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Real Estate (Schedule A) ........ . .................................... 1. 148,752.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 3,043.63 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 5,370.84 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) ............................. $. 157,166,47 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 12,780.76 ~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 94,789.09 11. Total Deductions (total Lines 9 and 10) ................................. 11. 107,569.85 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 49,596.62 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 49,596.62 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) X .0, 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 2,231.85 1g. 2,231.85 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 1 ti. 19. TAX DUE ......................................................... 19. 20. F{LL IN THE OVAL iF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 2,231.85 O REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME Theodore Motz STREETADDRESS 338 Allenview Drive CITY Mechanicsburg STATE Pa ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fi{I in oval on Page 2, 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. Flle Number Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. 2,231.85 2,231.85 20.08 2,251.93 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. 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 payments, benefits or qre? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 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 designation? ........................................................................................................................ ^ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND F{LE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994, and before Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rake imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (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 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a}(1.2)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, 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 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. f ~~~" LAST WILL AND TESTAMENT OF ELIZABETH MOTZ I, ELIZABETH MOTZ, a/k/a BETTY MOTZ of the Borough of Mechanicsburg, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereby make this my Last Will and Testament, hereby revoking all Wills and Codicils at any Lime heretofore made by me. FIRST: I give and bequeath unto my Daughter, ANN MARIA (MOTZ) REED, the sum of Five Hundred ($500.00) Dollars, if she survives me. SECOND: I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever (including interest and penalties thereon), which may be payable by reason of my death, shall be paid out of my residuary estate. Taxes on future interests and remainders may be prepaid. THIRD: I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal or mixed, of whatsoever nature, and wheresoever the same be situate at the time of my death unto my Son, THEODORE MOTZ. FOURTH: I nominate, constitute and appoint my Son, THEODORE MOTZ, to be the Executor of this, my Last Will and Testament. I direct that no such Executor acting hereunder shall be required to post bond or enter security in any jurisdiction. IN WITNESS WHEREOF. I. ELIZABETH MOTZ, a/k/a BETTY MOTE nav= hereunto set my hand and seal to/~jthis, my Last Will and Testament, this ,~ti~~t day of !