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HomeMy WebLinkAbout04-16-0915056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes ry PoBOx2sosol INHERITANCE TAX RETURN Harrisburg, Pa 1~12a-osol RESIDENT DECEDENT 21 08 0808 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 07/17/2008 05/29/1963 Decedent's Last Name Pritchard Suffix Decedent's First Name William (If Applicable) Enter Survlving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI T MI FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return ~ 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. limited Estate 4a. Future Interest Compromise (date of '_:;~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 B. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death :;.. 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Michael A. Scherer, Esq (717) 249-6873 c Firm Name (If Applicable) ~ -: ~ ;, ; ~ O'Brien Boric & Schere REGISTER~F~LLS USE QW_Y t,r"~ '~_~ T-? `~ ~-~-' `_ , First line of address ~> ~ r " ~~ ~ ' 19 W South Street ~ ~~~~ G = R . ~ Second line of address ~ ~~ ~ ~ ~ '_, ~ ~ ~ _ ~i -o " f V - Y City or Post Office State ZIP Code DATE FILED. -- Carlisle PA 17013 Correspondent's a-mail address: 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 true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE PERSON RES NSIB~L,/E FOR FILING RETURN DATE ADDRESS 6089 Yona Court, Mt. Airy, MD 21771 738 West Diamond Avenue, Hazelton, PA 18201 SIGNATUft~ ~Jf J~~2~P"AREFj~ TI-I~ t~AN REPRESENTATIVE ~ ~ ~ C IJ//~ I/A/-/~ ~/! 1 19 W.-South Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 08 '.0808 DECEDENT'S NAME DECEDENTS SOCIAL SECURITY NUMBER William T Pritchard STREET ADDRESS 712 Hanover Manor, Apt. 307 CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 435.14 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 435.14 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 435.14 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 :.................................................................................... ...... ^ ^Q b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ ^X c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 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. 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. §9116 (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 (O) percent [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 zero (0) percent [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 four and one-half (4.5) percent, 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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling 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-1500 EX Decedent's Social Security Number William T Pritchard 088-42-8756 Decedent's Name: RECAPITULATION 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. ' 27,313.57 6. Jointly Owned Property (Schedule F) ~::' `:::- Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) _:: Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 27,313.57 9. Funeral Expenses ~ Administrative Costs (Schedule H) ................. .... 9. 8,313.70 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 10. 9,330.05 11. Total Deductions (total Lines 9 8 10) ............................... .... 11. 17,643.75 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 9,669.82 13. Charitable and Governmental Bequests/Sec 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. ', 9,669.82 _.__....,, ___ ~-_ _ _.,., ._._. ,,,_.-_~ ._..._.-~.. .r_._.,_.,_,...._..~......_._.r.._..._._ ..,,...- , . ..._ ~w.,... ~. ._..._ . _.. ,,. .. 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 .0_ 15. 16. Amount of Line 14 taxable at lineal rate x .0 45 9,669.82. 16. 435.14 17. Amount of Line 14 taxable at sibling rate X .12 17. _.__ 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19. 