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HomeMy WebLinkAbout04-0802PETITION FOR GRANT OF LETTERS OF ADMINISTRATION known a5 / TO: Register of Wills for the County of Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, in the for letters of administration off the estate of the above decedent. h /.~ ~tf~lyorp~ci~r~iden~at .'~ ~ 6~ ~,P~sylv~a, with Decendent at death owncd property with estimated values as folllow$: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personml property in Pennsylvania $ (If not d6mlciled in Pa.) Personal property in County $. Va~ue of real estate in Pennsylvania situated as follows: Petifion~___. after a proper aearch ha_ the following spouse (if any) and heirs: Name ascertained ttiat decedent left no will and was survived by Relationship Residence THEP. P. FOR~, petitioner(s) respectfully request(s) the grant of letters of administration in thc appropriate form to the u-*ldersigned. ~ ~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 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 representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed%_~ subscribed beforg.mc this C'~-~ _ day of ~ ~ ~-~~egt~er No.. t- Oq- _l Oa. Estateof~ ~c~/~,~ ~~; GRANT OF LETTERS OF ADMINISTRATION , Deceased ANDNOW QI, A,)~XLL~ C~'-7 og..o©iJr .l~ , in consideration of the petition on the reverse side hereof, ~tisfactory proo~ving bee~resented before me, IT IS DEC~ED that ~ ~ ~a ·, ~ is/~e entitled to Letters of Admi~stration, and i~accord wi~ such finding, Letters of Administration ~e herebygrantcd to ~ -~ ~. o in the estateof ~t~ ~% K ~ FEES Letters of Administration ..... $ ] ~. Oo Short Certificates( ) .......... $ ~ · ~ Renunciation ................ $ ~.~ ,-, TOTAL $ q-~. c>,,...9 Filed .~.7.~..7.;..,~.?..o.~7 .... A.D. 19 ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE RENUNCIATION _ d~c~ased. County, Pennsylvania. The unclenched ~-.~-C-c~ -~---o~ ~_., ~)c-~,~ ~ of the above docedent, hereby renounce(s) the fight to administer the estate and respectfully askfs) that Letters be issaed to (Address) (Addre~-m) /(Add re.~m) ' I05 905 REV (01/04} This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. Calvin B. Johnson, M.D., M.P.H. Secretary of Health 3218341 No. Charles Hardester State Registrar AUG 1 Date :]:'1 IAL ":'- I CERTIFICATE OF DEATH ~ "~ (Coroner) ~ Cmberland East Pennsboro 300 State Street ~,~,~ ~ white West Fat~iew, PA 17025 C~bezZand ~~m~am,- -~ Louis Pa~ae ~ Melba Louise Archer Terry R. Payne m I1C Diller Road. New Cumberland. PA 17070 ~ O ~, ~y 10, 2004 i1~orkto~e Cre~to~ m~, York, PA 17~0~ ]~ FS 012 8~9 L ]m~.O. ~x 431, New C~e~land,PA 17070-0431 ~ , ~verse Effects of Combined Medications , ~'~ [ I coronary artery disease Michael L. Norris, Coroner 6375 Basehore Road, Suite #1 Mechanicsburg, Pa. 17050 AU BUREAU OF INDIVIDUAL TAXES ZNHERTTANCE TAX DZVTSTON DEPT. 280601 HARRTSBURG, PA 17128-0601 STEPHEN D TILEY 5 S HANOVER ST CARLISLE CONHONNEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLONANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN REV-1547 EX 4FP (01-05) 11-01-200q BLEVZNS SAHUEL D 02-03-2002 210Z-080Z ~-'~ .,_ CUMBERLAND 101 Amoun~ Remitted I HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REG/STER OF MILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETATN LONER PORTZON FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR DZSALLONANCE OF DEDUCT/ONS AND ASSESSMENT OF TAX ESTATE OF BLEVTNS SAHUEL D FILE NO. 21 02-0802 ACN 101 DATE 11-01-200q TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: 1. Reel Estate (Schedule A) 2. $. 5. 6. 7. 8. ORIGINAL RETURN Stocks and Bonds (Schedule B) (2) Closely Held Stock/Partnership Interest (Schedule C) ($) Mortgages/Notes Rece/vable (Schedule D) (~) Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) Jointly Owned Property (Schedule F) (6) Transfers (Schedule G) (7) Tote1 Assets APPROVED DEDUCTIONS AND EXEHPTZONS: 9. Funeral Expenses/Adm. Costs/Misc. Expanses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule 1) 11. Total Deductions 12. Nat Value of Tax Return 1:5. (9) (10) Char/table/Governmental Bequests; Non-elected 911:5 Trusts (Schedule J) Nat Value of Estate Subject to Tax 178/280.00 O0 O0 O0 99/511 O0 O0 O0 (8) 70,502.00 .00 NOTE: To insure proper cred/t to your account, subm/t the upper port/on of th/s fora w/th your tax payment. NOTE: 277,791.00 08-$1-200q 08-$1-ZOOq TAX CREDITS: PAYMENT DATE RECEIPT NUMBER COO0~$Z7 CDOOqS28 DISCOUNT {+l INTEREST/PEN PAID (-) 770.00- 31.67- BALANCE OF UNPAID INTEREST/PENALTY AS OF 09-01-ZOOq ZF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL TNTEREST. 10,098.00 31.67 TOTAL TAX CREDIT BALANCE OF TAX DUEI INTEREST AND PEN. TOTAL DUE 9,528.00 .00 3.87 $ .87 { ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUZRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDZT- (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SZDE OF THZS FORM FOR ZNSTRUCTZONS. ) ASSESSMENT OF TAX: ZE. Amount of L/ne lfi at Spousal rata 16. Amount of Line 1~ taxable at L/neaZ/Class A rate (16) 17. Amount of L/ne lq at S/bl/ng rata (17) 18. Amount of L/ne lq taxable a~ Collateral/Class B rate (18) 19. Princ/pal Tax Due · O0 x O0 = . O0 207,289.00 x Oq5= 9,328.00 · O0 x 12 = .00 . O0 x 15 = . O0 (19)= 9,:528. O0 AMOUNT PAID If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. (11) 70.~02. Do (12) 207,289. O0 (15) . O0 (1~) Z07,289. O0 RESERVATION: PURPOSE OF NOTICE: PAYMENT: REFUND (CR): OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in tho estate is transferred in possession or enjoyment to Class 8 (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the tawful Class B (collataral) rate on any such future interest. To fulfill the requirements of Section 1140 of the Inheritance and Estate Tax Act, Act Z$ af ZOO0. (71 P.S. Section 9140). Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side. --Make check or money order payable to: REGISTER OF NILES, AGENT A refund of a tax credit, which Nas not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available at the Office of the Register of Nills, any of the 13 Revenue District Offices, or by calling the special Z4-hour answering service for fores ordering: 1-800-361-Z050; services for taxpayers mith special hearing and / or speaking needs: 1-800-447-3010 (TT only). Any party in interest not satisfied alth the appraisement, allowance, or disalloaance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 181011, Harrisburg, PA 17118-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should ba addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17118-0601 Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decadent" [REV-150Z) for an explanation of administratively correctable errors. If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (51) discount of the tax paid is allomed. The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, tho first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day cf delinquency, or nine (9) months and one (i) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1981 bear interest at the rata of six (61) percent par annum calculated at a daily rate of .00016~. Al1 taxes ehich became delinquent on and after January 1, 1981 will bear interest at a rate which will vary from calendar year to calendar year mith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are: Interest Daily Interest Daily Interest Year Rate Factor Year Rate Factor Year Rate ~ ZOZ .000548 1988-1991 llX .000301 ~ 9X 1983 16Z .000438 1992 97. .0001~7 Z002 61 198~ 111 .000301 1995-1994 71 .000192 ZO05 51 1985 I~Z .0003S6 1995-1996 91 .000247 2004 41 1986 ZOZ .000Z74 1999 7Z .000192 1987 lOZ .000274 2000 7Z .O0019Z --Interest is calculated as follows: ZNTERBST = BALANCE OF TAX UNPAZD X NUIIBER OF DAYS DELINQUENT X DAZLY ~NTEREST FACTOR Daily Factor ,000147 .000164 .000157 .000110 --Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (1S) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must bo calculated. Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717)240-6345 Date: 12/06/2004 PAYNE TERRY RAY 110 DILLER RD NEW CUMBERLAND, PA 17070 RE: Estate of PAYNE DOUGLAS K File Number: 2004-00802 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) 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 ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 12/07/2004 Your prompt attention to this matter will be appreciated. Thank You. CC: File Counsel Judge GLENDA FARNER STRASBAUGH Clerk of the Orphans' Court IN THE MATTER OF THE ESTATE OF GLENN EDWARD GARRISON, DECEASED : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA · ' ORPHANS' COURT DIVISION · ' NO .21 - 03 -0802 CLAIM TO THE CLERK OF THE ORPHAN'S COURT DIVISION: Enter the claim of Nancy J. Gan'ison, 6202 Westover Drive, Mechanms~r~, Penn~]lvan~ 17050 in the mount of $30,000.00 against this Estate. The basis of the aforesaid claim is as follows: Pursuant to the Order of Cumberland County Court dated December 20,. 1999 incorporated in the Divorce Decree indexed to No. 96-6407 Civil, in the said court, the sum of $25,000.00 was awarded pursuant to Paragraph 10 of the Order and the sum of $5,000.00 was awarded pursuant to Paragraph 13 of the said Order. Written notice of said claim was given to the Estate of Glenn Edward Garrison, c/o Ronald D. Butler, Esquire, Butler Law Finn, P.O. Box 1004, Harrisburg, PA 17108-1004. Respectfully submitted, JAMES, SMITH, DIETTERICK & CONNELLY LLP P.O. Box 650 Hershey, PA 17033 (717) 533-3280 Attorneys for Nancy J. Garrison, Claimant IN THE COURT Of COMMON PLEAS OF CUMBERLAND COUNTY STATE OF ~ PENNA. NANCY J. GARRISON, Plaintiff .................................................. Versus GLENN E. GAILRISON, Defendant .................................................. DECREE IN DIVORCE AND NOW,.. December. 20, ...............19gg ..... it is ordered and decreed that Na=cy a. garrison plaintiff, and ................?.]..e.~.=. ?... ~.r.r.i.s.o.R ........................ defendant, are divorced from the bonds of matrimony. The court retains jurisdiction of the following claims which have been raised of record in this action for which a final order has not yet been entered; Decree in Divorce. By The Court: u~A'IFIED COPY ISSUED DEC~D1R~R~20~ .19~99 NANCY J. GARRISON, Plaintiff GLENN E. GARRISON, Defendant : 13I THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 96 - 6407 CIVIL : : CIVIL ACTION - LAW : IN DIVORCE ORDER AND NOW, this ,%~9'/~- day of ~-'~'/r~'~c , 1999, IT IS HEREBY ORDERED AND DECREED THAT: 1. Nancy J. Garrison, Plaintiff, and Glenn E. Garrison, Defendant, are divorced from the bonds of matrknony. 2. The Report and Recommendations of the Special Master is hereby approved. 3. Within 30 days of the date of this Decree, husband shall vacate the residence at 6202 Westover Drive, Mechanicsburg, Pennsylvania, and provide to wife a special warranty deed Iransferring all his right, title and interest in said property to wife. However, Wife will take the property, subject to the existing mortgage in favor of Fleet Mo, rtgage Corporation, and indemnify and Save husband harmless on account of any claims which may be made by Fleet Mortgage Corporation against husband. Any liens which may be again.qt the property, other than the mortgage, will be husband's sole and separate responsibility. 4. Wife shall be entitled to retain her IRA and her pension w/th the PSERS free of any claim~ by husband. 5. Husband shall transfer to wife, within 30 days of this Decree, the title to the 1990 Pontiac Grand Prix amomobile. 6. Husband shall be entitled to retain all his shares of stock in the corporation known as Interpak Systems, Incorporated, free of any claims by wife. 7. Husband shall retain any IRAs which he owns, whether they are marital or nonmarital or a combination thereof, free of any claims by wife. 8. Husband shall retain, as his sole and separate property, the 1994 Oldsmobile Delta 88 automobile or any automobiles that he has acquired subsequent. 9. Husband shall leave in the marital residence, upon his vacation of the property, the following items of household property: The washer and dryer, the couch, chair, leather recliner, and the king-size bed, mattress and box spring. Any and all personal separate property of the husband, with the exception of items owned by wife prior to the marriage which husband shall leave on the premises when he vacates. 10. Husband shall pay to wife the sum of $25,000.00, which shall be roiled out of his IRA. If there are no IRAs existing owned by husband, then husband shall pay to wife the sum of $25,000.00 in cash. The roll-over or payment of cash to wife shall occur within 30 days of this Decree. 