HomeMy WebLinkAbout03-07-11 , 15A56d41046
RED/-1500 EX (05-04) T' °
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes
' ` County Code Year File Number
`
'
Dept. 280601 INHERITANCE
TAX
RETURN
'~ ( ~ l~ J ~ ~ ~
DE
Harrisburg, PA 17128-0601 RESIDENT
CEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
.d o$`~~. ~~3g d~d9ao r O 0~0$ ~ 9~~
Decedent's Last Name Suffix Decedents First Name MI
~o.~S._. ~_ ~ A ~~ ~,
(If Applicable) Enter Surviving Spouse's Information Below
Spouses Last Name 5i_iffix Spouses First Name MI
r~Jo~~ T~~cS ~ A,.
Spouses Social Security Number
~y 4' ~ Q a ~ ~
~ ~? THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
' REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Firm Name (If Applicahle)
First line of address
Second Ilne of address
City or Post Office
State ZIP Code
r~
~? ~~
REGISTER LS USE Wj~I.Y
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DATE FILED L'
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Correspondent's a-mail address
Under penalties of perjury, 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 R ON RESPO IBLE F FILING RETURN DATE
o - ~--- 3- 4 - 11
ADDRESS
1? 1~. AcCoRN ~R._ [~otLtNG SPRtN~S,PA I~can7
SIGNATURE OF PREPARER OTHER THAN REPR ENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041046 15056041046 J
-~, ~;;
J .. . ~~s~'S~ 0 0 4 7
..
r Fy, ~~ Y`
REV-1500 EX ~ ;~~" Decedent's Social Security Number
,: sf...
'2~o`$~y`2 ,62 3 q.
Decedent's Name: ,~..~ 1~ ~~~_~._~ ., ~ e~
RECAPITULATION
1. Real estate (Schedule A) . ............................................ 1. ~
'{ `. ~ w
2. Stocks and Bonds (Schedule B) ....................................... 2. 2 ~; ~ GY 6 ~3a~
3. Closel Held Co oration, Partnershi or:Sole-Pro rietorshi Schedule C 3. ,
Y rP P A P( ) ••-
4. Mortgages & Notes Receivable (Schedule D) ............................. 4.
5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ........ 5.
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) C Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) .................................... 8.
9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10.
11. Total Deductions (total Lines 9 & 10) ...................... . ............ 11.
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
~~:
`.2t5''0~2y~i oo
.- =.+.,?ze". LiD~ a.^_"JC."„~i~z,52GM a_.ti-:~'n+,,_-
•..^x
53~~6'g~~~o~o~
r
35'.2 `3 ; o'o
an election to tax has not been made (Schedule J) ...................... .. 13. •
.
14
Li
12
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Li
13
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14 ,
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TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 // / ~~rr
(a)(1.2) X .OQ ~ o Y ~ T .
15.
Q+ Q`
16.
Amount of Line 14 taxable .,: -..
at lineal rate X .0 _ 16.
17. Amount of Line 14 taxable
at sibling rate X .12
y. 17.
_
_
18. Amount of Line 14 taxable
at collateral rate X .15 18. ~
00
19. TAX DUE ....................................................... ..19. !-
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505604204? 15056042047 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENT'S NAME
MAR #< S. D ows _
STREET ADDRESS •
t7 I~CDRr- .DRI~e
CITY ~ ~ t ~ t ~ ~ C R ~ N ~ ~ --- STATE ~~ ZIP ~,7~OT
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) - Q
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments _
C. Discount
Total Credits (A + B + C) (2) -' Q
3. InterestlPenalty if applicable
D. Interest
E. Penalty
Total InterestlPenalty (D + E) (3) - Q
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) --, ~ ~---'
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) _ C~
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) - Q -----
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 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 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 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? .................................................................................................................. ...... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 three (3) percent [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 zero (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 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 zero (0) percent [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 four and one-half (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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI~IEDI~ILE B
STOCKS & BONDS
ESTATE OF
MA2 ~ S. ~ a Val S
FILE NUMBER
2110-O~a6
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
'~ MUTUAL, FUNDS
USP~A ~$ao ~tr'CG~2y'i'Gks~irg,~,~sah {~NfonioyTX
FuN t7 U
I. ~~reSs eve ~ w w~t ~~N~ ~Qcc'~ eht~~ ~ ro453
~
V
V (~ ~. ~{~ 3 s (Hares 'Dom V A S v,>~. ~~ 4 y~.