/ G~~ 19S? . (SEAL} (SEAL) Signed, sealed, published and declared MOTZ, a/k/a BETTY MOTZ, as and for her Last the presence of us, who, at her request, in the presence of each other, have subscribed thereto. ~~Vtu~•~ ~~-~' _~~~~ by the said ELIZABETH Will and Testament, in her presence, and in our names as witnesses .. ~~ a1x REV-1502 EX+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Matz 21-09-0985 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compeNed to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1• Home located at 408 Orchard Lane, Mechanicsburg, Pa. 17055 148,752.00 * Settlement sheet inducted. To determine Fair Market Value -Listed sales price was $154,000 subtracted $5248 in which I provided as Seller assistance. Thus $148,752.00 TOTAL (Also enter on Line 1, Recapitulation.) ($ 148,752.00 If more space is needed, insert additional sheets of the same size, REV 1503 EX+ (6-98) scNE~u~E s COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 ~ ProPertfl jolntlyarrtNd wkh right of wrvivorship must 6e disclosed on Schedule F. (If rrrore space is needed, insert additional sheets of the setrre size) OMB NO. 2502-0265 r A. B. TYPE OF LOAN: DEPARTMENT OF HOUSING 8 URBAN DEVELOPMENT U S 1.QFHA 2.QFmHA 3. QCONV, UNINS. 4. XQVA 5. QCONV. INS. . . SETTLEMENT STATEMENT 6. FILE NUMBER: HART 7. LOAN NUMBER: 213591981 8. MORTGAGE INS CASE NUMBER: LAP101060608144 C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(POCj" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. 1.6 3P96 (HART.PFDlHART/22) D. NAME AND ADDRESS OF BORROWER: STEVEN R. HART and ALLYSON M. HART E. NAME AND ADDRESS OF SELLER: THEODORE MOTZ, Executor of the ESTATE OF ELIZABETH MOTZ F. NAME AND ADDRESS OF LENDER: BANK OF AMERICA, N.A. 2733 PAPER MILL RD, SUITE 7 WYOMISSING, PA 19610 G. PROPERTY LOCATION: 408 ORCHARD LANE PA 17055 MECHANICSBURG H. SETTLEMENT AGENT: 20-1624913 GUARANTEED ABSTRACT SERVICES, INC. I. SETTLEMENT DATE: November 20 2009 , UPPER ALLEN TWP, CUMBERLAND CO. PLACE OF SETTLEMENT PRUDENTIAL THOMPSON WOOD REAL ESTATE 3815 Market St, Camp Hill, PA 17011 , J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price 154,000.00 401. Contract Sales Price 154,000.00 102. Personal Pro a 402. Personal Pro e 103. Settlement Char es to Borrower Line 1400 8,986.81 403. 104. 404. 105. 405. Ad'ustments For Items Paid B Seller in advance Ad'ustments For Items Paid 8 Seller in advance 106. Coun R Taxes 11!20!09 to 01/01!10 58.46 406. Coun 1T Taxes 11!20/09 to 01/01/10 58.46 107. Ci Tax to 407. Ci Tax to 108. School Tax 11/20/09 to 07/01/10 1,132.62 408. School Tax 11/20/09 to 07/01/10 1,132.62 109. 409. 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 164,177.89 420. GROSS AMOUNT DUE TO SELLER 155,191.08 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest mone 1,000.00 501. Excess De osit See Instructions 202. Princi al Amount of New Loans 157,311.00 502. Settlement Char es to Seller Line 1400 15,478.07 203. Existin loans taken sub'ect to 503. Existin loan s taken sub'ect to 204. 504. Payoff of first Mortgage to MEMBERS 1ST FCU 37,359.98 205. 505. Pa off of second Mort a e 206. 506. 207. 507. De osit disb. as roceeds 208. 508. 209. SELLER ASSIST 5,248.00 509. SELLER ASSIST 5,248.00 Ad'ustments For Items Un aid 8 Seller Ad'ustments For Items Un aid 8 Seller -~ 210. Coun R Taxes to 510. Coun R Taxes to 211. Ci Tax to 511. Ci Tax to 212. School Tax to 512. School Tax to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. ESTATE INHERITANCE TAX to GUARANTEED ASST 2,500.00 218. 518. MUNICIPAL LIEN to UPPER ALLEN TOWNSHIP 519.52 219. 519. 220. TOTAL PAID BYIFOR BORROWER 163,559.