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HomeMy WebLinkAbout02-01-13PETITI FOR GRANT F LETTERS REGISTER OF WILLS OF COUNTY, PENNSYLVANIA Petitioner(s) named below, .who is/are 18 years of age or older,- apply(ies) for .Letters as specified below, and in support thereof aver(s) the followitig and respectfully request(s) the grant of Letters in the appropriate form: Decedent's Information Name: _ Sour r t/.hsN, TrC a/k/a: a/k/a: a/k/a: Date of Death: S.lv~ir,2Y ys', 3r1 t3 File No: (J~~ ' ~/ ' ~ ~~' (Assigned by Register) Social Security No: iy,- y~ - 1 y ~ Age at death: (.p Decedent was domiciled at death in ~~rrdt~,a-~s,,~ County, /h,,,r,~sy cvwi,~ (state) with his/her last principal residence at /y/ /Si[ID6 L csal.E Lf ,rrf,,. e.,nsyl.cwio U/ntSt,[c~..n Street address, Port Office and Zip Code Clty, Township or Boroogh County Decedent died at 1741 N~6t.tGST=7r./~/ RodA,l'7110 1~M4Lls8v/1L p.fyONlrr Oa Street addrost, Pmt Otlice and Zip Code City, Township arBorong6 County State Estimate of value of decedent's property et death: Jjdomicfled in Pennsylvania ............................ All personal property S ~. 000 Jjnot domiciled in Pennsy/vania ........................ Personal property in Pennylvania S Jjnot domiciled in Pennsy[vania ........................ Personal property in County S Value ojtm! estate in Pennsylvania ......................................................... S 6 t71t7tr) TOTAL ESTIMATED VALUE.... S ~t~Gt'Ja Real estate in Pennsylvania situated at: ~ Ni BatOltr SCR-t~l / 7010 iytrs~ WyrS,M,~A,,,>o Lyl1~p~,ps/p (Attach additional sheets, ifneceuary.) Street addreu, Port Offke and Zip Code Clty, Townrhip or Borong4 Coaaty ® A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they islare the Executor(s) named in the last W ill of the Decedent, dated trdJl+tO~ nt ~b4' and Codicil(s) thereto dated State relevant circumstances (ag. nnnnciation, death of sa ecator, eta) C Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, ntiplivorced, wwas not ~ ~ a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. 3~g), and dji~ot hld bom or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated persollfl 2 GY ~ tY1 7D (~NOEXCEPTIONS ^EXCEPT[ONS ~ A r rn M t/s ~ ^ B. Petition for Grant of Letters of Administration (If applicable)u~ ~ t> ° c.t.a., d.b.n., d.b.n.c.t.a., pende ©iti~luragtte a tia, d,~ay`~'tainoritate If Administration, ata or db.n.ata., eater date of Will in Section A above and r~jnplete IKt~of IN~jrrlls~ Except as follows: Decedent was not a party to a pending divorce proceeding wherein the groundsAbr=divorce had~,n estabtis~as de)'ined in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person. ^ NO EXCEPTIONS ^ EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by the following spouse (if any) and heir (attach additional sheets, il'neeessary): Name Form RW-02 .~~. la~unntr Page I of 2 Oath of Personal Representative COLi1i0~SVE,~LT}{ CF PcVVSYLV?,VLa } 4 SS: C it is ~: T Y p F P.UttdL/4L/byl~ Official Lsc Only ~ ;:V. S.~ur:g] I i sLpN ~,.sysyr Zoe 7W A~vTEd3 M~6 owiJaS FieO A.~ /93 She Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as Personal Representative(s) ofthe Deceden t e etitioner(s) will well and truly administer the estate according to law. Sworn to affirmed a bscribed before ~ Date 1~ / - ! 