HomeMy WebLinkAbout81-00192
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OATH m' l't;lt!lONAI. RI(PRI':!oi.:NTATln~
COMMONWEALTH OF I'IlNNSYLVANIA SKI
COUNTY OF CUMlmRLANI>
Do faro mo, lI)C R081stor far Iho I'rabllto ,af Wills IInd Sr'11111118 afl..ollofs af Admll1lslrnllan In IInd far tho Caunly af
CU~borlllnd, porsal1'lIl1y cllmo
Kenneth 8. NolDon
wha, bolns duly Bworn' ,da, e a
af Iho lasl WllInnd Toslamont of
doposo al1d say Ihalas
C:url1on 11. Neleon
Exeouto]'
deceased
he "~wlll wellnnd Iruly ndmll1lslor Ihe soods IInd chllllels, rlghls IInd credlls af sllld docellsed IIccordlnll la hlw, And
,also will dlllsonlly comply with,the nrovlslol1saf t,he IlIw relalln81a Transfer Il1herital1cos, bworn...llnd subscribed befare lno,
Maroh17 81
A..o", 19
Reglstor
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DECREE
Bo it romql1!bored Ihlll on Iho
19th ',day of
"
March
,A,0,,19 81 ,Ihore was prabaled and
,
recardcd Ihe IlIsl WIlI'/lIld Testalllcl1t of
Meohuniosburg
OurBon n. Nbl.on
lalo af
Deceased, L~Uers Tell tumontury were granled 10_ Ke',nn\1th
Witness my hal1d al1d afflclal seal the day I1l1d year IIfaresald,
, Cumberland counly, ponl1sylvanla,
E. Nelaon
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I.Ml'!' \iITT,]', AND 'I'IUfl'JlAMIUN'JI OJe OAl1AOH Il.Nlm.,~ON
--- ..----- -.--.....----.-.-....-
T, DARSON ]of, NJI:r,SoN, o'rhho nnt'o\lrl,h of' Mnpluw:t oohm'r:,
Oounhy or Oll~lbo\"lnnd nnd Sladle c\f' l'onnflylvnnln, bfli.ng oJ' 'fI~J\1lld
find rl1npr\lllhrr. mlnd, lnamOl'y IIml nnCloT'llt;nnr'l1n/r, 1'10 n\l\lto, , publ:lnh
,nnd ,deollll"e l;h:la my 1f\l1b \i/l11 And 'l'flI11.f\l1lont,
1,
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T d~.l"er.dl the pf\Y1nnnb oJ' all lilY j\lll t; debhs rmel J'ur1e:rnl
expenOl!l1l .nR aoon, 'Rf't:Ol' my dAOOflflfl Ail bho l1omo onn be oonvon1.ently
dona,
'.
(d
T f!1.va /Jnd IHH)UElnth all ',I'1.1'no nnd/()T' SAvingn Oel'l;J:ricnl11;lEl Whlon
:r mny hAve /Jt the t:1mf'l or my cleHhh ~dth 'Phe OommonwEJaJ.hh Natidnal
13nnk, to ,my non,Knnneth 1~. Nflll1on, i.nhT'1ll1b, neverthlllt'lElIl, l.or
tht'l J'011owing purposeD,ho ~ttl
'.p.wo d:1.vi.rle the' anme:1.nl.o 1)\0/0 Aqunl I1har~ef1 ond 1.0.\101.d ona
'.,
slloh AlJ111l1 shaY'A l.n tpum t . foptha bflnef1. I. of' my. rr,rnndaon, .Tef',t'ra'y
iii. Nelaon, a.nd to hold the l'~mf\;\n1.ng Aquol shore In.b:ruat fop t.he
benef1t oJ' 1II}T r:ra\1cldflUff,htel", ,Sul1on' D, NalFlon, !lnd ll0 1.nVAllt and
l"e1:lWast t.he l1/lme, i.noluel1ng l;he rlght at hln 1.101,.. rllaol'/lltlon,
..