11. The parties will sign all ritles and documents necessary to transfer ownership of assets to each of the parties as herein provided in the distribution of assets set forth above so that all transfers are accomplished withln 30 days of this Decree. 12~ Husband sh~T! pay to wife alimony in the sum of $800.00 per month through the Cumberland County Domestic Kelations Office to begin u~on the entry of a Divorce Decree in these proceedings. The amount and duration of alimony shall be subject to modification and termination on petition of either party as allowed under Section 3701(e) of the Domestic Relations Code, Specific Termination provisions in the Domestic Relations Code will also apply. 13. Husband shall pay to wife withha 30 days of this Decree, the sum of $5,000.00 which will be applied to wife's counsel fees and appraisal fees. BY THE COURT: IN THE MATTER OF THE ESTATE OF GLENN EDWARD GARRISON, DECEASED : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION _. : NO. 21-03-0802 CERTIFICATE OF SERVICE I, John J. Connelly, Jr., Esquire, of James, Smith, Dietterick & Connelly, LLP attomey for the Claimant, Nancy J. Garrison, hereby certify that I have served a copy of the foregoing Claim on the following on the date and in the manner indicated below: U.S MAIL~ FIRST CLASS~ PRE-PAID Ronald D. Butler, Esquire P.O. Box 1004 Harrisburg, PA 17108-1004 JAMES, SMITH, DIETTERICK & CONNELLY LLP Hershey, PA 17033 (717) 533-3280 PA I.D. No. 15615 IN THE COUNTY OF CUMBERLAND, STATE OF PENNSYLVANIA PROBATE DIVISION IN RE: ESTATE OF: FILE NUMBER:21200408,QZ ~ ':,:.-;:> CJ'l L_ C) ~,~;o ',-:XJ ;;?CJ >,i'''' DOUGLAS K.PAYNE Deceased. ..',' >:.:. co n ~I'-, / STATEMENT OF CLAIM The undersigned hereby presents for filing against the above estate this statement of claim and alleges: I. The basis for the claim is ORLANDO UTILITIES COMMISSION ACCT# 1296174-1054221 2. The name and address ofthe claimant is ASSET ACCEPTANCE,LLC PO BOX 2036 W ARREN,MI. 48090 3. The amount of the claim is $ 129.25 , which amount is now due and owing or, if not due, will become due on ,200_. 4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty is 5. The claim (is) (is not) secured. If secured, the security consists of Under penlties of perjury, 1 declare that I have read the foregoing, and the facts alleged are true, the best of my knowledge and belief. UL DATE this UFco. day of January, 2005. '~ '-- r"' ~ ( 00>t.v "- ,;p --~o {i-l C") ;::;~ ,;'--) - ,.;~ _:~ ;:'.J r' 'j ~ -' r-'.) (J1 <.n AFFIDAVIT OF ACCOUNT STATE OF MICHIGAN COUNTY OF MACOMB Debtors Name: Account Number: Original Creditor: OOUGLAS PAYNES 15454436 I ORLANDO UTILITIES P.L Conaton, being sworn, deposes and says that she is the Manager of Probate at ASSET ACCEPTANCE LLC, (creditor). The corporation ia a Michigan corporation located at P.O. BOX 2036 WARREN, MI 48090. The affiant is authorized to make the statements herin pursuant to authority granted by the corporation. The corporations' business records show that there is due and payable on account 1296174-1054221 the amount of $129.25 date on a debt originally held by / ORLANDO UTILITIES and assigned to the corporation in the normal course of business by the original creditor or their lawful assignee. The affiant states that to the best of his knowledge, information and belief there are no uncredited payments, counter-claims or offsets against said debt. Said account has been assigned, transferred and sold to ASSET ACCEPTANCE LLC with full power and authority to do and perform all acts necessary for the collection, settlement, adjustment, compromise or satisfaction of said claim. Further, the undersigned acknowledges that in making the assignment, ASSET ACCEPTANCE LLC is now the owner of this account, and has complete authority to enforce the rights of the original creditor with the debtor, and that the assignor or original creditor has no further interest in said debt for any purpose. Dated 06th day of January 2005. ASSET ACCEPTANCE LtC By: ~1-.~/f)U P.L. Conaton P.O. BOX 2036 WARREN, MI 48090 Subscribed and sworn to before me this 06th day of January 2005. Notary Public Kelly Olson My Commission Expires: October 11, 2006 County of MaCOmb, State of MiChigan C1/06/05 9 :28 AM TMO JEBTOR Name:PAYNES DOUGLAS City: St: Zip: Cty: St: ASSET ACCEPTANCE LLC SELECTED Ssn:192500048 Zip: Clnt:990633 AALLC/ORLANDO UTILITIES List:09/26/03 Srv:03/23/00 p195:R ~AYMENTS No payments. PROBATE ORGNL CREDITOR :990633 FIDUCIARY :ADM: TERRY PAYNE COUNTY : CUMBERLAND CASE NBR :2120040802 BALANCE :129.25 DATE :01/05/2005 DATE OF DEATH :05/07/2004 CLAIM DATE :01/06/2005 STATUS OF CLAIM PUT A ONE HERE ,1 CANCEL CODE AF6000 W801 DEC LAST W80l DEC FIRST W80l DEC DATE waOl DEC MATCH TU LAST NAME TU FIRST NAME TU DTE OF DEATH TU LAST STATE TU PAY LOCATION PREY COLL :TMO ** END OF REPORT ** COMMISSION 9/03, Time:13 Calls:3 Cane: Cbr: Ph: Born: Sa1: COF: , 1296174-1054221 Con:2 Bal: 129.25 Org: 129.25 FIDUCIARY ADD1 : 110 DILLERD ROAD FIDUCIARY ADD2 FIDUCIARY CITY :NEW CUMBERLAND FID STATE & ZIP :PA 17070 FIDUCIARY PH NO COURT NAME COURT ADD1 COURT ADD2 COURT CITY COURT ST ZIP COURT PHONE NO ENTER COURT ID COURT CRT ADD CRT ADD2 CITYSTZIP CRT PHONE :CUMBERLAND COUNTY :COURTHSE-REG OF WILLS :1 COURTHOUSE SQUARE : CARLISLE :PA 17013 : 717.240.6345 IN THE COUNTY OF CUMBERLAND , STATE OF PENNSYL VANIA PROBATE DIVISION FILE NUMBER:2120040802 IN RE: ESTATE OF: DOUGLAS K.PAYNE Deceased. o :::n =.."2 '" C;;) ,~~~ L...,q / STATEMENT OF CLAIM ill -" The undersigned hereby presents for filing against the above estate this statement of claim and alleges: } -, I'.) Ul (.n 1. The basis for the claim is CHASE MANHATTAN BANK ACCT # 5431430115598523 2. The name and address of the claimant is ASSET ACCEPTANCE.LLC PO BOX 2036 WARREN.MI. 48090 3. The amount of the claim is $ 1657.31 , which amount is now due and owing or, if not due, will become due on , 200_. 4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty is 5. The claim (is) (is not) secured. If secured, the security consists of Under penlties of perjury, I declare that I have read the foregoing, and the facts alleged are true, the best of my knowledge and belief. DATE this 'p~ d'yo' JM""Y'20:J~ ' J-;lro~ - ~ XI (-n .