3 me thi d ~[.!~ Date By' Date nr th Regitter Date BONDRequired:QYES ~NO FEES: Letters ...................... S ,~ (Q~) Short Certificate(s)...... U' ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)............ Bond ........................ Commission........ .... . Other ~_,,, _~ Automation Fee .............. . 1CS Fee ..................... TOTAL ..................... S Ta the Register ojWi!!s: Please enter my appearance by my signature below: Attorney Signature: O ~ ~ .~°_+ ,.. ~ Ca:! ~ 7D ~ ~ O t;ls :h Printed Name: _ ~ ~ ~ t"'a ~ Q Supreme Caurt '~ 7C ~ n Q ~ O O ~ ~ ID Number: Firm Name: O C ~ ~ Ca ~j ~ IT1 Address: F-~ ~ O I Phone: Fax: ~ ~ Email: DECREE OF THE REGISTER _ r~ I Estate of -~~ Q ~~! ~~ File Nio: lam{ - f~- 6 ~o~ a/k/R: AND NOW, ~=:~8~l~'hrtLG!-~f~~ / ,~Qf~ , in considei!ati n of the foregoing Petition, satisfactory proof having been presented before tne, IT IS DECREED tha Let ers ~ are hereby granted to '_- ~ ~ ~_ in the above estate and (if applicable) that me tnsattment(s) dated /V oUe/h/:te/ ~: described in the Petition be adtnitted to probate and f~ti Q.ra_A] .._.. .inn iana~ _. _._ .. r. cn __..... H 105.805 REV f9/111 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate ihis_copy by photostat or photograph. RECOROEO OFFICE OF Fee for this certificate, $6.W Ilrrr'f""~ This is to certify that the information here given is REGISTER OF W! II ~SNOFp'~---._ pp ~a`'pZ` ~yys~ aUiy t~~i~a w(t dmre asaLoc:al1Reg strar.)cThe orDinal ~~13 Ell 1 ~~ ' ~~~z3 certificate will be forwarded to the State Vital ~~ ~ ~- a; Records Office for permanent filing. e~ERK O~ = o __ .. ,~,[; ~m1~%ae.« JA 2 8 013 P 19 0 6 5 8 9 3 ORPHANS' c '`~~ '~p~°''~~ ~} ~~ 4~ JMfNTJOE„~;Im' Certification Number CUMBERLAND CO, P Local Registrar Date Issued _._ _ , rypa/Print In COMMONWEALTH OG PENNSYLVANIA .DEPARTMENT Of HEALTH . YrtAI RECORDS Permanent CERTIFICATE OF DEATH _. _.. -. =~.. ~.. ~j C ~S S Q Y a 3. Dewden<'{ Legal Names (Pint, MI d e, Ua4 SuMx) 2. Sex 3. Sec1a15acurlty Number 4. Data Death (MO/Oay r) (Spell MPI John J. Wa1ah, Jr. Males 197-42-1476 January 25, 2013 5<. At<-Lear Irthdw (Vd) 6b. Un r 3 Year Sc. Untl r Da 6. Da[e of Birth IMO Day/Year) (ape I Month) 7a. eirthplaw (city sntl State or Foreign GOYn<ry) Months Days Hours Mlnutaa O A ril 20f 1952 Jb. elrtnpiate (copnty) 8a. Real once (Stara Or FoMlgn Country eb. Raaltlenca (SIroM sntl Number - Intl Vtla Apt NO.) c. Did Decedent Uve In s TOwnz Ipi Owes, a.waent lly.d In twp. e .Real enw County) 41 Brid a Street Cum erland 8•. Raslaenu (Zip Coda) jb NO, decetlen<IlVed wlMln Ilmltz Of Nam C:t ztrtl-twil gtld city/born. 9. Ev<r In U6 rm<d FOrt<ai 10. MirAal Status Pt Tm< Of Death Marrl<tl WI Ow< 31. 9uNlvlnt Spgxf<'a Nam! (If wl(@, glut n}ma prlOr t0 Rrst marrla3<) Yaa [] NO Q Unknown Q Divorwtl Q Never Married Q Unknew 32. Fslhar'a amt Nrat, Mltltll<, Les4 3ufflx) 13. Mother's Name Prbr tP Flrft Mardage First. Mltltlle, LaaY Wa sh Sr. S Ivies Mae Bi le 34a. I rment'a Name 14b. RelatlOnahip to Daw ant 14t. In ormant's Mal ant Atltlrosa (Stroet and Number, CIN. State, Zip C o - I So; 207 Painters Crosain Chadds Ford PA 1931 ....................................................... ...................................... I/Death Occufrod In • HO{PI<al~ t~ IAPetlenC efeo es< ... Vic.. Pny o..a .. ... .. w~ .. ... If Dash Otturrea Som whero Other Tfian a H ~--~ ~-~•~-~~-~ ~~-~~ ~-~ zPltal: ~ ~~~t~t HOSPICe FacllitY ~.