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Home My WebLink About80-00398 NO. 21.80 39;;:; PETITION FOR LETTERS OF ADMINISTRATION IN THE ESTATE OF ,....G~~n.4!?J:m..,.J."....~t,~,~,~~)}........., DECEASED. To "..,.. !1,~:r;y'", q,,',., ,r:.,~~~,f!l",...""",..""..,....".""."....",...",."..."""""" ,..'""..,...,.. Register of Wills 1'01' the Count)' of Cumberland. in the Commonwealth of Pennsyl\'lInia, The Petition of "..' ."~,~);J;y'"H,9.U.:j,\').gli\1:""",, ,.., '" "..',.'"..", """,."....', ",..."."...""",,"'" .."",..,..,.....,.."..., ...."""""".."",......,"" "",.""""" ","'" respect fully sho\\'el h tllll t "'q~~,1;1.,g9,'),Y.\')....J...""S,l;,~i?-_n......,..,"',.,. 'd t fLower Allen Township C I' '1' I C t, St te of Pennsyl was n rest en 0 ....."............................".....................J-lol.ough "tlItlICI ,lilt Dun ~ I. a . . vania, and a Citizen of United States, IInd depIII.tell this life intestate in the County of ..Cumhe,'l:latld ."......,....,..,........,.""".., ." IInd State of "..,p.l?:~:r:\!:l,y.Jy.?!:\;i,,?,.,',. ",."., ",.. ""......,...."",.."..""""""....,....,....,....".."., on .......S,UJ:\~flY................ the ........,f.i,.+.Ii,l;......,......... da)' of ,..............Jun.e................,....... A. D" 19,8,0...., at the age of .....z.a...... )'ears, That the said ...9.w,~!:\~,l?ly.:r:\,),:....s.,t;,~,?\.~~,I}..........,........ deceased, lel'l surviving the following named widow or husband. heirs and next to kin, to wit: Name Relationship Residence ................................................................ ............................................ n:l-.3....T,.yp,9dl",D.d"e....,......,..,. Lancaster Penna. .........................1...................................... ".~ ~17,t;,Y... !:\9,:U t,l}g g,r.....,.."""""..", ""., 9.?.\-!gb,1; ~,r."."."".."", ................................................................ ............................................ 14"..~1;i,...,C.Q:\l);.l;,.....".............,.."....., ,~~g.~~~~,~,'?P.-..',',.r..~!:l:~,~.:..,.....,",.. ,t?9....q,\'l!i\'lI'.~11!J:\~"M",........,',...., ~,~~,~!?~~~"'~g,~.~,'..,g~gJ9,~ia .. r. ~ggy'.. !:\ii\r..i?,b.?w,."""",.....", ..,...... "'," 9.?.\-!& b,\; ~,r...",.."....".. ................................................................ ............................................ .,:!. !?~:r:\n~.. ,g.?:;:~);) t, 4J".. ,..",.....,...", """ 9.?.\-!&tJ ~.r.""",......".. ................................................................ ............................................ ................................................................ ................................................................ ............................................ ................................................................ ................................................................ ............................................ ................................................................ That those above named include all of the next of kin, so far as known. The said decedent was possessed of personal property to the estimated value of $..4..?Q.Q,:,Q,Q.............. and of Real Estate, less incumbrance, to the estimated value of $...J:\9,n,~..,................. as near as can be ascertained. That the said Real Estate in so far as is known is located in ............,....,............,..........................,...... ........................................................................................................................................................................................ Therefore, your petitioner(s) respectfully apply(ies) for Letters of Administration in the above . named estate, of Petitioner (><) /j/2-/ . ",.lit~V:iiitt~~~r'{?'....,....,.........,..,.... .""" ..,;Ul~,..1.Y.n9.~Jl"P.);'Jy.~,..,..,......,..........,...... Dated ...J.J.1tJ.~.......1.Cl.........................,.. A, u" lH.,8,Q.. Signature and Address ",.,"',.~~~,g~~,~~:r;,'"..~,~!:\~.~y.~y.~~,~~............,.... ........................................................................................ t/to COMMONWEALTH OF PEN/>;SYLVANIA 1 COUNTY OF CUMBERLAND .t ss: , ,..,...."....",...."....",..""..""".."..,...,""',......," ~~,~,t.l...~~,~,~~~~E!,r.,'" "",.""""",....."....,..,...".....,........,..,.. named in the above application being dull' ......,..~:w9.m..,....................... according to law, sa)' that the facts set forth in the above application are true to the best of ..,I;J.,~}q.. knowle(~e ''1IC1 belief, ".........,..""..I?w:c;g:1;]."""",..,.. ".."..'", and subscribed 1 ,.4k~Wy,:t6;tNri,g~~tr.s-"".."'.....,....,..""'.."'..,. before me, \ ",.,.."""..""".."" "...."".."" ."""""""".............,.."..,"",.. .".~~.......,..,~'~"..,..,..,....."'2' A. I~" 19..,~,Q.,' "."..".",.."",....""""""".""".."..,',....,',..,......',..'"....'...." ,...::J21~"",e.:."''l~i~~~~.... """.."""""",.,."".."".,..""""."....,',...,'.........'jji73 1 Filed: ....~~,~~,.....1.~"..,....~~!1,l?,..,........,..,.........., At torne)': .." }~,l1!:l:..!1~, ..:E.Il:l<,i,!:\..........., .......,....' (over) 21.80 ;~9(:4 No................................. Renunciation and Request ------ In the M.lter of the Est.te of .....g~.~?,~,o.,1.y.~..,~,:..,..~.t.~,~~~~......,......,.......,........,..,..,...,...,..,...............,.........., To .......................~~?;.Y...,9..~..,~~~,;!...,..,.......,................,......,.......,..,........,.........., Esq" Register for the prob.te of Wills .nd granting Letters of Administr.tion for the County of Cumberland, in the Commonwe.lth of pennsylvani., ......~"" the undersigned, being the ...."~~'::~h~,~E..,g.f.,..(;,Y!.~E!.g.<?JY.I\..,~L..,,?.t.~.~,9m~n.,,.,"..,.".....".,..,..,... .................................................................................................................................................................................................. .................................................................................................................................................................................................. ................................................................................................................................................................................................. .................................................................................................................................................................................................. do hereby renounce ...........FE.Y.,...,...................,....,.....,......'.. right to have Letters ..Q.f.,..A,9m:hn;i,.~,!;.r.J!,t..t.QD.,.....,.... ,.............,...,.,......"......,.........,',.."."........,..,..,..., on said Estate issued to """.me...",..,...",.........",..."...,......."....,...."...,.., ....,.........,....................,......,...........,.....,..........,..,...,.....,............ ..........,..........,...,......... and do hereby request you to gr.nt the same to ...,',...,.~~~,~.Y.,..!i,~,~,~~.!.I:~,~.!:,....,..,..,...,.....,.,..,.....""....."...,...,.."."........".,",.."....,....,....,',..,.,'..,......,...,...., Witness.........,.......,h.nd,................nd sea!...,.......... ..thiS...."......=..l..P....t.&,.......~..,...,........,........ day of .....:!.~~,~......,...,.....,.................,..........A, D. 19..~,9.. , ~.~ii~.f~.....,(L.S., ,..,.........,....",..""",..,....,.......,...".,....,...............'....... ,...".....,...."..."....,.....",...,.......,..............,.(L. S.) .............,...,',..,' "".",....."......,.....,..,',...,..,...,",....,.., ,.,.."....,....".,..,....,..,..,.,.,.........,................(L.S.) ",.....,...".,..."""",..,...,...,...,..,.,..,......,....,....,...,.....,.. ",.."....,.....",...........,.,...........,..................(L.S.) ".....,.....",."".".."..."..,........,.....,.................,.........,. .",....,..,...,."...,.."...".,...........,.,................(L.S.) ..,.........,.,..",.."..,....,......"..,...,...,...,......"....".......".. ",.."