110 'l"f'ltaln fla1:d 08r1111':l.oal)eo ~d,th the af'orElll1Autloned RAnk, whether
t118 Sf\mt'l be oonstdl!ll"od 1egb]! lnvnlltmAnt.r~ I'''T' ill'\1I111!181l u.ndor. the
"
lawn of the OOmrnCJT\l1Al'Ilbh of' }'nntlsylvunlo., nnd to 0011eob the 1.noomo
the!'efrom and to npply'bhll nAll lnoo~le ('and any aooi1l11Ulll.tAd; inoome)
to the oom:rorhnbla f111pport, mnlnhnnnnot:\ and MhJl\II'I.lon of each of
my respeotlve rl,randohUdren, lml:D "'!loh reFlpoot1.ve ohU,d nttflins
,
t.ha flrr,A of l',went.y-t.wo (22) yanl's Df' Ilcr."', /l11"whloh t1.mfl a),l
aoo1ll'nulntion of' net tno01ne, tor;l'lt.heI' 'w1f1h the pI'tnoi,~a.l of Eldd
truat fundahnH he p/l'ld (lVA'I' to s1\oh oM:Ld, Ihhe1,nrr, my AXpl'e~B
de~'I~e bhat. aaid trufltfunds" both prthoi.pal and lnoDm~aB nh~Vd~
bA tined pJ1blA.'!1i.ly 1'01' :t;hn p11y:pone 01.' provtdlnr~ my' gl'andohllCll'en
if
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I:.liliti.SY1'if1tiJ.Altili.lillQJ; TAX GENERAL INFORMATION
I. fl.rrn!~.RESPONg!!IJU:Qfi RETU~N
SocII on 101 ollho Inhorltnnco and Estnlo Tnx Act of 1961 provides thnt Iho followlnR porsons shall propare nnd file
II roturn:
a, Thoporsonnl roprosentllllvoor Iho oslllte of tho docodenl os 10 proporty ol.lho dobedont aQI11I,nlslored by hlll1
nnd such nddlllonal proporty which Is or II1(W bo sUbJoct to Inhorltanco Tax of which he/she shallhaVo or
nCQul re knowl odgo:
b, Tho Ironsfo[oo of prO/lorty upon,tho tronslor ofWhloh Inherllanoo Tax Is or 1110Y bo In!posed by the 1961 Statute,
Inoludlng n tnlstoo 0 proporty lronsforrod 111 trust, provided lhol no sepnrnto raturn noed be modo by tho transforoe
.01 property Inoludo(llnlhe ro\llrn 01 0 personnl ropresonlnllvo, , '
2. PLACE FOR FILING
Tho return Is 10 bo f1lod In dUllllofllll wllh Iho Roglstor of Wills of the oounty \','horoln the decedent resided,
3. liME FOR FILING
The roturn I,s duo nlnelllonlhs nftor Iho docodent'sdeoth, unles~nn oxton sian for filing has bOen applied for and
gCflnted by tho Sooretory of Revonuo within the nlne-lIIonlh period, ' ,
4, EA!!...URE TO FILE RETURN
~,", I ,. ,
8ecllon791,01 tho 1961 Slnluloprovldes thttlll , , ,any parson who willfully lolls ,to 11100 return or other report
required 01 hll11, , ,sholl be personallY 1I0blo, , .10 a ponolty of 25% of tho tax ultimately found 10 be'llue or $1,000
whlchovor Is Ihe lesseLlo be recovered by tlloDepnrtlllent of ReVllnue'os dobts,ol like amount ore recovoroble by
10w,II
~, TAX RATES
Inherltanoo Tax I spoyoble at the rot,e of 6% 011 transfers to lineal descondonts, such os father, imoth,er, husband, wi fe,
son, daughter, grandohlldren, grandparont, son-In-law and daughter-In-law and at the rate of 15% as to 011 others, '
6. pAYMENlOFW
The tax ilssossed on the transfer of proporty reported In the return Is due 9 months ofterlhe decedent's death. Interest
atlhe roto 01 6% por qnnum oqcrues thereafter until poymont Is made, All payments received ore first applied to any
Interest which may be duo with any tem,alnder applied to the tax, IF TAX IS PAID WITHIN 3 MONTHS AFTER THE.
DECEDENT'S DEATH, A DISCOUNT OF 5% OF THE TAX PAYMENT IS ALLOWED,
,- ;- '
All checks should be mmlo payable to the Regls,ter 01 Wills of the county wherein tho decedent resided and are
received sublect to the final determination of the Deportment of Revenue,. .. .
7, F'AILURE TO pAY
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'The taxes 1Il,IPO"S,Od, togethor with anylnteros{ thoroon;are a lien upon real property" which lien remalns,l,n effect u,ntll
the taxes and Interest have been paid In full. The taxes l11ay be sued for against any real.property In the, decedent's
es\ato or against. any (HOporty belonging to 0 lransforoellnblo for the tax.
