HomeMy WebLinkAbout04-0812 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
ORPHANS' COURT DIVISION
IN RE: ESTATE OF RHODA L. CAMPBELL
FILE NO.:
PETITION FOR SETTLEMENT AND DISTRIBUTION OF ESTATE NOT IN EXCESS
OF $25,000.00 (Sec. 3102 Probate Estates & Fiduciaries Act)
TO THE HONORABLE, THE JUDGES OF SAID COURT: aC'., x~
The Petition of Less C. Roadcap respectfully represents: ~ ~
1. Your Petitioner is Less C. Roadcap, nephew of the deceased,~:Rhoda L.~.Campbeh
(incorrectly indicated on the Will as "Lester" Roadcap). , ~ ::~ ~
2. Rhoda L. Campbell was a resident of Cumberland County,Pennsylvama,°~ and died' on
October 12, 2003 at the Beverly Healthcare nursing facility in Camp Hill, Cumberland County,
Pennsylvania. Her Will has not been probated but is attached hereto and marked as "Exhibit A"
and incorporated herein by reference.
3. The decedent's death certificate is attached hereto and marked as "Exhibit B" and
incorporated herein by reference.
4. The entire estate of the decedent, Rhoda L. Campbell, consists of the following
property:
A. Checking account at M&T Bank, Account #3740102359 in the name
of the decedent and her Power of Attorney, Michael L. Bangs, Esquire. The total
of this account is $1,544.22.
VERIFICATION
I hereby verify that the statements made in the foregoing Petition are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section
4904, relating to unsworn falsification to authorities.
L~ss C. Roadcap '
3
WILL
OF
RHODA L. CAMPBELL
I, RHODA L. CAMPBELL, of the Borough of Lemoyne, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will previously made by
me.
ITEM I. I direct that all my just debts and funeral expenses, including my
gravemarker and all expenses of my last illness, and any and all taxes and
assessments imposed by any governmental body as a result of my death, whether
on property passing under this will or otherwise, shall be paid from my residuary
estate as soon as practicable after my decease as a part of the expense of the
/
administration of my estate.
~'~ ITEM II. All the rest, residue, and remainder of my estate, real, personal, or
~ mixed, of every nature and wherever situate shall be divided equally between the
~ TRI-COUNTY BIG BROTHERS AND SISTERS ASSOCIATION and the DOMESTIC
VIOLENCE SERVICES OF CUMBERLAND AND PERRY COUNTIES.
ITEM III. All of the interests of the beneficiaries hereunder shall not be
subject to anticipation or to voluntary or involuntary alienation nor shall they be
subject to any execution or attachment.
ITEM IV. I appoint LESTER ROADCAP, executor of this my last will.
ITEM V. In addition to the other powers and authorities granted to my
personal representatives by Pennsylvania law and by the other terms and provisions
of this will, I hereby give to my personal representatives the following powers and
authorities effective without court approval and until actual distribution of all
property: to compromise any claim or controversy; to make distribution
in
cash
or
in kind, or partly in cash and partly in kind, and in such manner as my personal
representatives may determine and at valuations finally to be fixed by them; to
invest in all forms of property, including any stock or other securities in
any
corporate fiduciary or its successor without restriction to investments authorized
for Pennsylvania fiduciaries, as my personal representatives deem proper, without
regard to any principle of risk or diversification; to retain any or all assets of my
estate, real or personal, without regard to any principle of risk or diversification; to
sell at public or private sale, to exchange, or to lease for any period of time, any
real or personal property and to give options for sales, exchanges, or leases, for
such prices and upon such terms or conditions as my personal representatives
deem proper; and to allocate receipts and expenses to principal or income or partly
to each as my personal representatives deem proper in their sole discretion.
ITEM VI. I direct that my personal representatives and fiduciaries shall not
be required to give bond for the faithful performance of their duties in any
jurisdiction.
