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HomeMy WebLinkAbout04-0543HEATH L. ALLIEN N. DAVID RAHAL CHARLES W. RUBIENDALL Tr ROBERT L. WIELDON EUGENIE Ie. P£PINSKY, JR. JOHN H. IENOS 1TF GARY Ie. FRENCH DONNA S. WlELDON BRADFORD DORRANCLE JIEFFRIEY S. STOKIES ROBERT R. CHURCH STEPHEN L. GROSIE R. SCOTT SHEARIER IELYSE £. ROGIERS CRAIG A. LONG¥1EAR DONALD M. LIEWlSTIT BRIDGIET M. WHITLIEY OOHN A. FIEICHTIEL ELIZABIETH U. GOLDSTIEIN BARBARA A. GALL STEPHANIIE KL£1NFIELTER KEEFER WOOD ALLEN & RAHAL, ATTORNEYS AT LAW 210 WALNUT STREET P. O. BOX II963 HARRISBURG, PA 17108-1963 PHONE (717) 255-8000 EIN No. 23-0716135 w .keef m Glenda Famer Strasbaugh Register of Wills for Cumberland County 1 Courthouse Square Carlisle, PA 17013 Dear Ms. Strasbaugh: LLP IESTABLISHIED IN 1878 OF COUNSEL: SAMUIEL C. HARRY WIEST SHORIE OFFICIE: 415 FALLOWFIELD ROAD CAMP HILL, PA I?011 (Tl?161:~-5800 WRITER'S CONTACT INFORMATION: (717) 255-8027 E-marl address: bwhifle,y~,kee fcrwood, corn Enclosed for filing, please find the following: Petition for Probate and Grant of Letters for the Estate of Geraldine P. Leedy. The Register of Wills for Dauphin County has administered the Oath to the Personal Representative, Susan Crispen. Last Will and Testament of Geraldine P. Leedy, dated December 3, 1997, consisting of three (3) pages. The Will includes a self-proving affidavit executed by the testator and two witnesses. 3. Death Certificate for Geraldine P. Leedy. 4. Department of Revenue Estate Information Sheet. I am also enclosing a check in the amount of $342.00 to cover the probate fee, extra pages fee, JCP fee, and seven (7) short certificates. Please forward the Letters Testamentary, short certificates and receipt to me. Would you also date stamp the enclosed pages marked as confirmation copies and return them as well? Thank you for your assistance, and if you have any questions regarding the enclosed, please contact me. Very truly yours, KEEFER WOOD ALLEN & RAHAL, LLP Bridget M. Whitley Encl. cc: Susan Crispen, Executor PETITION FOR PROBATE and GRANT OF LETTERS Estate of Geraldine P. Leedv No. ~ also known as To: Register of Wills for the County of Cumberland Social Security No. ! 72-01- 7 ~ ! ~eceased. Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut in the last will of the above decedent, dated December 3 and codicil(s) dated in the named ,1997 Robert H. Leedy~ the Executor named in the Will. predeceased Decedent on March 12~ 2002; Petitioner is named as alternate executor (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with er last family or principal residence at 325 Wesley Drive, Lower Allen Township (list street, number and muncipality) Decendent, then 89 years of age, died May 21 , :k~ 2004 at Holy Spirit Hospital, East Pennsboro Twp.. Cumberland County, PA . Except as follows, decedent did not marry, ,was not divorced and 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 $ 365. 000,00 (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 presented herewith and the grant of letters theron. request(s) the probate tes t ament ary of the last will ~i~d codicil(s) (testamentary; administration c.t.a.; administr//tii>n d.b.n.c.t.a.) ~"~ ' - - Susan Crispen ~.~ 4300 Valley View Road ~ lqarr~.qh,,rg.. PA 17112 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 3 COUNTY OFf 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 affirm¢~ and subscribed -~~/~,~.~/~,//,~/ bef0retme _this .ff"/'~ day of ~ Sus'~n C~r~.sp~n- - /- ~ ~ ~ " 0 !~r'- Register ~v_ No. ~ - o~- ~ ~ Estate of Geraldine P. Leedy , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW the reverse side he'of, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated December 3, 1997 described therein be admitted to probate and filed of record as the last will of Geraldine P. Leedy and Letters Testamentary are hereby granted to Summn Cr~ mpmn i~__ZSOA, in consideration of the petition on FEES Probate, Letters, Etc .......... Short Certificates(7 ) .......... ~ ~:~ .. s s~ Filed . .]aO7. !.0.7.2...0~.'