z • rn~erha;Q-i'oaa,( ~uhcj A'oc~• el,~~n 2~5a
~7y. a~i st'iaYeS ~P.~ ,f~~,~E, q~ S3~J,
~. W o r l l~ Cs ro w ~ ~~Nd r4ac-F efnGQi n 7~T S
S? z. g i 1 3 (na.~ne S jJoD V 4l! C 9,0 Q~
4. MoKey MaYke-i• ~~v,
d I~~. ~~d~~ O4a7
y~7Q3•~.'zo sl~a~a5 ~e7v ~~,.~~ y, 793.
TOTAL (Also enter on line 2, Recapitulation) $ 2 8, !p {p 3.
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX t (197)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF A^ A n~ C. ~O W ~ FILE NUMBER ~'' 0 ^ ~' Q
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 Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~~ 2005 A~~RA RL. I(o,D00.
;Z, C~eckinq gcCov-~t.+ Qv~~i~
US AA ct$QO F'~~~Qe,ricks6ur
'p AT E' ol~ DEA'[I~ R~~~NoE
5~ v i n S 0~ C C o v h "'~' 6!~td i n`
vSAA x,60 ~redertr,~csb~n
pa-r~ n ~ D Ear ~ ~a ~ ~ Nc E
~~ y8oa
2~, ~~q,,,w ~Q N ~a H i o~ 1 ~(
i71 3,~~1.
Dgza
Rd •~ sgtn QN•fr~n i a,T~(
3, 72 P~.
~-{ . ~ ra ke ~a e a cc o u K ~ ~ ~ ~ i n (02.0 ~
A~ ~oo -~~cs~~ d. ~af~,q,v~h~o TX
V 5 q ~ ~rcc~e~n ~
Lti4TE o~ DEATH T3A~A.NC~ 2 16q,
~; M-SCett,a,heo~5 clo+k~n ~~N/kTE~
TOTAL (Also enter on line 5, Recapitulation) I $ 2 ~~ ~ ~ "1 .
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
SCFIEDIJLE M
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATNE COSTS
RESIDENT DECEDENT
ESTATE OF ~ ^ ~ A ~ ~ • ~ O ` _' ~ FILE NUMBEt~ f 1 ~ _ O ~ n
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
,. ~o~~rn.o;~n - 1Zo~ ~~ Hera` -~-~ovit,~. 3OoO.
CA2 ~~s~e, ~A
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State Zip
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
4.
5.
6.
~.
Street Address _.
City State
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Retum Preparer's Fees
I~eai ~-~'e~f' o ~ (~J ~ 115 ~' 'Pro `oars ~ ~e e5
Zip --
X23.
TOTAL (Also enter on line 9, Recapitulation) I $ 3 /~3.
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI~IEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
M~~K ~: meows 2~ ~o - o Iq ~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
,. ~(i~e. IC~O%
~'e~esa. A. ~tiws
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
9800 Fredericksburg Road
San Antonio, Texas 78288
USAA®
02350.713M.JSS163742749.01.01.10
EST OF MARK S DOWS
MAJ USAF RET
17 N ACORN DR
BOILING SPRINGS PA 17007-9415
Dear Mrs. Dows:
February 22, 2011
USAA is committed to providing excellent service to its members. As you requested, I am
providing the following information for the retirement account of the late Mark S Dows.
USAA #: 240 21 34
Fund name: Aggressive Growth Fund
Account # ending in: 9653
The account value on February 9, 2010 was:
Share Accrued Account
Shares Price Dividends Value
184.423 $26.81 NA* $4,944.38
*Fund does not accrue daily dividends.
If you have questions, please call a USAA member service representative at
1-800-531-USAA (8722).
