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HomeMy WebLinkAbout03-0971 I, MINNIE C. BARM©NT, of Mechanicsburg, Cumberland County, Pennsylvania, do hereby make my last will and testament, revoking all testamentary dispositions heretofore made by me. 1. If my daughter, Judith A. Lees, survives me, I give to her all my estate, real and personal and wheresoever situate. If my said daughter, Judith A. Lees, predeceases me, I authorize her to appoint by her last will and testament my entire estate to any beneficiaries that she shall select without limitation ,Df any kind as to the identity of the said Oeneficiaries. i nominaze, constitute ~nd ~Dpoint Zhe 5aic Judilh bees to be my ~--xecutrix. ,~I~,4ES$ '~EREOF, ~ have nereunlo set my han~ and ~eal to this my last 'NjTM ~nd ~estament ~h~s ~ day of October, 1981. Signed, sealed, published and declared by the above-named Minnie C. Barmont, as and for her last will and testament in the presence of us who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses this day of October, 1981. WILLIAM J. MADDEN, JR., ESQUIRE 240 North Third Street Harrisburg, Pennsylvania I, MINNIE C. BARMONT, of Mechanicsburg, Cumberland County, Pennsylvania, do hereby make my last will and testament, revoking all testamentary dispositions heretofore made by me. 1. If my daughter, Judith A. Lees, survives me, I give to her all my estate, real and personal and wheresoever situate. If my said daughter, Judith A. Lees, predeceases me, I authorize her to appoint by her last will and testament my entire estate to any beneficiaries that she shall select without limitation of any kind as to the identity of the said beneficiaries. 2. I nominate, constitute and appoint the said Judith A. Lees to be my Executrix. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my last will and testament this ~ day of October, 1981. Signed, sealed, published and declared by the above-named Minnie C. Barmont~ as and for her last will and testament in the presence of us who~ at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses this day of October, 1981. WILLIAM J. MADDEN, JR., ESQUIRE 240 North Third Street HarrisburG. Pennsylvania 4. The Decedent's Will designated her daughter, Judith A. Lees, as Executrix and sole beneficiary. The Decedent's daughter predeceased her on June 28, 2000. See Certification of Death attached as Exhibit C. 5. In the event the Decedent's daughter, Judith A. Lees, predeceased the Decedent, the Decedent's Will gave a power of appointment to name a new beneficiary to Judith A. Lees. This power of appointment was not exercised, as Judith A. Lees died intestate. Consequently, the Decedent died intestate. 6. Petitioner has caused to be conducted a genealogy search in order to find living relatives of the Decedent. No living relatives have been found. See affidavits attached as Exhibit D. 7. Decedent owned no real estate at the time of death, and the value of her personal property at the time of death was limited to $1087.49 contained in a checking account held by Allfirst Bank, Harrisburg, PA 17101. See attached Exhibit E. 8. It is believed that, at the time of death, a debt of $595.49 was owed by the Decedent to Manor Care Health Services, 940 Wahmt Bottom Road, Carlisle, Pa 17013. 9. It is believed that, at the time of death, no Medical Assistance lien was owed to the Department of Public Welfare. 10. It is believed that, at the time of death, Decedent had no other creditors and owed no other debts. 11. This belief has been adopted after conversations with Decedent's ex-Son-in-law, Arthur Lees, who had, and exercised, Power of Attorney over the Decedent since July 21, 2000. See Power of Attorney attached as Exhibit F. 12. According to Mr. Lees, the Decedent spent her last years at Manor Care and her only income, Social Security income, was used to pay for services Manor Care provided. 13. According to Mr. Lees, the Decedent had no creditors or debts other than those mentioned above. 14. Petitioner has incurred expenses in preparation of this Petition and in the g~alogy search that he caused to be conducted. Those expenses equal $ 6¢-3r00. 55z, e~ Statement attached as Exhibit G. 15. Petitioner proposes the following to be the distribution of this Estate: · $6~ to'6'T6'hn C. Porter. Attorney at Law, for services provided for the costs of administration · Remainder in the Allfirst checking account, up to $595.49, to Manor Care Health Services, for medical and nursing services wSthin the last six months of death · Should any funds remain, to the Commonwealth via escheat. 16. This schedule of distribution is in accord with ~3392 of the Probate, Estates, and Fiduciaries Code.