-y Decedenf'a HOms~•~ Eme • Room/Out tisnt Daad en Arrival Nunl Hom JtPn -Term Gro FacIIIH 0thar (Sped 1 1 b. Faclllty amt If rtot InstltutlOn, giw street ana number; 13c. CItV Or Town, Sdt<, an alp Code 15d. County of DsaM a o n ro o Slane Hoe ice Har r i®bur PA 17110 Dnu hin .~ 16a. McMOtl Of DVpoaKlon Q Burial bamatlon ~ p 16b. Date oT O G~1113 G 11 16c. Place OT Dlspoal[lon (Name o} ceme[ery, crematory, Or Other pla~el Q RsmoNl from Snte Q DOnatlon other (s etl ) Januar 31, Evans Crematory 16a. LOCH on DlsvwltlOn (City dr Town, Start, and Ilp) SJa. Slgnatura n ervl<e Llcenzes Or PenOn In Charts oT Indrmant iJb. License Number c town PA 17088 FS 012 849 L iJO. Nam< and Cnmplat< Atltlr<af et Fun<ral F<Glity n O Box 4 1 New mberland PA 17070-0431 ffi 1g. DeeetlenY{ Education -Check [he box that ba{t daacHbas the 19. Dawtleni of Hbpanlc On{In -Check the 2D. Dewtlent's Racs - GMck ONE OR MORE races to lntlleaee what hlghes<degree Pr IwN w school compladd at Vl• tlma OT death. box shat best tlascrlbes whHlter the tlewdent Ma dacetlant considered hlmsel! or herself to be. Q 8th gnda or lase la Spanish/Hlspanlc/Letino. Check CM "NO" White Q Korean Q NO tliplema, 9th - 12th trade bok If tlecedent Is not Spanish/Hlapanlt/Le<Ino. Q Black or AMean AmeHcan ~ Vletnameu tg HI{h fchg0l tradYata er GED compla[}tl (g No, not SpanNh/NlaPenlc/La[InP Q Am<rlcan Intllan Or Alafka NPKV< Q Oth<r Asian Q Seme cOllety crodl<, but no tlegfee Q Yea, Mexican, Mexican Amerlcsn, GM1lcano Q Asian Intlien Q Na<IVe Hawallan O AswelKa tletroa (e.g. A.ny A9) Q Y<s, Puerto Rican Q Ghineca Q Guamenlan or Chamgrro Q gs<halor's datroe (e.g• 6A, AB, BS) Q Yes, Cuban Q FlIIPIno Q Samoan 0 Masdr•a detrae la.g. MA, MS, MEnB. MEd, MSW, MBA) Q Y<s, oMar Spanish/Hispanic/La[Ino Q Japanese Q Other PaciRC Islander C] Doctorate (a.g. PhD, EtlD) Or ProhsslOnal degree (Speelfy) Q O[her (Sp<clfy) D DOS DVM LLB lD 21. D<c<tl<nt' Slog a Race Self-Oa{IgnatlOn - Ch<Ck ONLY ONE tO lndlts[< What tM1. dac.dant conald<r<d hlmfalT or h<rsa11 to be. 22a. D<cad<nC s UsVal OCNpi<IOn - Indlca[<typ<01 Work Whlt< ~ JaOan<i< Q Samoan don< tlurlnt moat eT workint IIT<. DO NOT USE gErIRED. Q Black or 4/dcan Amanwn Q KOroen Q O[her Paclflc Islantler _ Q Amerltan Intllan or Alaak} Natlw ~ Viatnam<aa Q DOn'f Knew/Not Surs U Aim Retire d Q Azlan Intllan Q ONrer Aalan Q Refufatl 226. Kind Of BYSiness/Industry Q Chinese Q Na<IVe Hawallan ~ O[her (SPecify) Q FIIIPInO Q Guamenlan or Chamorro Arm r ea a. D}d rOnounw tad Mo Day 29 Itnature arson ronouncing ea[ On y w an applies a c. L tense Num er 1Y KRSON WHO PRONOVNCES OR CERTIFIES Og TI 23tl. Dad 9linetl (MO/Dav/Yr) 2a. nm. eT Death 11 1 ~ PM 25. was Medical Examiner or Coroner GPndcddi O Yas No CAUSE OF DEATH z AbPrealmate 26. Part 1. Hofer the cha n of awntf--tllseaaas, Injuries, or tompllta<lons-that dlractlV ~ausatl the tleeth. DO NOT sorer terminal events such ss cardiac arrant Interval: rasplntOry arr<ft, er vantAcul}r Rbrllla<IOn wl Ut showlnt the .aolOgy. OO NOT 0.BRAFVIATE. Ent<r Omy ana cause am a IIn<. Atltl atldltlonal lln.a K naC<SSiry 1 Onset to D<ath [hO .A _ ~ IMMEDIATH CAU6E - - ~ a ~ r l N ~ /~ ~ Q~ [J'v'.I t' ~!t] C 1 ../ t <<.