435.14 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 15056052059 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER William T. Prichard 21-08-0808 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. (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-PROBATE PROPERTY ESTATE OF FILE NUMBER William T. Pritchard 21-08-0808 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. ITEM NUMBS DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENTAND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF OEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE ~ TIAA No. C9614508 3,468.02 100 0.00 3,468.02 2. TIAA No. D3415959 2,552.58 100 0.00 2,552.58 3. CREF No. V3415956 6,470.73 100 0.00 6,470.73 4. TIAA No. 35450451 1a,842.so 100 0.00 ~s,842.so 5. CREF No. 45450459 11,718.49. 100 0.00 11,718.49 6. TIAA CREF: Mutual Fund Retirement 13,931.88 100 0.00 13,931.88 TOTAL (Also enter on line 7 Recapitulation) $ I 56,984.30 (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 FILE NUMBER William T. Pritchard 21-08-0808 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Hoffman Roth Funeral Home & Crematory, Inc. 2,791.38 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 Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. The Sentinel: legal advertising s. Cumberland Law Journal: legal advertising 9. PA Dept of Revenue Zip Zip TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 4, 500.00 303.00 150.00 278.32 75.00 216.00 8,313.70 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER William T. Pritchard 21-08-0808 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIE5 INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER William T. Pritchard 21-08-0800 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE t TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 ~ William and Ruth Pritchard parents 100.00 738 West Diamond Avenue 2 Hazelton, Pennsylvania 18201 Christie Pritchard ex-wife II 287 North Pleasant Street Canandaigua, New York 14424 Christie Pritchard has received the TIAA CREF retirement funds ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET 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 I $ 0.00 (If more space is needed, insert additional sheets of the same size) Human Resources Department Shippensburg University 1871 Old Nlain Drive Shippensburg, PA 17257-2299 0®~~~_ SHIPPENSBURG ~INIVERSITY October 8, 2008 Ms. Lisa Taddei C/O O'Brien, Baric, & Scherer Law Offices 19 West South Street Carlisle, PA 17013 Dear Ms. Taddei: www.ship.edu/hr Office: 717-477-1124 Fax: 717-477-4037 E-mail: hrC~ship.edu Please find enclosed the final pay for William T. Pritchard in the amount of $10,309.37. This encompasses the regular salary for pay periods ending 7/18, 8/1, 8/15, and 8/29 ($9,459.12), sick leave payout (10 days totaling $3,074.22), and one unused personal day ($307.42). It also includes the deduction of $1,549.07 for the direct deposit amount on 7/18/08 (we were too late to stop the direct deposit), and appropriate social security and medicare taxes. Please accept our condolences for your loss. If you have any questions, please contact me at 717-477-1123, X3109. Sincerely, ~, `ii `~~'~`~ ~`-- Mary Jane Diffenbaucher Payroll/HRIS Manager mjd cc: Lisa Taddei 10/21/08 w/ Enc. • A member of the Pennsylvania State System of Higher Education ' ~ i G ' ~~~ SUBSTITUTE FORM 712 This statement has been prepared as a substitute for U.S. Treasury Department Form 7I2 which does not apply to our annuity contracts or certificates since they have no life insurance features. Name of Decedent: William Prictchard Decedent's Date of Birth 05/29/1963 Decedent's Date of Death:. 