~ ~ Section 3392 of the Probate, Estates and Fiduciary Code provides in pertinent part: If the assets of the estate are insufficient to pay all proper charges and claims in full, the personal representative, subject to any preference given by law to claims · due the United States, shall pay them in the following order, without priority as between claims of the same class: (I) The costs of administration. (2) The family exemption. (3) The costs of the decedent's funeral and burial, and the costs of medicines furnished to him within VERIFICATION I verify that the statements made in this Petition are true and correct. I understand that false statements made herein are subject to the penalties under 18 Pa. C. S. § 4904 relating to unsworn falsification to authorities. P er, John C. Porter, Esquire 105.805 REV 9/86 This is to certify that the information here given is correctly copied f'rom an otiginal certificate of death dub' iilud with mc as I,ocal Registrar. The original certificate will be fbrwarded to thc ,qtate Vital Records ()fi]cc for permanent fiiUw,. WARNING: It is illegal to dupliCate this copy by photostat or photograph. Fee for this certificate, S2.00 P 8805814 No. COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,..~..le C ~ 17.~ I ................ I ......... ~'--' ~t - ' . - at-merit [. Female J~- 19/' --42 -- 7833 Manor Care Health Services Carlisle, PA 17013 .~Mxnc~'U~ ,7~m~. Pennsylvania ~ ,z..~9~....~,~.,.~ South Middleton Twp. ,~ Cumberland ~ ,~.~ ~ ~ ,,. Edith Amalta Carlson ~ 1010 W. Spring Valley Road, Wellsville, PA 17365 ~,,~ January 10, 2003 ,,~ East Harrisburg Cemetery *,t Harrisburg, PA 17109 m 1~, I~ ~. i ...... ' ............................. g~P~O -~ ~,,~ )~ .............. : ....... : ....................... '"' It~y ~ ,,. William Cloyd Broclous ~Mr. Arthur Lees ARNING: IT IS ILLEGAL TO ALTER THIS COPY OR 'FO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH. ( OM /ION'Nii t -! 'i OF I' .:N!'4S'~ t_'~ ,LNIA ~)[FA!i I~IENF ~: I- F. ALftl VI!-AL F~ [-OqDE ',<)(:,:,L 'I;'JH; 'FIAFi'S ::ERq'IFICATICIN CF DEATH CERT. NO. T 468¢,358,.. June 29 2000 Date of Issue or'This Cedification Name of Decedent .... Zud-~ _A. Lees Sex .... Fcmc,!e ....... Social Security hie .... !86 ~- _28 -_=_3_t52___ Date of Death June 28, 2000 ............ Birthplace "---~ ~' .... ~"p~'~" "' .... ~'y Pennsylvania Date of Birth __ July 20, Place of Death __ .~.. e_,-,,- u~-.~,-ol rt,,,.k,.,-1,,,,,4 n,~,,.~-y ~. P~n~.~horo To~mahio Pennsylvania Race_ ';;kite ...... Occupation _ T~s~,r~nce Ilnderwriter Decedent's Marital Status __ ,Married .... Mailing Address 10~0 _ Informant Hr. L. Arthur Lees Funeral Director Name and Address of Funeral Establishment -Cock!ln Funeral Heme,Znc., 30 N: Part I: Immediate Cause Part I1: (a)__ Probab!c Pu!mcnary Embe!us (b) (c) (d) Other Significant Conditions ---~¢-~ Lc~-t Knee Rep!ace~_ent Manner of Death Natural ~XX Homicide [] Accident E-i Pending Investigation [] Armed Forces? (Yes or No) No ,qnr~n~vallev Road Wellsville Sit'el ~ - Cib¢ or Towu Scott D. Brenneman, FD PA Dillsburg, PA 17019-0424 Interval Between Onset and Death Describe how injury occurred: Suicide [~ Could not be Determined Name and Title of Certfier (M.D., D.O., Coroner, M.E./ Address 6375 Ba~esl,uL-e ""--'", ~"'"'- ~ ,~-~o~.,,.-g, DA 17f~ This is to certify that the inform'ation here given is correctly copied fror~as original certificate of death duly filed with me as Local Registrar.~i~e.,~i~~rtl~t,~llr~~arded to the State Vital Records Office for permanent filing:"~'''''-''''-"'''~ AFFIDAVIT I, Arthur Lees, as former son-in-law and Power of Attorney to the decedent, Minnie C. Barmont, have no personal knowledge of any existing relatives of Minnie C. Barmont. Arthur Lees Dater- /89 EFFORTS MADE TO FIND LIVING RELATIVES OF MINNIE C. BARMONT On behalf of Attomey John C. Porter, I, Rebekah J. Miller, have researched to find the living relatives of Minnie C. Barmont. I have made the following efforts. 1. I found that Minnie's maiden name was Brocious and her mother's maiden name was Carlson by looking on her Certificate of Death. 2. I found that Minnie was bom in Dagus Mines, Elk County, Pennsylvania, and lived and died in Carlisle, Cumberland County, Pennsylvania, by looking on her Certificate of Death. 3. I used a variety of genealogy websites to locate individuals with the last names mentioned above in Elk and Cumberland Counties, Pennsylvania. I found no living persons related to Minnie Barmont. 4. I called all individuals with the last names of Barmont, Brocious, and Carlson listed in the current Cumberland County phone book. The responses are listed on the chart below. No relatives were found. · 5. Internet directories listed six persons with the last name of Carlson living in Dagus Mines, PA, Minnie's place of birth. 