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HomeMy WebLinkAbout09-07-12DECEDENT'S ESTATE ~~J , ~ ~~-, ~ J -~ ~ ._. _. - _- ~-~ ~, r~i C~ ' ... '-r.~ _l~ . COURT OF COMMON PLEAS OF r`^`' ~~~~ `: -' ~7 ~~ :~? CUMBERLAND COUNTY, PENNSYLVANIA ~'_-~; .Wt-e ~==_~ ~-> ORPHANS' COURT DIVISION ~ .~- `-`' ~ n ESTATE OF LILLIAN M. PALMER No. 2011-0 l 249 DECEASED PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If space is insufficient, riders may be attached. Attach the spouse 's election, if any; the papers required under items 8-19 inclusive; and any instrument pertinent to the adjudication. INCL UDE A TTACHMENTS A T THE BACK OF THIS FORM. Name of Counsel: THOMAS E. FLOWER Supreme Court I.D. No.: $3993 Name of Law Firm: FLOWER LAW, LLC Address: 10 W. HIGH ST., CARLISLE, PA 1701.3 Telephone: (717) 243-5513 Fax:~717) 241-4021 Form OC-01 rev. 10.13.06 Page 1 of 10 ,~ ~~ Estate of LILLIAN M. PALMER 1. Name(s) and address(es) of Petitioner(s): Name: CAROLYN L. MILLER Address: 24007 FERNLAKE DRIVE HARBOR CITY, CA 90710 Deceased Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: NONE Is this the first accounting by this fiduciary? ..................... Yes No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2. Decedent died on 08/05/2011 Letters Testamentary or Letters of Administration were granted to Petitioner(s) on 11 /22/2011 Date of Will (if applicable): 01/17/2005 Date(s) of Codicil(s) (if applicable): 09/16/2005 Date of probate (if different from date Letters granted): Was a bond required? Yes No If yes, state amount: Are proofs of advertising of the grant of Letters attached? ......... Yes No Dates of advertising of the grant of Letters: JAN 31, FEB 7 & 14, 2012 (SENTINEL) FEB 10, 17 & 24, 2012 (CUMBERLAND LAW JOURNAL) Form OC-01 rev. 10.13.06 Page 2 of 10 Estate of LILLIAN M. PALMER Deceased 3. Was decedent survived by a spouse? ............................. Yes No If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? ............. Yes No (See Section 2201 et sue. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, so state): 6. Did decedent marry after execution of Will or Codicil(s)? ........... ~ Yes No Were any children born to decedent after execution of 'Y Will or Codicil(s)? ........................................... ® es ®No If yes, give names and dates of birth: Name: Date of Birth: 7. If required by the Medical Assistance Estate Recovery Act, 62 P.S. § 1412, was a request for a statement of claim sent to the Department of Public Welfare? .............................. Yes No Form OC-0/ rev. 10.13.06 Page 3 of 10 Estate of LILLIAN M. PALMER Deceased 8. Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa. O.C. Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs if there is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Name and Address of Each Parry in Interest ~ Relationship and Comments, if any 1 Interest CAROLYN MILLER DAUGHTER 1/2 24007 FERNLAKE DR HARBOR CITY, CA 90710 KENTPALMER I SON 11/6 1606 STATE ST HARRSIBURG, PA 17103-148 Form OC-Ol rev. 10.13.06 Page 4 of 10 Estate of LILLIAN M. PALMER Nome and Address of Each Parry in Interest ~ Relationship and C CHRISTIAN PALMER GRANDSON 2379 Shermans Valley Rd. Elliotsvurg, PA 17024 ANNETTE STRAUB 1128 STONE ARCH RD. NEWPORT, PA 17074 B. Identify each party who is not sui juris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each. NONE C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O.C. Rule 12.4). ALL PARTIES IN INTEREST ARE SUI JURIS D. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. N/A Deceased Interest 1/6 GRANDDAUGHTER ~ 1/6 Form OC-01 rev. 10.13.06 Page 5 of 10 Estate of LILLIAN M. PALMER Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Admitted? Will Claim Be Paid In Full? MANOR CARE HEALTH 473.89 IYes No Yes No SERVICES LLC PO BOX 637602 CINCINNATI, OH 45263-7602 ~ ~'eS ~ Yes JITTERBUG 29.51 No No DEPT 892102 PO BOX 122102 DALLAS, TX 75312-2102 PA DEPT OF PUBLIC WELFARE 63,940.85 Yes No ~ Yes No DIVISION OF 3RD PTY LIABILITY RECOVERY SECTION, PO BX 8486 HARRISBURG, PA 17105-8486 Yes Yes No No If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? ................................ Yes ~No Was family exemption allowed? ................................ Yes No Family exemption claimant's name and relationship: Name: Relationship: Form OC-01 rev. 10.13.06 Page 6 of 10 Petition for Adjudication, Page 6, Item 10: Schedule: Order of preference under Section 3392 and proposed pro rata payment of claims: Class 3 claims: Manor Care, Total amount of Class 3 claim.....$ 473.89 Proposed payments .........................................$ 98.09 Pa. Dept. of Welfare, Total amount of Class 3 claim...$25,592.11 Proposed payment2 .......................................... $ 5,297.3 8 TOTAL DEBT PAYMENT: $ 5,395.47 ' 473.89 = (473.89 + 25,592.11) x 5,395.47 = 98.09 2 25,592.11= (473.89 + 25,592.11) x 5,395.47 = 5,297.38 Estate of LILLIAN M. PALMER Deceased 12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate Tax paid, the date(s) of payment(s), and the interest(s) upon which paid, are as follows: Date Payment Interest N/A 0.00 0 13. On the date of death, was the decedent a fiduciary (personal representative, trustee, guardian, agent under power of attorney) or surety on the bond of a fiduciary? ................... Yes No If yes, provide the name of the estate, indicate whether an account has been filed and confirmed absolutely and all awards performed, or, in the alternative, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? .................. Yes No 15. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed or attached, provide a copy of the assignment, renunciation, disclaimer or attachment, together with any relevant supporting documentation. Form OC-01 rev. 10.13.06 Page 7 of 10 Estate of LILLIAN M. PALMER Deceased 16. Had the decedent been adjudicated an incapacitated person? .......... Yes No If yes, attach a copy of the Order if available; otherwise state the Court, term, number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. NONE B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? ............. Yes No 18. If a reserve is requested, state amount and purpose. Amount: Purpose: NSA If a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the .... Yes No . . ......................... parties in interest? .......... . If so, attach a copy of the notice. 19. Is the Court being asked to direct ............ Yes No the filing of a Schedule of Distribution? ............. . " !Y N As to real estate only? ........................................ ® es ® o Form OC-01 rev. 10.13.06 Page 8 of 10 Estate of LILLIAN M. PALMER Deceased Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggest(s) that the distributive shares of income and principal (residuary shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/Proportion NONE B. Principal: Proposed Distributee(s) Amount/Proportion NONE Submitted By: (All petitioners must sign. Add additional lines if necessary): f.. 1 ~_ ~ ~,,r~ Nam of Petitioner: CAROLYN L. MILLER Name of Petitioner: Form OC-01 rev. 10.13.06 Page 9 of 10 Estate of LILLIAN M. PALMER Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that he~she is titre of the above-named name of corporation and] that the facts set forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities). ,~ f : ~.-~. Signature of Petition"er * Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. Signature of Counsel for Petitioner Deceased Form OC-Ol rev. 10.!3.06 Page 10 of 10 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: THE ESTATE OF LILLIAN PALMER, No. 2011-0 l 249 deceased Late of South Middleton Twp. CERTIFICATION OF NOTICE I hereby certify that written notice of the date, time and place of presentation for audit of the First and Final Account for the Estate of Lillian Palmer has been given by first class mail on September 7 , 2012, to every unpaid claimant who has given written notice of a claim and to every other person known to have or to claim an interest in the estate as beneficiary, creditor, heir or next of kin pursuant to Pennsylvania Orphans' Court Rule 6.3. Date: ~ 7 Z Thomas E. Flower, Esquire Attorney I.D. No. 83993 Flower Law, LLC 10 West High Street Carlisle, PA 17013 (717) 243-5513 Creditors: Tina M. Wise PA DPW Estate Recovery Section PO Box 8486 Harrisburg, PA 17105-8486 MANOR CARE HEALTH SERVICES LLC FACILITY 0372 PO BOX 637602 CINCINNATI, OH 45263-7602 JITTERBUG DEPT 892102 PO BOX 122102 DALLAS, TX 75312-2102 Beneficiaries: Carolyn M. Miller 