Loading...
HomeMy WebLinkAbout03-0601 PETITION FOR PROBATE and GRANT also known as To: Deceased. Social Security No. ~0 OF LETTERS / Register of Wills for the County of CgtmLS~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age ot older an the execu! ~}7 in the last will of the above decedent, dated and codicil(s) dated in the named (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~to~/~e.r[a,not _ County, Pennsylvania, ,with ~ last family or principal residence at '7~t/~ tS~,r-/~;s,~ /~-7(e. ~3~ ~ffo ~ (list street, number~nd muncipality) Decendent, then ~ years of a~e, died _ ~ ~ , ~J, roUow [ aia .or not i;o c d anldid ot h v;a adopteU after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully_.,___.request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. lYleeham'cxbu OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF C_dlMi3~"~L~AJ~ The petitioneris) 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 a~ truly administer the es~ccording to law. Sworn to or affirmed and subscribed ~ ~ /~ b~re me this_~~ day of [ '~n .~/en~ No. Estate Of 0~. aC-~t~t- 'T& l, ~q-:z , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated ~'-'~1,. I O ~ ::3 described therein be admitted to probate and filed of record as the last will of and Letters ~-~ I ~re hereby granted to .~t~ -~.. ~ ~',~ s :' ~' j~,O,,'~ in consideration of the petition on FEES Probate, Letters, Etc .......... $ ~.~ Short Certificates( ) .......... $ ~~ation ................ $ TOTA~ Filed~.~.~ .......... ~'~/ATTORNEY (Sup. Ct. I D No ) ~ ~'~-/~'~ ADDRESS 7/7- 7~ PHONE REGISTER OF WILLS OF C tam t36W.2A~g) COUNTY OATH OF SUBSCRIBING WITNESS ~ a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that //'~ ~oar,5 present and saw ,/~,g,q ~,~ ~ T ,~. Z ~t TZ , the testatr~'~ , sign the same and that ~ signed as a witness at the request of testat~x in her presence and (in the v ........ of ..... ~, .... r) (ia4~4gesenee~L~he ot~er ~.,u ........... : Sworn to or affirmed and subscribed before e/,/~.~ day of I~EGI~R OF WILLS OF t~ame) (Address) (Name) (Address) COUNTY OATH OF NON-SUBSCRIBING WITNESS // familiar ~ffth the signature of /~ ~ , / ~ cofffcil testat// of (one of the subscrib/i6g witnesses to) the / will presented herew/{th and ,/ ~ / . codicil ] :t / believes theTre on the will isin the hTriting of ,/ tO the best of ____Zowledge and belief./ / Sworn to or affirmed and/fubscribed before f" // me this / day of ' (Name) / ~9 (Address) Register (Name) (Address) REGISTER OF WILLS OF Cu,~B~-z~ COUNTY OATH OF SUBSCRIBING WITNESS codicil (each) a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that present and saw the testat ~, sign the same and that signed as a witness at the request of testat in h presence and (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this day of (Name) 19 (Address) Register (Name) (Address) REGISTER OF WILLS OF 0_.u_m t3cCT-eZ,,~t/~ COUNTY OATH OF NON-SUBSCRIBING WITNESS -(~teh-)-a subscriber hereto, (-e~°a-) being duly qualified according to law, depose(s) and say(s) that familiar with the signature of testatrix of (c~no Of the ~,,bqcri_h,_'ng witnesses to) the will presented herewith and that .-.~ believes the signature on the will is in the handwriting of to the b(~est of ~r knowledge and belief. / Sworn to or affirmed and subscribed before (:vamej (Address) his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as I.ocal R,egistrar. The original certificate will be forwarded to the State Vital Records Office for permanent ~ling. WARNING: It is illegal to duplicate this copy by photostat or photograph. Registrar P 9331420 ..[,.,..