2
IN WITNESS WHEREOF, I have hereunto set my hand this ~ ~, day of
, 1996.
RHODA L. CAMPBELL ~
The preceding instrument, consisting of this and two other typewritten
pages, each identified by the signature of the testatrix was on the date thereof
signed, published, and declared by RHODA L. CAMPBELL, the testatrix therein
named, as and for her last will, in the presence of us, who at her request, in her
presence, and in the presence of each other, have subscribed our names as
witnesses hereto.
3
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
The undersigned, being the testarix whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, does hereby
acknowledge that I signed and executed the foregoing instrument as my last will, that
signed it willingly; and that I signed it as my free and voluntary act for the purposes therein
expressed.
RHODA L. CAMPBELL
Sworn or affirmed to and acknowledged
before.._., ..me by the tes_~ix, named above
this,.~ [j(~ay of ~..~.L .~ ~-~.--, 1996.
I~otary P~blic
I~,r AI~ Twp.,
COMMONWE . Y::
( SS:
COUNTY OF CUMSERLAND
ana
whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw the testatrix sign and
execute the instrument as her last will; that she signed Jt willingly and that she executed Jt
as her free and voluntary act for the purposes therein expressed; that each of us in the
hearing and sight of the testatrix signed the will as witnesses; and that to the best of our
knowledge, the testatrix was at that time 1 8 or more years of age, of sound mind, and
under no constraint or undue influence.
Sworn or ~ffirmed to and /
acknowl~dflod b~fore m~ this
2~Y of ~ 1996.
~ S. CHE~,,
~w~ ~ Twp., CumGor~ ~.,
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
. -, " OCT 1 6
P 9648581
No. ~ Date
~ev ~'a7 COMMONWEALTH OF PENNSYLVANIA" DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
,. mi00a~ ~ Cat~z)~,// /,. /-I,.180-0~1-f758~J,. IOJl]YO~
__..____.__. ,,c,.,,..__. "--0'
SEP 0 ? zoo
IN TIlE COURT OF COMMON PLEAS OF (?tIMBERLAND COIJNi'¥
ORIel IANS' COURT DIVISION
1N RE: ESTATE OF RIIODA L. CAMPBELL
PETI'i ION FOR SETTLEMENT AND DIS'I RIBUTION O1: ESTATE NOT IN EXCLSS
OF $25,000.00 (Sec. _~ 102 Probate Estates & Fiduciaries Act)
')~N ORDER
2004,
motion
L.
AND NOW this day' ~....]/i, .,~ , , upon
Bangs, F~squirc, attorney Ibr Less C. Roadcap. the within named bank is hcmby authorized to pay
over to the said Less C. Roadcap thc account ofRhoda L (anpbcll and thc said Less C.
Roadcap shall pay all outstanding bills and laxcs and distribute the net balance according to the
within Petition.
BY TIlE (O1 RI.
OFFICIAL USE ONLY
REv E×*,6-00; REV- 1500
DOMMONWEALT,O PENNSYLVAN,A INHERITANCE TAX RETURN FILE NUMBER
DEPARTMENT OF REVENLJE
DEPT2B060 RESIDENT DECEDENT 0 -8 2
HARRISBURG. PA ~T1Z8 0601 COUNTY CODE YEAR NUMBER
DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCrALSECURITYNUMBER
D
E ~beL[ Eho~ L. ~80 09-5753A
C DATE OF DEATH (MM-DB YEAR) DATE OF BIRTH ¢MM- DD-YEAR) THIS R~URN MUST BE FILED IN OUPLICATE WITH THE
E
D Z0/Z2/2003 Z2/23/~9~0 REGISTER OF WILLS
E
N (IF APPLICABLE~ SURVIVING SPOUSE'S NAM E (LAST, FIRST AND MfDDLE INITIAL) SOCIAL SECURITY N UM DER
T
4 ',date of dear h
HpR b 1, OriginalReturn ~. SupplementalReturn 3, RemalnderReturn priorto12 ~3
CA P B 4, Limited Estate . Future Interest Compromise (dateofdeathafter lZ-~-8Z) ~, Federal Estate Tax ReturnRe~uired
E P I O ~ 6, Decedent Died Testate , Decedent MaintainedaLivingTrust 8, Total NumberofSafeDepositBoxes
CRAC ~ ,'Attach copy o f Will) (Attach copy of Trust)
KOTM
E
S
9.
