.2 >, !ii -_....,.....-,.__..------<~,~ . .,-.----------1------- OATI-I OJ! 1'lmSONAI, Iml'RESENT A TIVtJ COMMONWI<ALTlI 01' I'I':NNS\'LV ANIA COliNT\' 0'.' (.lAr~\i3t'R.I A:ND i i' nM Till' Pl..'litl(lIll'l'h) ilhnn'-llanll'd ~Wl'il1hl 01 art'il'lllb) rhallh~' "ilall'llll'l\I~ inlhc foregoing pClition arc lrlli..' <lllll ...'{l!Tl'll III till' Ill':,l f_IIII,,' ~Ihl\\kdgl' alld hL'liL'f or l)l'liIIOlll'r(q and that liS pt..'rsonal rcprcsen. latlvl,'(>') ,II llw aho\'l' dl'l'vdl'llt pf.-'tiliollL'I(\) will wl'll:lIldy\IIYIIHllJIllli'iler tile l'stalc at:~ording to law, S\\ 0111 .. In (II. ,dTill11Vd and ~uh\L'lilwd I /--;:;i:')~' /:;-/" .:LY'/-n~.i, bL'fol'l'."h"IIi- 6111 da, "I' _'~ I. n .._' ,,'"' \)fl ~.t\'\B(.K I') '1"1 . \I / / ~ ~-'I c 'J.,~.("'''''Pt\VPfJ3(C/,.\.A~~- ,~ /(l'l!./\'(I'I" l 7;l J5-:2.1(7~t:J.. ~ !Ill!', II;' illS 11m! illT roHtli!'~ mfltl!'l\:AlIJ,;'uOI WArHlING: IIll; II.LI.GAI. 1'0 AI 'UIIIII~; COpy on IO DUPLlCA'l' l1YI'1I0l0!llA' Oil i'1I010GIIAI'II. C(JMMotIWtAt f11 or Prtlll-;'d VM1L\ ULPMIH,1Ul1 of' IlFAI III Yll^l HLUIPD', LOCAL IH,GIS'IIIAH'H CEIHlrlCATIOI<! 01 DEA1Ii CERT. NO. 3656256 i"""'''''''''''-' /"\~\\ II ill I'//{ .'.'. 'I"~-' .41,:;: ", ~ .~ ',F~ Uf "" (~" ~.~ "., , '" ~i, .:,~~.J ~ 13 1'''' '"~ ~./ '.,}r>lfEN\ ~\ ~~"'" ~Lt!(!jji!{ULiJJ-~ //-.l;-").' 'l .. -'l~I,,-lInii-l1~lllliIT.~ /J~jiillj.iim-~ ~, , ~. ---'- ~ Sex..., .. /- ..-.. ..j /;:1i,/.l;~(ra:.J'J "e? , . f..;., "';\'1'" /1 /</ ().3YY~ ......_SOOiill SrH:Uiity No, . .e'?-.,J"u .m 0{<!:~~!.'..~.~.._- .. !' _ 1'111 Namo 01 D0codont 0'110 of Death.~ / /-c,?::.L~,.. .. Dilte 01 Birlh __._'}~t..j.L'~'I-~7.;fl_(~~~. ' ,_~__n---___" ._ un_ . V /~A<:'C .r_f"t(~,.,!.., ';.Ii ;;-,'uqhu Ir"",--.hl' ..f'e.npsylvania u__2'/;P -/7' Birlhplaco -;. . Place of Doalh /i/-:fcJ/t:,':S(,,/~ pX~CJ.:?'fJ:;('/f /'.v' Race. g.'i{.t:.re-"u. OccupntiOl, ( ,d:~<I"('1{ U()(:[Jclonl's Mnllino AcIdrostl . i?.c, y H,.."'''' / / I ( Marital Status,:((0-:'~)_f~~;~:.~~__ I~> -_:.0; Annot! FOI:OflH? (Y08 or No) ,,,.~__. . J)~'P0'){'4._n..,Li;g/ 70.1'" "'f, n Ifr~'n ",,,.1,' Pwt I: j --:/~J,q./l r:.:',.?,J!"'!;d:6,.. :;, .. ,,) _ ~~~{J(~'~___~:~~~~~/'~:l"ttl_~~_._~__ I, , Inlerval Selween : Onsel and Death . , _n ___ __~_.Lnn"~'''~__~~~__ _"_T I , , .___ ..__.,T-._______. -. ....,!_~____,__._________~..,~..,,_.. , , (c) ..,._._,~. ......cm..."____. ......._.._~__...."_~_~_~.,,c, .'_, ..mu.' "".,,,..,.c ...~_u.,._,~_L_......_,._"~_,, I , (d) .c-...'.'_.-c--.---- ......_n_'_...n.."."~..c. ._..'......._~._ ....... ..'_~m..."..__m____.'......._..: .-' --..---,..__.._~~-'''_.. Part II: Otll'lr Slgnlfioant COnclilions -' ~. ',<., CJ.IM'; ;:.L('.6.lf:,<"<<.I.tJC;,!';:{<<~!,f",lJ!:;/~.,::'Y~'L-::/;*c1~~:ct!:,~.,/.i'&: 'i:;;;,_0',:,,/,1.k.~'!i.JC'.' !1,,!diY^1$iL-, MannBI of DBath DBSoribo 110W Injuryocourrod: Irnrnocllo1le Cause /' ' (a) c.c,.".~-,<,(,::;,6"""'1.J-"1J'cj."~",-;,,,,_,d,~:'"--,:, i,;:.,.-Jr__ Inlorrnanlt:/fd,l(:0'J''::;~ )/qC'" rV! ., ,,_, FliIwral DirBctor Nama and Acldless of" _, I'unernl ESlatJllshlllonl u,../t'>(.rI'A./, d!'_,ld.C, ~,l/;/Ef'{Jf (b)Llh~M'fL/2--6.c(!' (' it,(J:::p~.<(.. Natural ~r Homiciclo [] Accidont [J Pendinq Investiqation II. Suicide I J Coulc! not bo Ootenninod [I .~.__"_,,_~~~__.._~ _'Kr._~"' ~T_~__...~~n_~. Namo find Tille of Certfior_6..ifJ/,rf,jcc,JtZ,,,ik:r.d;;:-,/ ,,---- ,..c.,m,,_ ..m__ . m'.' ~ V "'J' / /). .7. /. ;.'...::;.1..._."_-.... ..(M."...p...:'.~,o_,..'..o..\)rollor,.M,E,) Aclclress,...~';:;_'1:J".u,. "._,...} ".....f:.. /_ZZ:Z1J.l.LE.J,(,':i~,,;./ ,,0/, / . /I. n. .. - ... .. .... . ..." This Is to cerlify Il1al lho informallon IlOro qivon is corroclly copiocl IfOlll an orlninql oertlficato of death duly filed will1 mo (IS LOGnl RO(Jlslrar, T 'OllClln"~i /\,p,IIIILilI0 will 1>0 lorwardodlo the Stato Vital Rocords OUicp 101 pfJrmanonllilin -2., ) /"\ "'i- .ty ( I .>,1 .y rf. \ ':_ '. '1 I ___ ,\>'11 )r.",! /,' /l'~'~ u(, ./ ,.J~- .~:?U.~:C....j!,,,,,,c,' ...-' . (.:; '" ..i, '.,1',' ;,,1" "","')[',1 // . .~> ~-'l? .n-o,iW1T~';;:;;-.fhi-ri:DflF,<;::;F ;.-- -~ another for the minor'H honei'll.. Huch guardian Hhall have the powor to UHe pl'ineipal as weJ.l as income from time to time for the minor's support and education (including college edueaUon, hoth Ilraduato and undorgraduate) without regard to his or her parent's ahllHy to provirle for sueh Hupport. and education, or to make paymont for these purposes, without further responsibllit.y, to the minor or to tho minor's parent or to any pOl' son taking eare of the minor. ITEM VIII I I rlireet that all t.axos that may be assessed in consequence of my death, of whatever nature and hy whatever jul'isdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my est.ate. ITEM IXI I appoint my son, Charles Edward Yocum, Jr., executor of thl.s my last will. Should my son, Charles Edward Yocum, Jr., fail to qualify or cease to act as executor, I appoint CCNB Bank, N. A., executor of this my last will. ITEM XI I direct that my executor or guardian or their successors shall not be rl.'quired to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS fI~i> WHEREOF, I have hereunto set my hand this , 1987. I -t![ day of lfxJR(\'I" i.,._._.l) Ma e ,ne ~. Yocum (. ( /t( ('(<.~,,) (J " The preceding instrument, consisting of this and one other typewritten page identified by the signature of the testatrix, Maxeline Z. Yocmn, was on the day and date thereof signed, publishod and declared by Maxeline Z. Yocum, the testatrix therein named, aH and for her last will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. ')' .oJ " . 'Z i ?' ,. .t...btf.-/ ~ jtS1C.Jl<-j"~" ! ,. 2 u~ :;~~;l C;!: Cl, ;r! -'l\ = g $ ; ~ t~ i ~ . . . ~ ~ g T ~ J i.~ ffi \ . . ... .... N ffi S! ~ c:> I 10 I' 0 ~ 0: ~ I', " "''''j'.''J'' j,dvt. ~OMMOIW~f.YIVAN'^ nt;PAI~!M[NT 01' REVrNUE [)fYl280001 ItAHRISOUR . f'A 111 1 [1ECFllr:NT'S NAAll: (lAST, fiRS!. AtjOMIOOlf: INITIAl) lJ~Q ~ t)ja,-,f 1J!ocf., II) 'llilil''''' wilt '~, 9C"",SNIII~"~ ~ (\ Y f l~;1I ~r 0::'/ 1't1:)1003iS (If '''''lI''"," "1f<V1~'G SI'OIl"'~.Ir;'RSI' ANO IIIOOLC"""'! r,llt"""URIIY NtJII"R ~ ~Z~ lill5:g O~~ tm c ~ 1- Onginal Return [] 2 Supplemental Return 0 J Rtlm~illder ReluffI(IIAllloliMalhPl\Ot!>> '2-lJ8~) L~l 4. limited Estale [J 48. Future In\elest Compromise (llatllcl ~alI1olfter li.TH}) [] 5, Federal Estate Tax Return Required p:g 6, Decadent Died Testate IAn.-:I1CllpyotV{IIl) rJ 7, Decedent Maintained a Li'o'ing Trust (Art~hCOfltorTru5t) ~ 8. Tolal Number uf Safe Deposit Bo;(os [J 9. Litigation Proceeds Recoil/cel [:'-110 Spousal POl/orty Credit (Ilale of ljellth beM'oon 12.3'.91 and \.\,9~l [] 11. Election to tax under Sec. 911J(A) (AlYch Set! 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAM\.t I '\ . ' . r.OI-.\PLl:fEMAILlNGMlDRf:SS e, '-~ uL~) (~-1- (?o 9w. ({:, ~'_ (:J 'E:::'r-:>OL{~ n C;q ---- , 6 61l ,)c:T ::0 .~; ~" >.n ;1',\ , C'-1 , , .,.... .j.:'., C/c5, "3 I 3 I /-, i;o , ; " S, 6 13 , ".I (8) ( f 7' , t'50 . rei dQ,,1i, Y: 'il q,GIO 3(.., REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT !z w Q W CJ W Q ,-z <:.. ( , ~j 15- ,;]1 'l-~. FILE NIIMHER ,) I c " 00 (") ." C' I ,,:> 1 i I I 1 711 f '1 7 <' I OAH'OF BIRHI o f I; )1 / '1' I ex ~---niitRITURN MUST BE FILED IN IlOPLICATf Wmt If'E REGISTER OF WILLS --- -. 1-7020:;:-- (11) ;)-(,31 r .,;if , I ~l L, 17 7 ..;;t- 7 IE w o z ~ VI l:! 0: o " FlHUNI.},IF. THEf'HONf' NlJMOER ./1 -2 -]/1) 1:>2- -~S5-L- == (12) (13) - Roel Eslate (Schedllle A) (I) 2 Slocks and Bonds (Schedule B) (2) 3. Closely Held CorpOJation,Partllernhlp or Sole-PlOprielornhlp (3) z o 5 ::l l- ii: < o w u: 4 Mortgages & Not" Receivable (Schedule D) 5. Cash. Bank Deposits & Miscellaneolls Personal Property (Schedule E) 6 Jolnlly Owned Property (Schedule F) 7 Inter-Vivos Transfers & Miscellaneous Non.probale Property (Schedule G or l) 6. Tot.1 Greo' A..eto (tolallines 1-7) (4) (5) (61 (7) (14) 1'72...., 1T7 .d 7 9. Funeral E.penses & AdmInistrative Costs (Schedule H) (9) (10) (15) . , \0 Debls of Decedent. Mortgage liabilities, & liens (Schedule I) 11. Tot.1 Oeductlooo (Iolal lines 9 & 10) z o ~ ~g "'lI. :Ii o C) 12 Net V.lue of E,t.te (line 6 minus line 11) 13. Charilable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net V.lue Subject to Tu (line 12 minus line 13) 15, Amount of line 14 taxable at lhe spousal tail. rate I I X ,0 See instructions on reverse side lor applicable peroonlag9 16 Amounlollin.141"eble / ( i:' CO 1 7 ., 1 at6%rate ' '7 / . c7 x .06 17 Amounl of line 14 taxable .) <,/" 00 0 6 at 15% rata I .J . x .15 (16) (17) (16) ;o,l1'r.t1 3?:r 00 10 ,S'7:3 (,4 16. Tu Due 19 - > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Uo(lm f)l'!naltics of pequl'f, I dedaralhal! have examined this return, including ik:companylng schedules and statements, and to the best 01 my knOWledge and t~liel. it is Irue, correcl and complete Declaration "t praparer olher lhafl the oorsonal roolllseolalivo is based on all Infof1nahon of which 0I0Cl!VOf has ~ know~ae, SIGNA IllRE O~~~80N RESPONSIBLE FO 11ING RETU~N' ADDRESS 7(1 T7 J-. (/0 C~j"""/ .' <~. /8.0 (:rN :oe L{f(t.J.Jl,;dlx,!tl,' r/I~( S GNA TlIR 01" PARER 6THER EP A TIVE ADDRESS;:) C'ltJ~ ,) -~~ (j'Lt8c'r' j] &/{1. 