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Home My WebLink About03-0391 i<. f-- \\1 ~ ~ '-.... ~~ .~ ~ K ~6~" '\- ~, ~ ~'~ """"-:;:::. \ ~ ~ "" ~,~, V\ '0 ~ -=:: ~~ ~ ~, ~ ~ ~~~ " ...;::. -:;:::. - <:::) ~ \~ ~F:- -- ~~ ~~ ", ~ .() ~ " '~ - \.__" (' \ .7\ I,I;:! "]..., c"'{ Ct,"',' ~ --> ~'v" ~G ell' "'c( -=::> ~ -S:. '~ - ,\.. ~> \ \.....),,'~ -"0, I i'~ :'. , r-..." C\. :,,'J ::l '\' -,' I' ' \ " ' ~" '-" .)_V \f'~ o ~ ffi ~ ~ ~~ 00 >-~ t!:l~ ~~ ~~ Zr:/J o~ -r:/J ~~ o~ ~~ ~~ t!:l0 ~~ ~~ ~- ~~ ffi~ ~~ ;J ~ ILH In!;~. -fj 0i--:;:'i',r ,_,-,,-.~ ,Ij...._~) \...-'1 . lllt -) .., ; r', 2005 AUG 22 P;112: 13 UJ fJ) erai .. :x: 1-1'0 lX..-I fJ);:)C ....10...... ....IU..-I 1-4 30 Ue:( u. Q.. o~ :z: .. lXe:(UJ UJ....I....I I-lXfJ) fJ)UJI-4 I-4CQ....I t.!):ElX UJ;:)e:( lXUU :E...... 0\ 1'0..-1 \.C\ \.C\cO\c l-,,"ctOC UJINcN lX..o I I I e:(..-I co 1'0 0\ t.!)INCC lXNII..-I e:(cN..-I\.C\C :ENCNC..-I ~ s ~ ~ ~h~ c.;..; o~~ OfJ) ~;3~ ~:E..OZO" ,$e:(Z~(1)~Z rJJ ~ r:/J ro;,::: ro U ~e:(r:/JO~O~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT WEAVER JOANNE M 33 BOURBON RED DRIVE MECHANICSBURG, PA 17050 _____n_ fold ESTATE INFORMATION: SSN: 202-16-4597 FILE NUMBER: 2103-0391 DECEDENT NAME: ADAMS MARGARET M DATE OF PAYMENT: 08/22/2005 POSTMARK DATE: 08/20/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/28/2003 NO. CD 005713 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $1,822.36 I I I I I I I I TOTAL AMOUNT PAID: $1,822.36 REMARKS: CHECK# 764 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS PETITION FOR PROBATE and GRANT OF LETTERS Estate of /9']dc~¥ a a' e fl- /q4. ~da, a~q.5 No. also known as To: Deceased. Register of Wills for the County of -' in the Social Security No..,~ - l~ ~ 5(5~f 7 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 execu~ in the last wilt of the above decedent, dated Pr-~, ~, ~ 7' find codicil(s) dated ' ~ £u TO 4- ~ na~ed ~O (state relevant circnmstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~0~/'>e,- fa, ,~ d ~ ~'- · . . Countv. Penns lva ' ' . ,, v ma w~th . . ~~e~d~~ (list street number and muncipality) ~ De~,~b~ 7~ ~~died ~e~~ ~ ~ ~0~ ~ Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted 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 requests(s) the probate of the last will and codicil(s) presented herewith and the grant of letters_ 4 e'~ 7~ ,m e,~ ~a/. v/ theron. (testamentary; adminjs(rration c.t.a.; administration d.b.n.c.t.a.) tative(s) of the above decedent petitioner(s) will we~e~Struly administer th~tate according Sworn to or affirmed and subscribed ,~ ..~g,~d~ /~. ~~ before me this 6~ch day of [ /// ~ ~ -- - ( OATH OF' PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 3 COUNTY OF E'o~r~¢~' c,a-~'O f ss 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- to law. No. -o$ -3q t Estate Of MARGARET M ADAMS , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW HAY 7, 2003 the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 8-5-1992 described therein be admitted to probate and filed of record as the last will of MARGARET M ADAMS and Letters TESTAMENTAR_.Y are herebygrantedto JOANNE M WEAVER AND JAMES J ADAMS , in consideration of the petition.on FEES Probate, Letters, Etc .......... $ 270.00 Short Certificates( ) .......... $ 60.00 g~hvuva~yovaX)~. EX.T.R&. PAGES. $ ti. O0 JCP $ 10.00 TOTAL $ 349.00 ._ 5-7 -2003 Filed "~:'a'fi &a' ¥~66b't'dF' ~ib'~_6h~' '~-' ? :~003 ATTORNEY (Sup. Ct. I.D. No.) ADDR~SS PHONE WILL OF - 03 -3q I I, ~ARGARET M. ADAMS, revoke all my prior Wills and codicils and declare this to be my Will. FIRST: I direct that all of the expenses of my last illness, funeral, and burial be paid as soon as practicable after my death. SECOND: I devise and bequeath all of my estate, real and personal, wherever situated, to my husband, Delber~ Adams, if he survives me by ~hir~y (30) days, but if he does not so survive me, then I give all of my estate under this Will as follows: (a) I give all of my jewelry to my daughter, Joanne M. Weaver, if she survives me; and (b) I give all of the rest