6. I called Directory Assistance and asked for all numbers for persons in Dagus Mines, PA, who have the last name of Carlson. Martin J. Carlson was the only person listed. A message was left for him on September 5, 2003, to remm my call. As of September 9, 2003, no response was received. 7. I called Directory Assistance on September 9, 2003, and asked for the number for a Brocious in Dagus Mines, PA, Minnie's place of birth. No listing was found. 8. Arthur Lees, former son-in-law and Power of Attorney to Minnie Barmont, signed an Affidavit (8/30/03) stating that he knows of no living relatives. Name. Phone Number Date Response Bernie and Donna Carlson 432-9041 7/3/03 left a message - no answer Bud Carlson 737-0650 7/3/03 All from Luzeme County - no relation CA 486-4375 7/3/03 No relation. Carl E. Carlson 776-3583 7/3/03 No relation. Charles Carlson 249-2234 7/3/03 No relation Chas Carlson 732-7283 7/3/03 Wrong Carlsons Christopher Carlson 728-3387 7/7/03 No relation. Ilona Carlson 761-8487 7/7/03 No relation. Jason Carlson 986-9819 7/7/03 No relation. Jason T. Carlson 732-2502 7/7/03 No relation. KA 761-2959 7/29/03 No relation. LeeAnn Carlson 766-8099 7/7/03 No relation, but a Robert Carlson in Erie might know. Lorelei Carlson 730-0936 7/7/03 No relation. Lorna Carlson 774-6034 7/7/03 Will call her mom and call back if anything is known. Never called back. Martin C. Carlson 795-6034 7/7/03 Left a message. Resonded with No relation and don't call back. Max Carlson 730-0936 7/7/03 No relation. Paul Carlson 532-7716 7/7/03 No relations on E. Coast R.D. 532-9776 7/7/03 Married name - No relation. Richard C. Carlson 774-0338 7/7/03 Left a message. 7/29/03 Robert Carlson 697~8074 7/7/03 Left a message. Ronald Carlson 774-4922 7/7/03 No relation. Tami Carlson 766-4351 7/7/03 No relation. Thomas Carlson 258-5145 7/7/03 No relation. Timothy Carlson 731-6195 7/7/03 No answer. Allen Brocious 243-9742 No relation. Chris Brocious 791-0569 6/30/03 Left a message. Danl and Pamela Brocious 985-1605 6/30/03 No relation. Lewis Eugene Barmont 532-4238 6/30/03 No relation. Informed us that Sherry and Ted Barmont are his son and daughter-in-law. Sherry Barmont 532-4455 No relation. Ted Barmont 423-6024 No relation. rote://-/g--O_X Rebekah J. Mffler EFFORTS MADE TO FIND LIVING RELATIVES OF MINNIE C. BARMONT On behalf of Attorney John C. Porter, I, Cheryl E. Rittgers, have made contact to find the living relatives of Minnie C. Barmont. 9/22/03 - Contact was made to Maria Lutheran Church, Louella Moyer, Church Treasurer and Councilwoman. 9/23/03 - Received call from Louella Moyer stating that three members from the Maria Lutheran Church were contacted. None of them knew or heard of an Edith Carlson who married William Brocious. They knew of Frank, Art and George Brocious, but no William. Date: Cheryl E. l~:ttger~ (~- "~ NUMBER DATE! TRANSACTION DESCRIPTION c'A¥~,,,'lEflT DEBIT -,iCODEiFEE, ~ .,:DEPOSIT 0RED[T,-, S.~,.~"'",.~~ '~ ~ MINNIE C. BARMONT L. ARTHUR LEES JR., POA 12..67 D.~rE 3144 60--83/0313 1922 $ D~ )1 ,LA IC',i k ::t ? :~ r--,O B ?," ~ kt, L, ORDER OF allfirst AllGrst Baok NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE ("YOUR AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa. C.S. Ch. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I have read or had explained to me this notice and I understand its contents. Date 7'- Z -oo l~t~U ~ ~. i~R~o~r (Principal) DURABLE GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, that I, MINNIE C. BARMONT, hereby revoke any General Power of Attorney that I have heretofore given to any person and do hereby appoint my son-in-law, L. ARTHUR LEES, as my Attorney-in-Fact (hereinafter "my Agent"), authorizing my designated Agent to perform on my behalf, with full power to transact any and all business in my name as though I myself were acting. DURABLE POWER: Power Not Affected by Disability This Power of Attorney shall not be affected by my subsequent disability or incapacity. GENERAL GRANT OF BROAD POWERS: My Agent is hereby given the fullest possible powers to act on my behalf: to transact business, make, execute and acknowledge all agreements, contracts, orders, deeds, writings, assurances and instruments for any matter, with the same powers and for all purposes with the same validity as I could, if personally present. SPECIFIC POWERS INCLUDED IN GENERAL POWER: Without limiting the general powers hereby already conferred, my Agent shall have the following specific powers which are included in the foregoing general powers: 1. Banking and Financial