HomeMy WebLinkAbout09-09-09 (2)217
REV-1737-A EX (9-00)
FILE THIS RETURN WITH:
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
Ez-
W
W
V
W
e
W i ~
v
v 6 m
t
~~
S
0
V
METHOD
_O
F-
H
a
Q
V
C1C
W
V ~"'
C~
V V
a
~-
~1
FIRST, AN
REV-1737-A
INHERITANCE TAX RETURN
NONRESIDENT DECEDENT
DATE OF DEATH.(MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
05-24-2006 01-31-1914
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
^X 1. Original Retum
a. Limited Estate
6. Decedent Died Testate (Anach copy of wii~
9. Litigation Proceeds Received
2. Supplemental Retum
4a. Future Interest Compromise (date of deatn after 1z-tz•az>
7. Decedent Maintained a Living Trust (Attach copy of Tnut)
10. Spousal Poverty Credft (date of death between 12-31-01 and 1-1-05)
AL~~CORR1=SPn~tnkturG ~~n ~,.«,~,-...,.,.- ---~.
NAME
FILE NUMBER...::., ....: .,.... ....
9 9 - ~`' - ~ ~- oc~-~3
COUNTY CODE YEAR NUMBER
19-1
SOCIAL SECURITY NUMBER
3. Remainder Retum (date of death prio~to 12_~3.s2)
5. Federal Estate Tax Retum Required
0 8. Total Number of Safe Deposit Boxes
^ ~ ~. Election to tax under Sec. 9113(A) (Attach sch o>
tobert G. Fre COMPLETE MAILING ADDRESS
FIRM NAME (HAppl~cable) 5 South Hanover Street
're & Tile Carlisle, PA 17013
TELEPHONE NUMBER
17-243-5838
REFER TO METHOD OF COMPUTATION IN THE NONRESIDENT DECEDENT INSTRUCTION BOOKLET (REV-1736
Check One: [~ Flat Rate [~ Proportionate (Complete Worksheet on Reverse Side)
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership orSole-Proprietorship
(Schedule C)
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
t3. Jointly Owned Property (Schedule F)
Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
1 ----z-
106 500 ~ ~ ~~ ~5~~~~~,'~
Y .. "..M/
C~ f.~~~
3~
(4) r ; -;
.
A ,ter . .-,~`~ ~•
..._
(6) 0
~) 0
(8> 106 500
(9> 15 237
(1 °) 0
13. Charitable and Governmental Bequests/Sec 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
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (A)(1.2)
0 x .0
1t3. Amount of Line 14 taxable at lineal rate 91 263 X .0 45
17. Amount of Line 14 taxable at sibling rate 0 X .12
18. Amount of Line 14 taxable at collateral rate 0 X .15
19. Tax Due -Make check payable to Commonwealth of PA
.. . ..
'-~ ~~ }> BE Sll!RE TO ANS~M1fERALL QUCSTIOMS DN,°R6YERSE_SIDEANDk,RI
(11) 15 237
(12) 91 263
(13) 0
(14) 91 263
(15) 0
(1s) 4 107
(17) 0
(18) 0
(19) 4 107
< <
a
N
rn
i~
U
N ~
O
~~ zoaaooooW _~
a.Jp ~ c
Z
aa~ °' ~ ~ ~ ~ ~ ~ ~~ w wow o •N ac
W Z ~ } ~ ~ ~ ~= y 'c C~
~'J~ ~ ~ ~ ~'~~ ~~ m ~~
ZZN =~ ~ ~~E o~ ~ y~
x Z Q ~; ~ O p ~ y_ ~ E~ ~.°. ~ .~...