of my estate, real and personal, wherever situated, in equal shares to my children, James J. Adams and Joanne M. Weaver, who are living at the time of my death and to the then living children of any deceased child who shall take, in equal shares, the share my deceased child would have received if living. THIRD: Any property passing under this Will to a person under ~wen~y-one (21) years of age shall be paid to such person's surviving parent or guardian as custodian for such person under the UniformGifts to Minors Act of any state. FOURTH: Ail estate, inheritance, transfer, and other death taxes, including interest and penalties thereon, payable because of my death on the property forming my gross estate for tax purposes, whether or not it passes under this Will, shall be paid from my residuary estate as an administrative expense before the computation of any shares therein. FIFTH: In addition to all powers granted by law, I give the Executor or Executrix acting hereunder the following powers: (a) To retain and invest in all forms of property without regard for the principle of diversification; (b) To sell real and personal property at public or private sale for cash and/or credit; (c) To distribute hereunder in cash or in property, or partly in each; and (d) To settle or compromise claims. SIXTH: I appoint my husband, Delbert Adams, Executor under this Will, but if he fails to qualify or ceases to act, I appoint my son, James J. Ad~s, and my daughter, Joanne M. Weaver, as Co-Executors under this Will, but if either of them fails to qualify or ceases to act, I appoint the other -2- as sole Executor or Executrix under this Will. I direct that no Executor or Executrix shall be required to give bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this .'~ay of August, 1992. '- MA~ARET M. ADAMS Signed, sealed, published and declared by MARGARET M. ADAMS, the Testatrix above named, as and for her Will, in the presence of us who, at her request, in her presence, and in the presence of each other, all being present at the same time, have hereunto subscribed our names as witnesses. 6720 Frankfor4 Ave.,Phila.,PA 19135 Address 6720 Frankford Ave.,Phila.,PA 19135 Address -3- COMMONWEALTH OF PENNSYLVANI& : COUNTY OF PH~'LADELPHI& : SS. I, F~tRGARET M. ADAMS, having been duly qualified according to law, acknowledge that I signed the foregoing instrument as my Will, and that I signed it as my free and voluntary act for the purpose therein expressed. We, having been duly qualified according to law, depose and say that we were present and saw ~%RGARET M. ADAMS sign the foregoing instrument as her Will; that she signed it as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing and at her request signed the Will as witnesses; and that to the best of our knowledge she was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Witness Witness and sworn to before me by. and . ~A~,e ~. ~~ day of August, 1992. Subscribed, sworn to or affirmed, and acknowledged before me by ~tR~ARET M. ADAMS, the Testatrix, and subscribed witnesses, this Notar~ Publ~ · Philadelphia, Philadelphia County ~y Commission Expires July 4, 1994 - 4 - Mc.tuber, Pennsylvania Association of Notaries LAW OFFICE OF JOSEPH G. M. A1VIACI 6720 FRAI~KFORD AVEI~UE PHILADELPHIA, PA 19135 (215) 332-2627 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 002613 WEAVER JOANNE M 33 BOURBON RED DRIVE MECHANICSBURG, PA 17050 ........ fold ESTATE INFORMATION: SSN: 202-16-4597 FILE NUMBER: 2103-0391 DECEDENT NAME: ADAMS MARGARET M DATE OF PAYMENT: 05/27/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 02/28/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $12,219.75 REMARKS: JOANNE M WEAVER TOTAL AMOUNT PAID: $12,219.75 SEAL CHECK# 860 INITIALS: AC RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS .CERTIFICATION OF NOTICE UNDER RULE 5.6(a) / 0oo3 Admin. No. To the Register: I certify that notice of (beneficial interest) .e. state administratio~ 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 /~ O~ ~ff)~ : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except_ "2 Signature Name ~~.