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Home My WebLink About05-23-08 (3) , ...-J 15056041125 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburq, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN 2 1 0 8 RESIDENT DECEDENT File Number o 0 1 4 2 Date of Birth 192304311 o 2 032 008 06031939 DYARMAN JACOB MI M Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW [g] 1. Original Retum D 4. Limited Estate [g] D 2. Supplemental Return D D 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death D 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numberr-) = 7 1 7(~ 4 3 @ 0 c~O :$ 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received D D D D 8. Total Number of Safe Deposit Boxes - -- H A R 0 L D SIR WIN I I I Firm Name (If Applicable) I R WIN LAW 0 F F ICE REGISTEa~s USIi-<lNL Y C: ~!;. S3 rz.:; (. . (} j ...->-~ .. First line of address 6 4 SOU T H PIT T S T R E E T -0 Second line of address '\) -y'" '-:? "" o City or Post Office State ZIP Code DATE FILED CARLISLE P A 17013 Correspondent's e-mail address:irwinlawoffice@gmail.com Under penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ')/1{; 00 "('Hl"' e. ~ bLM,\^~ .5 f L.3. r 0 k' ADDRESS 0 4 F IR IELD STREET APT NEWVILLE PA 17241 DATE CARLISLE PLEASE USE ORIGINAL FORM ONLY PA 17013 Side 1 L 15056041125 15056041125 ...-J ~ --.J 15056042126 REV-1500 EX Decedent's Name: JACOB M. DYARMAN RECAPITULA TION 1 . Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) ............ ...................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) .. ........... ........ ... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 Separate Billing Requested. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7) ........................ . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.O _ 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .O~ 1 2 8 0 3 8 16. 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 4 2 6 7 9 at collateral rate X .15 18. Decedent's Social Security Number 192 3 0 431 1 0 0 0 0 0 0 0 0 0 0 0 0 5 o 4 3 0 0 0 0 0 0 0 0 5 0 4 3 0 0 3 3 3 5 8 3 0 0 0 3 3 3 5 8 3 1 7 0 7 1 7 0 0 0 170 7 1 7 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042126 o 0 0 5 7 6 2 o 0 0 6 4 0 2 1 2 1 6 4 o 15056042126 ....J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME -JACOB M. DYARMAN STREET ADDRESS 33 PARKER ROAD File Number 00142 CITY NEWVILLE STATE PA ZIP 17241 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 121.64 3. Interest/Penally if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 0.00 Total Interest/Penalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 121.64 A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 121.64 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 0 b. retain the right to designate who shall use the property transferred or its income; ............................... 0 0 c. retain a reversionary interest; or ................................................................................................ 0 0 d. receive the promise for life of either payments, benefits or care? ....................................................... 0 0 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... 0 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... 0 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P .S. 99116 (a) (1.1) (i1)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return 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 zero (0) percent [72 P.S. 99116(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 four and one-half (4.5) percent, except as noted in 72 P .S. 99116(1.2) [72 P .S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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. REV-1502 EX + (6-9B) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER .JACOB M. DYARMAN 00142 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is iointly-owned with riaht of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 !'lEV-1503 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF -'ACOB M. DYARMAN FILE NUMBER 00142 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1504 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSEL Y.HELD CORPORATION, PARTNERSHIP OR SOLE.PROPRIETORSHIP I FILE NUMBER 00142 ESTATE OF .JACOB M.DYARMAN Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1507 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF ..JACOB M.DYARMAN FILE NUMBER 00142 ITEM NUMBER 1. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. NONE DESCRIPTION VALUE AT DATE OF DEATH 0.00 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOB M.DYARMAN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ITEM NUMBER 1. FILE NUMBER 00142 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH 2,600.00 2. 1993 CHEVROLET TRUCK Value based on sale price See attached Exhibit "B" MISCELLANEOUS PERSONAL PROPERTY Value based on sale price 2,250.00 3. ERIE INSURANCE Refund of Unearned Hazard Insurance Premium 166.00 4. ERIE INSURANCE Refund of Unearned Motor Vehicle Insurance Premium 27.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5,043.00 REV-1509 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF .JACOB M. DYARMAN FILE NUMBER 00142 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. B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S V AWE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY.HELD REAL ESTATE. V AWE OF ASSET INTEREST DECEDENTS INTEREST 1. A. NONE 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY ESTATE OF ,JACOB M.DYARMAN I FILE NUMBER 00142 DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. NONE 0.00 0.00 TOTAL (Also enter on line 7 Recapitulation) $ 0.00 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF JACOB M. DYARMAN FILE NUMBER 00142 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME INC 2,229.1::3 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attomey Fees IRWIN LAW OFFICE 1,000.