."",...",.",..",.".,..,...,.......,..............,'(L.S.) "......"..,....",.""..".""..............,..,."...,.,'..,......,.,.',... ",...,......"..""",."..,...,.......................".,...(L.S.I INHERITANCE TAX RETURN FOR INSOLVENT EST A TES (Instructions on Reverse Side) COUNTY NO. ..:)/..(('1 ,'j?f' STATE NO. REV.~19 E)(+ (7-s01 . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT (Xl Exec. () Adm. Other Name Betty Hollinger Social Securily No. 188 -12-3862 2113 Lyndell Drive Address Estate of Gwendolyn J. Steadman Lalit address Bethany Towers . (STREET) I- 335 Wesley Dr~ve >- z Mechanicsburg PA 17055 '" w ., " u W {CITY) (STATE) (ZIPI ::> u " w ii: " Date of Death June 1. 1980 Social Security No. 162-22-4987 TYPE OF ASSET DESCRIPTION Personal " " ~ I- w ~ ~ ., .' ( i::: u, C;I el\"; I.J./L.....' 0..... e::V1 0-' ut1 ~c: OFFICIAL USE ONLY DATE ~ z " ;: u ::> " w " " z ., ~ ?- m w " 6/12 6/12 6/12 OFFICIAL USE /1_/l~~L'!3 (STREET! Lancaster, PA (CITY) (STATE::I (ZIP) Under penalties of perjury, I declare that' have examined this return and to the best of mv knowledge nd belief it is true, correct and complete. <- SI lature of Flducla Date ESTIMATED MARKET VALUE DEPARTMENT VALUA TlON (OFFICIAL USE ONLY) Miscellaneous Furniture Medicare Payments Commonwealth of Pa.-Rent Rebates $ 468.00 148.79 228.00 ~ i c: In ._~ ...,....J ;:i~ ::':<.i g;.J cScx::. ,"'-' :':1~S2 u:.L. 1.oJ"" .j"> '-,' TOT AL $%4.79 I do hereby certify that the above assets were appraised in accordance with Pennsylvania law. f/tZMU'J1 Hf't'" 111 Hj) APPRAISER ATE NAME OF PAYEE NATURE OF CLAIM AMOUNT CLAIMED Register of Wills Myers Funeral aome Richard Patterson John M. Eakin Letter of Administration Funeral Expenses Medical Bill Attorney Fee $ 17.00 481. 00 721.00 100.00 TOTAL $1,319.00 ql/iJ!/ @. ,:f:ux~) RE TER OF WI 5 ~- ~ -,fj DATE ASSETS: INSTRUCTIONS TYPE OF ASSET _ Indicate whether the asset is real estate, personal property, transfer or jointly..owncd. DESCRtPTION _ list 011 assets owned solely by the decedent or owned jointly with another party or parties as tenants in common or as joint tenants with right of survivorship at the time of death. Include the deccdcnt.s p~rccntage of ownership, the name (s) and relationship to the decedent of the surviving joint owners and the estimated market value of the decedent's interest as of the date of death. Include intangible personal property titled in the nome of the decedent but payable at death to another party or parties including but not limited to P.O.D. U.S. Savings Bonds and tentative trust accounts. List any property transferred by the decedent within two years of death for which he/she did not receive valuable and adequate consideration. Describe 011 real estate located in Pennsylvania by lot and block number, street address, number of acres and include 0 general description of the land and buildings. Also, include the book ond page number in which the deed;s recorded and the exact title os indicated on the deed. DEBTS & DEDUCTIONS _ Unsatisfied liabilities incurred by tho decedent prior to his/her death are deductible against his/her ta)(able estate. In addition to debts incurred by the decedent, other items arc claimable including the cost of administration, attorney fees, fiduciary fees, funeral and burial expenses including the cost of 0 burial lot, tombstone or grave marker. List the date on which each debt was incurred and/or paid and the names of each payee. Provide a brief e.xplanotion of the nature of each debt claimed and the amount being claimed, Evidence to support the decedent's or the estate's lialJility far the debts being claimed should be attached to this return A family exemption may be claimed by a spouse of a decedent who died domiciled in Pennsylvania. If there is no spouse, or if the spouse has forfeited his/her rights, then any child of the decedent who is a member of the same household can claim the C'IC'emption. In the event there is no such spouse or child, the exemption can be claimed by a parent or parents who are members of the same household as the decedent. .... -::s: m ~ ID r- " n m ~::r' ." ~ :z: 0 z 1-" n m tIl Z 0"' 0 ~ Ii ; - " .