HomeMy WebLinkAbout02-0915
PETITION FOR PROBATE and GRANT OF LETTERS
No. 2.\-02..- CU.5
To:
ANN/~
MAtJREfr
Estate of
also known as
Register of Wills for the
Deceased. County of CUMBER! ,ANn in the
Social Security No. / :3 ., t1 9 3 9 :3 ~ 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
and codicil(s) dated
named
, 19_
(state relevant circnmstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in C'" ." .A ~r ~ud County, Pennsylvania, with
her last family or principal residence atS..,,'-"f,! tv~c f- ~ I."",. ~ hie.. /-'h ..- /f,., 1..,c,.6,'h,h""",
77~ !f)!7L.-DR. r:.J.Ir/Rr.J-I J(tJAJJ r.h"'p jJ ILL-I J?A. ,7..,/
(list street, number and muncipality)
Decendent, then ,~ ;"00,2-
at .
Except as follows, decedent did not marry, was not divorced and did not have a ch ld born or adopted
after execution of the will offered for probate; was not the victim of a killing and w s never adjudicated
incompetent:
9.006 00
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:
$
$
;
I
,
.
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and cOdicil(s)
presented herewith and the grant of letters
theron.
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA } S8
COUNTY OF CUMBERLAND
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 e state according to law.
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I, -Q2_ ,.1
No. ?1_0?_Ql'i
Estate of
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW OC:'PORRR 'II. ? n n:;> xWlL-, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREEDthattheinstrument(s) dated will 2-21-1991 ('on;(';' 1 ?1-lQ94
described therein be admitted to probate and filed of record as the last will of
ANNA MAURER
and Letters TESTAMENTARY
are hereby granted to GI,ORIA SHAPIRO
~~>..~\~
egiste, o[Wills ~
extra pages 12.00
codicil FEES 10.50
Probate, Letters, Etc. ......... $ 40.00
ShortCertificates( ) .......... $ 3.00
Renunciation ................ $ 5.00
jcp $ 5.00
TOTAL _ $ 75.50
Filed 10-9-2002
... in"cii.ied. t.o. exe~.. i 0.":9:":.20.02
ATIORNEY (Sup. Ct. 1.0. No.)
ADDRESS
PHONE
~
RENUNCIATION
21-02-915
In Re Estate of
A t\ n &,
1'77 CLO II'-e r'
deceased.
To the Register of Wills of
((/Vl/1"bcr/ClV'.A
County, Pennsylvania.
The undersigned of
the above decedent, hereby renounce(s) thUght to administer the estate and respectfully ask(s) that Letters
be issued to
WITNESS
hand this
day of
,19_.
;7-~ ~~/
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(AddJ",,)
(Sianature)
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(Address)
(Signature)
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(Address)
H105.805 KEV'l!8(;
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the Srare Viral Records Off,ce for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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P 8385679
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COMMONWEALTH- OF PENNSYLVANiA. OEPAR1MENl OF HEALTH. VITAL RECORDS
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LAST WILL AND TESTAMENT
OF
ANNA MAURER
,9.1-o~-g 16
IN THE NAME OF GOD, AMEN:
I, ANNA MAURER, residing at present in the Township of
Nutley, County of Essex and State of New Jersey, being of sound
and disposing mind, memory and understanding, do hereby make, pub-
lish and declare this to be my LAST WILL AND TESTAMENT in manner
and form as follows, that is to say:
FIRST: I hereby revoke, cancel and annul any and all
other wills or codicils of wills by me at any other time hereto-
fore made.
SECOND: I direct that all my just debts and funeral
expenses shall be paid as soon as reasonable after my decease and
that all inheritance and estate taxes which might fall due as a
result of legacies bequeathed hereunder shall be paid by my Execu-
tor out of my residuary estate and shall not be charged to speci-
fic legacies.
THIRD: I give and bequeath to my beloved sister-in-law,
GLORIA LAMAR SHAPIRO, of Harrisburg, Pennsylvania, the sum of FIVE
THOUSAND ($5,000.00) DOLLARS. In the event that my said sister-
in-law shall predecease me, then I direct that said sum shall
lapse and become part of my residuary estate.
FOURTH: I give and bequeath to my beloved friends, WEN
CHEN and SPRINA CHEN, or the survivor thereof, of Nutley, New Jer-
sey, the sum of TWO THOUSAND ($2,000.00) DOLLARS.
FIFTH: I give and bequeath my household furnishings
and belongings pursuant to a list which I have provided to my
Executors.