-) c::) ::":";~) -, "...... ,;', c:) -Tl AFFIDAVIT OF ACCOUNT STATE OF MICHIGAN COUNTY OF MACOMB Debtors Name: Account Number: Original Creditor: OOUGLAS K PAYNB 13542241 PROVIDIAN I CHASE MANHATTAN BANK P,L Conaton, being sworn, deposes and says that she is the Manager of Probate at ASSET ACCEPTANCE LLC, (creditor}. The corporation is a Michigan corporation located at P.O. BOX 2036 WARREN, MI 48090. The affiant is authorized to make the statements herin pursuan~ to authority granted by the corporation. The corporations' business records show that there is due and payable on account 5431430115598523 the amount of $1657.31 date on a debt originally held by PROVIDIAN I CHASE MANHATTAN BANK and assigned to the corporation in the normal course of business by the original creditor or their lawful assignee. The affiant states that to the best of his knowledge, information and belief there are no uncredited payments, counter-claims or offsets against said debt. Said account has been assigned, transferred and sold to ASSET ACCEPTANCE LLC with full power and authority to do and perform all acts necessary for the collection, settlement, adjustment, compromise or satisfaction of said claim, Further, the undersigned acknowledges that in making the assignment, ASSET ACCEPTANCE LLC is now the owner of this account, and has complete authority to enforce the rights of the original creditor with the debtor, and that the assignor or original creditor has no further interest in said debt for any purpose. Dated 06th day of January 2005, ASSET ACCEPTANCE LLC '?L .rDnfL~ By: P,L, Conaten P.O. BOX 2036 WARREN, MI 48090 Subscribed and sworn to before me this 06th day of January 2005, Notary Public Kelly Olson My Commission Expires: October 11, 2006 County of Macomb, State of Michigan 01/06/05 9:28 AM TMO DEBTOR Name:PAYNE DOUGLAS K Adr1:300 STATE ST 2F City;ENOLA St: PA Zip:17025 ASSET ACCEPTANCE LLC SELECTED Ssn: 192500048 POE:SHIFLETT CLEANING Lgl: Cty: Cane: St: Zip: COF: Clnt:990628 AALLC/CHASE MANHATTAN BANK 7/03, List:08/04/03 SrV:11/26/00 Ltrs:7 Time:21 Aty:O 'AYMENTS No payments. PROBATE ORGNL CREDITOR :990628 FIDUCIARY : ADMIN: TERRY PAYNE COUNTY : CUMBERLAND CASE NBR :2120040802 BALANCE :1657.31 DATE :01/05/2005 DATE OF DEATH :05/07/2004 CLAIM DATE :01/06/2005 STATUS OF CLAIM PUT A ONE HERE ,1 CANCEL CODE AF6000 waDI DEC LAST W801 DEC FIRST Wa01 DEC DATE Wa01 DEC MATCH TU LAST NAME TU FIRST NAME TU DTE OF DEATH TU LAST STATE TU PAY LOCATION PREV COLL : JOY URIGINAL LENDER :PROVIDIAN LENDER ** END OF REPORT ** Cbr: Ph:717-72a-aa5aB POE Ph; Born:08/01/1960 Sal: , 5431430115598523 Calls:O Con:2 Bal: Int: Org: 1559.03 1657.31 98.28 FIDUCIARY ADD1 :110 DILLERD ROAD FIDUCIARY ADD2 FIDUCIARY CITY :NEW CUMBERLAND FIO STATE & ZIP :PA 17070 FIDUCIARY PH NO COURT NAME COURT ADD1 COURT ADD2 COURT CITY COURT ST ZIP COURT PHONE NO ENTER COURT ID COURT CRT ADD CRT ADD2 CITYSTZIP CRT PHONE :CUMBERLAND COUNTY :COURT HSE/REG OF WILLS : 1 COURTHOUSE SQUARE : CARLISLE :PA 17013 :717.240.6345 :PR-CUMB-PA :CUMBERLANO PROBATE CT :PA : 717.240.6345 IN THE COUNTY OF CUMBERLAND , STATE OF PENNSYLVANIA PROBATE DIVISION FILE NUMBER:2120040802 IN RE: ESTATE OF: DOUGLAS K.P A YNE Deceased. '" = ,':;;;;~',L , ., ;.....;;;;p, ~ :'T"n, "le:.:, ,--~ ~::2 I STATEMENT OF CLAIM ~, ". J 'f'j C':) C~} <:) .,.'., .ti The undersigned hereby presents for filing against the above estate this statenleiJ,F\if -CJ claim and alleges: f"~) 1, The basis for the claim is CITIBANK ACCT # 7738169107719000 <':1 Ul 2. The name and address of the claimant is ASSET ACCEPTANCE,LLC PO BOX 2036 W ARREN.ML 48090 3, The amount of the claim is $ 2997.60 , which amount is now due and owing or, if not due, will become due on , 200_. 4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty is 5. The claim (is) (is not) secured. If secured, the security consists of Under penlties of perjury, I declare that I have read the foregoing, and the facts alleged are true, the best of my knowledge and belief. DATE this (j}H~ day of January, 2005,,) ~.:J~ J ~b~ i,}- . CO) - i r1 ') C) AFFIDAVIT OF ACCOUNT STATE OF MICHIGAN COUNTY OF MACOMB Debtors Name; DOUGLAS K PAYNE SR 15783243 CITIBANK/RADIO SHACK I CITIBANK Account Number: Original Creditor: P.L Conaton, being sworn, deposes and says that she is the Manager of Probate at ASSET ACCEPTANCE LLC, (creditor). The corporation is a Michigan corporation located at P.O. BOX 2036 WARREN, MI 48090. The affiant is authorized to make the statements herin pursuant to authority granted by the corporation. The corporations' business records show that there is due and payable on account 7738169107719000 the amount of $2997.60 date on a debt originally held by CITIBANK/RADIO SHACK I CITIBANK and assigned to the corporation in the normal course of business by the original creditor or their lawful assignee. The affiant states that to the best of his knowledge, information and belief there are no uncredited payments, counter-claims or offsets against said debt. Said account has been assigned, transferred and sold to ASSET ACCEPTANCE LLC with full power and authority to do and perform all acts necessary for the collection, settlement, adjustment, compromise or satisfaction of said claim. Further, the undersigned acknowledges that in making the assignment, ASSET ACCEPTANCE LLC is now the owner of this account, and has complete authority to enforce the rights of the original creditor with the debtor, and that the assignor or original creditor has no further interest in said debt for any purpose. Dated 06th day of January 2005. ASSET ACCEPTANCE LLC ~L.OoYU~ By: P.L. Conaton P.O. BOX 2036 WARREN, MI 48090 Subscribed and sworn to before me this 06th day of January 2005. Notary Public Kelly Olson My Commission Expires: October 11, 2006 County of Macomb, State of Michigan 01/06/05 9:29 AM TMO ASSET ACCEPTANCE LLC SELECTED 'JEBTOR ----------------------------------------------------------------------------------------------------------------------------------- UAYMENTS No payments. 