•- .. co c ~. rn r
Z d' a w 3~ a ~_ ~`~ -'- g ~ ~y aci ~ o
m Z ~ s y ~_ w% ° ~- m _>
y W Z W y ~° ,~ '~ W ~ i `~ d ~ ~ ° cya ~ ~ ~i ~ H
Z b1 - W ~ y ~~, rw,,, ~ p Q ~ ~N E^~ ~ a °~ ° eo
O p p a~i o. c °~ c y ° O ~ ~ ~ cC ~:^v°i .ono Zvi ~o
F= j1
m
O V LL y a~ ~ w ° ~ m LL ~° °~ O`er`' ~ c «ry °a~
moo ~ y ~ ~ ~ ¢~ap ~_ ~~~z ~~' ~ ~~~
O ~ o. ~ ~ y•~ W Z e ~ g. ,rid "~ ~ y ~. ~~ wy o
Z 1W- ~ H h ~ °' ~ a ~~ H Q m ~ ~~ m c~ ~co cg
.I LLp ~ '~ •. ~~ L ~',~ OJ ~~ zvi~,~, ~~c ow o
O ~ o ° m° W ° ~ ° ~~~
° a~
..IF-OW ~ `o w ayi ~ ~° ~° ~o ~-p ~ ~ ~y co ~~ ~°w °~ ~c~
O m m = ,~ y ~ ~ = E c ~ ° c Z p ?`d cN Z'a~ ~.> ~ >N ~ a~i o
~'~' O a H c E ea c `o ~ ~~ Q W ~ ~ ~$ ~C°~ °., y ...vj •-~ y
=n.J~ ~° $ 'y z, ~- Q• :-oco02 ~o ~ ,~y `~° c any
~QO ~ c ~ co y ~ c cc ~"" V ~ `Yg :~8 ~o`~ °o°~ a~N acic~
W W ~ ~ E ~ .~ ~ a ~ • ~ N ~~ o ~ ~ ° ~ c s~ o o ~ Q
2 ... d 3 d o ~c v, o ... ~•..
NF-aW c a~ a~ ~ r.,, ~ c~° ~~Z ~ ~y°~ ~y$m ~ ~...,
Q W ~ 5 ca m ~ co m ° a~ -~ Q ~ m o m rn x •- ea ~ ~ •- gi y g. `~ ~
W Z ~ _c c c ~ ~ -c - ~ _o v c •~ Z .o E co o~ E ° E r-
NJO .~ w :°. c ~~ ~~'_ ~a om c.>_Ey r-°°1 CS »..
_ ~ Gl O N ~..
~ Y m Z ~ ~ ~ ~ ~ 'e _y ~ ~ F.. a ~,m y Z~ m a°i ~ c""au~ m yyya „_, cad
a V ~ _ 'O ~ ;O t ~ o .. y .~. y~ ~ ~ ~' X ~ ~ C
LLiOZ~O cd a ci ~ a Oca Oaf ~c m°y~ ca~~~ ~01 ~~E
J J ~ 'n ° c ~ c d o
~ a~ ~ y = ~ °
'L °' y ~~~ a c~ y >K
V M ~ N O L ~ ~~ ~ 0 0 O O
C + I- d ~ ~ + ~ (jJ ~ m H ~ c ~ .s ~ eo ~ yc X
N Q1 ~0 C W O ~ ~ ~ ~ ~ ~ j ~ C ~ C N ~ ~ ~ ~ ~ !~0
/~~ ~ ~f g, •o t_h +~ N C y ~ {' ~ ~ C`~ U ''. lOi C ~ uyi C .~ ~ W J cC0 v ~ ~ ~ ~ .~.. J
ii ~ '.w~ V) .d ~ G1 C O N y r' y C C O Q ° y ~Q ~ ~ Cr0 ~ Co I" C ~ C C
~ ~ c~¢aoci =ou.i _.~ =~ Q m ~ ~ ° ~ c ~ c ° ~y ~~•,., E° Q ~ g' E o ~
f.. ~ c. ~- a ~ o t- ~, cn v~ m ¢ a ¢ a ¢ a m
~ ~ ,_
r N N Q O O
d' '~ Z
a
J
~"
V7
~. ^ ~
v N^ ^ ^ .-. .•~
V W a, II II II Iv
+ ~' LL` O O O
m D Q O O
+ v
v C
to
~ ~ ~ ~
~ ~,
W ~ ~ ~
~ ^ ^ ~ ^ ,~
o ~3 ~~ o Z: ~ ~ ~ v ~ x x x x
w o ~ •~ .~
o • ~ ~ ~
:~ o
m ~ ~° ~ ~ y~y ~ ~ ~
. w L m O, G a J y O
.r ° m .- '>
- as c ~ N ~ ~ ~ y ~' ~ aMi
c ~a ° m ° :` ma C
y U C~ ~ >K .o.~ o c " a a a c N r. o m ° ~ ~ ~ ~ p~ ~: o~
y a~ c = a ~ ~ a~ ~ ~ ' a ;~ 8 '• ~
~ da ~w ~ yj V M~ c o ~ O c~o~ m ~ ~~ cow, ~N aR Oth Ocr1 Ito y
v ~ fA a 77 ~ f~A ~` Of 0 C f: ~ L A/ ~' "" N G_ lC0 ~1 ~ ~ y ~ ~ C ~ C ~ C C
a; c y c y o c .ate. yrn
~ N M •sf ~j
~' N c+i •ef tp ~p ^ ~ ~ F.
~,
m
a
c
0
c
O
V
x
F=~
°
2
d
a
O
m
217 White, Donald N.
REV-1737-1 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA NONRESIDENT DECEDENT
DEPARTMENT OF REVENUE AFFIDAVIT OF DOMICILE
DEPT. 280601
