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HomeMy WebLinkAbout04-15-13 1565611185 REV-1500 EX(02-11)(Fl) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO Box 280601 INHERITANCE TAX RETURN Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 169-14-5825 08102612 63161926 Decedent's Last Name Suffix Decedent's First Name MI ZIMNISKI JOSEPHINE M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) © 6. Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ❑ 9. Litigation Proceeds Received ❑ 10. Spousal Poverty Credit(Date of Death ❑ 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRIDGET M- WHITLEY, ESQ - 717-2334= 1U0 M n REGISTEPIF YILt6USE SM-Y r r; cn First Line of Address ts1 ^ f SKARLATOSZONARICH LLC ' Second Line of Address ry j rtit 17 S . 2ND ST- , 6TH FL -n City or Post Office State ZIP Code DATE FILED HARRISBURG PA 17101 Correspondent's e-mail address: BMW@SKARLATOSZONARICH- COM Under penalties of perjury,1 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. SIG RE OF PERSON RESPONSIBLE FOR FILING RETURN DATE KATHLEEN A - HARRIS DRESS 1D1 RICH VALLEY ROAD MECHANICSBURG, PA 7055 SIGNA RE OF PREP A R OTHER THANK PRESENTATIVE DATE , f, BRIDGET M . WHITLEY RESS 17 S - 2ND STREET, 6TH FLOOR HARRISBURG, PA 17101 PLEASE USE ORIGINAL FORM ONLY Side 1 1565611185 OM46473.000 1565611185 1505611285 REV-1500 EX(FI) Decedent's Social Security Number 169-14-5825 DecedenfsName: Z I M N I S K I JOSEPHINE M RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 .00 2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . 2. 41345-00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3. 0 . 00 4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , 4. 0 . 00 5. Cash,Bank Deposits and Miscellat'feous P€rsonal Property(Schedule E) . . . . . 5. 10,367-00 6, Jointly Owned Property(Schedule F) ❑ Separate Billing Requested , . . , 6. 563-00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) El Separate Billing Requested . . . . 7. 0 . 00 8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , 8. 151275- 00 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 31544 -00 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) , . . . . . , , . 10 0 .00 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. 31544 -00 12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , 12. 11,731 - 00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , 13. 0 .00 14. Net Value Subject to Tax(Line 12 minus Line 13) . 14, 111731.00 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.0- 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate x_0_!j5 111731.00 16. 528-00 17. Amount of Line 14 taxable at sibling rate x.12 D . D D 17. 0 .00 18. Amount of Line 14 taxable at collateral rate X A 5 0 . 00 18. 0 . 00 19, TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 528 -00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505611285 1505611285 OM4648 3.000 REV 1500 EX(FI) Page 3 File Number Decedent's RWplete Address: DECEDE AME IMN S I JOSEPHINE M STREET ADDRESS 101 RICH VALLEY ROAD CUMBERLAND CITY STATE ZIP MECHANICSBURG PA 17055- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) S28 - 00 2. Credits/Payments A. Prior Payments 0 . 00 B. Discount 0 .00 Total Credits(A+B) (2) 0 . 00 3. Interest (3) 0 . 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box 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) 528 - 0 0 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 . . . . . . . . . . ❑ c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 0 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. 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 surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. 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)].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 21 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 percent[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 percent,except as noted in[72 P.S.§9116(a)(1)]. a 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)]. 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. OM4671 2.000 REV-1503 EX+I&%) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Josephine M. Zimniski All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 125 Shares Met Life Stock 4,345 Valued at average of high/low prices ($34.76/share) TOTAL (Also enter on line 2,Recapitulation) $ 4,345 3w4696 1.000 (if more space is needed,insert additional sheets of the same size) REV-1548 EX+(11-10) pennsylvania SCHEDULE E DEPARTMENTOF REVENUE CASH, BANK DEPOSITS, &MISC. INHERITANCE NETURN PERSONAL PROPERTY RESIDENT DECEDED ENT ESTATE OF: FILE NUMBER: Josephine M Zimniski Include the proceeds of litigation and the date the proceeds were received by the estate. All propert 'ointl owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Wells Fargo - Safe Deposit Box - $10,366.70 10,367 TOTAL(Also enter on line 5,Recapitulation) $ 10,367 OW46AD 2.004 If more space is needed,use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Josephine