HomeMy WebLinkAbout06-01-07
REV. 1500 EX + (64O)
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INHERITANCE TAX RETURN jFILENUMBER
I 21
_I COUNTY CODE YEAR
~I SOCIAL SECURITY NUMBER
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REV-1500
OFFIC!AL USE ONl. Y
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
RESIDENT DECEDENT
06
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i DECEDENrS NAME (LAST. FIRST. AND MIDDLE INITIAL)
! Clark, Helen F.
'--
I DATE OF DEATH (MM-DD-YEAR)
09/04/2006
206-10-8996
00823
NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
i
03~~ Remainder Return (date 01 death prior 1012-13-82)
o 5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
o 11 ~ Election to tax under Sec. 9113(A) (Attach Sch 0)
24 North 32nd Street
Camp Hill, PA 17011
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~ 'b~iCIAL US[~'?~L,(
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(1 ) None
(2) None
(3) None
(4) None
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(5) 104,175.89
(6) 7,629.36
(7) 111,614.41
o 2. Supplemental Return
o 4a. Future Interest Compromise (date 01 death after
12-12-82)
o 7. Decedent Maintained a Living Trust (Attach
copy of 'rrust)
o 10. Spousal Poverty Credit (dale 01 death between
12~'-9'.a~d 1-1-95)
THIS SECTION MUSTBE COMPLETED;ALLCORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
: Debra K. Wallet
~
FIRM NAME (II applicable)
. Law Offices of Debra K. Wallet
DATE OF BIRTH (MM-DD-YEAR)
12/08/1917
!(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
~-1-.-0riginal Return
o 4. Limited Estate
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6. Decedent Died Testate (Attach copy
01 Will)
9. Litigation Proceeds Received
.....
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011.
~ELEPHONE NUMBER
717/737-1300
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(8)
(9)
(10)
6,404.02
46.95
12. Net Value of Estate (Line 8 minus Line 11)
(11 )
(12)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116{a){1.2)
z 216,968.69 .045 (16)
0 16. Amount of Line 14 taxable at lineal rate x
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11. 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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0
~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
>> BE SURE'TOANSWERAii. QUESTIONs''oNlREVERScSIDE'AND'RECHECk MATH<<
Copyright 2000 form software only The Lackner Group, Inc.
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223,419.66
6,450.97
216,968.69
216,968.69
9,763.59
9,763.59
Form REV.1500 EX (Rev. 6-00)
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Decedent's Complete Address:
STREET ADDRESS
824 Lisburn Road, Apt. 214
CITY
Camp Hill
i STATE PA
[n------
ZIP 17011
I
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
9,763.59
4,500.00
236.84
Total Credits (A + B + C)
(2) 4,736.84
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thEOVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3)
(4)
0.00
(5)
(5A)
(5B)
5,026.75
5,026.75
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................. 0 ~
~: ~:::~ ~h;e~~~~i~~~~s:~~e~=s~~~. ~~~~I. .~.~~. ~~~.:.~~:.~~. .~~.~~~~~~.~. .~.~ .i.~. ~~.~.~.~~.;"""".'.'.'.'.'.'.'.'.'.'.'~~::::::::::: .'~"". El ~
d. receive the promise for )ife of either. payments, benefits or care?........................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.......... ................... ............................................................ ........................ 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?................................................................................................................ ~ D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN.
Under penalties of pe~ury. I declare that I have examined this return. including accompanying schedules and statements. and to the best of my knowledge and belief. it Is true. correct and complete. Declaration
preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Christy R lark
1322 Longfellow Circle
Roseville, CA 95747
301 l.1::J:J 7
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SIGNA TU
ADDRESS
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Debra K. Wallet
ADDRESS
DATE
~Ii!. aJ~
24 North 32nd Street
Camp Hill, PA 17011
~
~S', :200 1-
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax ~ate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. ~9116 (a) (1.1) (Ii)]. The statutedoes not exemota transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P .S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116
1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
ESTATE OF
Clark, Helen F.
