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Home My WebLink About03-0634PETITION FOR PROBATE and GRANT OF LETTERS also known as ~ Deceased. Social Security No. [ ~, t[ - ~ (.? - 9 ~7o~ 0 The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut_A~g~'~/~ in the last will of the above decedent, dated /~. ~ ~' O /~ ,t.;// 2_ oo '~ and codicil(s) dated /L/~ To: Register of Wills for the County of (~n~'~'/n~C/ Commonwealth of Pennsylvania in the named (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in [if4 bet la ad . . (~ounty, Pennsylvania, with h O p last family or principal residence'at -Q ! 0 E [ I( c.O o 'od f~ ia, /[le~q Cam. l~er/a~r} [30~0 ' - ' (list street, number and muncipality) Decendent, then '?/?_ _.~__ years of age, died , }-t~ A/ 0 S ~ 0 0..~ Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: ,~//4- .. Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ L7 tO/ 0 0 O, 0 6 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal 'property in County $ Value of real estate in Pennsylvania $ situated as follows: 71 '? ,(°l/,c ood WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA -1 COUNTY OF ~ ~,rn ,~,o,~/.,q-,u d 3' ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and tr. uly administer the estate according to law. Sworn to or affirmed and subscribed ,- ~ ~ be[ore me this ,4~'7-~ day of I '~ ~" Estate Of NO. DECREE OF PROBATE AND GRANT , Deceased OF LETTERS AND NOW the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated described therein be admitted to probate and filed of record as the last will of and Letters are hereby granted to ~.~-~m~ ~.k~O-)/~-.?.. /4~g> /~/~,~,~.5 ~_-_-_-_-_-_-_-_-_-~e_~,~q~ ~ in consideration of the petition on FEES Probate, Letters, Etc .......... Short Certificates( ) .......... $ ation ................ $ TOTAL .. Filed .. ~~ .................... ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNEI codicil (each) a subscribing witness to the will law, depose(s) and say(s) that herewith, (each) the testat. , sign the same and that request of testat.__ in h__ presence and (in the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this day e,~ 19.__ Register duly qualified according to present and saw signed as a witness at the ~nce of each other) (in the presence of the (Name) (Address) REGISTER OF WILLS OF COUNTY OATH OF NON-SUBSCRIBING WITNESS (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and sa?s) that, /A/_P /~'/~e familiar with the signature of ~//a~/~ ~.~.~(_?/'/~ ~ .~ testat.__ of (one of the subscribing witnesses to) the presented herewith and that to the best of codicil believe/~ the signature on the ~is in the handwriting of knowledge and belief. Sworn to or affirmed and subscribed before me this ,~,,eT'~,' day of ~-~M~--~~ egtster (Name) (Address) (Name) (Address) his is to certify that the information here given is correctly copied fi'om an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for per~anent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9 2 g 8 9 8 3 No. ~ Date Local Registrar JUL 2 5 2003 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,. Alberta s. 77 w,. ~ Cumberland ,,~ Nurse' s Aide ,,~ Healthcare 717 Elkwood Drive ,~m~NCE ,~ New Cumberland, PA 17070 ~o.~ ,L Frank Bacewicz Theresa M. Usewicz : August 22, ' I ~ '-k 1025 [henandoah. pA I:-= I, New Cumberland g 717 Elkwood Drive ' ' ,--' It ' I~ white ...~. Pennsylvania ~ .,.0 ~.~ Cumberland I,,. Josephine Gavinowicz ]~. 1409 Old Reliance Road, Middleto~, PA 17057 ~.~._~,~ i:~c~,~--~-,.~,-~ i=~.c~. D~. July 28, 2003 ~d~anto~ Gap National Cem.[~,,~nvl[le, PA 17003 n~U [L~E"~NUM~. ]~O~~l~ ParthemoreFH & CS, Inc. ~,. FD 013 340 L m.P.O.Box 431, New Cumberland, PA 17070-0431 y. Ye~) DUE R3 {OR AS A CONSCIENCE OF~ Name of Decedent: Date of Death: Will No. To the Register: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) aA ~ c~00 2> ~ - ~3~ Admin. No. I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ~:} - ")-O,~ - Name Address ~u ?