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Home My WebLink About81-00066 IJj t.O ,.... co I ,.... C\l . o Z <I; p.. 'p.. l-i , Ei3 "" c;: f;l ,... 0 -. E-< '~ ~ .:l,: ~ I<i! ~ <1: (1~ H ~ 1-1 0 \,' H H .~ ." .... o ~ ... y lO -0 ... tn U.I '.\" \J \ Gb PETITION FOR LETTERS OF ADMINISTRATION IN 1'HE ESTAn; OF ....!-:.!:~~.~!:.~.~,..y..~...~~,~!:......................... DECEASED. '1'0 ...................,....,.... r:-. {), n,~!:.. r.;, ,',...~ ;~:,!'l.:[ f:..................... ..,.................,..................... Hegi"tcl' of WillH 1'01' tho COllnt)' of CUl1lhcl'iand, in thc Commonwcalth of PennHylvaniu. Thc Poli lion 0 f .......:J. ~.I,1 !1... ,I,t,:,...~ <7. ~,n.." '! F,l,~.,.!!: ~ ,<?,Il,,! .~.~"'~.~" ..K,E!,~!!....,.........."..""................................. ..........................,.. .................. ,.......... )'OHIIOC( fully Hhowclh Ihal ,..,.f..!:~~.~F,l-"',~,.X.:... .~.~E!.~.................".......... w '1 1" Lower Allen TownHhip. " . I II" II re"" ent 0 ...........................,.........................'....WC<llCHgdx . CnmhcI'land County, State 01 Pennsy- vllnia, Ilnd II Cilizyn of Unitcd StllteH, Ilnd dcplll.tcd this life illtestlltc in tho County of ....!;;J.!.W.9.!i!.~Jf:I.\1d ...............................""..... a))(1 S tllte II I' .",.. J:,1i\ !E1,~ Y.~.Y. ,!.t). t?,......",...........,......"......,......,.....,........"......... ,........... on 'l,'.I.1~,h.~g.~Y................... tho ..,......~.~!).~L.......,......,.. da.\' of .....q,!11.!1.~!11.D~........................... A. D., 19.?:1-....., lit the Ilge of .........,...... ~.ell).s. That the said ......~.~.~.~~.~.?~...y..~....~~.~.~.............................., deeellsed, left sUI'viving the following named widow or husband, heirs Ilnd next to kin, to wit: Nume Richard C. Keen Hela lionHh ip Residence Son ............................................ 213 South Hendricks Avenue .. 'Ext'oil';'" 'P'A" '..... '1:'9' j .41"............... ................................................................ ....................,.....".................................... ............................................ ................................................................ John H. Keen ................................................................ Son 108 North First Street ................................................................ McConnellsburg, PA 17233 ............................................ ................................................................ ............................................ ................................................................ ................................................................ ............................................ ................................................................ ................................................................ ............................................ ................................................................ ......,.....,.."...........,...,.....,.........,......,.....,.. ..,.........,."......................".... ...........,...."..........,...,..",....,...........",....... ..............,...,."..".........,...,.....,....".....,...... ',................................,......... ............,.........................................."....... ...................................,............................ ............................................ ................................................................ Thut those above numed inelude all of the next of kin, "0 fur as known. The suid decedent was pos"essed of personal propel.ty to the estimated vlllne of $.../,P..9..9......~... and of Reul Estute, less incnmbrance, to the eHtimated value of $..3...5.::.Q.O'.Q....:::: as near as can be ascertained. That the said Real Estate in so far as is known is located in ....t:!:1.~..,~.~~!1.~.~}p....~J...~.<?~?~.~....~llen .......................................................................................................................,........................,....................................... Therefore, your petitioner(s) respectfully appl)'(ies) named estate. Dated ......cJ.~}D..~1.]...:...'0..,?:~.... A. D.. !!),Y/" Signature and AddreHs for Letters of Administl'alion in the above of Petitioner(s) .' ....laJ-.. N '-1/ -<U C."(hj.'...".......,"'.,...,.'^::.."...~,.........,................... , /C<.,cj\.<>..~.fLC I,L,"-.... ...,""......,..........,................................................................ ........................................................................................ ............,................................,.........,................................ COMMONWEALTH OF PENNSYLVANIA } ss: COUNTY OF CUMBERLAND ...!U.g.!'!.~ !;.g.. .r;.~... .~.~<7.!1... ~.!1.g...;r 9.bn.,. !J,~..,. ~,~.~.!1......",.,..."..,.........",.... '..,..',...,......,.,." ,....'