[ H105 $43 Rev2/87 tYPE/PRINT PEHMANENT 8L ACK INK 7043 Carlisle pike Lot 321 Carlisle, PA 17013 FATHER'S NAME (F~M. ,,. John Ward Helen A. Ptaszek COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,.F~!e ,. 209 --12 -- 5621 *- Jul 9 003 I ~m~ I BImHP~CEiC~ ip~(~~ --~m,~, y . 2 Sii~~ .. 7043 ~li~i* Pike DC 321 '~iT~"' '~""' Nhite 114r ~ Its. ACTUAL FD-011667 L 695 Julie Oourt Mee-hanicsburg, PA 17055 12,,B~lj~ ~ ~ofrlrr?, p~ 17007 pe,$on who p~onouncea ~eath. J DATE PRONOUNCED DEAD {Month, Day, Year) 6:00 A M ,~. July 9, 2003 DUE TO (OR AS ^ CONS[OU ENC£ OF): ~UE TO (OR AS A CONSEQUENCE DE): c. DUE TO DATE OF INJURY ITiME OF INJURY {M~.h. Day, Year) ~m. [] i.~C~ o~ .NJUR¥*,~ .~,. ,~. ~. ~ o.~ LAST WILL AND TESTAMENT OF MARGARET R. LUTZ I, MARGARET R. LUTZ, an unremarried widow, currently of 7043 Leiby's Mobile Home Park, Lot 321, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and aH prior Wills by me at any time heretofore made. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be distributed to my three (3) daughters who survive me, to wit: NANCY FAY GIRARD, BELVA KAYE GARMAN, and HELEN ARLENE PTASZEK, in equal shares. In the event any daughter of mine fails to survive me, her share shall be proportionally divided between those daughters who survive me, per capita. In the event two (2) of my daughters fail to survive me, their shares shall both go to the daughter who does survive me. I nominate, constitute and appoint my daughter, HELEN ARLENE PTASZEK, to be the Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix, I appoint my son-in-law, THOMAS F. PTASZEK to be the Executor in her place and stead. In the event that he is unable or unwilling to act as Executor, I appoint m y granddaughter, BETRACY LEE NYE, to so serve as the Executrix in his place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~_~'/~~ , A.D. 2003. day of ]~L~G~I~ET R. LUTZ (SEAL) Signed, sealed, published and declared by the above-named MARGARET R. LUTZ, as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Will No. Margaret R. Lutz July 9, 2003 Admin. No. 21-03-0601 TO THE REGISTER: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on August 5, 2003: Name Address Helen Arlene Ptaszek 695 Julie Court, Mechanicsburg, PA 17055 Nancy F. Girard 7043 Carlisle Pike, Leiby's Mobile Home Park, Lot#331 Carlisle, PA 17013 Belva K. Garman 228 Hempt Road, Mechanicsburg, PA 17050 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: August 5, 2003 CHARI ~ES E. SHIELDS, III 6 Clouser Road Mechanicsburg, PA 17055 Telephone: (717) 766-0209 Counsel for Personal Representative GEORGE M. HOUCK (1912-1991) CHARLES E. SHIELDS, HI A TTORNEY-A T-LA W 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG, PA 17055 June 17, 2004 TELEPHONE (717) 766-0209 FAX (717) 795-7473 Register of Wills Cumberland Coumy Court House 1 Court Square Carlisle, PA 17013 Re~ Estate of Margaret R. Lutz No. 21-03-00601 Dear Register of Wills: Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Margaret R. Lutz Estate as well as Check No. 138, in the amount of $2,022.14 for Inheritance Tax due and Check No. 137 in the amount of $15.00 for the filing fee. Thank you for your kind attention to this matter. Very truly yours, Charles E. Shields, III CES:slk Enclosures (4) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 004070 SHIELDS CHARLES E III 6 CLOUSER ROAD MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 209-12-5621 FILE NUMBER: 2103-0601 DECEDENT NAME: LUTZ MARGARET R DATE OF PAYMENT: 06/21/2004 POSTMARK DATE: 06/21/2004 COUNTY: CUMBERLAND DATE OF DEATH: 07/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $2,022.14 TOTAL AMOUNT PAID: $2,022.14 REMARKS: SEAL CHECK# 138 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV. 15~0 EX (600) COMMONWEALTH Of PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 Z LU o LU o REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) 07-oq.