_.er, g'o 8 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signature Name Address ]t[O Telephone Ol Capacity: ~Personal Representative Counsel for personal representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be deter- mined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or prop- erty will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, CARLISLE, PA InreEstateof ~L(~9¢/ /t::f ~301%'~/( ,deceased, Estate No. (Name and Address) Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent Al6e /'ct dayof T~[~ , ~aO~ ,at Pennsylvania. / ~e Decedent died testate (with a Will); or~ The Decedent died intestate (without a Will). The personal representative of the Decedent is (name, address and telephone number). County, ~ If the Decedent died testate, the will has been filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, Pa. 17013. Phone No. 717-240-6345 If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, Pa. 17013. Phone No. 717-240-6345 A copy of the Will or Petitign may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: ~5' -/~~'. Signature' ~M~-*~ ,fi'~..ff~.~- ~[om, pt~ ~3~A'~.~t ~ Name r~nt - ~ "*- *~ ~ (p ' ) ! ~ewe~ .~1- ~g~;/ ~ z Telephone (J) [/)) Capacity~entati~ Counsel for personal representative Theresa Usewicz 1409 Old Reliance Rd. Middletown, PA 17057 October 20, 2003 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re~ Estate of Alberta M. Bohenick File No: 21-03-0634 Estimated Inventory and Inheritance Tax Prepayment Dear Register, Enclosed please find a prepayment of $8,800 in estimated inheritance taxes due for the above referenced estate. Also enclosed, is the requested inventory for the estate under Article IV, Fiduciaries Act of 1949. Thank you, Theresa Usewicz Co-Executor STATUS REPORT UNDER RULE 6.12 Admin. No.: a) -03-0~$t/ Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes [-'] No ~ 2. If the answer is No, state when the personal representative reason,ably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: ao Did the personal representative file a final account with the Court? Yes _ No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes [-] No [--] Date: Co Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphans' Court and may be attached to tiffs report. Signature Name Capacity: Address Telephone No. [~'~rsonal Representative [--] Counsel for personal representative I 0 ox'p COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, Theresa Usewicz and Thomas Bohenick being duly sworn according fo law, deposes and says that he/she, Co-Executors of the Estate of Alberta M. Bohenick late of New Cumberland , Cumberland County, Pa., deceased and that the within is en inventory made by Theresa Usewicz & Thomas Bohenick .., the sa~d Co-Executor~ of the entire estate of said decedent, consisting of all the personal property and real estate, except real estate outside the Commonwealth of Pen,n, sylvanie, and that the f~gures opposite each item of the Inventory represent it's fair value as of the date of decedent s death. and subscribed before me, ~ . /! ,/ ~ II ~ -" JCARMELO dl C~DIO, N~ P~lic ] L~e ~m, ~m~ C~n~ /MY Comm= 0n F b. 25, Date o~ Death 23 Co- Exec_~Yo~ - 1409 Old Reliance Road Middletown, PA 17057 1114 Whitehall Drive Harrisburg, PA 17110 Address July 2003 Day Month Year INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal representative. 2. A supplement inventory must be filed within fhlrf¥ days of discovery of additional assets. 3. Additional sheets may be affached as to personalty or realty 4. See Arflcle IV, Fiduciaries Act of 1949. > Oz< Z O ~ ~ ~ Z & Inventory of the real and personal estate of Alberta M. Bohenick deceased 6. 7. 8. 9. 10. 11. Metropolitan Life Annuity Joint Ownership w/Theresa Usewicz. 