.............,..... named in the above application being dul~' .......,~w.g.nl............................ aceonling to law, sa~' that the facts set forth in the above application are true to the best of ..t:!:1,~J!;.. knowledge and belief. St'JORN . ............................"........,..... ,.... .......... and subscrIbed before me, Janur:.ry 27 nl ............................................................ A. D., 19.......... .....~.?lkuj....{!.:.. ~~.a/...,.:.......,... ('" / 7-< Heglstel' 1"...J..".";,...,;';......;~).:...........,.,.........."...,...."............ .,..:!t?~...J.I..I\.~,~~,.........,... ...,....................... ...CJ...(.(,.ts;;,:,..~};;,.G:...V'"f,7r:>.,.. ,............,. ...,...,.... ..................,.........,.."....,.......,............',............................ Filed: ........!.'?:!?~;.!:.y.....~.??!.....1.~.?.:~,............,....... (o\'er) Altol'ne~': ~F~~~~~F~.~~ig'~..'~.~.~..............S. ,153 /1-1<;'/, ,3 Harnsburg, PA 17101 . ~ -- ._---~. ~ ~~.~.~ i. . , .~'.-'., . ;._,":<"'1~' -:, ~?:J:"'~I .-~.,.,.t. \ lI3J?"':~ij'. File No..1 \ - ~\ -lo to REV.455 EX" iJ.RO) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "F" STATEMENT OF DEBTS AND DEDUCTtONS Estate of_U2.t.ence V. Keen Date of Death 1/22/81 WHEN CLAIMING THE FAMIL V EXEMPTION, COMPLETE THE FOLLOWING: Claimant N/A Relationship to Demur,"! N/A Claimant's Address at time of Decedent's Death N/A ITEM NO. DATE NAME OF PAYEE REMARKS AMOUNT $ 19.00 2.00 18.00 7.13 12.68 485.00 83.03 6.00 314.00 85.00 175.00 2,727.00 35.46 9.91 74.17 76.32 65.00 6.72 10.69 49.89 50.50 8.38 t Shore Times Riverton Consolidated \'1ater Company Rollin Greens Cemetery UGI U.S. Post Office Revenue Service Issuance of Letters Two Short Certificates Advertise Letters Advertise Letters Re ister of Wills Cumberland Law Journal Grave r.larker Gas Service Stamps Federal Income Tax H ar CPA Robert L. Tecau M ers-Hall Funeral Home, In Tele hone of PA Pre are Tax Returns Expense of Last Illness . Funeral Expense Martin, Tax Collec or Real Estate Taxes ~ Robert Hamilton, M.D. of PA Gas Service Expense of Last Illness PP&L UGI Lower Allen Townshi Bell Telephone of PA Gas Service Sewer and Refuse ** Continued TOTAL I hereby certify that to the best of my knowledge and belief the foregoing is a just and true statement of debts, funoral oxpenses and expenses of administration submitted to the estatera:.~ulyoJ(,.!t"~heritance Tax purposes. 'fO.,o.. {I.C\<"..O July 14, 1981 SIGNATURE OF FIC:UCIARY DATE OFFICIAL USE ONL V DEBTS AND DEDUCTIONS ARE ALLOWED tN THE SUM OF $ 1/ "18'/, &/ '1 AT I ~ % TAX RATE 0l71L0f0 a . ~~~ f .GISTER OF W L.L.S 1~-.2.;(-?1 DATE 'S133HS "ll x ,,'108 3sn A~VSS3J3N SI 3JVdS lVNOI1IOOV :ll 'Slqap aYI 6u!Aod JOj AI!llqlsuodsaJ aYI palUnSSD soy O'IM uosJad aYI Aq pauBIs aq IsnlU UIJOj aY1 'L 'palUIDI~ BUlaq lqap y~oa jD lunOlUD aYI Jalu3 '9 'palU!Dp lqap Y~Da JOj ulunlo~ S~JDlUaJ aYI UI UOllouoldxa japq 0 aplhOJd '5 'aaAod Y~Da jO salUDU aYI Jalu3 .~ 'Plod JO/puo paJJn~uI SOM lqap y~oa Y~!YM uo alDp aYI Jalu3 'E 'pals!llUall Y~Da 01 SJaqlUnu ah!ln~asuo~ uBIssV 'Z 'uwnlo~ lunOWD aYI uI paw!op lunowo a~l puo uwnlo~ s~JowaJ aYI U! "uolldwaxa AIIWOj" Jalu3 'luapa~ap a~l 01 dl~suO!lDlaJ Jay/sI~ puo SSaJppD 'awou s,luDwlol~ aYI alD~lpuI 'paluIDI~ 6ulaq sl uOlldwaxa Al!woj aYllI '1 ,,:!,, 3ln03HJS ~NI13ldWOJ ~O:l SNOllJn~lSNI ~ ~ W W >- >- z 0 ~ ~ I.t. I.t. 0 E- O CIl 0 Z 0 CIl CIl >- E- d ~ w Z Z E- W E-< W z ::l 0 ~ 0 i::i ~ S ::.: w w Z ~ Z 0 U '" Z ~ ~ CIl ~ 0 0 -< :1 w u 0 ~ 'UJnla~ XD1 awo~ullonplh!pul.O~.Vd WJOj uo palJodaJ aq Plnoys wall aWO~U! alqDxDI SIY1 'sasodJnd XD1 awo~ul DIUDhlAsuuad JOj alqDlJodaJ S! alDIsa uo BU!JalS!U!WPD UI paWJol'ad Sa~!hJaS JOj 'JOIOJISIU!WPD JO JOln~aXa UD 'Alawou ~ah!lDluaSaJdaJ alDIsa uo 01 Plod uO!losuadwoJ :310N 'sMDl alolsalul DIUDhlAsuuad aYl Aq JO II!M 0 Aq ssod ~~!YM Slasso ISU!06D AluO alqoMollo sl uOlldwaxa AI!WDj aY1 'luapa~ap aYl so Plo~asnoy awos aYl jO sJaqwaw aJO O~M SIUaJDd JO IUaJDd 0 . Aq paw!op aq UD~ uO!ldlUllxa aYl 'PIIY~ JO asnods ~~ns ou S! aJa~IIUaha aYI ul 'uo!ldwaxa a~I wlol~ UD~ Plo~asno~ awos a~I jO Jaqwaw 0 sl OYM Iuapa~ap aYI jO PI!Y~ Auo ua~l 'sly6lJ Jay/sI~ pallajJoj SD~ asnods aYl ji JO 'asnods ou S! aJa~I II 'D!UDhIAsuuad U! pal!~!wop pa!p O~M IUapa~ap 0 jO asnods 0 Aq paw!DI~ aq Aow uO!ldwaxa Al!woj V 'alnpay~s slYI 01 pa~~Dllo aq Plno~s paw!ol~ 6u!aq slqap aYl JOj Al!llqD!1 s,alolsa aYl JO s,luapa~ap a~llJoddns or a~uaplh3 'pam 5! UJnla~ x01 a~uollJa~ul a~I WO~M ~1!M SIl!M jO Jals!6a~ aYl jO IDhOJddD a~l 01 pa!qns aJD alDlsa UD ISU!DBo paw!op Bu!aq slqap 11'1 'sasuadxa IDpnq palolaJ Ja~IO PUD Ja~Jow ahoJ6 JO auolsqwol 'Iollopnq 0 jO ISO~ a~l 6u!pnl~u!sasuadxa 10!Jnq puo IDJaUnj 'saaj AJo!~np!j 'saaj AauJOllO 'UO!IDJIS!U!WPO jO ISO~ a~1 6u!pnpUI alqDW!DI~ aJD SWal! Ja~IO 'alolsa JO luapa~ap a~l Aq paJJn~uI slqap 01 UO!l!PPO ul '~loIsa alqoxol Ja~/s!