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HomeMy WebLinkAbout10-18-12IN RE: ESTATE OF John R. Adams Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION Estate No. 21-11-1098 PETITION FOR SETTLEMENT OF SMALL ESTATE To the Honorable Judge of the said Court: The Petition of Joan D. Adams who is the Administratrix of the Estate of John R. Adams, respectfully represent: 1. The Petitioner Joan D. Adams is the Administratrix of the Estate of John R. Adams. 2. The above-named decedent died intestate and Letters of Administration on the Estate of decedent were duly issued by the Register of Wills in and for Cumberland County Pennsylvania to your Petitioner on October 20, 2011. 3. The names and addresses and relationships of all persons having an interest in the Estate of the decedent as heirs or next of kin are as follows: John R. Adams, Jr. 804 Jacaranda Drive, son e~ ~== Largo, FL 33770 ~~ - "°~' ~ ~-, ;~' . . cx~ ~ ~ ,1~ ~ Jennifer Adams-Gusoff 1001 Easton Road, 606 M daughter ~=-- -~~ ._._ _ ; - Willow Grove, PA 19090 ~~"~ ~ ~ t- - . ~,~__ _ , Jeanette A. Schoonover P.O. Box 1660 daughter c a ~ : 0 ~ -a - ~ - : r Carthage, NC 28327 v ~' G:' ~~ r:r: Joan D. Adams 339 W. North St. widow ~, ~.r,' Carlisle, PA 17013 4. The decedent was survived by Joan D. Adams, Spouse, who is entitled to claim the family exemption under 20 Pa.C.S.A. Section 3121. S. The total value of the decedent's Estate is less than $ 25,000.00 and consisted of the following assets which had the following May 10, 2002, values: First Union Corp.. 1 SO shares x $ 3.33 each $ 499.50 Sterling Financial Corp. 663 x $ 13.05 each 8,260.65 Page 2 Orrstown Bank Acct. # 413372 6,669.67 TOTAL $ 15,429.82 6. The expenses of the decedent's last illness and funeral have been paid and there are no unpaid creditors of the decedent not provided for by this Petition. 7. A Pennsylvania Inheritance Tax Return has been filed and the amount of tax due upon the decedent's estate has been paid. A copy of the inheritance ax Return and a copy of the statement of the Department of Revenue showing no tax due is attached hereto as Exhibit "A" and "B" and made a part hereof. 8. The following is a list of claims against the assets of the decedent which are to be paid: Hoffman-Roth Funeral Home -Funeral $ 2,196.07 Son of A Butcher -Funeral Luncheon 1,350.00 Organist & Ushers 150.00 Programs & Flowers 150.00 Joan D. Adams -Family Exemption 3,500.00 Duncan & Hartman, PC -Legal Fee 1,500.00 Register of Wills -Probate Fee 112.50 Fickel Insurance Agency -Surety Bond 320.00 Register of Wills -Bond Filing Fee 15.00 Cumberland Law Journal -Legal Notice 75.00 The Sentinel -Legal Ad 178.92 Register of Wills -Agent for PA Inheritance Tax 53.07 Register of Wills - PA Inheritance Tax Return Filing Fee 15.00 Bank of America 3,008.75 Joan D. Adams - Administratrix Fee 1,500.00 Postage 29.34 Register ofWills -Petition Filing Fee 15.00 TOTAL $ 14,168.65 Page 3 9. The assets remaining after deduction of all items in Paragraph 8 amount to $15,429.82 less $14,168.65 in claims fora net balance available for distribution of $ 1,261.17. 10. It is proposed that the following distribution of the decedent's net Estate be made to the following creditors, heirs or next of kin: John R. Adams, Jr. 804 Jacaranda Drive, son $ 210.20 Largo, FL 33770 Jennifer Adams-Gusotf 1001 Easton Road, 606 M daughter $ 210.20 Willow Grove, PA 19090 Jeanette A. Schoonover P.O. Box 1660 daughter $ 210.20 Carthage, NC 28327 Joan D. Adams 339 W. North St. widow $ 630.57 Carlisle, PA 17013 TOTAL $ 1,261.17 WHEREFORE, your petitioner respectfully request your Honorable Court to decree the distribution of the decedent's personal estate to the persons entitled thereto as set forth in Paragraph 10 above after payment of all obligations set forth in Paragraph 8 ~~ oan D. Adams, Administratrix y'~-'mil a William A. Duncan, Esquire Attorney for Petitioner ID # 22080 1 Irvine Row Carlisle, PA 17013 717-249-7780 VERIFICATION The undersigned having read the attached Petition, hereby verifies that the facts set forth therein are true and correct to the best of her knowledge, information and belief. This