8_ /;~l~ DATE :;Pt/FJ DATE /;., f:.,----' flil f,r Decl.1dent's Complete Address: ~iH:_A~':.i~.~_~)Q1,.'.13-51 '1~-,~=.~,..r~ ,=~~=. ----~~~~....... ._-+~._~-=:l clv_uu:=~_i'~ Lti_::~:_~~~=~~~-=:~ -. ~AY[P;1-' _~:r7 fro ~ s~l Tax Payments and Credits: 1. Ta~ Due (PHge 1 Une 18) 2. CrodilslPaymnnls A Spousill P{lVorty Credit .~_._,___.._..._..,u~._'".-..~.~... B, Prior Paymonls C.l1iscounl (1) /iJ; 5[3 , (.,1 --_...._---_....---_.__._..,._~'~ .. ...._--_..~._.~-_._._.,~-,..--~.., Tolal Credits (A' 8 + C) (21 ~__' 3, InteresllPenally il applicable D,lnleresl E Penally ----~_.~---- 4, TolallnteresVPenally ( D ., E) (31 II line 21s greater than line 1 + line 3, enler Ihe difference This Is the OVERPAYMENT. Check box on Page 1 Line 19 to request a refund II line 1 + line 3ls greater than line 2, onler the difforenco This is lhe TAX DUE, ___R____~____.__. --,....._~_.~~~----.- 5 (4) (51 _,It;, (1L~L A, Enler the In\efest on Ihe lax due (5A) 8, Enter lhe lolal 01 line 5' 5A This Is Ihe BALANCE DUE, (5B) --(d, S'13. C/f . " Make Check Pa~able to: REGISTER OF WILLS, AGENT, ::. 'T , Itl.UJHlIV. l II..J1U.1 w1 Bn_-~~"'~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PL.ACING AN "X" IN THE APPROPRIATE BLOCKS 1, Old decedent make a transfer and: Yes a, retain the llsa or Incoma of the property trensferred; .' ,[] b, retain the right to designete who shall use the property transferred or Its Income:.. ".. ., [] c, retain a roverslonary Interest: or"., ' .. [] d. receive the promise for life of either payments, benefits or cere? . . .." lJ 2. If death occurred on or before December 12, 1982, did decedent within two years preceding deatl1 transfer property without receiving aclequate conslderetlon? If death occurred after December 12, 1982, did decedent transfer property within one year of deall) without receiving adequate consldera1ion? .' ,.. [] tst 3, Old decedent own an "In trust for" m payahle upon death hank account or security at his or her deathL" [] 4, Old decedent own an Individual retirement account, an"uity, or other non-probate property? .. [] No gj ~ 'R.J ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN .u~~ill,;~.li?J:t'\'~i~J{i\!:l;l\r,\I,t;);i'mr:' 1!'R/:\'9i\\&tt::' (~lJ~'*';\U'!\;: i:i')'),U:~,;,!t, ,'. '.'j"'::U:;!!i(!':n:'n! i:!'~,(i!'mnl1l!~):I~'ii~li 72 P,S, ~9116 (a) (1,1) (i) prov,ded for the reduc1ion oj the tax rate Imposed on the net value of transfers to or for the llse of the surviving spouse from 6% to 3% for dates of deall) on or after July 1, 1994 and before January 1,1995 72 P,S, ~9116 (a) (1,1) (Ii) provided for the reduction of the rate Imposed on the net value of transfers to or for the use of the surviving spouse from 3% to 0% for dates of death on or after January 1, 1995, The statule QQ!!Ln.9.Le~.\illill! a transfer to a sUlvlvlng spouse from tax, and the statutory requirements for disclosure of essets and filing a tax return are stilt applicable even If the surviving spouse Is the only beneficiary. FOR DATES OF DEATH ON OR AFTER JANUARY 1, 1995. Please answer the following question tlY placing an "x" In Ihe appropriate space, Old the decedent create a trust or similar arrangement which Is solely for the surviving spollse's benefit for his or her entire lifetime? Yes [J No (l5'Q If you answered yes to the above question, Ihe tax on the trust or similar arrangement is postponed until the death of the second SpOllse, at which time it will be fully taxable at the rate(s) applicable 10 the remainder beneficiary(ies). Enter the value of the Irtlst on Schedule .1, Part II, in order to remove It from the calclllation of Ihe lax due In this eslate You may wish te fite Schedule 0 in order te make the election available under Section 9113. If the election is made, the Irust or similar arrangement IS taxed in the estale of the first decedAnt spouse, the portion of the Irllst or similar arrangement whiell benefits the sllrviving spollse Is taxed at the zero tax rate, and the remainder is taxed at the rate(s) applicable to the remainder beneficialy(leH) If YOll choose to make the elecllon, you must attach Schedule 0 to a timely,liled tax retllrn, along with Schedule(s) K and/or M in order to show the apportionmenl of the tlUst or similar arrangemenl between the surviVing spollse andllle remainder benef,clary(ies) APPRAISAL F'''r':r)''al.~~operty of tlL1XfLlH(.. Y (Ie ,J"1 ... t., l,j (I' , I;'" I. Ii, '.~L .,AN b (/) I ' , . ^I'pt rd<;e~.~y'..~~uck E. Brlckor ..~.~O.~"".L. . ~~t?\,')~ ,i, I ITEM VALUE ITEM ___~~_.__...._~___'_"'_~C"_.___m'__'~____"_ - .......,--.-..- -~-_._-~ .. ,I i'1. LUj((,sC,1l_.__..__....'..IS.\l.o..:>II.!'r<.\,l..'---.--' . I, IvtcFl,!..<1:!L.::'>-... ._3_9.1')( ,...S<-,6., Uu .. [J(I (I '/'1 (,J! f"! tK......_ , I / ((1/J.f,;.~L_.w__..."'_""'" ..LbJJ.vj~(>{J/IJ.:J /llirC...._._c.. . ( . i, 'I '!',6!.J:if.:1i'..Jl1.1af.___m.___._._. .. 2.(),D~. .i' ()ft.jl.(j/J;i[A..,~.c -..-' , . i C ;l,_I1'.__._'_n_'__.__... . .2Jld.j .. j/(fl/cl/ _u__ i 'i (? P () ~~e' tt. ._____....._._ifp"p~....1f!] L~'A.,~I,'!ILI2 /.Lt.L..._. , 'i ,./ ')(...1'1/'1 e.__~_..n__'_ .._'m..__' ../..6. :.1!._0....l).tlJ.("(L._j.'~~:N:2. .. _.m"_~___ - ...'. , I, ((.A!fz::.,f{. .__..._._ .._'!.!::..d.':3..._E.;{C:[C(:'~.(]IZ:"~---.__._- . Ill.'(_~_______.___,_..._..., .' /(),t1~ ....? ';\~Tl"/")rbtl~ .'>. .,. ." Ii! le ';1.fl}-l.5L___.________..___ .. ..IQ,O.9 ._ll >',,],))1)1(('2--. --'''-''''''-- ) !) "JL$... ___._' .... /b~"._ ., ,t"1~ .~ J, I'~I>...:.D/.tLS.,,__~ I' " Pi;)!! (Z.dnr' _5b.,Q~,..LJh.0'i.Ld,;\'-Il,l5l.L=.1..--...---c-. .. :J_~,;:~~!!iJ!.L-. ~=:...-,:~.. .<t~~.-;:~cZ;ldi.,~J/~iiij!.;;:.;i~-....=..-l ," f) I' I' 1 iJ ,.1 " ..,'~...-----.---------.....",....!.Q.~-...1F....-.-...--........ ........--,-.........-...-.-.-.. _', i" /L1f'C(" LJlk'cTlZ" --..-. _~~~.QV ,.f}lt{:.,..,.ILE;-)jA:1,,~::I4'1l."J-.tif~~r:<:'-'P 'I J~'.(,' C<:.Lt-! L~ /l... CI} l1!1.fff__..__...._. ._?0.JJ.! .._/'Lv..p1-7'-:h""-___.L~.:::--~!.'iL , ' I ,.L I A ,'LiLY- <S I Ai JZ _.____0.JJ.A.~) .---...-..-....-----.---... , ...fll' i (; L;j (l<;Jil::j.........iJJ:j,LDa.LL.~.6..!~':.-- B4::J.b.~ ,_ ... ..d......_..__._.._,._ ----.--.... I I'I!',/"{L~. .....____,J();.~Jl_ ---..-,... ..--~-.-------._~ .~... ..1 /:):!!,~ ,:.~~~::;~ S c r_~=:~~..==- ..~',~"~ _.___.=..=..=..=.=.:=~=-~.=.=..==..: I /, , , .f..! ,V..:'J..5 .~~f:.J!.f.__.._.. /lQ.Lc.l..~____...__.____..._.._~__.1....__,__..._... I. ../' c'} .c"':f ,I I~ TV.____.____.. _~jQ.:,a..lI_.._......__,_._..._.___._~.:.............~... I F! ) ,I /j ( t /(1, H ,_l. c _._.~.t __~__..~______._.,_h'~'___..... . .._... _0_" ___._._._.......,......__.~.__._..........____h____ . .[.: <: (,..5LJ.Y--.L.'..t~~___..__!(\U __._._...._____....___._._._.__c. _~~/~..JL!LL. Ace! Af1, '5(/117, __...lfj~lJ!~ ......_..___.____._______________.,__,.. . c' . / .',. /Z___ _______,__.~_ ...'?-'.f!(~ .----...---~~~....--.--.-.---. .') (;'. _.i.~~~L oi:.JJ! .__.._._._.,,_'10',.?1(, ._.__..____.___._.__..__~____.__"._. _L2.iih'.J3.~ ___.___.__mm__ .......r;)\) 16 v ....._,____._.._... _..... ._ __._,_______.___._<_____~ _._ I' '1; (\ !'Q.~__.___.__.__......_5D,.Qf~ __._____~.___m_____.c_._____.__..."_ " .1 i.' I.') l C' t( t :; T ___ __._ ._S}_<.~.E.__._._______ _____.._.._...._____._._. _" .J .'1 'I r,~w f... oas..r 5 L,O j'C..__ )2:.(JA,!~ ___.__..___...m___.___m_...._~__... .j'" j ,I ::.TlJpL _____..... ...:!A-".2.._.___.._..___.,.._,... . "... .m.. ......--.. .. . , I ,--......-- ....._-, .....-..-..---.........---.........--...........-..-..-....;..-- ., I I \I It! Ii , """ ".. ,,,,, \ BfA" ::1~~~~!l"" --- .~~~~gi~~~:~~~~~t_." ~'"!" '''' .. _~ 11 '':.I.r!C}' '..X':':"~"-- __'__ _ _ _ i'r 'I ". L n 't:' I .U:'. ,,'CR,n,O. -..,- T-";;;~;'---- .. ';;';.,''';;.~;;--- ~------ - -- -'----- ---~- I~I ,,,, I It C'., ( ,:J rn , j Ii It' ,n a I lie r'c, ,1 u'--'i ' 1'0 ,J, The ~'" \ II P", let' I ~(, r>" .1,1(', (S ,1 'I, q V ,'I \\!"Oluo,un l>loln, ((c,-/J'1') o)loroo 8. Admlnl."atl". Co.," NIl! 1. P.nonal Representative Commi..lons . ' Social Security Number of Personal Representative, ---~~ Year Commissions paid ---- lfooo, O() 2. Attorn.y Fees \)O(\(t[C( t!J. OUNf1 (Si(" .' U f'1(r.\ 3. Family Ex.mptlon Claimant Address 01 (,Iaiman! at decedent's dealh Street Addr... - City H. (, 00 Relallonshlp ~ Stole ~___ Zip Code 4. C. " 2, 3, 4. 5, 6, 7. a, 9, Probate Fees (\1 (y.I)f' (I (1 nc' Cc U IdS:! ,'k ',3t:') (( V [.p [All i 1.5 Mlsc.lIan.ou, E1cp.n..': . C\ l f)\.I)~dculct LCl[,lI Jell r (Iell - 1('8(.\ I nc)(l(~ 71i', (let hiD ( . Nl"JU:') (1 t. Vi! I' hI; 1/\2; C,hu.(' t. () I t (1'('( All ell c,(\e\' (, C/(J(! lit 1':,((1 Y'~ (dC'') i [, 1<' :~)(' j /I <,'} ILJ 1\'+ cf l J n)<j ~~LlI" ((I I I u nch- 6 C 1\ 0 h ('"Ju C I1.U (cll (~uc\.ldq J(\n- hele.( ,&, .(cUW(C\( -L- '1 f(r:J 'Io..~e~ Ac\ \A1 (lhC((7 M.rv', .r(e /)/ter::, f)CL(r~{i { C ('e I nLj)i t r'J<fvJ i I 1:,.