~ ISU!06D alq!pnpap aJD Yloap Ja~/s!y 01 JO!Jd Iuapa~ap a~1 Aq paJJn~u! sa!l!l!qD!I pa!js!lOSUn NOI1VW~O:lNI XVl3JNV11~3HNI1V~3N3~ '.. GENERAL INHERITANCE TAX INFORMATION Unsatisfied liabilitios incurred by the decedent prior 10 his/her deoth ore deductible against his/her taxable estate. In addition to dobts incurred by the decedent or ostate, other items ore claimable including the cost of administration, attornoy loos, fiduciary lees, funeral and burial expensOS including the cost of 0 burial lot, tombstone or grove marker and othor related burial expensos. All debts being claimed against on estate ore subject to the approval 01 the Register of Wills with whom the Inheritance Tax Return is filed. Evidence.to support tho decedent's or tho ostate's liobility for the debts being claimed should be attoched to this schedulo. A family exemption may be claimed by a spouse of 0 decedent who died domiciled in Pennsylvania. If there is no spouse, or if the spouse has forfeited his/her rights, then any child 01 the docedent who is 0 member of the some household can claim the exemption. In the event there is no such spouse or child, the exemption con be claimed by o parent or parents who ore members of the same household os the decodent. The family exemption is allowable only against assets which pass by a will or by the Pennsylvanio Intestate Lows. NOTE: Compensation poid to on estate representative; namely, on executor or administrator, for services performod in administering on estote is reportable for Pennsylvania Income Tax purposes. This taxablo income itom should be reportod on form PA.40.lndividuallncome Tax Return. t"" '" " ('l ~ tTl ~ ~ z ;.. 0 0 '" Z Z Cl ('l C " ..., ~ ~ tTl tTl ~ Z :>:l ~ S' 0 z z ..., tTl Z S' ..., -< '" tTl - S' '" z 0 '" 0 ..., S' ." ." :>:l ,- ~ ~l ..n - .' a: 0 <.' "" Z ;,~- Ii.. ....:.:,'., (~) ~ ~~~ :..;' C) N ,,' I;:';:...) Cl I.. ' l.": 0':' 0:; - ..:.~? ~d ~ 0:;5 '" SO Wu .J () -< -< tTl tTl ~ ~ INSTRUCTIONS FOR COMPLETING SCHEDULE "F" 1. If the fomily exemption is being claimed, indicoto the claimant's nome, address and his/her relationship to the decedent. Enter "family exemption" in the remarks column and the amount claimed in the amount column. 2, Assign consocutive numbers to each item listed. 3. Enter the dote on which oach debt was incurred ond/or paid. 4. Enter the nomes of eoch payee. 5. Provide 0 brief explanation in the remarks column for each debt c1oimed. 6. Enter the amount of each debt being claimed. 7. The form must be signed by the person who has assumed the responsibility for paying the debts. IF ADDITIONAL SPACE IS NECESSARY USE 8%" x 11" SHEETS. Inventory of the reol ond personol estate of F l.Q!..en.C,e..-Y_L....Kc.en deceased. Lot 33, Block L on the plan of Highland Park, Lower Allen Township, 40,000.00 Cumber~and County having thereon erected a dwelling known as 1396 Lowther street, acquired from N. P. Ninneman et ux by deed dated 7/21/50 and recorded in Deed Book K-14, page 405. One (1) Series H U.S. Bond issued in February, 1976. $1,000.00 Misc. household goods and furnishings located at 1396 Lowther Road, Camp Hill, Pennsylvania 17011 $1,500.00 1,080.427 shares of IDS Tax Exempt Bond Fund, Inc., held by Florence V. Keen, Trustee for John H. Keen $3,576.21 Commonwealth of Pennsylvania State Retirement Fund Pennsylvania Blue Cross and Blue Shield Benefit Payments Pennsylvania Blue Cross and Blue Shield Benefit Payments Pennsylvania Blue Cross and Blue Shield Benefit Payments Social Security Death Benefit $180.83 $31. 50 $145.23 $289.87 $255.00 TOTAL 46,978 64 COMMONWEALTH OF PENNSYLVANIA l. COUNTY OF CUMBERLAND I 55: _.i!.QHtLH,._J5.J;:!);tL<!!'l,d,.!U,Cl:!~mLC,...1<r,;,Eli,-,__ boing duly ....swax.n____ according to law, do pose. and say. th.t lt1lI ,.Jhe.y,I-___,__ ExeClJtoriL__,___,__..~..__. of tho Estato of Florence V. Keen late of -Lo,w,er ..Allen._Townsh~p,~~.,. ._____, Cumberland County, P.., decoa.od .nd that the within i. an inventory made by ..R.:lc..hilJ.c:i.C".,.B,e_e_n anc'LLopn-1! ._KeeJ:l_., tho ..id Execu tor s of the entire e.tate of .aid docodont, con.isting of all tho porsonal property .nd real e.tate, oxcept re.1 estate outside the Commonwealth of Penn.ylvania, and that the figure. oppo.ite each item ,of the Invontory repro.ent it'. fair v.lue as of the date of decedent'. doath. t-,...L II )(.QQ........... Sworn to and sub.cribed bcloro mo, g...k...JLC . \.(............... ) , /'1tl.,J d.-..-". 'l ~. "_0" 19 PI / , , (/ J ) 1-;-7'- v),,/\,,"-,.l..,_i2, ~u (/ .,' ~VLV Ll..v;"'<-o..-J "- 'tlA-D.,{../ I~,:o '1t7rC-::.,..<--r'~'_d~,./J (Afi;"t..J<.) L.!h~ I) / ') VL Executor. Adminiltrator j Addrus Date of Death 22 Day Januau Month 1981 Yur INSTRUCTIONS J, An inventory mu.t be filed within three mor,th. after appointment of personal repre.ent.tive. 2, A .upplement inventory mu.t be filed within thirty day. of di.covery of addition.1 assets, 3. Additional sheels may be attached a. to personalty or realty 4. See Article IV, Fiduciarie. Act of 1949. n ::1 n~ =u~ %:\l ~o ...." r:T.l, .._0 ~.;.;? - ,n'" - . .,~:., ,_. ~, :';:T"J >:~? N ',' :J ",;:; h "oJ , . . .. r) ~." E: ,") .