HomeMy WebLinkAbout04-0462PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of ;~J~o ~, ~ ,~ ,,e' ~/'/d No.
also known/tX To:
Deceased.
Social Secur~
Register of Wills for the
County of
Commonwealth of Pennsylvania
in the
The pet~.t, io.n of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in ~O,o~. '~,r',~/~'~t/,~ County, Pen sylvania, with
h ~'~.-~' last family or principal residence at .~r; ]-i~L.~.~"~¢,'~,~.S ~ ,~,~e~-_~r'~,~l,~'~e~
(list street, number and municipality)
Decendent, then . 5"'c~ years of age, died ~ ,.~ <~ ~r/ ,
at
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $
(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:
Petitioner after a proper search ha,_..f__ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
..... _ .
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA } ss
COUNTY OF ?~'~ ~/~ ,~_
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
representative(s) of the above decedent petitioner(s) will well and
truly adminisIer the estate according to law.
Sworn to or affirmed and subscribed
before me this ~ ~ ~-~-~ day of
-- ~ " C Registe/r
Estate of
No.
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW __--~'~,~t-~ t q "~" '~' ~_~O/, in consideration of the petition on
the reverse side hereo~, satisf~tctory proof having been presented before me,
IT IS DECREED that
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of
Register of Wills~~~/~
FEES
Letters of Administration ..... $ /z~.~) D
Short Certificates( ) .......... $ .~, tO0
A~.enunciation ................ $
~.~2 $ /~. o~
Filed~../~ ..... A.D~ ~e ~
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
his, i~ to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
l.ocal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for'~!S certificate, *2.00~
'04 lfitrJ 14 P1:40
R;.!0327153
2o0,,
Date
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
Connie S
55
Cumberland
of
371 Burgners Road
Carlisle PA 17013
Glenn Albert
Darhower I~'emale I' 198 - 42 - 6252 . I,tla7 9, 2004
371 ~ursaers Road I,~'~'~'e' 1,0 ~te
'~ ~ ' ,~12em "~"*' ~A*~~ ~ W. ~r~r, Sr
Robert W. Darhower, Sr.
Vivian - Detter
371 Burgners Road; Carlisle, PA 17013
I~.' Holly Springs C~netery I~.' Holly Springs, Pa 17065
~.~ B~t~rs~U~eral Hcrae, Inc., Carlisle, PA
Lower Frankford
Ross Distribution
[] 5/13/2004
FD 012633 L
4:00A.. lq. May 9, 2004
Pending Investigation i I
I~JlS~* ~,~~I)~l~I .........................
~T~ichael L. Norris, Coroner
6375 Basehore Road, Suite
-~~f~'~~~:~[~"~:~'~:~'~"~)'~ ~ , Mechanicsburs, Pa. 17050
....
Cumberland County - Register Of wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 08/02/2004
DA_RHOWER ROBERT W
371 BURGNERS ROAD
CARLISLE, PA 17013
RE: Estate of DARHOWER CONNIE S
File Number: 2004-00462
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 08/24/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
GLENDA FARiqER STRASBAUGH
Clerk of the Orphans' Court
Will No. Adm~.. No,
! certify U~at notice of (bm~ld~ intezm) ~ required by link :LS(a) of tl~ Otphms' Court Rules
served on or mailed to the following beneiieiazies Of the above-captioned estate oo _
Name Address
Notice has now been given ~o all pe~r, ons entitled thereto under Rule 5.6(a) except.
Date:
Capacity; PerSOnal Rc ink',dc nlatlvt:
__~Connt, el fur porsuual rcTroal:~ntatlvt~
REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
~
Z
W
C
W
o
W
C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OtJl'J 'E
DATE OF BIRTH (MM-DD-YEAR)
d5 Oq lOOt} 10 4 Igtl-8
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
J)AR~ouJE~ 1(C)~E.R.T uJ.
FILE NUMBER (
'2.. I -0 C
COUNTY CODE YEAR
-O~fL~-
NUMBER
s
SOCIAL SECURITY NUMBER
lqg 4--2.
