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HomeMy WebLinkAbout03-02-11 CHARLES E. PETRIE, ESQ. n © i-.,~y -~ ~ T'? +~- 3528 Brisban Street -~ -~a ~. .. h ' -' Harrisburg, PA 17111 ~ -~., ; ~ ~ . (717) 561-1939 f~= <.~~ ~ ^' ~: ;..; ~"_ (717) 561-4121 (FAX) ~-~ ~~'° ?~ - l Sup. Ct. ID 29029 `~' ~ .- '~ ~: ATTORNEY FOR PETITIONER ~ -~ c.n ~~ IN RE: : IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF ELI CEKOVIC Deceased NUMBER : o(r ~ - ~ ~ ~"' ~ ~ ( PETITION FOR SETTLEMENT OF SURVIVAL ACTION NOW COMES Your Petitioner, ELLEN MARY MESSINGER CEKOVIC, Executrix of the Estate of ELI CEKOVIC, Deceased, by and through her Attorney, Charles E. Petrie, and respectfully represents as follows: 1. That Your Petitioner is ELLEN MARY MESSINGER CEKOVIC, the surviving spouse of Eli Cekovic (hereinafter referred to as "Decedent,") and the Executrix of his Estate. Copies of the Decedent's Last Will and Testament and Certif cate of Grant of Letters Testamentary are attached hereto as Exhibits "A" and "B," respectively. 2. That the Decedent died on July 29, 2009. Decedent was 81 years of age at the time of his death. 3. The circumstances surrounding Decedent's death are as follows: On the morning of July 9, 2009, Decedent was struck as a pedestrian by a motor vehicle operated by Robert A. Banks, in front of Decedent's home on Wertzville Road, Hampden Township, County of Cumberland, Pennsylvania. Decedent was taken to the Milton S. Hershey Medical Center, where he died on July 29, 2009. CHARLES E. PETRIE, ESQ. 3528 Brisban Street Harrisburg, PA 17111 (717) 561-1939 (717) 561-4121 (FAX) Sup. Ct. ID 29029 ATTORNEY FOR PETITIONER IN RE: : IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF ELI CEKOVIC Deceased NUMBER PETITION FOR SETTLEMENT OF SURVIVAL ACTION NOW COMES Your Petitioner, ELLEN MARY MESSINGER CEKOVIC, Executrix of the Estate of ELI CEKOVIC, Deceased, by and through her Attorney, Charles E. Petrie, and respectfully represents as follows: 1. That Your Petitioner is ELLEN MARY MESSINGER CEKOVIC, the surviving spouse of Eli Cekovic (hereinafter referred to as "Decedent,") and the Executrix of his Estate. Copies of the Decedent's Last Will and Testament and Certificate of Grant of Letters Testamentary are attached hereto as Exhibits "A" and "B," respectively. 2. That the Decedent died on July 29, 2009. Decedent was 81 years of age at the time of his death. 3. The circumstances surrounding Decedent's death are as follows: On the morning of July 9, 2009, Decedent was struck as a pedestrian by a motor vehicle operated by Robert A. Banks, in front of Decedent's home on Wertzville Road, Hampden Township, County of Cumberland, Pennsylvania. Decedent was taken to the Milton S. Hershey Medical Center, where he died on July 29, 2009. 4. Decedent sustained medical expenses in the approximate amount of $150,000.00. 5. Your Petitioner and Robert A. Banks, through his Insurer, Tr. avelers Insurance, have settled all claims arising out of Decedent's death for the sum of Two Hundred Fifty Thousand Dollars ($250,000.00). A copy of the General Release signed by Your Petitioner is attached hereto as Exhibit "C." This amount represents Robert A. Banks' maximum liability insurance coverage. Robert A. Banks has no further assets of substantial value from which Your Petitioner can collect further funds. 6. Your Petitioner has settled an underinsurance claim with State Auto, the insurance carrier for Decedent's vehicle, for the sum of the maximum underinsurance coverage of Fifty Thousand Dollars (50,000.00). 7. Your Petitioner is satisfied that the total recovery of Three Hundred Thousand Dollars ($300,000.00) is the maximum recovery in this case. This sum is sufficient to protect the Estate and the interests of Your Petitioner, the lienholder and other creditors. 8. Your Petitioner has filed a Pennsylvania Inheritance Tax Return with the Register of Wills of Cumberland County, Pennsylvania. Since Your Petitioner is the sole heir/ spouse of the Decedent, no inheritance taxes are due to the Commonwealth of Pennsylvania. Attached hereto as Exhibit "D" is the Department of Revenue's Notice of Inheritance Tax Appraisement, Allowance or Disallowance of Deductions and Assessment of Tax, indicating that no inheritance taxes are due to the Commonwealth of Pennsylvania. 