~ >- -ti ;2: ~ 0- W ~ ...9 ~ "" 0- ~ . W ~ ~ ~ ...5} ll. ~ U 0 0 III ~ I 0 W W C '" .. :c "" . .. ~ l- ll. ll. C 0- oJ U. :> ~ ~ Z oJ <( 0 ll. 0 u. :I: W 0 <( w ~ ,;. <( > Z "" U + Z 0 :z: ~ c ~ .; III Z ~ 0 "" I>: U Z w <( 0 .... ll. "'0 ..:l c ~ - . I -.: 0 ~ Jl "'0 ... ~ E + .! 0 I . ~ 0 oJ U u: '" .' ". R~V"44'1 EXt (g",,!!O) COMMONWEAL TH OF PENNSYL VANIA OEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIOENT OECEDENT STATEMENT OF FIDUCIARY (Instructions on Reverso Sid~) Estate of FLORENCE V. KEEN Last Addross_lli..LLowther Road Camp Hill, PA Do te of Dea th Januarv 22. 1981 Social Security No, 17011 Slote Fi I e No. (CITYI (STA TE) (ZIP) County File No, .;.) t - ~ \ - (01.0 1, Decedent died: (x ) Intestate (without a will) ( ) Testate (leaving a last will--capy attached) 2. Is the filing of a Federal Estate Tax Return required far this estot~? Yes_ No x 3. Executor ( X) Administrotor John H. Keen and Richard C. Keen John H. Keen 1396 Lowther Road Camp Hill, PA 17011 171-30-7210 (John) Social Security No, 207-34-6120 (Richard) Richard C. Keen 2]3 South JjpnarickR IIvpnllP Exton, Pennsylvania 19341 11.IP) Namo Address (CITY) t~T A Tel 4, All correspondence should be mailed to ( X) Attorney Fiduciary, 5. If an attorney is representing the estate, indicate: Name William Fearen Telephone No, 238-1731 Address 31 North Second Street Harrisburq. PennsYlvania (CITY) (STATE) 17101 (ZIP) List all sale deposit boxes registered in the decedent's individual namel or jointly with, or as an agent or deputy of another, or in decedent's individual name with right of access by another as agent or deputy, !nclude the name and address 01 the bank or other institution where the safe deposit box is locoted, the nome (s) in which the box is registered and the relotionship of the joint holders to the decedent, NAME ANU ADDRESS OF BANK OR OTHER INSTITUTION IN WHICH DECEDENT MAINTAINED A SAFE DEPOSIT BOX NAME OR NAMES IN WHICH SAFE DEPOSIT BOX IS REGISTERED RELATIONSHIP OF JOtNT HOLDERS TO DECEDENT or! Q Under penolties of perjury, I declare that I have exomined this return, including accomponying schedules and stotements, ond to the best of my knowledge ond bel}el i~,i~yu:, correct and complete. J^~ j( 1 LL" . ~C\. k'...u- July 1.4, 1981 SIGNATURE OF FIOUCIARV DATE QUESTIONS CONCERNING PROPERTY TRANSFERS 1. Did decedent, within two years of death, make any transfer of any material part of his estate without receiving valuable and adequate consideration? (Answer "Ves" or "No".) -1lLl_ 2. Did decedent, within two years of death, transfer property from himself/ herself to himself/herself and another party or parties (including a spouse) in joint ownership? (Answer "Ves" or "No".) NO_ 3. If the answer to one or two above is "Ves" and the transfers are claimed to be nontaxable, provide the fOllowing information: a, Age of decedent at time of transfer. b. Copy of death certi fi cate. c, Affidavit by the attending physician indicating the state of decedent's health at time of transfer. d. All other information supporting nontaxability of transfer. 4. Did decedent, in his/her lifetime, make any transfer of property without receiving a valuable or adequate consideration therefor which was to take effect in possession or enjoyment at or after his/her death? (Answer "Ves" or "No".h:o a, Was there any possibility that the property transferred might return to transferor or his/her estate or be subject to his/her power of disposition? (Answer "Ves" or "No".) b. What was the transferee's age at time of decedent's death? 5, Did decedent in his/her lifetime make any transfer without receiving a valuable and adequate consideration therefor under which transferor expressly or impliedly reserves for his/her life or any period which does in fact end before his/her death: a. The possession or enjoyment of or the right to income from the property transferred? (Answer "Ves" or "No",) -HG- b. The right to designate the persons who shall possess or enjoy the property transferred or income therefrom? (Answer "Ves" 0r "No" ,) ,( , 6, If the answer to five b. a~lOve is "Ves," was the right reserved in decedent alone ( ) or decedent and others ( ). 7, Did decedent in hiS/her life:ime make a transfer, the consideration for which was transferee's promise to pay income to or for the benefit or care oi transferor? (Answer "Ves" or "No".) 