50% Taxable $53,830.08 x 50% Met Life Total Control Money Market Option Account # 404-3976896 Met Life Total Control Money Market Opti'on Account # 404-4268631 Cumberland County Burial Ail Checking Account ~IRA Money Market Met Life Pension Payment' Final Comcast Refund Decendent's Residence: 717 Elkwood Drive New Cumberland, PA 17070 Stocks & Bonds - Estimate Total 26,915 20,471 12,571 N/ 3,417 6,021 11,973 7 20 47 129,000 O0 5,000 O0 215,461 08 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 0O31 57 USEWICZ THERESA 1409 OLD RELIANCE ROAD MIDDLETOWN, PA 17057 ........ fold ESTATE INFORMATION: SSN: 164-20-7920 FILE NUMBER: 2103-0634 DECEDENT NAME: BOHENICK ALBERTA M DATE OF PAYMENT: 10/22/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/23/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $8,800.00 REMARKS: THERESA M USEWlCZ TOTAL AMOUNT PAID: $8,800.00 SEAL CHECK# 125 INITIALS' SK RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH Of PENNSYLVANIA DEPARTMENT Of REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 May 4, 2004 '04 i'i/ti' -7 P .? :E~4 Smoker, Smith & Associates 339 West Governor Road Hershey, PA 17033 Telephone (717) 787-3930 FAX (717) 772-0412 Dear Sir/Madam: Re: Estate of Alberta M. Bohenick File Number 2103-0634 This is in response to your request for an extension of time to file the Inheritance Tax Return for the above estate. In accordance with Section 2136 (d) of the Inheritance and Estate Tax Act of 1995, the time for filing the return is extended for an additional period of six months. This extension will avoid the imposition of a penalty for failure to make a timely return. However, it does not prevent interest from accruing on any tax remaining unpaid after the delinquent date. The return must be filed with the Register of Wills on or before 10/23/04. Because Section 2136 (d) of the 1995 Act allows for only one extra period of six (6) months, no additional extension(s) will be granted that would exceed the maximum time permitted. Si nce rel. l.l.l.~,~--; Document Proce~ng Unit Inheritance Tax Division STATUS REPORT UNDER RULE 6.12 Name of Decedent: A~berta M. BohenRck DateofDeath: July 23, 2003 Will No. 2003-00634 · AOInln. INO. 21-03-0634 Pursuant to Rule 6.12 of the Supreme CO.~rt Orphans' Court Rules, I report the following with respect to completion oft he adm~i~ion of the above-captioned estate: 1. State whether administration of the estate is complete: Yes No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: Did the personal representative file a final account with the Court? Yes _ No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: N/3. c. Did the personal representative state an account informally to the parties in interest? Yes~ No ["-] Co Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphans' Court and may be attached to this report~~ /~ ~- _~~ Signature Theresa Usew±cz, Co-executrix Thomas Bohen±ck, Co-executor Name c/o 1409 Old Reliance Road H±ddletown, PA 17057 Address (717) 939-7635 Telephone No. Capacity: ~ Personal Representative [--] Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 May 4, 2004 Smoker, Smith & Associates P.C. 339 West Governor Road Hershey, PA 17033 Telephone (717) 787-3930 FAX (717) 772-0412 Re: Estate of Alberta M. Bohenick File Number 2103-0634 Dear Sir/Madam: This is in response to your request for an extension of time to file the Inheritance Tax Return for the above estate. In accordance with Section 2136 (d) of the Inheritance and Estate Tax Act of 1995, the time for 'filing the return is extended for an additional period of six months. This extension will avoid the imposition of a penalty for failure to make a timely return. However, it does not prevent interest from .accruing on any tax remaining unpaid after the delinquent date. The return must be filed with the Register of Wills on or before 10/23/04. Because Section 2136 (d) of the 1995 Act allows for only one extra period of six (6) months, no additional extension(s) will be