. .................. Bridget M. Whitley (S. Ct. No. 33580) ATTORNEY (Sup. Ct. I.D. No.) 210 Walnut Street Harrisburg, PA 17101 ADDRESS (717) 255-8027 PHONE his. is to certify that the information here given is correctly copied from an original certificate of death duly filed v:ith 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. No. ~ Date Fee for this certificate, $2.00 Local Registrar [YPE/PRINT BLAC COMMONWEALTH'OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH (M~Ot y-Ye CAUSE~erlany ~ad~ lo i~ateEnmr (~Se~eUNDERLY~G ~ PLACEOF NJURY-A ~ ~ s~eet f~ om~' ILOCATtON(Str~t.C~ly~own. Slate) i I, GERALDINE P. LEEDY, of the TOWNSHIP of LOWER ALLEN, COUNTY of CUMBERLAND, COMMONWEALTH of PENNSYLVANIA, being in good bodily health and of sound and disposing mind and memory, and not acting under duress, menace, fraud, or undue influence of any person whomsoever, merely calling to mind the frailty of human life, and being desirous of disposing my worldly goods while I have the strength and capacity so to do, I do make, publish and declare this my LAST WILL AND TESTAMFNT. I hereby revoke, cancel and annul all my former Wills and Testaments, including codicils thereto, by me at any time made, and declare this alone to be my LAST WILL AND TESTAMENT. AS TO SUCH ESTATE AS IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ: ITEM 1. I direct that my Executors hereinafter named, pay and discharge all of my just debts, funeral and testamentary expenses. ITEM 2. I order and direct that I be buried in a lot which I own situate at the Harrisburg East Cemetery, Harrisburg, PA. ITEM 3. All the rest, residue and remainder of my entire estate, wheresoever situate, and whatsoever it may consist of, I give, devise, and bequeath, absolutely, and in fee, to my dearly beloved Husband, ROBERT M. LEEDY. In the event that my dearly beloved Husband, ROBERT M. LEEDY, dies with me in a simultaneous disaster, or fails to survive my death by thirty (30) days, then I give, devise, and bequeath, my entire estate, wheresoever situate, and whatsoever it may consist of, as follows: A. I give, devise, and bequeath any and all Harris Financial stock that I own at the time of my death to MATTHEW J. COWAN, per stirpes. In the event that Harris Financial stock changes its name, then of course, this request will go to the successor stock company as well. B. ~ I give, devise, and bequeath sixty percent (60%) of my net residuary estate to SUSAN CRISPEN, per stirpes. GERALDINE P. LEEDY~' Page 1 of 3 C. I give, devise, and bequeath forty percent (40%) of my net residuary estate to JOSEPH BANKS SHEESLEY, per stirpes. ITEM 4. I nominate and appoint ROBERT M. LEEDY as Executor of this my LAST WILL and TESTAMENT. Should the Executor named fail to qualify or cease to act as Executor then I appoint SUSAN CRISPEN as Executrix in his stead. ITEM 5. I hereby direct that all my personal representatives, as well as their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. LTEM6. I order and direct that my Personal Representative(s) named herein use the legal services of JAMES M. BACH, as Attorney for my Estate. ~ I direct that all estate, succession, legacy, inheritance or other transfer taxes, however designated that shall become payable by reason of my death in respect of all property comprising my gross estate for tax purposes, whether or not such property passes under this LAST WILL, shall be paid by my Executor out of my residuary estate. ITEM 8, I grant to my personal representatives herein named, in addition to, but not in limitation of those powers vested by law, to be exercised without prior application to or approval of any court, the power and authority to retain indefinitely any property, to invest and reinvest any assets or the proceeds derived from the sale of assets, although said investments may not be of the character prescribed by law, to sell, convey., assign, transfer and encumber any property, to pay, settle or compromise all claims, to make distribution or divisions in cash or in kind, and in general to exercise all powers in the management of any property hereunder which any individual could exercise in the management of similar property owned in his own right, and to execute and deliver any and all instruments and to do all acts which may be deemed necessary and proper. OltIN ~U~E-51qT GERALDINE P. L~.DY "~L~A M. WADGE ~) Page 2 of 3 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF CUMBERLAND ) SS I, GERALDINE P. LEEDY, the TESTATRIX, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. Sworn to or affirmed and acknowledged before me, by: GERALDINE P. LEEDY, the TESTATRIX this 3un day of December, 1997. G~RALDINE P. LEEDY fi/ ATTORNEY JAMES M. BACH, NotAry Publtc~ Cumberland County My Commission Expires May 13, 1999 j,~¢,l~ M. BACH, ESQUIRE // NOTARY PUBLIC ka Mechanicsburg, PA 17055 My Commission Expires: 05/13/99 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF CUMBERLAND ) SS We, JOHN ]~LU_G/~LT_ and ~ ]~f__~l~C~, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw TESTATRIX sign and execute the instrument as her LAST WILL; that the TESTATRIX signed willingly and that she executed it as her free and voluntary act for the purpose therein expressed; that each witness in the hearing and sight of the TESTATRIX signed the WILL as witnesses; and that, to the best of our knowledge, the TESTATRIX was, at the time, 18 or more years of age, of sound mind and under no constraint or undue influence. LISA M. WADGE, witnesses, this WITNESS ; ~/~O~ I~U~ENT Sworn to or affirmed and acknowledged before me, by: JOHN NUGENT and day of D_t.c,.