Thank you,
USAA Shareholder Account Services
240 21 34.49216.31268•DM02350-SAS.SAS45 58126-0108
9800 Fredericksburg Road
San Antonio, Texas 78288
USAA®
02350.713M.JSS163742750.01.01.11
EST OF MARK S DOWS
MAJ USAF RET
17 N ACORN DR
BOILING SPRINGS PA 17007-9415
Dear Mrs. Dows:
February 22, 2011
USAA is committed to providing excellent service to its members. As you requested, I am
providing the following information for the accounts of the late Mark S Dows.
USAA #: 240 21 34
Account ##
ending in Fund Name
2450 International Fund
7978 World Growth Fund
0907 Money Market Fund
The account values on February 9, 2010 were:
Account # Share Accrued Account
endin in Shares Price Dividends Value
2450 474.841 $20.71 NA* $9,833.96
7978 572.911 $15.87 NA* $9,092.10
0907 4,793.270 $1.00 $0.01. $4,793.28
Total Value $23,719.34
*Fund does not accrue daily dividends.
If you have questions, please call a USAA member service representative at
1-800-531-USAA (8722).
Thank you,
USAA Shareholder Account Services
240 21 34.49216.31268•DM02350•SAS.SAS45 5812&0108
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.................................. _.... _ .
Subject: USAA Private Investment Management
From: TERESA A DOWS
Message DateJTime: Thu Mar 03 07:43:52 CST 2011
Thanks again Lee for all your help!
REPLY
Message History
p .From: USAA Date/Time: Thu Mar 03 07:42:06 CST 2011
Message
Dear Mrs. Dows,
Below is the value's of Mark's accounts as of 02/10/2010.
Checking account ending 4800 -Balance = $3,126.71
Savings acwunt ending 0920 - Balance = $3,728.12
If you need anything else, please let me know.
We value your business and the opportunity to serve all your financial needs.
Thank you,
Lee Johnson
USAA
Please let us know how we are doing by answering this survey.
» Start Survey Now
USAA Wealth Management is a service of USAA. USAA means United Services Automobile Association and Its
affiliates. Investments provided by USAA Investment Management Company and USAA Financial Advisors Inc.,
both registered broker dealers. Flnancfal planning services and flnandal advice provided by USAA Flnandal
Planning Services Insurance Agency, Inc. (known as USAA Financiai Insurance Agency in California, License #
OE36312), a registered Investment adviser and Insurance agency and Its wholly owned subsidiary, USAA Financial
Advisors, Inc., a registered broker dealer.
Previous
Copyright W 2011 USAA.
https://www.usaa.com/inetlent memberemail/MemberEmail?action=ViewMessage&Email... 3/3/2011
~~ 9800 Fredericksburg Road
1 ~ San Antonio, Texas 78288
USAA®
May 28, 2009
Estate of Mark S. Dows
C/O Teresa A. Dows
17 Acorn Drive
Boiling Springs PA 17007-9415
Dear Mrs. Dows:
As you requested, below is the account value information as of February 9, 2010 for USAA Brokerage
Account number ending in 6205.
Registration:
MARK S DOWS
Symbol Shares Share Price Dollar Value
CASH 20.170 $1.00 $20.17
MSFT 30.245 $28.05 $848.37
KEG 50.000 $8.96 $448.00
RAp 625.000 $1.29 $806.25
NANX 60.000 $0.77 $46.20
TOTAL $2,168.99
If you need further information, please contact a member service representative at 1-800-531-8181.
Sincerely,
Milton L. Green
Investor Account Services
USAA Brokerage Services is a division of USAA Financial Advisors, Inc., a registered broker dealer.
..
LAST WILL AYD TSSTAMBNT
OF
YAEK STEVBII DOtAS
I, MARK• STEVEN .DOWS,, presently on active duty as a Captain with the United
States Air Force, a legal resident of the City •oi Carlisle, State of
Pennsylvania, do hereby make, publish and declare this instrument to be my Last
Will and Testament, and hereby revoke all prior wills and codicils made by me.