granted that would exceed the maximum time permitted. Sine.,erely, .,. Claudia Maffei?Sfipervisor Document Processing Unit Inheritance Tax Division REV-1500 EX (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER -- 0 3 0 6'"3,34 COUNTY CODE YEAR NUMBER I-- Z W 1:3 UJ z Z X DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Bohenick, Alberta M [)ATE OF DEATH (MM-DO-YEAR) DATE Of BIRTH (MM-DD-YEAR) July 23, 2003 August 22, 1925 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A ISOCIAL SECURI'PI( NUMBER 164-20-7920 REGISTER OF WILLS SOCIAL SECURITY NUMBER THIS RETURN MUST BE FILED IN DUPLICATE W1TH THE [X-----~ 1. Odginal Return [--] 2. Supplemental Return [--~ 3. Remainder Return (date of death pdor to 12-13-82) ['~ 4. Limited Estate [--~ 4a. Future Interest Compromise (date of death after 12-12-82) [--~ 5. Federal Estate Tax Return Required [X----] 6. Decedent Died Testate (Attach copy of Will) [--~ 7. Decedent Maintained a Living Trust (Attach copy of Trust) 0 8. Total Number of Safe Deposit Boxes ['--~ 9. Litigation Proceeds Received [---'] 10. Spousal Poverty Credit (d .... , d,,th betw,,, ,2-3,-9, and 1-,-95) [--~ 11. Election to tax under Sec. 9113(A)(A,ach SchO) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: COMPLETE MAILING ADDRESS NAME Theresa M Osewicz,Thomas Bohenick Co-Execs FIRM NAME (If Applicable) ~T/A TELEPHONE NUMBER 717-939-7635 C/O Theresa Usewicz 1409 Old Reliance Rd Middletown, PA 17057 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Propdetorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) ['~ Separate Billing Reduested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Ad ministrative Costs (Schedule H) (9) '10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule ~) (10) 1 1. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 129,900--. 55,603 26,915 (8) 218,403.00 24,713 1,775 (11) 26,488.00 191,915.00 191,915.00 (12) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec, 9116 (a)(1,2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate. 19, Tax Due 191,915 x.o __ (15) x.0 ' 045(16) x .12 (17) x .15 (18) (19) 8,636.18 8,636.18 · > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W4645 1.000 Decedent's Complete Address: S']]:',EET ADDRESS Alberta M. Bohenick 7].7 Elkwood Dr CITY I STA'[E New Cumberland, PA 17070 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D, Interest E. Penalty 8,800 431.81 Total Credits (A + B + C) H) (2) Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line I + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. , A GENT A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Pa (4) (5) (5A) (5B) 8,636.18 9,231.81 595.63 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; ....................... r-~ [-~ b. retain the right to designate who shall use the property transferred or its income; ......... [~ r~ c. retain a reversionary interest; or ................................ [~ [-~ d. receive the promise for life of either payments, benefits or care? ................. r---] [-~ 2. if death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................ [~ ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? [~ [-~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................ [~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Declaration of preparer other than the personal representative is based on all information of which preparer~as any knowledge. SIGNA'I%IRE OF PERSON RESPONSIB~4E FOR~ILING RETURN/~ / // ' / ADDRESS - ~ ~ ' ~"- Theresa Osewic~. & Thomas Bohenick C/O Old Reliance Rd, Middletown, PA SIGNATI~ OF PREPARER OTHER THAN REPRESENTATIVE 1~ 0 9 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tree, correct and complete. DATE 17057 mDo~ss ker Smith & Associates, 339 West Governor Rd, Hershey, PA 17033 DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfem to or for the use of the surviving spouse is 3% [72 P.S. § 9916 (a) (I .1) (i)]. For ,dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfem to or for the use of the surviving spouse is 0% [72 P.S. § 9116 (a) (1.1) (ii)] 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 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. 