~ Litigatio* Proceeds Received ~10. Spousal Poverty Credit
(dateofdeathbetween~Z-31 91and 1-1-95~ ',AttachSchO)
THIS SEC~tON;MUS~BE COMPlEtED ~EL CORRES~ONBENCE &~ONF DENT AE~ NFORMATION SHOUED BE DIRECTED TO:
~ NAME COMPLETE MAILING ADDRESS
oCRu Hichael L. ~as 429 Sou~h 18~h
~ F~RM NAME (If Applicable)
R
E ~ C~p Hi11, ~A 17011
S T TELEPHONE NUMBER
717/730- 73~0
1. Real Estate (Schedule A) (1) ~o~e OFFICIAL USE ONLY
2. Stocks and Bonds (Schedule B) (2) No~e
3. Closely Held Corporation. Pa~nership or (3) No~e
Sole Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4) ~o~e
R 5. Cash. Bank Deposits & Miscellaneous Persona~ PropeAy (5) 1,761.77 s
E (Schedule E)
C
A 6. Jointly Owned Prope~y (Schedule F) (6)
P
I ~ Separate Billing Requested
T
U 7. inter Vivos Transfers & Miscellaneous Non Probate Prope~y (7) ~o~e
L (Schedule G or L)
A
T 8. Total Gross Assets (total Lines 1-7) (8) ;, 76~ . 77
O 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 4 , 868.00
N 10, Debts of Decedent, Mo~gage Liabirities.& Liens (Schedule I) (10) 980
11. Total Deductions (total Lines 9 & 10) (11)
12, Net Value of Estate (Line 8 minus Line 11) (12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
O SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
M
~ 15. Amount of Line 14 taxable at the spousal tax
T
A T rate. or transfers under Sec 9116(a)(1.2) 0.00 X 0 0 (15)
X A
T 16. Amount of Line 14 taxable at lineal rate 0 . 00 X 0
~ ~7. Amount of Line 14 taxable at sibling rate 0.00 X 12 (17) 0 . 00
O
N 18. Amount of Line 14 taxable at col[atera~ rate 0.00 X 15 (18) 0.00
~9. Tax Due (19) 0 . 00
Copyright ~c) 2000 form software only The Lackner Group, Inc Form REV- 1500 EX (Rev
Decedent's Complete Address:
STREET ADDRESS
46 grford Road
Bethany Health Care
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C, Discount
Total Credits( A + B +C ) (2) . )(}
3. Interest/Penalty if applicable
D. Interest
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X' IN THE APPROPRIATE BLOCKS
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
;'GNATUREO~:~ONRESPONSJBLEFORFILINGRETURN Less C. Roadcap [SATE
~ //,/~ ~/ 1298 Star Route 25
,~ ~ 2J / ~ 429 South 18th Street
REV 1508 EX + (1-97)
SCHEDULE E
COMMONWEALTHOFPENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERrTANCE T~O( RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Rhoda L. Campbell SS¢/ 180-09 5753A 10/12/2003 21-04-812
Include the proceeds of litigation and the date the proceeds were received by the estate All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRrPTION OF DEATH
1 Beverly Health Care Refund 20.07
2 Blue Cross/Blue Shield Refund 197.48
3 M&T Account 1 , 544.22
TOTAL (Also enter on Dine 5. Recapitulation) $ ] , 761. 77
more space is needed, insert additional sheets of the same size)
Copyrightlc) 1996formsoftwareonlyCPSystems, lnc Form REV-1508 EX(Rev 1 97:
REV ~ EX+ ~-97/ SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rhoda L. Campbell SS¢~ 180-09-5753A 10/12/2003 21-04-812
Debl of decedent must be reported on Schedule I,
ITEM
NUMBER DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
1 Musselman Funeral Home 4,856.00
B. ADMINISTRATFVE COSTS:
1, Personal Representatives Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney's Fees