-JJ.;)~Lt!'S; Ii!, !..:J.<,;j /fl1.!-_ totAL (Also enter on line '1 . Recapitulation) (If mo'. .pac. I. n..d.d, In..r' additional .h..'o 01 .am. .1...\ - &0.0(1 ~,::,J.O (1' (J ,(,0 II. ~ <(-;3. 'N ,~()0' DO Q.53, <MJ ::31~IN" IJC.W . ,1 ?_X :;1 , '}5- S l- J.~ 7"3 ~91 1{',lIl^ LIl I:. I" ::111 'III 1,11111':11"1. Iii till': 'J;:'., II. 1111111 ::\", 11111111111':1111, 1'1\. 1','(1(11 1".111111': ','I','.IIYI./,';I'1 VIIIII'lI^l, (\(I' ~...u.j~.I~t~_~I{!.!(' ;" Yrl('I(II! f~(.p..!l'J)IL{I,'t I Il, /'}'ll NO\l(,,,,!t('/i :' I 1'1')/ ,,;,,P"_',_~_,,,,,,c _'_'~ ...--,1 ,-,. - '-'-~ '"'" ,~_.. ._.~..._.~,.. .,-<-<"-. _.-- l:nl'V\OCH) 0[' I,'\ll\oral 1)1J'(J(~Lf)t,1 HIlIIHI;,!'!' .~_,.~......_...,"""...~,,,,oo-_p," '1'r:l\IHd'011 of' Hn/lJ;d 1111 \.0 1"1I11f!1'1\ I Ilnlnfl J,~H:'\_L, _,,__,~"'''~'"'''U_''__ 11:lIllfd 11I\ 1I1{ fll' (l tl Ifll' !\\If!C \ nl \ ~',ml 'l'I'I'I\ LIIlI1Il L", ~ ,- --~, r, _.0 -. ~.",," ,- lh'nnlllll(~ [\Jut (~;\f\l~o.Ltfll~ ,,_'".+~_o_ _..~."...._...._.,....~_.'.n~"'~' Or_HIllin U on tllHt II ml\.()l',~ U vo ~.. u - _.~ _.- - -~,"_.. ..H'''''-' Ji:xLf':t (:l,:ll.'/f,n ^HL()\l:t\'nd Cllflf'!\ _~_..~..._.."~___.___~+-'~nr"'U'-_- lIa \ I'd I:Oflr;(U' . ..___ ~,,_ -- -- - n.,.,..... -.- _.~,-'"..~ -.,~ < lh~n nT 1"lln\l\I.\on t\ll'l. Vlltlnl'rd. !HI'onL{),l' r\nl.'vloon f(lJ.'.Vln\-lll1(~/ Vli1llnt.\oll/I'lal',I)....._, -.,.....,," ......."..-.................'-........ lli'>ll of' 1,'aeIJ\tlnn and FllJ10I'all),\1.'1Jcl,ol' :Jrfl'v.\.oOl"\ ,['0.1: II'lllHH'aJ (~l"'(lm(lll.y/Il\. tn/:~nl'vl{~o .~ - -.-~--..,..~ n - ~_., - ---,.~ ,.,.,.. ....,- ...........~, ~~ ,. - .~- ,. linn of.' ~'at~ll \ 1,1.0[\ HIlI\ VllllfH-'ill l)\r.'{lOLol'f:nt'vlooo for f'1omQrJi\1 ;~r'I'vl(~n _.__' ...00___.. _".,~-___,--~-.._. .._~<.n~_'." 11!\fJ of" J1fjll\prnnllt. fl.lld. Fllt\(ll'al IJ11'{H~L{)r :\oJ.'v.\nnn foj.' Or1\vonldn nnJ'v1.c~n ~ _.. ....~. _. __ _ ".__ -.-"" .... .-..-.'.. .... -'- ......, - _H_ _.a.'~'," -.~.. .--<-".' --.. IIp'1rnn ({J(\f\!\n L C:Ufll:h) ...J,r'JUi\.I. ~,.,_~'n. -- _"n" .,...--,.... -.- ..~_." ..u. '..-'~ ".- +.. -, ".., L\IIi'HHlll'" (Local) ,........- ........." H...._..................-.................'.....--.... 1!IIHllly (~,,,. (LlH"\.I)... ...., .. .,........,...n.... .... _..__uu........"....-........... ,1"10\101' (hI.' ,n: 1.'l'<I'a1 11\lll'CH111.1oH 01: IIItHdlll1g (Lot.'ltl) _.._uo..". !.('flrl <:fll'/OlofT,,Y Uru: (\.nr..:ll) .._,_...._._~_..._.....n...__.___.-<,..._....,.,......,~--"u. {!I1I\_I',~n l'ne 11110 arLOI' It ,11\10 Ih(I\.lIn 4'.._,..._~:....__n.~....'" -"" (~llrtl'f',n JlI'!: In'ln rtf'I,OI.' a '1'1\10 Had\l1fJ ...._~._u..._..__~~_~_." (1'" r;I-;{J t,- __' ,. ~...._ -- - _u.. n_'" -~ ,. .-~...... ..-..,~, -- - ----.~.-- .......-....- ~~~.~. +.. {}(II.f1r Ihll.'lill (~lqll1f.lt1(lI"" ~___.__"__ ~.-,-_... ......,~.'.a...;......~_p.n~--.H.Hc--"~ 'I'nnl. at. Cr'W,t.f'l','1 . ..-'''-' ..,-.....~._.,.._~...._-- 1.1I\lfll'\III~ Povll~n/AJ'U l'ird:'1 Ut'fH'I\;lo -"'----.........,-..-.........p.....-"-..--.. ~\nl'v\.nO llhrln~n hy Vl'll1l.?~f)r!lp!l.lly __'.'H~..._.__..........~..._"....:""a._"'.._~__H ^ I :11.1101-' Jndl~(jll\el\ \, (~'l nlll ..., __ .. "....... '" -. _.~. -... ~ -.".-... -.. -.... -.. .-- ~..~.. n, c4-i... ..' 11"1',\ '\ 1.01: 11001'. _" _,.... .... .. -" ...... -. - -.. ........ ..'" c........ -.." n..__........ ...-... -- ...... fh'1Il01'.1 al I'\d Ll P rllpn r.' I 00 .. _ --- _'" _ u. ___ ----> _ """.. _,..._.... .'.'''' ....... -. ~-~...."... H" ~". II,nyn" (!nrdn pl'I' .. -. "._.~'n.~....~,..__~_.~__~..._~,...__.,_.~,..".~M'~----O --........ Tfllllpn 1,'l\J"Y (; 1':\ vo j'~'J{(;t'- ~ _ ...._... ,,_,,_~. - -- ~~H ~ -.....-_..-... --- ...-.,..... d'" -. ",""~ 11111:11\1 UI()\.I,III(~ ...._~.~"...-,...._-''',_..- .._._____l__.,........, lltll' 1/\1 01 n 1.11 \ 11(~ _.. ........_____. . _ ____,...._.~____~.___...... - ...~.- ...... ---... - -~..... ...... 1I'11'l,,\' i11ol.ltllll\ .._.._._____H-'_........ li'llI'\I:' 1l11nn {l r lln!;l:-;j "'(1-- \.r-:;- ^ lHll.h(Jt' II', 1l1(~)r,iljUH(;iiin-... ~... - _.....P ~"r -- u., 11r,,:oJ V\III~ 0(' 1l<>lln\IlI'l f'1'I1in ^Iltlll\ol.' 1"lIllrll,~I.L 1l0lll0"----.-"''''''''''''- 111I111",I\a\.11 I\,"'\nl (110 III \.on OJ.' l1oror'loll.\.on)---.._........._......-......c" 1l.1 rO(~ t CI'nllla \, \011 -....." --.. - _'M - -.. -.".. -~. ..~ - -,. -.....- ---- -~. -... - --~. -, - -- .,_...~ (~t'nHlo:l.tOI'Y CII.'\l'r,nn -....,_._~--,._~-_.~ It('IIIO tory Cll'l r(l,on..' ,...~.'.~~~__~~=~..-~.~::~. .._:.~._~==:~~.~~=-~=~= __.~.n___.,_..HO"_ II'JIi''inpm: IluLlel1 --....-..-............ ^ \ 1.' f'rtl'n .__.____..__...'_"~.'n_.___....,,__.._,__~_._._._ -_..._,~..... "'--~"'-'" C:rll.'\.\n~;,l.uopj "'\-(1['Ll\o iJ,>,j tL-'ll;;;:;LrJ'.cca L,)-rr-oOJtl Oil' -.." ......- 1':J'.>f1" I'n,.CiL.\I~d...'lI','u:lLi_._.t',.I(III':)I.'.L.. ..._.u.. u.......=::::~:. --- ...-.... -- c... u.... I' InH nl'n~Ji.llq C...sf~l/J,I./,__..Mu.u.(','l'.J'm'_.. .___.-..nu~-- -- --..-.---... -.. --.." Cnrlln t.m.'Y llot ". -~ ..--;-"" ..~- t. ..~ -.-.--.-.------.-.......--........-... ....-'"..~--~~----~._~~~----~- L !.0rgy._ _ __.__RL:.\.,....~/J.U{~c_Jl'..'ll~dw.I!.,.L_.~~___ _ ,........,... --- ~".-'. --- .._~ ^I \.ol'naUvo 1101l1;l.\nol.' .. .. ..-.. __uuc,__u...... ._"._ _.__...._ _. "_n_n____._.___.~___ .___.________. u....~. __._.._ _m.._.__~_~_._. .-....---...- -'I1I'I;^ 1. I~O(l, 0;,\ ---'-"fio:_t-/1i! O!l,O() ~LI,(!_O ..3~_._uQ '1/10,00 ~_.._, ___"~a_ _ ..~ ... 11 t", on .... "'_T_...."n___a,.__,.--. "'Iuii'. i,;i ~~"~~__,".,,'.~~~!T_~-r: i; ',0 0(' ~.~_._,~_~_.r..<_J ._._.. __.4.__..".,.,..+__.....,.-C. ~. ~~~._..'n.."..;.-...,__ '~1;<::nfJ -p;;yn ~. ..~,.__~JX:~JU: ..~.,,-.~-~.- -...---,.,-, ~..~____~_...._<o__.;. ~.._________~'_""K ._ ..---_.._.__.-"~~ _......_------.~->.--~.-. _.--..._._~.---_. ,~ ".'_UO-;;'Z-.-(l[l ~~~~:[Q'(,:Qi) ___._l__~~_~}J! ~~--~._. P;-.'Tii1 .._.___._fl._____._~.._ ~:: " 0 ',I,} . '1, \ (J\l\';H ,'l'~'\()('ahlc Rt'taillnstallnH'lIt (:Olltrarl ami ~~l'curH) \ \ I"I'L, \H\ I'll. ' , '\ "I',"""" { fool '\ '\ 'f_', " l','1t H'Lld I"~ 1'11.1 ..J (,qlli! \'1\\\\ ~,l, 1'1 \'il!~ 1'0,11\1\ >11, :i1\!lN"lIIIWrll!" '-illl','1 ;\<1I\III1,o,P,\ j"ill\\ '/I'U:h-! .lId,1 11"'I'!"lll;1' ,;, 1\'J 1';!lLL'iul,'li\ II.d IL'i'l..!dll" 1'\ I \1;<1 \1 ;j",\I,i.l _J' \\">1.,11,'1.1 \\.'1' ii,,,ti'lh ,I~;"" I i '11'1, .111; " Iii I 11.'1'!;",I\lII!' 1'\ 11111'1 l. J ~l> \ J J I i: i 1- \ 11' N I , 1\l1llk h~' Hlld Il('r,,/.',' I) ,~'lkr .11111 ll'ii \'iil'i'i': 111\ 'Vlll('h!l~\'I"1 \VlTNI:~;SI-lll IIIAll'\II,_'hihl'l ,I :II'l", \lj huv illld '-;(.l\.'! :li.,!~,," I;' ,i'II'll 1'\11' PI ht,_ ;1.\,i)'ILiU'd h ii. i '\('\01, lIw tull\,wjl\~ Itt~I\1" III 1.1(' PHI\-idl't! <!I \1',('.1 IIi Ih': ilhll\T;' lwd,i',l !'J;, nil/III IIll';"_'IILlII['1 [',Ilk!! 'C;,,'l)iC ':',")' Iii ,'I d"';" , tl' .'.1 ii\;' 1(1)l1\'i pri1\ldt'd rl1lllt'lll\lI, \\ illlll\11 !'i'I'illo! H' Ill,' ili.l\ul ('.1',\ ,nHllll il\' \11'.dld 1t<'Jli; jlH"iiilill,!!. It llil' I iHI" pi IL'II';I 'Ii:\ild' L"It'[" \\lh'l'II"'111 ..lhlll hI' jrH'\'(1lllhl~' I,: i!1 nO'! (W H(llt!;\!. H HlllT~+ 'Ihl' llliri:il Hh>llhrl'VI"!i'd hv tl\!: 1\1!.1\'l'Ul;'ill MI' ~liliw'n It V Iii, IIbil' III ',mil !~d!d\'llill\l:ldi:i/, ,wld '1', "IHI 1l1('IlHlh! pin!; Illndv di;'k'lHh'd I'rlm\ nu' I'urdlll..t,' .\1.1'1"" or Ullrltd Hluhl'i (I (J('lllllj('lnt'l II d,+ IlJlt'I'llli;IlIWllIliillhllH'Ii[lIl',llllljl'; i I ; ,lOci ,111l\lll~',t"'Sh), ' '" ,',I' -" " ,'i " ',' "" -.p,\\I'{',) ;'i\lmhukfHil' ".1 {'!!!W,'I...! ( .J Ildw,\ ) ,,( 1,1 pi .J I'Jilllltk 11['1,1\1 '''I ('hoit!' L.I SIlk II) '~hk ,I 'dlll'll' 21111 (:hOI\T i,\lu,IIIi'I'lIl1lf,l,il';I, SII'iH' .,1 ,,'lli1p,'1 "I (jd\J n..l j,jl'liuii'I' ~;i1I,'k J ("'i_'" ~Ild l'll"k,' 1~,llhll\" 11l1l11'H,.' 'jluildillc '\"1'111'11 Nii,I~) I, !, n.'~dlf1UPH .. \ I Hi 10\ f L"fli(HtMATIO!'(: ,Vii it' rAlllmllll Hi~di!'. illl dl'i,',iI;,'d Iii l\lid I o',hO\'\'1 (H) Li.'"'' {'urilfl\:ilk'llh'olllll {(1jS~"'lllld HIi'll! "I' llill.'Ii!l~'i,i (PJ Vllull(~iJ (ElllnH>I {fq r-.1i\iiS(,k\lllll,('I\\'iil\i~!('lYI'\ 1'1:\];' (OJ ~'Ie\llilfllll 1Ii1111/1' 1;<1',(' n l).rn'ilalhnlllf\ Ch,il}'t' {II ('u<.t_('h (J) hli\t'lid Illh! I,K) ",., Illlvflll\\,nJlI ',iiil)ll!IIIll'/li\/llilalllll,\~!lt t'.'t.'" (I,IOtht;r (,to' \' , 1M) Utl\'\Illll'lllillit1l1 ;Jlld F\'l"lnllll,!' j<'...... (N'ISHh~', 'Ill... 4, TOTAL C,\SIII'IlIl'C i I Ihl'lI ,';\ I'n:~IIZ,\TION OF '1'111' c\~IlIlNT I'INANCE\! (II l111ll1 Cl';h Priu' (21 A. (',\'\llUnwn I',IYUKI\! ~. n, TmdiLl1\' Old A~,ll'~'fll'!IH Ni.l C, Total nOWl1 l'nyrm'llt (:11\ ,I 2111 (:\) Unpaid l\lIlaili:e' nl ('!hh 1,ln','i' (1 ., 2(') (41 Plnamc Chah',li (I qWl (51 'f\\(/11l 'fl\lillll 'BilLilli,'l' 1:-\ f' ,II ',lifh 1'\).',hL" in "1'';:ptdl1ll,~L' with lIll' t'Ollll\Vl11!! dhchHml: ..,WIl'lIll'IIL l,i'\'.'1 ~M,l\ililillll \"H~,"I dilW'I'hillil', ill" Inll'lll 'm" idlll:1 ,. Ildi'l11 ~')' .\, I'I'I<;MIZ.\110" OF ('ILIIH:JiS 'I, \ I 1\'\111\\' ,j' Inndnillili,(' I"~ lwltw 11l1(,.'hll~('d 1\11 llV' alil!