3w4646 1.000 REV-15~,2 ~ + (6-98) COMIvlONWEALTH OF PEI~NSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Alberta Bohenick 21-03-0634 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 properly 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 jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1. 129,900 Decedent~s personal residence at 717 Elkwood Dr, New Cumberland, Cumberland County, PA. Legal Description Deed Book 16 W, PG 64 Sold 12/15/03. Value listed is selling Price TOTAL (Also enter on line 1, Recapitulation) $ 129,900.00 3W4695 1.000 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-~8) COMIVlONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Alberta M. Bohenick 21-03-0634 All property jointly.owned with right of survivorship must be disclosed on Schedule F. iTEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 213 Shares Metropolitan Life Common Stock valued at Date of 5,985 Death value of $28.10 per share TOTAL (Also enter on line 2, Recapitulation) $ 5,9 8 5.0 0 3w46g6 1.000 (If more space is needed, insert additional sheets of the same size) REV-I$09 EX + (698) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Alberta M Bohenick 21-03-0634 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. Theresa Usewic= Daughter 1409 Old Reliance Rd Middletown, PA 17057 JOINTLY-OWNED PROPERTY: LET'mR DATE DESCRIPTION Of PROPERTY %Of DATE Of DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FIt'~NCIAL INSTITUTION AND BAt~( ACCOUNT DATE OF DEATH DECD'S VALUE OF I~tJMBER OR S~MILAR IDENTIFYING NUMBER. ATTA04 DEED FOR NUMBI=R TENANT JOINT JoIhr~.Y-t-ELDREAL ESTATE, VALUE OFASSET INTEREST DECEDENI"S INTEREST 1. A. 01/2001 Metropolitan Life Insurance. 53,830 50% 26,915.00 Co annuity contract # 550005346. See attached documentation listing Theresa Usewicz as co-owner TOTAL (Also enter on line 6, Recapitulation) $ 2 6,915.0 0 3W46AE 1.000 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) COMMONVVEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE" OF Alberta M. Bohenick FILE NUMBER 21-03-0634 Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT ITEM NUMBER 3e 8. 9. 11. 12 13. 14. 15. 16. 17. FUNERALEXPENSES: Parthmore Funeral Home - New Cumberland, Funeral Lunch Funeral Travel Reimbursement PA ADMINISTRATIVE COSTS: 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: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach ex~planation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Accountant's Fees Smoker Smith & Associates Tax Return Preparer's Fees Register of Wills The SEntinal - Advertise letters The Patriot News Advertise Letters Bank Charges PP & L Sewer & Trash American Water Verizon AT & T Mark Heckman - Property Subtotal Appraisal Estate Property Lawn Care & Maintenance of Ex13enses from pg 2 Sch H TOTAL (Also enter on line 9, Recapitulation) $ 6,694 40 171 3,150 266 95 182 36 186 115 70 103 43 3OO 300 12,962 24,713.00 3W46AG 1.000 (If more space is needed, insert additional sheets of the same size) REV-15'I1 EX+ (12-99) COMMONWEALTH Of PENNSYLVANIA, INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ~$TAI'E OF FILE NUMBER Alberta M. Bohenick 21-03-0634 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 4.. 2O 21. 22. 23. 24. 25. ADMINISTRATIVE COSTS: 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: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Billman's Trash Removal SICO - Haul contents of house Robin Gasperetti - Tax Collector Peerless Insurance North American Shipping - to ship bequest Met Life - Reimburse final pension pymnt Closing Costs - Sale of House TOTAL (Also enter on line 9, Recapitulation) $ 320 495 5 11 92 1,027 71 10,941 12,962.00 3W46AG 1.000 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12.