HomeMy WebLinkAbout02-0259PETITION FOR PROBATE and GRANT OF LETTERS
also known as To: - '
Register of Wills for the
Social Security No. j
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/a~l~-18 years of age21~ older an the executS,x
in the last wilt of the above decedent, dated
and codicil(s) dated
in the
named
, l~ Zc,~ /
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in ~n.l/s~d~i~/_//~_~ County, Pennsylvania, with
h ~.~ last ~mily or principal residence at P'lE-,FSb to /4 [,/~//~/~t C7.//'4/, ,dt/ff~
{list street, number and muncipality)
Decendent, then ~ 7 years of age, died ~C T-O$~'-/X'- Z 5 ~9 Z O0 !
Except as follows, decedent did not m/arry, was not divorced ~nd 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:
Decendent at death owned property with estimated values as follows:
(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:
WHEREFORE, petitioner(s) respectfully ~quest(s) the p. robate of the last will and codicil(s)
presented herewith and the grant of letters ~(.f ~H/~. e~ 777/~,/¥
theron. (testamentary; admfnistration c.t.a.; administration d.b.n.c.t.a.)
OATH OFPERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF :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 truly administer the estate according to law.
Sworn to or affirmed and subscribed
before me this 2 7th day of
~ ~Februarv ,-~2002
Henry A. Budz~ski
Presiding Judge- Probate Div.
CirC[iit Court of Cook County
Estate 0f EARL W ~r , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW M~C~ la~ ?0(37
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated 10-10-2001
described therein be admitted to probate and filed of record aa the last will of EARL,!N REBER
and Letters
are hereby granted to HET.]~N MARIE TATE
×99~ ~ in consideration of the petition on
FEES
Probate, Letters, Etc .......... $ 40.00
3.00
Short Certificates(I) .......... $
~ .e.x~t..r.a...pg..g.e.s.... $ 9.00 -
jap $ 5.00
MARCH 13, T2(~q~L $ 57.00
Filed . ca'~led' 'attorney' ~' 3'-'1'3=(3.2. ' '
A .T~TORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
60:6V fl ~_lt~ ZO.
]05.805 REV 9/86
This 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 forwarded 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 ~r, ~ ~/
.,/,,";~7.
~_~'/ t Local Registrar
P 7 7 4 5 0 4 6
OCT
0
No. ~ Date
,,v 2~,s? COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
Earl W. Reber ,.male1"187 -- 09 --9229]4.0ct.23o2001
A~(La~ ~W I UNOE" t YE~87 V~. -- ii ~ ~U~"'""--' '~{ .~/,N°v' 27' 1 9 ,m~- ~.'~ O~ ~ ~, ~',~ Reading,PA~ ~=~c~~c~'~
~ ~NO ~ ~N~STRY ~ E~R~ ~NT'S ~m ~
~ ,,. ~ylv~ia
- ~ ,,,~.~ Up~r ~1~
974 Walnut Way,~ssi~ Villi ~
~c~ics~, PA17055-2015 ~ ,, ~rl~d
~.s~c~=.a~, ~ H. R~r .,. Ida ~ ~ltz
~1~ M. Tate ~40 Clausen Ave.,West~ ~rings, ~ 60558
~~a/~ ~ J.m-013163-L
I~.
..........................................
i,,.:_.....,___.t.%_?."_-'-.,~ ...... ,., .... ,..,, ..... -, ,~ ,,,.. ,,,.. .,, ,, ..... -,,,.,~
LAST WILL AND TESTAMENT
OF
EARL W. REBER
KNOW ALL MEN BY THESE PRESENTS, That I, EARL W. REBER, of the
Township of Upper Allen, County of Cumberland, and Commonwealth of Pennsylvania, do
make, publish, and declare this instrument to be my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
FIRST: I direct the Executrix hereof to pay all my just debts, funeral expenses and
costs of administration as soon as conveniently may be done after my death. I further
direct the Executrix hereof to pay all inheritance, estate, transfer and succession taxes
which may be levied or assessed upon any property which is included as part of my gross
estate for the purpose of any such tax.