- .?..oo_~ I oq-/? - l?l? (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) OFFICIAL USE ONLY FILE NUMBER .2 I - o3 COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER I~1 1. Original Return [---J 2. Supplemental Return ~1 3. Remainder Return (date of death pder to 12-13-82) [~ 4. Limited Estate i~1 48. Future Interest Compromise (dateof death after 12-12-82) [] 5. Federal Estate Tax Return Required r~ 6. Decedent Died Testate (Attach copy of Win) r'-'-J 7. Decedent Maintained a Living Trust (A~ch copy of Trust) ~ 8. Total Number of Safe Deposit Boxes [--'] 9. Litigation Proceeds Received [~ 10. Spousal Poverty Credit (date ofdeam between 12-31-91 and 1-1-95) [] 11. Election to tax under Sec. 9113(A)(Attach Sch O) FIRM NAME 0fApp~ico~e) TELEPHONE NUMBER COMPLETE MAILING ADDRESS 1. Real Estate (Schedule A) (1) --' t~- 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Propdetomhip (3) ' ~) -- 4. Mortgages & Notes Receivable (Schedule D) (4) -- 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) P _E~.: O P/,. 7/- (Schedule E) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total beductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) 6. Jointly Owned Property (Schedule F) (6) -- O -- ~ Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L)' Tota~ ~ro.e A.eta (total Lines 1-7) (8) ~ I~ ,30/, ~ 7 (11) I~ ~&~'.o~, (12) (13) OFFICIAL USE ONLY (14) ~l~qqI 9'3(.. 4,1 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due ~ x .o O (15) ~ q~ 95~.&1 x.0 qs (16) ~:) x .12 (17) 0 x .15 (18) (19) ¢ ,1, o ~.z. 15~ 0 > ~* BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STREET ADDRESS Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty ISTATE tzIP (1) ~ Total Credits (A + B + C ) (2) Total Interest/Penalty ( D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) O (4) ~:) (5) ~/ ,~ zz. /.~' (5A) ~ Make Check Payable to: REGISTER OF WILLS, AGENT 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 dght to designate who shall use the property transferred or its income; ............................................ [] c. retain a reversionary interest; or ......... i ............................................................................................. : .................. [] d. receive the promise for life of either payments, benefits or care? ...................................................................... [] [] 2. If death occurred after December 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 secudty at his or her death? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................ ' ........................................................................................ [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perju~/, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF,PERSON RF_.,SPON~IBLE FOR FILlinG RETURN DATE ADDRES§ H~'~.~N ~,.~Z~Ar~' P~",~ SIGNATURE OF ERB~RER Q.THEE TH/~t REPRS~F~ATIV~, .~ __ DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. I~'V-1508 EX + (1~1) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Sche~.,le F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 700. oo I!0. oo I .% 5"o0. 13', · 17 mdt ?/ TOTAL (Also enter on line 5, Recapitulation) $ ~ ~,. 0 ~, · 7~0 (If mom space is needed, insert additional sheets of the same size) ;HEET # OF.