\\'iiWI ,:dllL'I,'r)' '. 'i\ \1 Ii \ P,;1['lipli,11I \ i; " Ik~\'1111UtJ" , I' i fk~nl\lUd!i df~ll' Y i ;-.! :':- '~ , , x .JhiHlill' Sltt! _, x \ I' I"~! ,',j\ 1l"n,IHci '. ',/1",1 t:;I'/II\\t.\'I'ION (\il{ll', \ , , \ \ , 1\."''''1'' f< 1', ",-, p- , , i' \.. 'fVplJ: ,.'Type: .. TIll ,ST nlNlllNli ~'hi(ld '1 .,Miidi\l/l , , ( \',Llii"i \/ ,L1 0,; ! \\j'I!\I .~ ~ j.hllil'lal \011111\\11 ITyl'i'i '!, \, .... ,1'lIiii'I'H1110Illl!l [i.~;\~:\~;;~\,:;~,~~~;~',~:;;~,:t ~':,~ ::~::~,~~~~~;~~~;~:,~',..:,::' ...;.... OOtilYOll, (". _..................,... :'~.~ ,,$ ,":. ",.. _ :t, YOll!! i'{d'/;1fJH SCHEOULE Wll.L Dr.l ilq'lIllllf(IIPtlYl1ltH1l9 -~---_..,._--- ......~.4..."_.~..~H.,_,_"~___K -....,..,...~..-.."~... " r0lM. Of F',WMUHG TIl\J 11;('Cii<1I'/lIlI\'illi 1'1<1"<" p<lidi)!lm ye,l! 11/1'1\' 1I111(fn ,11) p.'IVl\l!lIll'; 11:; fi('II(;dllir."J"1 j' ,0", r'):~'J ," ",r' i '",,' ".. " ' __,,___'~"'""_.'__' .'". _._~_,~'__'K_" _...................__.p... c_._ 101M gill!' 1'!iI"~ Tllu \Olfll,t:(hll '"I ,'It Ij,'mlil. hh~l<:di'lrl i",ii (i, 01 $,.., , 'J ,f' $ j AMOUN~ F'NANqR~ Ill" ~l<lll,unl of l)rl;t\~-~i\)lJltl(,d to yull 01 01) Y()tlf..~,&nnll -~.. ._..,---~-..,---..-,_.._- Amounl 01 P;\Jrl\onlf, $ f'ltMP;:lym(!nIDveDrllfl l'tjijj'{I,IHflf, rla;tf'IH,!'; Nil Oll~j ,.I MlIlIlIliy onllio "IOii:1rloill' /\(111 Lhtn 01 Birth $ hl~HHt;l(l'~i ':iiqrVthf1l1 p(I}!t~cHV(i ~I IndiVIdual flN!!!!i!!' _I loint '~I' !'I! Y, y"q ,U',' f'i\ll\l\ II ~cnlri\y itlkrnl ul'flll' 1'00<1', Hi PII'jI.'n:, l" II,",' 11!lfi..haq~d '.Ii' in pUll "I Ill.. lUll' I, p.lid Ilndl'l 1111" i\iFiClI]I"!! hl'ld ill il i\ll'l~h;liIJ,'," 1,.1 ! 'I' 1'1:1 'I '.,! H '/(111 pal' nil i'nd~', )illll')II'IHI\ Im\l' 111 1',1)' d 1"'\1.011\ JllIl ',I'l! IIld\' I.... l)lllilkd I" i1I<'1I>1\ I ,,j 1',li' ,Ii \10<' 11l"il'"'' ('11.(1)'" 11 \1 I Ill\' (()1ll.1I111kr of Ihi~ AI1,t'...bl\~'1l1 (illdildill:: Illl' (;'In,of 1'11'\ 1',1111', IllIlhi.' 1('\,'1"" '_I,k II"I.-,I! I I'ill ;iddlll''liid iii!ll'ili,dillli'Jli"\1l il(l11IU\:lIh'!i ;',;,<1, ';\ !,'I,f1lir,:d paYIl\l~1l11H \'ull hdll(t' Ill\' ,,'\lI~dl1l('d old\<: , :!IId prl'p.i\W"ll! rd\l\liL IIn,1 PUlil!ili'" 11 .' ,,\~'(+I;:7;,~'t Ill('lll YOUI' ('0111 fal'{ t'I~llg;~I-::~\~;!~i;~~"T;;:;:(i;~:.flll11IS-I;;~17rl~'\~(i~:';'il;;:':~,c;'~~':';;;;~';':;;I~fi~:i~Tr;j~i;;:-~'h'1'('-l~il'n(l.j~~, 'I rihl I t';' ' III IS Ic;Rl:l:MENT ARISES ()li')' OF,\ I 'm;~d :Illm ('REIIIT S,\ 1.1', 'Nil IS Sl 11,11'1''1 TO 1m: ,\IlIHTIO'\.1 I. (; I \1 ,: \ I I'IW\ {"IONS SET I'<J1O'II ON TIlE I{IWEI{SI< SIIlE 1I1<IIEOF,TIIESAIW 111:1\1. IN('OI(i'IIl<.\ll',lIl1UIEIN II\' IH'II.IU '" I li",l'f\T\ llw fi~'.ht 10 fl.,fIlSi,' lil H('\'l'pllhi'l "\)'It"'IHl'ilt l\'ilbinli'n I 10) (bv... "I' I Ill' lb.' \I','I~'"I II\' 1l1\t1!\ Ill)' llh' 11111>'1I,\'.i'l 111\,1 l..ili,d 11:1', '\~'I\'l'nwlll...hidllw hilldillL', upon th'~ 111.'11.." l":l'I,IlI'!I';';, ,liln\llli"\I~\I\IJ ,,"Ull',' ,'.II'" ~\I\d .1','ilgW, 111'IIlc 11.Illi\'.' h~'I\'111 IIII~; \(;tU:EMENT ANllTlIE FMIIIY I'HOlECTlON CEIfl'IFH'i\'1 V, IF \I'I'I.\('\BI.I<;, I 'mill IN ,\1.1.'1'11I'; 10\ I" \ '. I ,; 1\ \l \'Iit\I\lSI':S IlETWI':EN TilE l'AIU'IFS. ,\NII \0 ,\( ;ENT, SAI.FSI'FIlSO\, olt () ntHI llF,I'IlI',st'.'n',ITI \'1 01' , If', II 1'\1i 1\ II,IS .\I!TlIORITY TO MOlllll\" .'\IlIlTO 01< l'Il;\1o<(;i,: ,INY OF TIlLn,lliW: .1,\1l ('O:\llITIONS SI:I' H \11.1 1/1\ i !h \I: Ii' I \ 11 NT ,\NII/OII Till': FA "I II ,Y 1'!lOTF( ''1'10\ I. 'HlTIFICATE. ~i(nll'ETO'l'm:I'IJH('I!,\'1 H 'II II _,I l) Ll'1': .'\grl'l'!lIcnl hdl 11 I.' \iillll"hlll ~\i ill! 1',,111;:111.> dll) bL\ll~ SP;I\'l'" \,:llil!,'d lil:1 rIH1111kll'I~' filkd Ii, l"lr'I' llllhl'. \l'fl.'('llli'fH lit ih,'llOW ~/nu "i!'li It 1. h\\ ','ilU IliI\'!' Ill/' lip.!\! 1,1 1":1'.' (l!l ill ::d', '\',' Ilw 11111 ,if1\I\UII( d\h' ;\fld 111)'\'. I' \' '1\;')11 \.;Ildl:it'lj', t'f ldHillll it P,UII,d :"illl"i ,q ;" ,;.,\I"l' ,1li"'\ IIq. .il.." N(l11l'1 TO ,\S~IG!'\I':I::; or SI:III;I{ 111]ldl l' Ill1hi~ l'ml'tfnU~r l,t'l'dH funlt'll<'t b ~.llh.it'd I ,all dnlms lIlId ddl'Il.<';{Is which till' (Il,litlll' dJlI!'t'ht\~;i..r) rllllltl l1'hll \ ;!~~H\il', 1 Ui, I "1'lId", nl' !'o\'nil"~N (lhluhH'd PUI'SHunt lu'nltu 01' with 1hl'I'j'(I('('('cl~ hl :,r. Hn'oH'I'~' IWl't'llIHln II,' tIll' dl'hl{l/, I PUI'rlLn'r',1 l,h',!), (I!;\ ."",,1 I,,,\d 1111' (khllll' (I'Ul'dlil\l'rllll'('('IIlIlI('r, l'lWIII.',FI{'S 1(1(;\11' TO ('\NIEl, \~l'('I'n1t'llt \\llS 'iolldh'(1 ut YOIlI' 1'l",jdl.'IH'l' :lIllI,' OIl dn lwl '\HulllH' ~:tttt{b 01' \,rl'\il.'l"', \ 1111 IHll\ I ,lIlt'I'lllIl" I\~'n'!'!ll h" " l",; I,. !lli' ('onlpllll~'t th,' nutkp 11111\( "iay thllt YOIl flu ,wI w:1ll1 HI!' gOIHh HI' S,'l'\ lvl"i lllltl 1Il\1..llll' ml\lled hd'ol'\' llllllllH'ilj i(" ,h'.' rll"ll'l' ~HH .;1~1I thh A~n'('lIH'111. 1"01' nil \'\plill1;ltl(111 uf 1hl', rl~hl, s('t, 1111' nolkl' or l'Jll\\'I'lhHllll fOl'lIl whh'h ,'P\I ~I ,I l'(II" ill' 11111; Ai!n'l'llIi'lIt. j:\Uli1 !\ I~l':d L,llt\" l~l,,'(l\, '<II', "~"Hj, 1'\\"", , .J,!o~'" _T THIS IS NOT A HI U r':Xpl,llltIli()1l of Y(lllr Medicilrl' Part B J kill' Ii (, M!:orCAMf. Unltl.d ....lthC.N' rns Co, P.O, BOX 10085 Ali~lISTA, IlA 30"""OUll Mt_~ _WO'r",~1;llj1'-'" MAXI' I.I NE 1 \'0<.;1 1M (;{jlJ f1 S 1 UIUIA f'A 1"/(12[, IG(l2 \.;Ulll,fllill,1 lIlllil., _'llIlk~' dilll'd Il.i (IL' o'i , l'lLlI \ ILl) It' l,d,11 \1c,llt:;I\ :II'IJt,,\';.t!. " ~ \ ~l \\'r 1);lld \i'lll 11I'11\ltli'r: )"il(ll r"(i1II\'~I'(lil<;ihili[,,: " ~j it) " "I ~,' ~u;-t',l-:[ ~tjJ.~~':i i, - ~ I , ", \'''111' Ml'dil'urt, IIll1nbl'I' I,: 1\'.\.17X.I {,.{,IJ(,~ Your Ill'nrlli\'I' ,I,l.~'.(:~l~l.~!~ ""lgulIl/'1I1 ',mjfWtWl.~,f," I''''nll~,!.!>.\!!!!.thls ll"tlCl' (~.'c lh'J!~~~fl!":.'I~nrl'I",,!!:!.nllt!"!!,L, 1111.1. SI!IIMITTEIJ 11\': \L!ilifH~ nddr('ss: r'DMUNDO\I'I('/. \1', \ 11\ IN FlU';! 1:\1, ,'Id.\ N .11Ul ST, STI 2111, I IilHRISflllln;, 1',\ 111111 ,i'; ILIII''i St',rkt'S 1111(1 SI'I'rjn ('iHh,'", --. ,. .-.. ._.-.-~'". ,-. ('o"lrollllllllhl'I' 'J'I.1.15.1t7111IWII " f{ F!IESmIAN ,\ I. 1l, I Sllh\~'qll{'nl !lfhllil;!! l'aH~ ((I(),Jt~') I Suh'ol'qUC'1I1 hi Il'J'jLd 1'111(' ((jCIL\:,) , I Sllh'~'-'qU{,lll IJO<;pitHll'dlT ((j{j.~J2) 1 SUhl;('quclIl hu<,piLtll'il1l' (.cN.?J2) n .j.:!E~n.~~ ~1('f1"'"I'I' _~lH""('d '\'1;1 !.~ 1:111;\' ',i". I,', 19'17 \,,\ 1\ If/I)? '-;'''. I'" I(Jln 'i'l\ 1'1, jq{>7 '1'111111 $ 'l1!,IIO '111,1111 '!II,IIII I 'l1!,11I1 $, lilll,CIO $ iltl \\ , !, Jf! ,. I ,lei', ~~ . l I I ,If I " , $ I ;'Tj' ,',; , . \1111 s: ,~__.._.-.i_____......... ~_'____'_.'---'-__""_ - ,-.....-----.~" .--------,.~-.--"--'".--~-...-._n._.~..~._~..__.....m~,...'.,~._ a -rbi>, information j~ being sent to your private illstlrl.'f, They willr('\'icw it' (0 see if ndditill/lul lJ('I\;' fils CHn he paitJ. Scn'd llny questions regi'll"lling Y(lllr ~tJpr'lcl1lel1tnlli{\l1l' fiL'i III thVIII, \fdlr privntc 11l!'illrcr is Your Supplcrnclllal ('()" 1,IIL' ilppro\"ed IlIllOUlll i~ hased Oil (he I'vc ',c1l\'dule, {;!'TIL\I.INr()R~IATJON ,\nOIlT ~'EII!('A\(E rill '.1';1',(\11 i'j here! Generally, ~leJIc:trl' will em'('/' \Jlh~ flu ~hot 10 prO{l'c( you through thc.)'f'ar'!, rlu seWiOl\; 1,1: '",ur h,'"lIh care p",vitlel' where.' "II eHn I:vl \'(illl fill ,hol, If 1'011 hlive Medicare Parlll, and YOllr p('(wider ",'" I'''' whal Medicare pay', thvll :\I "dkillT will pay for "OUl" fill ,hol. (",I a fill ,hol, "olllie fill, Y1Ill l'allproll'('( yourself 1'1'0111 ~(lI1l(' pnetllllollLI ill/(>Cl InllS hy ~('tllllg II Plll'UIllO('(\{'('HI vil('clnatlon, P;II[ Hj and your health care pnl\'hkr ,J(.'("cpt~ what :\1cdkltl"(~ pay,'i, thell t\1cdkalt' will pa,\' fur ,Villlr I\P"l!!llncflccal \',l(Tinatloll mil\' h(' illl Vtltl c\'n 1I('I_'d,..ilf-lk VPlII' dOdot, " , If 1'('" han' Mv<lll"",' \'ilcdnalinll, ()Il\' ~\..:,,, 1_1~0l, 1'"'1 lIn,~NT: Jfyoll hlll'e quesll,,"s ubout Ihl~ notk~, cull till' ~h'dlclll'll 1'''I'I'ln lit IInJtl'd 11I'"llh('nl'e IllS co. III Iclillli".1 \.445~ 01' see us 1I12143l'erlml'ter I'nl'lm"II)'. ""U"stll, 10.\ 3U9U9.4~7(" y"" w'" Ill"'" Ihll ""II",' II',nlll I 'Iutlll't Us, ,/,,, -'1'1" a/ ""I' dcclsllIll,YlIU IIIUsI wi'll. to lis I",flll'!' JUUI' ~4, I'IWI. i;I'I' #1 "" Ih~ IHu:k, - ~"!"'-",f!',., ~ J J U .~~ 11i___~~- lIf~~<V'''':';;~~"~' TillS IS NOT;\ BILL I '\plan:il iOJ) or Your Mcdi('(\)'(' Part B Benefit\;, 1 .d..l~,,-.nt~;l'.!.l\\: ,<,on-OOQ83814'V73\\H 3"U"O~ '06'N'2"NN"N"N IJ >1f'OICARE IJfd tod He., thC.re I no Co p,o, BOX 100118 f,UGU~TA, OA 30000-0900 r.~)iI:'''''.Mf'' ')Ullll1!IIYJ ~)ll,hl'lllll.llrt' 1!IIlt'(~ pet "~,I, \'1" W, XI: LI NF I YOCUM C,('9 B ~;T [ IlrlI,^ P^ 1702Ci\CO;> I (II ~tl (h;l I I","": Il'I,d \kdl~';ll(' d\'Pl'(\\'l'd: '~ (, " "I \ \ \\'l' paid Y')lIl l'I1l\i,kr: Ylllll" (111;11 l'1:<.,11l1l\<.,iI1ilit\,: \,'''"' ~1l'11l"""I' nllmh.... 1'1 WA.17H.1f,.ftlJ(,~ .-rr~ ~ 1l1'l1l1"'ut,,!!!!J!,ls nollel' (S!.~)he ""ck f"'X..!!ll":(,!nll'~""!!.'Il~n.l__,... YOIII' prClddl'1' n~'I'_l]~1y_~! 1I,ldglll\II'II1. ~ -~'!\'I"'-,"'Y1 1111 I.SI:II~1I1TE()Il\'1 \1 \:!il1l' addl('SS; I\SS()CI i\TEIl (,\ II. Ill<) I.