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 76.00 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. CUMBERLAND COUNTY REGISTER OF WILLS - File Invenotry and Appraisement 30.00 TOTAL (Also enter on line 9, Recapitulation) $ 3,335.63 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) '* SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOB M. DYARMAN FILE NUMBER 00142 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 "ey."" "'."* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF .JACOB M.DYARMAN SCHEDULE J BENEFICIARIES FilE NUMBER 00142 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pnclude outritt spousal distributions, and transfers under Sec. 9116 (a (1.2)] 1. KATHRYN D. ROWE Collateral 106 BIG SPRING TERRACE 25% RESIDUE NEWVILLE PA 17241 2. WILLIAM C. DYARMAN Lineal 4 FAIRFIELD STREET 25% RESIDUE NEWVILLE PA 17241 3. MICHAEL M. DYARMAN Lineal 5 MILL STREET LOT 5 25% RESIDUE MT. HOLLY SPRINGS PA 17-65 4. WANDA L. WEARY Lineal 2142 RITNER HIGHWAY 25% RESIDUE CARLISLE PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. NONE 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. NONE 0.00 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) "": ., LAST WILL AND TESTAMENT I, JACOB M. DYARMAN, of 33 Parker Road, Newville, Cumberland County, Pennsylvania 17241, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as J could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my companion, Kathryn D. Rowe, and my three children, William C. Dyarman, Michael M. Dyarman and Wanda L. Weary, share and share a like. 5. I nominate and appoint my son, William C. Dyarman, to be the personal representative of my estate, to serve without bond. 6. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 25'" day of January ~i J~OY)l D:-~ (SEAL) jiACOB M. DYARMAN .'---./ >0. . '.. ~ Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ~ rt " ~ A ,/ (..~'-- /~--c:. /, 0- i ....'. ~ ACKNOWLEDGMENT AND AFFIDAVIT WE, JACOB M. DYARMAN, SARAH A. HARDESTY and JANE E. ADAMS, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his last will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as a witness and that to the best of their knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. 1~'Vl1 iJ;~/ ~JACOB M. DY ARMAN ~"P1P-if SA"t .. HARD . - - .. -:-:. ~. . t~.t"""u.. J E E. ADAMS COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND :ss: Subscribed, sworn to and acknowledged before me by JACOB M. DY ARMAN" the testator herein, and subscribed and sworn to before me by SAR..~r" A. HARDESTY and JANE E. ADAMS, witnesses, this 25th day of January 2008/ . . l, ,. -: ..... . /\ I.f.. / Lk' . ( .) I /. V f.- /'-'-- ,. / A'" {/II A \.~/ " ' " Y" Notary Public ; COMMONWEALTH OF PENNSYLVANIA NOT ARlAL SEAL Harold S. Irwin Iii, Esq, Notary Public Carlisle, Cumberland County My commission expires February 06, 2011 . ~..--_..-----=--.QF---EAl~MARKE:CVA[llG:B'l_ - THE ISSIIING AGt;~T ~.;j0rnmE7AweaJfA-OI-t'ffiASVlvarua .ueD~rtme~~ ~ ~ ~~~~D::lI~~ ~~F'Vhl v ,(./ Hil'r~~~~=~"::~'" ::---:OUlWLusad:' _ . c: =~=4~ _ ~___~___ MV :~U:::I= ~ tilt. ~;-:~-~~:;;IL~-- TYPE OR PRINT ALL INFORMATION AS REQUESTeD 08041 342j- =00l-58i" O()L~~- Velllcie Identif,catlon Number (VIN) ometer ea II1g IGCEC14HIPZ165337 1 0 9 0 0 0 IZI B AGENT VERIFICATION OF FAIR MARKET VALUE. Check ( .t ) the appropriate block: !XI I certify that the average Fair Market Value for the vehicle described above is $ 3.750.00 as verified by the current edition of a PennDOT approved publication. Name of Publication: The Automobile Red Book Last Name (Of FuJI Business Name) First Name MAINS CO'Pllrchaser last Name First Name D PURCHASER/SELLER EXPLANATION Agent N~mbe r 83-205 Date 2/16/08 Midclle Name PA 0 IPhOl(lIO# DONALD L & REGIN~.Bn 10# Date of Birth Midclle Name PA OLlPholo IOIt Date of Birth Explain in detail why the purChase price listed on Form MV-l. MV-4ST, MV-217 or Applicant Summary Statement is less than 60% of the average Fair Market Value, or if the vehicle is over 15 years old and the purchase price is less tllan $500, explain how the purchase price was determined, or if the vehicle Is not listed in a PennDOT approved publication, explain how the purchase price as listed in Section A was determined. Please use additional paper if more space Is required. NOTE TO PURCHASER: All additional audit of this vehicle sale bv the Deoartment of Revenue may occur Please retain copies of this form, your cancellcld check or original cash receipt, and your receipt from the seller of this vehicle, along with either your copy of the Application for Certificate of Title (MV.1), the Vehicle Sales and Use Tax Return/Application for Registration (MV-4ST) or the Application by Financial Institutions for Certificate of Title After Default by Owner (MV.217A). If you fall to reply to the Department of Revenue, you will be assessed for the estlmated amount of lax due. Price agreed upon between buyer & seller E SEAL AND SIGNATURE OF SELLER - NOT REQUIRED FOR VEHICLES PURCHASED OUT-OF-STATE 2/16/08 YEAR ATH S T A M P F SEAL AND SIGNATURE OF PURCHASER SUBSCRIBED AND SWORN TO BEFORE ME: co YEAR H COMMONWEALTH OF PENNSVLVANIA BARBJ?~ilJf.~~I:'W~~~~!tiift Bormff~ &~u~!jU~~tI IN My ComM ii~t4ifeO~*.ca:Am'l THIS FORM MAY BE PHOTOCOPIED l/We state that l/we have read and signed this form after Its completion, and IIwe swear or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to the penalties of 18 PA C.S. Section 4903(a)(2)(relating to false swearing), which shall include puniShment of a fine not exceeding $5,000, or to a term or imprisonment of not more than two years, or both. '\fY1ature of Selier ^ Vd . {. ih Signature of Co-Selier Telephone Number ( ) I!We state that IIwe have read and signe t is orm a r s comp etion, and we swear or affirm that the statements made herein are true and correct. and that any statement made on or pursuant to this form is subject to the penalties of 18 PA C.S. Section 4903(a)(2)(relating to false swearing), which shall indude punishment of a fine not exceeding $5,000, or to a term or imprisonment of not more than two years, or both. Sign~ PU~chaser j ,t? ~..-G .".~.. J- Signature -Pur~aser 12 =-- cJ.-L ~1' C2..e-/t:...<:-. ~---1..- Telepho N ( ) Messenger No. 039023 717-530-7797