__.TOTAL SHEETS I (consignor) hereby commission you to sell the items listeo above & on the attached sheets to the highest bidder by public auction. I certify that I am the owner of the above listed items and have good title and the dght to sell them. I cert fy that the items listed are free from all incumorances. I agree to accept all responsibility for providing good title and for deliver~ of title to the purchaser. It is agreed that the consignee is not responsible for the loss of any item due to fire, theft, damage, etc. I understand that a % commission will be deducted from the gross sales of my items. "No Bid" items will be disposed of at the d~scretion of the Auctioneer/Auction House. Payment will be made to the consignor with n days from. date of sale. Date Consignor Signature Date Auctioneer/Auction Staff Signature BUYER ITEM CHECK NO. ,.._ EXPENSES~ ~-~-- % COMMISSION SETTLEMENT TOTAL CONSIGNOR SALES · TOTAL EXPENSES NET PAYABLE TO CONSIGNOR CONSIGNOR'S SETTLEMENT COPY 5 BUYER _ ITEM BUYER ITEM ITEM 46 BUYER ITEM ~._ {LOT 8/25/2003 CHARLES E SHIELDS III 6 CLOUSER RD MECHANICSBURG PA 17055 The information which you requested on the account(s) of MARGARET R LUTZ (Social Security Number 209-12-5621 ) is/are as follows: Account Number 30057335 50266134 90865004 Class of Account SAVINGS SAVINGS CHECKING Date Opened 110599 100899 090597 Principal Balance 275.00 2003.24 2018.91 Accrued Interest .01 .17 Balance at Date of 275.01 2003.41 2018.91 Death Account Ownership SOLE SOLE SOLE Name of Joint Owner, if any Date Ownership 110599 100899 090597 Was Established Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership Name of Joint Owner, if any Date Ownership Was Established Additional Information Requested Sincere~Ly, r--- .~ ] ~ ERrN WATTS SENIOR SERVICES REP. RO. Box 171 I. HARRISBURG, PENNSYLVANIA 17105-1711 Toll Free 1-866-WAYPOINT (I-866-~_129_7646). IN YORK AREA 717/815-4500 · www. wa~lpointbank, com REV-1510 EX + (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LClTZ, SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RB. ATIONSHIp TO DECEDENT AND THE DATE OF ~ISFER. % OF NUMBER ATTACHACOPYOFTHE DEED FOR REAL ESTATE. DATE Of DEATH DECD'S EXCLUSION TAXABLE VALUE 1, VALUE OF ASSET INTEREST (~FA~PUCAaLE hlSEI~IC~/t ,E'X~,qES$ F/AI/74,'E/,~. ,d~OY/~rw~j' ~g 3?/o7o¢. ~1 I 00~o - ~ - ~.5 7, 2.o¢. ~ / TOTAL (Also ~er on line Z, ~ecapitulation) $ ~ -.~0_ ~ ~1 insert additional sheets of the same size) OL:U~' i 4/2883 !E,: 47 7174414SEt8 PAGE ~"'" ~. Barbera L $imondet ::" ' 08/13/2003 05:15 PM TO'. CC: Subject: David R Lyon/FieldANH/AI~FA~AMEX PLEASE READ-OEATH CLAIM REQUIREMENTS FOR CLIENT 16654960 0 001, MARGARET R LUTT_ Au._.t, us~ 12, 2003 DAVID RAYMOND LYON STE 201 5006 E TRIN'DLE RD MECHANICSBURG, PA 17050-3651 Dear DAV'rD RAYMOND LYON: Thank you :flor 7o~ recent inqui.u., regm'cling MARG.~U~,ET R LUTZ% accounts. ~.ese arc the value.~ or ibc accmmt~ as of 07/09/2003. At the end of this le~ler, you will find a Li~ or beneficiaries shown in our mitia.~, rc~,iew of the deccase~I's accotm~s. I1WPORTANT .RE.i~N DER(S): accordance with various re~fla:loB, age:nde, Amscan Express FJnmn~ Advbo~ will ~nt~ue to mail monthly/queerly stm~.~ts .for thc d~cas~ to the dec~qsed% ad&~s ffrecord. ~e only individual(s) ~an.t~ a,flmfirafion to change fl~e addrm, s of~e deems~ and th~3s, r~jmc~ fl~c m~ling ad~s of~¢ ~atmmts, is the Ex~tor(s) of fl~c E~me of ~e decms~. ~e .~.ts~ Dm~ Ol~ Statement Fora n~, incNd~ a default lump sum option [or mmui~t ~d life inm~ce in wNel~ the BmeficJ~ w~l rec~Ve a checkbook, wi~ imm~ate acc~, to ~' ~mds ti!rough. Mmb~b~ B~ng. ~m ~an a check, Account l.tbrmafion AnnuitJe.q - Po~t ] 985 Account Nmnber 9300494.4361 5 004 ~dividual · Annuities - Post 1985 Ac, counl Number ~ 93004944361 5 0'04 Thc dale of death values provided are for estate tax ptupos~ and arc not '~'alues to be paid. Account~ tomy be mbject to markel fluctuation as grwemed b~' each product. Please note tlmt the values indic~tcrl ~or any L~fc Insarancc product(s) relied, lhe gross death benefit al d~e of death, not the rash value. Account Disposition EV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ITEM NUMBER Debts of decedent must be reported on Schedule ]. DESCRIPTION FUNERAL EXPENSES: AMOUNT ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) HEleN ,~JJ/~Z~'lli~' Social Security Number(s)/ElN Number of Personal Representative(s) Street Address ~,~.