252..
o 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
lq3 - 3b -L{.b31
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
a 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
~
Z
W
C
Z
o
D..
(I)
w
D:::
D:::
o
U
NAME
COMPLETE MAILING ADDRESS
-J
;.,~.)
f",,,,)
(8)
o
FIRM NAME (If Applicable)
TELEPHONE NUMBER
(11 )
(12)
(13)
o (-8310 e>O )
o
o
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1 )
(2)
(3)
(4)
(5)
o
CJ
o
C>
(14)
C>
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It:
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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)
(7)
o
o
()
o
cJ
o
\r
(6)
()
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)
12. Net Value of Estate (Line 8 minus Line 11)
(9)
(10)
83'10 ,00
D
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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
~
::)
0-
:E
o
o
><
~
15. Amount of Line 14 taxable at the spousal tax 0
rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15)
16. Amount of Line 14 taxable at lineal rate CJ x.O_ (16)
17. Amount of Line 14 taxable at sibling rate 0 x .12 (17)
18. Amount of Line 14 taxable at collateral rate 0 x .15 (18)
19. Tax Due (19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS O[)
f:~ "-
CITY C A-R.. L t-s,l ~
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
STATE pl)..
(1 )
()
o
()
o
Total Credits ( A + B + C ) (2)
o
3. Interest/Penalty if applicable
D. Interest
E. Penalty
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
t!>
C)
o
o
(!)
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
a. retain the use or income of the property transferred; .......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life 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? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................. .............................................................. ........................ 0
No
~
M
M
[if
~
~
~
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 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 i n all information of which preparer has any knowledge.
ADDRES
31/ 80J?StlEt!.S (!~/.s Le.-
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
fJA
1'(/13
DATE
- OS-
ADDRESS
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 transfers to or for the use of the surviving spouse is 3%
[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 0% [72 P.S. 99116 (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. 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 4.5%, 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 12% [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.
, ~EV-1~ EX+ (6-9.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
~(jtJU'U=-
S. W/-fOWtL..
FILE NUMBER
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 jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
No~b""
/\La N 1;
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1503 Ex. (1-97)
'*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CO tU rJ L~
S J::>AlLHq oJ~
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE;
NoAle
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
R~V-1504 EX+ 11-97*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE 0'0
LOrJN'1f
C; . D h R-H-tJ u)e~
FILE NUMBER
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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONe-
NC),j~
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
"":"'''''''''''', '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF G
OtJtJfcC
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
5 VAI-H-o u) Efl-
~ 1 -r-l ..L:
J\J Q i\J t:::.
State
FILE NUMBER
1.
Name of Corporation
Address
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
2.
3.
City
Federal Employer I.D. Number
Type of Business
Product/Service
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting / Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? D Yes D No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? D Yes D No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? DYes D No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82?
DYes D No If yes, D Transfer D Sale Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a written shareholder's agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
10. Was the decedent's stock sold? DYes D No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? DYes D No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
DYes D No
12. Did the corporation have an interest in other corporations or partnerships? DYes D No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been
secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
flEV-1500 ~X+ (9-0.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF r ,
~rJlJ(fZ
1. Name of Partnership ~ "
Address - ,e
City
2. Federal Employer I.D. Number
3 PA-I<.f--JowEK-
FILE NUMBER
Date Business Commenced
Business Reporting Year
State Zip Code
3. Type of Business
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
c.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? 0 Yes 0 No
If yes, provide a copy of the agreement.
Date
11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
. R:V-1507EX+ (1-97) '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF A /\
\JJ/J 1J (€'
s
1)" rLt..fQ JWrL
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
f\lo~~
f\.\OIJ~
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV'~EX.I'.n '-*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EST ATE OF /'.
COrJtJ lIE.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
DkfLHow ElL
FILE NUMBER
s
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
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
1\10t0r;;-
~~o ~~
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
",:'..".,'.n .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF (\
LOf\J1J l6"
s
DA-ItHO WaL-
FILE NUMBER
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.