SIXTH: I give, devise and bequeath all the rest, residue
and remainder of my estate, whether real, personal or mixed prop-
erty, and wheresoever situate, whereof I may die seized or possessed,
or to which I may be entitled at the time of my death, and including
any property over which I may have the right or power of appointment
under the Will of another, all the foregoing hereafter termed my
"residuary estate" in eleven equal shares as follows:
(A) ONE SHARE to my beloved niece, ANITA HAKIM, of Mill-
ville, Pennsylvania;
(B) ONE SHARE to my beloved niece, FRANCES GUGLIOTTA,
of Parlin, New Jersey;
(C) ONE SHARE to my beloved niece, SANDRA HAYES, of
Lake Parsippany, New Jersey;
(D) ONE SHARE to my beloved niece, CYNTHIA TAMOWSKI, of
Hollywood, Florida;
(E) ONE SHARE to my beloved niece, PATRICIA GULLY, of
Lake parsippany, New Jersey;
(F) ONE SHARE to my beloved niece, ANNA MARIE WEINGARTH,
of Sayreville, New Jersey;
(G) ONE SHARE to my beloved nephew, WALTER J. LAMAR, of
Port Orange, Florida;
(H) ONE SHARE to my beloved nephew, JOHN LAMAR, of Flem-
ington, New Jersey;
(I) ONE SHARE to my late husband's beloved niece, SUSAN
WREN, of Grand Prairie, Texas;
(J) ONE SHARE to my late husband's beloved niece, FRANCES
(POLLY) MAREK, of Arlington, Texas; and
(K) ONE SHARE to my late husband's beloved nephew, FRANK
(DEKE) MAREK, of Carrollton, Texas.
In the event that any of the aforenamed beneficiaries
shall predecease me, then I direct that the share which he or she
would have received shall be divided among my surviving benefi-
ciaries named in this Paragraph.
SEVENTH: I nominate, constitute and appoint my beloved
nieces, SANDRA HAYES and FRANCES GUGLIOTTA, as Executors of this
-2-
my LAST WILL AND TESTAMENT.
I direct that my Executor shall have full power and
authority to sell, transfer and convey any property, real or
personal, which I may own at the time of my death, at such time
and price, and upon such terms and conditions as my Executor
may determine, and to do every other acts necessary or appro-
priate to complete administration of this will. I further
direct that my Executor shall not be required to furnish any
bond or other security for services as Executor.
**END OF WILL.
AFFIDAVIT**
NEXT PAGE IS WILL PAGE SIGNING AND SELF-PROVED
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ANNA MAURER
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07016-WILL PAGE-SIGNING AND SELF PROVED AFFIDAVIT
ADGRVST-1
c 1990 ALL-STAl:E LEGAL $UPPL Y CO.
ONE COMMERCE DRIVE, CRANFORD, N. J. 07016
INWITNESSWHEREOF,Ihavehere'lt,!,tosetmyhandandsealthis 21st dayof Feb. ,1991.
C4Z'7'2C;:"~/ aU J~/--
/ ANNA MAURER
This Will was SIGNED, SEALED, PUBLISHED and DECLARED by the above named Testator (or
Testatrix), as andfor his or her Last Will and Testament in the joint presence of us , who, at his or her request
and in his or her presence and in the presence of each other, have hereunto subscribed our names as
witnesses, this 21st day of February
,1991
Signatures
Names of Witnesses
___~~ -,4.:.._~~_--__________
.~ , /
_~_~-,<._b__ ~~^----
ROSE A.DROLLAS
PATRICIA M. VENTURA
I,
ANNA MAURER
the Testator (or Testatrix)
sign my name to this instrument this 21st day of February
,1991
, and being duly
sworn, do hereby declare to the undersigned authority that I sign and execute this instrument as my Last
Will; that I sign it willingly; that I execute it as my free and voluntary act for the purposes therein expressed;
and that I am 18 years of age or older, of sound mind and under no constraint or undue influence.
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_L-.:.lY.1.t.,f( ,~/.J#{:-'--0-"t'0--_.-------------
/ .
ANNA MAURER Testator (or Testatnx)
We, the above named witnesses, sign our names to this instrument, and, being duly sworn, do hereby
declare to the undersigned authority that the Testator (or Testatrix) signed and executed this instrument as
his or her Last Will and that he or she signed it willingly; that each of us, in the presence and hearing of the
Testator (or Testatrix), hereby signs this Will as witness to the signing thereof by the Testator (or Testatrix);
and that to the best of our knowledge the Testator (or Testatrix) is 18 years of age or older, of sound mind and
under no constraint or undue influence.