9. If this Petition is granted, the settlement proceeds will be distributed as follows: (a) Such sums as are necessary to pay all of Decedent's medical expenses in full, including the lienholder. (b) The sum of $50,000.00 to Attorney Charles E. Petrie, which sum represents his commission for representation of Your Petitioner and the Estate of Eli Cekovic in this matter. (c) All remaining sums shall be payable to the Estate of Eli Cekovic. WHEREFORE, Your Petitioner respectfully requests that Your Honorable Court enter an Order directing as follows: 1. That Travelers Insurance Company shall pay the settlement proceeds in the above case in the amount of $300,000.00 to Attorney Charles E. Petrie. 2. From said proceeds, Attorney Petrie will distribute the proceeds as follows: a. He will expend such sums as are necessary to pay all of Decedent's medical expenses in full, including the lienholder. b) The sum of $50,000.00 to Attorney Petrie, which sum represents his commission for representation of Your Petitioner and the Estate of Eli Cekovic in this matter. c) All remaining sums shall be payable to the Estate of Eli Cekovic. Respectfully submitted, r~~~~ CHARLES E. PETRIE 3528 Brisban Streett Harrisburg, PA 17111 SUP. CT ID NO. 29029 (717) 561-1939 Voice (717) 561-4121 Fax PetrieLaw(a~,AOL. com CHARLES E. PETRIE, ESQ. 3528 Brisban Street Harrisburg, PA 17111 (717) 561-1939 (717) 561-4121 (FAX) Sup. Ct. ID 29029 ATTORNEY FOR PETITIONER IN RE: : IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF ELI CEKOVIC Deceased NUMBER STATEMENT OF COUNSEL As attorney on behalf of the above-named Petitioner, I, Charles E. Petrie, Esquire, recommend to the Court the settlement amount of $300,000.00 to the Executrix of the Estate of Eli Cekovic, Deceased. This is a fair settlement under the circumstances set forth in the Petition. Further, it would be in the best interest of the Estate to settle this claim in the amount set forth above. Respectfully submitted, c~~~~ CHARLES E. PETRIE 3528 Brisban Streett Harrisburg, PA 17111 SUP. CT ID NO. 29029 (717) 561-1939 Voice (717) 561-4121 Fax Pe trie Law(a~,AO L. com COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN I verify that the statements set forth in the foregoing Motion/Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~49~4, relating to unsworn falsification to authorities. ^~ ~ r J ~,~~ ~'' DATE ELLEN CEKOVIC .. LAST WILL AND TESTAMENT OF ELI CEKOVIC rya c~ ~ -, , ..; • ~' ~ r.. _ _? ~?l t'ti~ ' ... r :'~ -= -- ~~ j ~,~,{ ~~ ... I, Eli Cekovic, presently of 6050 Wertzville Road, Enola, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament hereby revoking all wills and codicils previously made by me. I declare that I am married to Ellen Mary Messinger Cekovic and that all references in this Will to my Wife are references to her. I have three (3) children, now living, whose names and dates of birth are as follows Michael Jay Cekovic Elias Junior Cekovic Frank James Cekovic October 1 2 , 1 962 September 7, 1965 November 1 3 , 1 967 All references in this Will to my children include only the children named above. ARTICLE I I direct the payment from my estate of the expenses of my last illness and funeral as soon after my death as conveniently may be done. ARTICLE II I give all of my household furnishings and tangible personal property to my Wife provided she survives me by thirty (30) days. If my Wife fails to survive me by thirty (30) days, then I give all of my I I household furnishings and tangible personal property to my children to EXHlBlT "A" LAST WILL AND TESTAMENT OF ~~ C ~ c~ _.., ~ ~? ~> om- '` • t ~...! rn ~~ -- = ~ ~; ~~~ _~ _ w .a , -_ ..,..i ' ELI CEKOVIC I, Eli Cekovic, presently of 6050 Wertzville Road, Enola, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament hereby revoking all wills and codicils previously made by me. I declare that I am married to Ellen Mary Messinger Cekovic and that all references in this Will to my Wife are references to her. I have three (3) children, now living, whose names and dates of birth are as f ollows Michael Jay Cekovic