(){ i1STS 1'( " KSII CI',NTliWI 1\1<. ';11' ,'Ill MIFIIANICSIIIII((" 1',\ I ill',:; 1l1l11" Sl'I'llct'~ HIHI St'rdl't.' ('otll''i (,;;;iir.Ji;";"~;li';rij7.1:1 (;:i'~.i:1 ~ till 1l0NALI> (' )WIWECI\ M,Il, \ Fchn e'(al1lllt' hl'illl ('n,"\{1'J'}(l Prnfcs<;jonal rhar~',(' I DuppleT cl.'hnl" ,\11\, hetll'! (q,t1:':O.2h Prnks'ilonal CllHl~~l' 1 Dnpph.'I' tll1m flow ((}:U1S-~(1 profcssil,}I1al LllalP,l' ..~,~~~Ill'~~ M(,til('lIl't, ..!~l'lll:o":(\ 'i,,\ II, I,,'n $ .1"',1111 $ (Ill , ';~~ ~;!,\ IlllJtn ~2.lj .Oll 27 .IS .',..\ H, It)tJ7 l?~..JJi.I Ill) Totnl $ (,I~ ,110 $ l) I ,~t; _....____~._.....___~__.~_._.~.L...__.~__.._~...._,~ ______~___r_<_+.,.__,__.~_......---".H_..._.......___<_H.~.._.__~_____ ~(nLSI a Thh ltlf\lrtnfltlnn hi heing St'nt lo YPllr private jnl,IIITr. They wi11IT-~'ic\Y n In ~ec If additional lwn\.'fit~ C:lIl he paid. send 1111,\' qllcstiolh r('~ardillg your suppknwlllallwl\eJits tn them. \ ,;]\1 1'11\';IIC In\l\lcr is Your (~'l)l'klll('nl,d ('()" h Th'_' :lI'Pro\'l'd nmounl is hW1Cd (In thL' fL'e ~("hvdtll(', (;I\IH\L '\r()H~l;\TI()N AIIOliT MEI)WAHf rll\ ~':'a\\lll i'l1cfl:l nt'nerally, i\,kdicull' will covcr {illl' fhl ...hut {(l protect Y(ltllhnHlgh the yC'ar'..:, fill ~eal\on, A'l YOUT health care pnwidcr whe I"l' YlItI ('[Ill t',l'l your flu shot. If you ha\J(.:' t'v1i.'dicarc Pari Bl Hnd yom provider "<'('''i'l', what Medicare pay', Ihen Medic,,,,, will 1"1) I'm )(tllr l1u shol. (lei a Jlu,hol. 11<1llhe flu, \'(\\1 i'all pro(l'ct ynursl'1f from \OIllC PIlL'\1IlH1llia infcctllll)S by getting a pnCUIIHH.'llCl'ol \'i\('cillatlo11, If you h\l\'c 1\1L'dinu(' 11.il! It, lllld ~'llllT lwalth carl' pl\lviLkl' ;ICL'l'ph wh:ll ~vlCi.lil'''ll' P;\ys, thell tvkdil'lI1'i.' will J!dY ill!' Yl1llr \Hl"cinatiull, (lne l"l'Iq")('l'II('('(l1 \'nl'dnllllnn Illil; Ill' all Y1lll ('\'VI' IIL'nl...""k Yllur dlH.:llII'. ~'..'l"~.",~ - ,~,~,".,",,~!\"i 1\11" 111,T,-\NT: 1I)'olllllwe qlll"tlollS "bonl Ihh nllllt'l!, 1'1,11 the Ml'llklln' ('''1'1'11'''1111'111'''<1 1"'alll1('III'(' III' CO, a\ liln",H.1.'.44~S Ill' SI'oIlS 111 27431'crlmelcr 1'lIrkwlI)'"\ugllq,,, loA 3119119.4~7(', YIIII 11111 IH,,'(1 lid, II nil I'" :r .\')11 ~'llllli" I liS. '1'" "\'1'"'" ' "'slon, ~'nu InU,t wI'111'Io liS h.,r".., .I,,,,,' ~,1, I'I'IH, S"e /12 011 tlH,I""'h, ,,'(' '\; ,i ,.~, 1\1'1,)\\ I, I, "!'l,c;tH. _lJ. __~VI 1FM.W,~~-"=' TillS IS NOT A BILL I ':Xpl:lll:llion (II' 'Your Mediclll'l' Pal'( B Bellerit,; :";047'00083al0-a7a50'~c t "Ol'O~' N'" NN N' N 11 Mr.nlCARE IJnl tvd He.lthc.r.. Ino Co, P,O. 60X 100118 AUOIJHA, 111\ 309UY"09g9 ~:~~~". - ~~,/'i~',.j'~'",";;"~ ~\:' ~;11l1l11l1l.1) 011111., IIl1lh'I' 1IlII1'd llt,{ ,~I, I'}"" r~ 'I^XI LlI~[ Z YOCIIM (;(1',1 n ~iT I HOI^ P^ 1702[, I GO~ 111\ ,11 \ 1\:11 I'L ' \1,(;11 '1,'dic.!I\' ,q111lil\\d; " \\'(' pdid ~'illll Pl(l\idl'!': "(lur lld:d /l"'lI1Hldhilil.\': ,~ , ""ur Mrdlcnrl' nnmb"" h: W,\.17H.II,,(,'J(,~ \,(JIII' 1,,'o\'ldt'f IlITt'.ph'" U~i.IjII~n"H'1I1. ..... iT] ~,,~1PM"1 lfW'Il__... Iklnll, ntJf~!I.'-!hI~-'!.!ltle~ jSee t.I!e._~ll.c!, rOl,~I!!!)~!UI~~l.'~Il,,\t.I(,.n)..__ ..... 1111 , Sl !IIMlTTEU II": CRI,MA Y I'AR NI'S i\SSI )(,1/\1,/,; I ~j(', \1 ,ii,,,!, ilddl('''! 1041'RFORIlI(()i\IJ, CAMI' 1111.1., 1'.\ 111111 .._...~,~ _. "___._., H'.__'~.. . ..__.__~~"",...""._~'"_..___.. I>alt.\ Ml'llll'HI'I' .n!\lljlEo.v/~il :'i!:\~!<:.I:~.!!,,~_S.'~I'\I,'~.( '0,1," COlllt'ollllllnlH'I' ')7,1,1;;..16.1%1111 IIEHIlI<:RT M l'tI!lNES ~I.(), I ()fficc/oUlP~llicl1l \i~ll. cst (I)())L\) ~,..J:.!~!.~!:l~ ~~ 1)" \ I, 1""7 $ \1.:',\ $ ,1,1,,\1 "()'ITS: - _'.n......_....:.... _._~."......n_..~"'.._.".,_._..,_.~__ __-.----i_._..n_.......-----.+-4-........_._.~_.___,,, il lhi" Informal Ion is bclng Sl'111 hI ynm print!l' llhurn. They will review It to see if dddilioila I lp'ndit!\ call he Pilid, SL'ndany qUl'qjotls n:gilldlllg Y(IlH suppll'llwlltal hencl'lt!\ to U\elli, )",1([1' private insurCl' h. 'Vnur SuppknWl1lal ('()" 1\ 1 ,II(' ;q\pwved illlWUllt is tlH: pJ'ovidcl''s Helll,lI rhan't' 1'\11' this sv.l'\'lre, (:1-:\1:11 \1. INH1RMATION 1\1\(111'1' ~IE(}(('''HF. II" ",'aSOH II horc! GClIcrnlly, MedicHre will ((<I'or "Ill' flu Sholloprol"cl Ytllllhrough Ih" year" fill ,CHwn, Ad: .\"i11I' Iwalth earc'pnwldcl' \\'Iwl'l~ ynu cnll grl your flu ..hnt. If you huv;; Medlcare Pmt D, and Y(iUr j1Hl\'idrr 'I' "1'1', II'IIal rvkdic,"(' p"y', Ih"11 tvll'dic,"c' lI'illl'"I' 1'''1 YOllr flu ',h,,!. (it'I" 1"111.\1",1, 111>1 the flu, y (llf (',1,11 protect yourself fWTll sOllle Pill..' 1I11HH\ia Infect inns by gt'lling 11 pneumococcal \,(lc:t'lnatin!l, If you haw Mrdk,IH ['ill I II, ,,"d your health carl' pr"videl (jeceplS II'lwl MdicH,C p"Yh, then Mcdicnre will p"y flll YC)UI vH(Tinaliou, One Pllf'llIlHH.'o{'ca! v(1('cinaliol1 milY he all you e\'C!' IH'l'd",a;k youI' doctor. ..~.. - l\lI'OIlTANT: Jryou ha\'e q\l~stlllns nblllll Ihlh ntlllet'. ('all th" Mt'dklll'C ('111'1'1,,1' "lll1lh'lllh'nlthflll'(' la, co, ill 1.~:illI.K.1,H4~~ nr see liS 01 274.1l'rrlmder 1'11I'kwn)', Augustn, (;..\ ]119119.4;;76, \'lIn wlllllt,,'d Ihl, ulltlcl' If,'ou "JIIlnd liS, 'I'll "11(1(,,11 (1111' dl'clsl(Jn,~'fllI1UuNt \fI'Ue to U~ Iwful't, JIlIll' 2.1, JlJ(JK, St'(, #2 flll lilt, lind" , " ~_: l"; .. )~l II ., I, ~ " "!,.W ,,*fo~ .I..;t;[ \Idf" !!d'l\\ " 10 !lIIfrtr.~'i'fi.) ,.i.~ tal "'1.1W.~t':"'1!'11"1"'-' TillS IS NOT A HiLl I ':xplan:ttioJ) or Y (HII Medicare Part B BCIH.'lll:, 24141-00053377-88007' 1.8-01.02'N.1NNN'~ lJ MEPICARE United He.l~hC.re Ins Co, P,O, BOX 10086 AUQUSTA, GA 30999-0999 h... 7''IMo~~<liitl'ti{if !,-I"'I SlIlIllllllr.\ of lllb nl.tl_lyS II i,1Il,1I .Idli 11 MAXIl I Nf. l YOCUM {;08 n s'r U.IOLA PA 1702G 1 (,(1',1 Ipl:d ('h;III'~'i,' -I (1[;d ~lt-dil-;IH' i1PPIP"'t'd' \\\' ILd!! \'1111 [11(1\ ill,'I: ';lllll InLd Il'<'11\lIl".jl1ilil\: ''-, ~1!l.!:.:<,r,,'J._p Yllur Ml'lll(',"'(' I1l1mh(',' ISI Wi\.17N.Il,.6'U,:< YOIlI' 111'0\ Illt'l' ,IILI.~~~~J!,~l.'_~! II"" Ig !\\I1I' 1\ i 1 ~~''--tH4I' ~1ftlf~\';~:1'"!~~~ 1)1'11111~.~,IJ".~I!!1.1!l..!'!!Uee (See !11~!l.!'.~J'!I:.mUl'l:.I'~I(~I,:m~.II11I1.'_,I_ 1111,1. SI!IIMI,["l'EIlIIY, ASSOCI ^ TI'I> (',\ IW!Cl!.O( ",STS 1'( , \hllil1gaddrt,,,: H:;(,CENTl'I(Y 1>1(, MI't'IIi\NWSI\l! 1((;, 1',1 !711\". nllll'\; S'~nlccs """ SI'I'\ln' ('11"1" (:;;"I~;j';;iill'I;I,i' '17:\\N.j,,'1411111 KENNETIl .J ~1.\ \' ~1.Il, Illlitial inpatient l\l1\SUlt (i.Jl}:'~"I) 1 Subsequent Iitl'l'ital "a,e (')!I:I I) I Suhs.equent hll<;pil<111.'i1tl'-(IN2,\2) t Suhsequent hospital ('lilT' (IN.~.12) ",(~I\I~:!ll: '\h'dkJlI'l' .__;~~_PlIIY\ !"l '''(IV 14,1997 ~-;\ IV IS, \lN7 ~~\j\' 1 (1, \()(J7 '--in\' 17,1'}(i7 $ !~O.(HI $ I pi \ <I0,llll .\1. ;iO,IlO '1(, I HUll! I ,1(, ;:"" $' ,"iii-:-im '; :>1,\ ,(i \ Tllln\ N()'l'I''s, 11 This lnfoflllaticln Is heing sCllllo your I'liVilll' Insurer, TlIr)' willlTview it to SO{! if nddithllHil IH'l\l'Ht.\ CfllI he paid. Send nny question'. l'\T,mdlllg your suppknwntnllll'udits'tllll1l,,\lll. \'\\\11' private il1~lIt'n i" Your SUppkl1H-'lllid CO.. I. The IlI'I'r<1\'('d ant'lI'"1 '" liasl'd l\n I lie Ie., .,,,Ii,,,lulc, CINER\I, INFORMATION A!lOlIT MElllCAl(F '-','w Y,,"r, Mllre Medkare Benefits! ~It'l!kan' I"", added benefils.ll\ liell' yon slny he:dlliy, These h"'Il'f1ls 'l<IIV indud, nil andpl1t'UmOl'll(:('al shlll~ (Ml'dil'iUt' pay" lOll",); pap :o.llll'HfS; induding pelvic (Ill(! hrl'llsl exam and yearly nWillIll!li'" i 11\1 Pmt n deductible); and colt\rectal (.',111(,(,1' sn{,~~l1jllg Talk 1<' YOllr dOl'lnl' 11losl'c if thl'se-lH'nefiIS llredvhl fili \,,>11. Even nlllrc Mcdic1\n' hcndit<, will be ;i\'idlahk hq'lnning ,hil,~' \, l()(}~t Lllllk for IlHlI(' 11110I'm\\tlol1, You CUll protectyolU'fil'lf hum .';Oll1l' plH'lIlll11llid 1 Jfcdillll'i hy gl.uing a PIH'UlllnCll('('HI \'llL'l'inatloll, If you have \1",[\, Part B, and Y(lUr h~(llth earl' prn\'idcr arl'('pL.; Wh,llt\tcdicarc pnysllhcll i\kdicllll' ,\ill pilY [(11' your \,IH;r111utillll, (1m 1'Ill"ul\I(l~'ill.'('(d \':lnillalitlll111ay Ill' all Yl\\ll'\'rl' lle~'lL" .Isl, your dudlli, ,.ill', J" \ ;\L 1IiI,1Q:I ._~,~'1,~iW/"1i'Jl 1\1 i'ORTAN1': If~"u hu\'(' (IUtsllons ub"ul this UOI"'l', lull thl' M"lllt'lll'l' 1'11,.,.11'1' III IiIlill.,lll""lthl'llI'" Ill' ('(). "' I ~:!III.N.\.\.44~5 '"' sill' us ul274.\ "l'rlml'lrI' I',"'k\lll)', ,IIl,~"stu, (i.1 ,(II~(I'1,4!17(" y"" \1111 Ill"'" this "0111'<' If ,\'1111 ('(lIllnet us, T.. ullr!'ul Ollr d,d,llln, ~f1lll11llst WI'IIl' III 'IS 1ll'I'IIrt' .1111)' (17, I'I'IN, S('l' In Oil (Ill' ""..I;, 'f;;i"hh~t4tM - ;"'li)u-n~If)27Wn '''''O~1~4'8;'01cfn'N' 1~N." .N'N (1 Hi()l(;A~[ !I, Il(1(J ..., t.hCil'~" I 'Hi! Co. il "OK 1006tl li'.H.lI!Sr". GA 30'nl.~()IHUl . " - ~~~ilt;','J';}" ~,~~~~ T THIS IS NOT;\ BiLl Explalliltjol1 or )/0111 Medicare Pm"t B lkllclil .~~_.I~;l\i.'\'., i ~lIll1lHlln ufthb 1I1111t.'t, IllllI'1I ,1'111 ,I ---......,--..,.-....."'.,.,. ..- lei I,I,\Xfll/.lF Z YOCUM I;!\q n '51 I ,"'iiA I'^ 1702[/-,1602 Tntal dldl.l'.l'.\: l'!ddll\lnlit'.Hc ,qqllll\'\'d, ;. We l'iH'I','lIul lltU\ id..'r, YIIUl[lll,,I n:"I'(I!l"il.dil\ \"111' Mcdlc~l'~ nllmher ISI \V1\.17H.I~.