8. FILING OF FALSE RETURN
AllY porsonwhowlllfully makes a fnlsereturn or report required 01 hi", sholl, In accordance with Section 793,of the
1961 Statute, bo guilty of a mlsdomonnornnd, on convlctlonlhe[eof, shall be sentenced to llay a line ,not exceeding
$1,000 or undorgo Imprlsonlnent nole~ceedlng aile yoar or both, '
lliL-rg: 00lllPol1sallon pallllo fin eslate representative; nallloly, onexocutor or admlnlslralol, 101 servlcl1s porlormed
Inl1(IIIIInl51erln8 on oslololsroportablefor Pennsylvoninlncomo Tax purposes, This laxable IncqlllO Itom should bo
rOjlOlllld on form PA-40-lndlvllluollncome Tax Relurn. '
QUESTIONS CONCERNING PROPERTV T,RANSFERS
\, Plddeceder,t, within two yoms of dOlllh, make any t[/lnslor 01 any motorial ~nrl of his oslato wilholll rooalvlnp.
volllablo and adequate consldoratlon? (Answer IiVOS" or "No'! ,) _ No ,
2, Old dacedol1,t,' Within two years of daath, transfer ~rOporlYfrollll1llllsoll/ he,rsolf tohlmsolf/hersolf and lInothor ~lIrty
" or pmtles (Including 0 spouse) Injolnl ownership? (Answer 'IVes" or "No",) -!i2..
'3, II the answer to one or two nbovo Is "Ves" nnd Ihe trnnsfers me clnlmod toho nonlaxnhle, IHovldo tholallOwlng
, Information:
n, "Age 'Of decedent at time of Irons for, None
b, 'Cdpy of denth certlfloato, '
c. Affldnvl,\ by theatlendlng Physlclnn Indlootlngtho stoto of decode nt's heelth nt limo 0(, trnnsfor,
d, .Allother InfolOlatlon sllpporllng nQntaxahlllty of transfor, "
4, Pld docOdollt,ln hls/herllfetllne,mnke any trnnalor of ~ro~erty without rocolvlnga vnlUllhle or ndeqllnto consideration
t~erefor whlah wosto toke effect In ~qsse5slonor onjoymenl nt or nltor hls/herdonth? (AnsWel IiVOS" or "No",) No
,e, .Wes thereeny possibility thot lhe'~ropertytrnnsforred might return to lrnnsferor or his/her ostuto or he sUbjoct
: to his/her power of dlsllosltlon? (Answer "Ves" or II Noll ,) No '
b. "Whot WllS the lrons/eroe's age at time of decodont's donth? Nnt'le
5,' O,ld.dooedent,In hls/hor,IHetlmo meke any trnnslor without receiving a vuluable and mloquate con,Rldo, rollon1hore/or
under whlchlransforor axprossly or Impliedly reservos for his/her 1110 or llny period which doos In loot OI1d before his/her
dellth: '. , .
a, TIlo pbssesslon or onjoymont of or the right to Inopl11o from the proporty trnnslorrod? ,(Answor "Ves" or ."No" ,) No
b, The rlgllt to deslRllhlO'the persons who shall possess or enjoy the properlylrnnsferred or Income thorofrom?
(Answer IIVes"or IINo",) No' , "
, I-
6, If theanswQr to Jive b, above Is "Vos," was tllo rlghtresorvodlnde~iedont olono ( ) or deco(lonl and othor~( },
,
7. Old dQcecienlln hls/her,.llfetlme lIIak,e a transfor, the consideration lor which WOR transfereo'sPfomlRe 10 ~ay Incomo
to or for tile benefit or COre of transferor? (AnswerIlVos" or'IINo",) No
a,Dld ciec~dent, nt any tlmo,transfer property, lhe bll1ellc,lal enjoyment of,whlch WllS subject to cllango, booause of '
l\:reserved power to 01 ter, amend, or revoke, or which oould revert to decedo"t 'undor terms 01 ,trnnsfor or by operatlbnof
law? (Answer liVes" or 'INo'.',) No
If the ,onswerto elghlabove ISHVo ,"WllS the power lnhltar, lllllend or revoke the,lnterost of the beneflclal'yreser~ed
In tho' decedent olano ( ) or decede t and others ( j.,
i!