'ROBATE JRIGINAL LENDER Name:PAYNE SR DOUGLAS K Adr1:300 STATE ST # 2F City:ENOLA St: PA Zip:170253178 Ssn:192500048 POE:SHIFLETT CLEANING Lgl: Cty: Cane: St: Zip: COF: Clnt:990644 AALLC/CITIBANK 11/03, List:12/02/03 Srv:02/28/01 Ltrs:8 Aty:O , 7738169107719000 Time:7 Calls:O Con:2 ORGNL CREDITOR FIDUCIARY COUNTY CASE NBR BALANCE DATE DATE OF DEATH CLAIM DATE STATUS OF CLAIM PUT A ONE HERE CANCEL CODE AF6000 WaDI DEC LAST wa01 DEC FIRST W801 DEC DATE Wa01 DEC MATCH TU LAST NAME TV FIRST NAME TV DTE OF DEATH TV LAST STATE TlJ PAY LOCATION PREV COLL LENDER ** END OF REPORT ** :990644 :ADM: TERRY PAYNE : CUMBERLAND :2120040802 :2997.60 : 01/05/2005 :05/07/2004 :01/06/2005 ,1 :JDY :CITIBANK/RADIO SHACK Cbr: ph: 728-8858! POE Ph: Born:08/01/1960 Sal: Org: 2809.31 Bal: 2997.60 Int: 188.29 FIDUCIARY ADD1 :110 DILLERD FIDUCIARY ADD2 FIDUCIARY CITY :NEW CUMBERLAND FID STATE & ZIP :PA 17070 FIDUCIARY PH NO COURT NAME COURT ADOl COURT ADD2 COURT CITY COURT ST ZIP COURT PHONE NO ENTER COURT ID COURT CRT ADD CRT ADD2 CITYSTZIP CRT PHONE :CUMBERLAND COUNTY :COURTHSE-REG OF WILLS : 1 COURTHOUSE SQUARE : CARLISLE :PA 17013 :717 240 6345 JRD/June 30, 1992/17858 In Re: Estate of Douglas K. Payne Late of East Pennsboro Township ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Estate No,: 21-04-0802 NO, 21-2004-0802 NOTiCE OF FAILURE TO FILE CERTiFICATiON AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT ORPHANS' COURT RULE Personal Representative: Terry Ray Payne Counsel for Personal Representative: Date of Grant of Original Letters: 08/27/2004 Date of Delinquency Notice: 12/07/2004 The undersigned, Glenda Farner-Strasbaugh, Clerk of the Orphans' Court, in accordance with Rule 5.6, 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 the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on December 7, 2004, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule 5.6(e) 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 counsel for the delinquent personal representative. Date: 01/19/2005 ~,=~ Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File rm~'t, 1.00'1- Q:3oA.M A hearing is scheduled for at in Courtroom No.3. If the Certification of Notice is file' prio, '" <h, h=iog ""c, <h, h~ciog will ,,<0="0011, b, '",,~A:~ Georg!: V6ffl ., ,;)/- {fI- O~Od-- CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: U" u..~0\. "> k..; d:_ Qp.........{\e..... , Date of Death: ffi",--. , "1 ~ 00 '-l , Will No. Admin. No. 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 1'1= Address (\0 1'\"- Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: \\ 5\\c.S . . /::v?~-~ Signatur i . ~ ~. ...- ". Name -\ ~ _. ,..... n n"... ~ " , ..~. t'~,,, I'l"'- ". , . Address \ \ Cl U. \ \ e.< Q.. J-.. \\e.... ~""'\:,€..(" It,,.J... P /\. llulu N LD ("',; Telephone (1'-0 It ~ .. (., <. :l ~ \ r.~''') I Capacity: L- Personal Representative _Counsel for personal representative ~ WELTMAN, WEINBERG & REIS CO., L.P.A. AnORNf,YSATLAW 175 South Third Street, Suite 900 Columbus, Ohio 43215 800.325.9965 614.801.2710 www.weltman.com BURLINGTON, NJ 609.914.0437 CHICAGO, 11. 847.940.9812 CINCINNATI, OH 513.723.2200 CLEVELAND, OH 216.685.1000 DETROIT, MI 248.362.6100 PHILADELPHIA, PA 215.599.1500 PITTSBURGH, PA 412.434.7955 February 25,2005 Cumberland, Register Of Wills One Courthouse Square Carlisle, PA 017013 ('~ r-....) I;:~:::') c~..;) C.J"l Re: Estate of Doug K Payne Case No. 21-04-0802 Our Client: Portfolio Recovery Account No. 0557441638490 Balance Due: $1,461.60 Our File No. 4108433 w -r) 1-"') 1'1 Dear Clerk of Courts: 1',) 0\ This law firm represents Portfolio Recovery in connection with its claim which we wish to file on our client's behalf into the estate of Doug K Payne, deceased. Enclosed is our check in the amount of $1 0.00 which we understand is the filing fee for this claim. Our client's claim is based upon its account number 0557441638490 in the amount of $1 ,461.60. As of the date of this letter, this is the amount due. Inclhded with this letter is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fiduciary of this estate. It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the undersigned. Thank you for your cooperation in this matter. SSH:sek Enclosures cc: Terry Ray Payne None \/" WWR#4108433 FORM 93-0.C. DIVISION IN THE COURT OF COMMON PLEAS of CUMBERLAND, REGISTER OF WILLS, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF No. 21-04-0802 DOUI! K Payne , Deceased For an installment loan with Portfolio Recovery, Account No. 0557441638490 CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your official records of the claim of Portfolio Recoverv c/o Weltman. Weinberg & Reis Co.. L.P.A.. 175 South Third Street. Suite 900 Columbus OH 43215 (Claimant) in the amount of $1.461.60 against the estate of the above named decedent. This claim is filed under Section 3532 (b) (2) ofthe Probate, Estates and Fiduciaries Code. The said decedent, who resided at 300 State St 2f PA 17025 , died on 05/07/04 (Address) Written notice of this claim was given to Terrv Rav Payne None (Personal representative, if any, or counsel) Enola at Will Not Give Address. Address or Personal Representative, if any, or counsel WWR # 4108433 STATEMENT OF ACCOUNTS FOR: Portfolio Recoverv DECEDENT'S NAME: Doug K Payne ADDRESS: 300 State St 2f CSZ: Enola, P A 17025 SSN: 192-50-0048 DOD: 05/07/04 ACCOUNT #: 0557441638490 BALANCE DUE: _$1,461.60 EXHIBIT A ~ " \ r., ;-) \<:......e:. Ie \',- 0 \ Ci'-k,_(-"t,,:, ',\' -'-r\~A:X: \'--', \' \. t: 1-, '-J ','-..'-':'i..'-"'- \ ~-, C\~ ~)~ f . :.~') (:' \~ \;:'. ~I;:'._ -[ '\ V''-'~__ '(""', \) ----:;--' ',' , ---'\- L.; -y- J.,_.. 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(:......~ '.;- ~ ~~_ ,_. , 1\ C. ;rd'-JL~ +0. ~<::.:t ~~ --l\'-f: '" '\-' --\--c; ~\ \ e. 0- She ,~~-T l.~ ". b' L>-J::3- C~ce'\ e_.n.c\c,,=~ } c'--~ ~"'<L CL.:.~,,--\ ~O'"-~ \<h..lol. --r\,,-e_\~ -\-6-\-l.!.-. -\-'\.~~L \c\..,,-A., \o'--d\.. -+a S~. (I , ,'i "" ~ C~..c-.J t_,,-,-.:1- " --'\\ ') I :::. \~ "'~-'\. . "E._ c,\~ \e.h~(jr'\ ("Ai- -r\, E- (~ ~,--r -\- \-.0...: ~ . -r- \ \~ cl"~, 0, c, ',\, L....:. (_.... I \--, .~ \ i- -\-'-"-..-- ('- t_.D'l...... G ,~.:.:t" l,.i;""": "'-:'.- t"\ Q. 'J~r' C~ L~.-A \oc~ " ..~ "(\~"...( '. 0.\- (....i_ \ \ c:l-c:=':'~.i..,,_ i" ',_ (.J . C'-.J ~ +~ ~-Th~G' --L \-") \""~ 'yt;~ cl ''(0 \-. U ' c....~\ CJ.L..... Clrv:J\ l,'-J v.-- ~ \.::.... l~(""'" q.. \~C"......:: .- ('~ --.y\." -(~~ I-'r'\ \,,€.., \ ~'('/\"<-..L,.. --r A- f --tV"\ <c, ,.".... I....-J \.:y~ -t'~.- ~ \~ ~~~. -t-"l;:j --\'C C:-u ,"-c,- \) \ 'E?~\C .x. ./ ej (.~-1 \) ~~r-<.""" -\-\ ,::..'. :-'\ _ _.J.._ c.... ................ v"- (,.c},.....L. \ -.,' \'{'. \~. \ ~ f r c... ~ <:::;; l~ ,~ C.:c... ~T:- ,'{,<,.9-'~~ C"",,>c1. -t\-..o~-i- --tV" \ S 1J'.<y-... I '1---0..>1 <- cc",'(:.:.,-.S,b, \ .~~ ~+ , -'\ -1 ..'" \ .:.~ \ ~ ~~ \..~S -\- ~ '" <.. b le-,'^-- 'l'c'_.:-\-<..t.~ X'\''\. '-\ o t\c... e... ~.