1 Ir, 8, Did decedent, at any time, transfer property, the b61eficial enjoyment of which was subject to change, because of a reserved power to alter, amend, or revoke, or which could revert to decedent under terms of transfer or by operation of law? (Answer "Ves" or "No".) t"~ , 9. If the answer to eight above is "Ves," was the power to alter, amend or revoke the interest of the beneficiary reserved in the decedent alone ( ) or decedent and others ( ). REV-453 EX+, (10.S0) COMMONWEALTH OF PENNSYLVANIA ,OEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "0" BENEFICIARIES (Instructions on Reverse Side) Estate of Florpnce V. Keen BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED DECEDENT Richard C. Keen son es son es DATE OF BIRTH 6/23/45 8/7/38 The above beneficiaries were living at the time of the decedent's death except for the following: NAME Not A licable . .If additional space is necessary I use 8%" x ,,'' sheets. INTEREST OF BENEFICIARY 50% 50% DATE OF DEATH REVa4!l4 EXt 18a,80) COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE TRANSfER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "E" JOINTL Y OWNED PROPERTY (lnstmctiolls on Roversa Side) Estate of F'l nrpn,",p V Kppn . , TOT AL PE VALUE OF DEP ARTMENT i ITEM DESCRIPTION MARK ET Rc DECEDENT'S V ALU AT ION , NO. VALUE ENr INTEREST {OFFICIAL USE ONL YI 1 Checking Account #50450328 Dauphin Deposit Bank and Trust Co. Held jointly with her son, John H. Keen, esta- blished prior to 1965. $ 282.58 50% $ 141. 29 2* Savings Account #1561711 Dauphin Deposit Bank and Trust Co. Held jointly with h"r two sons, John H. Keen and Richard C. Keen, established 8/18/80. 7,125.48 33 1 3 2,375.16 3* C/D #1525021983 Dauphin Deposit Bank and Trust Company owned jointly with her two sons John H. Keen and Richard C. Keen. 10,372.33 33 1 3 3,457.44 Purchased 10/7/80. 4 Savings Account 315605701 Dauphin Deposit Bank and Trust Co. held jointly with her son John H. Keen, esta- blished 2/28/77. 14,367.97 50 7,183.98 5 U.S. Bonds held jointly with her son John H. Keen: eries Face Arnt. Date of Issu E $100 2/76 94.68 50 47.34 E 50 1/76 50.76 50 25.38 E 100 7/76 94.68 50 47.34 E 50 3/76 47.34 50 23.67 E 50 4/76 47.34 50 23.67 E 50 5/76 47.34 50 23.67 E 50 12/76 45.94 50 22.97 E 50 8/76 45.94 50 22.97 E 100 10/76 91. 88 50 45.94 E 100 2/79 82.08 50 41.04 E 100 6/79 80.72 50 40.36 E 100 12/79 78.76 50 39.38 , EE 100 2/80 52.08 50 26.04 H 1000 1/80 1,000.00 50 500.00 E 100 6/78 84.56 50 42.28 E 200 11/78 166.24 50 83.12 , E 100 10/77 86.84 50 43.42 TOTAL If additional space is necessary, use B'f' x 11" sheots. ~ ~ >- ~ <: ~ ;:.. z 0 - !( 0 ~ >t, I ~ !-o 0 <fJ 0 Z 0 en <fJ :>< !-o 0 - ~ Z !-o ~ !-o ~ Z Z ;j 0 - 0 <: ~ z ~ ~ ~ (:\ ;J u " ~ z Z !-o Z - Q <fJ ~ 0 0 <: ~ <: ~ u (:\ "" :J 'lSaJa1U! 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SNOIlOnl:llSNI Ri~IJ.4!l4 EX+ IR~6l'11 COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "E" JOINTL Y OWNEO PROPERTY (Instructions all Rl,'VOrSlJ Sido) ~. ~~i~f '~1~l;0 ,..;;,\*.t'~V\~....'lj..t, ,,~..:.. Estate of F] orence V. Keen , . TOT AL PE YALUEOF DEPARTMENT ITEM DESCRIPTION MARKET Rc DECEDENT'S VALUATION NO. VALUE E INTEREST {OFFICIAL USE ONL YI . NT , 5 Series Face Amt. Da te of Iss e E 100 1/78 86.8 50 43.42 E 100 2/77 89.2 50 44.62 E 100 6/77 89.2. 50 44.62 E 100 8/77 86.8. 50 43.42 H 1000 6,/77 1,000.OC 50 500.00 E 100 8/75 101. 2E 50 50.64 E 100 10/75 101.28 50 50.64 E 50 11/75 50.6/ 50 25.32 E 50 12/75 50.7( 50 25.38 E 50 11/71 62.7. 50 31.37 E 50 11/71 62.7. 50 31.37 E 50 12,/71 62.90 50 31. 45 E 50 5/75 52.16 50 26.08 E 50 6/75 52.28 50 26.14 E 50 7/75 52.28 50 26.14 E 50 2/75 52.16 50 26.08 E 50 3/75 52.16 50 26.08 E 50 4/75 52.16 50 26.08 E 50 1/74 57.14 50 28.57 E 50 2/74 55.34 50 27.67 E 50 3/74 55.34 50 27.67 E 50 4/74 55.34 50 27.67 E 50 5/74 55.34 50 27.67 E 50 6/74 55.48 50 27.74 E 50 7/74 55.48 50 27.74 E 50 8/74 53.72 50 26.86 E 200 9/74 214.88 50 107.44 5 50 10/74 53.72 50 26.86 E 500 10/74 537.20 50 268.60 E 50 11/74 53.7 50 26.86 I E 100 1/73 119.16 50 59.58 E 50 2/73 59.72 50 29.86 E 50 3/73 59.72 50 29.86 E 50 4/73 57.84 50 28.92 E 50 5/73 57.84 50 28.92 E 50 6/73 57.98 50 28.94 E 50 6/73 57.98 50 28.99 E 50 8/73 58.12 50 29.06 ! E 50 9/73 58.12 50 29.06 E 50 10/73 56.28 50 28.14 E 50 11/73 56.28 50 28.14 E 50 12/73 57.14 50 28.57 E 50 8/72 61. 38 50 30.69 E 50 9/72 61. 38 ~~ 30.69 E 50 10/72 59.44 ?O ?? TOTAL , If additional space is nccossary, use B'I," x 11" sheets, REIJ-4M EX+ lo:e-Ol COMMONWEAL TH OF PENNSYL VANIA DEPAR'rMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "E" JOINTL Y OWNED PROPERTY (Instructions 011 Revvrso Sic/oj ~ ~~...""., : or;,' ~ , .'~t' ,,\t:~~f;:}~;" ~.~& ~ . ITEM TDTAL PE VALUE OF DEPARTMENT DESCRIPTION MARK ET RCENT DECEDENT'S VALUATION NO. VALUE INTEREST {OFFICIAL USE ONL yJ , .. 6 Series Face Aml. Date Issued E 50 4/74 55.34 50 27.67 E 50 5/74 55.34 50 27.67 E 50 6/74 55.48 50 27.74 E 200 9/74 214.88 50 107.44 i E 50 7/74 55.48 50 27.74 i , E 50 8/74 53.72 50 26.86 I I E 100 1/73 119.16 50 59.58 i i E 50 2/73 59.72 50 29.86 I , E 50 3/73 59.72 50 29.86 E 50 4/73 57.84 50 28.92 E 50 5/73 57.84 50 28.92 E 50 6/73 57.98 50 28.99 E 50 6/73 57.98 50 28.99 E 50 8/73 58.12 50 29.06 E 50 9/73 58.12 50 29.06 E 50 10/73 56.28 50 28.14 i I E 50 11/73 56.28 50 28.14 E 50 12/73 57.14 50 28.57 E 50 8/72 61. 