~' ~/~,/../~' C')~ Year(s) Commission Paid: State /c~,~j¢ Zip Attorney Fees C/-/,~,~'[~-5 ~ 51rC'/~.-~D$ .~- Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Street Address City State__Zip Relationship of Claimant to Decedent Accountant's Fees s~ Tax Return Preparer's Fee TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) e~7. ql Market Plaza }gay · Mechaniesburg, PA 17055 Phone: 697.4696 July 28, 2003 Nancy F. Girard 7043 Carlisle Pike ~_.ardsle, PA 17013 · FUNERAL HOME Michael J. Malpezzi Owner The Funeral Service for Margaret R. Lutz We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Solid Pecan Casket 10 Ga. Steel VaultSteel Register, Memorial Cards, Ackn. THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Opening Grave Cemetery Equipment $500.00 Ne~vspaper Notice3 - Local $100.00 Clergy/Mass Offering $74.00 Certified Copies of the Death Certificate $100.00 Flowers $16.00 Additional Death Certificates $185.50 Monument Engraving $ I 0.00 TOTAL CASH ADVANCES AND SPECIAL CltARGES $100.00 $1085.50 $3260.00 $3260.00 $2735.00 $1650.00 $58.OO $7703.00 SUB-TOTAL INITIAL PAYMENT / DISCOUNT / CREDITS TOTAL AMOUNT DUE $8788.50 $8788.50 %~77~~ I SCHEDULE I COMMONWEALTH OF PENNSYLVAN,A / DEBTS OF DECEDENT. ESTATE OF . ~:~ ~- -- '"' FILE NUMBER L U-TZ, ~,~ ,4-1~E'7- ~y. -7-4-05- Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION waP ,,.z £/ee/r,',. Servi~e TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) AMOUNT /¥o,~ ~-/z.z&' , ?¢ "~~ / SCHEDULE J COMMONWEALTH OF PENNSYLVANIA ~ BENEFICIARIES INHERITANCE TAX RETURN ESTATE OF t. ~ "T'Z,. ,'~/'~ ~' ~' ~ ~ 7- ~;~. FILE NUMBER NUMBER II. 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) HELEN /I-/~/..EIVE PT',,%SZEK 7oq8 C,,~.~L/.$ZE R/IcE ' C /I. ,,~ L / ~ L ~. ,, ,,d,,ff /70/3' IE~ O-H /M// c .; zg t,, .qG . ,~.q /705-0 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART,II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If mom space is needed, insert additional sheets of the same size) LAST WII'L A~ESTAME T~[T~21~~ARET_ R. LUTZ I, MARGARET R. LUTZ, an unremarried widow, currently of 7043 Leiby's Mobile Home Park, Lot 321, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, Publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. I direct the payment of all my just debts and funeral expenses as soon at~er my decease as the same can conveniently be done. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be distributed to my three (3) daughters who survive me, to wit: NANCY FAY GIRARD, BELVA KAYE GARMAN, and HELEN ARLENE PTASZEK, in equal shares. In the event any daughter of mine fails to survive me, her share shall be proportionally divided between those daughters who survive me, per capita_. In the event two (2) of my daughters fail to survive me, their shares shall both go to the daughter who does survive me. I nominate, constitute and appoint my daughter, HELEN ARLENE PTASZEK, to be the Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix, I appoint my son-in-law, THOMAS F. PTASZEK to be the Executor in her place and stead. In the event that he is unable or unwilling to act as Executor, I appoint my granddaughter, BETRACy LEE NYE, to so serve as the Executrix in his place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~f*yr' ., A.D. 2003. day o f _(SEAL) Signed, sealed, published and declared by the above-named MARGARET R. LUTZ, as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. BUREAU OF TNDTVZDUAL TAXES INHERTTANCE TAX DT¥/STON DEPT. 28060! HARRISBURG, PA 17128-0601 COMMONNEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REV-Z56? EX AFP C01-03) CHARLES E SHIELDS III 6 CLOUSER RD MECHANICSBUR$ PA 17055 CUT ALONG ZS ..........REV- ].547 '~'?