~f.~ ~~j Address 0~..~ ~ Telephone (~/~ ~¢/ ~ Capacity: ersonal Representative _ Counsel for personal representative Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 1/10/2005 WEAVER JOANNE M 33 BOURBON RED DRIVE MECHANICSBURG, PA 17050 RE: Estate of ADAMS MARGARET M File Number: 2003-00391 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of. Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 2/28/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARN~H REGISTER OF WILLS cc: File Counsel Judge REV-l500EX(6-00) REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT '* COMlAONWEALlH OF PENNSYlVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 1712lHl601 FILE NUMBER 21 03 391 CCXJmv CODE YEAA NUMBER I- Z W C W U W C DECEDENTS NAME (lAST, FIRST, AND MIDDLE INITIAL) Adams, Margaret SOCIAL SECURITY NUMBER DATE OF DEATH (MM.DD.YEAR) 02128/2003 DATE OF BIRTH (MM.DD.YEAR) 07/07/1925 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) w ... ",:SOl ,,"'''' w"g :E:~....l ".... .. <( ~ 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (AttadI ~y of WiI) D 9. Litigation Proceeds Received D 3. Remainder Retum (date ofdealh prior to 12-13-32) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attad1SChO) D 2. Supplemental Return D 4a. Future IntersstCornpromise (date 01 deaIh afler 12.12-82) D 7. Decedent Maintained a Living Trust (A1tld1 cqly tHrust) o 10. Spousal Poverty Credit(daleofdea1hbetween12-31-91ll1'Kl1-1-95) ... Z W C z 12 Ol w '" '" o " 111I SECTION IIIIIIIT.~ ALL COrli.lUDNtlEIlCI_ ~ _~ lIHOUIJ) EIlIRECIED1O: NAME COMPLETE MAILING ADDRESS j) _ f\ JoAnne A. Weaver 33 "BcxJ,,-hor] ~o 'Orl V c: FIRMNAMEIIf_J lVleChCl..m c..sburc I PA TELEPHONE NUMBER I I 7 /'. -nV (717) 691-1678 l_U \ (1) (2) (3) (4) (5) z o ~ ...I ;:) l- ii: c( u w rx: 1. Real Es1Bte (Schadu. A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortyages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or l) 8. Total Gross Assets (total lines 1-7) 9. Funeral Expenses & Administrative Costs (Sdledule H) 10. Debts of Decedent, Mortgage liabil~ies, & liens (Sdledule I) 11. Total Deductions (total lines 9 & 10) 12. Net Value of Estate (Line 8 minus line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts tor which an election to tax has not been made (Schedule J) 240,360.00 :",) 58,609.00 (6) 45,852.00 (7) ,!,.., ......" ii I..!::::- 344,821.00 (9) (8) 9,400.00 11,980.00 (11) (12) (13) 21,380,00 323,441.00 (10) 14. Net Value Subject to Tax (line 12 minus line 13) 323,441.00 (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I-' ;:) D.. :::E o U ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x.O~ (15) 323,441.00 x.O~ (16) x .12 (17) x .15 (18) (19) 14,555.00 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 14,555.00 19. Tax Due 200 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 'Zf ,.,. BE lltIlETO_ALLGtI.,iCllll8ON__ lIECHECK MAlM < < Decedent's Complete Address: STREET ADDRESS 33 Bourbon Red Drive CITY Mechanicsburg I STATE I ZIP 17050 PA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credlls/payments A. Spousal Poverty Credit 8. Pnor Payments C. Discount (1) 14,555.00 12,220.00 645.00 Total Credlls (A + B + C ) (2) 12,865.00 3. tnteresUPenalty if applicable D.lnlerest E. Penally TotallnteresUPenalty ( D + E ) (3) 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 (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,690.00 A. Enter the interest on the tax due. B. Enler the total of Line 5 + 5A. ThIS is the BALANCE DUE. (5A) (58) 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; ..................... ................ ........ ........"......... ............ .. .. 0 ~ b. retain the right to designate who shall use the property transferred or its income; ................. 0 J(I c. retain a reversionary interest; Dr...... ............................... ................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? .................. ............. 