SECOND:I give, devise and bequeath unto my wife, HELEN M. REBER, rest,
residue and remainder of my estate, realty and personalty, howsoever designated
wheresoever situate provided that she is living on the thirtieth (30th) day after the date of
my death.
THIRD: In the event that my wife, HELEN M. REBER, does not survive me or
does not survive by the said period of thirty (30) days, then in that event, I give, devise and
bequeath all the rest, residue and remainder of my estate as follows:
1. One-tenth (1/10) share to Bible Baptist Church in Shiremanstown;
2. One-tenth (1/10) share to Child Evangelism Fellowship, Inc. of Cumberland
County.
-1-
3. My grandson David W. Tate.
4. My granddaughter Cherie Tate-Sullivan
5. Remainder to my daughter, HELEN MARIE TATE, per sfirpes.
FOURTH: I appoint my wife, HELEN M. REBER, to be Executrix of this my Last Will
and Testament. I do hereby give to the Executrix hereof full power, discretion and authority
at any time or times to sell, at private or public sale, mortgage, lease, pledge, exchange or
otherwise deal with or dispose of the property comprising my estate as deemed best, to
settle and compound any and all claims in favor of or against my estate as deemed best
and, for any of the foregoing purposes, to make, execute and deliver any and all deeds,
mortgages, contracts, leases, bills of sale or other instruments necessary or desirable
therefore.
FIFTH: In the event my wife, HELEN M. REBER, fails or refuses for any reason
to serve as Executrix of this my Last Will and Testament, then in that event I appoint my
Daughter, HELEN MARIE TATE, as Executrix of this my Last Will and Testament.
LASTLY: I direct that no fiduciary appointed by this, my Last Will and Testament,
shall be required to give bond and that if, notwithstanding this direction, any bond is
required by any law, statute or rule of court, no surety shall be required thereon.
IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and
Testament, consisting of three (3) typewritten pages on the margin of which (except this
page) I have affixed my initials this//_)'~th day of October, A.D. 2001.
-2-
Signed, sealed, published and declared by, the above-named Testator, as and for his Last
Will and Testament, in the presence of us, and each of us, who at his request, and in his
presence, and in the presence of each other, have hereunto subscribed our names as
attesting witnesses.
-3-
County of Cumberland
Commonwealth of Pennsylvania
ACKNOWLEDGMENT AND AFFIDAVIT
We, EARL W. REBER, the testator, and the undersigned witnesses to the Will, the
attached or foregoing instrument, having been qualified according to law do depose and
say:
(a)that I, the testator, do hereby acknowledge that I signed the instrument as my
Will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b)that we, the witnesses, were present and saw the testator sign the instrument as
his last Will, that he signed it willingly and as his free and voluntary act for
purposes therein expressed; that each of us in the hearing and sight of the
testator signed the Will as a witness and that to the best of our knowledge the
testator was at that time 1'8 or more years of age, of sound mind and under
no constraint or undue influence.
Sworn to or affirmed before me by EARL W. REBER, testator, and Beth Myers and
Amy Knauer, witnesses, this//t)/%th day of October, 2001.
~=~'~ W. Reb~r
By: Davi~W. Kn~'
Attorney I.D. #21582
eth M~'ers
",~nael Byerl. / ' '-(~ ~
-4-
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Date of Death:
To the Register:
I certify that notice of (beneficial Interest) estate administration required by Rule 5 6(al of the n,-.,~,. ~,
· · . , ,.,.~,.m,~ Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on ~ - /~ - W-L..
Narn~
Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: 3 - / ~ '-' 0 7_----
/
Signature
Name
Address
Capacity: _ Personal Representative
~nsel for personal representative
/'7050
REV - lEO0 EX + (~1~0)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT, 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECE-DENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Reber, Earl W
DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR)
10/23/2001 11/27/1913
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LASTi'~IRST AND MIDDLE INITIAL)
Reber, Helen M
~. original Return [] 2. Supplemental Return----
[] 4. Limited Estate []
[] 6. Decedent Died Testate (Attach copy []
of Will)
[] 9. Received []
IAME
Thomas J. Ahrens
FIRM NAME ~ f ado icab e)
] Ahrens Law Offices, P.C.