~.~)- ..... ~'~' 'J~JYz-~ ESTATE O~ ~UTZ DATE 08-16-Z006 ESTATE OF LUTZ DATE OF DEATH 07-09-Z005 FILE NUMBER 21 05-0601 COUNTY CUHBERLAND ACN 101 I Amount Remitted MARGARET HAKE CHECK PAYABLE AND REHZT PAYMENT TO: REGISTER OF HILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 RETAIN LONER PORTION FOR YOUR RECORDS ~ (01-03) )TZCE OF INHERITANCE TAX APPRAISEMENT, ALLONANCE OR ~t .ONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX /~¢~ MARGARET P FILE NO. 21 05-0601 ACN 101 DATE P 08-16-2006 TAX RETURN HAS: (X) ACCEPTED AS FZLED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAZSED VALUE OF RETURN BASED ON: 0RZGTNAL RETURN 1. Real Estate (ScheduZo A) (1) 2. Stocks and Bonds (Schedule B) $. Closely Held Stock/Partnership Interest (Schedule C) ($) ~. Mortgages~Notes Receivable (Schedule D) (~) 5. Cash/Bank Doposits/Hisc. Personal Property (Schedule E) ($) 6. Jointly O~nad Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Tote1 Asse~s APPROVED DEDUCTIONS AND EXEHPTZONS.' 9 Funeral Expenses/Adm. Costs/Hisc. Expanses (Schedule H) (9) 10 Dabts/Hortgaga Liabilltles/Lions (Schedule T) 11 Total Deductions 1~ Not Value of Tax Return 22/096.76 .00 .00 NOTE: To insure proper .00 credit to your account, .00 submit the upper portion .00 of this fora ~ith your tax payment. 59/206.91 (e) 61,501.67 (10) 15,857.12 15 NOTE: ASSESSNENT OF TAX: 15. Amount of Line 1~ et Spousal rata (15) 16. Amount of Line 1~ taxable at Lineal/Class A rata (16) 17. Amount of Line lq et S~bling rata (17) 18. Aeount of Line lq taxable at Collateral/Class B rata (18) 507 96 (11) 16.365.06 (1~) 66,956.61 Charitable/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) Nat Value of Estate Subject to Tax (lq) Zf an assessaent was issued previously, lines 14, 15 and/or 16, :17, reflect figures that lnclude the total of ALL returns assessed to date. 19. Principal Tax Due TAX CREDITS: PAYMENT RECEII' I DISCOUNT INTEREST/PEN PAID (-) .O0 DATE 06-21-2006 NUMBER CD006070 .00 66,956.61 18 and 19 ~ill · O0 x O0 = . O0 66,936.61 x 065= 2,022.16 · O0 x 12 = . O0 · O0 x 15 = . O0 (19)= 2,022.1q AHOUNT PAZD BALANCE OF UNPAID INTEREST/PENALTY AS OF 06-22-2006 2,022.16 .00 16.26 16.26 2,022.16 TOTAL TAX CREDZT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) ZF PAZD AFTER DATE ZNDZCATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. RESERVATION: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoy.ant to Class 8 (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Caemoneealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the laaful Class B (collateral) rata on any such futura interest. PURPOSE OF NOTICE: PAYNENT: REFUND (CR): OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act Z$ of 2000. (72 P.S. Section 9140). Detach the top portion of this Notice and submit aith your payment to the Register of Ni118 printed on the reverse side. --Make check or money order payable to: REG/STER OF NZLLS, AGENT A refund of a tax credit, ahich Has not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-IS13). Applications are available at the Office of the Register of Nills, any of the 25 Revenue District Offices, or by calling the special Z4-hour ansaering service for forms ordering: 1-800-362-Z050~ services for taxpayers aith