0 g 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 Win trust foru or payable upon death bank account or security at hiS or her death? ... 0 J8] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....... ........................ .................. ......... 'g] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Undltr pen3ties of peljury, I dedilll1hat I have exarrined hs relull, iOOUllng acco~nying sdIBwles and s1atBments, and III !he best of my knowledge and belief, it is true, COiled and COOlplete. Dedaraion of preparer oller flan 11& personal r8l1"888ntatiV& is based on all inl'amation of which prelHWr has any knowledge. A E~dPE.~~~::~i}i(;SRN ____ J;~5~_~A~/7/j~J /t:J'~' <J';~1 M~I',}_ WM~'~f1D,.)_~ ;36 f3~U,k>C/r? ;z.~-:J f)~ _ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ ~ ------- .1"1'1ec.h41'JLL:Shi,JLj , ~~---LZ!I--=>-'V---- ADDRESS For dates of death on or afler July 1, 1994 and before January 1. 1995, Ihe lax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 PS g9116 (a) (1.11 (III 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 PS, 99116 (a) (1.1) (ii)] The statute does not exemDt 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 lax 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 stepparenl of Ihe child is 0% [72 PS. g9116(a)(1.21J. The lax rate imposed on the net value of transfers 10 or for the use of the decedent's lineal beneficiaries is4.5%, except as noted in 72 P.S. 99116(1,2) [72 P,S. 39116(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, 99116(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. REV-1503 EX+ (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF maryuref Itda M 5' All property jointly-owned with right of survivorship must be disclosed on Schedukt F. FILE NUMBER c7- I -0 3 -.31/ ITEM NUMBER 1. DESCRIPTION Please refer to Schedule 81 (2 pages) for d411il VALUE AT DATE OF DEATH 240,360.00 TOTAl (Also enter on line 2, Re<apitulalion) $ (If more space is needed, insert additional sheets oUhe same size) 240,360.00 Schedule B1 page 1 of 2 Margaret M. Adams 5.5202-16-4597 see sch B1 File number 21-03-391 pg 2 of 2 Ave FV @ see sch B1 Comoanv CUSIP Shares bw PAR S/share DOD General Electric 369604 1 0 3 34 Common 24.05 817.70 General Electric 369604103 2688 Common 24.05 64646.40 General Electric 369604 10 3 34 Common 24.05 817.70 General Electric 369604103 672 Common 24.05 16161.60 General Electric 369604103 100 Common 24.05 2405.00 General Electric 369604 10 3 168 Common 24.05 4040.40 General Electric 369604103 336 Common 24.05 8080.80 EDS 285661 104 40 Common 0.01 15.65 626.00 Rockwell 773903 10 9 920 Common 23.02 21178.40 Hughes Electronic 379442 83 2 30 Common 10.15 304.50 General Motors 370442 10 5 230 Common 12/3 33.7 7751.00 Caterpillar 149123101 1380 Common 47.1 64998.00 Boeing 097023 10 5 76 Common 5 26.31 1999.56 Southern Company 842587107 265 Common 5 28.44 7536.60 Southern Company 842587 10 7 200 Common 28.44 5688.00 Southern Company 842587107 465 Common 5 28.44 13224.60 Arvimeritor held by admin 267.66 14.94 3998.84 Delphi 160 8.05 1288.00 CNXT held by admin 920 Common 1.38 1269.60 Cy1ec held by admin 32 Common 29.03 928.96 Acct number Morgan Stanley Van Kampden US govt sec 645068738 2010.00 10588.82 240360.48 Schedule B1 page 2 of 2 Margaret ~ 5.5202-16-4597 File number 21-03-391 GM GE CAT ROK CYT EDS GMH BA SO ARM Delphi CNXT 2/28/2003 2/28/2003 2/2812003 Hl l.Q AVE 34.12 33.58 33.85 24.19 23.74 23.965 47.55 46.7 47.125 23.22 22.8 23.01 29.57 28.7 29.135 15.91 15.39 15.65 10.26 10.03 10.145 28.12 27.24 27.68 28.35 28.49 28.42 15.53 15.15 15.34 7.84 7.79 7.815 1.45 1.37 1.41 3/3/2003 Hl 34.01 24.5 47.35 23.3 29.45 15.95 10.23 27.86 28.67 15.34 8.02 1.42 3/3/2003 l.Q 33.08 23.8 46.8 22.74 28.4 15.35 10.08 22.02 28.25 14.8 8.06 1.37 3/3/2003 AVE Averaae 33.545 33.6975 24.15 24.0575 47.075 47.1 23.02 23.015 28.925 29.03 15.65 15.65 10.155 10.15 24.94 26.31 28.46 28.44 15.07 14.935 8.04 8.05 1.395 1.3825 REV-1509 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Margaret Adams FILE NUMBER 21-03-391 If an asset was made joint within one year of