I FILE NUMBER
I
21 - 06 - 00823
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
no. _ __ ___ ~____
I M&T Bank Checking Account #950798124
VALUE AT DATE OF
DEATH
33,115.52
DESCRIPTION
2
M&T Bank CD #31003913154587
69,593.14
3
The Woods personal care home account
380.00
4
Miscellaneous personal property at personal care residence (Lazy Boy chair, cabinet armoire)
50.00
5
Cash in possession of Decedent
20.00
6
Personal jewelry (2 rings, watch, broken earrings)
50.00
7
M&T Bank check
7.03
8
Patriot-News credit
3.20
9
Credit from The Woods
957.00
TOTAL (Also enter on Line 5, Recapitulation)
104,175.89
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen F.
! FILE NUMBER
21 - 06 - 00823
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A Christy R. Clark
1322 Longfellow Ci.
Roseville, CA 95747
Daughter
JOINTLY OWNED PROPERTY:
ITEM ! LETTER
NUMBER I FOR JOINT
TENANT :
-L.
, DESCRIPTION OF PROPERTY 1 'I 0;. OF 'I DAT EATH--
~~6~ 'Include name of financial institution and bank account number! DATE OF DEATH DECD'S V~~0EDOF
JOINT or similar identifying number. Attach deed for jointly-held real 'VALUE OF ASSET IINTERESli, DECEDENT'S INTEREST
estate. " 1
12/15/1978 PSECU CD #0206108996-50 3,760.32, 50%1 1,880.16
, ,
A
,
2 A 12/15/1978 PSECU CD #0206108996-51 3,760.32! 50%i 1,880.16
3 A 12/15/1978 PSECU CD #0206108996-52 1,369.031 50%1 684.52
, I
I
6,369.031 ,
4 A 12/15/1978 PSECU CD #0206108996-53 50%' 3,184.52
I
1
TOTAL (Also enter on line 6, Recapitulation)
7,629.36
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
I FILE NUMBER
21 - 06 - 00823
i
- ----
!l1.is s~hedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. _~__~__
ITEM . DESCRIPTION OF PROPERTY ,I DATE OF DEATH I % OF r I
NUMBER Include Ihe name of the transferee. their relationship to decedent and the dale of transfer. VALUE OF SSETI DECO'S i EXCLUSION i TAXABLE VALUE
I Attach a copy of the deed for real estate. i A r INTEREST (IF APPUCABLEL
! Allstate Performance Plus Annuity #GA0842920 111,614.411 100% I 111,614.41
I
Clark, Helen F.
TOTAL (Also enter on line 7, Recapitulation)
111,614.41
*'
SCHEDULE H
FUNERAL EXPENSE5&
ADMINISTRATlVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen F.
Debts of decedent must be reported on Schedule I.
ITEM I
NUMBER. DESCRIPTION
A. FUNERAL EXPENSES:
Auer Memorial Home and Cremation Services, Inc.
2 Slate Hill Cemetery
3 : James Gingrich Memorials
4 Baughman Church (funeral service and luncheon)
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
1.
Social Security Number(s) I EIN Number of Personal Representative(s):
2.
Street Address
City
i Year(s) Commission paid
Attorney's Fees Debra K. Wallet, Esq.
Zip
State
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4.
City
Relationship of Claimant to Decedent
Probate Fees
Zip
State
5.
Accountant's Fees Kern & Company, PC
6. Tax Retum Preparer's Fees
7.
1
Other Administrative Costs
Photocopies, postage, etc.
2
UPS Store (overnight mail and certified mail charges for income tax returns)
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
, FILE NUMBER
21 - 06 - 00823
AMOUNT
187.74
285.00
180.00
250.00
2,500.00
345.00
500.00
30.00
94.28
2,032.00
6,404.02
.
ScheckJIe H
FW1eI'aI Expenses &
Actnir~dti>le Costs cadinued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen F.