special hearing and / or speaking needs: 1-800-447-3020 iTT only). Any party in interest not satisfied ~ith the appraisement, alloaence, or disallowance of deductions, or assessment of tax iincluding discount or interest) as sho~n on this Notice must object aithin sixty 160) days of receipt of this Notice by: --Nritten protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in ~riting to: PA Oepartq~ant of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Reviee Unit, Dept. 280601, Harrisburg, PA 17125-0601 Phana i717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three (5) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. The 15Z tax amnesty non-participation panalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you mould appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning aith first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000164. All taxes ahich became delinquent on and after January l, 1982 will bear interest at a rate ehich will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through 2004 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ 202 .000548 T~-B-1991 1IX .oao~ol ~ 9x .000247 1983 162 .O00q~8 1992 92 .000247 2002 62 .000164 1984 112 .000501 1995-1994 72 .OOOl9Z 2005 52 .000137 1985 132 .000356 1995-1998 92 .000247 2004 42 .000110 1986 102 .000274 1999 72 .00019Z 1987 102 .000274 ZOO0 72 .OOOlgZ --Interest is calculated es folloes: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen IlS) days beyond the date of the assessment. If payment is made after the interest computation date shomn on the Notice, additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Margaret R. Lutz Date of Death: 07-09-2003 will No. Admin. No. 21 03-0601 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes ~ 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 f~ile a final the Court~ Yes No ~)~ . account with b. The separate Orphans.' Court No.!i~(if any) , the personal represent.ative s account is: c. Did the personal representative ~e~an account informally to the parties in interest? Yos/~, d. Copies of receipts, releases, jOinde~ and approvals of formal or informal accounts may be filed wi'~h the. Cerk of the Orphans' Court and may be attached to this report. Date: August 31, 2004 Signat~ure Charles E. Shields, III, Esquire Name (Please type or print) 6 Clouser Road, Mechanicsburq, PA 17055 Address 1717 ) 766-0209 Tel. No. Capacity: __Personal Representative X Counsel for personal representative' (MAH:rmf/AM3) -~ of BUREAU OF INDIVIDUAL TAXES COMMONWEALTH OF PENNSYLVANZA DEPARTMENT OF REVENUE NOTZCE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DZSALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX CHARLES E SHIELDS III 6 CLOUSER RD MECHANICSBURG PA 17055 DATE 08-16-200~ [~:~;~:~EsTATE OFC~ LUTZ MARGARET i ~211; ~TEC OF ~ATN 07-09-200~ FZLE NUMBER 21 05-0601 CUMBERLAND I ~ Amoun~ Remt~ed [ ~K ~AYABLE AND RENZT PAYHENT TO: REGISTER OF WILLS CUNEERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS REV-I$~7 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DZSALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF LUTZ MARGARET P FILE NO. 21 0~-0601 ACM 101 DATE 08-16-200~ TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVA¥iOH CONCERNING FUTURE ~NTEREST - SEE REVERSE APPRAISED VALUE OF RETURN DASED ON: 0RZSZNAL RETURN 1. NlI1 Ei~I~I (SchIdule A) 2. S~ocks and Bonds (Sch~dull B) $. Closely Held S~ock/Pmr*nerihlp Inheres* (Schedule C) q. Her*gages/No*es Recetveble (Schedule D) $. Cash/Dank Deposi~s/Htsc. Personal Proper~y (Schedule E) 6. Jointly O~ned Proper~y (Schedule F) 7. Transfers (Schedule G) APPROVED DEDUCTIONS AND EXENPT?ONS: 9. Funeral Expenies/Adm. Co$~s/Hisc. Expenses (Schedule H) 10. D~b~s/Hor~g~ge Liabilities/Liens (Schedule I) 11. To~I1 OId~c~tons 12. Ne~ Value of Tax Re~urn lq. NOTE: ASSESSHENT OF TAX: (1) .00 (2) ,00 credl~ ~o your (~) .00 submt~ ~hl upper per,ion (~) .00 of ~h~s form wt~h your ($) 22,096.76 *ex peymen~o (&) ,00 (?) $9 ~204 (8) 61,~01.67 15,857.12 (9) (1o) 507.9~ (11) t~.