the decadent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A- James J. Adams B. JoAnne A. Weaver C. ADDRESS 1046 Buggywhip Drive Warrington, PA 18796 33 Bourbon Red Drive Mechanicsburg, PA 17050 RELATIONSHIP TO DECEDENT son daughter JOINTLY-OWNED PROPERTY: LETTER om DESCRIPTION OF PROPERTY 'OF DATE OF DEATH ITEM FOR JOINT "ADE INClUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VAlUE Of NUMBER TENANT JOINT IDENTIFYING NUMBER_ ATTACH DEED FOR JOlNTlY-HELD REAL ESTATE VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A- 09130/1998 General EIeclric-Plus acct. number 92414403786 20,134.00 50 10,067.00 2. B 0913011998 GMAC(General MotoIs) acet number 9013030038 75,327.00 50 37,664.00 3. A1B 0311212000 First Bank and Trust acct number 100915677 32,956.00 33 10,878.00 TOTAL (Also enter on line 6, Recapnulation) $ 58,609.00 (If more space is needed, insert additional sheets of the same size) . GE Interest Plus Account Number: 9241043786 BEGIN- NING MONOAY 03/24 03/31 04/07 04/14 04/21 UNOER $15,000 RATE YIELD 2.00 2.02 2.00 2.02 2.00 2.02 2.00 2.02 2.00 2.02 $15,000 TO $49,999.99 RATE YIELD 2.25 2.27 2.25 2.27 2.25 2.27 2.25 2.27 2.25 2.27 OYER $50,000 RATE YIELD 2.50 2.53 2.50 2.53 2.50 2.53 2.50 2.53 2.50 2.53 DELBERT ADAMS & MARGARET ADAMS JT TEN JAMES ADAMS JT TEN 1046 BUGGY WHIP DRIVE WARRINGTDN PA 19136 11437 Summary of Investments, Interest, and Redemptions for the period: MAR 26, 2003 THROUGH APR 25, 2003 $ 20,169.041 $ 0.00 $ 38'~'1 ~ .1l.lllITT O.W ~ 20,207.5. I Date Type of Activity Amount Balance Infonnat.on I Current WHILE"OUR MOVE TO OUR NEW AGENT BANK IS COMPLETE,50ME INVESlORS GE Interest Plus Rates CONTINUE TO USE OLD CHECKS OR SEND MAIL TO OUR PREVIOUS ADDRess. and Account Infonnatlon; PLEASE STOP DOING SO IMMEDIATELY AND 51!! THE ENCLOSED NEWSLETTER 1-800--433-4480 FOR MORE IMPORTANT INFORMATION. 24 hotn/dav, 7 days/week Service Representatives: 03/26/03 BEGINNING BALANCE 20,169.04 1-800-433-4480 04/25/03 INTEREST PAID 38.54 20,207.58 Monday - Friday 8:30 am to 7:00 pm, ET Ovemiaht: Deliveries: GE Interest Plus clo Union Fedef"al Bank 4000 Pendleton Way Indianapolis, IN 46226-5224 ACH and Wire Transfers: Union Federal Bank ABA#" 274070442 su.ary of Year Interest this Period Total Interest Year-ta-Date Tax Withheld Interest Invested 2003 $ 38.54 $ 150.06 $ 0.00 -..- .... .,-." -'_.'-~--"------'---- -?'-~"'-~'-'--"-'--'-'-'---"-~"---'-'-"---'--:~._--_._. . GE Intel'est Plus Additional//JIIOBtnumt Fonn Account Number: 9241043786 '" Hoc D Oleck jf address has changed and complete reverse side. Investments made by check cannot be redeemed for twelve business days after the d1eck is first credited to the account. Chll!(:k/ sl60<lllll8ll $ ... .. Total Mall check(s) and this form to: DELBERT ADAMS & MARGARET ADAMS IT TEN GE Interest Plus P.O. Box 6293 IndIanapolis, IN 46206-6293 I: 50 ~ ~lIlo '1001: '1 21, ~ol, 3 ?Bl7,II" DemandNotes byGMAC Quarterly Summary GMAC Demand Note \lEIWIJ IIlTE NIIIIIER: 9013030038 1 ITE/I IIIAlIED PAGE 1 OF Z MARGARET ADAMS & JOANNE A WEAVER JT TEN 33 BOURBON REO DRIVE MECHANICS BURG , PA 17050 BEGINNING MONDAV 02/24/03 03/03/03 03/10/03 03/17/03 03/24/03 03/31/03 RATE ANNUAL VIELD 3.05 3.05 3.05 3.05 3.05 3.05 3.00 3.00 3.00 3.00 3.00 3.00 CIl _ CLUB - JlIJN _ AND SA'IE $20. SPOUSE AND R VlIIltE CIIlLIIlEN INCI.UIIED AT NIl Ell11lA COST. ANt IWtE III IlDIlEL p'~ vem:LE ClI\IEJlSI. INCI.UDES 24 HR ROADSIDE SERVICE FllR T_. LOCIUllIl", FL.U TIRE, .... START>> EtER&EIICY fUEL, TRIP ROUTIlC, TRIP INTERRUPJ'I1II REIt8JRSEtENT., IIISClIUIlfS & 1lIlRE. JOIN AT 1-800-997-7846 III _.IlIItllI'ORCl...CllIIISA'IE. Summary of INVESTMENTS, INTEREST, and REDEMPTIONS for the period:JAMlARY 1. ZOO3 T1lROUGIlIIARCII 31. 2003 Opening Balance Investments Interest Redemptions Other Charges Closing Balance '74,963.06 . ..110 -. _1.33 .....15.~. ..110 066.68'.3' . :;tW;;>>lll~HltrlW ::m:W$iif~MnNi:;'t;MltMlt;i ::'::'::'::"{~lliiI3{::'t,: :'}}:'fiiiiii:,illiiiiii~iiitt Yi{t8iiij(i!!#iiit{{',',. o..-............."..........,........"........."..'N............. .