M. Zimniski If an asset became jointly owned within one year of the decederXs date of death,it must be reported on Schedule G SURVWF-IG JONTIBAANT(S)NAME(S) ADDRESS Ri3ATI0NSHPTO DECEDENT A Harris, Kathleen A 101 Rich Valley Road, Mechanicsburg, PA 17055 Daughter JOINTLY OWNED PROPERTY: LETTER DATE DESCRFMON OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMEER OR SIMLAR DATE OF DEATH DECEOEAlPS VALUE OF NUMBER TENANT JOINT IDENTIFYRNGNUNBER.ATTACH DEEDFOR JOINTLY HELDREAL ESTATE VALLE OF ASSET NrEREST DECEDENTS IMTREST 1 A 2/21/2008 Wells Fargo Checking Account No. 4057 1,126 50.0000 563 TOTAL (Also enter on Line 6,Recapitulation) $ 563 9w46AE 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+(10-09) SCHEDULE H pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND w,+JTANCE TAX RETURN ADMINISTRATIVE COSTS RESNTDECEDENT ESTATE OF FILE NUMBER Josephine M Zimniski Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1 None K ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 3,519 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 Register of Walls — PIT filing fee 25 TOTAL(Also enter on Line 9,Recapitulation) $ 3,544 9w46AG 2.000 If more space is needed,use additional sheets of paper of the same size. REV1513EX+(01-10) SCHEDULE J ponnsylvania e DEPARTW-W OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Jose hive M. Zimniski RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS[include outright spousal distributions and transfers under Sec.9116(a)(12).] 1, Darryl J. Zimniski Dillsburg, PA All of Residue: 11,166 Son 11,168 2 Kathleen A. Harris 101 Rich Valley Road Mechanicsburg, PA 17055 Wells Fargo Checking Account No. 4057 Inventory Value: 563 Daughter 563 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. ([ 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 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 swasAl z.000 If more space is needed,use additional sheets of paper of the same size. I, JOSEPHINE M. ZIMNISKI, of Shawanese, Harveys Lake Borough, Luzerne County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all Wills and/or Codicils thereto heretofore made by me. FIRST: I direct my Executor, hereinafter named, to pay all of my just debts and funeral expenses as soon as is convenient after my death. SECOND: I give, devise and bequeath all of my property, real, personal and mixed, of whatsoever nature and wheresoever situate; to my husband, William J. Zimniski, provided that he survives me by thirty (30) days. THIRD: If my husband, William J. Zimniski, is living on the date of my death, I hereby nominate, constitute and appoint him, my said husband, Executor of this, my Last Will and Testament. FOURTH: If my husband, William J. Zimniski, predeceases me or does not survive me by thirty (30) days, I distribute my Estate as follows: (A) If my daughter, Kathleen A. Harris, is living on the thirty- first (31st) day after my death, I make the following bequests and devises: (1) To my daughter, Kathleen A. Harris, I give and devise my real property situate at Shawanese, Harveys Lake Borough, Luzerne County, Pennsylvania, improved with a tavern and living quarters. (2) I give and bequeath to my said daughter, Kathleen A. Harris, all of my household and personal effects contained in the aforementioned tavern and residence (not including cash or securities) . (3) I give and bequeath to my daughter, Kathleen A. Harris, all of my right, title and interest in and to the Pennsylvania Restaurant Liquor License for the tavern hereinbefore mentioned. (4) All of the rest, residue and remainder of my Estate of every nature and wherever situate, I give, devise and bequeath to my son, Darryl J. Zimniski, of Dillsburg, Pennsylvania, provided he survives me by thirty (30) days. If 4iy said son predeceases me or does not survive me by thirty (30) days, I give, devise and bequeath all of the rest, residue and remainder of my Estate to my son's wife, Marie Zimniski, and his daughters, Maryclare and Stephanie Zimniski, or the survivors of them, in equal shares. (B) If my daughter, Kathleen A. Harris, predeceases me, or is not living on the thirty-first (31st) day after my death, I make the following bequests and devises: (1) I give and bequeath to my grandson, James Scott Harris, the sum of Ten Thousand Dollars ($10,000.00) , provided he survives me by thirty (30) days. If he does not survive me, the said bequest shall become part of my Residuary Estate disposed of in the following paragraph. (2) All of the rest, residue and remainder of my Estate, of every nature and wherever situate, I give, devise and bequeath to my son, Darryl J. Zimniski, provided he survives me by thirty (30) days. If my said son, Darryl J. Zimniski, is not living on the thirty-first (31st) day after my death, the residue of my Estate shall be distributed in accordance with paragraph FOURTH (C) . (C) If my daughter, Kathleen A. Harris, and my son, Darryl J. Zimniski, both