HIiV.46J "'XI (lO.Ull) ;
COMMONI'/HAL TH OP P6NN8VLVANIA
DHPARTMaNT OP RaVaNUR
TnANspaR INH8nlTANca TAX
RaSIDaNT DaOaDaNT
Eststs 0 f
SOHEOULE "0"
n~N~FloIARle8
IInsltllolllJIIS rJlIlI/lvors/I SIc/IJ}
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BBNBFICIARISQ A~D ADDREsses, ,,' RELATIONSHIP SUllVIvao DATe or INTEReST OF BeNeFICIARY
DEoEDeNT BIRTH
Jerrl"ElY' W. Ne ls0IL_'''''''H__u,_u_u Drl\./'lslJHirL" __,~_ y'~'!:.I_____; ."-+ ~-H-~"'-"-4~_____ ]jJ),O .19lJ, 90-llhure
602 Illast OOOVlll' 0\;, In savings dcrtlri~
~....-._~.__._~-.._------.. -..-.'"- - - ..._..~---.
Meohan:toshurg, Pn, 1701'1' Qat~ wHh Oommon-
, :?,) .........-...-----...- --...... -- -----
w/;lHlth Natl, Bunk:
... ......---".,P._--~ -~...-,.....,......-- --
Susan D. No1.11on UrnnddnJllthllel' Yft!1 Ifl11,0 . 1Qr;.QO_Ah,,~~
602 East o 00 V flT.' St, . . in aavinga ollt'tii't-
.-
Meohnniosb\it"h Pa 170~<; , oatcHI with 0 -
w/;lol.llh Nntl, Bank
- -
KennAth E. Nelllon !J;\,.,n ,il.old,.,o ....."l.."n..... .
~
602 Fiaat Ooover St, U/ltat.e
-
Meohaniollhurg, Fa. l70!'i!,
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_____________...._n _.. ,,_...,.... ._..... ~____. ,._ _.~_~_.___.__H" ." nc ___.,_, ..-,- ~.. ..._u . ur.'__. .-------~-, - --"~._, ....... ,_._..ft,~,_."~,,,"_ '~~_.__~_'._~_4"__
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.._______.._r_~_~_.__., ~n_____~_._ ~...__ -.......-. u ---- u ".u~_ ......_.....'..._.r______ ---~ -~-_.. .. u ,'r_, n ~. _____n______ --~.
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,rhe sbove beneflolariRI wers living 01 tho time of tl1atJaoetJent'l death exoolJt forthe following I
NAMe
If Iddltlonallpaaa II naaallQrV, UIO aW' k 11" Ihootl.
"
DATE OF OeATH
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W~UOTIONS FOR COMPLETING SOHIlOULIi "E"
,
'Schedule "B" mUQt Include all propartY, roalancllJerSonal, owned by tl1o,deooderH lolntly with another",
partY 'or pertles Pllolnt tenantewlth right of survivorship, Botl1 tanolble encllntenolble property ore to bo
Inoluded, Lilt real estate first,
1., Describe ell realllroporty eslndlootod In,tl1o Instruotlons for Schedule "A", Duaorlbe ~I\ personal property
aelndllloted In tho Instruotions for Sohodule "B"i Includo tho namo, arlcll'f)89 andreletlollsltlp to tho
deoedent of theoo.ownor (sl and the date tho lolnt ownflral1lp wos ostebllshod,
2, Ind!oate the total Inerket vallie of the jointly owned prollol'ty,
, 3,ltldloPle,the peroentege of, the dooedont'!, Interosl.
4, Indlcete the murket valuo of tho dllOoclol1t's Interost.
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INHERITANCE TAX SUMMARY SHE!::T
(BUREAU USE ONLY)
21~81~0192
__a____~~~~.__~._u~.__<_~~..._~.__~,_,_._~..
R~Vi... RKt ("'01
FII. Numb.r
E.IQI. Nam. _._~~_Qfl,P_~Ol},.ll~h~BJ!lJ1jL,._..",u m~.m~_m'_"""
001. of D.alh _.-'..c_____MLI~gh..2LJ_9.,~J___..~_~---
Social S.ourl.lyNumb.r
184 ..Q.2~l!iJiL___".__
REPORT OP INHERITANCE TAX APPRAISER
-
I!I Original
o Supplomonlal
o ~omalnd.r
I, the undtrllvn.d duly app.lntod Inh.rltan.. TIK Apprele.,ln and f.r Ih. C:.unly./ cumbe~la~d "
P.nn.yl~anla,.,.d. ".ptallully report that 1 hav.,appralud the reol and p.,lInal properly aa rijiert.d In I . farov.lno
,.Ium.t th.valu.. e'I /arth appultOlach lI.m In th.lut column 10 th.liahl In 6 h.dul.. "A", "B", "e", and !le"
Dat.dl Bep~ombet' 25. 198+ .