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 61,105.57 300. CASH AT SETTLEMENT FROMITO BORROWER: 600. CASH ATSETTLEMENT TO/FROM SELLER: 301. Gross Amount Due From Borrower Line 120 164,177.89 601. Gross Amount Due To Seller Line 420 155,191.08 302. Less Amount Paid B/For Borrower (Line 220) ( 163,559.00) SJ2. Less Reductions Due Seller (Line 520) ( 61,105.5 303. CASH (X FROM) ( TO) BORROWER 618.89 603. CASH (X TO) ( FROM) SELLER 94,085.51 The undersigned hereby acknowledge receipt of a completed copy of pages 182 of this statement & any attachments referred to herein. Borrower Seller EO E TZ ecutor of the ESTATE OF LI Y: Page 2 L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price $ 148,000.00 6.0000 % 8,880.00 PAID FROM PAID FROM Division of Commission IIIIB 7OO 8S FOIIOWS: BORROWER'S SELLER'S 701. $ 4,665.00 to THE HOMESTEAD GROUP REALTOR INC. FuNDSAT FUNDS AT 702. $ 4,415.00 to PRUDENTIAL THOMPSON WOOD REAL ESTATE SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 9,080.00 704. SETTLEMENT DEPT MGMT FEE to PRUDENTIAL THOMPSON WOOD REAL ESTATE " 200.00 Note: Line 701 Includes Adjustment of 200.00 For SETTLEMENT FEE 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee % to 802. Loan Discount 0.8750 % to BANK OF AMERICA 1,376.47 803. Appraisal Fee to 804. Credit Report to LANDSAFE CREDIT 35.00 805. Lender's Inspection Fee to 806. Flood Cert Fee to LANDSAFE FLOOD DETERMINATION 26.00 807. Tax Service Fee to 808. Document Prep Fee 809. 810. 811. 812. VA FUNDING FEE to DEPT OF VA 3,311.00 813. 814. 815. 816. 817. 818. 819. 820. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 11/20/09 to 12!01/09 @ $ 23.700000/day ( 11 days %) 260.70 902. Mort a e Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ars to POC 904. 905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance 3.000 months $ 37.92 er month 113.76 1002. Mort a e Insurance months $ er month 1003. Coun R Taxes 10.000 months $ 41.49 er month 414.90 1004. Ci Tax months $ er month 1005. School Tax 6.000 months @ $ 151.40 per month 908.40 1006. months $ er month 1007. months er month 1008. AGGREGATE ADJUSTMENT months $ er month -507.30 1100. TITLE CHARGES 1101. Settlement or Closin Fee to 1102. E-Mail Document Retrieval to GUARANTEED ABSTRACT SERVICES, INC. '" 50.00 1103. Title Examination to 1104. Title Insurance Binder to 1105. Document Pre aration to LAW OFFICES OF CRAIG DIEHL DEED 150.00 1106. Nota Fees to NOTARY CLERK "$30 40.00 1107. Attorneys Fees to includes above item numbers: 1108. Title Insurance to GUARANTEED ABSTRACT SERVICES INC. GA6.09-135 1 148.75 includes above item numbers.1101, 1103- BASIC RATE 1109. Lender's Coverage $ 157,311.00 L08-2011924 1110.Owner's Coverage $ 154,000.00 8222638-79287327 1111. PA END:100, 300, 900 to GUARANTEED ABSTRACT SERVICES, INC. 150.00 1112. 1113. Insured Closing Letter to LAWYERS TITLE INSURANCE CORPORATION "* 75.00 1114. Overnight Fee/package to GUARANTEED ABSTRACT SERVICES, INC. " 12.00 1115. Overnight Fee/payoff to GUARANTEED ABSTRACT SERVICES, INC. 9.00 1116. Tax Cert Fee to GUARANTEED ABSTRACT SERVICES, INC. 5.00 1117. 2009 COUNTY/TWP TAX to MARLIN A. YOHN SR, TREASURER 558.83 1118. 2009 SCHOOL TAX to MARLIN A. YOHN SR, TREASURER 2,039.22 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recording Fees: Deed $ 62.00; Mortgage $ 96.00; Releases $ 158.00 1202. Ci /Coun Tax/Stam s: Deed 1,540.00• Mort a e 1,540.00 1203. State Tax/Stam s: Revenue Stam s 1,540.00; Mort a e 1,540.00 1204. RECORDER OF DEEDS 1205. RECORDER OF DEEDS 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve to 1302. Pest Ins edion to AN'S COMPANY *'&HI,RADON 385.00 1303. REPAIRS to MIKE SHEELY HOME INSPECTIONS 895.00 1304. 