~ \ .c....... Co. ",:,>,' _ f'\.. . c' Q . l - '-' ~ ~ <-7=(j~'o~ \ ~-- ':- ...-'\ {-) Q \, ~ '\ Ct- '\'1'-<... .~ OF REV1 1500 ~IC: ~~~~~;j:, INHERITANCE TAX RETURN t=-h !f'l~8-c;'JOl . RESIDENT DECEDENT ~_. . --- ...."' -. . FILE NUMBER CODE YEAR NUMBER I I\\I\I.D[. I, [,e'.f'; I ~I ~ S~OCIAL SECURITY NUMBER \q~ - ~O -O(ji~ 1 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE L . REGISTER OF WILLS -.-----~-. i SOCIAL SECURITY NUMBER ..-- I '-" ___1- S I\L-\\,: E I L:\ST . _S?9Jg_~~ ~_..~~_~~ Il~ I T [,.;.L i \ {'--J \ -fd i=uture Illterest COfliprol1 St: .,Iler 3. Remainder Return (dale of death pnor to 12.13-8::: Sc.:JfJier~lell!cll r"\8lUfll cJ -lrllsl, 5. Federal Estate Tax Return Required 8. Total Number or Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) IAltaCh C)) S;xJusal (~:'eljlt .\ 1';-;.5 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: E_\~,=,'i. ?~~~Z_~_~_______u_1 C~;\~ET~~L~~:OR~ ! 0 :~~q__~__uu_ ___I \\e~., ~,\::'....- \'^'~ QA- \\.QleJ !:<tidi L~SUl:: I.Scneuult' 1) 2J o o o CJ o S~JC~,:) Closelj':anllerSiW or So:e-fJrOfJr,elorsnii; -+ 1'/ll)f\::Jcije::: & !~CI8S ..:lCI<2 IScredule D! 141 ~::\S;1 D2PSI[S & i.li:;cellaneous Per'sonal Propeny Schel;.lii:; E: Propei I\ I Scr ieJule F <: . . _. SepLiia',e 6:\lliI9 : 6, o TrcHlSfe:'s :\ 1'.\lscellaneous Non-Probate Propenj CL- LL <~~ ?j) o l' Jtal Gross Assets (WU: 1-7' (8) E; c< Costs ,Sd1eouie Hi Q 1..... "~U\:) Liabilities 6. Liens! Scrledule ! 11u! rtJ ~ (.-J lural D2(juctiofi:-.i 0. (11) _ Iht Value of Estate ,]I!!lLlS ~lrle l' (12) 3equ8:)ISiS.::C: 9113 Trlls!s for Mlicn cHI election [u tal. lias ueep \ 13) VaILlt:: Subject to T~~^ fiV1L1S L,ile ( 14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES r\ '--' xO _ (15) 1-. ~ r-- 0_ (16) c x12 ( 17) (.1 '!UlIil! x 15 (18) ~ <{ : .~;: 0 ue 119) ~ 0- _J ~~I'3'f~~f~~1~:tI1~.I~f~)~r~~;rnt1U'l;~ ~----~ > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < ~~~- , {.; <_: e (:: ~-; I J I ZIP l'\. c, ;;l.';- 1 '-.------'1' STATE 0-: " A- Cradhs: (1 ) c" Tala I Credits ( A + B + C ) (2) TotallnterestJPenalty ( 0 + E ) Lille enter tile uiffereclce ThiS IS the OVERPAYMENT. Chl:U, Ij0X on Page '1 Line 20 to request a refund (3) (4 ) (5) C (5A) (58) -:It 0 Ui:::1f'I Lil18 emer tlie Jinerence. Tn,s Uie: TAX DUE. ~\ EnIdr' fnt~ j .JE:: Uk j -~ 5,~ ThiS IS tr18 BALANCE DUE, Make Check Payable to: REGISTER OF WILLS, AGENT I:JLEASE ,;j"'JSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS [flE:: Lise or ::icome of [f18 ;Hopeny [ransfern:;d ." Yes ",,,,,,...,,,,.,, .".,. ""'" ".." .",,, ",,,,,....' ...... D who snail Lise lile P-Oij8rly lrdnsf~rled ur its income; ",,,,...'.....,....,..............,,...... D ...... .,,,...........,.......................... D ,.,' ""..,.".",...,. '....."".""......,.,, .'''.. .."..."".".. D No rg' []:, ~ ~. I. ,;::;";2lit;i-II n,ake CI [ransrer 3ilU: ~ ~ ,~: "~liE ANSWER TO ,clINY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. :118 prom~se for life or eilrler payments benefits ~xurred aftd Oecembei' '\ 2. \ 982, diel Liececlblil 'J-:ilister' property witrlin one year of death o r::-;C8j,1119 adequate conslderJtion',- "".......... ,....... ......' ..... ... '......... ............... I .ki-':8dem (}.Vf\ em "in [rust for" or payable upon dE:aIh OeHii'. axount or security at his or her death? .............. 0 0.\11 all Incilv!cjual Rel!Cerri8m .Q..CCQUfIl. Jfmulty or Jther lion-probate property which desig na riOll '/ ..... .,....,.........,...............,.............. D . ~ cl -:- ~tiH(:nel1ls. anJ to me best of my knowledge and belief, it is true. correct and complete, iily kno.:;lellgCJ -~1~1-L).B.~_QL2ffi.s0N- r~<~SPq~6LE F8FrFfL-nyG RETURf~_ ",,/ c,,~Z~'--~;/~>) ',,::,(/<:--C-,-)___~__ L . __u~ .... ~/ . ~/".r ~ '; \ '\ \,,,,. ,-','<..:(~-,-), \\e.l.........: C~.---,-"'~'J,:.:- \('\"'-"'''''~ , PREP.:'.RL~;:. '~T:-iER TH'f~N REPRESENTA:iIVE DATE dJ~<o /0(, ~)~- t -l u-l.. ~ DATE ld~t;S vi (Jf'. 1904 befor'e JaIlU~lr! '11995 me teL". rate irt!po:S'jd on the net value of transfers to or for the use of the surviving spouse is 3% S 39'~ I ! '1 1 0S,5 [he lei" fale :rnpGSl~(J Oil the' li:.';['/cllue !rclilsfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (3) (1.1) (ii)~, :I S!J'IVillg3pouse rr,JIII [elX. CiilCi Uk ::oLJtutO(\ requirements for disclosure of assets and filing a tax return are still applicable even if a i~ilikl uf age or younger at dea[h to or for the use of a natural parent, an adoptive parent, Uit: 1t:IICldiles IS 4,5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. S9'116i,a)(1)]. [U [fll~ of We u8cecierits ~iltJlif1gs IS 12~ilJ [72 PS. ~9'116(a)(1.3)J. A sibling is defined, under Section 9102, as an (je.,;cCUIIl ;'vf1dllei uy- bl,Jod Gr (Idopilon, <' ST/\ TE Of PErIJi\iSYL VANIA 20 U J\J .(,{ OF C u IVt BERLAN 0 SHORT CERTIFICATE CLEIVDA FARNER STRASBAUGH ~-~' e -= 'C c r" ,-=:~ [he Probate of wills and Granting __ "-..1rn_ini s tra ti on in and for 1~~ e;.r s t e.~-~ 1_'C)U.rlCY, do hereby certify that on cnc? of ./lug-us c / Two Thousand and Four; :-',e" =: -= er-:: O~=- ,':-iDlvIIIV/STRA T/ON n._'01T!1:;()ll rnl \\/ere 'granted by the Register or S c.J. ..L l.~~ ',,__ ~_IJ] on cile jvE DOUGLAS K -ce c)r EAST PENNSBORO TOWNSHIP . ~ 1 ~ i...J ...J. :.-- ,~~ e c e as e j , c: c P_4 \/ NET ERR '/ RA '1''' ,L.:J."';:!. ,':::,',' :':'!, ,~huu/t: -l:"':-," ~:_':"-, ,-. , [2 ::.:t S c s ~ ]l (:' c? J:J ~~ 0:]} ;'v'.T-f.EJ ~C{ EJ() 1~~1 ':2~1VC' n,::;Lc~un co set my hand and affixed the ,--' -= r -1- :,~ e ac ,~_ Z.~l'-< L 1- ~I ~,~~I ;;-iE1ViIS':'LV_~NI]i / this 27th day of August ..:.. ',: i <~-; :"2 :3 ~:i:2 <...--1 .;..:::1 ~--: L1 r' I 2004-00802 ;...u. 27- 04- 0802 ~~ e 507/2004 J 92-50-0048 '--\, ",---' --.....,.-::::::",- '--\ '--:;::-:.\\ \-.... , \ C,/<.\ \ C ....~ ~-,~3'---")\i:LO\CY',-,~, \[~ Register Of Wills ~_ {,.-. /\ (".., !+J ''-';f -\'J\...fy\~ -;-. - ru~,-)Vv'\ v fv:l~'1-JJ-ICI[Ill ,'.~.,~:~F21.