07/172008 VALUE OF CONTRACT/CERTIFICATE AT DECEDENT'S DEATH Contract/Certificate Number Issue Date of the Contract/Certificate Date of Death Value of the Contract/Certificate Remaining Investment in the Contract/Certificate TIAA No.: C9614508 09/19/1999 $3,468.02 $0.00 CREF No.: U9614506 09/19/1999 $0.00 $0.00 TIAA No.: D3415959 09/01/2002 $2,552.58 $0.00 CREF No.: V3415956 09/01/2002 $6,470.73 $0.00 TIAA No.: 35450451 07/01/2003 $18,842.60 $0.00 CREF No.: 45450459 07/01/2003 $11,718.49 $0.00 Mutual Fund 07/01/2003 $13,931.88 $0.00 Notes: The Date of Death Value of the Contract/Certificate represents the value of the Contract/Certificate as of the participant's date of death. The Remaining Investment in the Contract/Certificate represents any remaining after-tax contributions made to the Contract or Certificate by the participant. The Remaining Investment in the Contract/Certificate is non-taxable to the beneficiary when it is paid. THE UNDERSIGNED MANAGER OF TIAA-CREF HEREBY CERTIFIES THAT THIS STATEMENT SETS FORTH CORRECT AND TRUE INFORMATION. Signature Date Beneficiary Services Team Aprit 1, 2009 i.* t1J: tt __.........__.~..u..~.-..~:~'iiv;:~u u..y ........v.e.._. ~ -....asis~~...y..~.,.....:iiei:}:teli......__~.... u~:~i:•?. Sa f rJtiitiea Fonr 9 ~ (e!B?; Wes' Grout, Rodieclat. NY F©FttK es Uasited 3tato~ r~ankruptcy Coucf: ' ;::~>:>;~:;::;:~:: <=:~~•::<:~:~.: ' M;!~ ~(D;~i~f >'-~/ tSttriC4 0# PE~PSYSV11idZA M~D~LS' bs ~ (Name of Debtor cat i(WividlW(, anba~ ,.ast, Faro, ~ie~ fitamC of .3Dint Debtoc(svass~YtkaaL r;rs; Alyddl8;: PRIT.C~ARD, P/Z'~~174lsC ?. AI! Cater Names uses: by the Z•lebtor in the last 6 years A(! Other Name. used by the :taint Debtor 9n the last 8 years (fneiudo mattwo, maiden; and trades namosl'. IiOlP;e ~ (induda marries:, maden. and Vsde nmrys): t( 1 Sac'. 5ec!*ax ; v. No.litmore than one. Nate aH; Soc. Sec.l3ax i.D. No. (irmae Ms'n one, state aH): 8756 Street Addres$ Of Debit3.' (Na. 8 Shmat, City. State & Zit ~+T { Sliest Otddress Of Joint DebioC '(ta. & Sueet, Ciry, State b Zip Colo) ^22 HANOOER l~i1VrTR #30 7 f{ CJ4RLS3F.E Pli. f ~G23 County s>f Residence ar of the s ~ouaty of Resider ;e or of ths3 PrlriGl 8i ?IaC¢ OS BUSineSS: C(;O3B~R.G~DtD - P11r-c(pa( piece. of BUSUIeSS: Naffing Address of debtor i+i ditrararrE cram meat +xfdraasi: ~ Mailing Address of Joint Debtor ;r drffrent tram:vae• aadsess): S11it~ Location of Prirtcipad Assets of Bus6tess Debtor (!r dtflerent frdn street address abover IIIt:M' .~PPLYC,ASL>~ ..... v ._ ._. .. Yrtmusa {Check ors} applis:aDle box;. Q Debtor has beer± damicistad Or has heal a rgsidertce:, principaE place :7t' business, or pnineipaf. assets in this- District for 48~ days immediately preceding the date of this petition: or for a jonget~ past bf such 1 SC days. than. Er, any other District. ~ There is a bankruptcy ^ase concerning debWls aff'iiiat$, genera( partner, or pattites~s(tiF~ pendinr~ iri this District. rj,+pe of Debtor (Cttecii al's boxes that apply; ~ Chapter oc Secttttrt of Barigiruptcy Cor)ss tlnt~er Which ~ I»dividual{s j (~ RailsYjas7 ttte Ps3titiCrr is Ftlett {Chock onr, box} ~. Carooration ~ Stockbroker ~, Chapter? ~rhapter'~ 1 ~ Chapter t3 Partnership d Commodity s~roker ~ ~ Chapter $ [~ Chapter 'l2 '~ rJther ~ Sec. 304• - Case ancillary to fore!$r, proceeding Nature ayf 4ehta (Check aria box} F!lfn~ t=om (ChrrY, onr3 box) C Consumen-vosi-Business ~ Business (~ Fu{S Fifiny Fee attached Chapter 4 t SmafE Business (Chr~k a6 boxes that Apply; t ~ Filing Feb to ~ paid iri instafisttsxts (Applicable to individuals only; debtor is s smai; 5usirte55 as ds~(tnad in t 1 'v.S.C. § 10 ~ { hAusi: attach Ssgned application for thg ; ouR's canstderation [~ aebtbr i5 aRS; erects h: be cartsidera~d a small nosiness under 1 cert~YirxJ that the dsabtor is unable to paty fee exs~pt ir. instalErrsents t 1 tt,5.C E i,2tje? jflptronal? Rule 1006{D;. 5se Offraiat Form r~s7. 