4th tr SEWER $112 to UPPER ALLEN TOWNSHIP 51.13 60.87 1305. OUTSTANDING SEWER BILLS to UPPER ALLEN TOWNSHIP 378.15 1400. TOTAL SETTLEMENT CHARGES Enter on Lines 103, Section J and 502, Sect' 8,986.81 15,478.07 or oiyi ix,y yaye . w u iw amtm, ie , u ie ary~riean roa eciumwieage receipt m a c°mpre[ea coPY oT Page L m 1f113 Iwo pag~,Siafement. Certified to be a true copy. .e~~/\% V G NTE ABSTRACT SERVICES, C. Settlement Agent (HART/HART/21) REV-1504 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDt~LE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 Schedule C-1 or C-2 (induding all supporting information) must be attached for each cbsely-held corporatioNparfnership interest of the decedent, other than a sole-pioprietaship. See ir~s4uctions for the supporting information to be submitted forsale-proprietorships. ITEM NUMBER VALUE AT DATE Not applicable 0.00 TOTAL (Also enter on line 3, Recapitulation) I $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (6-98) SCI~IEDVLE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES ~ NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT _. ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 AN property joirrtly~wrrad with right d survivorship must be disdosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDI~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 Indude the proceeds of litigatia~ and the date the proceeds were received by the estate. Afl property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM 1 Members First Credit Union Account Number 18601 Balances as of 6122/09 Checking Balance - 38.73 Savings Balance - 5.11 2 Car -1991 Cadillac 3 Jewelry 4 Home Furnishings 5 Clothing/ Apparel) TOTAL (Also enter on line 5, Recapitulation) ; (If more space is needed, insert additional sheets of the same size) VALUEAT DATE 43.84 4, 000.00 500.00 327.00 500.00 5, 370.84 ~t MEMBERS 1st FIDERALCREDrf t)NION ~~ n~~~ o: 5004 Louise Drive PO t3oY 40 Mechanicsburg, PA 17055 www.memberslst.org Main Switchboard: (800) 283-2328 EZ Cali: (717) 697-4372 or (800) 28&4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (800) 237-7288 7477 1 AV 0.335 14953-7477 Ir~~lll~rrllirr~~l~lrrlrirrilrr~rrllrl~~lrr~llll~~~lrrlrr~irll • ~ ELIZABETH MOTZ 408 ORCHARD LN ,~ MECHANICSBURG PA 17055-6141 ,.,.,_ ,_ Statement of Accounts Jun 25, 2009 thru Jul 24, 2009 Account Number: 18601 Balances at a Glance Checking : 93 , 27_ Savings : 5.11 Certificates : 0.00 .,,.,Loans : 36 ,136 , 66 Money Management : 0.00 Swipe 5 YTD Reward : 0.05 Page : 1 of 2 Your aggregate balance as of July 1st is $49,262.34. An aggregate balance of 62,500 and having 3 products will place you in the Silver MLR level. Would you like to receive a full calendar month statement? Sign up for eStatements to ay! A k an associate for details. tJ~~t3~~- CHECKING ACCOUNTS 11 - CHECKIWG Date Trat>sac~iorr Add~ions Subtractions Batanoe " _.., .. ~ =-x6.73 ; Joint. Owner: THEODORE MOTZ Jul 07 Withdrawal Overdrawn 006013 33,0A_ 5,73 In the amount $66.78. Jul 13 Withdrawal Overdrawn 009008 33.00- 2T.27- ta the amount $210.00. Jul 16 Withdrawal Overdrawn 006013 33,00_ 60,27_ In the amount $66.78 PETSMART CORP Jul 20 Withdrawal Overdrawn 009008 33.00- 93.27- In the .amount $'L10.00. ./u/ 24 Endit9 6t~aixae 93.27- ~.Y !°~' and NSF Fae Summery _. _ _ _ NSF Item Fees for Statement Period 132.00 NSF Item Fees Year-to-Date 396.00 Courtesy Pay Fees Year-to-Date 330.00 SAVINGS ACCOUNTS 00 - REGUU4R SAYINGS rx~t,R Tran~eaMinn ~ Orirli ,i~f ~4'"r ~_ Joint Owner: THEODORE MOTZ Jul 01 Deposit Dividend 0.11 Annua/ Pe~zaar-bg~e Yid Eamed 0.480'IL lhxn Ar/O1/ZOOt9 Uunugoh UB/30/2n1f,~ .lu/ 24 End~g Balance 5.11 --- Continued on following page --- REV-i5D9 IX+ (oi-io) ~~i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SC~IEp1~LE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Elizabeth Motr 21-09-0985 If an asset hccame jdMly owned within one year of the dccedeM's date of death, it moat be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• NOT APPLICABLE B. C. ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER fOR JOMT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL II95T11UTION AND BANK ACCOUNT NLN~IBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY HELD REAL ESTATE. DATE ~ DEATH VAU~ Of ASSET % OF DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A• NOT APPLICABLE TOTAL (Also enter on Line 6, Recapitulation) I ~ 0'00 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) ~ Pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR REtATIONSNIP TO DECEDENT AND THE DATE DF TRANSFER. ATTACH A COPY of THE DEED FDR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. NOT APPLICABLE TOTAL {Also enter on Line 7, Recapitulation) $ ~ 0.00 If more space is needed, use additional sheets of paper of the same size. REV-,1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDEPIT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS - ESTATE OF FILE NUMBER Elizabeth Motr 21-09-0985 Decedent's debts must be reported on Schedule I. TTEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Zimmerman Aurer - Funeral Cost 2 Funeral Luncheon 3 Flowers (Family) B. 1. State ZIP 10,210.26 600.00 289.62 1,000.00 2. Attorney fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State _ Relationship of Claimant to Decedent ZIP 4. 5. 6. 7. s 9 ~o ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Years} Commission Paid: Probate Fees: Accountant Fees: Tax Retum Preparer Fees: Will Filing Estate Notice -Cumberland Law Journal Estate Notice- Sentinnel Newspaper Walters Monument Company- Engraving of Stone 330.00 75.00 155.88 120.00 TOTAL (Also enter on Line 9, Recapitulation) I # 12,780.76 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERTfANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Motz 21-09-0985 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. BEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Settlement Charges on Sale of residence-408 Orchard Lane Settlement Sheets Induded 15,478.07 2 Municipal Lien to Upper Allen Township - On settlement sheets 519.52 3 Mortgage Balance on Residence - On Settlement Sheets 37, 359.98 4 Bank of America (Credit Card) 10,330.48 5 VISa Credit Card -Members First Credit Union 13,413.95 6 Golden Living Nursing Home 14,655.69 7 PharMerica (Unreimbursed Medication Costs) 1,194.53 8 Montour Oil 1,057.09 9 PP&L Electric 300.82 10 United Water 85.04 11 West Shore Ambulance 140.06 12 Comcast 88.88 13 Glassmasters 86.98 14 York Waste 87.00 TOTAL (Also enter on Line 10, Recapitulation) I ~ 94,798.09 If more space is needed, insert additional sheets of the same size. _ __ - -- ~ for. ELIZABETH Morz Account 1Vumbar. 442710001726 0170 dine 2008 Statement Credit Line: $11,400.00 Casir Cred' Available• BankofAmerica or tt ~.~-°--•~---------- - - - --- ----- ______ ...._. -_ -_ _ ,w..~. • __ ~ Formfom~aoon on YourAccoun~>rsrt _ - '. .: ~:_. -. _• _ ~ www.bankofamericacom l Summary of Transactions Billing Cycle and Payment Information Cap toq-free t-800.789-8885 T~° hearirg-impaired t-eW-3as-3178 Previous Balance $10,257.48 Oays in Billing Cycle 29 } _ Payments and Credits $210.00 Closing Date 0611y09 ~ A~r7Payn~entato: Purchases and Adjustments + $0.00 P O eOX ~E9 CA I Periodic Rate Finance Charges + $38.70 Payment Due Date 07/07!09 ~ WILMINQTON, DE 19888-5019 Transaction Fee FnanCe Charges + $0.00 Current Payment Due $210.00 , 8~~~ ~: _ Past Due Amount + $210.00 ; BANK OF AMERICA New Balance Total $10,086.18 Total Minimum - ~ P.O. BOX t5028 Payment Dua '~ :.::..._ WILMINQTON, DE 19850-5026 , .- _. Promotional Posting ~~ Transaction Reference Account P and Credits Offer ID Date Date Number Number Amount PAY BY PHONE PAYMENT. 06110 210.00 GR OUR RECORDS SHOW YOUR ACCOUNT iS PAST DUE Promotional CorrespondingAnnua! APR Balance Subject to Category Transaction Types Daily Periodic Rafe Percentag8 Rate Type Finance Charge Cash Advances _......_.... _.......... _.... _ __ ___..OD1301496.. __ _._4:75.%____ _..._.1,. ...__. ..........