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HomeMy WebLinkAbout01-29-10PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES ~-, r i 1 AND FILE N0. 21 -c~`1~21 PO BOX 280601 '1'E TAXPAYER RESPONSE ACN 09176093 HARRISBURG PA 17128-0601 .r;(~ ~~`l ~--v DATE 12-01-2009 ~Y 1543 en'AFP P08 BB7 ~' ~~~~ ~~~, ~9 r~,~;ai'~: ~~ TYPE OF ACCOUNT EST. OF ORPHA M DOUDEN ~ SAVINGS $SN 194-28-8479 ® CHECKING Gc~ DATE OF DEATH 10-29-2009 ~ TRUST ~~ COUNTY CUMBERLAND ~ CERTIF. !~~'~~~` 'ti"~'~~ 4"~-r REMIT PAYMENT AND FORMS T0: ** JEFFREY DOUDEN REGISTER OF WILLS 119 EWE ROAD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the infonation is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-1 1 Dat® 06-06-2009 7o ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 7 6 1 .4 0 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 100.00 Amount Subject to Tax 7 6 1 .4 0 NDTE: If tax payments are made within three months of the decedent's data of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Potential TaX DUe 34.2 6 ~` ~5:~ Any Inheritance Tax due will become delinquent nine months after the date of death. P~T 1 TAXPAYER RESPONSE A. ® The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain r C H E CSC ~ ~ ~~~ a discount or avoid interest, or check box "A" and Wills and an official assessment will be issued by return this notice to the Register of the PA Department of Revenue. Under pe lties of erju y, I Clare that the facts I have reported above era tr/~ue, correct and comp t o tFya•~p st of y kno ledge and belief. HOME C -] ~7) ~G3 ~76Zq `l/J WORK C 7('~ ) 302- -f Y30 ~' 2g /O TAX Y S NATIIRF TGi counur u:7uaro ,,.rte ~ IUTAL ltniar On LlnB 5 Of TeX computation) BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 .PENNSYLVANIA INHERITANCE INFORMATION NOTICE AND r: " , ~ ~- `T'AXPAYER RESPONSE REV-1543 E~-11FP CDB-BB) .. .. T FILE N0. 21-(~'~~~I ACN 09174455 DATE 11-26-2009 ~~~~ vA~i 29 At1 lQ~ 36 ~, f- ~~ QR~--IA~'~ '~ ~!~'' JEFFREY DOUDEN C~~~~:T~ , - ,. y 119 EWE ROAD MECHANICSBURG PA 17055 EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decadent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this forty and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-05 Date 06-05-2002 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 6 896 43 payment to the Register of Wills. Make check " , . payable to Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax ~ 3 448 22 NOTE: If tax payments are made within three , . months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due 155.17 ~ ~~'? Any Inheritance Tax due will become delinquent . nine months after the date of death. P T TAXPAYER RESPONSE ~ 1 A. ® The above information and tax due is correct. Remit payment to the Register of Wills with two co pies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B ~ The above asset has been or will b t d d t id it . e repor e an ax pa w h the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. PART If indicating a different tax rate, please state '' '~• relationship to decedent: ~ ! << ~3" ~k `f '~i'+~ , ~~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS „~,,;,~„ a ' +,• ~~~~,~9,~y:~, ~y~•~ ~~. LINE 1. Date Established 1 °^~•' 2. Account Balance 2 $ ~` 3. Percent Taxable 3 X ~• $ ' 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 +~ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under pens Ses of p jury I de are that the facts I have reported above are true, -c7orrecot and compl the ~ o my know dge and belief. HOME C 7~7 ) 763""/62 / WORK C7/7)~OZ~/y~O / ZSlO TAXP SI ATURE TELEPHONE Nl1MBFR eTF TOTAL (Enter an Line 5 of Tax Computation) S PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES _ AND FILE NO. 21~~'f~~' PO BOX 280601 ~ HARRISBURG PA 17128-0601 - '~_ TAXPAYER RESPONSE ACN 09174456 ~~ ``r DATE 11-26-2009 u3~ ~ sae-fle:'. Z~lO .iA~ 29 ~~ i0~ 36 c~ c~=,~-~ f-~ ~~ ~~~ i V~.14~ 7 aRP~-i~ "5S '~"~' ~ ~ ;n j~ JEFFREY DOUDEN 119 EWE ROAD MECHANICSBURG PA 17055 EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-40 Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due Date 06-05-2002 Established $ 6,194.12 X 50.000 $ 3,097.06 X .045 $ ~ ` 'j,, t,~' 139.37 PART CHECK C ONE BLOCK ONLY To ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check payable to "Register of Wills, Agent". NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent nine months after the date of death. A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs tan is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART IJ below. PART If indicating a different tax rate, please state ~~,f.' ''y~r~ ~~~ 2 relationship to decedent: DEPlI~' ~~ ~~~~~~" ' :. TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~~` ~~~ LINE I. Date Established I ~ '"""'~""'k9 „~;;~„ BR 2. Account Balance 2 $ 2~ `„' 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due 8 $ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Und r e alties perj ry, I eelare that the facts I have reported above are true, coLrrecpt,and co 1 to th bes of my k wledge and belief. HOME C ~~7 ) X63' 7(,z WORK C ~7) ~OZ, -l'Jr3~ i ZFS ~O T Q TPNATIIRF TFI FPNf1NF NIIMRFR TIATF TOTAL (Enter on Line 5 of Tax Computation) # PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES ~' ~`f AND FILE N0. 21-~~-j~~~ PD Box 2BO6o1 - ~ TAXPAYER RESPONSE ACN 09174457 HARRISBURG PA 17128-D601 •~ _ m_5~©t~~oe-`oar DATE i1-26-2009 ~~ ~~ ~~N 29 ~~ 10~ 3~ ~.,~ ~~• \ , 1~ v ~i` ~~~ ~~i`~I~~~ C~rl ~'N, v -- JEFFREY DOUDEN 119 EWE ROAD MECHANICSBURG PA 17055 EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-mewed decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction frog the financial institution, attach a coDY to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-41 Date 06-05-2002 To ensure proper credit to the account, two Established copies of this notice ^ust accompany Account Balance $ 15 186 20 payment to the Register of Wills. Make check " . , payable to Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax $ 7 593 10 NOTE: If tax payments are made within three , . months of the decedent's date of death, Tax Rate X , OCFS deduct a 5 percent discount on the tax due. Potential Tax Due $ (Q~ 341.69 a~ Any Inheritance Tax due will become delinquent i th ft t d . n ne mon s a er he ate of death. P T TAXPAYER RESPONSE ~ 1 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid i nterest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C 0 N E ~ BLOC K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Com plete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state a relationship to decedent: TAX RETURN - COMPUTATION LINE I. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due s PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under enalties er ury, declare that the facts I have reported above are true, correct and c p to to tie e t o my nowledge and belief. HOME C 7~ ) ?63`'7 `Ci WORK ( 7/ 7 ) 3©2 ~ (~J~ l ?.$ lO T P ER SIGNATURE TELEPHONE NUMBER ATE TOTAL (Enter on Line 5 of Tax Computation) $ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES '~ AND FILE NO. 21 "~-I'Z, PD Box 2ageol TAXPAYER RESPONSE ACN 09174458 HARRISBURG PA 17128-0601 „ „ _~ DATE 11-26-2009 REV-1543 IX AFP (OB-33) ~~' .J~ C~E~r<. i~ . 5 (}, T a~CHr,``± ~ ~~<,~~ a EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. JEFFREY DOUDEN 119 EWE ROAD MECHANICSBURG PA 17055 MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, You were a ioint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this fors and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Plaaso call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-47 Date 06-05-2002 To ensure prover credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 14,928.73 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are ^ade within three Amount Subject to TaX $ 7,464.37 months of the decedent's date of death, Tax Rate ~( . 