\ >'"d ~f" ~ ~ c-' " o l> Z !: ." 0 n >- m >- ~ 0 >- Z >- 0 0 0 vo 0 0 3: C'l n c: 0 .... !: r- '" m 0 m m " z '" >- Z z r- m , 7- m .... m .... !J z !J vo 0 !J z .... -< vo m vo ~ !J II> ;; vo 0 .... Z 0 '" ::s: " !J "11 "11 , >- III " '< ::! Ii () ::s: w ~ 0 :>;" ~ ~ ID W z ID " n V1 ID rt " ::r' :oJ -0 " ID ~ :<C p. en " ~ Ii ID 0 ~d " c-' 1-" tIl t-' ~. ~ n c-' "Ill , tIl ID ~Ii '" P. 0"' '< -< mID ;. R c.... -< ;j t:l m m " >- I:l:l " OQ Ii '" >- ~ ~ 1-" en '" 1-" ~ ~ rt a c-' ~ '"d ID ID P. ," III III 1-" P. :oJ , !3 0. n c-' III a " ~ 0 V1 V1 INFORMATION PLACE FOR FILING _ The return is to be filed in duplicate with the Register of Wills of the county wherein tho decedent resided. liME FOR FILING _ The return is due nine months after the decedent's death, unless an extension for filing hos been applied tor and granted by the Secretary of Revenue within the nine"month period. FAILURE TO FIL.E RETURN _ Sec.tion 791 of the 1961 Statute provides that" . . .ony person who willfully foils to file a return or other report required of him shall be personally liable. . .to a penalty of 25% of the tax ultimately found to be due or $1,000 whichever is the less to be recovered by the Department of Revenue as debts of like amount arc recoverable by low." NOTE: Fees paid to an estate representative; namely, an executor or administrator, for services performed in ad. ministering an estate is reportable for Pennsylvania Income Tax purposes. This taxable income item shoud be reported on form PA-40-lndividuol Income Tax Return. INFORMATION To insure proper credit to your account, the name of the estale and file number should be cloarly print- ed on the chock or money order. This assessment is made in accordance wiUI Section 708 of tho Inheritance and Estate Tax Act of 1961 (72 p,S, ~ 2485.708), To the extent that inheritance tax is paid within three (3) months after the death of the decedent, a discount of five (51 percent is aliowed (72 p,s, 9 2485,716), Inheritance Tax, other than tax on a future interest, is due at the date of the decedent's death and becomes delinquent at the expiration of nine (9) months after the decedent's death (72 P,S, S 2485-711). Inheritance Tax on a future interest is payable within three (3) months after the transfer takes effect in possession and enjoyment and is delinquent thereafter (72 P,S, ~ 2485-712), Calculate interest from the delinquent date shown on the face of this form to the date of actual payment using the following interest table: ---------..------------------------------------- - - --- ---- -------- ---- -- ----- 1 month ,005 4 months ,020 7 months ,035 10 months ,050 2 months ,010 5 months ,025 8 months ,040 11 months ,055 3 months .015 6 months ,030 9 months ,045 12 months ,060 1 days ,00017 11 days ,00186 21 days ,00352 2 days ,00034 12 days ,00203 22 days ,00369 3 days ,00051 13 days ,00220 23 days ,00386 4 days ,00068 14 daVs ,00237 24 days ,00403 5 deys ,00085 1 ~ davs ,00250 25 days ,00420 6 days ,00101 1 davs ,00267 26 days ,00437 7 days ,00118 17 days ,00284 27 days ,00454 8 days ,00135 18 days ,00301 28 davs ,00471 9 days ,00152 19 days ,00318 29 deys ,00488 10 days ,00169 20 days ,0033S 30 days ,00500 -- --------- ------------- - --- -- --- -- - - - --- --- ---,---- - - ----------- ------ Any party in interest, including the Commonwealth and the personal representative. not satisfied with the assessment may object thereto within sixty (60) days after receipt of this Notice as provided by Section 1001 of the Inheritance and Estate rex Act of 1961 (72 P.S, 9 2485,1001), Make check or money order payable to: .'Register of Wills, Agent" Mail to the address listed below: REV.S23(10,78l COMMONWt:ALTII OF I't:NNSYI.I'ANIA IIt:I'AItT~n;NT (il" ImVt:NlJt: Iltlltf:AU ot' FlEW Ol't:IlATIONS INm:llITANCE TAX D"'ISION O"~'ICIAL NO'I'ICl~ (W INmmI1'ANCI~ TAX API'IlAIS~;MENT ANIl ASSESSMENT OF AR~n~'rS NO'r SUB.J(<~C1' TO AIlMINIS'I'RA'I'ION *' Date:,_ April 9. 