3. Family Exemption: (if decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4, Probate Fees Register of Wills 1.2 . 00
5. Accountants Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL (Also enter on line 9, Recapitulation) $ 4,868.00
(If more space is needed, insert additional sheets of the same size)
SCHEDULE I
COMMONWEALTHOFPENNSYLVANiA DEBTS OF DECEDENT,
RES'~ENT OECEDENT MORTGAGE LIABILITIES, AND LIENS
ESTATE OF FILE NUMBER
Rhoda L. Campbell SS¢~ 180-09-5753A 10/12/2003 21-04 812
ITEM
NUMBER DESCRIPTION AMOUNT
1 PharMerica Network 980.75
TOTAL (Also enter online 10, Recapitulation) $ 980.75
(If more space is needed, insert additional sheets of the same size)
Ccoyrightlc; 1996 form softwareonly CPSystems, lnc Form REV-1512 EX (Rev 1 97:
REV 1513 EX + (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
IN HERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rhoda L. Campbell SS# 180-09-5753A 10/12/2003 21-04-812
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DO Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec 9116(a)(12)]
ENTER DOLLARAMTS FOR DISTRIBUTIONS SHOWN ABOVE ONLN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B, CHARITABLEAND GOVERNMENTALDISTRIBUTIONS
1 Big Brothers & Big Sisters of Capital Region
1500 North Second Street
Harrisburg, PA
2 Domestic Violence Services of Cumberland and Perry Counties
Post Office Box 1039
Carlisle, PA
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET 0.00
(If more space is needed, insert additional sheets of the same size)
Register of Wills of CUMBERLAND County, Pennsylvania
INVENTORY
Estateof Rhoda L. Campbell No 21-04-812
also known as
Date of Death 10/12/2003
. Deceased Social Security No. 180-09-5753A
Less C. Roadcap,
Personal Representative(s) of the above Estate deceased, verify that the items appearing ~n the following Inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent. that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned
no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this
Inventory I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities
Personal Representative
Attorney: Nichael L. Bangs Signature: ~ , ~ ot.C4,.¢4,~:2..,¢~
ID No: 4~263 Signature: L~ C. R6adeap
Address: 429 SouEh 18Eh Street ~ddmss: ~298 Star Route 25
_C~p Hill, PA 17011 Millersburg, PA 17061
Telephone: 717/730- 7310
Telephone: 717/692- 2490
Dated:
Description Value
(See continuation page(s) attached)
(Attach additional sheets if necessary) Total: I, 761. 77
include the value of each item. but such figures should not be extended into the total of the Inventory
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSysterns. Inc.
Form #RW-7 (1992)
INVENTORY
Esnate of: Rhoda L. Campbell
Date of Death: 10/12/2003
County: Cumberland
CASH:
M&T Account 1,544.22
Beverly Health Care Refund 20.07
Blue Cross/Blue Shield Refund 197~48
1,761.77
TOTAL RECEIPTS OF PRINCIPAL ............... 1,761.77
-1-
REGISTER OF WILLS OF CUMBERLAND COUNTY
REPORT OF STATUS OF ADMINISTRATION
(For Resident Decedents Dying after July 1, 1984)
ESTATE NO. 21 - 04 - 0812
RHODA L. CAMPBELL
180-09-5753A
""
=
=
c.....
cn
fr"l
C-:,
C:-J
:.,':J
, "-1
Name of Decedent:
Social Security No.:
o
::13
-TJ
:;~F;
C~) ~L(
<-
;;.=,'"
-~
,,)
;"['1
(:~)
Date of Death:
10/12/2003
v
. "', ~--
. ~. _...J
;"-1!