-03) CC)MMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Alberta M. Bohenick 21-03-0634 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. ~TEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2. 3. 4. 5. 6. 7. Perscritptions - Express Scripts Esoterix, Inc iWest Shore EMS iCentral PA Hemotolo~ Center iCentral PA Hemotolo~y and Oncolo~ Assoc Central PA Hemotology and Oncoloffy Assoc The Hartford - Pension Reimbursement TOTAL (Also enter on line 10, Recapitulation) $ 20 234 482 428 258 15 338 1,775.00 3W46AH 2.000 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Alberta M. Bohenick 21-03-0634 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUIVIBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 l. 4. TAXABLE DISTRIBUTIONS[includeoutrightspousaldistdbutions, andtransfem underSec. 9116(a)(1.2)] Theresa Osewicz 1409 Old Reliance Rd Middletown, PA 17057 Thomas Bohenick 1114 Whitehall Dr. Harrisburg, PA 17110 Stanley Bohenick 1126 Cocklin St Mechanicsburg, PA 17057 Janet Euker 808 22nd St SW Loveland, CO 80537 Marie DoLts 1231 Van Buren Ave. St. Paul, HN 55104 Daughter Son Son Daughter Daughter 16.66% 16.66% 16.66% 16.66% 16.66% Frank Bohenick Son 16.66% 9463 W. 99th Pl. Westminster, CO 80021 ENTER D~LLARAM~UNTSF~RD~STR~BUT~~NSSH~~NAB~~E~NL~NES15THR~UGH18~ASAPPR~PR~ATE~~NREv-15~~~~VERSHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 3W46AI 1.000 (If more space is needed, insert additional sheets of the same size) }fis is to certify that the information here given, is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be fbrwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 No. ~ ~'~' Date Lo?1 Registrar JUL 2, ,5 7_003. Rev 2/87 COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,. Alberta M. Bohenick /" female ~-164 -- 20 -- 7920~- July 23, 2003 77 ~. ~ ~ ~ugust 22, ~ t~,,~ ~ I ],. 1925 henandoah, PA ~. Cumberland ~.New Cumberland ~. 717 Elkwood Drive ,,,. Nurse' s Aide ,~. Healthcare o. ~ ~ 3 (,~s.) ,~. widowed ~TU~ ,7,. m~. Pennsylvania ~ ,,,.~ ~.~ 717 Elkwood Dr~ve ,~s,~ ,.. New Cumberland, PA 17070 ~ r"/llrHE R'S NAME (First M ~e. I-esl) J,e. white Cumberland ,)~,~.o, Ne~ Cumberland ~,. Frank Bacewicz ~om~s.~ p.,~p,.~ ,,. Josephine Gavinowicz ~. Theresa M. Usewicz ~. 1409 Old Reliance Road, Middleto~, PA 17057 · ,~=~ ~ ~ a ~[.~. July 28, 2003 ~Bdlanto~ gap ~at~on~l Cem.[.~nnv~lle, PA 17003 ~:::~,~,~,~.;.~ ~,,~ .---,--- ~- . . 340 L ~=~. P.O.Box 4~1, New Cumberland, PA 17070-0431 ~am. . , ' ~.~, ~1 ~, ~ ~)~ath. DUE ~ (OR AS A ~;ON~EOUENCE 0~: OOE 'tO {OR ,~ A CONSEQ~£ NCE 0~: STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND estate of BOHENICKALBERTA M SHORT CERTIFICATE I, DONNA M. OTTO Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 5th day of August A.D., Two Thousand and Three, Letters TESTAMENTARY in common form were granted by the Register of said County, on the ~u~) , late of NEW CUMBERLAND BOROUGH in said county, deceased, BOHENICK THOMAS (~.~-, ~.~.~-, ~} to USEWICZ THERESA and and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 5th day of August A.D., Two Thousand and Three. File No. 2003-00634 PA File No. 21-03-0634 Date of Death 7/23/2003 S.S. # '~164~20-7920 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters WHEREAS, on the 5th dated March 4th 2002 No. 2003-00634 PA No. 21-03-0634 ESTATE OF BOHENICK ALBERTA M Late of NEW CUMBERLAND BOROUGH Deceased Social Security No. 164-20-792'0 day of August 2003 an instrument was admitted to probate as the last will of BOHENICK ALBERTA M late of NEW dUMBERLAND BOROUGH , CUMBERLAND County, who died on the 23rd. day of J~ly 2003 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, DONNA M. OTTO , Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to USEWICZ THERESA and BOHENICK THOMAS who have duZy qualified as