This affidavit must be completed and sworn to by a person having personal knowled a of t
facts, preferably by a surviving spouse or member of the decedent's family. hese
Name of Decedent
Legal Address at Time of Death:
Street Address
1161 Ea
City/Borough
State Zip Code
The following information is submitted in su '~ T 1046
pport of the statement-that the above individual was
not.. domiciled in the Commonwealth of Penns Ivania at the date of death.
1. Names and addresses of the decedent's aurvivin souse and members of his/her immediate Tamil
Name and relationship to decedent
Elaine Nicele
Street Address
~ ~ ~u4 wvncombe Park Lane
Name and relationship to decedent
State Zip Code
Street Address
City/Borough State
Zip Code
Name and relationship to decedent
Street Address
City/Borough State
Zip Code
7 nfr av- ~_ _ _ _.
-• ~~~ f.f fQ~ uowvenz ever uve in Pennsylvania?
If yes, during what periods?
m the 1920s to
3. Did the decedent spend time in Pennsylvania during the five years preceding death?
If yes, during what periods and at what address?
Yes ~ ~ No
Yes ~ X ~ No
4. What was the nature of decedent's places of residence during the five years immediately preceding death?
Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, and/or whether decedent r '
in a hotel or the home of relatives or friends.. esided
with his daughter in Maryland At all other times, he lived in his in Bronx, New Y
~• ••pa ufrQ veceaeni employed during the five years preceding death?
If yes, list the name and address of employer(s). ^ Yes ~ No
C nfr ~~- -'- - -
~• f./fY u ffe u~ceaenL leave a will?
If yes, state the court which admitted the will to probate, the date admitted, and attach a co U Yes ~ No
letters testamentary. py, including all codicils, and a certificate of issuance of
an
City/Borough
ew York, June
of Cum
7. If the decedent dId not leave a will, has an administrator of his estate been a ^
If yes, state the court which appointed the administrator, the date of appointment, and attach a certificate of the ssuance^of le No
tters of administration.
8. At any time during the last five years did the decedent execute a will, a codicil, trust indenture, deed, mortgage, lease or an o
document In which the decedent was described as a resident of Pennsylvania? Y ther
If yes, describe such document. ^ Yes ^X No
Date of Death
217 White, Donald N. "
NONRESIDENT DECEDENT AFFIDAVIT OF DOMICILE (continued
~. Had the decedent paid a tax on income or on intangible property to any state, county, or munici ali Page 2
If yes, where and when was it paid? p ty during the last five years?