C'""'
~
RM'RR
IHVBHTORY
Real Propllty (Sohodulo ,1,)
Plloanal P,apllty(hhodulo 0)
JalntoH.ld P,apllty.(hhidulo B)
"Iano/II' (hh.~ulo Cj
TOT ,1,1. GROSS ASSBTS
L... D.bt. and D.duotlono
(SCHBDULB P)
CLBAR VALUB OP B5TATB
o LIf. e.tal'
o Annuity
VII"UU ,1,1 IIPPRAIIBD
CODB
AOJUSTMeHTS
(HARRISBURO UIB OHLV)RBMAIHDBR ApPRAll8MBHT COOl
53 000 00 00+
85.406 07 10+
110+
none ~
138 406 07
..__.._..U"_._~-->~_J.~__~~...._ ,.................... _~. .~m......w__
0\0.
!!.ill
PACTOR
PRIHCI PLI
,
---->
-
FOR UIE OF RBOISTER OHI. V'
Ta. on $
Ta. on $
Ta. on $
To. an $
Ta. an $
B.,mpllan.
Talal B.tat.
~
61\
15%
TOTAl- TAX
IHTBRSST PROM
BALANCE
TO
L.u C:I,odltl
DATB OP PAYMB~T
AMOUHT PAID DISCOUHT
1+$
+
-
IHTBRllST
$ a
.
$ ,
I
S
IHTEREST PROM
BALANCE OUB
BALAHCll
TO
II
VIILUIl
-
COPB
-
-
,.
COMPUTATIOH OP TAX
$
$ -
$
$~
$
$
$
$
,1!H'J.1BMA]]Q~L
To fnlmo ~ro"o' orodlt 10 your I\uoounl, IIH' JIIHnU of Ih. U"I\II\ 1\1111 IlIu nUII,I>or IIlwuld 1>11 nlulI,ly p,lnl'
od IIn Iho ohook or monoy oruor. ..
Thl. OU8o"monl II IIHldo In oo.orelonulI wit!, 8I1UIIII'; 'IOU <il Ihll Inhorltllllco ond nllolll To, AOI of
1061 (72 p,a,g 2466.7001,
To Iho 0,11'" Ihat 'nhorltanoo'lox I. pllld wllhln 1I"ou 131 IIlonlhl oft", Ihu doolh of 1110 dOOlldo"l, 0
dlloou,,1 of flvo 161 po,oonll. allowod 1'/2 Mi, 0 2400,71 UI,
Inh8,I1on08 Tax, olhor Ihon 10' on II futur. Il1lo'U81, I. duo 011111I dl\llI.ol Iho docodonl'l dOlllhlll1d I>ooomo,
doll"qu8nt' 811ho 8xpl,ollon of nino 101 monlhl ofto, Iho do.odllnl'8 dOOlh 172 I1,B, 0 2400,7111, II1ho'I1al108
Tax on ofuluro ""0'011 II pOY8blo within Ihroo'13) mu",hl olior Iho lronolo, loklll offoolln "OBlolllon and
onloymonl ond I, doltnqllonllho,ooftor 172 I',S, 0 240r-,7121, e.loulolO Imo,o.' Irom 1110 dulll1l1u0l11 dOlo Ihown
on Ih. feoo of Ihl. fo,m 10 Iho dOl8 of oolual "OYnlonl u.lno Iho 101loWlnu 'nlornBllol>lo:
-,..--..'''-..........- --..---...-..... -.....---..--........ ..-........ --- .......---...,.....,.. ......-.... ~..- ...., '. -...---. -- ....- ....- - -... --
I m6nlh ,006 4 monlh. ,020 7 mOllllw ,036 10 munlhl ,060
2 monlll1 ,010 6 mOl1lho ,020 8 monlh. ,040 11,rnonlh. ,006
3 mo"lhl ,016 o monthl :030 U II10lllhl ,046 qmonth. ',000
-..._--
I dOYI ,000 t7 11 doy. ,00100 21 <loYI ,00362
, 2 daVI ,00034 12 dovl ,00203 22 dOV. ,00360
3 deYI ,oooal 13 davo ,oono 23 daYI ,00360
4 dOVI ,00066 14 day. ,00237 ~4 <lnYI ,00403
6 dav. ,00006 ' 1 G daYI 00260 26 daYI ,00420
6 dllY. ,00101 10 doy. ,00207 26 tlnV' ,00437,
" daYI ,00116 1 'I ilnYI ,00284 27 'InV8 ,00404
6 dayo ,00136 18 doyo ,00301 20 daYI ,00471
o <laYI ,00162 19 day" ,00310 20 <loYI ,00488
10 deYI ,00180 20 <lay. ,00335 30 dOVI ,00600
.'... -""...-.-----......... ......"";'!-......... ........- -. "',"'- - ........-- --....., ---.. -.-.... -..- ---- - -......... ..............-..-. -...."" .....