(,'I65 \'''111' 1"'''1 Idl'l' ,\t"'ll,"'II ""II'"'''''' ~;~; "IH)!.t j"l~;~i(l'tlce (S~i' the b~k rOf mOf,'lnl'o"lll11tlop.) ' , "W' ilf "._"",<>,d ,'-..", .'"'...........-~--~...........---_.,._--,-_...~......._....~.,.__.~~-.~._,~-_....,... .....- "~.... -,...._-.-.--,---_.-..-,,,,. ..,... Hili ',III<\1fTlEt.l In. Mt\lIRLI'.N 1I1{EN~t\N-II'Iit\VI';I( ()1'~1. ,I"~ ""'.hlies;: 1<'1' llcl\ SII~IMLI(l)I\I[ I'IA/.I\. ENOl.;\. 1'1\ 1711,~.\ liilJtI lniif, l(ill(f St'M'ltt's IInd StllTl1't' ('odtlS . . i-:;;;rt;;;r;,ii;;;t)(;;:ijj,I.\H',iiiiil'l'lIIl1 MAl'nEEN IIIn:NN^N,\\'EA\'Elllll'~1 I Dehride ;"fed",1 ski" (11111111) I Snal'i"gllll-Sllilds(II'lIO-.\IOH) I Snill'illl' "I' addi, ;"",d Ilails (11711 ,510H) '('"I Ii I " ...UI_llm'~ i'-l{'i1II'ili'l _.;\1'1"'''' ('II I hilL'; $ ~\, 1111 'f.: "j'- 1.1.110 , \ ,{Ij! , H,IHI i ,-~\ Ih\ ~ (,("lI(I $ !i,1 ,"d" II "I n.~. _.._...._~_~_~.~.___... "..n.."'"_.., -..-.,.. ... ""...-.. ....._.___.~.~_.__._...~._.~_~ m_..'~u<'."_^_'__,,,,___,_~~____..__,," l!li 'lvin' IS CJuhlCl't to a I L'dUl'1Itln ur~ht' papw.'llt HlIHlunL Tht' teduttlnu is \{l percoll!. I.lli!', 1'1\ :I\IUl'lilatill~llt\ lwing sellt lp Y(lur private InSI1Il',I', TIH'y\\'illl'l~vicw lll~l M'll if Hddilh)nHI lit', cilHlll' paid, Sl'l\d nllY (!I1l",linl1(, ll'gilrding youI' ,'~\Ipplcnwn.l"II}{'"dil~ ttllhl-'lll. I" il'n'" illstl.n j, 1'0111' Supplell"'lIlal CO.. Iii ;lppw\'rd !l111011lll is hll"cd 11111111.' kl' sthl'dulc, Ii 1-'1 pptllVi'd ,1IlWtlllt j<; thl' pro\'idcr\ actual c!llll'f!(' Iln lhi'l ~cr\'kc, (,1 '\! II"/' 1;\1'(JH~IAT'(lN AIIOli!, ~IEDll'Alll: 'c,,, Yn,. \I"r[' Medicare Ill'lI",ils! \l,'di,'iI(,(' h", ad,blltcndil,\ (II help YOII SillY h"lIllhy, The'" l>t'ndl...,,,,\\' iwllid Illl ;~~:d IIl\CUlllllrlltTUI ~hlltf.;, (t\I('dl(,i1I'C pil~"\ IfIO"i'l; papSmClll"S; includiug pdvic lIlld tl\l'llq exam nnd ycall~,lti;lriiP." f ii. I';;r t.li dnIUl'tihlc); fllld l'olllll'l'ldl t'IHl('CI ~cll'(lIillg, TlIl~ to YIIUl' dO('lllf 10 h{,(~ If thl'<.,ulwllcfils iiI(' I i,:~ht 1111 \':"; ! \"li Illfll(: M\'dil'ill(~ hcndit...willlw itvidlitbll' hqdnl1lng.luly l, 1<'1),1.\ I,('.(I~: 1'111' mol'(' inftHlll.'lli(lIl. ! 'l!' III I'ltl!(,'vl \'(1Ul"i('lf flllm sOllle IHll'lIllltilll" illfcl'ljoll.~ by ~{'ltjll,~ a 11Ili'IIIII!1\,(Jt'l'HI \'ill'c'inatilll\, If Vill.l h<l\'t i',,\;.;l( l' ! I 111<.1 \11\11 Ill'illlh ran' IH'l'rldl'l !H'Cql\'. whdl ~tl'dili\IT PilY~. Iht'lll\kdl(',II\' will J1:(~ lor Y{llll ~'dc.'dfldlilll1. ()I\ -.... "","'r .1~m--Mi;'J;;'-,;,-" 1.\1"11111.\:'<'1': If)uu hllve qllf~tl(l"s 111"'''1 th'. 'IlIlk,', ,,"11 the Mf.III'IH'r 1'1I1'1'lrl'1I1 t:1I111'llltl'lIllIll'III'1' '"' (0 ill 1\:<" '; , ',1,1~5 or .~t 118 111274.\ I'~rhuvh'r ,,".'klm)', AUlllldll, (iAJ0911~"4571" \'(111 ullluvvd 1111. U(ltl,,~ If ,\tll.I ""lilac' us. '\.. ;1;'1'1,,,1 'HIl' d,'d_h,n, )'f111 mil.. Ilfll. 10 ", 'H'!',,!,I' Jul)' 27, IIJ9~. S"I' If~ ,,,,Iht' Itllt'l" i".' ,~ '';:f,ij\!-'Jjl..-A-U.. I ,<-'t~\(l11 J ',': If I 1:""1>1 - -~ -{II :l.i rJ, ltl NN U 0 'W. ..4,_~.~\W'r'!~~'-'''-' '1,'1 i ~.I...' I,'.'~ 1\'1 )"," <. ~'i'; . " ,I \ ~ '. ,t 1,'., . t,'I i llt:,d tht"t'~ 1l\1~ l:n (\~,i)' i (1nett U\, tlA .JO09f4-0U~O 1;,;.;pl:\l1;\I il)11 or Yl li! IVledh'arl' Pad B Ikll(1 _ _~ ...._,,~I'IfIft;l\llf>, 'I, ":'.f,~!~ ~- i J"it ,-' VI)UI!ll 'I \ r'li 17u~:G I (;f):~ \"""""".' ,,111,1, ,,,<ill\' Ii,,, 1'1'''1 "'11,1" 1 r l'tI :\ \'" I,f II ' ;Q'11I l'\ I 1\\ ( I"', \( I ~, Ii r l't (\'. i,l, I : 'jYl"<1 1'1\,d i',: 'IH,wil,:III\ _~7"_>>'___ ,. ~'fl'N:"i." "I \'~dil'urc 11111111"'1' is: WA,17H.l(,.(,~(,~ '", -,__:'W:'i~~..~ . I h!:i.,I!~!.L~!: .\c~!:.!\l!'l!l!!:"-l~n'.e,~ '!(I'I:I'I :\U~III,i. ''''111''1'1111\\': l!1'1'()\\'f'\ /lIU>I()I.(I(,\, NI',()(, ,,,;,,'''' '.III()W~ll'I.Y:'-l:,IIW\', /'~III' \ iIlIS();' 1.\, 1';\ 1',"11 \'0111' 'll'/Itllh'" j.'~'l~~~tl:l:~ I\'".,ii'.'\!" ~~ ~ ~ .., 1 ~ _ it .~. n 1.11l:.!(r,.;" !\Ii!\ " 0,'\~'~ tl'~'~~ 1,1!,I(1 SI,~1'\ leI' ('~~~Il'~ Clllll....llIlIII1hl'l' '11W711,11l12YIU; llOIlEHT 1l,\HI ):" 11'1" ~I.l', 'I EkltnwludllfLllll rrl'ol.t (O\\llll~ _~:~llIl:W' ,'\ P,;lI " i :'\"1110 't Hi ~,,,"~_.,__....,..__,..,. _ . .. '''''_'T' ...___....~__.,..~.....~~.H~ -- _._-~"_.._~'"',.. i" I "'. 1 illtlu\lllt i~ hW,l~d (Jill Ill' h.'t, ~c1n'd\lk" 'C>iF\lIlM,\'I'ION 1\1101 "I' ~lEnf(',\ln~ Y""I"'Y, I(q,ort Mt'diclln frllud by rallilll', I ,~II().4'II,H477, 1\ Ii ""1\111 pI<' 1\1 r,..llId would k d,"lIl', yn\l did Hol P:\'l:i\'I~, If yml havf' nn\' othel qUlJslilln~ n!JIHII )'lIi1l I,\:tlm, I'lt'H';l~ cnlllaul'thc' fdrdl' ;' f..-' k \lh{~'lC 1\\II\1hl'l !\hn\\ n 1.111 t hl~ liD! icf', ~ ',I"'f\.' M~'di('i\I'C Jklll'Ii(-~~ M~'dkl\IC ha~ lldch'd ll~~lldil5 III help ~;(!U; L\)' hl'(~ltlh' Tlll'-~,(' \Wlldil lit" 'l"~hll-(\('CHI :ll\{d'~ (~1l'dl{,IHl.' pup IOO':~-Ji r;~r ."lllr.Ji'!i; including p~:\ k Hud \ll't'l\!;t IL\,\\lI nwl ye"d I)'il H ih',hrrli\llt-l; lint! CIllnl'l.'I,.:!ul lllmTr S~ l'lTnill!\, Tol~ t(l YOUI' dildOI' 1'1 ',('I' lllhl'lil h(ltu-flls rd~l'i (,'hI I'd ',PH'! f,h',dklfll' \t{~lld\{<. wllllH' Il\;dL\bL-I"'giunillg.Julylj l{)IIH, I.llil'k (OJ llHHt) luffll Hlj\di11l, -.,',1....' - - M!h-lLo{'~'Ji.'"",;"~~, iT'll .lOll hilI.' '1111',1111'" ,,1"'lIt thl- ,,,,ll~('. \'olll,hl' ~l~dirlll'I'I'I"" I"r III \!"II~,' 111,,,"1"'1110 ill' i 'I i,l~~ 01' bee IIW 11ll7-l.\ I'el'lllll'ln 1'lIrkwlIY, ,\IIII1.Ia, Ii" ;\1I~U~.,1~7(" \ 111111111111'1,,1 thl\ ,,"111'1 11 " 'II ~lI11ta(:' "8. 'I P 'll'pl'ul n1"'th'didHH. ~-ntlIIlIlS" \Hlhl tit US 11I,!I'UI'(l Nm'ember 14, 19')8. Sl't' #l.. IItl thl' hi\t'k, )tj,'H' ,,~I\ Ii.; \",1 _;\lllhll~ \ I ' "Hi;/If, ",mil, ftl'11!:!IIIHHh'I.1i nlwW'~III1IL\('III'II" SI'WIIIlI' (L\\I~ '\ I'll\! J;,\1! i,I'\11 I ilt;~n : lIL'(l hU11 flnl} HIIII 11\1111 !iFII 111111 i l!i'tUUI;, It<U,WIR 1 \l\I\\Hilll'N/\<)~\ll ,I \h',(,lllll'RllllOll il,l.,~ \~ 1 1'lt}1l1l1 j.'I,H\III\lltdl' 'lH\lH,'rW~,\\ltl~' 1.11 !I!' .. \ I"HI t"dl.dn-\'"I !_\\_'"_'_I1' I ,\ !<J1l11 IINI II'I,"!! I !','\ 1 I' !,I HI 1II,HlUl II,follllj til,M'-1 ,1,\,,;: \111 i' j' ,jl f_\\.;r I i"~ L',.!l.q,\',\-. II''.!! \I,fdlli, U';'lt('h ! 1,(1 ~,~ 11.\111.,.....,111 ,j' III,\!I',;\( 'Ilil; Pc';;tUl-llil'! , 1'\1\1'1'1(\ NI,.'."N ,I, I"\I\'~,LIIU 11\1' ""111 S il\1 \'\1, 11\ I ,Iii', 11'1 " ,\1,\1\ I IIHIlII"I)I\,NI'LI 1''\ 1'\\'1,11": i ,III,IN, \'111' "II I RlfR\WARUr 11111 11111'''11\11 I'HI \1111 ',I.: 1'1 jH~ I 1\-\1 \~H I I'"INI', \\1."1'111111'; 1'11\1,'11 1'1 llN'1 t; Ill'!lIl'.\ll-\lI[II~ l'110lill 1III,\ll'lllhl{; ,-'" Fi"';-;'-'~ fi!'.' ," "._of_r.'_' ,\fl\ll;'_ dl'>t\,\,i'j,,/oIUj-'!!1 \- ',.~ 1 !II" (,llll'I[ I ',., _ fnll Ihl \-, I, oj/f~ 'J ,_,;;""'.......,....,'_...,C..Q"I.......i''''''~_...........~-~.''.'n..'''''--.._E,---t,..,,_.."'~.,;r...;..'..~","'...- ';'p;; h1.'l,1H1'.1l Irq.\1 li""H1AII\"\'IN 1,,\\\Il-\m-L :,\Uil\II:I.l'J!1I11,;n 1\'\\'\11."1.111111''-\ l.:l\l'IJlfli!/l !(lIUIIIIJH-1 .l(\{IHI. ' \lllllf"';\I,\\I\',VI\I'1 1.11,\11- .,i;', I ",llllO \ I.,~ml i IM,ln~ 1_ 'J,J,llill U{ILVIU \ Ul \) 'ji H1111Mlln'11,~,j \ HflII~:~lImH ,II '1'11'1'" ~1'\"\I,\11I' i'i;':! t'-\lt , !H~iT!lIJ'l(l:tlll"'l!nl{ \)I.IIoI('71:\'Mnl\:i:\/1l J.II(,'^7i'.\'^" ~,\\ \/1' ('I7IJi'.\\'S,vo'/II'('II. "j-\-I \-'i , \lVi'! " \!II "."'7 ijlt\f) t'il \,\1111.;' I(VI f ~1,,,1I1111_ I ~,r\tI:"H lit IH lll";( HlJ' lIu~; , ; I'''''''';'' I HiliiH\ ! .I1J'J- \ \('1'!' ..... '. .c' .~ ~ ,{Hi i.. " Ifll\lllj('Ajln,\llIn\71~U(ll\N{)II\ P;\ \.11.11'\1('.11'11'\1.111111111'''\11''11' ,I "A CI\I'.Il\1 I',I\'I"'NI .'IIlANI', \1111 L\II,II.I' ~.-4 , \ (II." ((', LJ "1 b~'\) I) 1,1,1,1 <. ......+.. "'<i (I',(\. .. III\!WKKU~ litH "1,11' ^,1Il~ l'IlI,I'\I'lIS )'1 <IN"\' ",\I INl I' I'(mil \ I',IRNI'I\ 11m: 1'1'1\1, 'I' 1"'I''iI,':RI'IJHhW'1.J 1111\ 1'1'.1\\1111 '1"1':\1, I"'IN'I S " IJ; 1\ , \.1 'WI; I ",,, 1 ['IIIH'H\..t ;,11.1:1; ,\Nl1AllllJSIMitllf.: "",... . ( ..':11 MJ\'A.'-K-r.~ \:'-'i~iN",\'Nt ,t.~fii^"UI':~1 "n,1 "',,' '1',\\'/III./'lIS'i\~Ui I N.JW lhl, ,-\,-," l'~r\JII'l ~ il. Ill. . CAPITAL SELF STORAGE CONTnOL INFOF1MATION 1llI'II(1!\I'li 1 IlHIVI ! W.l\A, "1\ l!n~,r, UHI', /I 7';lI~'IJBStj' tH /.11';\1'1,\1 jl ""',\'4: 1\\ \IU(",l" ,,''''', U(r~()lJ ([}III llr( t(f(l.\ f,... l~aL~ h"' l', WI I) . At II HNA' I "I' ,),,)1 W.>i,..li~f. ILLI ill) 'JJ,~.1 HI, 1<,\"11 0-1 J ~ 1>1"\" II"; IIcrNSI: N(I,nllL,,;j'J,~1) 'ft! ,<,~, ':. CAllI} IH) IlAIl ({'f'll)',,\' "f'lll .~ ~> Ii/II' 1"1<,, C ~"" ", \ \ /,.\,.\1 n ',\(~ll n l\'t!lll^1 I d' t '. ,)0) ,I,)" \ I;i 1 nl At $ , /'- ^IIUvr. p^ 'nu HI! " !I Mon 11111(11 I ill (,,)itl '~I ' ., .') (_.\(., l"I'~_h' Ii ,,~'.:'::.(/j ~ " ,"P'0'~:~~::/':\ ~ i .,f 'i {- J (d<ilH) " ..' I H'.~~ p...nt P^Y't __._n_<_' ", A.DVAtICF pfo.'(MCNl Mil' "H'ClJl1ll'i tlfl'OQrl \,,,,: Ill"'I.', I",..! I!J,,-" , I, ., ~ .- ........=.~_.~.,_..~.----.~~-_.....- =::::.. It,iipORl'ANi' ::::,:: ..: ........ ..___....n.... fi OcellI'''''' '"lltl rwllfy C"p1t1l1S81f f11orflUfIIll\ WllHl\~j I'" adv.m:u of lhellHl1Ihutlcm dat.U occuplllnllnlfl(IlU \1' i,!