-~-'.-I
3 Giant Food (supplies for Co-Executors while in PA)
4 I Travel costs (from Florida) incurred by Michael Clark, Co-Executor, for funeral
5 Travel costs (from California) incurred by Christy Clark, Co-Executor, for funeral
FILE NUMBER
21 - 06 - 00823
I
!
Page 2 of Schedule H
70.00
637.00
1,325.00
.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
ESTATE OF
Clark, Helen F.
FILE NUMBER
21 - 06 - 00823
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
AMOUNT
Verizon
18.95
2
Sue Tobias (last beauty shop bill at The Woods)
28.00
TOTAL (Also enter on Line 10, Recapitulation)
46.95
REV-1513 EX+ (9-00)
.
SCHEDULE J
BENEFICIARIES
i
I
~
i FILE NUMBER
I 21 _ 06 - 00823
! AMOUNT OR SHARE
i OF ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen F.
NUMBER ,
mn__~+-
I ! TAXABLE DISTRIBUTIONS (include outright spousal distributions)
. ,
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
! RELATIONSHIP TO
I DECEDENT
----L_ _D.o.N.oU.l&t..Irullllle(s)
, Christy Rae Clark
1322 Longfellow Circle
Roseville, CA 95747
Daughter
1/2 of residuary estate
2 Michael Lowell Clark
1531 N. Drexal Road #53
I West Palm Beach, FL 33417
Son
1/2 of residuary estate
I
I Enter dollar amounts for distributions shown above on lines 15 through 18. as appropriate, on Rev 1500 cover she~t
II. I NON-TAXABLE DISTRIBUTIONS:
IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
I BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE1f
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LAS T
W ILL
AND
TESTAMENT
o F
H E LEN F. C L ARK
I, HELEN F. CLARK, of New Cumberland, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory, and
understanding, do hereby make, publish, and declare this to be my
Last will and Testament and hereby revoke all other wills and
Codicils, if any, that I have made.
FIRST: It is my wish, and I direct, that after my death, my
body be cremated through the auspices of the Harrisburg Cremation
Society and that my ashes be buried in the cemetery plot next to
my late husband in Slate Hill Cemetery, of Mechanicsburg,
pennsylvania. I also wish that a memorial service be held within
a week of my burial at my home church, Baughman Methodist Church,
in New Cumberland, Pennsylvania.
SECOND :.
All the rest, residue, and remainder of my Estate,
of whatever nature and wherever situate, I give, devise, and
bequeath in equal shares, to my son, MICHAEL LOWELL CLARK, of
West Palm Beach, Florida, and to my daughter, CHRISTY RAE CLARK,
so long as each shall survive me by thirty (30) days. Should
either of my children fail to survive me by thirty (30) days, but
be represented by children then living, these children shall
take, per stirpes, the share to which my child would have been
entitled if then living.
)
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THIRD: All interests of any beneficiary in the income or
principal of this Estate, while undistributed and in the
possession of my Executor, even though vested and distributable,
shall not be subject to attachment, execution or sequestration
for any debt, contract, obligation or liability of any
beneficiary and, furthermore, shall not be subject to pledge,
assignment, conveyance, or anticipation.
FOURTH: All inheritance, estate, and succession taxes
(including interest and any penalties thereon) payable by reason
of my death shall be paid out of and be charged generally against
the principal of my residuary estate without reimbursement from
any person.