-L--;1~j\Jjl~'~ ~)I \~j.l\i~4 'IIURE _4ND IMPRESSED SEJ.4L COIVIlVION\VEALTH O.F PENNSYLV ANLL\. DEPl\RT:\lENT OI1'REVENUE REV-869 AFP (1.) (5) l'-i DATE: 11/16/2005 TERRY R ~:)AYI.,IE 110 DILLER }~D NEW CUMBERLAND} PA 17070 Estate of: PAYNE DOUGLAS K Date of Death: 5/2/2004 File NUluber: 21 04- 0802 (Certified AiJail-Return Receipt Requested) Dear TERRY l,{ PAYNE: A revic"\\' of ])epartrnent records has disclosed that you are responsible for the settlement of the above estate, or that you represent the responsible party. As of this date, you have failed to respond tu prior contacts to resolve this n1atter. This is to again advise you that the above estate is in a delinquent status. According to Depart111ent rc:'cords, as of this date, the estate is still not settled. rhc:' Inheritance and Estate Tax Act ll1andates the filing of a tax return and paynlent of all outstanding liabilities by a personal representative of the estate or a transferee within nine rYlonth of the decedent's death. T'he !)cpartn1cnt's recDrds sho\v that this estate remains open because: i\.~ IN}IEl~ITA:\CE 'fAX U.ETUltN lIAS NOT BEEN FII.;ED. If the return has been tiled, it is ill1ponant that you contact us immediately. If this estate \vas l)pened for the purpose of tiling a la\vsuit, please provide this office in writing with the term and docket nLU11ber of the la\vsuit so that \ve 111ay postpone any further action. This notice shall serve as a 1()f111al dernand on you or your client from the Departnlent of Revenue. If y'(}U hlil to file the return, the ])epartlTlent n1UY institute legal action requiring you to appear in court to sho\\/ cause J()r your failure to cornply \vith the law. A finding of contempt in this 111aUer cuulcl subject you to additional penalty and/or incarceration by the Orphans' Court of Cumberland County. H.ETUl~:\'S SII()ULD BE }i'ILED AND CIIE(~KS ~lA.DE I)A~ YA.BLE 'I'(): l~EGISTEI~ (}F WILLS. l\GEN'f l\ny questions regarding this estate~ please CONTACT: Sincerely, Bonnie Whetstine HARRISBURG DISTRICT OFFICE STRAWBERRY SQ 4TH & WALNUT STS HARRISBURG, PA 17128-0101 (705)338-6 l-' /c: Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/29/2006 PAYNE TERRY RAY 110 DILLER RD NEW CUMBERLAND, PA 17070 RE: Estate of PAYNE DOUGLAS K File Number: 2004-00802 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. 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 is due by: 5/07/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, An-~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel REV 1100 EX (6-00) I- Z W C W U W C W I- ~~en o~~ Wa.O :I:OO O~...J a.a:I a. <( . ~COMMONWEAL T~ OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN 9:!M'ORc; - Oy>o'l RESIDENT DECEDENT COUNTY CODE YEAR - NUMBER- - - SOCIAL SECURITY NUMBER \9 i: - ~o - oatt~ DATE OF BIRTH (MM-DD-YEAR) 05 o~ ao~ oa(o~ 19~o (IF APPLICABLE) SURviVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N\Pt NAM~e..r~"l R. ~ ' Y' ~ FIRM NAME (If Applicable) ...~.,,,,,.,,,,~_.,,,..,_.,,,,,,,,_.- ~ 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of Will) D 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy of Trust) D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 3. Remainder Return (date of death prior to 12-13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) I- Z W C Z o a. en w ~ ~ o o z o ~ -I :J ~ a.. c( u w ~ z o ~ ~ :J a.. :E o u >< ~ TELEPHONE NUMBER ,j ., \\ - '1r-t4- Co~ ~\ 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) COMPLETE MAILING ADDRESS \\C) 1Ji-\\~ ~ f\~ ~~~ \~ QJ\ \\.UlC,) (1 ) (2) (3) (4) (5) 4. Mortgages & Notes Receivable (Schedule D) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested () r-- ,-"-1 '1J :,.,z (~? ~~ ,') t..) i I ',:=)~ :-i :}2 :tP :::: ~ rv ('.) (6) (7) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 2fi o 9. Funeral Expenses & Administrative Costs (Schedule H) (9) (10) 18 10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) o 12. Net Value of Estate (Line 8 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 Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20.0 x .0 _ (15) x .0 _ (16) x ,12 (17) x .15 (18) (19) fi 0- CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT pt. Decedent's Complete Address: STREET ADDRESS ~~ S~+-c.... ~~~~ " .. d~ F\.oo r- CITY (f'C,"-"- I STATE ,p.A- I ZIP \ l\. ~ a-s- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) c Total Credits (A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( 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. a (5) (SA) (5B) A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. ~() 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;.......................................................................................... D b. retain the right to designate who shall use the property transferred or its income; ............................................ D c. retain a reversionary interest; or.......................................................................................................................... D d. receive the promise for life of either payments, benefits or care? ...................................................................... D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........... ................... ...................................... ............ ..... ........ ..... ............ D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D No ~ i ~ ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of 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. SIGltATU~~~BLEF~ ADDRESS CJ ~ \\a. ~\\\~ ~~ ~ ~~~\C\~ SIGNATURE OF PREPARER OTHER T~AN REPRESENTATIVE ~_A- \la\..u DATE ~/ ,;). <0 } 0 ~ ADDRESS DATE \\ ,~ ~\) - "-l.~ '-l ~ ~~.'1 ~""\S" >n the net value of transfers to or for the use of the surviving spouse is 3% For dates of death on or after July 1, 1994 and before Janu [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax ra The statute does not exempt a transfer to a surviving SpOt the surviving spouse is the only beneficiary. \<.. \L msfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. luirements for disclosure of assets and filing a tax return are still applicable even if For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a ( If age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)]. 1tye tax rate imposed on the net value of transfers to or for t~ 3ficiaries is 4.5%, except as noted in 72 P.S. S9116(1.2) [72 P.S. s9116(a)(1 )]. .,. The tax rate imposed on the net value of transfers to or fo ~s is 12% [72 P.S. S9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the de~~",v, OL, HI'vll'C( uy UTWU or aaoption. C01\lJVIONWEA.LTH OF PENNSYL VA.NIA DEP..'-\.H.Tl\1ENT OF REVENUE !:::J -.\.....'::i.