verification is made subject to the penalties of 18 Pa.C.S. section 4904 pertaining to unsworn falsification to authorities. an D. Adams, Administratrix Dated: "~ ~ ~ 7 ~~ IN RE: ESTATE OF John R. Adams Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION Estate No. 21-11-1098 CERTIFICATE OF SERVICE I hereby certify that I served a copy of the Petition for Settlement of Small Estate and Decree and the attached Memo of same by mailing same in the United States Mail, first class, postage pre-paid on the 17`h of September, 2012, addressed as follows: Joan D. Adams 339 W. North St. Carlisle, PA 17013 John R. Adams, Jr. 804 Jacaranda Drive, Largo, FL 33770 Jennifer Adams-Gusoff 1001 Easton Road, 606 M Willow Grove, PA 19090 September 17, 2012 Date Jeanette A. Schoonover P.O. Box 1660 Carthage, NC 28327 Attorney for Plaintiff I Irvine Row, Carlisle, PA 17013 717-249-7780 ~,,,~ 15 0 5 61014 0 REV-1500 ~` ~°~-~°~ apartment of Revenue Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN Harrisbu PA 17128-0801 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY 1 8 5 2 0 5 9 0 3 0 5 1 0 2 0 0 2 Decedent's Last Name Suffix A D A M S (ti Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix A D A M S Spouse's Social Security Number 1 7 5 4 0 6 8 5 8 OFFICIAL USE ONLY County Code Year File Number 2 1 1 1 1 0 9 8 Date of Birth MMDDYYYY 0 8 2 2 1 9 2 8 Decedent's First Name MI J O H N R Spouse's First Name Ml J O A N D THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGIST FILL IN APPROPRIATE OVALS BEL ER OF WILLS OW 0 1. Original Retum ^ 2. Supptementaf Retum 3 Rem i 4. Limited Estate ^ 4a F t . a nder Retum (date of death rior to 12-13-82) ^ 6. Decedent Died Testate ^ . u ure Interest Compromise (date of death after 12-12-82) 7 D 5 F ^ ederal Estate Tax Retum Required (Attach Copy of Will) ^ 9. Litigation Proceeds R i . ecedent Ma(ntained a Livin Trust (Attach Copy of Trust) g --- 8• Total Number of Safe Deposit Boxes ece ved ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 11. Election to tax under Sec, 9113(A) CORRESPONDENT -THIS SECTION MUST B Name O) E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX NFORM ATION SHOULD BE DIRECTED TO: W I L L I A M A D U N C Daytime Telephone Number A N 7 1 7 2 4 9 7 7 8 0 First line of address 1 I R V I N E Second line of address City or Post Offkx R 0 W C A R L I S L E State ZIP Code P A 1 7 0 1 3 REGISTER O'FV~3 Y `~ '~L7 r't .-~'- ~._.~ ~-`- f'^ `"1~ ,~ ~~~~1 _ `' _;-i ~ --t DATE FILED ." ~- - USE ONt~l/ ~ t_ ._ r ~, r~ '~ "7 - ~ - --~ ~3 _ ~ ~ _; C_J t _ ~ ~r=~ p ~ '~ -- --n Corrospondent's e-mail address: b i 11 a d u n c a n h a r t m a n l a w• c o m Under P d perJex~-. I dedane that 1 nave examined this velum, . t< is true, carocx and complete, Declaration d prepsrer other than the+~~ ~~~~ s~tteeules and staternsnd„ and to the best d my knowled~ and beset, SIG TORE tZF PERSO RESPONSI FOR FLUNG RETURN ~~ n~~ b based ~ ~ ~~~ d which preparer etas ~ ~~,~~ ~ DATE ADO ss O1-/ 3 -I ?, 339 W. NORTH ST• CARLISLE SIGNATURE OF PREPARER OTHER TNAN REPRESENTATIVE ~ A 17 013 DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ;` ~~~ ,.r ~;~ 150 561014 0 ~~~tt` . ~~- 150561014p J J 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: J O H N R• ADAMS 1 8 5 2 0 5 9 0 3 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 2. Stocks and Bonds (Schedule B} ........................ 2 8 7 6 0. 1 5 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages and Notes Receivable (Schedule Dj ......................... . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 5. 6 6 6 9 . 6 ? 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 . 0 0 7. Inter-Vivos Transfers S Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 5 4 2 9. 8 2 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 0 0 6 2 . 4 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ . .... 10. 3 0 0 8 . 7 5 11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 3 0 ~ ], . 2 4 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 2 3 5 8 . 5 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 14. Net Value SubJect to Tax (Line 12 minus Line 13) ...................... 14. 2 3 5 8. 