Executor(rix) and have agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office the 5th day of August 2003. K'egzsser oz ~z±'±s / **NO~E** ALL NAMES ABO~E APPEAR (LAST, FIRST, MIDDLE) MetLife® MettJfe PO Box 17i'00 Denver, CO 80217-0700 1(800) 638-7'732 ~ ~tw.metlife.com Overnight Address MetLife 1125 17th St Denver, CO 80202-0202 ALBERTA M BOHENICK THERESA M USEWICZ 717 ELKWOOD DRIVE NEW CUMBERLAND, PA 17070 001-0125 Transaction Transaction Date Description Page ~ of 2 Confirmation Statement 5/9/02 Preference Plus Select B Plus Class 550005346 Non-Qualified ALBERTA M BOHENICK THERESA M USEWlCZ ALBERTA M BOHENICK ROBERT STENGLE I (717) 691-5900 Account Summary Account Balance on August 15, 2003 Dollar Amount Unit of Transaction Value $0.00 8/15/03 Death Benefit $53,830.08 Fixed Interest Account $53,830.08 Unit(s) this Transaction MetLife® MetLife Please make your check(s) payable to MetLife. DO NOT SEND CASH. Write your account number on the check(s) and mail to: MetLife P.O. Box 371537 Pittsburgh, PA 15260-7637 For change of address please complete below: Street Address City ................................ State ....... Zip .......... FOR IRA ACCOUNTS ONLY: Is this a rollover contribution? __Yes __No If not, for which tax y. ear are you making this contribution? Mail-in Stub ALBERTA M BOHENICK THERESA M USEWICZ ALBERTA M BOHENICK 550005346 :~:~oo::.oo:.o~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~lIE~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ BUREAU OF INDIVIDUAL TAXES INHER/TANCE TAX DIVISION DEPT. 280601 HARRTSBURG, PA 17128-0601 THERESA M USEWICZ lq09 OLD RELIANCE RD MIDDLETOWN PA 17057 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOT/CE OF INHERITANCE TAX APPRAISEMENT, ALLO#ANCE OR DISALLOHANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 07-26-Z00q ESTATE OF BOHENICK DATE OF DEATH 07-23-2005 FILE NUMBER 21 03-063q COUNTY CUMBERLAND ACN 101 Amount Raait~ed REV-I;q? EX AFP C01-03) ALBERTA M MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LZNE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-033 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BOHENICK ALBERTA MFZLE NO. 21 03-063q ACN 101 DATE 07-26-200q TAX RETURN HAS: (X) ACCEPTED AS FTLED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAZSED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Reel Estate (Schedule A) 2. Stocks and Bonds (Schedule B) $. Closely Held Stock/Partnership Interest (Schedule C) (3) q. Mortgages/Notes Receivable (Schedule D) (q) E. Cash/Bank Dapos/ts/M/sc. Personal Property (Schedule E) (5) 6. Jo/ntly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expensas/Adm. Costs/H/sc. Expenses (Schedule H) (9) 10. Debts/Mortgage L/ab/Z/ties/Liens (Schedule I) (10) 11. Total Deduct/ohs 12. Net Value of Tax Return 129~900.00 5~985.00 .00 .00 551605.00 26~915.00 .00 NOTE: To insure proper crad/t to your account, subm/t the upper port/on of th/s fore w/ih your tax paymant. 15. Iq. NOTE: ASSESSMENT OF TAX: 15. Amount of L/ne lq a~ Spousal ra~e :16. Aeount of L/ne :lq taxable at Lineal. ICl. ass A rate 17. Aeount of L/ne lq at S/b:1/ng rata I8. Aaount of L/ne :lq taxable at CoZ~atara:1/CZass B rate :19. Pr/nc/pa:1 Tax Due TAX CREDITS PAYMENT RECEIPT OTSCOUNT DATE NUMBER TNTEREST/PEN PAID (- IO-ZZ-ZO03 CD003157 q31.81 (lB) .00 x O0 = .00 (:16) 191,915.00 x Oq5= 8,636.18 (:17) . O0 x 12 = . O0 (~8) .00 x 15 = .00 (ZB)= 8,636.18 ANOUNT PAZD 8,800.00 TOTAL TAX CREDIT 9,231.81 595.63CR .00 595.63CR BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (:.::. :;:~ (15) ~ ::::ii~ . O0 Nat Value of Estate Sub.~act to Tax ~':) .... 