~:z~2ea~1997. ,~ .~t% LISA M~ WADGE t~ J~ M. BAC~, ~SQUIRE / / NOTARY P~LIC ~ Mechanicsburg, PA 17055 My Commission Expires: 0~/13/99 Page 3 of 3 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Geraldine P. Leedy May 21, 2004 Admin. No.: 21-04-0543 To the Register: I certify that notice of estate administration required by Rule 5.6 of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on June 15 2004: Joseph B. Sheesley, 111 Shell Street, Harrisburg, PA 17109 Susan Crispen, 4300 Valley View Road, Harrisburg, PA 17112 Matthew J. Cowan, 74 Ivy Parkway, Atlanta, GA 30342 Notice has now been given to all persons entitled thereto under Rule 5.6(a). Date: June 15, 2004 Bridget 1~I. Whitley, Esq. d' Keefer Wood Allen & Rahal, LLP P.O. Box 11963 Harrisburg, PA 17108-1963 Capacity: Counsel for Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND PENNSYLVANIA TO: In re Estate of Geraldine P. Leedy, deceased, Joseph B. Sheesley 111 Shell Street Harrisburg, PA 17109 Please take notice of the death of decedent and the grant of letters to the personal representative named below. The Decedent, Geraldine p. Leedy, died on the 21 st day of May, 2004, in East Pennsboro Township, Cumberland County, Pennsylvania. The Decedent died testate (with a Will). The personal representative of the Decedent is Susan Crispen, 4300 Valley View Road, Harrisburg, PA 17112, (717) 652-3181. The Will has been filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013-3387. Phone number (717) 240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: June 15, 2004 B~~hitley, Esq. Keefer Wood Allen & Rahal, LLP P.O. Box 11963, Harrisburg, PA 17108 Telephone (717) 244-8027 Capacity: Counsel to Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHER~VISE Vfaether you will receive any money or property will be determined wholly or partly by the d ' ' e, ce.dent s w~ll. If the decedent died without a will, whether you will receive any money or prop~ c5 will be determined by the intestacy laws ~it~f ';"' Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND PENNSYLVANIA In re Estate of Geraldine P. Leedy, deceased, TO: Susan Crispen 4300 Valley View Road Harrisburg, PA 17112 Please take notice of the death of decedent and the grant of letters to the personal representative named below. The Decedent, Geraldine p. Leedy, died on the 21st day of May, 2004, in East Pennsboro Township, Cumberland County, Pennsylvania. The Decedent died testate (with a Will). The personal representative of the Decedent is Susan Crispen, 4300 Valley View Road, Harrisburg, PA 17112, (717) 652-3181. Date: June 15, 2004 The Will has been filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013-3387. Phone number (717) 240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Bridget M. Whitley, Esq. ! Keefer Wood Allen & Rahal, LLP P.O. Box 11963, Harrisburg, PA 17108 Telephone (717) 244-8027 Capacity: Counsel to Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws Pennsylvania. ~' BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND PENNSYLVANIA In re Estate of Geraldine p. Leedy, deceased, TO: Matthew J. Cowan 74 Ivy Parkway Atlanta, GA 30342 Please take notice of the death of decedent and the grant of letters to the personal representative named below. The Decedent, Geraldine p. Leedy, died on the 21 st day of May, 2004, in East Pennsboro Township, Cumberland County, Pennsylvania. The Decedent died testate (with a Will). The personal representative of the Decedent is Susan Crispen, 4300 Valley View Road, Harrisburg, PA 17112, (717) 652-3181. The Will has been filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013-3387. Phone number (717) 240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: June 15, 2004 Bridge{ M. Whitley, Esq.J Keefer Wood Allen & Rahal, LLP P.O. Box 11963, Harrisburg, PA 17108 Telephone (717) 244-8027 Capacity: Counsel to Personal Representative HEATH L ALLEN N. DAVID RAHAL CHARLES ROBERT L, WELDON EUGENE E. PEPINSKY, August 3, 2004 KeEfeR WOOD ALLEN & RAHAL, LLP 210 WALNUT STREET R O. BOX ll963 hARRISBUR(~, Pa 17108-1963 PHONE (717) 255-8000 EIN NO. 23-0716135 www. keefe~Nood.com (717) 255-8032 Fax: (717) 255-8003 E-Mail: sgarcia~kee ferwood.com Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re: Geraldine P. Leedy Estate #62,304 