5 8 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.o 1 1 7 9. 2 9 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 1 1 7 9. 2 9 16. 5 3. 0 7 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 1 g, 0. 0 0 19. TAX DUE .................................. ... 19. 5 3 • 0 ~ ................. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1,505610240 1505610240 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME JOHN R• ADAMS STREET ADDRESS 343 W. NORTH ST• File Number 21 11 1098 cinr CARLISLE STATE Zip PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 5 3 • 0 7 A. Prior Payments B. Discount 3. Interest Total Credits (A + B) (2) ^ . 0 0 4. If line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT (3) 2 5.2 6 . Fill in oval on Page 2, Line 20 to request a refund . (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE . (5) 78.33 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE'APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ^ .................................................... .................. X b. retain the right to designate who shall use the property transferred or its income; ............................... ^ 0 c. retain a reversionary interest; or ................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X ^ D 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ...... 0 ............................................................. 3. Did decedent own an 'in trust for' orpayable-upon-death bank account or security at his or her death? ......... ^ X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .......................................... ^ ........................................................ X ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .: For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the survivin s use is 3 percent [72 P.S. §9116 (a) (1.1) (i)j. 9 Po For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)j. The statute does not exempt a transfer to a survivin s filing a tax return are still applicable even if the surviving spouse is the only beneficlary. ~ from tax, and the statutory requirements for disclosure of assets and For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or y~inger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. §9116(a)(1.3}j. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX + (8-98) SCHEDlJLE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN R• ADAMS 21 11 1,098 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 1. FIRST UNION CORPORATION 150 SHARES X $3.33 ~ OF DEATH [SEE SHARE INFORMATION ATTACHED] 499.50 2• STERLING FINANCIAL CORPORATION 663 SHARES X X13.05 [SEE DOD INFORMATION ATTACHED] 8260.65 TOTAL (Also enter on line 2, Recapitulation} I i 8 , ? 6 0 • 15 (If mae space ~ needed, insert addrtanal sheets of the same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDtlLE E CASH, BANK DEPOSITS, & MISC. _ PERSONAL PROPERTY ESTATE OF FILE NUMBER JOHN R• ADAMS 21 11 1098 Include ttte'n~ers sf litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~. ORRSTOWN BANK CHECKING ACCOUNT # 413372 OF DEATH [SEE ATTACHED DOD LETTER] 6669.67 _ TOTAL (Also enter on line 5, Recapitulations I s (ll move space ~ needed, insert additional sheetr o1 the same size) 6.,669.67 REV-1511 EX+ (10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER JOHN R• ADAMS 21, 11 1098 Decedent's debts must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-BOTH FUNERAL HOME 2 ] 96 07 2• FUNERAL RECEPTION - SON OF A BUTCHER CAT ERING , , . 1 350 00 3• ORGANIST 8 USHERS , . 4• PROGRAMS & FLOWERS ],50.00 150.00 B. ADMINISTRATIVE COSTS: 7. Personal Representative Commissions: Name(s) of Personal Representative(s) JOAN D • ADAMS 1, 0 0 0.0 0 street Address 3 3 9 W• NORTH S T• City CARLISLE state P= ZIP 17 013 Year(s) Commission Paid: 2 0 ], 2 2, AttomeyFees: DUNCAN 8 HARTMAN PC 1, 000.00 3. Fatuity Exemption: (If decedent's address is not the same as claimants, attach explanation ) . Claimant JOAN D • ADAM S 3 , 5 0 0 • 0 D street Address 3 3 9 W• NORTH S T• city CARLISLE state P= ZIP 17013 Relationship of Claimant to Decedent W I F E 4• Probate Fees: REGISTER OF WILLS 112.