NO~~
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 identifying number. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
'~'''''''.''.n .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATEOF C
_OIJAJIE
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
s
D A-Ill-f () uJ E /?.
FILE NUMBER
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.
N
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
NUMBER VALUE OF ASSET INTEREST (IF APPLICABLE)
1.
O"Jk~ --........'" ---.".,.....
--
TOTAL (Also enter on line 7, Recapitulation) $
(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
COtJNt/E
FILE NUMBER
$. D fJrll H6 DJ~
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
~ WI r-J G- 131<..01 H E t<.S J:ufJ-t IUl L ~d {'-\ ~
Mr Ha L-LY Ce MfC7E~'1
C ~Lt U€ t1 t"H (}l ~ ,q- '-
00
5'7'70
1000
)600
"=-
t!)O
--:::::-
<>-4I!J
-
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.
Attorney Fees
--
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant 1<oe.€JL.T u), U~KH()v)6K
Street Address .3'1 , etJ~6 N~;e....s Rb
City ~ A fLl,IS~ State fA Zip
J1CJ/3
Relationship of Claimant to Decedent
I-I iJ~el;/11 b
--
4. Probate Fees
--
5. Accountant's Fees
---
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ g 3 rJ 0 .00
(If more space is needed, insert additional sheets of the same size)
REV.1S12 EX + '1-97)
.
i 1 .
: ,-..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF C I
OtJlJ IE
s
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE liABiliTIES & LIENS
-p A y(f-{ 0 uJerL
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
rJorJG
DESCRIPTION
AMOUNT
p.Jald~
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
~EV-1513EX+ (9-00.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
CoNN/€.
s
DI\'rLHow~R-
FILE NUMBER
M
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 [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
O,J -G' j....-' ,--
-
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.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
~EV-1514 ~X+ (12-0.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on REV-1500 Cover Sheet
ESTATE OF C
aNN I E
s
UM.l-Jo u) ~
FILE NUMBER
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
LIFE ESTATE INTEREST CALCULATION
NAME(S) OF LIFE TENANT(S)
DATE OF BIRTH
NEAREST AGE AT
DATE OF DEATH
TERM OF YEARS
LIFE ESTATE IS PAYABLE
o Life or 0 Term of Years
o Life or 0 Term of Years
......---,.
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table .................................................
Interest table rate - 03 1/2% 06% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
ANNUITY INTEREST CALCULATION
NAME(S) OF LIFE ANNUITANT(S)
DATE OF BIRTH
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which annuity is payable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . .
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( )
3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................
5. Annuity Factor (see instructions)
Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions) ..................................................
7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 ..................................................$
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
REV-1644 EX+ (3-84)
tk'
~~~ ~.
I. Estate of
INHERITANCE TAX
SCHEDULE "l"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL FILE NUMBER
o,l\llJ IE
s
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(First Name)
(Middle Initial)
II.
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for 011 remainder returns when on election to prepay has been filed under the provisions
of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
Remainder Prepayment:
A. Election to prepay filed with the Register of Wills on
(attach copy of election)
B. Name(s) of Life T enant(s) Dote of Birth
or Annuitant(s)
(Date)
Age on dote
of election
Term of years income
or annuity is payable
C. Assets: Complete Schedule L- 1
1. Real Estate
2. Stocks and Bonds
3. Closely Held Stock/Partnership
4. Mortgages and Notes
5. Cosh/Misc. Personal Property
6. Total from Schedule L- 1
D. Credits: Complete Schedule L-2
1. Unpaid liabilities
2. Unpaid Bequests
3. Value of Unincludable Assets
4. Total from Schedule L-2
$
$
$
$
$
$
$
$
$
III.