24007 Fernlake Dr. Harbor City, CA 90710 Kent G. Palmer 1606 State Street Harrisburg, PA 17103-1487 Christian Palmer 2379 Shermans Valley Rd. Elliotsburg, PA 17024 Annette Straub 1128 Stone Arch Rd. Newport, PA 17074 FLOWER LAW, LLC 10 W. HIGH STREET CARLISLE, PA 17013 James D. Flower, Jr. Thnmac F. Flnwer PHONE: (717) 243-5513 FACSIMILE: (717) 241-4021 September 7, 2012 Notice of Filing Account Re: Lillian M. Palmer Estate Dear Sir/Madam: This letter will advise you, as required by law, that the First and Final Account of Carolyn L. Miller, Executrix of the above-mentioned estate has been filed for Audit with the Orphans' Court Division of Cumberland County Court of Common Pleas, Cumberland County, Pennsylvania. The Account, which does not include a Schedule of Proposed Distribution, will be presented for audit, confirmation and distribution on October 9, 2012, at 9:30 a.m. A copy of the Account is enclosed. If you have no objections to the Account, or the matters set forth within the Account, no action is required. However, if there are objections to the transactions shown in the Account, or omitted from the Account, you must file with the Clerk of the Orphans' Court Division, prior to 9:30 a.m. on October 9, 2012, and in writing, objections thereto in conformity with the Cumberland County Orphans' Court Division Rules. In the absence of timely written objections, the Court will assume that you have no objections to the Account and the right to object will be waived. Very truly yours, FLOWER LAW, LLC Thomas E. Flower Enclosures PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Jackie Cox, Sales Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): January 31, February 7 & 14, 2012 COPY OF NOTICE OF PUBLICATION N TI E QF RANT OF LETTERS TESTAMENTARY ;Letters Testamentary in the Estate of LILLIAN M. PALMER, deceased, late of South Middleton Township, Cumberland County, Pennsylvania, have been granted to the undersigned. All persons knowing themselves to be indebted to the said estate will make payment immediately, and those having claims will present them for settlement to: Carolyn L. Miller, Executrix c/o Thomas E. Flower, Esquire . FLOWER LAW, LLC 10 West High Street Carlisle, PA 17013 FLOWER LAW, LLC Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication a t ue. Sworn to and subsc 'bed before me this Notary Public My commission expires: ~i ~ i ~'~+~ i ;~1 ~ ~~ 1, f°~ ~_ it E3Ai4'':~I ~iN~d i~C`r;~~,D~JI~! 3f fi ~~^viZff F~lli}!IG CARLISL>` EOR~J~,N, C~ „' i:RL~~!~? ~~TY PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, ~~;~• February 10, February 17, and February 24, 2012 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Palmer, Lillian M., deed. Late of South Middleton Town- ship. Executrix: Carolyn L. Miller c/o Thomas E. Flower, Esquire, Flow- er Law, LLC, 10 West High Street, Carlisle, PA 17013. Attorneys: Flower Law, LLC. ~- , -~ ~,isa arie Coyne, Editor ~_ SWORN TO AND SUBSCRIBED before me this 24 of February, 2012 Notary .,r~ NO1ARlAL SEAL DEBORAH A COLUNS Notary Public CARLISLE Bt~ROUGH, GUMBERLAND COUNTY My Commission Expires Apr 28, 2014 NOTICE OF INHERITANCE TAX pennsy van~a ~ BUREAU 0~ INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP C12-11) PO BOX 280601 HARRISBURG PA 17128-D601 THOMAS E FLOWER 10 W HIGH ST CARLISLE DATE 06-25-2012 ESTATE OF PALMER LILLIAN M DATE OF DEATH 08-05-2011 FILE NUMBER 21 11-1249 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 08-24-2012 P A 17 013 - 2 9 2 2 (See reverse side under Objections ) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT-ALONG-THIS-LINE----- -~ --RETAIN-LOWER-PORTION-FOR-YOUR-RECORDS- E- ------------------- REV-1547 EX AFP C12-11~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: PALMER LILLIAN MFILE Fi0.:21 11-1249 ACN: 101 DATE: 06-25-2012 TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED 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) 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) cl) .00 C2) .00 C3) .00 C4) .00 C5) 7 , 847.91 C6) .00 C7) .00 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. c8) 7 , 847.91 C9) 2,290.40 clo) 64,446.75 11. Total Deductions C11) b6,737.15 12. Net Value of Tax Return C12) 58,889.24- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .00 14. Net Value of Estate Subject to Tax C14) 58,889.24- NOTE: 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. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .0 0 X 0 0 = .0 0 16. Amount of Line 14 taxable at Lineal/Class A rate (16) .0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate C17) .0 0 X 12 = .0 0 18. Amount of Line 14 taxable at Collateral/Class B ra te (18) .0 0 X 15 = .0 0 19. Principal Tax Due C19)= .0 0 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. FIRST AND FINAL ACCOUNT OF CAROLYN L. MILLER EXECUTRIX FOR THE ESTATE OF LILLIAN M. PALMER NO. 2011-01249 Date of Death: Date of Executor's Appointment: First Complete Advertisement of Grant of Letters Accounting for the Period: AUGUST 5, 2011 NOVEMBER 22, 2011 FEBRUARY 10, 2012 NOVEMBER 22, 2011 -AUGUST 31, 2012 Purpose of Account: CAROLYN L.MILLER, Executrix, offers this account to acquaint interested parties with the transactions that have occurred during her administration. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: Thomas E. Flower, Esquire FLOWER LAW, LLC 10 West High Street Carlisle, PA 17013 (717) 243-5513 c ~ ~ :.~-, ~_ '~. r '~ - .~_~ ~ ,_ _ ;_~ _ .. __ _. _; 7~ - _..,, _ . _ _. -- ~... , L .% ~ ~ , .'~ , ~.. ..SP.'a ^~ + l" ~ r ~~` ` ~~\\\!4 SUMMARY Proposed Distribution to Beneficiaries: PRINCIPAL: Receipts (Less Disbursements) Debts Administrative Expenses Fees and Commissions Total Disbursements [NONE] Page No. (5,395.47) (560.04) (1,892.40) 7,847.91 (7,847.91) 0.00 PRINCIPAL RECEIPTS 02/01/2010 Bank of Landisburg, funds on deposit $ 7,469.45 Refund, Highmark Blue Shield 378.46 TOTAL PRINCIPAL RECEIPTS: DISBURSEMENT OF PRINCIPAL DEBTS: Manor Care, Prorated portion of $473.89 Class 3 claim $ 98.09 Pa. Dept. of Welfare, Prorated portion of $25,592.11 Class 3 claim 5,297.38 TOTAL DEBT PAYMENT: (5,395.47) ADMINISTRATION EXPENSES: Register of Wills: Probate fees $ 120.50 Inheritance tax return filing fee 15.00 Filing Fees, Account and Adjudication 160.00 Publication of executor's notices, The Sentinel 189.54 Cumberland Law Journal 75.00 TOTAL ADMINISTRATIVE EXPENSES: (560.04) FEES AND COMMISSIONS: Carolyn L. Miller, Executrix's Commission $ 392.40 Flower Law, LLC, Attorney Fees 1,500.00 TOTAL FEES AND COMMISSIONS: (1,892.40) 7,847.91 2,452.44 1,892.40 00.00 3 STATE OF CALIFORNIA ) COUNTY OF ) SS. Carolyn L. Miller, Executrix under the Last Will and Testament of Lillian M. Palmer, deceased, hereby declares under oath that she has fully and faithfully discharged the duties of her office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been acknowledged in the foregoing account and; that, to her knowledge, there are no claims now outstanding against the estate, except as disclosed in the foregoing account; and that all taxes presently due from the estate have been paid. f -, ~ ~ ~ ~, Carol n .Miller, Executrix S this 1VVLCAl ,' 1 1L V11V ~ ~ ,, -- and subscribed before me 4 Jurat State of California County of ~ S ~i G- ~.~t- ~ .. Subscribed and sworn to (or affirmed} before me on this A day of t, e~ J ~ . ~ t L._ t.._~-1~._ 20 (Z by ~+'Z- proved to me on the basis of satisfactory evidence to be the person who appeared before me. 1 Signature (Notary seal) ~:~a , ~~ L. J. KELLY ~F` l~ ''~°~ Commission # 1845107 ~ y`~~~ ,- Natary Public - California z "~ ~~ Los Angeles Gaunty D h1y Gomm. Expires Air 17, ?_013 .~ OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT ~~_ tom: ~ ~ . ~=-t~~.:. ~'T- ~S Ty {Title or description of attached document) ~S (Title or description of attached document continued) Number of Pages I ~ Document Date ~ ~ ~ ° 1 ~ (Additional information} INSTRUCTIONS FOR COMPLETING THIS FORM The wording of all Jurats completed in California after January I, 2008 must be in the form as set forth within this Jurat. There are no exceptions. If a Jurat to be completed does not follow this form, the notary must correct the verbiage by using a jurat stamp containing the correct wording or attaching a separate jurat form such as this one which does contain proper wording. In addition, the notary must require an oath or affirmation from the document signer regarding the truthfulness of the contents of the document. 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