~.. r"~ r~r'l'~r-/ t (Final dlfa}N Or wnaKlOn Due to (Or Pz s ConiGgUanca OF)-. / j r.auWnt m aeaeh) f b, j Sao Vantlally Ilat cOndltions, DV<Ce (Or }s a consaquan« Of): 1( any. laadlnt M the pate ~ Iladd en Ilne a. Enter the t. UNDERLYING 4YSE DUa [O lOr as a comae Of): 4 quanta ! (absa,e or Injury that Initiated th4 Wentz rosuitlnt d. In death) IAST. Dues to ter as • cenfequanc< Of): 2t. Part 11. Enter ether I but not resultant In the underlying cause {Non In Part 1 2J. Was an eUlOp{y pe rmetli O Yea No ~ 28. Were autopsy flntlings available ~' to compled the cauaa of death? O Vas NO 29. If F}me a: 30. Old TOOaCte Ua Gontr4buta t0 DNthi 31. Mannlr Of Daat Q NOt Pratn}nt wl[1,In Paft ytar Q V<s Q Probably ~ N}tural Q Hemlclda Q Pretnan<a«Ima ra death Q NO ~ Unknown Q Accident Q Pentllnt lnw,tlYtlon ffi Q Not pMgnant, but prognan[ WAhln 42 tlaya oT death Q Sulcltla Q GOUId not ba dadrmined Q Na[ pretnant, but, pragroM 43 days to 2 YNf before tleath 32. Date of Injury (Mo Dsy/Vr) (Spell MOnfM1) ~ Unknown It Pregnant wghln the Pert year 3 . Time of InluN 34. Place M INVry (a.t. hpma: conRruttlgn alla; farm; acho0l) 35. Loce[lon o} InJOry (3tr@et sntl NumDlr. Glty, 3ta[e, 21p Code) 36. Injury a< Work 37. I(Trenapor[atlon Injury. SpaGTy: 38. Dsscribs How Injury Occurrod: Q Vas Q DClvsr/OPerator Q Ietlea[rlan NO Q Pass<nt.r Q Other (Spaclfy) one): 39 ar ( hack enl ^ CY GrtlNlnt PhYfltla - TO [h< baft Of my knowiaag<. aNfh eccurraa due tp fha Caua<(l) and m r ctatatl Q Pronquneing S Certllying ph clan -YO the boat of my knowlatlN, tleeth eccun.d at the ama, data, sna plat and due tP the cause(s) and manner ode<d Q Medlcel ExaminarjCOroner t basis of azsmina[lon, and/or Invastltatlon, In my OplniOn, death occurretl at the time, dad, and Plata, sntl tlua t0 the was s) and m oar sta[etl M O Y1.''_((rf Slgneturo Or wrtiflsr: TKIe Of caKlRSr: License Number: 39b. N}m<, P fa ana Zip Cod! Of P.rson GOmplatlnt Ga Ufa et DaaYr jltam 26) 39c. Dad Sltnad ( O/Dey/yr 40. Reg s rar s Vtrlct um ar ~ 41. etlstra [nature 4 at f rsr a S~ MO y r ~ ~ - i ~JL ao ~3 i o?~, 43. Amendments DlfpealtlPn Parml[ NO. O V I S S J D REV OJ/2011 Will of John Joseph Walsh Jr Part 1. Personal Information I, John Joseph Walsh Jr, a resident of the State of Pennsylvania, Cumberland, declare that this is my will. Part 2. Revocation of Previous Wills ~ ~ ~ rnrn ° I revoke all wills and codicils that I have previously made. m ~ ,-"r, ~ ~ ~nr~- ao ~~ Part 3. Children ~* ~~„ ~ ~-' ~ c I have the following children now living: John Joseph Walsh III, Jenn~e~ V~sh aa°d°n Jillian Nell Walsh. ~ ~ ~ rn ~ c~ ]C~ N !n 4 Part 4. Grandchildren ~ ~ I have the following grandchildren now living: Xander Donnelly and Donavan Ellis. Part 5. Disposition of Property A beneficiary must survive me for at least 45 days to receive property under this will. As used in this will, the phrase "survive me" means to be alive or in existence as an organization on the 45th day after my death. If I leave property to be shared by two or more beneficiaries, and any of them does not survive me, I leave his or her share to the others equally unless this will provides otherwise. My entire estate is all property I own at my death that is subject to this will. I leave my entire estate to my children John Joseph