0 Yes ~ No
10. To what regional office of the Internal Revenue Service did the decedent forward his Feder
years preceding death? al Income Tax returns during the last five
Internal Revenue Service Center for New York_
11. At the time of death, did the decedent own, individually or jointly, any interest in real property, including lease-hold
personal property located in Pennsylvania? s or tangible
If yes, describe the property in detail nX Yes ~ No
144 West Orange Street, Shippensburg, PA 17257
12. In what business activities was the decedent engaged during the last five years precedin d
Indicate whether decedent was employed or otherwise engaged in business, and state the nam sand the addresses of the e
corporations with which the decedent had such business affiliations. (Except for employer listed in #5) P rsons, firms or
Retired
13. What is the estimated gross value of the decedent's estate, wheresoever situated, exclusive of real ro e
located outside of Pennsylvania? p p rh/ and tangible property
•1A Aa a~_ ~:~_ _~
•~• ~• •~~~ ~~~~~o ~~ a®ain, ara the decedent own or operate an automobile?
If yes, in which state was it registered? ~X Yes n No
ew York
15.
At the time of death, was the decedent a member of a church or any other organization?
If yes, provide the name and address of the church or any other organization.
Yes ~ ~ No
16. State the purpose or reason the decedent owned real property in Pennsylvania.
Decedent inherited real estate from mother.
17. Include any other information you wish to submit in su
at the time of death. If more space is needed, insert additional sheets of same sizethat the individual was not domiciled in Pennsylvania
Name of person completing affidavit
Relationship to decedent
Street Arlrl~n~•.
- - - ---• --- City State
Zip Code
Under penalties of perjury, I declare that based on m
info ation rovided on this form is t ue, correct an~ledge of the decedent, the
Signature of Derson_comoiat~-,n e~r1~.,;a
~~.5,~
217
REV-1737-2 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE A, PART 1
REAL ESTATE
IN PENNSYLVANIA
ESTATE OF
White Donald N. FILE NUMBER
Part 1 must include all real property owned by the decedent individually or as a tenant in common with another part ies havi
situs in Pennsylvania. Property which is jointly-owned with right of survivorship should be disclosed on Schedule FyAll real es g its
must be reported at fair market value which is defined as the price at which property would be exchanged between a willin bu sate
a willin seller neither bein com elled to bu or sell both havin reasonable knowled a of the relevant facts.g y and
ITEM
NUMBER
DESCRIPTION
~ . House and Lot of ground, 144 West Orange Street, Shippensburg, PA 17257 VALUE AT DATE OF DEATH
2 Vacant lot, West Orange Street, Shippensburg, PA 17257 80,000
26,500
PART 1 TOTAL
$ 106 500
Pro ortionate Method Onl fromReverse side $
0
(If more space is needed, inse0rt additonal sheets oft 1 Reca itulation $
he same size) 106,500
L I
REV-1737-6 EX + (g_00)
REVERSE SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
NONRESIDENT DECEDENT
ESTATE OF
White Donald N. FILE NUMBER
ueors of decedent must be re orted on Schedule I.
ITEM NUMBER
DESCRIPTION
A. FUNERAL EXPENSES: AMOUNT
1.
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
2, 500
3. Probate Fees
4• ~ Accountant's Fees
5. I Tax Return Preparer's Fees
6. Miscellaneous Expenses
Expenses of sale of 144 West Orange Street, from HUD-1 settlement statement
Expenses of sale of West Orange Street lot from HUD-1 settlement statement 6,416
Real estate taxes paid 4,355
Less, real estate tax proration, 144 West Orange Street, from HUD-1 settlement statement 1,644
Less, real estate tax proration, Orange Street lot, from HUD-1 settlement statement -596
Lawn care -222
1,140
Use Schedule H ONLY for proportionate
method of tax computation.