Institutions; General Financial Powers. To deposit any funds received for me in my accounts in such bank or trust company or other depository as my Agent may select, either in my name or in my Agent's name as Attorney-in-Fact. Bo To withdraw from and to draw any check or other drait against any monies held for me at any bank, saving fund, or other place of deposit, whether such account was created by me or by my Agent. Co To endorse notes, checks, and other instruments which may require my endorsement. D. To pay all debts now or hereafter incurred by me. Eo To borrow money and to mortgage or pledge any property, real or personal, now or hereafter owned by me as security therefor and to satisfy of record any indentures of mortgage now or hereafter standing in my name or acquired for my account. To have access to any safe deposit box standing in my name or in my Agent's name for me, and to add to or remove the contents of such box; provided, however, my Agent shall not use such box as a place in which to keep any personal property of my Agent. Go Generally, to transact any and all business for me with any bank, trust company, or other depository. 2. Stocks, Bonds, Securities, and Investments A° To sell, exchange, pledge, assign, transfer, and deliver to any person, at my Agent's discretion, all or any part of any stocks, United States Savings Bonds, other bonds, notes, mortgages, interests in partnerships or other securities, and any and all personal property standing in my name or belonging to me, or over which I may have any power or control. To make, execute, and deliver on my behalf all necessary deeds, assignments, or transfers. Bo To register any or all of my securities in my Agent's name as Attorney-in-Fact for me. C. To vote my securities in person or by proxy. Do To transact all business in relations to any stocks, bonds, securities, or other property in the nature thereof~ to deposit the same under agreements of deposit; to participate in any plan of lease, mortgage, merger, consolidation, exchange, reorganization, recapitalization, liquidation, receivership, or foreclosure with respect thereto; to exercise any rights to subscribe to new issues thereot~ and generally to exercise all rights of management and ownership with respect thereto. Eo To invest in any form of property, all funds and securities held or received for my account, keeping such cash reserves as, in my Agent's discretion, are necessary or desirable to meet conditions as they may exist from time to time. In the exercise of this power, my Agent may invest in any variety of real and personal property as in my Agent's discretion appears to be prudent investments, and my Agent shall not be liable to me for any error ofjudgment in the making or continuing of any investment. Real Estate. To sell, exchange, pledge, assign, transfer, and deliver to any person, at my Agent's discretion, all or any part of my real property, standing in my name or belonging to me, or over which I have any power or control. Bo To make, execute, and deliver on my behalf all necessary deeds, assignments, or transfers. C. To operate real property, separately or jointly with others. To lease for any term any real property and to vary the terms, including rent payable, of any lease. To alter, repair, improve, mortgage, divide, exchange, join in the partition of, or give options with respect to, real property. F. To buy in any judicial sale any property on which I hold a mortgage. Generally to transact all business and to exercise all rights of management and ownership relating to real property. Claims, Law Suits, Compromise, and Miscellaneous Powers. To demand, sue for, levy, collect, and give proper receipts for all sums of money or property now or which may hereafter become due me from any source whatsoever, including all estates or trusts, proceeds of insurance policies or other property of any kind whatsoever. B. To join with other parties in the compromise or settlement of any claims. Co To make, negotiate, sign, and perform any and all agreements and contracts now in course of negotiation, execution, and settlement by me, or which may hereafter in the opinion of my Agent be to my interest or advantage; to effect, procure, and continue insurance of any and every kind and description; and with full power and authority to manage any real and personal property and conduct my affairs generally. Do To employ attorneys at law and such other agents, employees, or representatives as my Agent may think proper, and to pay any claims, fees, expenses, wages, demands, or obligations for which I may now be or may hereafter become liable. 