$zt3t:58 _._ purchases 0.013014% 4.75% T $5,832.33 Annual Percentage Rate for this Billing Period: 4.75% (Includes Periodic Rate Finance Charges'and Transaction Fee Finance Charges that results in an APR whit ettoeeds the Corresponding APR above.) APR Type DeSati6ons: APR Type: T~ Temporary APR (APR for special circumstances) F~aP~ B~~ a 10,330.40 '1M1f ~IU- ~- 210.00 M0.~1~ Q~Ayiy„k 13 0100861800042000000210000004888936014586980 rrllrilltrtirrtrltrlrrlrrrihrurlrlrltirlr(rrtrlrtlrtrrllrrrlrrl ~ Chec«hereforachanpeofna8ngaddreasorphonenumbe~(sl. Pi~ae provide a~ corrections on the eeverloe aide. BANK OF AMERICA -.--...,r.-.-_._..~._~.._..-__T_~ -~.__--_ ___ P.O. BOX 15019 ( _ - _ -- - _ _ WILMINGTON, DE 19886-5019 I ACCOUNTNUMBEI~ 4427100017260170 Si3 0616 8N ]78 950 1 10109 tte01 AT 0.357 ELIZABETH MOTZ 408 ORCHARD IN MECHANICSBURG PA 17055-6t41 rrrrrr4rrllllrlhlvrrr4Prrrlrhrlrrrlrrrrlrtlrlr~tlrltllrtlrr I: 5 2 ~.n a a a ~n~~ NEW BALANCE 70TAL• $10,086.18 PAYMENT DUE DATE• 07/07/09 - 6Rerf4rnrnrMwintEaebsu! ,~. ~ ~~ Cv~ this peyrnent coulvon akmg with a check or money order payable to: B+4N/C OFAMERtCA L ~A?CCt Lt_ Cneannn. ~~ ~'. ,e, ~~..,..., .~ PLEASE DETACH COUPON AND RETURN PAYMENT USING THE ENCLOSED ENVELOPE - ALLOW S DAYS FOR MAI! DELIVERY _ _ _ ~ - NEME~RS 1ST FEDERAL CU ~ CAccount Number 5000 LOUSE DRNE 4287 5900 0018 6011 IdECNANICSBLIRG PA 1T055-4899 ~1 MEMBERS 1'~ •senras,.a,~rruaow ~ Cbsing pate ~ .New BaM~~ 7ots~ ~;.. j: J ~ -0-7-116/0-9- ~ 32,739.95 "'"'08/10/09 check bcoc m indicate name/address charge on bads or this cawwn AMOUNT OF PAYMENT ENCLOSED -^ ELIZABETH MOTZ 11~ MAKE CHECK PAYABLE TO: 408 ORCHARA LN ""~ MECHANICSBURGPA17055~6141 ~ ~ I,Ilnlluuulll,lulu,l,Inl,I,l,u,lllu,l,-,lllu,lnl,l) _.~.,. ~8 visa ~ ~ Po Box 4517 Iwlllu,lliuulrlul, „ll, ull,luln,lllln,luln,l,ll CAROL STREAM 1L 601971517 21 4287 590D 0018 b011 00273995 01341395 5 'I~q~!rPawaw~~o1~aar~yno~lA ~sp,ooe„wua6ewi«a~r.M~ PUe Pe~IseP eQ 1!'e ~pB1Pleud!o at! ~ ~ lD ~Il ~s rw ~ar~-'~r!o~ ~ ~p •~ aaP ~I ~e ~a ~e r.wooa m(a Pam ~ ~ '~aan ~. ~~a ill "~+P~!~8414~M~>aV~l!QaPee~warat+auo~u~!e,IIP~84FBu?uaNuauenot'~p~Bupws+r8 ro4 aB1~+a+I ~4M1 wa!Q aaaald . eaexrd a4i,eye ~ !p>~ ax +b Pte! ~PPe ~p a penbai aioR 1!~S ~P~ lol a •i9upw u ~saibei Raw na('paaooa awR uo e+P ea~e41~ s st ouap I! 'M!~ !~- ~eP a^n ~ Pe1~p oq 1e4s Na 'fin u Rgop a roe!a-s s9 Raw (odyer,p owes eip u ~uodnon ~ ~p N~ 'Misuersre nat 41M pepNC-d ~ ueie ~ oda~O 'qqs pptuRed i~u- •B~a) p apolpd e41 ~ b uo 41AI wo sruauwupbo+ ~ a mio~oo >~ aP red sruaurtsd,o ~ ~ ~ suo!r~4 ~, Pen!aoeu srueuu(ed voaao tuauRed ~ uo Palms rnnxa ~ a rd!aoer ~ oV P ~ PeNP~ oQ MM .013~VAVd M?3FtJ 311VIY. asap 041 ~eqe M e41 P MCI ~A ~ P uo!IeoQ ~ P P~+!a~+ $M~d '~ .. ~d '~~lgWl~~plo~~Ql~ao4oP!~PP~~a!!9o41~1sav~AR9~P~PP~PPo~~tl.'Q+~Pull~~s!!J. ~~~p~9P!~P~ •seer B!u~ao-ud+'sppep'spiouufed Rue pa1~g114 Pus •saaw,npe V~ b r,9U Rut PPs'ReP 4~ paiaaaa mod p axnre9 8wnBeQ e1p selelBM 'eapP9 ~P aBa,are e4I ree of 1ao~e~Pe 4~'elQealdde F Pue) p~lo.~+geA ~ . ~ a area a~!pd eM - p Paadtsoo ee ~ eyw a ~! sa6~p aa~~ a~ ~asO ~o ~d ~ a awe SeeB1p~ I° oao4e9 MeN ~ ~r Paced aosi8 au. 'ere0 ~ n+e~d aV- ,o uo R~ptaw xiac uo unals 'oo+tals8 «~H e4t+fed ~ raR • h~~ lzsu noit uo Buuecide (aaua,pe ~' p Pus) saeeipnd ~ Rue uo'puo x +~ ~ ~~ t ~ a gge~dde ~ pegaeds s J PaPeW P' V~ pue) se~tpnd p eawaleq a4l+p eile~p .~ P~!MPPo w dsuaqu pixie o f '(s~pssua~l N,azro Qu!PR~) ~m8 ~e0 oBa,r++V - 9 PWwW X409 P~ Pue M~elers ~ Io ~ ~ aA ~ P~ st pm rodro ian ~ 4a>wl1 ~ raR ~ seoruss PVe sP~ P ~ l~U pUe ~eMY,~ ~I rr~oooe Holt a PalIeY9 aD,sip +.~ ~iL •~-~+!