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. REGISTER OF WILLS - BOND FILING FEE 15.00 8• FICKEL INSURANCE SURETY BOND 320.00 9• CUMBERLAND LAW JOURNAL - LEGAL NOTICE 75.00 10• THE SENTINEL - LEGAL AD ],78.92 11• REGISTER 4F WILLS - FILING FEE 15.00 TOTAL (Also enter on Line 9, Recapitulation) ~ s If more space is needed, use additional sheets of paper of the same size. ],D, 062.49 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS w~n~~vr FILE NUMBER JOHN R• ADAMS 21 11 1098 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM I NUMBER DESCRIPTION 1. BANK OF AMERICA TOTAL (Also enter on Line 10, Recapitulation) ~ s If more space is needed, insert additional sheets of the same size. VALUE AT DATE OF DEATH 3,008.75 3, 008.75 REV-1513 EX; (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES JOHN R • ADAMS NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS pndude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1. JOAN D. ADAMS 339 W• NORTH ST• CARLISLE, PA 17013 2• JOHN R. ADAMS 804 JACARANDA DRIVE LARGO, FL 33770 3. JENNIFER A• GUSTOFF 1001 EASTON RD-, # 606 WILLOW GROVE, PA 19090 4• JEANNETTE SCHOONOVER PO BOX 1660 CARTHAGE, NC 28327 FILE NUMBER: 21 1 ], RELATIONSHIP TO DECEDENT Do Not List Trustee>(s) 1098 AMOUNT OR SHARE OF ESTATE Spousal Lineal Lineal Lineal SOi ,16.61 ],6.6i 16.61 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 TOTAL OF PART tI -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. s If more space is needed, Use additional sheets of paper of the same size. NOTICE OF INHERITANCE TAX Pennsylvania BUREAU OF INDIVIDUAL TaxES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE ~ ~ INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX DEPARTMENT OF REVENUE PO BOX 280601 REV-1547 EX AFP (12.11) HARRISBURG PA 17128-0601 ' DATE 06-11-2012 ESTATE OF ADAMS JOHN DATE OF DEATH 05-10-2002 R FILE NUMBER 21 1I-1098 WILLIAM A DUNCAN COUNTY CUMBERLAND 1 IRVINE ROW ACN 101 CARLISLE PA 17013-3019 APPEAL DATE: 08-10-2012 (See reverse side under Objections) A~ount Re~itted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SpUARE CARLISLE PA 17013 CU T ALONG THIS LINE _ ~-~- R_ETA_IN-LOWER POR_TION_ FOR YOUR_R_EC_O_R_D_S___~_ R EV-1547 EX AFP C12-11) NOTICE OF INHERITANCE TAX APPRAISEM - --"-"------------ DISALLOWANCE OF DEDUCTIONS AND ASSESSMENTAOFOTAXCE OR ESTATE OF: ADAMS JOHN RFILE N0.:21 11-1098 ACNs 101 DATE: - _ •~ 11 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) CI) '0 0 NOTE: To ensure proper 3. Closely Held Stock/Partnership Interest (Schedule C) C2) 8'76 0.15 credit to your account, C3) .0 0 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) of this form with C4) .00 Your 5. Cash/Bank Deposits/Misc. Personal Property CSchedula E) tax payment. 6. Jointly Owned Property CSchedulo F) (5) 6, 669.67 7. Transfers (Schedule 6) C6) .0 0' (~) .00 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: C8) 15,429 82 9. Funeral Expenses/Adm. Costs/Misc. Expenses CSchedula H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) C9)- X0.0 6 •9 clo) _ , 008 75 11. Total Deductions 12. Nat Value of lax Return C11) 13, 071.24 13. Charitablo/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C12) 2,3 5 8.5 8 14. Net Value of Estate Subject to Tax C13) .0 0 NOTE: If an assess~snt was issued previously, lines 14, 15 and/or 16,141 2'358.58 reflect figures that include the total of ALL returns assessed to date.and 19 will ASSESSMENT OF TAX: --._. 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate C15) 1,179.29 X 00 .00 17. Amount of Line 14 at Sibling rate C16) _ 1 79 ?4 X 045 = 53.07 c17)- nn x I2 .00 18. Amount of Line 14 taxable at Collateral/Class B rate C18) I9. Principal Tax Due • 00 X 15 . 00 TAX CREDITS: (I9)' 53.07 PAYMENT RECEIPT DATE DISCOUNT (~) NUMBER INTEREST/PEM PAID C-) AMOUNT PAID 01-13-2012 CD015458 06-04-2012 SBADJUST 25'26- 78.33 .00 .O1 TOTAL TAX PAYMENT ~, s` 1 ~~i~~ r ~• ~ 5 3. O 7 .~y s J BALANCE OF TAX DUE .00 +4 w. , r• :.~,rr~r~_ ,~ INTEREST AND PEN. .00 . TOTAL DUE .00 IF PAID AFTER DATE INDICATED. s FOR CALCULATION OF ADDITIONAL INTEREST. TAL DUE IS REFLECTED AS A "CREDIT'• (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.