Elias Junior Cekovic Frank James Cekovic All references in this-Will to my children include only the children named above. ARTICLE I I direct the payment from my estate of the expenses of my last illness and funeral as soon after my death as conveniently may be done. October 1 2 , 1 962 September ?, 1965 November 1 3, 1 9 6 7 ARTICLE II I give all of my household furnishings and tangible personal property to my Wife provided she survives me by thirty (30) days. If my Wife fails to survive me by thirty (30) days, then I give all of my household furnishings and tangible personal property to my children to be divided among them as they are able to agree; if they are unable to agree, then said property and furnishings shall pass with the residue of my estate. ARTICLE III I give the rest, residue and remainder of my estate to my Wife provided she survives me by thirty (30) days. Should my Wife fail to survive me by thirty (30} days then I give the rest, residue and remainder of my estate in equal shares to my children who survive me by thirty (30) days. If my Wife and all of my children fail to survive me by thirty (30) days, then I give the rest, residue and remainder of my estate in equal shares to my grandchildren who survive me by thirty (30) days. ARTICLE IV A. I appoint my Wife as the Executrix of this Will. In the event of her death, resignation, renunciation or inability to act in that capacity, then I appoint my son Michael Jay Cekovic as the Executor of this Will in her. place and stead. B. No bond or other security shall be required of any Executor/Executrix appointed in this Will. C. The Executor/Executrix shall receive reasonable compensation for his or her services performed as determined by the Court in which this Will is admitted to probate. D. I give my Wife in addition to and not in limitation of the powers given by law or by other provisions of this Will, the following powers with respect to settlement of my estate, to be Page 2 of 7 exercised from time to time in the discretion of my Executor/Executrix without further order or license of the Register of Wills or of any court: 1. To borrow money from any person including any fiduciary acting hereunder, and to mortgage or pledge any real or personal property; 2. To hold shares of stock or other securities in nominee registration form, including that of a clearing corporation or depository, or in book entry form or unregistered or in such other form as will pass by delivery; 3. To engage in litigation and compromise, arbitrate or abandon claims; 4. To make distributions in cash, or in kind at current values, or partly in each, allocating specific assets to particular distributees on a non-prorata basis, and for such purposes to make reasonable determinations of current values; 5. To make elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift or other tax returns and the payment of such taxes, without obligation to adjust the distributive share of income or principal of any person affected thereby; 6. To retain any property, pending distribution hereunder, to invest in or purchase any property without restriction to legal investments for fiduciaries, to distribute property in kind, to compromise claims, and to sell any property at public or private sale; 7. To manage, control, repair and improve all estate property; 8. To procure and carry at the expense of the estate, insurance of the kinds, forms and amounts deemed advisable by the Executor/Executrix to protect the estate and the Executor/Executrix against any hazard; 9. To employ any attorney, investment adviser, accountant, broker, tax specialist or any other agent deemed necessary in the discretion of the Trustee; and to pay from the Trust estate reasonable compensation for all services performed by any of them; Page 3 of 7 10. To conduct alone or with others any business in which I am engaged or in which I have an interest at my death, with all the powers of any owner with respect thereto, including the power to delegate discretionary duties to others, to invest other property held hereunder in such business and to organize a partnership or corporation to carry on such business; ARTICLE V My Wife and I are executing