E. Total value of trust assets (Line C-6 minus Line 0-4)
-::"
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (line E x line F)
(Also enter on Line 7, Recapitulation)
Invasion of Corpus:
A. I nvasion of corpus
$
$
$
o
(Month, Day, Year)
B. Name(s) of Life T enant(s)
or Annuitant(s)
Dote of Birth
Age on dote
corpus consumed
Term of years income
or annuity is payable
C. Corpus consumed
D. Remainder factor (see Table I or Table II in Instruction Booklet)
E. Taxable value of corpus consumed (Line C x Line D)
(Also enter on Line 7, Recapitulation)
$
$
$
f
REV.1645 EX+ (7.85)
'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-'
REMAINDER PREPAYMENT ELECTION
-ASSETS-
FILE NUMBER
I. Estate of
(Last Name)
II. Item No. Description
A. Real Estate (please describe)
(First Name)
Total value of real estate
(include on Section II, Line C-1 on Schedule L)
B. Stocks and Bonds (please list)
Total value of stocks and bonds $
(include on Section II, Line C-2 on Schedule L)
C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2)
(please . list)
Total value of Closely Held/Partnership $
(include on Section II, Line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes $
(include on Section II, Line C-4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property $
(include on Section II, Line C-5 on Schedule L)
III.
TOTAL (Also enter on Section II, Line C-6 on Schedule L)
(If more space is needed, attach additional 8Y2 x 11 sheets.)
(Middle Initial)
Value
$
s
REV-16M, EX + (3-84)
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION
-CREDITS-
FilE NUMBER
I. Estate of
(last Name)
(First Name)
II. Item No.
Description
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities $
(include on Section II, Line 0- 1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list)
Total unpaid bequests $
(include on Section II, Line 0-2 on Schedule L)
C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets $
(include on Section II, line 0-3 on Schedule L)
III.
TOTAL (Also enter on Section II, line 0-4 on Schedule L)
(If more space is needed, attach additional 8% x 11 sheets.)
(Middle Initial)
Amount
$
. .REV-164~ EX+ (9.{)()*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev-1500 Cover Sheet
ESTATE OF
FILE NUMBER
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF BENEFICIARY
RELATIONSHIP
DATE OF BIRTH
AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
o Unlimited right of withdrawal 0 Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) ......$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 0 6%, 0 3%, 0 0% . . . . . . . . . . . . . . . . . . . . . .$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One 0 6%, 0 4.5% ...........................$
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ......$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) ......$
I 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$
(If more space is needed, insert additional sheets of the same size)
. .REV"64',EX 11.92) ..
COMMONWEALTH OF PENNSYlANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91)
i FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) ....................................................................
1. 0
2.
3. 0
4. 0
2. I nsu rance Proceeds on Life of Decedent............................................................................
3. Retirement Benefits.........................................................................................................
4. Joint Assets with Spouse.................................................................................................
5. PA lottery Winnings..................................................... ...................... ................... ........
6b.
6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a.
6c.
6d.
6. SUBTOTAL (Lines 6a, b, c, d) ......................................................................................... 6.
o
o
7. Total Gross Assets (Add lines 1 thru 6) ............................................................................. 7.
8. Total Actual Liabilities.............................................. ........... ..... .... ................. ................. 8.
9. Net Value of Estate (Subtract line 8 from line 7)................................................................ 9.
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II.
d
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Returns for decedent and spouse. )
Income: 1. TAX YEAR: 19 2. T AX YEAR: 19 3. TAX YEAR: 19
a. Spouse ...................... 1 a. 2a. 3a.
b. Decedent................... 1 b. 2b. 3b.
c. Joint .......................... 1 c. 2c. 3c.
d. Tax Exempt Income..... 1 d. 2d. 3d.
e. Other Income not
listed above ........... 1 e. 2e. 3e.
f. Total............ ....... ....... If. 2f. 3f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
( If)
+ (2f)
+ (3f)
=
(of- 3)
4b. Average Joint Exemption Income ..................................................................................... =
If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part III.
PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or S 100,000, whichever is less.......................... 1.
2. Multiply by credit percentage (see instructions) .................................................................. 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................................ 3.
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate.................................................................................................. 4.
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. 5.
REV-1649 EX + (1-97)
'.
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
DA-eJ-+o W €-r~
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CnfJ/d It
Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) ofthe Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
s
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin souse under a Section 9113 A trust or similar arran ement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made.