Gentlemen; ~IO~ ~. Enclosed please find an estate check in the amount of $57,000 representing payment on account of the Pennsylvania Inheritance Tax due for the Geraldine P. Leedy Estate, File # 21-04-0543. Please forward the receipt for this payment to my attention at the address listed above. You may contact me at 717-255-8032 if you have any questions. Very truly yours; KEEFER WOOD ALLEN & RAHAL, LLP Sha/'ron M. Garcia Legal Assistant for Trusts & Estates Enclosures Cc: Mrs. Susan B. Crispen COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG, PA ~7126 O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV 1162 EX(11 96) NO. CD 004244 WHITLEY BRIDGET M KEEFER,WOOD,ALLEN & RAHAL P. O. BOX 11963 HARRISBURG, PA 17108-1963 ESTATE INFORMATION: SSN: 172-01-7014 FILE NUMBER: 2104-'0543 DECEDENT NAME: LEEDY GERALDINE P DATE OF PAYMENT: 08/06/2004 POSTMARK DATE: 08/05/2004 COUNTY: CUMBERLAND DATE OF DEATH: 05/21/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $57,000.00 REMARKS: TOTAL AMOUNT PAID: 857,000.00 SEAL CHECK//205 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS KEEFER WOOD ALLEN & RAHAL, LlP 210 WALNUT STREET P. O. BOX 11963 HARRISBURG, PA 17108-1963 h.,lll,,,lll,,,.,Ih.lh.,ll,,,ll.l,,I.l.,,lll,,,,.,ll,ll,,I Register of Wills Cumberland County Courthouse I Courthouse Square Carlisle, PA 17013-3387 AEV-l5QO EXl6-00j !)'UcS 2>40' 6'C 'l'<i BaS-.CD :r:-ttAi REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ~~b as CD OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 FILE NUMBER 21-04-054L NUMBER COUNTY CODE YEAR w ~ ",-CO 00:'" w"-O rOO 00:-> !!-lD <i ~ Z Ul lil &l o DECEDENTS NAME (LAST, FIRST. AND MIDDLE INITIAL) Leedy Geraldine DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-OD-YEAR) 5/21/2004 1/3/1915 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 172-01-7014 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE P REGISTER OF WILLS SOCIAL SECURITY NUMBER 00, 04 006 09 D 2. Supplemental Return D 3. Remainder Return (data cl deal\'\ pfiol \0 12-13-82) D 4a. Future Interest Compromise (date 01 death after 12-12-8:2) D 5. Federal Estate Tax Return Required o 7. Decedent Maintained a Living Trust (Attach copy 01 Trust) L 8 Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (':ata of d""'tn.bat....an 12-3\-91 "00\.1-95\ D 11. Election tn tax under Sec. 9113(A) (AttachSchOI Original Return Limited Estate Decedent Died Testate (Attach copy of Will) Litigation Proceeds Received THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T AA INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAIUNG ADDRESS ... % W o % o .. U> w a: i5 " P.O. Box 11963 Bridget M Whitley, Esq FIRM NAME {Ii Applicable} Keefer Wood Allen & Rahal, LLP 1ELEPHONE NUMBER Harrisburg, PA 17108-1963 717-255-8027 1. Real Estate (Schedule A) (11 o r.,) ,m) OFF\CIAlUSE~lY ;"1 2 Stocks and Bonds (Schedule B) (2) 32,064 3. Closely Held Corporation. Partnership or Sole-Proprietorship (3) o o 384,045 o , ( 4. Mortgages & Notes Receivable (Schedule OJ (4) 5. Cash, Bank Deposits & Miscella.n.eous Personal Property ISohed"'. E) (5) -'"} z o i= :3 ~ c: <( u Ul a: 6, J~ Owned Property (Schedule F) U Separate Billing Requested Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) (6) ,:,:-] 1') o 416,109 (B) 21,210 1,741 (11) (12) (13) (14) 8 Total Gross Assets (total Lines 1-7) 9 Funeral Expenses & Administrative Cost,;; (Schedule H) (9) 10 Debts 01 Decedent, Mortgage Liabilities. & Liens (Schedule I) PO) 11 Total Deductions (total Lines 9 & 1Q\ 22,951 393,158 o 12. Net Value of Estate (Line 8 minus Line 11) 13 Charitable and Governmental Bequests See 9113 Trusts for which an election to tax has not been made (ScheduleJ) 393,158 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 atlhe spousal tax 0 % rate, or transfers under Sec. 9116 (a){1.2) ,0 0 j:: 16 Amount of Line 14 taxable allineal rate 0 , .0 .. .. :J 0 "- 17 Amount of Line 14 taxable at sibling rate x.t2 " 0 393,158 0 lB. Amount of Line 14 taxable at collateral rate x .15 X .. Tax Due .. 