_____.L:;5:::_~7::__~"'::."::----------------~~-~--.P_r~~f~.c:::t_-3-t-r_e~_~L!'l_ll.1::~~X_!_ NJ___~JJ-10
Witness ROSE A. DROLLAS Address
:I
-;'~L.<' <,"_ )'h. Q~u..,--,- 36 Hope Street, Nut1ey, NJ 07110
_____________________________L________________________-------------------------------------------------------------
Witness PATRICIA M. VENTURA Address
STATE OF NEW JERSEY
SS.
COUNTY OF ESSEX
Subscribed, sworn to and acknowledged before me by
ANNA MAURER
the Testator (or Testatrix), and subscribed and sworn to before me
by ROSE A. DROLLAS
and PATRICIA
//-----------,
NTURA ' , the witnesses, this
21st day of February
,1991
,
FIRST CODICIL TO THE
LAST WILL AND TESTAMENT OF ANNA MAURER
;;2/- 0;). -q IS
I, ANNA MAURER, a resident of Middlesex County, State of New
Jersey, being of sound mind and understanding, do make, publish,
and declare this to be the First Codicil to my Last Will and
Testament dated February 21, 1991.
The S~NTH paragraph of my will is amended and changed to
read as follows:
SEVENTH: I nominate, constitute and
appoint my beloved sister-in-law, Gloria
Shapiro, and my beloved niece, Frances
Gugliotta, as Executors of my Last Will and
Testament.
In every other respect, I hereby confirm and republish my Last
will and Testament dated February 21, 1991.
IN WITNESS WHEREOF, I hereby set my hand to this First Codicil
to my Last will and Testament this :A j day of 11'7/1 V'G " , 1994.
~/~~
Anna Maurer
The foregoing instrument consisting of two (2) pages was in
our presence signed by ANNA MAURER and declared to be the First
Codicil to her Will dated February 21, 1991. We at her request,
and in her presence at the same time have hereunto subscribed our
names as witnesses on the above date.
a~d
~itness
--Ill
~A~reSiding
-j</7-<JJ117 ~/1I.~~?3ob
STATE OF NEW JERSEY
.
.
:
COUNTY OF
.
.
I, ANNA MAURER, the Testatrix, sign my name to this instrument
this ~ day of 11, 'tr (:,0, 1994, and being duly sworn, do hereby
declare to the undersigned authority that I sign and execute this
instrument as The First Codicil to My Last Will and Testament; that
I sign it willingly; that I execute it as my free and voluntary act
for the purposes therein expressed; and that I am 18 years of age
or older, of sound mind and under no constraint or undue influence.
!ir--- 1nLl~~
A MAURER
We, the above named witnesses, sign our names to this
instrument, and being duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and. executed this !,
instrument as her First Codicil to her Last will and Testament and
that she signed it willingly; that each of us, in the presence and
hearing of the Testatrix, hereby signs this First Codicil as
witnesses to the signing thereof by the Testatrix; and that to the
best of our knowledge the Testatrix is 18 years of age or older, of
sound mind and under no constraint or undue influence.
Subscribed, sworn to or
affirmed and acknowledged
before me by the above
named Testatrix and by the
witnesses whose names appear
~osite on the.~ day of
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ptness
R~~ dtMA h;r;(;~A)
tary ublic
ROSEL V~,l SOI1Rr:\\lTINO
~N'tY Pi.i~t!C OF Nf::'.... Jt:'i'\.:3EY
lilY COM~ eXPIRES JUNi: i 8. 1997
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Witness
REV-1&iOEX(B-oo)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0801
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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OFFICIAL USE ONLY
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DATE OF DEATH (MIl-DO-YEAR) DATE OF BIRTH (MM-DD-YEAR)
197 - II - 0 2.-
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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01. Original Retum
o 4. limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Utigation Proceeds Received
o 2. Supplemental Retum
o 48_ Future Interest Compromise (date of death aftar 12-12-82)
o 7. Decedent Maintained a living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (date of daath betwaBll12-31-91 and 1-1-95)
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FILE NUMBER
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CQUNT1 CODE YEAR
_ _ !!t ...L S
NUMBER
SOCIAL SECURITY NUMBER
135'" - 09
3'13
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date ofdealh priOl'to 12-13-62)
o 5. Federal Estate Tax Retum Requited
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach$chO)
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NAME
COMPLETE MAILING ADDRESS
QFFICIAL USE ONLY
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(12)
(13) I1CO--V~
(14)
(19)
FIRM NAME (If Applicable)
TELEPHONE NUMBER
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(1D) ':ItI/p . (17
(11)
1. Real Estate (S_A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule OJ
5. Cash, Bank Deposits & Miscenaneous .Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total G..... Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I)
11. Total Deductions (Iotall.ines 9 & 10)
12. Net Value of Estate (lineS minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tex (Line 12 minus Line 13)
SEE INSTRUOTIONS ON REVERSE SIDE FOR APPUCABUE RATES
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15. Amount of line 14 taxable at the spousal lax
rate, or transfe.. under Sec. 9116 (8)(1.2)
'.0_ (IS)
16. Amount at Une 14laxabre at lineal rate
,.0_ (16)
, .12 (17)
, .15 (18)
17. Amount of Une 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
19. Tax Due
200
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
S REET ADDRESS
CITY
:4
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
ZIP /7d//
Total Credits (A' B' C) (2)
3. InteresUPenally if applicable
D. Interest
E. Penally
TotallnteresUPenally ( 0 . E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box an Page 1 Line 20 to request a refund (4)
5. ff Line 1 . Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interesl on the tax due.