0 4 5 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ (q, ~' 335.90 nine months after the date of death. PART TAXPAYER RESPONSE A. ® The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of CHECK Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state y ~~ " 2 relationship to decedent: '"" TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1_ 2 3 X 4 +~ 5 - 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Un r enalties of er y, I d Clare that the facts I have reported above are true, correct and co o to t~ t of y kno edge and belief. HOME c 7r7 ) 763v~ WORK (7~ 7 ) 30'Z ~~~~ i ~C~ r ev a rr_uer~iaF TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) 4 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 \''`- =° REV-154 ~~ 7lFP ,(OB-087 PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE - AND FILE N0. 21'~7-,~~~ ;: TAXPAYER RESPONSE ACN 09174459 c,, ti. - DATE 11-26-2009 200 ,~~ 29 A~ 10~ 36 ~~% ~'1!' CU~~:~~c, ~i :~; ~~.. ~P. JEFFREY DOUDEN 119 EWE ROAD MECHANICSBURG PA 17055 EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a coDY to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state a relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties pe jury, declare that the facts I have reported abov~ef are true, correct and c p to tithe be t f my nowledge and belief. HOME C 71 / ) 763 ~76~9 "`j~s WORK C ~f7 ) 30Z `! „3C~ 1 2~ /~ T P F CTf,NOT1IRF TELEPHONE NUMBER ATE TOTAL (Enter on Line 5 of rax ~omputa a one s PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES ~?'~;", -_ AND FILE NCI. 21`(~-~~~-~ PO BOX 280601 + TA~CPAYER RESPONSE ACN 09174460 HARRISBURG PA 17128-0601 ~_,. ;: ! , ..,~- " ~ -' DATE 11-26-2009 REV-1543 IX AFP (OB-08) 201 ? 29 AM {D~ 36 V ~L( if\ , ~,- o~Pw~~~~ ~ ;,uls~T JEFFREY DOUDEN 119 EWE ROAD MECHANICSBURG PA 17055 EST. OF ORPHA M DOUDEN SSN 194-28-8479 DATE OF DEATH 10-29-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a Soint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 217940-49 Date 06-05-2002 To ensure proper credit to the account, two Established copies of this notice must accomparq, payment to the Register of Wills. Make check Account Balance $ 10,013.02 payable to "Register of Wills, Agent". Percent Taxable X 50.000 C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3LJ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Sub]ect to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under nalties of rj ry, I aelare that the facts I have reported above are true, correct and co 1 e to th$b st of my kn ledge and belief. HOME C ~r7 ) ~~~'~~Q 2 WORK (~~7 ) 30Z- rY3o f 2g l~ rw w o rr_uwTUOr TFI FPNf1NF NIIMSFR AT OF TAX ON JOINT/TRUST ACCOUNTS TOTAL (Enter on Line 5 of Tax Computation) i REV-548 EX (12-p3) INHERITANCE TAX JOINT BANK ACCOUNT COUNTY FILE NUMBER 21 - 09 -1121 ApVANCE PAYMENT WORKSHEET INHERRANCE TAX RECEIPT NUMBER DECEDENTS NAME (LAST) (FIRST) ~~ Orplla DECEDENT DECEDENTS SOCIAL SECURITY NUMBER DATE OF DEATH INFORMATION 1-28-8479 1012912009 ATE ADDRESS OF DECEDENT CITY New Cumberland ST PA 1555 Simpson Feny Road NAME OF FINANCIAL INSTITUTION Member 1st Federal Credit Union FINANCIAL CITY STATE INSTITUTION ADDRESS Mechanicsburg ~jA INFORMATION TELEPHONE NUMBER `_T'~.,7 TYPE OF ACCOUNT ^ SAVINGS ^ CHECKING ^ TRUST ~ CERI7FICATE OF DEPOSIT d ACCOUNT ACCOUNT BALANCE (INCLUDE INTEREST TO DATE OF DEATH) ACCOUNT NUMBER INFORMATION 130.36 15 2179403 , ACCOUNT TITLE AS APPEARS ON SIGNATURE CARD OR CD ORIGINAL DATE E3 Orpha M Douden Jeffrey Douden 0610512002 NAME (Last) (First) (Middle Initial) Douden Jeffrey L SURVIVING ADDRESS 119 Ewe Road JOINT OWNER ~I.ry STATE ZIP CODE INFORMATION Mechanicsburg PA 17055 RELATIONSHIP TO DECEDENT TELEPHONE NUMBER Son (717) 763-7629 NAME (~) (~~) (Middle Initial) ADDRESS SURVIVING JOINT OWNER Cln, STATE ZIP CODE INFORMATION RELATIONSHIP TO DECEDENT TELEPHONE NUMBER NAME (Last) (First) (Middle Initial) ADDRESS SURVIVING JOINT OWNER Cm STATE ZIP CODE INFORMATION RELATIONSHIP TO DECEDENT TELEPHONE NUMBER (MIDDLE INITIAL) M ZIP 17070 ~7P 7055.__. ~ -- .:i !'s' ~___ -~- ._.,! . ______a e1_SJ Note: Please attach to reCe/pt Ivu>,~ ~