19 o ~(15) ~(16) o o (17) (lB) 58,974 58,974 (19) 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < -J' 3W46451 000 Decedent's Complete Address: STREET ADDRESS 325 Wesley Drive Cumberland County CITY I STATE I ZlP Mechanicsburg PA 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) 58,974 o 57,000 2,949 Total Credits (A + B + C) (2) 59,949 3. Interest/Penalty if appllcabie D. Interest E. Penalty o o Totallnteresl/Penalty (D + E) (3) o 4. If Line 2 is greater than Line 1 T Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 975 5. If Line 1 + Line 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5} o A. Enter the interest on the tax due. (SA) o B. Enter the total of Line S + SA. This is the BALANCE DUE. (56) Make Check Payable to: REGISTER OF WILLS, AGENT o PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS No OJ OJ OJ OJ []I OJ contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 0 [Jg 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 01 perjury_ I declare thaI I have examined tnis return, including accompanying schedules <l.l'\d sta\lllNlr1ts. ilIIe tc the best 01 my knowledge and oe)lel,II is true. correct and ccmplete Declaration of preparer other than the personal representative is based on all information of which preparerhas any knowledge 1, Did decedent make a trans1er and: a, retain the use or income of the property transferred; . . . . . . . . . . . . . . . b. retain the right to designate who shall use the property tr311sferred or its income;. c. retain areversianaryinterest~ar ........................ d. receive the promise for life of either payments, benefits or care? . . . . . . . . . If death occurred after December 12, 1982, did decedent transfer property within one year: of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 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 Yes D D D D 2. 3 SIGNATURE OF PERSON RESPONSIBLE FOR FILING RElURN Susan B. Crispen, Executrix ADDRESS 4300 Valley View Roaad, SIGNATURE OF PREPARER Oll-lER "TI-IAN REPRESENTATIVE Bridget M Whitley, Esq. ADDRESS Keefer Wood Allen & Rahal LLP ~-tliM'~ ,4up"j ~ DATE ~. q~- Harrisburg, PA 17112 ~Yh.~ DATE 1/ .16:/d s , PO Box 11963, Hbg., PA 171Q8-1963 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 tat the use oHhe SUNwing spouse is 3% [72 P,S. 9 9916 {al (1.1) (i)) For dates of death on or after January 1, 1995, the lax: rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% (72 P.S. S 9116 (a) (1_ ~) (ii)j The statute does not exempt a transter to a surviving spouse from tax:, and the statutory requirements for disclosure of assets and filing a tax relurn 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 naturi;ll parent. an adoptive parent, or a stepparent oflhe child is 0% [72 P.S. S 9116(a)(1 ,2)\. The lax 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. !3 9116(1.2) [72 P.S. 139116(a)(1)} The tax rate imposed on the net value oftransfers to or for the use ofthe decedent's siblings is 12% (72 P,S. 9 9116(a)(1.3)1. A sibling is defined, under Section 9102, as an IndiVidual who has at least one parent in common with the decedent, YkIether by blood or adoption. 3W46461000 REV-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Leedy, Geraldine P. Estate 21-04-0543 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1, 1,207 Shares Waypoint Financial Common Stock VALUE AT DATE OF DEATH 32,064 @ $25.565 per share 3W46961000 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 32,064 REV.1508EX.. (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY EST ATE OF Leedy, Geraldine P. Estate Include the proceeds of litigation and the date the proceeds were received by the estate. All prooertv ioinUy-owned with the rlnht of survivorship must be disclosed on Schedule F. FILE NUMBER 21-04-0543 ITEM NUMBER DESCRIPTION VALUE AT OATE OF OEATH 1 Allstate Renter's Insurance Premium Refund 7 2 20,000 Par Commerce Bank CD #8000262 20,000 Interest accrued to 5/21/2004 43 3 20,000 Par Commerce Bank CD #800388 20,000 Interest accrued to 5/21/2004 45 4 Commerce Bank Interest Check dated 4/25/04 due Decedent 46 5 Household Goods 100 6 19,991.76 Par M&T CD #31003914555271 19,992 Interest accrued to 5/21/2004 77 7 20,000 Par M&T CD #31003914512560 20,000 Interest accrued to 5/21/2004 14 8 M&T Checking #547886908 20,069 Interest accrued to 5/21/2004 1 9 Patriot News Subscription Refund 31 10 20,000 Par PNC Bank CD #31400204968 20,000 Interest accrued to 5/21/2004 34 11 50,000 Par PNC Bank CD #31300105441 50,000 Interest accrued to 5/21/2004 59 Total from continuation pages 213,527 3W46AO 1000 TOTAL (Also enter on line 5 Recanitulationl $ (If more space is needed, insert additional sheets of the same size) 384,045 Schedule E (Page 2) Estate of: Leedy, Geraldine P. Estate Item No. Description Value at Date of Death 12 PNC Bank Checking #5080033365 28,343 Interest accrued to 5/21/2004 o 13 25,000 Par PNC CD #31100110304 25,000 Interest accrued to 5/21/2004 11 14 20,000 Par Waypoint CD #266235573 20,003 Interest accrued to 5/21/2004 36 15 40,000 Par Waypoint CD #266238078 40,000 Interest accrued to 5/21/2004 105 16 Waypoint Checking #205004615 99,842 Interest accrued to 5/21/2004 16 17 Waypoint Financial Dividend Check dated 5/14/04 169 Total (Carry forward to main schedule) 