IELEPHONE NUMBER
717/697-1800
/ 7--
FILE2MN~COiI ....... 2002 00259
YEAR NUMBER
SOCIAL SECURITY NUMBER
187-09-9229
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
. R_EGISTER~OF_W!LLS
SOCIAL SECURITY NUMBER
] 3, Remainder Return (date of death prior to 12-13-82)
4a. Future Interest Compromise (date of death after
[] 5. Federal Estate Tax
Return
Required
12-12-82)
7. Decedent Maintained a Living Trust (Attach 8. Total Number of Safe Deposit Boxes
copy of Trust) --
10, Spousal Poverty Credit (date of death between [] 1 1. Election to tax under Sec. 9113(A) (Attach Sch O)
12-31-91
COMPLETE MAILING ADDRESS
5521 Carlisle Fike
Mechanicsburg, PA 17055
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B)
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) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
None
(2) None
(3) None
(4) None
(5) 6,612.30
None
None
8,721.87
(8)
(11)
6,612.30
8,721.87
insolvent
(12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
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, x .00 (15)
or transfers under Sec. 9116(a)(1.2) .......
16. Amount of Line 14 taxable at lineal rate
x .045 (16)
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)
Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
D"ecedent's Complete Address:
ISTREET ADDRESS
974 Walnut Way
I' Mechanicsburg
STATE
PA (zip 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits (A + B + C) (2)
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. (4)
Check box on Page 1 Line 20 to request a refund
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)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ..................................................................................
b. retain the right to designate who shall use the property transferred or its income; ................................
c. retain a reversionary interest; or .......................................................................................................
d. receive the promise for life of either oayments benef ts or c ? .....................
r , are .....
If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate cons derat on'~
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 des ~nat on?
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
pre__pare[ other_than the per~sgnal representative is based on all information of which pre__parent, has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
-- - - Western Springs, iL 60558
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
DATE
§ibN-ATUR-E OF PREISA~R OTHE~ TH,~,N REPRESENTATIVE
ADDRESS
DATE
5521 Carlisle Pike
Mechanicsburg, PA 17055
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. {}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 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 adopt ve 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.
COMMONWF-ALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Reber, Earl W
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 - 2002 - 00259
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 DESCRIPTION
Return of automobile insurance premium
VALUE AT DATE OF
DEATH
218.10
2
3
4
5
Check from Aflac
1996 Saturn Stationwagon - Bill of sale attached
Check from Aflac
Check from Prudential Financial
556.00
3,500.00
1,485.00
853.20
TOTAL (Also enter on Line 5, Recapitulation)
6,612.30
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Reber, Earl W FILE NUMBER
21 - 2002 - 00259
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
....... AMOUNT
A.
FUNERAL EXPENSES:
Musselman Funeral Home, Inc.
Rolling Green Cemetery Company
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
Attorney's Fees Ahrens Law Offices, P.C. -- Thomas J. Ahrens
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Helen M Reber
Street Address 974 Walnut Way
City Mechanicsburg State
Relationship of Claimant to Decedent Spouse
Probate Fees Cumberland County.