-............N............,.................... .. .. ...- 01131/03 INTEREST PAID 191.24 75,154.30 For Pro~us & ~icatlon c.n 1-888-271 86 OU2tV03 INTEREST PAID 173.15 75.327 .45 For Current Rate On!y oYlV03 _,IllN 1IRIIERIOOOOO1IIOl 8,815.00 66 .512.45 CaJl1..&OO-428-a32 03131/03 INTI!IlEST PAm 176." 66,68'.3' .......ND NOTE INFORMATION 24 hours a day catl 1-8Q0.548.7923 . C~t Balance . C Reorders . Investmenb: . Currant Rates . R_m~o... . Interes ":r: . pavrol'{Pena on Deduct ani . Cutomer eMu servic:e~s 8:30 a.m. ~ 7: p.m. ET Monday. Aiday TOO Users Call 1-800-258~9868 Owrsea. Em~l~s Call1-312.S 7~ 959 ABAII 071000152 http://www.dunandftotes.eom s.. "M"" for detllils 111111illlll.111111 mmt11.]~~~~~~~!!~ :~:lti~:.liilifM i:MW1i~.~.,."..",.tli~@:t ~;;:i::M:tjj~mm;;:; . . 2 0 0 3 $ 54 1 . 3 ~ $ 54 1 . 33 $ . 0 0 The farm below may be used 10 make additional nweslments to your GMAC Demand Note. (DETACH HERE) -- - .- - DemandNotes by~ Investment Form for GMAC Demand Note: 9013030038 IWl&NIET AD.UtS & .- A IEAYER JT TEN Address Changed? 0 C1t_1he box -. and complete the fonn on the __ side. Note: _lIS by ....... are subJoc:t 10 a ftve..IM.Ishllew, dQ' hold. MlMi~"lilurntAcWcliE~?:"@t@', GMAC Demand Notes The Northern Trust Company P.O. BOX 75920 Chicago, II. 60675-5920 Make _ payaIlIe (In U.S. DaIlars) 10: The Northem Tl1ISt ~.Agent. ..... mal tog_ willt Ihb farm 10 lite address _ Total _t must total at least S50 '1013030038 REV-15l0 EX> (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Margaret Adams FILE NUMBER 21-03-391 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 INClUCEnE IWE OF nETlW<<lFEREE, HIl: RELAllONSHIPTODECEDENT AN) DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBEF 1lEOATEOFTRANSFER. ....1TAOiAca>YOFnE[&I) FORREALESTAlE. VALUE OF ASSET INTEREST ",'''''-''''''' VALUE 1. Morgan Stanley 32,456.00 100 0.00 32,456.00 lJCCOIJnt number 645-102984-110 2. Morgan Stanley 13,396.00 100 0.00 13,396.00 account number 645-102985-110 1&2 co benficiary JoAnne Weaver(daughler) James Adams(son) TOTAL (Also enter on line 7 Recapitulation) $ 45,852.00 (If more space is needed, insert additional sheets oftha same size) ~ ... ~ ~ ... 0 .. .. . .. ~ N W JO el CD ~ E:: l!!! .i:li ~~ _CD lil!: sS -] .. 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(/) VS::: ro bO ~ o ~ s =:N -... -=N -=.. -St- f.1 CD ':' =N 61 -'J:" 0 -... ... .J~~a::C :_<(OG.. -= oOCl - <(wa: -=.... 1Er::. :C:Eza;l =NIiiO~ !=...~&!z =:oJc( -= IAa:O:J: == =<ID~ 1Il...::::Elb o w m ~ a: l!l - ~ ~~ m mCD ..Ill o- Il:.:: ... >o:~o ~~~a:~ -<(~:.:: -0 ~m~a:z~ !i$m~~'f c...JZOI-" u:8~...J:!&; "'a:a:O~iO ir<OOffi- >::i::E;..,~ ... o 'SI. . . fi ~ aE ~. 10 ~ ~ U t i~ m Dc a: oJ I i! l~l!;1iji )i']J!lo ::hc!: ~rh~ ~Jj~ loom t lL U a ~OOOONooooti ":0000000000 ~ IA .. .. ~ggggl!:gggo:o: EOOOO!OOOOi .5 .. .. ,,)~,; . ".... . .. e. .. fie -~ ~ .5~ ~ll ~ -!1! co... . C)C . ......,,, ; "u:~'" c, l! .. m ic::-- ::E iiSE~IS01 c." >". >..- "'J-" c"'" eif"!!. -""- li.a~ll g-El:~ ::Em::EcJ ::E:)(~<( ."0000 "''d''oooo MOoooo .. .. .. .. . Ii j - .: ~ .. :&i =- c .. ~ B .. l!' .. "" u 'il z !! .. Q {t .t .. ~ p...OOOOD\ooa... G\OOOClNOOON "';0000';000...4 ... III .... . . s c: o ::! ..ooOO..oOOO'N e;~~~~"':~9 ~ If)oooooooo'", . .. .. .. .!! ~ eE. .~ . ..- ~ g~ 21 ~ -lli~ ~.!: j C)CCIJ. .0 ... &G:ilS. I :! [h~U II tJlug"" E'ii.E~ .5 Ii g~ B-E'f .l! ::EUi::E Cl::E:>~ li ii!: ill ":. .. :: .: ~ :1 'I I ! ji~~ ~ :ilii!i .~ I ~ a ~ Ct. ~ ~ 0 l:l < ! s ;: :_- ~ lil ~ -C ~ II .5 ~, ~ II ',I.,' II ~ !!. Q,).. CII ': tl I = li ;; .! z a. '0 !l ii > REV.1511 EX+ (12.99) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDUU H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Margaret Adams FR.E NUMBER 2Hl3-391 Debls of dOC8donl must be roportod on Schedule L ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Malepezzi Funeral Home( includes Luncheon) Mechanicsburg, PA 9,400.