213,527 REV.ISII EX.. (12-99) COMMONWEALTH OF PENN$YL VANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Leedv, Geraldine P. Estate SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FilE NUMBER 21-04-0543 Debts of decedent must be r&ported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. Neill Funeral Home 7,605 Total from continuation pages 98 B. ADMINISTRATIVE COSTS: ,. Personal Representative's Commissions Name of Personal Repre~entative(s) Susan B. Crispen Social Security Number(s) / EIN Number of Personal Aepresentative{s) Street Address 4300 Valley View Road City Harrisburg State PA Zip 17112 Year(s) Commission Paid: 2005 2 Attorney Fees 12,250 3 Family Exemption: (If decedent's address is not the same as claimant's. attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 357 5. Accountant's Fees 6 Tax Return Preparer's Fees 7. 1 Keefer Wood Allen & Rahal, LLP Accrued and anticipated disbursements for filing fees, estate advertising, lost security bond, additional probate fees, and ot.her Total from continuation pages 900 TOTAL (Also enter on line 9, Recapitulation) $ 21,210 3W46AG '000 (If more space is needed, insert additional sheets of the same size) Schedule H part 1 (Page 2) Estate of: Leedy, Geraldine P. Estate Item No. 2 Description Amount Romberger Memorials lettering on monument Total (Carry forward to main schedule) 98 98 Schedule H part 2 (Page 3) Estate oft Leedy, Geraldine P. Estate Item No. Description Amount 1 miscellanceous expenses of administration Total (Carry forward to main schedule) 900 900 REV-1512 EX... (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RElURN RESIOENT DECEDENT ESTATE OF Leedv, Geraldine P. Estate SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS . ITEM NUMBER ,. Bethany Village Monthly maintenance Fee for apartment 2 Healthsouth Medical Care FILE NUMBER 21-04-0543 Include unrelmbursed medical expenses. DESCRIPTION VALUE AT DATE OF DEATH 1,102 10 29 600 3W46AH 1.000 3 Holy Spirit Hospital medical care 4 McKonly & Asbury TOTAL (Also enter on line 10. Recaoitulation) $ (If more space is needed. insert additional sheets of the same size) 1,741 REV-1513 EX+- (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Leedv. Geraldine P. Estate NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 lal (1.2)1 1 Matthew J. Cowan 74 Ivy Parkway Atlanta, GA 30342 1,207 Shares Waypoint Financial Common stock Inventory Value: 32,064 2 Susan B. Crispen 4300 Valley View Harrisburg, PA Road 17112 60% Residue: 216,657 RELATIONSHIP TO DECEDENT 00 Not List Trustee(s) Nephew Niece FilE NUMBER 21-04-0543 AMOUNT OR SHARE OF ESTATE 32,064 216,657 Total from continuation pages 144,438 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 3W46AI 1 000 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) $ o Schedule J part 1 (Page 2) Estate of: Leedy, Geraldine P. Estate Item No. Description Relation "Amount 3 Joseph B. Sheesley III Shell Street Harrisburg, PA 17109 40% Residue: 144,438 Nephew 144,438 Total (Carry forward to main schedule) 144,438 I, GERALDINE P. LEEDY, of the TOWNSHIP of LOWER ALLEN, COUNTY of CUMBERLAND, COMMONWEALTH of PENNSYLVANIA, being in good bodily health and of sound and disposing mind and memory, and not acting under duress, menace, fraud, or undue influence of any person whomsoever, merely calling to mind the frailty of human life, and being desirous of disposing my worldly goods while I have the strength and capacity so to do, I do make, publish and declare this my LAST WILL AND TESTAMFNT. I hereby revoke, cancel and annul all my former Wills and Testaments, including codicils thereto, by me at any time made, and declare this alone to be my LAST WILL AND TESTAMENT. AS TO SUCH ESTATE AS IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ: ITEM 1 I direct that my Executors hereinaher named, pay and discharge all of my just debts, funeral and testamentary expenses. ITEM 2 I order and direct that I be buried in a lot which I own situate at the Harrisburg East Cemetery, Harrisburg, PA. ITEM 3 All the rest, residue and remainder of my entire estate, wheresoever situate, and whatsoever it may consist of, I give, devise, and bequeath, absolutely, and in fee, to my dearly beloved Husband, ROBERT M. LEEDY. In the event that my dearly beloved Husband, ROBERT M. LEEDY, dies with me in a simultaneous disaster, or fails to survive my death by thirty (30) days, then I give, devise, and bequeath, my entire estate, wheresoever situate, and whatsoever it may consist of, as follows: A. I give, devise, and bequeath any and all Harris Financial stock that I own at the time of my death to MATTHEW J. COW AN, per stirpes. In the event that Harris Financial stock changes its name, then of course, this request will go to the successor stock company as well. B. I give, devise, and bequeath sixty percent (60%) of my net residuary estate to SUSAN CRISPEN, per stirpes. ~A cd~(R ~...e2d'tt GERALDINEP.