3. StalistecafJAs4mtrtistratlve frtfastttation (Estimates onlyr i 71i1u 5PACE la F(~F coon' uSE. oNiY C~ebtoc estimates that funds wifi bs3 avaitabk Son dfstributior to unsecurec ciediiors. ~ - ~~..s ~( Det~tor estimates that: ages any raxsainpt property -,s excluded and administratitre expenses ~ ~ ~'~' paid, there ~v'slE be rro funds available tot distribution to unsecured cres4itorg. ' Estimated Number of Creditors i~i5 isa~ts sc-sa` ionise z0ass4 l0oGaver ~ -' Y •, estimated Assets _, - , SU to 564,001 W 5100,001 lc 5500,OC'i +~ SS,1)W,04' k' S10,OOL',00' to 550,000.001 m fiAart. Man •,. - S6GA00 310G,00(: 5500,000 Si cnS4lbr~ 510 rri8br. 550 mip;on Si00 miifion 5140 million. ~ Estimated. Debts EO fu SSC 04`. *v 3101:,00: M 5500,00'1 x Si,00tf,407 w. SiC,00p,00i hr 550,000,001 t4 Marv than 550,000 Si4G,00(! 5500,OOC 51 milqu•. S1C miltiar. 550 miltton 5100 miltlor. S10C million ~ a a e ~ ~ ~ .. ~idL:: r~iii.'r.N~1~e<r ~ .L~;>lJfl%3r''~'1~1~~~7t:~ru~i,',.~.i::~..s},:s;~>..._....:.....,.,..,._.3.. (cm~aa! rortr ~) I;fn; } wee, Urnup, xca+eatcx, nr , of O~Ui1t1t~{' P#b~1Z00t'~ Name of c~ehtor(c} FaitltF 61, Page 2 {this gage must 68 i:orripieted and flies' in, every' Casey Where Case Number: Date F'~ert: Name Ot O®ata.": case: ~+n~maer vane rasa: !V~ district: kelationsttip: Judge' __ Signatttssta~ aF Oatrtar(t~ {tndirrlduafiJctrrtJ SEgnature of ~isbttlr (Corporatton/~arlnership; i declare under penalty of pefjury that the inforrtatian provided in this t declare +drtdAr penaity~ aF p~9rjiiiy that thg informatron provided in this petitior• is true and tartest. petttlptt is true slut tartest: and that 3 have fleet, authartzrect tc fits this (If petitioner ie ar. isxtividua- whose debts are primarily consame: debts: .petition or betiat? of flee debtor and has chosen to fits uinoer chapter Tj t 8m swats dtat % may prxeed under chapter 7, 4 t, `2, or 13 of title ? 4, United States Dade, understand Tt-e debtor requests reli9E its acgordartcg isith thi: chapter o° title t . , the relief avai ;each such chapter, and choose to proceed .United States Code, speGifre~ iR this petition: Under' chapt r . y l request tells. acr~ance the pter ale ? 1, :lniteC $tafea Code, ~~ it- fiia-p tttarl f ' `\, ` Sip are o « i Signature d Jdnt asbtr. Yelepnaw Nurrwer (>` noY rspreeerxed ar aeomayl aete~c^ y ~ r ~ Si nature Erf Attorney u r; t A (i4 fBOfAroornayfOrDebaor(R1 i Js. 72.9 3 PrinteG Nartw M. Aaorrwv for r(a; IJt1iP 8'ZRbL Off' b~ R. C1~2'P~~2'E~R Firm Name 5t32Y ~ ~R~ND3~.~$1~=T& Z~Q Aadcese JlCC~JltitlESBtTRG ilk - I7Q5G : h s;a,serwe osau~onxee lgdn„aua' Ptir:La6 NamM al.i3Ntioriiea tndtrwdua~ rdfe d r+u~horizecf kKh+Uu~ pats S'sgnawr$ a€ Na+s,f-ltarney Petitiar< Pteparer i certify ttsa: t am a tsankiuptcx deatior, preparer as defined in 4 4 ;:.S.C. § t 4U, that - prepared this d6curru{nt for compensation,. and ma+. f have provided-the deti^>nr ~wi1t~ a rapt of!this document: Printed Natst6 of flar.Wvpecy 1'ohYC,r, P+'aD~re~- Stici36 seourly tambor ncdra.a (7173 ~-&'-~3G ~ ~' }e°' ~. G,4r. TelopMne Nirrll~r pate ~thiRif lTo be romptated if deblwX is requited tc file pei-odc reports (e.g., forms 40K and 4>3Q; tirith tftie Sactnitiea acrd ~xchangt: Commissions pursuant to Seetsan 't3 ar 45(d) of the.5ecurities Exchange Act p° 1934 and is requbstisxi relief i,tnder chapter 44} Exhibit P. is attached and made a p,3r< of this petition. r t~chit~tf H T'a bs competed if debtor Is: are indivlsaua! whose debts are prlmari4y consumer debts} i, the aftamey for t}~ petitioner namtn} its the Foregoirsg petition, declare i that i have informed the pt3ti8t5ne! tft8t [he ac ells} may proceed under E ctfapcer 7, s , i,~, or 13 of ritle 1'4 , tirsited States Code, and have , exptai the ratief avail under acn sots chapte:: i ~ At>JOmey Sa asbtor(s; ~atH i G ~ Q ,,~_. Names 8rid Social SeCUrit~~ ssutrtbers'oi ail other individuals who prepares or assisted in preparing this document: If motet than ane pbtsor prepared this document, attach additianai sheets conforming K, itse appretiphate ot~icia? form fcr each person. $IArt2dXe d 68NCNp1Gy Pauua, propal+7i~ aza, r----~-,--~-._._._ A banfcruptcy Sbetitior, preparefa fsiiurl~ to comply witF: tht: provisions of title 1 t anti tr`e Federal Rules of 8nnkruptcy Procedure- may result in fines or imp~isorment flr txdh 7 t i3.i5.C, § 1tQ: 4E J.S.C. § 456.