38 50 30.69 E 50 9/72 61. 38 50 30.69 E 50 10/72 59.44 50 29.72 . E 50 1/72 62.90 50 31. 45 E 50 7/72 61. 24 50 30.62 E 100 7/72 122.48 50 61. 24 E 100 10/71 125.48 50 62.74 E 50 10/74 53.72 50 26.86 E 50 11/74 53.72 50 26.86 E 500 10/74 537.20 50 268.60 * For explanation of the basis for reporting these two items and all Series E bonds acquired within two years of the date of death, please refer to Schedule "Co. . TOTAL 520 001.07 ",?d, c t/. t1 A , . , ...4P' Edueof Florence V Keen \I additional space is necessary, use BY!" x 11" sheets. INSTRUCTIONS FOR COMPLETING SCHEDULE "E" Schedule "E" must include all property, real and personal, owned by the decedent jointly with another party or parties as joint tenants with right of survivorship. Both tangible and intangible property are to be included. List real estate first. 1. Describe all real property as indicated in the instructions for Schedule "A." Describe all personal property as indicated in the instructions for Schedule "B." Include the name, address and relationship to the decedent of the co,owner[s] and the date the joint ownership was established. 2. Indicate the total market value of the jointly owned property. 3. Indicate the percentage of the decedent's interest. 4, Indicate the market value of the decedent's interest. C ":l tl (') E; m >- :;; >- 0 0 U'l tl - Z Cl (') ~ tl ~ Z s: Z t'" m m 7: Z ;tl 9 - 9 t'" Z Z t'1 >-l m >-l Z 9 >-l ><: m - 9 U'l U'l Z 0 U'l 0 >-l 0 "l "l :>:l ~ .' . - <? .. 0 ",> Z C' . ~-... N ;;;f~ c:. ('J ..,.::": 77" ..~ Ll..l" ':7_..: CH-' ;;;, '3e3 Q::UJ o(7j , ~.::~ Uw ~5 ~~ ~ po -:;u u ><: ><: m t'1 >- ~ :>:l REV.SIB FO.C7.S0) ,~~ '1.'.",.' NOTICE OF FILING OF APPRAISEMENT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF' REVENUE BUREAU OF FIELD OPERATIONS John H. Keen 108 North First Street McConnellsburg, PA 17233 Richard C. Keen 213 South Hendricks Avenue Exton, PA 19341 RE: Estate of County of File No. Florence V. Keen Cumberland 21-81-0066 Dear Messrs. Keen: You are hereby notified that the nl"ie:in~l appraisement in the estate of _ Florence V. Keen has been filed in the office of the Register of Wills of Cumberland County on December 16 , 19 ~. Said appraisement reflects the falloWing valuations: Real Estate _ Personal Property Jointly Owned Transfers Total 40,000.00 6,978.64 20 . 001. 07 None 66,979.71 As to such tax that is paid within three months from date of death, a five (5%) percent discount is allowable. As to any tax that remains unpaid after nine (9) months (fifteen months when death occurred from December 22, 1965 to June 16, 1971, indusive; and twelve months when death Occurred prior to December 22, 1965) from date of death, interest at the rate of six (6%) percent per annum is charged. Any party in interest who is aggrieved by this notice may obiectthereta within sixty days after receipt of said notice os provided by Section 1001 of the Inheritance and Estate Tax Act of 1961,72 P.S. 2485-1001, P.L. 373. Date ~~0~~ December 16. lq8J Signed Title Chi ef Appmiser NOTE: This is not a bill. REV~4i57 EX+ (7-80) ~ ~i;:. ~ ' ,'~ ,,,,: (;.~'.l<,~:~ r 'JI?~~ ",,",.~~;,1~1I '.>"'~"-(:~;';~''';~.~' COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE TRANSFER INHERITANCE TAX RESIDENT DECEDENT INHERITANCE TAX APPRAISEMENT @ORIGINAL o SUPPLEMENTAL Estate of Florence V. Keen File No. 21-81-0066 County Cumberland Dote of Death Januarv 22. 1981 In the event that any future Interest in this estate Is transferred In possession or onjoyment to collatoral heirs of the decedent after tho expiration of any estate for life or for years, the Commonwealth hereby expressly reservos the rIght to appraise and assess transfer Inheritance taxes at the lawful collateral rate on any such future Interost. PROPERTY NOT INCLUDED IN RETURN BUT APPRAISED BY THE COMMONWEALTH ASSET SUMMARY DEPARTMENT'S APPRAISED VALUE 1. Total Real Property _ 5CH. "A". , , . ., $ .....Ml.,11nn nn 2. Total Personal Property _ 5CH. "B", '., $ 6,Q78 64 3. Totol Jointly Owned Properly _ 5CH, "E" $ :>n,nm .m 4. Total Tronsfers _ 5CH. "C". , ,'. . , ., $ None Unreported $ Unreported $ Unreported $ Unreported $ $ 40.000.00 $ 6,978.64 $ 20,001.07 $ None $ DLlFE ESTATE TOT AL GROSS ASSETS DREMAINDER DANNUITY TOTAL VALUE $ I do hereby certify that the above appraisoment is made in conformity with Pennsylvania law and has been filed this day with the Register of WiIIS'4;) ~ v~._~....() _~......c-- December 16, 1981 APP~ SER CATE n n ~ 0 ::; ~ ~ '0 " 0: ro .n Q) 0 z ~ ~ Q) '" 0 :>< ;,.; c.: .. P- ~ Q) tIl > .<:: '0 ;> ..., n J:1 Q) ~ n ro ..l () 'n n ..: 0: ,J :J:: .. - Q) Q) u z .. V) ~ - 0 a. E 10. 