PA Zip 17055
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
PA Inheritance Tax filing fee
Executrix notice in The Sentinel
Total of Continuation Schedule(s)
4,099.00
250.00
650.00
3,500.00
57.00
10.00
80.87
75.00
TOTAL (Also enter on line 9, Reca~ .... 8,~22-1.8~
~. ·
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Schedule H
Funeral Expenses &
Administrative Costs continued
Reber, Earl W I FILE NUMBER
............ I 21 - 2002 - 00259
Executrix notice in the Cumberland County Law Journal
Page 2 of Schedule H
75.00
~,, BUREAU OF ZNDZVZDUAL TAXES
'rNHERZTAHCE TAX DTVZSTON
DEPT. 280601
HARRISBURG, PA 17128-0601
COHHONNEALTH OF PENNSYLVANZA
DEPARTHENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSEHENT, ALLONANCE OR DZSALLO#ANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
THOHAS J AHRENS
AHRENS LAN OFFICES
5521 CARLISLE PIKE
HECHANXCSBURG
DATE 05-27-2002
ESTATE OF REBER
DATE OF DEATH 10-23-2001
FILE NUHBER 21 02-0259
C,~0~pTY CUHeERLANO
ACN 101
PA 17055
Amoun'l: Rom1 t'lced I
REV-1547 EX AFP C01-OZ)
EARL
HAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGISTER OF WTLLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LONER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-02) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF REBER EARL NFZLE NO. 21 02-0259 ACN 101 DATE 05-27-Z007
TAX RETURN #AS: (X) ACCEPTED AS FZLED ( ) CHANGED
RESERVATION COHCERNZNG FUTURE INTEREST - SEE REVERS=.
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es*ate (Schedule A) (1)
2. Stocks end Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Zntorost (Schedule C) ($)
4. Hortgagos/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) ($)
6. Jo/ntly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTZONS AND EXEHPTZONS:
9. Funeral Expenses/Adm. Costs/H/sc. Expenses (Schedule H) (9)
10. Debts/Hortgage L/eb/1/t/es/Liens (Schedule Z) (10)
11. Total Deductions
6/612.30
.00
.00 NOTE: To insuro proper
· O0 cred/t to your account,
.00 sube/t the upper port/on
.00 of th/s form with your
tax payment.
.00
(8)
8,721.87
12.
15.
14.
NOTE:
ASSESSHENT OF TAX:
1.6. Amount of L/ne 14 mt Spousal rate
16. Amount of L/no 14 taxable at L/heal/Class A rate
17. Amount of Line 14 et Sibling rate
18. Amount of Line 14 ~mxable
19. Princ/pal Tax Duo
TAX CREDITS:
PAYffENT RECETP1 DTSCOUNT
DATE NUHBER /NTEREST/PEN PA/D (-)
.00
(11)
6,612.30
No~ Value of Tax Return (12)
Char/table/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (13)
Not Value of Estate Subject to Tax (14)
:Zf an assess.ant was issued previously, lines 1~, 15 and/or 16, 17,
reflect figures that include the total of ALL returns assessed to date.
8.72].87
2,109.57-
ZF PAID AFTER DATE ZNDZCATED, SEE REVERSE
FOR CALCULATION OF ADDZT/ONAL INTEREST.
.00
.00
.00
.00
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDZT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THZS FORH FOR ZNSTRUCTZONS.)
TO?AL TAX CREDIT
BALANCE OF TAX DUE
XNTEREST AND PEN.
TOTAL DUE
AHOUNT PAXD
.00
2,109.57-
18 and 19 will
(1.6) .00 x O0 = .00
(16) .00 x 0~5 = .00
(17) .00 x 12 = .00
(lB). .00 x 15 = .00
(19)= . O0
STATUS REPORT UNDER RULE 6.12
Name of Decedent
Date of DeatlJ:
Estate Number:
Pursuant to Rule 6.12 of the Supreme Court Orl)haus' Court Rules, ! report the
following with respect to completion of the administration of the above-captioned est:itc:
1. State whetiner administratiou of tine estate is complete:
Yes t/ No
2. If tine aoswer is No, state wlneu the personal represeutative reasonably believes
tlJat the administration will be complete:
3. If tine auswer to No. I is Yes, state the following:
A. Did tlJe i)ersoual representative file a formal final account with thc corn-t?
Yes No ~
Date:
Capacity:
B. Did tine perso~Jal represent:ntive state an account informally to the parties
in interest'! Yes ~ No
C. Did the persoual representative file approvals of the account, receipts,
joi~Jdet's aud releases witln the Clerk of Orphans' Court?
Yes No ""/'
D. Did tine i)ersonal represeutative complete final distributiou?
Yes '/~ No
Personal Represeutative
~ Counsel for Personal
~ :~ Reprcscutative
Signature
Name (l'le_ase .type or p~'i~lt)
Address
Telephone Number
17aSo