FIRST: I direct that all of my lawful debts, expenses of last illness and
funeral expenses be first paid.
SECOND: I give, devise and bequeath to my wife, TERESA ANN DOWS, absolutely and
forever, all the rest and remainder of my property, real, personal and mixed,
owned by me at my death and all property to which I may become entitled or over
which I may have a power of appointment.
THIRD: In the event.. that. my wife, TERESA ANN DOWS, does not survive me, then I
give, devise and bequeath all of my said property in equal shares to my
daughter, SHAWN ELISE DOWS, and any other child or children born or adopted of
our marriage, per stirpes and not per capita.
FOURTH: Ii my wife, TERESA ANN DOWS, does not survive me for thirty days and ii
I shall dot leave any surviving children or issue of our marriage, then I give,
devise and bequeath my said property in equal shares to my lather, ARTHUR PAYNE
DOWS; my brothers, MICHAEL EDWARD DOWS, PETER JAMES DOWS and DANIEL PAUL DOWS;
and my sister, ELIZABETH SIDOR, or to the survivor(s) thereof.
FIFTH: Any beneficiary uader this Will who does not survive me for thirty days
shall be considered to have predeceased me.
SIXTH: I nominate and appoint my wife, TERESA ANN DOWS, to serve as my
Executrix without bond. In the event that she should sail to quality or act as
Executrix, then I nominate and appoint MICHAEL EDWARDS DOWS, Esq, of Hanover,
Pennsylvania, as Executor without bond.
SEVENTH: Should my wife, TERESA ANN DOWS, predecease me or for any other reason
fail to qualify or serve as natural guardian of any minor children who survive
me, then I nominate and appoint ROBERT and ELLZABETH SIDOR of Freehold, New
Jersey, as joint guardians of his, her or their person and estate, without
bond . /'~
0 0"..
~-~'~ Paga.O n~' ~`hree Pages
~~
~ ct
ca r --,
,
~
o ~
~
r
.~ +~
~-~ ~ v
EIGHTH: I desire that my .Executrix or Executor consult with the Personal
Aitairs Oifieer of the nearest military installation and the Veterans
Administration to ascertain ii there are any benefits to which my estate and
beneficiaries might be entitled because of my military service.
Page.Two of Three Pages
IN WITNESS WIiEREDF I have hereto set my hand to this my Last Will and
Testament, consisting of this page and two others, signed by me on all pages
this day of /~G((DUST A.D. , 19 $~, at Ramstein Air Base, (fermany.
EAL )
MARK TEVEN DOWS
The foregoing was at said date and place subscribed, sealed, published and
declared by said Testator as his Last Will and Testament in our presence. We
believe him to be of sound and disposing mind and memory at this time and to be
acting under no constraint, and we, at his request, in his presence, and in the
presence of each other, subscribe our names as witnesses, all of us including
the Testator being present together throughout the execution and attestation of
the Will.
,ra,~r~a ~. ~~s!,~v~r. ss~~. usaF
I_egai ,, ec rnC en
X26-82-3971
~_t.o, of
JERRY H. OVERBY, MSgt~ USAF
~9o cas uperintend~nt
~o-~-sb~o, a» CSw~~A
of ,~a~ u~e~ ~~ ~~ i
~,vl~~t:P,~-ua~ 6~ ~3~~ i
of
1h t+11 Y1~ ~ UfinR
n 0.-,~ . ~.~.
~~/~/
X386 ~-
Page Three of Three Pages
WITH THE US FORCES OVERSEAS )
AT RAMSTEIN AIR BASE, (IERMANY)
Before me, the undersigned authority, on this day personally appeared
MARK STEVEN DOWS , ~,wrl~~A `~ ' ~ S(/YlS(G(
:S~c- R R~ ~ 1 ()~ E~E'P ~_ and _~ a .~inv~p T• t~y ('s ~
known to me to be the Testator and the Witnesses, respectively, whose names are
subscribed to the annexed or foregoing instrument in their respective
capacities, and, all of said persons being by me duly sworn, the said MARK
STEVEN DOWS, Testator, declared to me and to the said witnesses in my presence
that said instrument is his Last Will and Testament, and that he had willingly
made and executed it as his free act and deed for the purpose therein
expressed; and the said witnesses, each on their oath, stated to me, in the
presence and hearing of the said Testator, that the said Testator had declared
to them that said instrument is his Last Will and Testament, and that he
executed same as such and wanted each of them to sign it as a witness; and upon
their oaths, each witness stated further that they did sign the same as
witnesses in the presence of the said Testator and at his request; that he was
at that time 18 years of age or over and was of sound mind; and that each of
said witnesses was then at least 18 years of age.