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s} Social Security Number{s)/EIN Number of Personal Representalive(s) Street Address c~ . state Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) Claimant StreetAddress c~ state .Zip Relationship of Claimant to D8cedent 4. Probate Fees 5. Accountarrt's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enler on line 9, Recapttulalion) $ (If more space is needed, insert additional sheets of the same size) 9,400.00 REV-1512 EX. (12"') .. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIUTIES, & UENS ESTATE OF FILE NUMBER Report debts Incurred by the decedent prior to deIth which rem8lned unpaid .. of the dill of deldh, Including unrelmbursed medal uptn.... ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Medical Expenses(Ho/y Spriril Hospital,Country Meadows, Phannacy, Messiah Village) 11,980.00 TOTAL (Also en"" on line 10, Recap~ulation) $ (If I1lOf8 space is needed, insert additional sheets of the same size) 11,980.00 Estate No.: 21-03-00391 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Estate of ADAMS MARGARET M Late of NASSAU COUNTY NEW YORK Date: 3/09/2005 NO.: 21-03-00391 WEAVER JOANNE M 33 BOURBON RED DRIVE MECHANICSBURG PA 17050 NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE Personal Representative: WEAVER JOANNE M Personal Representative Counsel: ** NO INFORMATION FOUND ** Date of Decedent's Death: 2/28/2000 Date of Delinquency Notice: 2/28/2005 The undersigned, Glenda Farner Strasbaugh, Clerk of Orhans' Court, in accordance with rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor their counsel, have filed with the Register of Wills or Clerk of Orphans' Court, his/her Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule, and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orhans' Court Rules, was given by the Clerk of Orphans' Court on 2/03/2005 and that the ten (10) day notice to file the status report has expired. Accordingly, in accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or their counsel. cc: File Personal Representative Counsel ~~~ Glenda Farner Strasbaugh Clerk of Orhans' Court A hearing is scheduled for May 06, 2005 at 9:30 AM in Courtroom No. ~.3 If the Status Report is filed prior to the hearing date, the hearing will automatically be cancelled. Geo~ J . Register of Wills of Cumberland County Name of Decedent: STATUSREPORTUNDERRUL~ . m()..'/1~ /f' -t /VI '-d a V11 s a I d <g } 03 d- I - 0 3 - Cr) 3 c:w Date of Death: Estate No.: 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: 1. . State ~h~r administration of the estate is complete: Yes ~ No 0 2. lfthe answer is No, state when the personal representative reasonably believes that the administration willbe complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the ~onal representative file a final account with the Court? Yes I12f No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal r~ntative state an account informally to the parties in interest? Yes H ~ No 0 I c. Copies of receipts, rel~ases,joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Dale: J/q{05 s~~ CJ~ -:JU 14//1 t/J -P W (2uu -f/r Name 3-:? 80[)/1od1/llt!/J//(/{;0 A'Pr!t?C h ' ) P 11-. I 70;:) (j ) /1 -to q I -/ b )V Telephone No. j Capacity: rg...fersonal Representative o Counsel for personal representative . , Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: f1 A ~ tU{f.'1 ~I z,~/oJ 2 \ - O~.. 003<1'( .4 1),411..s Date of Death: Estate No.: 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: 1. State ~~er administration of the estate is complete: , Yes .E1 No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration willbe complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a fmal account with the Court? Yes Gt' No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal ;;ePresentative state an account informally to the parties in interest? Yes 0. No 0 c. Copies of receipts, releases, joinders and approval offonnal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. s~8~ .5A-Mf.; 5- ,404r1 ~ Name Date: ~/'/03 r"". " IDyL ~J11'f LJ~,f' DL Address tv M(l/.v') fb-J /J!l- /317<' 2( t) ~'f) /l(k Telephone No. Capacity: 0 Personal Representative o Counsel for personal representative rft r'..'''