Walsh III, Jennifer Mae Walsh and Jillian Nell Walsh in equal shares. If John Joseph Walsh III. Jennifer Mae Walsh and Jillian Nell Walsh all do not survive me, I leave my entire estate to Donavan Ellis and Xander Donnelly in equal shares. All personal and real property that I leave in this will shall pass subject to any encumbrances or liens placed on the property as security for the repayment of a loan or debt. Part 6. Executor I name John Joseph Walsh III to serve as my executor. It John Joseph Walsh III is unwilling or unable to serve as executor, I name Jennifer Mae rake 1 of 4 Initials: ~ ~ ~ Date: ~,~~ Will of John Joseph Walsh Jr Walsh to serve as executor. If John Joseph Walsh tII and Jennifer Mae Walsh are both unwilling or unable to serve as executor. I name Jillian Nell Walsh to serve as executor. Flo executor shall be required to post bond. Part 7. Executor's Powers I direct my executor to take all actions legally permissible to have the probate of my will done as simply and as free of court supervision as possible under the laws of the state having jurisdiction over this will, including filing a petition in the appropriate court for the independent administration of my estate. I grant to my executor the following powers. to be exercised as he deems to be in the best interests of my estate: 1. 'To retain property without liability for loss or depreciation. 2. To dispose of property by public or private sale, or exchange, or otherwise, and receive and administer the proceeds as a part of my estate. 3. To vote stock; to exercise any option or privilege to convert bonds, notes, stocks or other securities belonging to my estate into other bonds, notes, stocks or other securities; and to exercise all other rights and privileges of a person owning similar ProPem'• 4. To lease any real property in my estate. 5. To abandon. adjust, arbitrate, compromise, sue on or defend and otherwise deal with and settle claims in favor of or against my estate. 6. To continue or participate in any business which is a part of my estate, and to incorporate, dissolve or otherwise change the form of organization of the business. These powers, authority and discretion are intended to be in addition to the powers, authority and discretion vested in him by operation of law by virtue of his office, and may be exercised as often as is deemed necessary or advisable, without application to or approval by any court. Part 8. Payment of Debts Except for liens and encumbrances placed on property as security for the repayment of a Pale 2 of 4 Initials: ~ ~ ~ Date: _~ Will of John Joseph Walsh Jr loan or debt. I direct that all debts and expenses owed by my estate be paid in the manner provided for by the laws of Pennsylvania. Part 9. Payment of Tazes I direct that all estate and inheritance taxes assessed against property in my estate or against my beneficiaries be paid out of alI the property in my taxable estate. on a nro-rata basis. Part 10. No-Contest Provision If any beneficiary under this will contests this will or any of its provisions, any share or interest in my estate given to the contesting beneficiary under this will is revoked and shall be disposed of as if that contesting beneficiary had not survived me. Part 11. Severabilitp If a court invalidates any provision of this will, that shall not affect other provisions that can be given effect without the invalid provision. Signature ~ ~1 I, John Joseph Walsh Jr, the testator, sign my name to this document, this (~j ' day of ~y~~g~ , ~, ~ f'-~l bR-rOGE S'f• ,/~ ,HB[ar-c.