''~~ i" ~ (SEAL)
MAR TEVEN DOWS, Testator
Subscribed and acknowledged before me by the said MARK STEVEN DOWS, Testator,
It.~/~'Y~,1'(~ J • ~-f s!/Y? S/~( ~~T~~~. ~~) E~7~ ~ , , and
,~ ~T A.D., 19
PAUL W. KNOTH, Capf, USAF
"+ :t Staff Judge Advocate
377-52.0342. 377 CSW/JA
Witnesses, thi '-f'•day of
6RAfiiEQ ~'
`~ ~t?IERAI i'o`+ritt
"~ of ~~loigrjr f!ubN
lU0 AD1it_1CATE
LE 0
U.3. C. 936
No. ~7~~'~~5
A• P A TITLE NUMBER (AS SNOWN u1'1 nr rnk.ncv n k kl ~._ _. . _..._- ~---- - PURCHASE PRICE
a
(Sea Nots on Revsree)
~~ 59~b9 1
tii V EHICLE IDENTIFICATION NUMBER CONDITION
0:
d
O GOOD O FAIR O POOR LEBS TRADE-IN
~H~QO70~
y1F~~NC4faX
B• ~ LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE NAME
.
TAXABLE AMOUNT
5 ~ 59 , 00
-'
CO-SELLER 7. SALES TAX DUE
~
C L AST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE NAME ~ pA DUPHOTO IDII DATE OF BIRTH * ~~
~ ~~ ~Q~ , 54
OR BUS. IDK
~~ft:EXEiMP siv
DOW T ,REASONCkDtlE~mua
CO-PURCHASER LAST NAME FIRST NAME MIDDLE NAME PA DLJPHOTO IDM DATE OF IRTH >> i humbe{~bM l w { , },~ ~ ;
. e~~.<F IRSf t ,- ~ _ i1 ~.-'.SECOND
A5$IONMEfiT A86LGNMl;Ht
_
~ STREET COUNT Y CODE
' ' '
~,fiXEMPTION NO. IfXEMI?TION NO. ' _
6 ~ _
N
« 1 J f1 AI.SJRI\ ~R ~ .. T. TITLE FEE ~~ . Cf1
:3 V
CITY STATE ZIP CODE DATE ACQUIRED/ REFER TO COUNTY CODES
- PURCHASED LISTING ON REVERSE SIDE
• OF YELLOW COPY J. LIEN FEE -1 j p,
19
!1
LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE NAME PA DLJPHOTQ ID# DATE OF BIRTH
IDk
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PROCESSING FEE OR n/~-
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O-PURCHASER LAST NAME FIRST NAME MIDD E NAME PA DLIPH0T0 IDIi DATE OF. BIRTH FEE EXEMPT NUMBER ' ''
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AS ASSIGNED BY THE
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~ STREET ~ COUNTY CODE ,~ DUPLICATE REG.
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CITY STATE ZIP CODE DATE ACQUIRED/ REFER TO COUNTY CODES
PURCHASED
8. TRANSFER FEE n
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- LISTING ON REVERSE SIDE
OF YELLOW COPY -
E• MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER 7. INCREASE FEE N 1 A
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uzi ~ MODEL YEAR BODY TYPE (CP, TK, ETC.) CONDTION 8. REPLACEMENT FEE ~ N ~ A
2005 SEDAN O GOOD O FAIR O POOR
TOTAL PAID a ~o.