(If more space is needed, insert addiU'oOn I sheets oEthe an line 9, Reca itulation $ 15;237
me size)
217
REV-1737-7 EX + (9-00)
REVERSE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
EST=
SCHEDULE J
BENEFICIARIES
N.
FILE NUMBER
,~~ ~ ~~a~ ~ dWheniproportionate method s electe rles of the Pennsylvania property.
d, Ilst all beneficiaries.
RELATIONSHIP TO
u1BER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY DECEDENT
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1 2 Do Not List Trustee a
1. Estate of Elaine Niceley, deceased ()( )~
11304 Wycombe Park Lane Daughter
Glenn Dale, MD 20769
AMOUNT OR SHARE
100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV-1737 COVER SHEET OR THE PROPORTIONATE METH I
ON THE REVERSE SIDE OF REV-1737 COVER SHEET, AS APPROPRIATE. OD WORKSHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
IB. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REVD-T/37 OVER SHR EIT
(If more space is needed, insert additional sheets of the same size)
0
~~••~w°•Aus•18. 2009 4:12PM South Central Home Settlements
A. Settlement Statement No • 0663~~~~~P. 2/3~a.~~.~~..<
B. T e of Loan U.S. Department of Housing and Urban Development
1. pFHA 2. !]FmHA 3. OCorn. Unins. 6. Fle Number OMB royal No. 2502-0265
5. Corn.lns.
4. VA 092105KUNKLEMAN 7. Loan Number 8. Mortgage ~tsurance Case Number
C. Note: Items marled ryp.o.c.)" wero paid outsWe Ora brinyy, they ors shown hrrre for information purposes end ere net included in the folds.
WARNING: It is s crime to knowngry make Idae statements to the Unted States on this or ~ TdleExpress Settlement System
cowidlon can induda a Ana andim rtsonment. For detafls sea: Title 78 U. S. Code Sactiona 00 hand Salmon 7010MaKies upon
D. NAME OF BORROWER: Wchard B. Kunldeman Printed 08/188009 at 16:28 RLH
ADDRESS:
E. NAME OF SELLER: Estate of Donald N. White
ADDRESS:
F. NAME OFLENDER:
ADDRESS:
G. PROPERTY ADDRESS: 138 West Orange Street, Shippensburg, PA 17257
H. SETTLEMENTAGENT: South Central Home SetOements, Inc., Telephone: 717-532-7387 Fax 717-532-6552
PLACE of SETTLEMENT: 126 East King Stree Shlppensburg• PA 17257
~~
1
12131109 ~ 37 03 407 Cotmly laYac~ uatme o7r4alrom ,r, ~„d b seller in advance
D6I3W10 bpd e~ enc ~ ~ • • r ~~ w ra3 uy~ 37 03
20.
TO BORROWER 6p0_- ~qSH AT
~J- 27.720.14 Fns r_..,es .,_,
SUBaSTgIaTnUTE FORM 1099 SELLER STATEMENT: Ths hformation contdmed herdn B important tax information and Is bring famished to the Intamd Revenue Serviea. Ir ou era
lima d01 abwi cprd)hit~hs the Gross Proci~ d jhls 1~rsyawcd~ )a Item is raquind to ba reported end the )RS detartnimas that d has not boon reported. The Contract Sdas Price daspjbad pn
Y requirod to file a return.
You are roqulred bylaw [o provide the se@lement agent (Fed. Tex ID No:
number, you my be wbjeet to civil w edmind pene6es imposed by law. n er sn es wltlr Your correct taxpayer IdenGficeflon number. If
P perjury, I earthy that the number shavn on this statemerYOit IsdO not provide your cortactt~axppayer identNication
TIN: ~ my eorect taxpayer iderdflrcation numbs.