1981 County C)V"'ulGd County File NL21..ao.o398 Bureau File No, 21~3lI8 We have recei~~ notiil that, as a result of the death of C r ..,,~. S.""-,, on 19_, you came into ownership of certain property through right of survivorship, which was formerly owned by the decedent. TO' Jcr- I CanIddI 'tK 11'0. P1.pl~. _.lNI'I~ .. '--..tallbala. I!&. 11055 Under the Inheritance and Estate Tax Laws of the Commonwealth of Pennsylvania SUCll transfers are taxable and the liability for the payment of the inheritance tax due is imposed upon you, as transferee, The property on which tax is hereby assessed consists of: Fin\: lle.ak " 'hus\: ce'rtificaCe of deplei\: .3687 Sa \:M ... of cIeoBcleG\: " .Jo/IDIlI Cerdlf.cII. ..t:abllalled below 1960 appraised by the Commonwealth, as of the date of death, at $ 5.011.45 50 % of this amount is taxable at the rate of 6 % DATE OF ASSESSMENT TAXABLE AMOUNT LESS: ALLOWED DEBTS NET TAXABLE AMOUNT ORIGINAL ASSESSMENT Apd,l 9. 1981 $ 2,:105.73 AMENDED ASSESSMENT $ ,_.: i "5' 'I. ,.' .' ~ AMOUNT OF TAX DUE If you pay the above amount within three (3) months of the date of death of the decedent, or on or before 19_, you may deduct a discount of 5 % of the amount of tax due, or / 60 . ::;.I( --------------------. --------------------- This tax became delinquent nine (9) months after death (one year if death occurred prior to December 22, 1965 and fifteen months if death occurred on or after December 22, 1965 but prior to June 17, 1971) and in addition to the tax, statutory interest al the rate of 6 % of the tax per annum is also due as of.' /Ii.", I. 191 / in the amount of !--. '/, /,; \, r{'.-" ...lj, \" I:; J" \~ ,"'.'" ., .... '. ',' \. i '. * If the tax is not paid by the above date additional interest is due at the rate of 6% per annum until paid I 5 /', .~ (j _L. h::--'-~-l..i-"----- j,-,iii . , ~t"" J,..J .'V ---------------------- TOTAL AMOUNT DUE I', $ \,,'". -".I J ~..' I $ APPRAISED BY: (Inheritance Tal( Appraiser) ASSESSED BY: __~___-:_'-~_/'--- (Agent for In, yommonwcaltlil / INSTRUCTIONS TO TAXPAYERS Make checks or money orders payable to: To insure proper credit to your account this Official Notice must accompany your payment. Mail or bring it to: Mary C. LeVie ~.9i.ter Of Will. Cll-lud county Court Bou.. Cwliale. .a 17013 NOTE: Any party in interest who is aggrieved by this notice may object thereto within sixty days after receipt of said notice as provided by Section 1001 of the Inheritance and Estate Tax Act of 1961,72 P,S, 2485-1001, l181:y c. Levie aegietc Of Will. C(~/..[)LlJ;.'L!C/;.,::---.I.;,....:.!~.:L:;; or '/.!ill:; C'~:':;'l', If you have already paid this tax to an executor, administrator, attorney, or other personal representative of the decedent for forwarding 10 the Commonwealth, list beiow the date paid, name and address of tile person to whom you made payment, their official title and the amount. Date Paid ~.ame arid. ~dd!es:) .of_?ayee Official Title Amounl Paid .~--"-----_.~_._,._--- Under certain circumstances, ii, after tile dale of deatll of the rlncr,denl, you personally paid funcral expenscs or other just debts of the decedent, witll lunds derived (rom tllC property herein laxcd, such amounts cxpended by you may qualify as deductions against Ihc gross valuc of tllC property in Ihe computation of tax due, If any sueh expenditures meet all of the three following tests, il is recommended that YOIl itemize the payments below, exeeute Ihe affidavit, and return this notice, The Register of Wills will examine Ihe debts claimed and allow those which he determines to be proper, The tax will then be recomputer! and you will receive an amended assessment of tax, THE THREE TESTS WHICH MUST BE MET ARE THAT: 1. You were personally legally responsible for these debts, and 2, You actually paid these debts and can furnish proof of SUCll payment, if required, aod 3, These same debls are not also claimed, for tax purposes, by an executor, administrator or other personal representative of the decedent handling the administration of the general estate of the decedent or any other transferee, Date Paid SCHEDULE OF DEBTS Name orPaYllQ=--=-T---=='=:D~~I@r~n,.QLQ~igjil6i(:~_--==-~::... . Amount Paid .