I3CTRANSFER OF PREVIOUSLY ISSUED PLATE (ADD 1 THRU B) ~~$ + Q
F• O PLATE TO BE ISSUED BY O TRANSFER b RENEWAL OF PLATE
DEPARTMENT (PROOF OF j
~ 71.6RAND TOTAL
BEND ONE CHECK IN
INSURANCE MUST BE O TRANSFER 6 REPLACEMENT OF PLATE
~ (ADO Y 610) THIS AMOUNT ~ `+
ATTACHED.) O TRANSFER OF PLATE 8 REPLACEMENT OF STICKER -~
O EXCHANGE PLATE TO BE p~,gTE Fi0' ~~~tu~R~ F }~.`~` 7 h':' °, REASON FOR REPIACMENT
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" ~ LOST O DEFACED O STOLEN O NEVER RECEIVED (Lost in Mail)
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SUED BY DEPARTMENT ..- . ~
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~MPORARY PLATE ISSUED EXPIRES th r NOTE: If'NEVER RECEIVED' block is checked, applicant must complete Form MV-44.
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INSURANCE COMPANY NAMt `"" DATE ? / 1 F 1.9111.11 _ (DATE Llf2 / 1 f_~111 T (? '-
ATTACH BINDER
I CERTIFY THAT ON MONTH DAY ~ I I A (PRINT NAME) AGENT ' "
ISSUING I HAVE CHECKED TO DETERMINE THAT THE VENICE IS INSURED AND - ~ 1; ~i~(1'? A Ofl _
AGENT ISSUED TEMPORARY REGISTRATION TO THE ABOVE APPLICANT, IN - _
INFORMATION COMPLIANCE WITH ALL APPLICABLE PROVISIONS OF THE VEHICLE I ~ ~ ,~ ~- N .. ,i '] r~~~yy ..
CODE AND DEPARTMENT REGUTATiONS. ~''~/ ~~'~ ~~ - ,<-"._, ~~.-... _- _ ~ 7 ~ / )~ ~ ~ V "'•tJOlt._
'~• LAVE CERTIFY THAT LANE HAVE EXAMINEDAND SIGNED THIS FORM AFTER ITS COMPLETIONItND E INFORMATION GNEN IS TRUE AND CORRECT. IF ANY EXEMPTION IS CLAIMED,
THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION. WYE ACKNOWLEDGE THAT IILNE MAY LOSE MY/OUR OPERATING PRMLEGES(S) OR VEHICLE
REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. WYE ACKNOWLEDGE THAT LANE
Q MAY BE SUBJECT TO A FINE NOT EXCEEDING 15,000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY FALSE STATEMENT THAT WYE MAKE ON THIS FORM. -
~ 7 ST Signature of Flrst~ Ter or , • Tele-pyhlone No.A A p C t~ [ c,
F ASSIGN- Signature of Co-PurchaserRitle dAuthorized Slgrrer A (~ f L ~ ~ 't "f Gz ` V 3 V .J
y. MENT
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u 2ND Signature of SewrW Ptlrcheaer orAuthortzed Signer Tebptnx» No. _ -
ASSIGN- ( )
MENT nature u er i e er
H, ~ ~ NOTE: IF A CO-PURCHASER OTHER THAN YOUR SPOUSE IS LISTED AND YOU WANT THE TITLE TO BE LISTED AS'JOINT TENANTS WITH RIGHT OF SURVIVORSHIP' (ON DEATH OF ONE
OWNER, TITLE GOES TO SURVMNG OWNER.) CHECK HERE O. OTHERWISE, THE TITLE WILL BE IssUED AS `TENANTS IN COMMON' (oN DEATH OF ONE OWNER, INTEREST OF DECEASED
OWNER GOES TO HIS/HER HEIRS OR ESTATE.)
NOTE: IF THE VEHICLE IS TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK O. IF BLOCK IS CHECKED, COMPLETE AND ATTACH FORM MV-1 L.
MESSENGER NO.:
3. APPLICANT'S COPY /TEMPORARY REGISTRATION (VALID FOR 90 DAYS)