~ a v ~ ~Aor'1 ~a NOI1ttW2103N11 21QdW1 Z ;o z abed NAME ACCOUNT NUMBER Elizabeth Motz 3959-92477 STATEMENT DATE TOTAL AMOUNT DUE 09/17/09 $14,655.69 66NSC-Carp ;Hill-3959 i'S00 Ardmore Blvd Ste 101 Pittsburgh, PA 1$221 4iZ-871-1000 Fax 412-871-1040 NAME ACCOUNT # STATEMENT DATE Elizabeth Motz 3959-92477 09/17/09 DATElPER{OD COVERED DESCRIPTION QTY/DAYS AMOUNT 04/18/09 04/30/09 Room Cha a 13 2,799.16 04/02!09 04/30/09 Barber & Bea 33.00 04/18/09 04/30/09 Ancilla Cha es 144.10 05!01/09 05/31!09 Room Cha a 31 6,459.60 05/01 /09 05/27/09 Ancilla Cha es 428.03 05/21 /09 05/21 /09 Barber & Bea 9.00 06/01 /09 06/21 /09 Room Cha a 21 4,521.72 06/04/09 06/04/09 Barber & Beau ~ t ~~:'`j;. ; . 9.00 06/01 /09 06/21 /09 Ancilla Cha es :~ ~; ~ ~; ~ 252.08 Private Statement PAYMENT DUE UPON RECEIPT - ~. y(.. TOTAL AMT 14,655.69 CUSTOMER: ELIZABETH MOTZ FACILITY: GOLDEN LIVING CNT CAMP HII,L Ph a r 1 V 1 1123 PEARL S11tEET DATE: ~ 10/21/09 ACCOUNT: 5702-48-37446 BROCKTON, MA 02301 PAGE: 1 of 1 PRIMARY PAYOR: INSURANCE POLICY#: 03959 EFFECTIVE DATES: 03/24/09-04/17109 PRIMARY PAYOR: INSURANCE POLICY#: 32241069076 EFFECTIVE DATES: 04!18/09-06/22/09 PREVIOUS PAYMENTS NEW BALANCE BALANCE: $1194.53 RECEIVED: CREDITS' CHARGES: DUE: $1194.53 DATE RX NUMBER DESCRII'TION QTY BILLED UE FROM WSURANCE CHARGES/ AMT INSURANCE ADJUST CREDITS Balance Forward: 1194.53 Amount Due: 1194.53 FOR YOtTR CONVENIENCE CREDIT CARD PAYMENT OR ELECTRONIC FIINDS TRANSFER FROM YOIIR CHECKING ACCOUNT ARE ACCEPTED AT 1PWW.PHARMERICA.COM ~~~~ ~~ ~Ziz~~~ _ ~~-- BILLING QUESTIONS: 08:30 AM - 05:00 PM PHONE: 866-251-5966 S ~~~ MEDICATION QUESTIONS: 09:00 AM -04:00 PM PHONE: 800-994-6337 PAYMENT ADDRESS: PO BOX 644458 PITTSBURGH, PA 15264-4458 PharMerica PHARMERICA 1123 PEARL STREET BROCKTON, MA 02301 RETURN SERVICE REQUESTED 31111-90AA CUSTOMER NAIvIE: ELIZABETH MOTZ ~',,r,~1 I-l Phase check box if address is incorrect or insurance ~'a LJ information has changed, and indicate change(s) on reverse side. 0101 Irllllll,d~l•~Ih~~~~rl~l~~llll~lar~•llllllllll~i~rlll~rluill TED MOTZ 408 ORCHARD LANE MECHANICSBURG, PA 17055-6141 I~.I,~.~d41~d!'ll..a.~illqulyi.~~,q„L.lu„IIPn~~~~l~ PHARMERICA PO BOX 644458 PITTSBURGH, PA 15264-4458 5702480307040406001194530 ~ PArfNG er au-sT>:t1~AnD, ascovtn. wsA oq AMERICAN EXPRE33, flu OuT eELOw. MASTERCARD CHECK CARD USING FOR PAYMENT ^ ^ DISCOVER !~. VISA AMERK:AN EXPRESS CARD NUMBER AMOUNT SIGNATUflE EXP. DATE DUE GATE 11/20/09 PAY THIS AMOUNT $1194.53 ACCT. # 5702-48-37446 FN:96MBA22 31111.80AA'TFtYOMMNBX002488 2RY0019KQ1.1 • TEAR HERE AND RETURN THE A80VE PORTfOh 1MTH YOUR PAYMENT • ~~~~ °ss~~~ sv~~cr~ STATEMENT _ , . ~. ~-Cp~1PA~ 10/27/09 Statement Date Accourrt No. 348525 RE: ELIZABETH MOTL408 OR CHARD UW./MECHANICSSURG PA f 705~ lC NO. ~ PREVtous BA~ANCg 1.Q67.09 MON.lDAYtYEAR R~ItE11iCE DESCRIPTION QUANTITY PRIDE TAX AMOUNT ~~••~ . F~~ ~~ ~ 5~~ ~ ~ ~ `p ~2~ '7 ` '~`~ ~ ~ . ~ _ .:._ _ _ ~ _.. -- -PLEASE FAY YH(S NEW BALANCE; $1,057.09 S1,Q57.09 Sae rsvase side for hnporhnl Hon tartcalflnp hte fee8.' B~ Rlphtt and other terrRa and corrdlrlorts that may apply to yoursccowlt. lAI`PORTANT MESSA~3ES: ~"~ ~~ QUESTfONS? CALL CUSTOMER SERVICE: 1 (888) MONTOUR 1 (888) 666-8687 CHARGES AND PAYMENT AFTER "STATEMENT DATE" WILL APPEAR ON YOUR NEXT STATEMENT OUR PAYMENT ADDRESS: Montour Home Comfort Services- P.O. Box C Marcy, NY 1 3403-07 1 1 DELIVERIES AND SERVICES ARE SUSPENDED. L3/1L.APICE IS DUE IMMEDIATELY We accept the following Credit cards: Montour appreciates your business! Thank you! ..For Your Records: Payment Amount: Check #: Date: 58/01!-7:078.71~07000DU4 SEE REVERSE SIDE FOR II~ORTAN'r INFORMAIWN PPL Electric Utilities Electric Service For: ELI7ABETH MOTZ-ESTATE 408 ORCIiARD LA MECHr1NICSBURG PA 17055 Find Duplicate Bill Questions about this bi11? Please contact ns Jan 4 at 1-800-34 5775 (1-800-DIAL-PPL) or write to: C~tomer Service 827 Hausman Rd. Allentown, PA 1$1049392 www.ppleleciric.com Electric Use This pact of your bill helps you enderstand your electric use. Types of Meter Readings: Actual - Adjusted Estimated Customer 0 i A ~ A +®~viai e'~~• PSge 1 ~~. _ _ a~~ '~ '~ 42410-82015 Summary Page Babnce as of Nov 16, 20[!9 5284.55 Chu es: Tota~PL ELECTRIC UTILITIES Charges $16.27 Total Charges $300.82 ~.