-r'l
f,~
o
--,'"
...."..
Name of Personal Representative:
Less C. Roadcap
1298 Star Route 25
Millersburg, P A 17061
['0
~
N
Capacity
( check one)
Executor X
Administrator
Administrator c.t.a.
Administrator d.b.n.
Is the administration of the estate complete? Yes_X_ No
If "Yes", how was the administration ended? (check one)
By court accounting
By account stated to parties in interest
Did the parties release the
personal representati ve?
Other(explain) Petition for Settlement and Distribution of
Estate not in Excess of $25,00; Order dated 9/9/04;
distributions made to named Charities.
Total amount paid to date to creditors and for funeral and $5,848.75
administrative expenses
Total value of distributions to date to beneficiaries
$749.02
If administration is not complete, estimated value of assets $
still in administration
NOTE: This status report is due no later than the due date for filing of the Pennsylvania
inheritance tax return or, if no inheritance tax return is required, nine (9) months after the
date of death; if the administration of the estate has not been concluded, a summary report
shall be filed annually thereafter until the administration is complete,
I certify under penalty of perjury that the foregoing information is correct to the best of my
knowledge, information and belief.
I
1/0/0)'
, /
Attorney for Estate
J
Date:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
tfiffiN,~rr' ('ifCF r![
BUREAU OF INDIVIDUA ,,J,' SiU~L) \,-'1 '~'_.::. NOTICE OF INHERITANCE TAX
",r:'I"
INHERITANCE TAX DIVISION qCt,:Y:T\:"; ~ - '" :I_"~ APPRAISEMENT" ALLOWANCE OR DISALLOWANCE
PO BO)( 280601 \ 1>.,1'_.'" OF DEDUCTIONS AND ASSESSMENT OF TAX
HARRISBURG PA 17128-0601
JU'IO M',9:lt9
2005 ,'.I,
CLER\\ Of: ,
ORPHtNS C\5.l~R1(,
lLrjj ;.' I' L 'J~\
MICHAEL L lillih'ttk;"'" "',, , '
429 S 18TH ST
CAMP HILL PA 17011
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-10-2005
CAMPBELL
10-12-2003
21 04-0812
CUMBERLAND
101
*'
REV-15~7 EX AFP 1l2-0~l
RHODA
L
AMount Rellitted
I CHANGED
III
[21
131
141
151
[61
171
.00
.00
.00
.00
1. 761. 77
.00
.00
(81
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER DF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
RiV=iSirj-Eit-iiFir-riii"=03Y-NOi'"iCE"iiF"i:"N'HEifii'ANCE-YAX-jiPPRA'iSEiiENi:--iir.rciwAifcE-O'R-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF CAMPBELL RHODA L FILE NO. 21 04-0812 ACN 101 DATE 01-10-2005
TAX RETURN WAS: I X I ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds {Schedule BJ
3. Closely Held stock/Partnership Interest (Schedule C)
~. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule f)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
1~. Net Value of Estate Subiect to Tax
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Amount of Line l~ at Spousal rate (15)
16. Amount of Line l~ taxable at Lineal/Class A rate (16)
17. Amount of Line l~ at Sibling rate (17)
18. Amount of Line l~ taxable at Collateral/Class B rate (18)
19. Principal Tax Due
~
[91
1101
4,868.00
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
1, 761. 77
".848 7"
4,086.98-
.00
4,086.98-
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
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" ICRI, YOU MAY BE DUE 5 j(
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I '\
980.75
(111
1121
1131
1141
.00 X 00 =
.00 X 045 =
.00X12=
.00 X 15 =
1191=
TAX CREDITS.
Cft"'.'" ..~tL.1 [OJ AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID [-I
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00