( ,...ad lu.nll.... Ihll tnl1nhlaHon (\"\01"1 Ill" l/l'll <In{ 0.1 W;' I Cllpllill !i.,l1 ~;lnlflqn Villi 1H\lnrrn fl dl'uqll (>1 ~ HI rfl 1'1 p!l.I'Iifln Ihfj plllpfl/ Ifln f1av W[l\\1l1l nnlWfl ^'IJ flllllllllurpliffHllill,nflll/'llll1'(IUllllillll ';I, 11i );(1 ';r,'" ;Hld!fl~,S prl1vldn!l t'v {){{UPHIlI UO;II\lfllll 111'1';1 II"!'!\' ~\h'llIqll ill 1'I111lfl'l ('\ 1111" dHlIhJrI 1)\ all<ll/l';" w'!hlll 11lI' Ii d\"fl\jll 1\ LlcLUpilnl hHf'll'ij\l\ dlJ\I'I~;I\~' "/llll Ci\I~11I1 :illll (;!(,lil'.j'l ii", ' $ ,_:,:~l" (I) !) H' ll(l hnld MI ..nr:\I;ily 1'.110111 r(Hlf"';!' nil 'IIn \lUll!'; (Illl\i'; I\q!fI(1fllfllll I hlri 'jllln rflpti"l'\nnl', 1\ \\,:', Li crud (Inp()~;ll HOI'" rll!lFilfll t~l\, "I" (Ii,! \i~';' I' ,""VIMIII. It!. (ill' nil \III! 1111'1 Uf\tU ,.nnln,<<OI\ nl'Jtll1' ; -~, .,.._.--~~_.--~.- ..-._""..-~..,,-~_.._- ~,-~..........------~-_..--.__.~~.-.~~.. \ \ 1\111 L111llWir\q IfI R 8IilTl!1\llfy pOflion (II \1\\1 ImIlP; ,U',d '_(llldl\I<I!\', /llthl!1 h.tllll/'lllfllll I All ".ym.t1t chlekllf' to b. d,,,wn to C..pll.' OftU 91(""08 'Illd ""flt H,l C.plt.' Selt Storlger 10 Pro'plcl UrlVO, (nolll, flA ,w~!\. !\II \11(1\11I1". liUJ 10 bo lTlIUlft \0 P III 1~1;~.8"!1!-' ,I 'i\\"lItl ~iflll Slmlga C:llHln't 1f'!l1I16'H:fl 011 \l1\t builthj \'.j (illli' ()I;CIlPI\f\\fl ;,1 ",II,,\'.1llh\,,1n tholf own in!lllf~l\efll()lllll\ 11Ioporly ~;l, Hill 1 jl\ UHlIOi'I'\ud p,l1fl\if\tHI ,I I _npllltl Sftlt SIO'&Qfl i\'l not ,~~pOIH\lhl{lI(l1 \tlflll. IiIIlHIHh'lHl or nHHH hpln oj l11"Tl.~ \0 ""I pmperty ftlOf6d 1\1 1M I~M"d prfHT11'ltHl rn.rUf_,."t 'I .....ktd to ",ak' f.n,.l p.yn'''1tl on or b.farl thl IIr., dfty M MDt. month, C.pK.IS.lf 8.0,.g. will ."tort;. · h" r~I\"'~" of 'S.oo tOf p.ym'n'l not m.d. hy tha fifth day ot~h. !Ml11UL ~_".__......~m _.~__"._____~~_.______.-_u.--..--.-----~ ..____._._.__H......~--.--_V..-~ __..~-_J'~" ,-_. \ lil," A'Jr\U;,Mf..NT, n\8(Kt fhi) (;,1 t. .f!.,) (lRY 01 I ' -'I \q w 11\'Jf~rn Arl(! > C.-C). (~!L /11' It' / ,f I, RENTAL AGREEMENT ." /) f:t.() , ,''1'/:1 blll....ftfl!\ (~^PH^\. nfl! ~_11nnA(1L bWin!\:)!;" :"111';11 ... :N[S~;ETl1, IhaIOWNUI,lon' h,,,,,I,y """. ",,10 CJI:CII"AN' a,,<I OCCIJf'AI, I <I"", ''''''''''1 1..,1'''' '"'''' c>wnr, 11 ", ""'I( "1'''''' "I', f I" ,.:.-.' ',,<I ( .' i" Ill' II I~, ~ ['''''1'''''1 U"," , E"..Ii<, I'A \ /O,!", I""""all'." 101",",<1 I., aJ '"'' 11""""'""" "" !I,fI ,,,"" 01 0111 1,1' ,Ii'" 4" 'I, <I'V'" :/.<. C, ,\ "? f;'. .,,,1 01\""'11 0" 1110 ,~//"I' i:I<11 01 $ ,)/, ' .} t, 1/1/'11 l\ I,,,,,..hy ..know,.dy'" ",oolpi 0' H'" """ "I' ,)1... ,If,", no pily,,,o,,'I,,' :1', <Ial" "I II'" "",nil' "I 'I', "1""'"'' ,o""lh' ,,,,,,.1, !I,o """ ,,' $_"-" a'.I 1110 ,,,,,I ,,,o,,'h' ,,,,,'n' a"'1 1I"'~!lln (If : --.~/): (' -t;", ;1" ,\ i,,,r!',' I linn AL: OCCUP^NT .h.lI ~,y os '0,,101 1m Iho ~'o",I..o Iho 'UIII 01 f j t, I) . 'I' ' ",,",H,ly, ON OR lIErOllF 1111 ,. ii' I , 'ACIl MOH1H lI"aughoul Ih. I.,m 0\ Ihl. ^g,..rnonl M ,.nls rec.'v.d hy OWNE~ .1\'" Ih.1i lh <I.y ", ".C\I monlh Willi'" ,,01<\'"'''' 0'1'''''1'' ,,/ IIv. (f5.001 dOli.'., ^II ch.ck. r.,"rnod to OWNrR hy Iho ".nk 100Io,"I1Ic1"ol 1\11,,1, 0' ""y 01111\1 ,,,..,,n will.' ""\I" In " III<'''!', ,!. ,,1\1"11" Chock. .Muld bo mod. poy.hl.IO CM'IT^L SELf' 9TOR^Or: ."d 9.nllo \0 1'",'po<;I,v" 11"''', [',mill, I'A '/O?', lll1\1l..' I'" , f"IUl1dl\hll't :' 101M AHD IlIHEW^L: ^"h..nd"' \1\. ItlnO ,poelllod ohov., Ihlft ^lIf..mool,hnll 1\" o",\"d,,(\ ""1<>""III",,lIy 10'"1''''''''' "I nlil' !," ,I(! "",,, MlltHlHo MONTl1w\lh ..d, rnnnwol h.loy ,ubl.,IIO ItIn IOlll,"ollh" ^g,..me,,' 1'"",",,<1, howo,m, "'" ,onl.1 ,"'" ""'1,,,11"" pao',,''''} , ,'''''''jlI \lIHII\ Ih,rly (301 d.y. w,ll\en oo\le"'o OGCIJP^N10011 al \I,,, ,,'pi,.IIOO ol.ueh I""'Y POI ""y 1'011'''' I"" ,,"w ","l ill ,,,III "'"," ","'''''''' ," i, I' ','11 h \t III in thll AR'''ltment, \ HnMIHAll0H: Ellh.. OWNER 0' OCCUPANT ,,\I'y lur",'o,,'.II'" 1111'0.",.."1 "'I '1""''1'"'' """" I',,"y""' 1101 ""y"w"o"" "",,,,, .,,' , \ ",.. """"""""'011 wt;ch .".11 o"'y he 0" ,",, 1".1 d,lv 01 ""y ".'ood.,,",,"'h r.llo," 10 p,ovld. II0UO." .Im.uld Ih.1\ r..,,1I In. ''''''J'' ,,' ,," tlolh'" (j/,(,I.I/ 11'1 , tllllnilHllH!f If)\ni!!id III d') ,I III~CE88 CAIlD: 111\111".11"'.. .,.IIICII\OlIRI. ",. ""c."10 whi<,h '" y'.""'" ',y ,""n ul" 1111'(1""'''' a'."""" "",,1, 0(,',111'/'/'. I "',,,,,...'..,, ,II iI" ,I' ,1II;!4 r.Rfd and 10'''.8 to felurnll 10 OWNH\ on or tJfllOl(l tl1ft e"twllvlt dRill 01 \flfll1Ifliltl[lI\ 1',,\111I. '0 timely "turn thl le04" Clld win "lull In I ,wln'y.lve ($25,00) dolin, c:hIlIU" \'rR!'ORIoIAHCI DIP0811: OCClJP^NlllO<Owllh "A""". wllh nWNEI11ho '111'" ul $ ,t." (I (! ,1"0 '0""1>' ",,,,,,,, ",,','wIIjOfI. Iho ..m.lo b. hold by OWNEI1.' A."llIlIy I'" lI\olu\l ~lId lallhl,,1 podo","""o allt' olJ'III1'f1I1UJ I>y nCl:UflAlII "I nil ",,' , "1'"",,,,,,,( OWNER II nol 'Bqu".d 10 '''II,.g.'.II''1 dOl,,,1I hom olhollundt Ttlo porlu"".'''''' dopo,!I" '01"'1/10"'" 10 Oc:curWII """, ", '" ,,,,,,/,,,,,"111e plOml...,n. IImoly ,..1',,"'.' Ih. .,po,.'mll 0\ II". ^Q,..m.lIl, 1..V'"II'h. 1'''"11''''' ill "".'" IIl1d ,,"'mly '''',1>,'''', '"'''''''' i " "",,,( iI,"1 upon hlylng me,.1I olh.. I..nll 0\ Ihls ^U,,,r,,,,onl OCCUPAH1 .g.... th.1 OWHEfI on.y, In .ddlllu" 10 oth.. ,.mo,h" II' ,,,,,d.d IlIlh'" ^g....ft.nl,.....ct.ny .nd .1I..nlund .h"9..p.ovlded to. In Ihl. ^o...monl, Inc~ldlllO oh..o" p,ovldod III ro",,'''''! , ,""Ill Ill" p.,fmrt1lnCI dtpOllt h.td by OWNER. ',," UlORY ll.H: ^. p.ovldod 1111111 p.nnlylvonll 9.".8..vlo.SI",00' !,.,"IIIY II"', 1\1:1 "I (l.ellflhe. 20, 11182, 1'.1.. I'hl, Ii" '", ,,' ". ,,' \ i. nWH!R h... 111ft upon III p...ano' proplfW 10c.lId .\lh. p..ml..., which lion oll.ch'. u 01 th. doll the p...nn.l prill"" 'I " "" ,,,,,,,,,.. ondwlllClh '..u....lorlo.ny o",..II.n o. ...u.lly Inl....I....pllhO..whl.h ..III p,'II' 10 Ih. doll when Ihlll"".1I""'" I,,, "", .lIdlo. olh" ........' ",...nl Of tutu..,III.un.d 10f .Iorlng, "'.....lnO, ..lIlng ondlor dlpO.IIIO o,uld p,op..IY pllr.."'" , I WIU1Y OF OWN.Il: OWNER Ihlll nol h.llobl.'O OCClJP^NT or 0 third party 10' Ih. ,... OI'OInov.1 oll",,,"lal'\Inl~"ty 111"",""'1 " " ""1 <<I nCClJPANl o. IIpon "hl,".'1Ii<1l lion hil' IIl1l1et,",1 OCGl!PMH .11..1" 1111" pO"II''''''I''''I'''<lV I" lit' ,10",,1 '" f<"W ,in,,'" " " t {l(CIlPANT lIIod I" lmn and d01l1 01 "ilium" l\ntl fHtr.UlIIV mUltont oJ(copt ll~; Ifll\rl'/lfI lllJl\hnl(\llr I1nc\ulld Pl\lly IF (l"mlll '\'.\\11(1'.'-1 II " ", , "I' AtIT 10 requlr.d 10 ~nmodl",.'V '"\0'10 OWH~R 1\ prop..ly whloh I. nol oWllld bY tho OCCUPMH 01 p"'~'"V .lIhl.cll(l · iI." '" r """... I. !lOW or h....II.. .Iorld o/Ioo.'.d ."hl pl..nl.... . "II,'VlijIOHG OH REVERse SID!: Ily 1110""11'.1'''''00 bolow, ,",111 OWN!;n '0'" nCCUI'AN I tI\:k""W'""'I" ","llhoy '"'''' /1111<1. ,,'" !;Hil'\ , "II 1111'1.""' 1\0\, ,:!,"IIlII"'" 01 ilII' A'l,o.",oll!. ",<:I\ltllnllll'" P"'ViOlt"," pO""'!!!lO '''1\ ,.",,'HI ,,0111 h.'O'" W""" R'" (1111' III ""', ",,,,,, ,', 1,'{l,111f1(M\ Ily ,,,l,,,ot\(lf'ill\d "HI 8f1 irnpnr",nlllnd flHl\ntJ' (I~ 1l10S~ 1Jf(IVa\i(IlI'l /IPP(IIHlfl~1 "bIlY!! I i I n ',~; Wlll-_fU.'Ur, tllo pl1uHtHl hlllt'l1 flul \lllllr I1llfld!' /HHIIHlillll un Iho day nnd VilA! [11)0""\ wl\llnll OWNI!n, qAI'1T ^' SI I I ',I OI\AI\I' I .II ') / I ' 11'1 \ i I I t (,i,dJtrAf~ I I.,' , / ,. --.~- ---'----_..,---_._---,-,-----_._--- - ---..~ ._--.. --'--'--, --- --- IrEM NUMBEII - '0'" "<0" ^", '" '''''N.,",,, "0""" IAI" "'" ",. ", ,.,""".""" -------..'---------..--- ...-..----.---....--....,..---. - /If mo,. .paco I. "..d.rI,-i~~~;;;.;rldi;i~"a' .h.."./ .0';;;;,;;/- -- -- Itf\l,tHl'il+ {J,a11 ~. I ... .. C(JM"10NWf4lIHOF n~IN5Y1YANIA .. INH'lfIfANCI 'A. ."UIN ftUlD'Nr Dfe.DIN' =,..,-"---'~-_._._._...-.,--,_.,- ESTATE 0' -.'_ 0(1 YeJ , ()f2. z, Yo U,( IIv SCHEDULE J 8ENE',C'AR,ES I --~.~;.;~-:..;,.-"-'---...:......;..~ FIlE NUMBEII . ~~'~~_:-~.......: . IrEM NUMBrR NAME AND AODllrss OF SENEFICIARY /9(17 - O()1.~,-<1 . f AMOUNr 011 SHAIIE OF urArr A, TaKah/e aeque"" , CJ]{i r {~$ 0J. toa I J. 160,/{/I. Jr, qgoo 6tU~ ,),., Ve. Ufper Iv(a r/Ix" G 1,(r),QU77,,-, ,{, IJ,Ac/tkf Cd LOt) /d Yo (./..( rh, ftoo 6~ ~( hn v~. t1f (k I' IJ(tIy 11>0 r () ,t.j D '.,,)0 77 ;;0 3. Aid rQko Alkef] YOWJ"--' q 300 6tliJ' w, ve_, ._ Uppc j' /c{j/ r/):JOro 1.A.0. ,)0 77.1./ If. !vIa / sha . Jc/ () Zt?,/ dCTS It/a L',I-tf~ Mt!(1rn Dnt/I!- i, f,h PA 17S-'/:3 .5 LaI'f'Y L, 6u)()(-'r (Poq ,fJ Slur(- (;(1010.. {J11 17{J,lS RELATIONSHIP -X)/1 r~'5(J.{(f:'., /IX'r sf I r (><','5 ...-._-------_.~--- -."--._~.....,....---- -----------. gru ,--Js;OI/ $~:(.JOO.,.,(J Bra ^J 5(1() .f'c-?.s-, 600. ('O r)1l:'.CP-, ~' 1,.5cJ(), 00 f\.l fllJl IJ..) ff, 000.00 " .------- - -----'-------- .------- -------.---.- . "--.-. 1. NAME AND ADDRESS OF 8ENEFICIARY i'G;;;;;,,-;;,o..--;;;;;;;;;;-.;;;;;;;;_____,_ _<___ '_~__ ___'_,__ ..--------.....--.--- -.---..----.--.............-..----., AMOUNr 011 SHAIIE OF ESrATE .---~.---'..'--_n___.__..,'_...,__.___..,___.. _.___ L.. IS,______,_ .----.-.