______.__' _____._,_.-=I~___,_,_~__,.___._..._.__..______.____..__------ -...--"-- -- ~",---,----,-----_._"'-------'--'--'--'-"'-"- ---.-- __.______ __..___________ .____.__.________~._______....._____....__u_ ___ -" ._._-_.._-~-_.._----_._-_._-_.~--------- ----+----.._' ----------.--..-----. --~----_.__._.._--------~~ ---- .---=c- -~--_._.- ------- .______ --______0_- -- ------ ----------- ..----- -------- ------- ---..-------.-.----. __,___. ____,____L.________ TOTAL $ .-------'----(attach separate sheet if req'uired) COMMONWEALTH OF PENNSYLVANIA) , SS: COUNTY OF I, hereby certify that the foregoing is a just and trlle statement of funerat expenses and other debts of the decedent.___________.__,___, for which I was legally responsible and which I did payout of the property Ilerein laxed, I further cerlify, that to the best of my knowledge and belief, these same debts will not be claimed by any other person, for inheritance tax purposes, SWORN AND SUBSCRIBED BEFORE ME THIS ,_",__ __.OAY OF ____ .__,_oo_ _ _.1 9 , ".-----------SIQnatu-r-eoITil;piycr------- __m__.___ -----------.--REP6RTOFRE-GISi'Ei~OF \~llLS ---- .-----.-- ..------- I, the undersigned, duly elected Register of Wills in and for the ':bove county do rcspectflllly report that I have allowed deductions listed above in the total amount of $--.-,-,-------.--,----.,.,,--- Date of Approval:______. -....---...--.- . . --Rcgisieiol'i;iils-~"--~--"- .-.-- JOHN MEAKIN MARKET SQUARE BLDG MECHANICS BURG PA 17055 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX NOTICE OF ASSESSMENT OF AMNESTY NON-PARTICIPATION PENALTY AND STATEMENT OF ACCOUNT DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIl/ISION DEPT. 280601 ItARRlSBURG, PA 17128-0601 m'luu~ IF' IU.tU 05-13-96 STEAOMAN 06-01-80 21 80-0398 CUM8ERLANO 101 GWENDOLYN J Amount RIIIl! Had l MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUM8ERLAND CO COURT HOUSE CARLISLE. PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ... iiE"v:i6'if7iiiCEiniFP-TIiPi6j----...--iNHERi'TANC'iCTAX-STATEMENT-Orn,C-COU'NT--ii..---n---------------- ESTATE OF STEADMAN GWENDOLYN J FILE NO.21 80-0398 ACN 101 DATE 05-13-96 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 05-05-86 PRINCIPAL TAX DUE: 121. 89 .............,...... ".' PAYMENTS (TAX CREDITS): PAYMENT DATE 01-18-96 RECEIPT NUMBER AMNP PEN DISCOUNT (+) INTEREST (-) 34.58- AMOUNT PAlO ,00 NOTE: THE 15~ AMNESTY NON-PARTICIPATION PENALTY IS COMPUTED AGAINST THE LIA8ILITY NOT PAID BEFORE JANUARY 18. 1996, THE FIRST DAY AFTER THE END OF THE TAX AMNESTY PERIOD. THIS NOTICE IS TO ADVISE YOU OF THE ASSESSMENT OF THE NON' PARTICIPATION PENALTY. THIS NON-PARTICIPATION PENALTY IS APPEALABLE IN THE SAME MANNER AND IN THE SAME TIME PERIOD AS YOU WOULD APPEAL THE ABOVE REFERENCED LIABILITY. PLEASE NOTE THAT THIS NOTICE DOES NOT EXTEND THE TIME PERIOD FOR THE APPEAL OF ANY LIABILITY OTHER THAN THE NON-PARTICIPATION PENALTV. INTEREST IS CHARGED FROM 03-02-81 TO 05-21-96 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM.* AMNESTY NON-PARTICIPATION PENALTY HAS BEEN ASSESSED TOTAL TAX CREDIT .00 121.89 145.72 267.61 BALANCE OF TAX DUE . IF PAID AFTER THIS DATE. SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI. YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRN FOR INSTRUCTIONS. I INTEREST AND PEN. TOTAL DUE 'plll\1I1n~111~ IIIq \lnl1l \SIIIJ.\UI lUU01\1PPII 'nnoN .~\ uo UMO~I .\IIP uOl\u\ndllloO \IIIIJ.\Ul .~\ .1.\111 .pIIU 'f \u..~lId 11 .lU....III..o III~\ 10 III\IIP e4\ puo~eq 1~lIp (~t) ueell11 0\ UOlllltnolao \.eJe\U1 UR \oetfoJ ttl" \uonbultep .e.008q MII\ 84\ .18\111 ponss1 .01\OH ~UV-~ HD~~Y4 ~S3H3~NI A1lYD X ~N3nbN1130 SAYO ~O H38NnN X OIYdNn XY~ 40 3~NY1Y8 = ~S3H3~NI :SMOTtOj ,. 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