FIFTH: I nominate, constitute, and appoint my son, MICHAEL
LOWELL CLARK and my daughter CHRISTY RAE CLARK as Co-Executors of
this, my Last Will and Testament. In the event of the
renunciation, death, resignation, or inability of either one to
act for whatever reason in this capacity, then the other may
serve as sole Executor. I direct that no representative named
above shall be required to post security for the faithful
performance of his/her duties in any jurisdiction insofar as I am
able by law to relieve him/her of such obligation. Any of my
representatives shall be entitled to reasonable compensation for
)
the performance of the duties set forth here.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this i~t" day of
Ot..to~t.r'
, 1993, on this, the Third of
Three typewritten pages. I have also signed the left-hand
margin of the first Two of these pages for purposes of
identification only.
r
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HELEN F. CLARK
/// /"' /
~
SIGNED, PUBLISHED, and DECLARED by the Testatrix, HELEN
F. CLARK, as her Last will and Testament, in the presence of us,
who at her request, in her presence, and in the presence of each
other, have hereunto subscribed our names as witnesses.
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ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of Cumberland
I, HELEN F. CLARK, Testatrix, whose name is signed to the
attached instrument, having been duly qualified according to law,
do hereby acknowledge that I signed and executed the instrument
as my Last will and Testament; that I signed it willingly; and
that I signed it as my free and voluntary act for the purposes
therein expressed.
'---, ~ 7 /1 .(,'J~ . J7 ,
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HELEN F. CLARK
CLARK, the Testatrix, this ~~
Sworn or affirmed to and subscribed before me by HELEN F.
day of a?~~L/
, 1993.
..~ ~..~. 7,
.--.7)/ /.'//f'~; ;----- -' /" ~e&~ ---.
, Notary Public
NJTA,f'I:,L SEAL
KATRINA K.. wt-.ss, t.!oli'r; Pl::,'is
tarlisle Bom, Cumb~rl2nd County, Pa.
W Commission Expires Sept. 19, 1994
A F F I D A V I T
Commonwealth of Pennsylvania
County of Cumberland
We, Debra K. Wallet and
/11.. ':j i / ;..) ,.. Go.. ;:'.c c..,. b--J
the witnesses whose names are signed to the attached instrument,
being duly qualified according to law, depose and say that we
were present and saw the Testatrix sign and execute the
instrument as her Last will and Testament; that HELEN F. CLARK
executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of
the Testatrix signed the Will as witnesses; and that, to the best
of our knowledge, the Testatrix was at that time 18 years of age
or older, of sound mind, and under no constraint or undue
influence.
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Sworn or affirmed
~lG II (Lbf!( f
witnesses, this jr-d day of
to and subscribed to before me by
and O//. ~f/fJ ~ )(;!UQ{lI!L____
0f;/~
, 1993.
.$//~z/~
Notary Public
NOTARIAL SEAL
K~ TRINA K. WASS, Notary Public
Carlisle Bor~, Cumberlund County, Pa.
My Commission Expires Sept. J 9 J 994
-----.--..---~ -....--1
O;i i 09,' II i 13 : :16 F.H 916 77 J 4 J 1 0
CHRISTf R. ClARK
'*'
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SAFE DEPOSIT BOX INVENTORY P0ge__oF.~... t
INSTRUCTIONS
(1) Cash: Report total only.
(2] Stocks: lisl in delail every common or preferred certifice:.. warrant or other rights found in bQx. Stocks ore
10 be designated by nOme of company, cer1i/icol~ number, dole of certificale, nome in which 5'OC~ is registered,
and number of shores and dcss of stock.
(3] Obligations of U. S. Government: Number of ilems. date of issue, foce value, nomes in which reghlered
Qnd type of ownership, i.e., jointly held, poyoble On death, etc.
(4) Bondi: De$;gnale by name, cmount, serio! number, or olher dluigno1ron. (oecrer Bands)
(51 Bank and Savings Clnd Locn Passbookst Slole nome of depositor, number 01 book, 1051 do1e cppecring in
beok, name of bank and branCh, end boiance.
(6) Jewelry, Coins, Stamps, Manuu:ripts, ete: Li~t and describe as fully 05 Fossible.
(7) Deeds, Mortgages, Current Insurance Policie. or other evidenc.s of indebtedness: List and describe os
fully as possible.
{al All other cont.nis.
05'09/07
13:38
FAX 9jo 771 .t310
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