~~\ 'IJ REV-869 At'i 1 t. OS) -'~ J _ <:S' 3 lr'~] I I)ATE: 11/16/20 t: ~) T E R i:~ ''/ R PAY N E 110 DILLEI~ RD NEW CUMBERLAND, PA 17070 Estate of: PAYNE DOUGLAS K Date of Death: 5/2/2004 File Number: 21 04- 08 C1 ~~ (Certified Mail-Return Receipt Requisied) l)L'ar TERR Y R PA YNE : A revie\v of I)epartment records has disclosed that you are responsible for the settlement of the above estate, or that you represent the responsible party. As of this date, you have failed tiJ respond to prior contacts to resolve this 111atter. TIllS is to again advise you that the above estate is in a delinquent status. According to 1)epart111ent records, as of this date, the estate is still not settled. The Inheritance and Estate Tax Act 111andates the filing of a tax retlID1 and payment of all outstanding liabilities by a personal representati ve of the estate or a transferee within nine f110nth of the decedent's death. The Departrnent's records sho\v that this estate remains open because: AN INlIERITANCE TAX H.ETUI{N lIAS NOT BEEN :FILED. If the retlu'n has been tiled, it is in1portant that you contact us immediately. If this estate \vas opened for the purpose of filing a la\vsuit, please provide this office in writing with the term and docket nU1l1ber of the la\vsuit so that \ve n1ay postpone any further action. This notice shall serve as a 1'or111al de111and on you or your client frolll the Department of H..evenue. If you fail to file the return, the Depart111ent 111ay institute legal action requiring you to appear in court to sho\v cause for your failure to c0111ply \vith the la\v. A fInding of contempt in [his 111atter could subject you to additional penalty and/or incarceration by the Orphans' Court of Cumberland County. I{ETUl~l\S SlI()ULD BE FILED AND CIIECKS YlADE PA.YAHLE TO: n.E(;ISTEI~ ()Ii' WILLS, AGENT A.ny questions regarding this estate, please CON'!'ACT: Sincerely, Bonnie Whetstine HARRISBURG DISTRICT OFFICE STRAWBERRY SQ 4TH & WALNUT STS HARRISBURG, PA 17128-0101 (705)338-6 Cc: ~, . .. SHORT CERTIFICATE S'i- /~TE 5F': P i\lSYL'V ANIA ::OUl'{: Y Of CU1VIBERLA1\!D CLEJ\/DA FARNER STRASBAUGH ~-~e == -=er.~; Cil- ttle Probate of Wills and Granting" stration in and for ~)U.r':C}fl do hereby certify that on of Augusc, Two Thousand and Fouy.. i 5' c~ 1:" ,I~~ c n c_~ "') ~_,.t} 2T'2-' A DIVllNiS TRA TiON __ Tl rm h'ere granted by the Register ot ::3 '-2 .l L~~ UriC on the /vE DOUGLAS J< ce or EAST PENNSBORO TOVV,YSHIP ~>.:=,cease,j, L() PA'r/jVE TERR RA Y F;1 ~:. ,'.LJJic:, _ J. :..-l ~ l-~ ~) C S ~ IJ. c: c:? I:) c..:~ e 1-~ ~_' t:- \,r C) Jc c:~~ j . t- ...-, ;::. i.-.) -.....'... _ ~ r 1- C e cl C C_41~L2-:;;J unco set my hand and affixed the ,f:EI~'l",. V'AIIJIli I this 27th day of August _ 1\' ']"J 21 _~_ ~ .I-."-~~ J C)i\/ l~-' ~\TJ-I E R El ,~--) l;~ __:1 ~~L .~ ':.-.l.,~_f L~ >~? ~~~,r~ _~i.I2 ~'1 1=:'1.,:) Llr~ . _ ___ c: 2004-00802 2 J - 04- 0802 .-1- ..._~~ 5.07/2004 J 92-50-0048 >-_.-\ ~: --:-~" '----' \ . c--:\,'i" ~ ., ,~~\ ,', .' ( " <~, ,{3---j\.1\....O'<:: Register Of 'vViJJs ~ (r-- ^, i 1 i\t i '-J I .\J"r~!)- r'~, \., ,r-.}, ,---;.--" , '-" \..).., \ ,.j ,_:~~T!J f,\'I'T:-IOLTI' ,JR1<JIIL.:.'u.1 ST~L;L4TURE' iiND IlYJPRESSED SEAL ------~-~IV'\- T- ~\ "f"i5r-~-~~-\-o.v~--~ -:.p~---eit --~o '-'.:r:--.-:t-"'",}~~-3~--o;;-i,=\--\;JQ- ---~~- ---~~~C>S;-~C)Q0)-~-n~4~~~ -..\-\-----~--- n:~~;-n~;~V~~~;--.~~=-;::;~-~~~::~~: :~n:-_~~v~;~~:~:;~-~\::-C-~~;n--~~- _m ..-------.._-----~---~-----.-------.-.. ....-- ..---------------.-:--crj.~~~-""~---~:L-~-~ ty)-'--O-I= ---- ---l1QTC(s-~-n~~Efo"">\~-- &\,00- -teb1 :~sc; ------------- - d\f"'~CS'-?r-~"""'\\;.,.,OQ -: ~ __n_n___n__ Q 0)0 -::.~-e-fI.. T 'ifcr~~f\ - .-... ..____._____u..__m. -- ___m_ --..--.-..------------.---- -------.-- ------ -.-----.---. .. -- ro""108e' -...-.Sl~..-;-ey.d ---- -- ------- --- __n______ <:;'J '/.. -.o-\-if'iY'f'~f i\-~:r--~9-""",-qJV)~- --------_______~~n_~________ - --- ------ ~v~"~~--F~- -.---..-------.....-- ---.....-.-...--..-.--------------..--.-..-.--------------.-- .\jd------~O----~\-~-\J~-~-(5J-..-- _mo' ----------~..-.- D)Ql.-.-'" e---r~-------------.---- .. , .,,---- ;~J g rr ~ , \",1 cP ~ w 0 ~ 0 Q .~) '2 ~ .(J ~ ,,'I J( ~ ,:"\ \V 10 l.., ,.,t, ~ ~ ~ Q() (b'V o d(.. 1/ b ~\ ~ / ~ ~ c. ~ ~ ;1 ? " ~9.J bO(l -=-\ - ~ 0 ? b _ 0 , ~ ."" - -::- - - - - - - - -::- - ""'- ~ ~ ~ & ? 6 J~ ~ ~~ 1- ~ ~r ~: . ~?- {;;: ~ ..l o ,'" t..l .~ ...,,:~ 1> 1J """'i~ 'iJ r: ;...t tr-: tfl OJ "'; r C -..- t'-', ?J c,Q 4'.} 1J 1- .~ 1./ ~ f-- .~ """" ~ In Re: Estate of PAYNE DOUGLAS K ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00802 NOTICE OF FAILURE TO FILE STATUS REPORT Personal Representative: PAYNE TERRY RAY Counsel for Personal Representative: Date of Decedent's Death: 5/7/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Comi Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report. If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to detennine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 5/31/2006 /zv ~L.I /J .A'l~ L~JJh.zv~. /j Glenda Farner Strasbaugh/ / Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX 06-12-2006 PAYNE 05-02-2004 21 04-0802 CUMBERLAND 101 APPEAL DATE: 08-11-2006 ( See reverse side under Objections) Amount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ~Yr~~~p~~~!~!~~f!~~______~___!~!!!~_~g~~!_~g!!!g~_~g!_!g~!_~~~g!~~__~____________________ REV-1547 EX AFP (103-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR ~. () DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DOUGLAS K FILE NO. 21 04-0802 ACN 101 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN TERRY R PAYNE 110 DILLER RD NE\LCUMBERLAND PA 17070 c; I J <" l-'- ESTATE OF'~' PAYNE REV-1547 EX AFP (06-05) DOUGLAS K TAX RETURN WAS: (X) ACCEPTED AS FILED DATE 06-12-2006 CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE 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) S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 .00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax If an assessment was issued previously, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS. NOTE: .00 .00 (11) (12) (13) (14) (9) (10) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. .00 00 .00 .00 .00 14, 15 and/or 1&, 17, 18 and 19 will returns assessed to date. US) (6) (17) (18) .OOX 00 = .00 X 045 = .00 X 12 = .00X15= (19)= .00 .00 .00 .00 .00 . . .......... ".......... T+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 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"" (CR), YOU MAY BE DUE 1 A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)