Wills at approximately the same time in which each of us is the primary beneficiary of the Will of the other. These Wills are not executed because of any agreement between my Wife and myself. Either Will may be revoked at any time at the sole discretion of the maker thereof. ARTICLE VI If any beneficiary or remainderman under this Will in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, any share or interest in my estate given to that contesting beneficiary or remainderman under this Will is revoked and shall be disposed of in the same manner provided herein as if that contesting beneficiary or remainderman had predeceased me without issue. ARTICLE VII If any provision of this Will or of any codicil thereto is held to be inoperative, invalid or illegal, it is my intention that all of the remaining provisions thereof shall continue to be fully operative and effective so far as it is possible and reasonable. Page 4 of 7 ' 4 ~ ARTICLE VIII All estate, inheritance and succession taxes, together with any interest and penalties thereon, payable as a result o.f my death and imposed with respect to any property, whether or not disposed of by this Will, shall be paid out of the residue of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this my Last Will and Testament, consisting of ? typewritten pages, including this attestation clause, to be executed, declared and published this ~ day of ,,`~;~°~ , 1989, at r~ r~'l ~ U Pennsylvania. +~~ ~~ ~~~ /~ R ELI CEKOVIC Residing at ~~ ~,, ,~ ~` ?c~ 7 ~ .~ ~ ~' ~ ~> , ~,, Residing a t ~ ~ ~ `~ i ~4 ~~~~o-~z,5,,~'/ ~`~,.~~ ~; ~`) .~ .; ~ ~< .~ ~ _{ ~ ..~ „~. ~~' ~...~' ~ ~`~;+~~ ,r: i.~!~'~. ~~ Residing a t ~ j ~'` ~ `~ ~~.,'.~f>~-f~^' ~~,~,~ . 4 ~ ~--, ... , ~, r ~ ~ A r ~ ;~ ~.~% a f s ~~ . Page 5 of 7 ,. ~ . ~ ` ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA: SS. COUNTY OF DAUPHIN • ~ ~ '~ I, Eli Cekovic, Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~. ~ ~ r; ELI CEKOVIC Sworn or affirmed to and acknowledged before me, by Eli Cekovic, Testator, this '~ day of ~ , 1989. ~1 . Notary Pu lic My Commission Expires: COMMONWEALTH OF PENNSYLVANIA: COUNTY OF DAUPHIN ,., w ....... ~3t;a'dk~rs~,L ~h3. ~lGY L. F{Tc, N~T~ ~' R4f~IC AFFIDAVIT HO~~! s~f, p;~,tFE~!!N ,i4~TY !~Y Ce~:i~E;~~(~.~N lFs~S NC31~. 5, t~ '~k~„~.;F~,, t~ f.~ ~`o'~~nTi'~ ;":=r.:Ci!'`wi~i:> i fti ~~'i~.:si SS. and ~~.R.c~ ~.,C'_2 i N , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified. according to Page 6 of 7 . A ~ ~ . ~ • ' ~ `! • law, do depose and say that we were present and saw Eli Cekovic sign and execute the instrument as his Last Will and Testament, that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed, that each of us in hearing and sight of the Testator signed the Will as witnesses and that to the best of our knowledge, the Testator was at the time eighteen or more years of age, of sound mind and under no constraint or undue influence. 0 a k ,~, F `ry ~`~~ '~ ,~ { p ~'" r ~~ Sworn or affirmed to and acknowledged before me, by ~. I~b~`l-A ~ • W ~Mpl~___~.R-_ - and ~. Q, e, A.~ i 1~ , this '•'1~'' day o f ~~~ ~.,,~ , 1 989. Notary P lic My Commission Expires: t~IGlKY L. F6Tc, !'~T~'~Y PU~.iC ti~R1"r~J~G, ©~atJF~F'i!V ~iif'~TY l~~Y;;~4S;~d~{ ~;FsES ~V(31t. 5,1 ~--_ _~, Page 7 of 7 REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA No . 2009- 00981 Estate Of : ELl CEKOV/C CERTIFICATE OF GRANT OF LETTERS PA No . 21- 09- 0981 (F%/St, Middle, Last) Late Of : HAMPDEN TOWNSH/P CUMBERLAND COUNTY Deceased Social Security No : 202-20-1973 WHEREAS, on the 24th day of February 2 010 an instrument dated September 7th 1989 was admitted to probate as the last will of ELl CEKOVIC (First, Middle, Last) for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: ELLEN MARY MESS/LAGER CEKO VlC late of HAMPDEN TOWNSHIP, CUMBERLAND County, who died on the 29th day of July 2009 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and who has duly qualified as EXECUTOR(R/X1 and has agreed to administer the estate according to law, all of which full y appears of record in my office a t CUMBERLAND .COUNTY COURT HOUSE, CARLISLE, PENNSYL VAN/A. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 24th day of Febiua~y 2010. ~ ~l egister 1 s -- ~ , eputy EXHIBIT "B" * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LA5T) GENERAL RELEASE KNOW ALL MEN BY THESE PRESENT That we. Ellen Mary Messinger Cekovic as Executrix of the Estate of Eli Cekovic, bezny or ~.~wr;,~ age for the sole consideration of Two Hundred Fifty Thousand Dollars, ($250,000.0i17 tc ;,s r,, y~~,r~ i~a-~ receipt thereof is hereby acknowledged, have remised, released, and forever disc-~dryec7 Robert A. Banks, The Standard Fire Insurance Company (Travelers) and for our heirs. executors au~±r~;strators. and assigns do hereby remise, release, and forever discharge Robert A. Banks, The Standard Fire Insurance Company (Travelers] and their successors and assigns. heirs. executors ar~d administrators; only, from any and all claims, demands, rights, and causes of action of whatsoever Kind and nature, including claims of liens from MEDICARE, any other health care provider or insurer. .:~ndl~~r any h~orkmen's Compensation insurer, arising from and by reason of any and all knowr~ ant; ;unknown foreseen and unforeseen bodily and personal injuries, damage to property an;~ consequences thereof, resulting from an incident which occurred on July 9, 2009. Wertzville Woad ~~al~~~c~e,, Township; Pennsylvania for which we have claimed Robert A. Banks to be legally +iat)if~ ~~ `o~ ~J1r~ic,,t~ liability is hereby expressly denied. t ;s also expressly understood between the parties that Ellen Mary Messinger Cekovic as Executrix of the Estate of Eli Cekovic shall be solely responsible for the repayment of any and al! +e;,s. including Medicare; workmen's compensation, health care provider, health care insurer andlor ar~y other liens, and Ellen Mary Messinger Cekovic as Executrix ofi the Estate of Eli Cekovic agrees to +ndemnify; defend and hold harmless Robert A. Banks and The Standard Fire Insurance Company (Travelers) from any and all claims or actions on account of any such lien. ,,~1e certify that there are no outstanding liens against us for child support in the Stag; car ~_'~~~,;~,yivan{a or any other jurisdiction. We agree to indemnify, defend and hold harmless Robert A. ~iarlks and The Standard Fire Insurance Company (Travelers) from any and all claims or actio-~~_ ~~~ account of any child support liens. IN WITNESS WHEREOF, Vlie have hereunto set our hand and seal this ___~~`'~ ~._ day of ~~~L` ~ __ in the year Two Thousand Ten. Sealed and delivered in the presence of: '~/U i .r N E S S : ~:`_.~ ~~..~ X ~C%zl ~ ~ f' '/" c _~ ~~'vbz'K'r--- Ellen Mary Messinger Cekovi~Executrix of the Estate of Eli Cekovic --~--- '_:::`'~~~fv?~:.~~;`JUEA~TH OF PENNSYLVANIA EXHIBIT "C" NOTICE OF INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX PO BOX 280601 HARRISBURG PA 17128-0601 CHARLES E PETRIE 3528 BRISBAN ST HARRISBURG PA 17111 C1) .00 C2) .00 C3) .00 C4) .00 C5) 300, 000.00 C6) 100,000.00 C7) .00 CUT ALON_6 THIS LINE _ ~ R_ETA_IN LOWER POR_TION_ FOR YOUR RECORDS E~ _______________ REV-1547 EX AFP C12-10) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE-OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: CEKOVIC ELI FILE N0.:21 09-[1981 4CN: lnl nATF~ n7_~~_~n~~ TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) pennsylvania ~ DEPARTMENT OF REVENUE REV-1547 EX AFP C12-10) NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. Cs) 400 , 000.00 C9) .00 Clo) .00 11. Total Deductions (11) .0 0 12. Net Value of Tax Return C12) 400, 000.00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .0 0 14. Net Value of Estate Subject to Tax C14) _ 400, 000.00 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) 400, 000.00 X 00 = . 00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) _0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate C17) _ _ 00 X 12 = . 00 18. Amount of Line 14 taxable at Collateral/Class B ra te C18) .0 0 X 15 = .0 0 19. Principal Tax Due C19)= .0 0 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID EXHIBIT "D" DATE 02-21-2011 ESTATE OF CEKOVIC ELI DATE OF DEATH 07-29-2009 FILE NUMBER 21 09-0981 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 04-22-2011 (See reverse side under Objections Aaount Re~aitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.