~•~ p~ n°~a I declare that I sign and execute this document as my last will, that I sign it willingly and that I execute it as my free and voluntary act. I declare that I am of the age of majority or otherwise legally empowered to make a Signature: under no constraint or undue influence. Witnesses We. the witnesses, sign our names to this document, and declare that the testator willingly signed and executed this document as the testator`s last will. In the presence of the testator, and in the presence of each other, we sign this will as witnesses to the testator`s signing. ,`/// iii/ //// //// Ii!' //// %I// //// Pale 3 of 4 Initials: ~~ Date: 2 0 Will of John Joseph Walsh 3r To the best of our knowledge, the testator is of the age of majority or otherwise legal °mnowered to make a will. is of sound mind and is under no constraint or undue influence. We declare under penalty of perjury that the foregoing is true and correct. this u, day of IV W 5'r, aQO g , at a~~a Q~, ~~-~~ ~mlv~, Ply . First N'ftness Sign your name: Print your name: P~~ r~ per' S v~ i9f'~- Address: al S Jl, R `A C~ S .~- City, State: N P~ C~U,13~IZ l.~,q,-~ ~,R~ i 1 a 10 Second R'itness Sign your name: Print vour name: Address: 3~ City, Star Page 4 of 4 Initials: ~ ~ Dste: r ~'Ls OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS c°wndsE2c..awn COUNTY, PENNSYLVANIA Estate of cT01~W JDS+60~9 w•Aas!¢, TR. Deceased P~ r#.2 pos ryP.wx and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well- acquaintedwith J~ud ~7sblH +,,...t~~r. T/1 and am/are familiar with the handwriting and signature of the decedent, and that the signature of _ PFD ~6T7/!°~K to the foregoing instrument purporting to be the Last Will and Testament/Codicil of ~~/ ~n ssa~ wrhs~+~ J72 is in his/her own proper handwriting. (Sign r X19 ~1 ~ ~~ a ,~ S'~,~ (Street Aaaresay (City. Stare, ZipJ Executed in Register's Office Sworn to or affirmed an~subscribed before me is ~ day of ~ , c~1i3 . Deputy f~'Re~ystfer®f Wills (S~grtature) (Street Address) (Cuy, State. Zip) rv w mrn o rn '^ °3 ~ o ~ ~ca ~ ~ A~~ ~'' ~ a o~ . ~~o ~ o ~'n ~~-~ ~ ~~ o ~ ~:, ~~ ~ o N~ Form RW-04 mv. !0./3.06 OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS Lyne~2~.~r~ COUNTY, PENNSYLVANIA Estate of ~0/x./ JZis60H was/} , ~/L ,Deceased /LIG/1,e,2p pyy-k,tso,/ and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well- acquainted with .ToN./ TvStpH w~h-sf+, Tit and am/are familiar with the handwriting and signature of the decedent, and that the signature of 2lcist~no p,`~-~tittn,/ to the foregoing instrument purporting to be the Last Will and Testament/Codicil of 3tl/W j~ishpN ./.~:.sr/ T2 is in his/her own proper handwriting. ignature) . ~ ~.s- 9' ~' ~~ ~treet~Addlre'sr ity, State, Z~pJ Executed in Register's Offtce Sworn to or affirmed and subscribed before me this _~~_ day of . 01~ . eputy for Register of Wills (S~gnature) (Street Address) (C~ty, State, Zip) rr; a ~ ~ e..a rn f*1 6~ p "o qo to ~ ado ~ ~-Q-t r~ o -r, 3 -*,~ ~E ~ ~ co ~rn ~ b rv 0 ~ Form RW-04 rev. l0.l3.Ob __