11~) -~= 1~1i~,915.00 Z~ an assessment Nas 2ssued p~evlously, llnes 14, 15 and/om,16, 17~ ~8 ~,19 Nlll neglect figunes that 2nclude the total o~ ALL ~etunns assei~S~ to,ate. IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULAT/ON OF ADDITIONAL /NTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A 'CREDIT" (CR), YOU HAY BE DUE I~-, A REFUND. SEE REVERSE SIDE OF THIS FORM FOR ~NSTRUCTIONS.) RESERVATION: Estates of decedents dying on or before December 1Z, 19BI -- if any future interest in tho estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for Iife or for years, the CommonmeaIth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate an any such future interest. PURPOSE OF NOTICE: PAYMENT: REFUND (CR): OBJECT[OHS: ADNIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (72 P.S. Section 9140). Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on tho reverse side. --Make check or money order payable to: REGISTER OF NILLS~ AGENT A refund of a tax credit, which ams not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1515). Applications are available at the Office of the Register of Hills, any of tho 25 Revenue District Offices, or by calling the special Z4-hour answering service for forms ordering: 1-BO0-56Z-ZOSO~ services for taxpayers with special hearing and / or speaking needs: 1-B00-447-5020 (TT only). Any party in interest not satisfied aith the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object mithin sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 1712B-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to tho Orphans' Court. Factual errors discovered on this assessment should bm addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. ZEOS01, Harrisburg, PA 1712B-0601 Phone (717) 787-6505. Sas page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is alloaed. The 152 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning aith first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6X) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January l, 1982 will bear interest at a rate which will vary from calendar year to calendar year aith that rate announced by the PA Department of Revenue. Tho applicable interest rates for 1982 through 2004 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rats Factor Year Rate Factor 1982 ZOZ .000548 ~'~'~-1991 llZ .000501 ~ 9l .000247 1983 16Z .000438 1992 9X .000247 ZOOZ 62 .000164 1984 llZ .000501 1995-1994 72 .000192 Z005 52 .000157 1985 15Z .000556 1995-1998 92 .000247 2004 4X .000110 1986 IOZ .000274 1999 72 ,000192 1987 lex .000274 ZOO0 7Z .OOO19Z --Interest is calculated as folloas: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (1S) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. BUREAU OF INDIVIDUAL TAXES TNHERZTANCE TAX DIVTSTON DEPT. 280601 HARRTSBURG,, PA 17128-0601 THERESA M USEWICZ 1409 OLD RELIANCE RD MIDDLETOWN PA 17057 COMHONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEHENT OF ACCOUNT DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN REV-16g7 EX AFP (OZ-OS) 08-IS-ZOO4 BOHENICK ALBERTA M 07-25-2005 21 05-0654 CUMBERLAND 101 Amoun~ Rem/~ed I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO~,,C,OURT HOUSE CARLISLE, PA~"~?01-~ _. NOTE: To insure proper credi~ ~o your account, subm/~ ~he upper por~Jon of ~for. h yo~:~:~ payment. CUT ALONG THIS LZHE ~ RETAZH LO~ER PORTZOH FOR YOUR RECORDS REV-1607 EX AFP [01-03) ~K ZHHERZTANCE TAX STATEHEHT OF ACC~--~ ........ ' ........... ESTATE OF BOHENICK ALBERTA H FILE N0.21 0~-06~ ACH !01 ~DATE/08-2~-200~ THIS STATEHEHT IS PROVIDED TO ADVISE OF THE CURREHT STATUS OF THE STATED ACN IH T~ HAHED ~ATE. ~H BELOH IS A SUHNARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BAEANCE, A~I~ IF APPL~ABLE, A PROJECTED INTEREST FIGURE. *'~ C~ DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 07-19-2004 PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYMENTS (TAX CREDITS): 8,656.18 PAYMENT RECEIPT ! DISCOUNT C+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 451.81 10-2Z-ZO03 08-0~-2004 CD003157 REFUND .00 8,800.00 595.63- IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" TOTAL TAX CREDIT 8,636.18 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.