0 n <'l ro 10. - t>.. n U U 0 !;: ~ 0 i:<: ~ ~ ""' 0 tIl 0 Z 0 tIl tIl :>< f-< 0 - ~ Z ~ ~ f-< ~ Z z :J 0 - 0 i:<: Z ::<: ~ z ~ z CI ;> u " ~ - ~ tIl ~ 0 0 ..: z ::: ~ u 0 c.. :i 1/29/81 1/29/81 1/31/81 1/24/81 1/31/81 1/31/81 2/6/81 2/14/81 2/11/81 2/21/81 2/28/81 3/1/81 3/7/81 3/14/81 3/28/81 4/4/81 4/4/81 4/11/81 4/25/81 4/25/81 CLECKNER a: FEAREN ATro",n:VIAT LAW HARIIISBURIl, PENNSYLVANIA PRINCIPAL CREDITS (Continued) Riverton Consolidated Water Company ,... ... Rolling Greens Cemetery - grave marker .... UGI Corporation - gas service ............. U. S. Post Office - stamps . .............., Internal Revenue Service - federal income tax ................................ Ashway and Haar, CPA - prepare tax returns ................................... Robert L. Tecau, M.D. - expense of last illness .............................. Myers-Hall Funeral Home, Inc. - funeral expense ................................... Bell Telephone of Pennsylvania ............ Pennsylvania Power & Light ................ Raymond Martin, Tax Collector - real estate taxes .............................. UGI Corporation - gas service ............. Robert Hamilton, M.D. - expense of last illness ................................... Bell Telephone of Pennsylvania ............ Pennsylania Power & Light ................. UGI Corporation - gas service ............. Lower Allen Township - sewer and refuse ... Bell Telephone of Pennsylvania ........ .... Pennsylvania Power & Light ................ Clifford Steinig, D.O. - expense of last illness ............... to. . .. . ... . . . . . . - 2 - n ~r,'" ....11,.'\ I.U:i. rLGi: 8...,5 $ 12.68 485.00 83.03 6.00 314.00 85.00 175.00 2,727.00 35.46 9.91 74.17 76.32 65.00 6.72 10.69 49.89 50.50 8.38 8.80 175.00 4/25/81 5/1/81 5/1/81 5/15/81 5/22/81 5/30/81 6/19/81 6/25/81 7/2/81 7/21/81 7/22/81 7/10/81 7/13/81 8/14/81 9/1/81 CLECKNER a FEAREN ATTORNEYS AT LAW HARRISBURG, PENNSYLVANIA PRINCIPAL CREDITS (Continued) Fine Art Photo - copies of papers ......... UGI Corporation - gas service ............. Riverton Consolidated Water Company....... Bell Telephone of Pennsylvania ............ Pennsylvania Power & Light ................ Fine Art Photo - copies of docu~ents ...... RobertL. Tecau, M.D. - last illness balance .................................................................... Fine Art Photo - copies of documents ...... Raymond Martin, Tax Collector - school tax.......................................................................... .. Register of Wills - file inventory ....... .. Register of Wills - file statement of debts and deductions ...................... Register of wills - file account .......... Madeline Kerstetter - notary fees ......... Reserve for payment of real estate tr ansfer tax ............................................................ Reserve for payment of real estate conlmission ................................................................ Cleckner and Fearen - attorney's fees ..... Lower Allen Township - sewer service ...... Bell Telephone of Pennsylvania Bell Telephone of Pennsylvania Bell Telephone of Pennsylvania ............ ........... .. ........... .. - 3 - ~GCK J.'J~L P~:t 8~'}(J $ 1.90 32.66 9.40 5.97 8.24 1.11 52.00 1.33 376.51 6.00 3.00 50.00 10.00 400.00 3,200.00 2,921.83 50.50 8.49 13.41 5.08 '. 9/26/81 PRINCIPAL CREDITS (continued) Pennsylvania Power & Light ................ 10/2/81 UGI Corporation - gas service ............. 10/10/81 Bell Telephone of Pennsylvania ............ 9/29/81 9/23/81 Lower Allen Township - sewer service ...... Pennsylvania Power & Light ................ 10/31/81 UGI Corporation - gas service ............. 10/31/81 Riverton Consolidated Water Company....... 11/13/81 Bell Telephone of pennsylvania ............ 11/21/81 Pennsylvania Power & Light ................ 12/24/81 UGI Corporation - gas service ............. 12/24/81 Bell Telephone of Pennsylvania ............ 12/24/81 Pennsylvania power & Light ................ 1/1/82 UGI Corporation - gas service ............. 1/2/82 Lower Allen Township - sewer service ...... 1/16/82 Bell Telephone of Pennsylvania ............ 1/22/82 1/22/82 1/22/82 1/22/82 2/5/82 2/5/82 CLECKNER. FEA~'13/81 ATTORNU5 AT LAW HARRIIBURll, ,[HHSYLVANIA Pennsylvania power & Light ................ State Farm Insurance Company - fire lnsurance ................................. UGI Corporation - labor of installation of hot water heater ....................... UGI Corporation - purchase of gas hot water heater .............................. UGI Corporation - gas service ............. Riverton Consolidated Water company....... Bell Telephone of Pennsylvania ............ - 4 - BGet: ll.r~ P~C[ 8ijl $ 9.13 16.95 5.08 50.50 8.00 21.64 14.82 6.91 8.84 25.00 7.33 11.05 82.50 50.50 7.37 15.05 96.00 65.00 365.00 93.71 6.25 7.16 2/26/82 3/5/82 3/12/82 3/12/82 3/27/82 4/2/82 4/2/82 4/10/82 4/16/82 4/23/82 4/30/82 PRINCIPAL CREDITS (Continued) Pennsylvania Power & Light ............ .... UGI Corporation - gas service ............. Bell Telephone of Pennsylvania ............ Raymond Martin, Tax Collector - 1982 county and township taxes ................. Pennsylvania Power & Light ................ UGI Corporation - gas service ............. Lower Allen Township - sewer service ...... Bell Telephone of Pennsylvania ............ Donald McCaleb - snow removal for ~Iin tel" season .................................... Bell Telephone of Pennsylvania .....~...... UGI Corporation - gas service ............. 12/28/81 Register of wills - Commonwealth of Pennsylvania inheritance tax .............. CLECKNER a FEAREN AnORNEYS AT LAW HARlllSBURG, PENNSYLVANIA TOTAL CREDl'l'S PI'ei: :.I ..!i r:;: ,-,. .:. L~lJ: ) - 5 - $ 13.04 82.50 6.73 74.75 10.74 59.05 50.50 5.02 30.00 9.27 47.84 3,323.88 $16,349.22 (/) 0<: _._--;-.;:::;:.-:-:.,~:'-- fiI ...1 . fiI ""0<: U 0 ~~ r~ ~ 2: r>l zzo [>l Ul OfilH ~ <:: ~:: :~ ~ U) 0 fiI r~ H ,.J U ~g o .:> ~ [>l U:><H t>., 0 Ul t>.,F'0 00:: ,,: 0 ZOfj OPE-< [>l .'- ~8 O~ fiI : <~ E-<U::J\O E-< fiI ~2O:: PO ~ 0\0 0<: ;.: i~~~ ::JOUI E-< OZ r-{ Ul . U 0<:. CO fiI :> . z UJ~ ...1(/)1 .H H ~~Zr-l 'U:Z ~ :I:fiI<CC'l .. o f>1E< 8l!'l:X: "-1 .' Cl I~ tfXIJ. :E "" . ~ ~ OH Z::J 0:: 0 ~ <C . fl<A HUOZ Z ..,~ '70 H Or.:l ~f>. H 1"1 ~;.: ....~ ... '., ....-. <""- ~.:.: ~ -' c..':: >. '~", "t:, ~,~ ::: ~ ,- ~ i ~ ~ ::::~~~~j~:~ ;:::. '-'-.,: ~j ;:l f :.) ~:. '.. ~ ,- 'c, ',,' ' ~ ~~ .. ,{;:J - , -~. ~ ...... -, '-:.; <- ~.- . C)"" OJ, r... ~;. 'C 'f;: _:~ "C-,' ;.. ;:; '-E ;:: ; oJ ';[ ;::: c:i ...... ...... _ ..;.: 'J, ,~:11 ~; ::t: -1,) ,- r.... .- "" :, c ~ ~ '~, "i~ ] ~ ~ ~ ,,"0 ,;;; ":' " " ,g ,~ C) ~ ~ t: "c ~ ~ V .r..: u - CJ 5 ~.2 :~ \.. ;... -E .T";'~' ... ..':_c ~ "E rf) ..... ~I r: ,c ;.):~ ~.J .'!J. ~ ... ~ '[: .... ~ -- ~ ,.... ~1 'I ~'. .~. C) ...... u -= ~ .. - - .' ~ ~ ,. :..; '" ~ ~ ';!: ..... :..:: c ,- ~ ~ 'c .::=; .3 =E - " C .....: ::J " { ~ \t~~~ ,; ~ u.. ...l \>\~o~ "('4 z "' \ 4: >- \ 1- ....~ ::; 0: w \""row z ...,,'M II """, n Z 0 ,\,.n ~ t- ;~ ''; u ~ .\ ,..~ W \, d .'C ~~ '-J:: --) ~ <( ~ z .. ~ m OJ o >- z (/) o z u z w w m n. ; ci " II o ::> z III ;;; (/) II II <( :t ~'171 I':l~~ ~o ~'1 "'1 , o " - -=- "..-- COMMONWEALTH OF:PENNSYLVANIA OEPARTMENT OF REVENUE BUREAU OF EXAMINATION OFFICIAL, NOTICE OF INHERITANCE TAX ASSESSMENT ~ ~ COUNTY FILE NO: /.. /J . /, /" DATE , I. ", .' .~..' ) ,',' /) . ,'/!? " "/ ') .' ,I, ,1~'..)1/ ? ESTATE " .~. ,'~< ",'. ::: ' TO: ',';:' /-! I. /) I , .,~. .' I FILE NO, '>, "// I J 1__' . ' '.', ,,' .', ( " I I I ' ~ '. I ,.( i~ 'f' COUNTY , .~ ":.~.~ . !; / I, . ~!. ~ . ~ n .~" ...J.: ". .-. / ..,~;;:i. ?I ,... (j .. I ._" . :. ,~,: :...- C '. f' .'/11/' / ,. II 1./ DATE OF DEATH Appraised Value of Estato: Real Estate Personal Property S I/., J , . J' .,.....' ) .;.c/ + ,( '/ 'I "j , I . , Jointly Held PropertylTransfers + . ,1 / ,J "7 , Total Gross Estate / S .u; ) .f '/q 1'1 l! Clear Value of Estate II /)-;11 I .-; I -- . $ / )'/;"" ;< /~ r;- ,.J ";/ Total Approved Deductions Less: Approved Charitable Exemptions -- Clear Value of Estate Subject to Tax S ..;-/~ :1'U',()? Amount Taxable @ 6% Rate $ /:...../ ,;- -;J, q Y /.1 ,'7 - / -- tax due s:2q'}"5??' -/ . Amount Taxable @ '5% Rate tax due TOTAL PENNSYLVANIA INHERITANCE TAX DUE s;;;j;;;S?.:.;9% * * * * . . A five percent discount totaling $ will be granted if the Inheritance Tax is paid by Less Credits: DATE OF PAYMENT AMOUNT PAID DISCOUNT INTEREST TAX CREDIT $ + S s = s + = + = Interest accrues at the rate of six (6) percent per annum on the unpaid balance of Inheritance Tax from to date of payment. Interest due if paid by is BALANCE OF PENNSYLVANIA INHERITANCE TAX DUE S -~.,";;;. ;.' (7 j/ . f- c '-;)01' I () ~ .,;.,.;J ..yl .. /./1J :':""/I..l.i.>LL~:1--' -~,V:'" f _ ___I, . Assessed by: ~// / //, 0'> .,.: . . Agent for \'fie ""glh Sell InformatIon on Rnverse Side ,.^-_< I.' _ / /:,:/_<i..-b-J v ., .-.- - -.".,-... .-..--.--"---' .....-...--..----.--- TAX AT G% TAX AT 15% ~~8~VED William Fearen, Att . TAXAT_% , I I~i~;:::~-._' -- ~ ~OM;O-~;;~;; OF P~'NN;~l;:NIA I 4 NO K 69913 DEPARTMENT OF REVENUE I . . ,: OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX I ~ '1 = ! ~ I ij I ~ I ! I I' , I 2 1 I 3 I I ADDRESS 31 North Second Street ESTATETAX Harrisbur 7101 .--ESTATEINFORMAT~N:-------------------------- DATE OF DEATH Janua 22 1981 FILE NUMBER 21-81-66 DATE OF PAYMENT December 30 1981 NAME OF DECEDENT Florence V. Keen m o COUNTY cumberland ----------------------- POSTMARK DATE REMARKS G PAID IN FULL SEAL RECEIVED BY R[GISTER or \:~JILLS ~ TOTAL TAX CREDIT LESS DISCOUNT PLUS % INTEREST (FROM 10-22-81To12-30i-B1 TOTAL AMOUNT PAID I / .I ,:'1 (. / SIGNATURE ., :/ 3.323.88 37.73 3,361.61 . . /~ .: ,/./ . - .' I ... N_.,.,.. C~ , ~~~.w..'.~'i.~~~'I.~t;',,;..,;{r.;,~pt.;.~~.~.''r~.:;i~;