5. Tax Matters. To prepare, execute, and file on my behalf and in my name any and all income tax declarations and returns, and any other tax returns and reports (including, for not limited to, protests, claims, elections, consents, closing agreements, waivers of statutes of limitations and extensions), and to represent me before the Internal Revenue Service or Treasury Department and any state or local taxing authority with respect to any claim or proceeding having to do with my tax liabilities, federal, state, or local, for any and all years. Power to Delegate. To substitute one or more agent or agents under my Attorney-in-Fact, to carry out any of the general or specific powers hereby granted. Specific Authority to Purchase "Flower" Bonds. To purchase United States Treasury "flower" bonds on my behalf and to borrow money as provided above for the purchase of such bonds. Specific Financial Powers Defined by Statute. The following powers are granted pursuant to Chapter 56 of the Pennsylvania Probate Estates and Fiduciaries Code as further defined therein: To make limited girls. My Agent may make girls on my behalf to any donees and in such amounts as my Agent may decide subject to the following: (1) The class of permissible donees shall consist solely of my spouse, my children, my grandchildren, and my great grand-children (including my Agent if my Agent is a member of such class). (2) During each calendar year, the girls to each donee pursuant to this power shall have an aggregate value not in excess of Ten Thousand Dollars ($10,000.00) or such greater amount as, and shall be made in such manner as, to qualify in their entirety for my annual exclusion from the Federal Girl Tax as provided in Section 2503(b) of the Internal Revenue Code of 1986, as amended, without regard to Section 2513(a) thereof (or any successor provision allowing girls to be split with a spouse). B. To create a trust for my benefit. Co D. E. F. G. To make additions to an existing trust for my benefit. To claim an elective share of the estate of my deceased spouse. To disclaim any interest in property. To renounce fiduciary positions. To withdraw and receive the income or corpus of a trust. .Specific Personal and Medical Powers Defined by Statute. The following powers are granted pursuant to Chapter 56 of the Pennsylvania Probate, Estates, and Fiduciaries Code, as further defined therein: Ao To authorize my admission to a medical, nursing, residential, or similar facility and to enter into agreements for my care. To authorize medical and surgical procedures. DURATION OF POWER, RELIEF FROM LIABILITY, REVOCATION. 1. This power shall not expire by reason of lapse of time. I hereby ratify and confirm all that my Agent acting hereunder shall do or cause to be done under this General Power of Attorney. I specifically direct that such Agent shall not be subject to any liability by reason of any of such Agent's decisions, acts, or failure to act, all of which shall be conclusive and binding upon me, my personal representative, heirs, and assigns. Furthermore, except in the case of malfeasance of office, I agree to indemnify such Agent, and hold such Agent harmless, from all claims that may be made against such Agent as a result of such Agent's service hereunder, and I hereby agree to reimburse such Agent in the amount of any damages, costs, and expense that may be incurred as a result of any such claim. This Power of Attorney shall be revoked by my giving to such Agent acting hereunder written notification of the revocation, which notice shall not be considered binding unless actually received. THIRD PARTY LIABILITY Any person who is given instructions by my Agent in accordance with the terms of this Power of Attorney shall comply with those instructions. Any person who without reasonable cause fails to comply with those instructions shall be subject to civil liability for damages resulting from noncompliance. This Power of Attorney is executed in ,~ counterparts, or which this is counterpart No. IN WITNESS WHEREOF, and intending to be legally bound, I have hereunto set my hand and seal this ~.1 $'[. day of J~d]~4 ,2000. WITNESS: MINNIE C. BARMONT ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA :  : SS COUNTY OF : On this 2 / day of 5r--c~ff5 , 2000, before me, the undersigned, personally appeared MINNIE C. BARM6NT, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and Notarial Seal. NOTARY PUBLIC [ Notarial Seal ! Frederick W. Spease, Notary Public [South Middleton Twp., Cumberland County lMy Commission Expires Dec. 06, 2003 Member, Pennsylvania Association of Notaries ACKNOWLEDGMENT I, L. ARTHUR LEES, have read the attached Power of Attorney and am the person identified as the "Agent" for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney, or in 20 Pa. C.S. Ch. 56, when I act as Agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. Date 2. 