(5A)
B. Enter the total of line 5 + SA. This is the BALANCE DUE. (5B)
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
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ..".......................................................................................................... 0
3. Did decedent own an "in trust For" or payable upon death bank account or securily at his or her death? .............. 0
4. Did decedent own an Individual RelirementAccount, annuily, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
[RI
l6J
I!i'J
~
gJ
~
f2i
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
',J
Under penalties of perjury, I declare that I have examined this relt.im, including accompanying schedules and statements, and 10 the best of my knowledge and belief, it is true, correct
and complete.
Declaration of preparer other than tile personal representative is based on aU infonnation of which preparer has any knawledge.
SIGNATUR F PERSON RESPONSIBLE FOR RETU N
DATE
'>,4. /)/1).. -1527/
DATE
f ').-,
5&:..
PI)
"
For dates of death on or aner 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 PS. ~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 twenly-one years of age or younger at death to or for the use of a nalural 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 lineai 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 fo 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 wnh the decedent, whether by blood or adoption.
.>-
CERTIFICATION OF NOTICE UNDER RULE 5.6Ia)
Name of Decedent:
/1 Jt/ A/A
.
Il/J A l/ J{ iF- I?
Date of Death:
.fu /r
/I :A &0 2-
I
Will No.
Admin. No. F, f<<= "# 2-0""2.- - C9d "71 S-
To the Register:
I certify that notice of (beneficial interest) estate administration 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
Name
Address
C-/("') Y' I I:l
fl1
<) h crf / 'rf)
,~? htl:.-tJ( V:i/~7e
4l"Y7Js/J/./7 FA, /7//.2-
. I
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Signature
Name
Address
Uk:< ~,p~1 FL"
I
~ ~ SJ..C-16.s-')
Telephone (75'6 3 'f "J
b ((if 7
Capacity: _ Personal Representative
~ounsel for personal representative
/7-9'8 -/.,p/
~ BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG# PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-20-2003
MAURER
07-11-2002
21 02-0915
CUMBERLAND
101
AltOunt R...1 tted
GLORIA M SHAPIRO
28 FAIRFAX VILLAGE
HBG PA
1 112-9501
*'
REV-1541 EXAFP UI-U)
ANNA
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ....
REY=is4j-EX-AFP-foFii3Y-iioi'"icniF-'rNHEii'iTANCE-YAirirpPRAiSEHEii;:~--Ai:.LOWANCnjR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF MAURER ANNA FILE NO. 21 02-0915 ACN 101 DATE 01-20-2003
TAX RETURN WAS: I X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..l Estate ISchedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. "ortg8ges/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
11)
(2)
(3)
I~)
(5)
(6)
17l
.00
.00
.00
.00
9.142.02
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. ExPenses (Schedule H)
10. Debts/Hortgege Liabilities/Lions ISchedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitabl./Gov.r~ental Bequestsi Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
NOTE: I~ an asses..ent was issued previOUSlY, lines
re~lect ~igures that include the total at ALL
ASSESSMENT OF TAX:
15. A.ount of Line 14 at Spousal rat. (15)
16. A.ount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Anount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
6,180.00
4.020.87
111)
112)
113)
11~)
(9)
110)
NOTE: To insure proper
credit to your account I
s~it the upper portion
of this for. with your
tax payaent.
9,142.02
lD.?DD 87
1,058.85-
.00
1,058.85-
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
.00 X 045=
.00 X 12 =
.00 X 15 =
119)=
.00
.00
.00
.00
.00
TAY C TS:
~RTI '" AMOUNT PAID
DATE ~ER INTEREST/PEN PAID 1-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REqUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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