"
Anv pa,tv 10 Inlo,all, Inollldlno Iho COlllrnanwonlth on(llh" pOlaoool roproooolallvo, "01 oollofioll With
Iho 0".0."1011\ mov 01>1001 Ih~'oto wllhln olxtV (001 dill'. .ftor tocoll>1 of Ihla Nolloo OB p,ovldod by Boollon
1001 of thd Inhorllan,,",ond e.lolo Tox Act III 1 001 {'/2 11,5, 5 2460.10011,
M,a~q .11onk or monny o,dor povablo to:
"RoglBter of Willa, Agont"
Moll to tl10 add,o.. IIBtod below:
i
9~NERAL INHERITANCE TAX INFORMATION
Unaatlafled Ilabllltloa Incurrod by tho docodont prior to hls/hor dOClth Clro doductlblo agalnat hla/hor taxable
nlato. In addition to dab,s Incurrod by tha dacodont or ostCltO, othor Itol11S litO olCllmClblo Including tho uoat 01'
admlnlstratlon/ottornoy leos,llduclary leOl, funorci! and burllll oxpon&os Including tho coat 01 a burial lot/ tomb.lone
or grove alarkar and athor rolated ,burial OXPIIMOS.
Alldebla being cllllmed agolnat an OItato ora subloct to tho (lpproYol 01 tho Reglator a/Willa with whom tho
Inherltanco Tax Return 1.lIle~. EYldonce to aUPllort tho docodont'a ar the ostato's,llablllty for tho debts being
clQlmod should bo attachod to thla schodulo. '
Alamlly exemption may be clalmod by 0 spouso 01 0 docodont who diad domicil ad In Pennsylvania. 1/ thero Is
:no spaulO"or II thespaulO ha.lor/olted hla/hor rights, ihon any chile! of the docodenl who Is a member 01 tho aame
houlOhold can claim Ihe'oxemptlon. In tho, oyont thllrolsno such .paulO'or child, Ihe o~'l1lptlon can bo clalmodby,
a parent orparohtl who oro mombors,ol Iho some housohold 01 Iho docodonl. Tho lamlly oxemptlon II allowable only
~galnst auet. which pauby a will or by the Ponnaylvanlo Inlostatlll.aw.. ,.
NOTE,I Compenlotlon paid to an ostale roprOlonlatlvo! namoly, an exeoutor or admlnlalrator, lor IOrvlcea
porlormed In admlnllterlng an oBtato la reportohle lor Pennlrh-nnla Incomo Tax purposOl., Thla taxable Inoome
Item ahould b~. reported on lorm PA.40.lndIYlduallnoomo Tax RoMn.
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z f.i ,~ ~ ~ p ,
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(',) Z ~ 0
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INSTRUCTiONs FOR COMF'LETI~G SCI:l.S.Q!.!LE "E"
I. lithe lamlly exemption I.' bolng claimed, Indlcoto Iho claimant's nama, addre,. and h'ls/hor relationship to ,.
the docedent. Enter "Ianilly oxemptlon" I.n tho rOlllorksQolumn and tho amount claimed In tho amount column.
2. AlSlpn consecutlvonumbers to oach Itorn Ilstod.., .
3. Enterthe.~olo on which each debt,waa Incurrod and/or paid.
4. Enter thenomes 01 eo.ch payee. ,
5. Provide a brle! oxplanatlon In the remarks colulnn lor oach do"t Qlalmod.
6. Enter the amount 01 oach debl being clalmod.
7, Thelarm must be signed by Ihe parson who has assumed tho rusponslblllty lor paying the debts.
IF ADDITIONAL SPACE IS NeCESSARy',USE aw' x 11" SHEETS.