-- ,COMMONW!ALTH OF PENNSYLVANIA DEPARTM!NT OF REVENUE I~; ) / 'I, ,i IUREAU OF JNDJVlDUAL TAKES IHHfR1TANCE TAl( OIYlSIOH DEPl, zaOb01 HARRISBURG, rA 1712B-Olt01 NOTJCE Of INHERITANCE TAK APPRAISEHENT. ALLOWANCE OR DISALLOWANCE OF OEDUCTIONS ANO ASSESSHENT Of TAK 10-12-19911 YOCUM 1l.17.1997 21 9'/-0959 CUMBERLAND 101 E-"~~A~=I~~~tt.d'-=.3 MAKE CHECK PAYABLE AND REMIT PAYMENT TOI REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 CUT ALONG THXS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ iiiV': ii4'7 -iiI'"App- iiiF9';-r-ilii'r-icnIP"YNHEii'i i' ANeE -TAx- AjijiiiA" i 9EHEilr;-,H.i.-6wANcE - OR- - -- ----- - - - - - - -- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX MAXELlNE Z FILE NO. 21 97-0959 ACN 101 DATE ESTATE OF DATI OF D!ATH FILE NUMBER COUNTY ACN DONALD BOWEN ESQ PO BOX B ENOL A PA 17025 !STAT! OF YOCUM TAK RETURN WAS' I X I ACCEPTED AS FILED RESERVATION CONCERNING ~UTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ONI ORIGINAL RETURN 1. R..l E.t.t. ISch.dul. Al ~. stock. and lond. ISch.dul. II S. Clo..ly Neld Stock/P.rtn.r.hlp Jnt.r..t ISch.dul. C) 4. Hortgle-I/Hot.. Receivable (Soh.dulM D) 5. C..h/Bank Oepollte/Hilc. Parlon.l Prop.rt~ (Sch.dule El 6. Jointly O"n.d Prop.rty ISchedul. FI 7. Transfer. CSoh.dule 0) I. Tot.l A...to III (21 ISl 141 IS) 161 171 I CHANGED 99,500,00 ,00 ,00 .00 95.313,1(, 5.043.40 -~ (81 APPROVED D!DUCTIONS AND EXEMPTIONS I 9. Funeral Expen.../AdM, COlt./Hine, Ewpenl8. (Schedule H) 10. Oeht./Nortg.g. LI.bllltl../LI.n. ISch.dul. 1) 11. Tot.l D.ductlon. 12. N.t V.lu- of T.. R.turn 13. Charitable/GovernMental Beque.tl; Non~elented 9113 Trusts <<Sohedule J) 14. Net V.lu- of E.t.t. Subj.ct to T.. If .n ........nt wa. i..u.d pr.viou.1Y, line. 14, lS .nd/or 16, 17 and 18 will r.fl.ct figur.. that includ. the total of ALL r.turn. a..e..ed to d.t.. ASSESSM!"T OF TAXI IS. A..unt of Lln. 14 .t Spou..l 16. AMount of Lln. 14 t...bl. .t 17. AMount of Lln. 14 t...bl. .t 18. Principal Tex Due TAX CREDITS I PAYHENT DATE 08-14-199B NOTE I rat. tin.al/Cl.Is A r.te Coll.tar.l/Cl... B r.t. RECEIPT N\HiDER AA296546 DISCOUHT 1+1 INTEREST/PEN PAID (-I .00 (9) 1101 11.51 U6I (7) 22,768.91 4.610.36 Ul) (2) US) _ U41 ,00 X .00. 169,977,27 X ,06. 2.500.00 X .15. (8) AHOUNT PAID 10.573.6(, TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE '* ,n.IU'IM '" 1....11 MAXELlNE l DATE 10-12-1998 NOTE; To inlur. pro~.r oredit to your .ocount, lub_it tha upper portion of thil for. with your tax pay..nt. 199,8~ ?7.~7q ?7 172,477 ,27 .00 172 .477-:z:r .00 10.198,64 375.00 10.573.64 10.573.64 ,00 ,00 .00 . JF PAJD AFTER DATE JNOJCATED. SEE REVERSE FDR CALCULATION OF ADDJTJONAL JNTEREST. JF TOTAL DUE IS LESS THAN .1. NO PAYHENT IS REQUIRED. IF TOTAl. DUE IS REFLECTED AS A "CREOIT" lCRI, YDU HAY IE DUE A REFUND. SEE REVERSE SlOE OF THJS FORN FOR JN5TRUCTJONS.I '911 [Ie) I;; :1:(1 CI..i nL'I1' RESERVATION I Eltat.. of Me..nb d~"n" on Of' before Qec..ber 12, nez ..- if any future lnter".t In the ..t.t. .. tranl,.rr.d tn POI,...Jon or .njo~..nt to Cl... B (collat.rall b,neflciari.. of the d.c.~.nt .fter th. IwpJratJon 0' IOY ..tate 'or lIf. or for y.arJ, the C:oHonwalth h.rlby .)CprllulY ,.1.lry.. ttMrlaht to appra'lI and ...... tran.f.r Irlherltanoa bM.' at tht htW'uJ CI... B (collatera!) rat. on any such future Jnl:.,.I.t. PIIIlflOSEOf' NOTICE I To fulfJ11 thCl "squIr..anh of Saotlor Z140 of thl Inherltancl and E.tab Tal< Aat. Act 21 of 1995, (72 P,S. S.oUon 9140), PAVMENT I DetlKlh tM top portion of thh Notice Itnd luh.it with your pay..nt to the Reglst,r of NUh printed on ttM "."'8r.. .tete. --..... ohook or Ihlney order payable tOl REGISTER OF MILLS, AOENT AfFtIaJ (CR)1 A refund of . hlo: cr.d1t, Nhlch Na. not requested on the Tft)( Return, .ay be requnted by C'Iot1pl.UnQ an "ApplJoaUon for Refund of PennSYlvania InherJtanc. Ilnd Estat. Te)(" (REV-Un). A"pUc.tlont are available at the Offioe of the R.ghter' of ..Jlls, an'l of the Z3 R.....nue District OfficlDl, or by caUlng the .paolal 24who'Jr Iltl...rb'tfil ..rvlo. nullbers for foras orderlngl In penn.ylvania 1-800~362-2DSD, ouhlde P.nn.ylvanla .net NlthJn 10081 Harrlsbura .r.. (717) 7a7~Il094, TOD' (717) 772-2?Sl (Hoaring I.palred OnlY). OIJECTlOHSI Any p.rty in Int.r..t not .atlsfied Nlth the .ppreJs..ent, al1owanoa or dlnl1owanc. of d'duotion., or ........"t of bt)( (Including dilcount or Inter..tl al .hown on this Notioe .lllt Object wHhln .hty (601 days of reoeipt of thb NoUce bYI ~,,"IN ISTRATlVE 'CORRECl'IONS I uwrltten protelt to the PA oepltrt.ent of Rev.nue. Board of Appellh. olllpt. 281021, Harrisburg, PA 1"12a~1021, OR --'lIctlon to hav8 the ..tt.r dot.r.1nad at audit of the account of the por.on..l rapr8.entathle, OR -~lPPa.1 to the Orphln.' Court. hctual error. dlscov.r.d on thls aneunnt .hould ba addre...d Jn writing to: PA Dap.rt.ant of Rev.nue, Buraau of Individual TOKU, AnN, Po.t "1S.....nt R.vJaw UnH, o.pt. Z8P601. tlarrhburg, PA l7128.06Cl Phone (717) 787-6505. Se.pago 5 of the bookl.t ~In5tructlon' for InhorJt.nce Ta~ Return for a R..ldent Dao~t" (REY-1!i0l) for .n .~planat1on of .d.inhtr.U....lY correctable orrors. DISCOUNt I 1f any taw due 1. peld wlthin thr.e (3) ee1ender Munth. .ft.r tha decedant's de.th. . fJv. p.rcent (5Y.) dl.count of the talo: paJd is alloMld, PENAL TV, Thl lS~ tIN ..na.ty non-p.rtlclpltion penalty I. co~ut.d en the total of the t.K end Int.r..t .......d, and not paid before January 18, 1996, tha fI,.st day aU.r the .nd of the tal( unosty plrlod. This non-partleJp.tlon Pln.lty Is app.alabl. in the ...a .ann.r and In the the u.e tI.. per lod a. yoU would appe.l the tal< .nd Jnter..t th.t h.. tHI.n .......d .. indicatad on this noUo., I"TatEST, Intara.t It ch.,...d beginning NUh first day of d.llnquency, or "In. (~) lonth. IInd ana (1) d.y fro. the data of de.th, to the data of pay..nt. Talo:e6 which boc,.. daUnqu.nt bofor. Januar)! 1, 1982 beer Interalt at the rete of .b (6;0 parcant p.r IInrn_ c.lcutated at n dalh rnte of .000164. All taKllls which becn.. dalinquant on and after JlnU8ry 1, 1982 will beer Jnt.r"tt lit n rat. which will vary frolll cal.ndQr year ttJ clII.ndllr yoar Nith that "at. .nnouncad by tM PA naparh..nt of R.....nu.. Thf'l appllcahle lnto,..t ratu fnr 1982 through 1998 are, ~ Intera.t Rat. Deily Int.r..t factor Y!n!' Intlll'..t Rat. Dall... Intllrut Factor 1982 20~ .000548 1987 9% ,000247 1911 l6Y. .000438 1981H991 H% .000301 1914 Il~ .0OUOl 1992 9% .000247 1985 U~ .000356 1991-1994 n ,000192 1916 1OY. .000274 199~~1998 9% .000247 -~.ntare.t h c.lculat~ .. followlI INTERRST . BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINqUENT X DAILY INTEREST FACTOR ~RAny HoUoa lnuad .ftlr the taK baoOlle. delinquent wUI r.flect an Int.ro.t calculBtJon to fifteen (5) daY' beyond the deta of the ........nt. If pay.."t h I18ti. IIft.r the Jntorut cOIIputatJon data .hown on the Hot;IQ', addltlonel Intor..t IN.t be cl1cul.tlct. I'I.I~AS": ..'I....: THIS 1U>:I'OItT WITHIN TWO \'EAI(S 01<' I,^'I'I~ OF III<:A'I'1I I(EC;AIUlLl':SS 01<' Tim S'I'A'I'lJS 0..' TilE I':STA'I'E. IF 1':S'I'A'I't<: IS NOT C:C )1\11'1 ,KI'I<:II, F1....: II (..12 1<'0l(M \'EAIU,\' lIN'I'I!' COMI'I,ETION STATUS RU'ORT UNDI\I{ IWI.I\ h,I2 Namc of Decedenl: IVv/ yr ( I ;lC Z. \/() CJ..) ()II." _.__,... _____,... ....__. ._n' F...n...-' .n'n.._'....._,....... ..,.--------.--.... Dale of Dealh: -ll.:::..L:=L::.:Ll_.-,.~...- .'- , . C co ' Will No,: 0 G!....l.-,---.-....--."- ^dnun. No,: --..-,----~,------- Pursuanllo Rule 6,12 of Ihe Supremc Court Orphans' ('ourl Rules, I reporllhe following with I'(.specl 10 eomplelion of Ihe administralion of Ihe above.captioned cslale: I, Stale whether IIdminisll'alioll of Ihe eslate is comple\C: Yes K No .--.-.,.-'." ... 2, If tbe llllswel' is No. slate whelllhe pcrsonalrcpresenlHliw reasollably helieves 1111\1 the adminisll'l\tlon will he cOlllplete: -~--,--.-.._..-.._...--....~.,--,._..-.....- 3, If the allswer 10 No, 1 is yes, slale Ihe followillg: c, Did Ihe personalrl'lucselllativc file a finalaccounl with the COUI'I'! Yes ___ No ."0:,,,-., The separate Orphans' Court No, (if any) for lhe pcrsonalrepresl'nlalive's accounl is:___..___..____...__.__~.,__.. Did the personalrcpresenlative slale an m:counl infonnally 10 Ihe pal'lies in Inlerest'! Ye., ..J--.-- No -,..------' Copies of rel'eipth, releases, .joinders allll appl'ovals of forlllal 01' informal accounts may be tiled with Ihe Clerk of Ihe Orphans' Courland Illay be allached to Ihis roP"" (~'\0;,uJilL~~- -"-.-'~lll'e ))_O(\.t!iA.~_:-Q~<CL___-..._~ Nnme (Plcase type or prill!) ~ O. f-JOY. {) C(\O(C{, PA I'7L\)~ L______"-~--n'-._.~.,.._--------------.--..............-.-' ^, IJ, D. Datl):_~()~~. ":i ~f",\ " C;) N A,ltll'ess " mt ,~. G.: -) ,_~ r: t3t~ -71 "7]:< '1;:; c c <'I J '. - :..J.;;L- - ._)_;J_"':J ,1_-'" _......____....._,___.._ __..___.__m____'_____.~_-'-.n-.- Telel'llolle NlI. (MAlI:nllIIAM.\) .. ClIl1l1cilY: ._..__'. .._" ...... _____.l'l'rs(lI\lIll{l'pll:SCl1tlll ivc .6......_.....Cllllnsl'l for I'l'rslllllll Represl'nt:ll i \'t' ItW.21