~ EDY Page 1 of 3 C. I give, devise, and bequeath forty percent (40%) of my net residuary estate to JOSEPH BANKS SHEESLEY, per stirpes. ITEM 4 I nominate and appoint ROBERT M. LEEDY as Executor of this my LAST WILL and TESTAMENT. Should the Executor named fail to qualify or cease to act as Executor then I appoint SUSAN CRISPEN as Executrix in his stead. ITEM 5. I hereby direct that all my personal representatives, as well as their successors, shall not be required to give bond for the f.\ithful performance of their duties in any jurisdiction. ITEM 6 I order and direct that my Personal Representative(s) named herein use the legal services of JAMES M. BACH, as Attorney for my Estate. ITEM 7 I direct that all estate, succession, legacy, inheritance or other transfer taxes, however designated that shall become payable by reason of my death in respect of all property comprising my gross estate for tax purposes. whether or not such property passes under this LAST WILL, shall be paid by my Executor out of my residuary estate. ITEM R I grant to my personal representatives herein named, in addition to, but not in limitation of those powers vested by law, to be exercised without prior application to or approval of any court, the power and authority to retain indefinitely any property, to invest and reinvest any assets or the proceeds derived from the sale of assets, although said investments may not be of the character prescribed by law, to sell, convey, assign, transfer and encumber any property, to pay, settle or compromise all claims, to make distribution or divisions in cash or in kind, and in general to exercise all powers in the management of any property hereunder which any individual could exercise in the management of similar property owned in his own right, and to execute and deliver any and all instruments and to do all acts which may be deemed necessary and proper. WITNESS~ Ji~ a NNU JJJlo.idJJ frfteff GERALDINE P. tE DY WITNES~ ~, l~6 LAM. WADGE --------------------END------------=------- Page 2 00 ACKNOWI F.DGMENT COMMONWEALTH OF PENNSYLVANIA ) ) ss COUNTY OF CUMBERLAND ) I, GERALDINE P. LEEDY, the TESTATRIX, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it willingly; and that I signrd it as my free and voluntary act for the purpose therein expressed. Sworn to or affirmed and acknowledged before me, by: GERALDINE P. LEEDY, the TESTATRIX this ~ day of December, 1997. ~.A rJl'/~.JJif.(....u~k- G RALDINE P. LEEDY v if ...,_...~_.,-- NOrARlAL 5EtL ATTORNEY JAt.AES M. BACH, Notary Public CumMrland County MyCommiS$iOn ElCpiroa: May 13, 1999 M. BACH, ESQUIRE NOTARY PUBLIC Mechanicsburg, PA 17055 My Commission Expires: 05/13/99 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) ) ss COUNTY OF CUMBERLAND ) We, JOHN NUGRNT and LISA M. WADGR, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw TESTATRIX sign and execute the instrument as her LAST WILL; that the TESTATRIX signed willingly and that she executed it as her free and voluntary act for the purpose therein expressed; that each witness in the hearing and sight of the TESTATRIX signed the WILL as witnesses; and that, to the best of our knowledge, the TESTATRIX was, at the time, 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and acknowledged before me, LISA M. W ADGE, witnesses, this.r.... day of W1TNESSOoJ2~ o VENT W1TNESS ATTORNEYJNOTNiiAl SfAl ~MES ."'1 SAC' U"CommCu,,!berll]~d c~~~!yNotary PUblic 'fty /SSIOnr. <;XPff6SMaYf3.1999 Page 3 of 3 Glenda Farner Strasbaugh Register of Wiils and Clerk of Orphans' Court Marjorie A. Wevodau First Deputy Kirk S. SOhonage, Esq Solicitor Register of Wills and Clerk of the Orphans' Court County of Cumberland One Courthouse Square Carlisle, PA 17013 (717) 240-6345 FAX (717)240-7797 INVOICE Bill To: InvoiceNo: Invoice Date: Estate of: Estate No: 199 2/4/2005 GERALDINE P LEEDY 21-04-543 BRIDGETR M WHITLEY, ESQ POBOX 11963 JA HARRISBURG, PA 171081963 35,00 Total $35,00 Qty 1 Fee Description Additional Probate Fee Total: $35.00 Olecks should be made payable to the Register of Wills, Tenns: Net 30. Please return one copy of this invoice with your payment. Thank you. Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Geraldine P. Leedv also known as , Deceased No. 2004-0543-' Date of Death 05-21-2004 Social Security No. 172-01-7014 I. Susan B. Crispen Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include aU of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. [/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Attorney: Brideet M. Whitlev C . '->..) _.f f,tJ-tIrA{..".!; I ~ t rI r()V4./ / . / 1.0. No.: 33580 Address: P.O. Box 11963 Dated: '/:s ~h 1" Harrisbure. PA 17108-1963 Telephone: 717 ~255-8027 Description Value See Attached (.) -:"""l (Jl N Total: $416,1 08.67 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, inciude the value of each item, but such figures should not be extended into the total Q1 the Inventory Form RW_7 (DauphinCounty)-Rev.9/92 20,000 20,000 19,991.76 20,000 20,000 50,000 25,000 20,000 40,000 Page 1 Leedy, Geraldine P. Estate Estate Inventory Valued as of Date of Deatb Cash & Cash Equivalents Allstate Renter's Insurance Premium Refund $ Commerce Bank CD #8000262 Interest at Date of Death Commerce Bank CD #800388 Interest at Date of Death Commerce Bank Interest Check dated 4/25/04 due Decedent M&T CD #31003914555271 Interest at Date of Death M&T CD #31003914512560 Interest at Date of Death M&T Cher.king #547886908 Interest at Date of Death Patriot News Subscription Refund PNC Bank CD #31400204968 Interest at Date of Death PNC Bank CD #31300105441 Interest at Date of Death PNC Bank Checking #5080033365 Interest at Date of Death PNC CD #31100110304 Interest at Date of Death Waypoint CD #266235573 Interest at Date of Death Waypoint CD #266238078 Interest at Date of Death Waypoint Checking #205004615 Interest at Date of Death (1) 7.00 20,000.00 42.99 20,000.00 44.72 45.96 19,991.76 76.87 20,000.00 14.01 20,069.01 1.00 31.00 20,000.00 34.37 50,000.00 59.06 28,343.48 0.34 25,000.00 11.39 20,003.39 35.62 40,000.00 104.98 99,842.41 16.37 . . .. Estate Inventory Cash & Cash Equivalents Waypoint Financial Dividend Check dated 5/14/04 $ 168.98 Total Cash & Cash Equivalents $ 383,944.71 No. of Shares Stocks 1,207 Waypoint Financial Common Stock $ 32,063.96 Total Stocks 32,063.96 Tangible Personal Property Household Goods $ 100.00 Total Tangible Personal Property 100.00 Total Inventory $ 416,108.67 Page 2 (2) STATUS REPORT UNDER RULE 6.12 Name of Decedent: Geraldine P. Leedy Date of Death: May 21,2004 Estate No. 2004-00543 Admin. No. 21-04-0543 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, 1 report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes-L-No 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 personal representative file a final account with the court? Yes _No X. . b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes No X d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date :May /~, 2005 Signature ~:~/11, ~ Bridget . Whitley, Esq ~ Keefer, Wood, Allen & Rahal LLP 210 Walnut St., P.O. Box 11963 Harrisburg, PA 17108-1963 j717)255-8027 J Capacity: _ Personal Representative L Counsel for Personal Representative BUREAU OF IND i) OFFICE OF DlIERITANCE TAX DIVIS , r.'STR O~ 11. "II (' PO - 281601 'r' o' I "I- ."q , : v;. I '1 ~ 1,,,, _~,~l _ISIURll PA 171Z8-D60 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT . REV-1607 EX AFP (03-851 2005 JUL 22 P/'l 2: 10 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN D6-27-2DD5 LEEDY D5-21-2DD4 21 D4-D543 CUMBERLAND 101 Allaunt R_I ttMl GERALDINE P CLERK OF ORPHAN'S COURT BRIDG~Utf!r:wJnnEV'~~A. KEEFER ETAL PO BOX 11963 HBG PA 171D8 MAKE CHICK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17D13 NOTE, To I....... p.--r crMIlt to your _t. ...It the upper portion of this fa... with your tlllC "_to CUT ALONe THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ .....~......~.......~..........~....~~................................................M............... REV-1607 EX AFp (03-05) ... INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATI OF LEEDY eERALDINE P FILl NO.21 04-0543 ACN lDl DATI 06-27-20D5 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STArus OF THE STATED ACN IN THE NAIlED ESTATE. SIIOlItI 8ELOW IS A SUIlIIARY OF THE PR_IPAL TAX DUE. APPLICATION OF ALL PAYIIEHTS. THE CURRENT BALANCE. AND. IF APPLICABLE. A PRO.IECTED INTEREST FIIlURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 04-11-2DD5 PRINCIPAL TAX DUE, 58.974.DD PAYMENTS (TAX CREDITS), PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 08-05-2004 CD004244 2.948.70 57.000.DD D6-09-2DD5 REFUND .DD 974.70- I TOTAL TAX CREDIT 58.974.0D BALANCI OF TAX DUE .DD INTEREST AND PIN. .OD . IF PAm AFTER THIS DATE. SEE REVERSE TOTAL DUI .DO SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN tl. IlO PA YItENT IS RElIUIRED. IF TOTAL DUE IS REFLECTED AS A '"CREDIT" (CRJ. YDU HAY BE DUE A REFWiD. SEE REVERSE SIDE OF THIS FORH FORINSTRUCTIllNS. J ~