~R;.06 (12) 4~, 956.6 ChIri~abli/$overn~en~iZ Siquis~s; Hon-elec~ed 9115 Trusts (Scheduli J) (15) . O0 Ne'l: Value Of E$~e~e SubJec* ~o T~ (14) ~,9~6.61 Z~ an assessment was issued prevlousZy, 11nes 1~, 15 and/or 16, 17, 18 and 19 will re~le~ flgures that include the total of ALL returns assesse~ to date. .00 X O0 = .00 4~*,9:56.61 x 045= 2,022.1~' · 00 X 12 = .00 .00 X 15 = .00 (19)= 2,022.1~* AHO~NT PAID 2,022.1~ TOTAL TAX CREDIT I BALANCE OF TAX DUEI INTEREST AND PEN. TOTAL DUE rAX CREDZTS: DATE NUHBER INTEREST/PEN PAID (-) 06-21-200~ CD00~070 .00 BALANCE OF UNPAID INTEREST/PENALTY AS OF 06-22-200q IF PAZD AFTER DATE INDZCATED~ SEE REVERSE FOR CALCULATION OF ADDZTZONAL INTEREST. 2,022.1~ .00 16.2~ 16.2~ ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE ZS REFLECTED AS A 'CREDZT' {CR), YOU WAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR ZNSTRUCTZONS.) GEORGE M. HOUCK (1912-1991) CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouzer Roads MECHANICSBURG, PA 17055 August 24, 2004 TELEPHONE (717) 766-0209 FAX (717) 795-7473 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Margaret P. Lutz No. 21-03-0601 Dear Register of Wills: Please find enclosed my check number 1283, in the amount of $16.24 for interest and penalty due from the above estate. Thank you for your kind attention to this matter. CES:slk Enclosure Very truly yours, Charles E. Shields, III ~ Attorney-At-Law COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOFREVENUE BUREAU OFINDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-l?62 EX(?1 96) NO. CD OO4310 SHIELDS CHARLES E III 6 CLOUSER ROAD MECHANICSBURG, PA 17055 ........ fold I ESTATE INFORMATION: SSN: 209-12-5621 FILE NUMBER: 2103-0601 DECEDENT NAME: LUTZ MARGARET R DATE OF PAYMENT: 08/26/2004 POSTMARK DATE: 08/25/2004 COUNTY: CUMBERLAND DATE OF DEATH: 07/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $16.24 REMARKS: TOTAL AMOUNT PAID: $16.24 SEAL CHECK//1283 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISTON DEPT. ID0601 HARRISBURG, PA 171Z8-0601 COMHONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEHENT OF: ACCOUNT RE¥-1607 EX AFP C01-D3) CHARLES E SHIELDS III 6 CLOUSER RD MECHANICSBURG PA 17055 DATE 09-ZT-ZO0~ ESTATE OF LUTZ DATE OF DEATH 07-09-Z005 FILE NUHBER 21 05-0601 COUNTY CUMBERLAND ACN 101 I Amoun~c Rem J.'l:'l:ed MARGARET P HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper credi~ ~co your account:`, submi~ ~che upper portion of thLs form wi~h your tax pey;en~c. CUT ALONG THIS L/NE ~ RETAIN LOWER PORTION FOR YOUR RECORDS *~ ESTATE OF LUTZ MARGARET P FILE NO. 21 05-0601 ACN 101 DATE 09-27-Z00~ THIS STATEHENT ZS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN TN THE NAHED ESTATE. SHONN BELON ZSA SUNHARY OF THE PRINCIPAL TAX DUE,, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE,, AND., ZF APPLICABLE,, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTHENT: 08-16-Z00~ PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYMENTS (TAX CREDITS): Z,022.1~ PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 06-Z1-ZOOR 08-Z5-ZOOR CDO0~070 CD00~510 .00 16.2~- ZF PAID AFTER THIS DATE,, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( ZF TOTAL DUE ZS LESS THAN $1`, NO PAYHENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A 'CREDIT" TOTAL TAX CREDIT 2,022.1~ BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.