SELLER(S) NEW MAILING ADDRESS: SELLER(S) SIGNATURE(S):
SELLER(S) PHONE NUMBERS:
(H)
(W)
~~~~w°•Aua.lB. 2009 4:12PM South Central Home Settlements __No.0663~~~~~-P. 3/3~
U.S. UtF'AK I MtN I Oh HOUSING AND UKIiAN ut-vt-I t n~Iw~N I .._ .~.._~ _ ,,,,.,...~......... _ ""'~^ ~~~~<
Estab d Dondd N. Whie
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUl}1 Setllemant Stdement which t hsve pnperad is a true and ecwreto account of this transaction.
UNITED STATES ON THIS OR ANY StMLAR FORM. PENALTIES UPON CONVICTION I have caused or will cause the funds to bs disbursed in accordance with this stdement.
CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18:
U.S. CODE SECTION 1001 ANp SECTION 1010.
BY:
• •~~..`..... ,...., ,.n. yr ov. art /.1`1N aGLLCJ'(
I hevo carolutly roviswod the HUD-1 Sdtlomant Stabmont and fo dta bast of my knavledga and beliot, it is a true end eccurde statertwnt of dl recdpts end disbursements made on my account or by me
in this tronsedion. I further certlty that I have recsNed a copy of the HUM Settlement Statsmont.
A. Settlement Statement
U.S, Department of Houc~® and Urban Devebpment
r,~,s.--- •-- --
e
"'~"~ Fwr M a ~EU.EH BTATEMe~rT: nr ~ ~ ~ 74
p"a 'dwo wnttlRna 1n~r~.~a.~a u°o~ws as' .~0t1e ruer,~` ~"n ~ 1°v~od 1o pa vapor w ~ ~ p ~ ~ p~ Hx'^'y R~v~r~,~ Eanmea, nyw+mo
Yeu ~ ~~ py law b pewOS Ilw NMYmw r~oll~ TAa CeMna Silos PAoo oaa bm ~ ~~~
E00/200 'd 2LBLEA21lL(XH~) PiHNS H P13a0Nd ~0 3]I~dO f1d1 92~S1 (361)8002-p0-SON
number you n~ oa kiDpq b awa ar +~ (Fid. Tar ro No. I61bat,L6) «Mn yar 6~ Y~
°~~ PanaNisi snposod by law. UndsrVenolYSS of potful osAi yl Bp°~il~onYikuiWwn,d~iOa rOt~ ~nlbe
T1N: _ ~ my oonoet ~Yor bon nmEOr
e~(s-NewiwuuNCaoo~ss; '~-- -""'- "'~~c-s~aNnnx+ElBr.
S `Rll&pfS) PHONE NUMBERfi
IM)
(W)
V•S• ~EPARTMIENT AF HAI LSfNr: enin ~ ~oew.~ ......... __. ___ __
WAfiP11N0: R IB A OgIME TO IWOW WCLY MAKE FALSL STATQIdGNTt.Tp TH6
CA MIOCLTUDE A RNE AND YAPS BdVHAR FORM PBNALTI S UPON CONVIf:TION
u.E. cone secnDN ~m~ ANn f:6 1~t0~ GETAIL6 6EE TITLE ~~
TAs Huo•~ swleme„f sw.,,,.m wlrich I fbw fe~W Wed k a true arb eeeursl. exa+rn er tliis
~~. I f We mused or Wql awe Ufe Nnnr b he d~p~r~d h ° w11A dde elewmenl,
SE7TLBMENTAOENf:
DATE:
E00/£00'd 2LBLED2L(L(XHd) mdHS H ~'i3a0NH d0 3]I~~O piHl 92~S1 (3f11)8002-DO-(tON
.. y mo n eue f+a~eauon. l (umwr anliy inei f niw'~"eeoNw a ~~ui HUDk 7~jy«ns a Sly~wnwN a frw en0 oeeuoh sfoWnad of qll -ooaiDb a~b d'
. Ad1W76111eille 111~de fM T y eeeeunl
~~
~~ ~.r ~~ 9~a ~~~