\,-" BUREAU OF INDIVIDUAL: t~Elr,_, INHERITANCE TAX DIVISION PO Bax 280601 HARRISBURG PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE r,r NOtICE OF INHERITANCE t~ '-APPRAISEMENt, ALLOWANCE OR DISALLOWANCE ,; OF DEDUCtIONS AND ASSESSMENt OF tAX ZGiJ5 MAY 16 M 2: 42 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-09-2005 ADAMS 02-28-2003 21 03-0391 CUMBERLAND 101 CLERi( c ORPHl\~rs CURT JOANNE A IWtt'ER! t>iD :::;0, 33 BOURBON RED DR MECHANICSBURG PA 7050 A.ount R..itted *' REV-1547 EX AFP (03-05) MARGARET M 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 ~ JtU'!."M",.Yf"1'IWM'!.m,"'!M "!II!'"!MMIt'rt'lMM"mr"l'WJtlTftNW1'~"'la:[!MlMM"IlW'.."""""""""""" """ DIS LLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ADAMS MARGARET M FILE NO. 21 03-0391 ACN 101 DATE 05-09-2005 T~ ETURN liAS: I X) ACCEPTED AS FILED I ) CHANGED RESERVATION CONCERNING FUT RE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN ASED ON: ORIGINAL RETURN 1. Real Est.t. (Schedule Al 2. Stocks and Bonds IS_du . B) 3. Closely Held Stock/Pa~t rship Interest (Schedule Cl 4. Ho~tgag.s/Not.s Receivab e (Schedule Dl 5. Cash/Bank Deposits/"isc. Pe~sonal Prop.~ty (Schedule El 6. Jointly Owned P~operty ( chedule fl 7. Transfers (Schedule G) 8. Total Assats III (2) (3) 1'1) (5) 16J 17J .00 240.360.00 .00 .00 .00 58.609.00 45,852.00 IB) APPROVED DEDUCTIONS AND E MPTIONS: 9. Funeral Expenses/Ad.. C stsIHisc. Expenses (Schedule Hl 10. Dobts/Nortgege Liobilit' s/LI.ns ISchedul. I) 11. Total Deductions 12. Nat Value of T.ex R.t ~n 13. Charit.bl./60Ye~nDBn al Bequests; Non-elected 9113 Trusts 14. Net Value of Estat. ubject to Tax (9) 110) 9,400.00 11.980.00 Ill) (12) 113) 11'1) ISchedul. J) NOTE: To insu~e prope~ c~adlt to your account, sulMi t the upper portion of this for. with your tax paywent. 344,821. 00 "1.380 00 323,441. 00 .00 323,441. 00 NOTE: I~ an assessment as issued previously. lines 14. 15 and'or 16. 17. 18 and 19 will re~lect ~igures t at include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. MIolM1t of Line 14 at $81 rate 16. Anount of Line 14 taxab _ at Lineal/Class A rat. 17. ~ount of Line 14 at SI ling ,..t. 18. A~nt of Line 14 taxab a at Coll.teral/Class 8 rate 19. Principal Tax Due S. 115) .00 X 00 = .00 116) 323,441. 00 X 045 = 14,555.00 117J .00 X 12 = .00 118) .00 X 15 = .00 119)= 14,555.00 AMOUNt PAID 12,219.75 DATE 05-27-2003 IRIIIBER CD002613 INTEREST/PEN PAID 1-) 643.14 ~ INTEREST IS CHARGED THROU H 05-24-2005 AT THE RATES APPLICABLE A OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . IF PAID AFTER DATE INDICATED SEE REVERSE FDR CALCULATION OF ADDITIllNA INtEREST. 12,862.89 1,692.11 109.16 1,801. 27 I IF TOTAL DUE IS LESS TMAN $1, NO PAYHENt IS REIlUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YDU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) BUREAU OF INDIVIllUALtAXES INHERITANCE TAX DIVISION PO BOX Z80601 HARRISBURG PA 171Z8-0601 ,.,--,..., ,-,.----r',.... COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT : I: !9 REV-1607 EX AFP (03-05J .~!'" DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-19-2005 ADAMS 02-28-2003 21 03-0391 CUMBERLAND 101 MARGARET M JOANNE:'A WEAVER 33 BOURBON RED DR MECHANICSBURG PA 17050 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: CUT ALONG THIS LINE NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ...... RETAIN LOWER PORTION FOR YOUR RECORDS +- REV-1607 EX AFP (03-05) --------------------------------------------------------------------------- *** INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF ADAMS MARGARET M FILE NO.21 03-0391 ACN 101 DATE 09-19-2005 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-09-2005 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-27-2003 CD002613 643.14 12,219.75 08-20-2005 CD005713 129.56- 1,822.36 TOTAL TAX CREDIT 14,555.69 BALANCE OF TAX DUE .69CR INTEREST AND PEN. .00 II IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .69CR SIDE FOR CALCULATION OF ADDITIONAL INTEREST. I 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. ) Rt.