DESCRIPTION VALUE
Part B Total $
(If more space is needed, insert additional sheets of the same size)
slofo
STATUS REPORT UNDER RULE 6.12
Name of Decedent: CO~ ~ U;
S. 1)A pt,1-JOuJ~
Date of Death:
s/qJOtf
. I
r:2 / - 0'/- Ol/fo J.
Admin. No.:
Will No.:
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 ~ther administration of the estate is complete:
Yes l.L1 No 0
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:
a. Did the ~sonal representative file a final account with the Court?
Yesy No 0
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative s~n account informally to the parties
in interest? Yes 0 N 0 ~
c. 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.,? _. /;)
Date:~f>/{js ~~~~
Signature
-.....
ROC..e::Ila...T iJJ \ DAR-HOWC:rZ..
Name
~11 Bute..6AJ(:;.fc5 R.D.
r2AIU-ISl.~ fJA- /10/3
Address
7/1 d'f~ 1.:r79
Telephone No.
?" : " iCaptiCitY: -cl'Personal Representative
t,V .
o Counsel for personal representative
uCJ{
08-01-2005
DARHOWER
05-09-2004
21 04-0462
CUMBERLAND
101
APPEAL DATE: 09-30-2005
( See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECORDS _
REY:is47-Ex-AFP-ioi:osi-NDTicE-oF-iNHERiTANCE-TAX-APPRAisEHENT:-ALLOWANCE-OR---------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
CONNIE S FILE NO. 21 04-0462 ACN 101
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
RE('()RDE[!l~~~~F(lfNHERITANCE TAX
'~~~~IIE!I'I\I:,~DIIANCE DR DISALLDlIANCE
,,~,Jlt; IDEMTIDNS,,'ND ASSESstlENT DF TAX
2005 AUG - I
Pf~ 12: 27 DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
ROBERT W DARHOWER
371 BURGNERS RD
CARLISLE
CLF'W r,:=
.J,I\ ,-';
ODPU!.' N"IDT
II i::'" !.."'__';._.-11
"I "F"
1._1'_,""
PA 17013
ESTATE OF
DARHOWER
*'
REV-1547 EX AFP (06-05)
CONNIE
S
TAX RETURN liAS: (X) ACCEPTED AS FILED
) CHANGED
DATE 08-01-2005
If an assess.ent was issued previouslY, lines 14, 15 and'or 16, 17, 18 and
reflect figures that include the total of abb returns assessed to date.
ASSESSMENT OF TAX:
15. lunount of Line 14 at Spousal rat. (IS)
16. Amount of Line 14 taxable at Lineal/Class A rat. (16)
17. AltOUnt of Line 111\ at Sibling ....t. (17)
18. ~ount of Line 14 taxable at CollaterallClass Brat. (18)
19. Principal Tax Due
DI
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..1 Est.t. (Schedule AJ
2. stocks ..,d Bonds (Schedule BJ
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Kortgages/Notes Receiv.ble (Schedule D)
5. Cash/a.nk Deposits/Hisc. Personal Property (Schedule EI
6. ~ointly Owned Property (Schedule FI
7. Transfers (Schedule GI
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
.00
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adn. Costs/Hisc. ExPenses (Schedule HI
10. Debts/Hortgage liabilities/Li8ns (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitab1e/Gover~ental BeqUBstSj Non-elected 9113 Trusts (Schedule ~)
14. Net Value of Estate Subject to Tax
(9)
(10)
8,370.00
.00
(11)
(12)
(13)
(14)
NOTE:
.00 X
.00 X
.00 X
.00 X
+
AI1DUNT PAID
IlUllBER
INTEREST/PEN PAID (-)
DATE
~
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
credit to your account,
sub.it tha upper portion
of this fo~ with your
tax PBYlI8nt.
.00
8.370 00
8,370.00-
.00
8,370.00-
19 will
00 =
045 =
12 =
15 =
.00
.00
.00
.00
.00
(19)=
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU IlAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FDRN FDR INSTRUCTIONS.)