-. ~ , r.......-.: .. -•~i Account Balance $300.82 12 !0 8 6 4 2 0 KWH -Average Per Day Meter Reading Information Meter #Z4o8o219 Nov lti Actual 34560 Oct 30 Actual 34453 17 Days KWH Billed 107 The g. raph shows the average number of K you used each day. You used 107 KWH m 17 days, or an average of 6 KWH a say. The average dailyy temperatrue for your area last month was 49F. ND 2008 Months 2009 Other important information on back ~ ttnl~ed Waxer pea]pi~fitanio CustQtrier 5eruise~~ttfer x3189 Adams i~nve. Humme~stown, PA 17035 y° ~~ i ~~.>~~'~ ;, tie .. e:,71~,5$!t~3fi52;' wun~~ ~dwater c©~irl .. . USAGE HISTORY Monthly usage in thousand gallons 0 ra V t.7 r9 O nrov uec Jan reb Mar Apr May Jun JuI Aug Sep Oct Nov Neat meter reading date: on or about 12/24/2009 SERVICE TO: MICHAEL MOTZ Billing Date: 11 /25/09 Account Number. 00200999527942 Previous Balance $69.81 Payments Through 11/25/09 $0.00 Balance forward $69.81 Current Charges Due 12/15/2009 $15.23 FI SERVICE ADDRESS: 408 ORCHARD to MECHANICSBUR6 PA 54235730 10/26/09 11/23/09 28 0203 0204 1 MGt ACTUAL fQUNALENT TO ],000 GALLONS SERVICE CHARGES $8.50 W-STAS SURCHARGE $0.04 CI WATER CHARGES $5.14 W-PEN DB $0.95 W-DSIC SURCHARGE $0.68 TOTAL CURRENT CHARGES $15.23 SEE REVERSE SIDE FOR IMPORTANT ACCOUNT INFORMATION :::: • ::::. .::::.::::. ~:. ~:-::.;:_::::.:::.;•;,:::::::::;::;•>:;~;:;:;:;;•::;~:;:;;:;;.;:;.::; w;>:::;+;yy: ~;::~;;:~;;:~:_ ~;::;;:;.::;::::;::a:•>::;;;:~;:: ~:;=rr~:.:x::.:::;.;:;;:~r::;:: ~a~:::•~:::3:y;:::~s>':~ii:is: <.:;~:;::;: _:;::::j° a>-;:='r'; ~~~:#-.,••i%;•`;:-~;::i:.g~i >r.'<:~?::5: - - - - . ';#i#:~?:~>:=:pis>?afi:= ~:?::<:s~= -- ..t.~:.::.~ .:::::::.:::..,: - ~~. -. :-:~~> . .., :.....r ...........:...,,.,. If you would like to pay your biD online, please visit our website at www.unitedwater.com and click on the Western Union's Speedpay icon. Save a stamp and go paperless today! log on to www.unitedwater.com or call Customer Service to find out more information and to enroll in eBilling. Approximate state tax included on this bill $0.69. r ~ ~~ 2.~ Z~~ ~ ~ ~~y BET~-I I1tIOTZ ~~ ~w L ~ F~t xtv D E so-sz~af23t3 ~ 0 ~J MECHAMCSBLIRG, PA 17055 .DATE e PAY'PO a 5 THE ORDER OF ~3 ~' ~D st M~c~ lv~ox 1~1.~~~~ ~ o~ ~~ DOLLARS 8 a~"""s.,w MEMO ~:23i382241~: 2i8370 i255~N 0205 M s., . ..------ MECHANICSBURG PA 17055 ~..~,. _r ~~ Creditor WEST SHORE EMERGENCY MED ~_ t~`~ DEAR ELIZABETH MOTZ Account # Amt Owed 185778W 140.06 s 4 z ., ~., ~ ~^° A~~SN ~o. ~ ~ z~~o4 THIS IS OUR FINAL NOTICE REGARDING THIS MATTER. IF THIS BILL IS NOT PAID WITHIN 15 DAYS OF THE DATE ON THIS LETTER, OUR CLIENT HAS ADVISED US TO TAKE FURTHER COLLECTION ACTIONS. YOU HAVE LEFT US WITH NO OTHER ALTERNATIVE BUT TO FORWARD YOUR PAST DUE ACCOUNT TO A COLLECTION AGENCY AFTER 15 DAYS. BE ADVISED THAT A COLLECTION FEE OF 18~ WILL BE ADDED TO YOUR ACCOUNT ONCE IT IS ASSIGNED TO AN OUTSIDE COLLECTION AGENCY FOR COLLECTION. PLEASE REFER ALL PAYMENTS AND CORRESPONDENCE TO: WEST SHORE EMERGENCY MED SVC * 205 GRANDVIEW AVE STE 21 CAMP HILL, PA 17011 * 717-972-4727 THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. 2213 Forest Hills Dr. Suite #2 • Harrisburg, PA 17112 • P.O. Box 60550 • Harrisburg, PA 17106 REV-1513 EX+ (O1-10) Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Elizabeth Motz 21-09-0985 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABL]_ DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Ann Maria MOtZ Daughter $500.00 2 Theodore Motz Son Balance ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. R NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I # If more space is needed, use additional sheets of paper of the same size.