3. 4. (Agent) (717) 249-1177 John C. Por er Attorney at Law 61 West Louther Street Carlisle, PA 17013-2936 (717) 24%4514 fax The Estate of Minnie C. Barmont C/O John C. Porter, Attorney at Law 61 West Louther Street Carlisle, PA 17013 E.I.N. 37-1455668 November 24, 2003 Date 1/23/03 1/24/03 1/24/03 2/7/03 2/12/03 March - July, 2003 7/29-31/03 8/27/03 9/22/03 9/23/03 11/15/03 11/17/03 11/24/03 11/24/03 STATEMENT Description Initial Consultation - Arthur Lees Review Will and other documents Review P.E.F. Code Annotated for precedent Telephone call to Ralph Wright, Esquire, Solicitor for Cumberland County Register of Wills Telephone call from Ralph Wright, Esquire, Solicitor for Cumberland County Register of Wills Clerk's Intemet genealogy research and telephone genealogy research Hours N/C 0.3 0.5 0.1 0.4 15.00 Follow-up genealogy telephone calls Letter to Arthur Lees Genealogy telephone calls to Dagus Mines' Lutheran Church Treasurer and Councilwoman, Lovella Moyer Clerk's conversations with Dagus Mines' Lutheran Church Treasurer and Councilwoman, Lovella Moyer Draft Petition File Petition ~t/ Filing Fee = ~?,69r00~ ~r/:~. *o ! ~¥ Statement TOTAL CLERK TIME THIS STATEMENT TOTAL ATTORNEY TIME THIS STATEMENT 0.6 0.2 0.2 0.4 1.2 0.1 N/C 15.4 3.6 Costs this statement Attorney Hours this statement = 3.6 x $125/hour Clerk Hours this statement = 15.4 x $10/hour Total Due $450.00 $154.00 ESTATE OF MINNIE C. BARMONT DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, COMMONWEALTH OF PENNSYLVANIA NO. - 0,3 - C/7i ORPHAN'S COURT ANDNOWthis5~1~day of ORDE~_.,~ ,2003, upon consideration of the within Petition under Section 3102 of the Probate, Estates and Fiduciaries Code For Distribution Of A Small Estate, a Rule/Citation is hereby issued upon Manor Care Health Care Services and The Pennsylvania Department of Public Welfare, Third Party Liability Section to show cause, if they have any, why the Decedents assets should not be distributed as proposed in the amounts set forth in said Petition. Rule returnable _~__ days after service thereof. BY THE COURT, Manor Care Health Services 940 Walnut Bottom Road Carlisle, Pa 17013 Department of Public Welfare Third Party Liability Section PO Box 8486 Harrisburg, PA 17105 John C. Porter, Esquire 61 West Louther Street Carlisle, PA 17013 IN RE: ESTATE OF MINNIE C. BARMONT IN THE COURT OF COMMON PLEAS ORPHANS' COURT DIVISION CUMBERLAND COUNTY, PENNSYLVANIA NO. 21-2003-0971 RULE WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Court of Common Pleas, Orphans' Court Division at a session of the said Court there to be held, for the County of Cumberland to show cause why if they have any, why the Decedents assets should no be distributed as proposed in the amounts set forth in said Petition. Rule returnable 30 days after service thereof. Witness my hand an official seal of office at Carlisle, Pennsylvania, this 8th day of December, 2003. Clerk, Orphans' Court Division I" Cumberland County, Carlisle, PA My Commission Expires on the 1 st Monday January, 2006 IN RE: ESTATE OF MINNIE C. BARMONT DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, COMMONWEALTH OF PENNSYLVANIA NO. 21-03-971 ORPHAN'S COURT CERTIFICATE OF SERVICE I, John C. Porter, Counsel for a Creditor of the estate of Minnie C. Barmont, hereby certify that a tree and correct copy of Petition under Section 3102, the Court's signed Order and the Court's Rule to Show Cause, were served this 10th day of December, 2003, by First Class Mail, upon those listed below. Manor Care Health Services 940 Walnut Bottom Road Carlisle, PA 17013 Department of Public Welfare Third Party Liability Section PO Box 8486 Harrisburg, PA 17105 John C. Porter, Esq. Counsel for Estate Creditor PA Sup. Ct. ID# 90152 61 W. Louther St. Carlisle, PA 17013 717-249-1177 REV-1500 EX (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 I-- Z 1.1.1 LM ILl I.- Z LU Z o 14.1 n, O x INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) DATE OF DEATH (MM-DD-~EAR) C I I DATE OF BIRTH (MM-DD-YEAR) o -o6- z:oo_'.'.'5 -"' zA - lifo 6 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) L-~2. Supplemental Return [~] 4a. Future Interest Compromise (date of death after 12-12-82) ~-~7. Decedent Maintained a Living Trust (Attach copy of Trust) [~10. Spousal Poverty Credit (date of death between 12-31-91 and I-1-95) '[~1. Original Return E~4. Limited Estate ~--~6. Decedent Died Testate (AUach copy of Will) [~9. Litigation Proceeds Received OFFICIAL USE ONLY 13. Charitable and Govemmental Bequests/Sec 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) (8) (11) (12) (13) (14) 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. x .12 x .15 (15) (16) (17) (18) (19) COMPLETE MAILING ADDRESS 61 S+, SOCIAL SECURITY NUMBER I':l THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER []3. Remainder Return (date of death prior to 12-13-82) ["~ 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ~]11. Election to tax under Sec. 9113(A) (Attach Sch O) 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) E~] Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) Expenses &Administrative Costs (Schedule H) (9) 9. Funeral 10. Debts Of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (~ ,00 (~ , O(~ O '00 OFFICIAL USE ONLY e -a0 0 O~OO 0 TELEPHONE NUMBER FILE NUMBER - o__3___ COUNTY CODE YEAR NUMBER Decedent's Complete Address: STREET ADDRESS CITY Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty ~ -00 Total Credits ( A + B + C ) (2) ~'(~- Total Interest/Penalty ( D + E ) (3) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund (4) If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB) 0 ' O0 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; .......................................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ............................................ [] [] c. retain a reversionary interest; or .......................................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ...................................................................... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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. DATE DATE ADDRESS ~..,.,~ -~. 1~-~O'¢2. -"~ For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a)(1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(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-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF · /V~Ah~.. C.-~:~.~/~^-~ FILENUMBER All real property owned solely or as a tenant in co~imon must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedul F. ITEM NUMBER 1. DESCRIPTION TOTAL (Also enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE Of DEATH S O, O~ REV-1503 EX + (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. FILE NUMBER SCHEDULE B STOCKS & BONDS TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH DESCRIPTION REV-1504 EX * (1~97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP FILE NUMBER Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corpomtion/parthership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER DESCRIPTION 1. TOTAL (Also enter on line 3, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH REV~1507 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER ITEM NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION TOTAL (Also enter on line 4, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH REV-IF~8 EX * (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the; ITEM NUMBER Iroceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshi = must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 5, Recapitulation) i $ ( G~ 7, "~ 9 (if more space is needed, insert additional sheets of the same size) L. ARTHUR LEES JR., POA ]2.2. 3143 "'l'J I · 'z'-'~¢-ill MINNIE C. ~ARMONT L. ARTHUR LEES JR., POA 12-67 PAY 'If) 'HIE ORDER OF ailfirst ailfimt B,nk Harrisburg, PA t7101 FoR REV-1509 EX + (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF · J'~6'; ~/~'; ¢-.--- C.. ~'~..(' iv~ o/~.J~''' FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A, JOINTLY-OWNED PROPERTY: D- I; bR DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTERES 1. A. TOTAL (Also enter on line 6, Recapitulation) $ O, O0 (If more space ~s needed, insert additional sheets of the same size) REV-1510 EX + (1-97) ~ COMMONWEALTH OF PENNSYLVANIA iNHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 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 % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1. ~O TOTAL (Also enter on line 7, Recapitulation) $ (~ O0 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ITEM NUMBER 5. 6. 7. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: ADMINISTRATIVE COSTS: Personal Representative's 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: Attorney Fees ~J'o~,,.,.C,. ~o~'~,~_/ ~['~'^e..¥ ~ ~o,.~,..,,, ~ (~<;o~>-~-.- Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees State _ Zip TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insed additional sheets of the same size) AMOUNT $ 657... OO REVd512 EX + (~ 97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ['~(/~.O/~ ~ FILE NUMBER NUMBER Include unreimbursed medical expenses. ITEM DESCRIPTION TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) AMOUNT REV-1513 EX+ (9-00~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER I II 1. SCHEDULE J BENEFICIARIES FILE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) IN RE: ESTATE OF MINNIE C. BARMONT DECEASED IN THE COURT OF~ LEAS OF CUMBERLAND COUNTY, COMMONWEALTH OF PENNSYLVANIA proposed distribution of assets from the above-captioned Estate is approved, and the Petitioner is directed to distribute the Estate's assets accordingly. NO. 21-2003-0971 ORPHAN'S COURT ~__, 2004, Petitioner's BY THE COURT, IN RE: ESTATE OF MINNIE C. BARMONT DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, COMMONWEALTH OF PENNSYLVANIA NO. 21-2003-0971 ORPHAN'S COURT MOTION TO MAKE RULE ABSOLUTE 1. On, or about, November 24, 2003, John C. Porter, Esquire, began the above-captioned matter by filing a Petition Under Section 3102 Of The P.E.F. Code For Distribution Of A Small Estate. 2. Upon consideration of that Petition, The Honorable President Judge George Hoffer issued an Order that commanded Manor Care Health Services and the Pennsylvania Department of Public Welfare to show cause, if they have any, why the Decedents assets should not be distributed as proposed in Attorney Porter's Petition. 3. Consequently, the Orphans' Court Division issued a Rule, returnable 30 days after service thereof, upon Manor Care Health Services and the Pennsylvania Department of Public Welfare. 4. The Court's signed Order and Rule were served upon Manor Care Health Services and the Pennsylvania Department of Public Welfare on December 10, 2003. 5. Since service of the Order and Rule, no answer has been filed by either Manor Care Health Services and the Pennsylvania Department of Public Welfare. 6. The Orphan's Court Division's thirty day deadline has passed. WHEREFORE, Petitioner humbly prays that this honorable Court approve of Petitioner's proposed distribution as set forth in his Petition: $632.00 to John C. Porter, Attorney at Law, for services provided for the costs of administration; remainder in the Allfirst checking account, up to $595.49, to Manor Care Health Services, for medical and nursing services within the last six months of death; and should any funds remain, to the Commonwealth via escheat. Date: Respectfully Submitted, Jo C). porterClsquir~eO~ Petitioner Pennsylvania Supreme Court ID No. 90152 61 West Louther Street Carlisle, PA 17013 (717) 249-1177 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 JOHN C PORTER ATTY 6i W LOUTHER ST CARLISLE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE , ~.ESTATE OF DATE OF DEATH FILE NUMBER ~I~UNTY ACN 03-22-2004 BARMONT 01-06-2003 21 03-0971 CUMBERLAND 101 Amount Remitted REV-tS47 EX AFP (01-05) MINNIE C MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA I7013 CUT ALONG THIS LINE ~- RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP COl-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BARMONT MINNIE C FILE NO. 2I 03-097I ACM IOI DATE 03-22-2004 TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate CSchedule A) 2. Stocks and Bonds CSchedule B) ~. Closely Held Stock/Partnership Interest CSchedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. PersonaZ Property (ScheduZe E) 6. JotntZy Owned Property (Schedule F) 7. Transfers CSchedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funera! Expenses/Adm. Costs/M/sc. Expenses CSchedule H) lO. Debts/Mortgage LlabtZtties/Ltens CScheduZe I) 11. Total Deductions 12. Net Value of Tax Return .00 .00 .00 .00 lr087.49 .00 .00 C8) 632.00 595.49 NOTE: To insure proper credit to your account, submit the upper port/on of this form with your tax payment. I$. 14. NOTE: 1,087.49 .~P7.49 140.00- Charltable/GovernmentaZ Bequests; Non-elected 9115 Trusts CScheduZe J) CI$) .00 Net Value of Estate Sub.~ect to Tax (14) 140.00- If an assessment Nas issued prevtously, lines ]~, 15 and/or 1~, 17, 18 and ]~ Nt[l to date. ¢~5) .00 x O0 = .00 c1~) .00 x 045= .00 CIT~ .00 x 12 = .00 C~8) .00 x 15 = .00 C19)= . O0 reflect figures that include the total of ALL returns assessed ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousa! rate 16. Amount of L/ne 14 taxable at LtneaZ/CZass A rate 17. Amount of L/ne 14 at Sibling rate 18. Amount of L/ne 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS PAYMENT RECEIPT DISCOUNT DATE NUMBER INTEREST/PEN PAID ~~FoFRP~LD uALFAT~[R HDA~ INDICATED, SEE REVERSE C 0 ADDITIONAL INTEREST. AMOUNT PAID TOTAL TAX CREDIT I .00 BALANCE OF TAX DUEl .00 INTEREST AND PEN. .OO TOTAL DUE .00 ( IF TOTAL DUE IS LESS THAN ~1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CA), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)