fail to survive me by thirty (30) days, I direct my Executor, hereinafter named, to sell all of my assets, realty and personalty, and to distribute the proceeds therefrom among my surviving grandchildren, the children of my daughter, Kathleen A. Harris, and my son, Darryl J. Zimniski in equal shares. FIFTH: If my husband, William J. Zimniski, predeceases me, or fails to qualify as Executor for any reason whatsoever, I nominate, constitute and appoint my daughter, Kathleen A. Harris, Executrix, of this, my Last Will and Testament. In the event both my husband and my daughter fail to qualify as Executor for any reason whatsoever, I hereby nominate, constitut< and appoint United Penn Bank, of Wilkes-Barre, Pennsylvania, Executor of this, my Last Will and Testament. SIXTH: I appoint United Penn Bank, of Wilkes-Barre, Pennsylvania, Guardian of any property which passes, either under this Will or otherwise, to a minor and with respect to which I am authorized to appoint a Guardian and have not otherwise specifically done so. Such Guardian shall have the - 2 - power to use principal as well as income from time to time for the minor's support and education (including college education, both graduate and under- graduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes, without further responsibility, to the minor or to the minor's parent or to any person taking care of the minor. IN WITNESS WHEREOF, I have hereunto setmhnancd and seal to this, my Last Will and Testament, this day of 1982. Y `.(SEAL) sep 'f ne M. rlski Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in our presence, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. J.. 3 - ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) } ss: COUNTY OF LUZERNE } I, JOSEPHINE M. ZIMNISKI, Testatrix, whose name is signed to the attache or foregoing instrument, having been duly qualified according to law, do here acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. f sephIne M. Zimnis Sworn or affirmed to and acknowled be re me, by J HINE M. ZIMNISK the Testatrix, this ,V7W day o , 1982. Notary Public ANNE MAfft EUCK,NOIARY PUBLIC AFFIDAVIT WiLKEs-BARRE,LUZERNE COUNTY MY COMMISSION EXPIRES DEC-6,1984 COMMONWEALTH OF PENNSYLVANIA ) Member,Pennsylvania Association al Notaries ss: COUNTY OF LUZERNE } and /77.[i.-/z t -Gam ••-- . the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that JOSEPHINE M. ZIMNISKI signed willingly and that JOSEPHINE M. ZIMNISKI execute( it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses, and that to the best of our knowledge, the Testatrix at that time was 18 or more years of age, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and acknowledged before fne brf . and this �?Q�._(� day of , 1982. Notary Public ANNE MAMI:ELICK,NOTARY PUBLIC VALKES-BARRE,LUZERNE COUIWY MY COMMISSION EXPIRES DEC.6,1984 Member,Pennsylvania Association of Notar* SAFE DEPOSIT BOX INVENTORY Page of INSTRUCTIONS The Department is authorized under federal law,42 U.S.C. §405(c),to use the decedent's Social Security number in administering this state tax law.The Department uses Social Security numbers to establish a decedent's identity and ensure proper credit for tax payments. (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S.Government: Number of items,date of issue,face value, names in which registered and type of ownership, i.e.,jointly held, payable on death, etc. (4) Bonds: Designate by name, amount,serial number,or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry,Coins,Stamps, Manuscripts,etc: List and describe as fully as possible. (7) Deeds, Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. ITEM ITEM DESCRIPTION NO. ff S' Z,inIVIs w .. ou6g,t/ 41c # 0P 11 44965 k -or Z i-AA(,k 4 �� et A,4iiWW ;�e_ .mss T Z 15 v 7 G R S �� Lhlk i►e TIFY UNDER kNALTY OF PERJURY-T AT THE ABOVE RECORD IS 15ERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: 3.,1 si URE sl TURE A 70 I AME t f PRINT AME N CH CK APPROPRIATE BOX BELOW: PRINT TLE DATE CHECK APPROPRIATE BOX: Executor(trix) []Administrator(trix) 12 ❑Estate Representative E]Joint owner of safe deposit box NOTE:Attach additional 8'/2"x 11"sheet(s) if ece ary or use duplicates of this page of form. SDPW7TPA(3.11(Page 2 of 2 ,4 48500041046 ' ej REV-485 EX(05-04) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Cade Year File Number Deceden�s Last Nagle Suffix First Name n MI ADDR�S OF DECEDENT STREET:_ CITY: y� /� STgT ZIP CODE NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX/j,G l►� �r NAME: SIRE T D ��—L! D tTY: jA �� TAT ZIP CODE: In NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING a. RELATIONSHIP: Ice SIRE ADD E CITY: T E: ZIP CODE: b. NAME: lri l� NSHIP:fJ�� CITY ST ET AD . : /�e�/ Z C. N l!!f�-/+�y L J I HIP: STREETADDRE S: e— CITY: STATE: ZiP CODE:_ S 1,4v NAME MID ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: 0 STREET ADDRESS: CITY, STA E: 1 O F: e NAM OF PERSON M KING LAST ENTRY ` DATE D TIME?F(AST'ENTRY etJ c� DATE qF CO ACT TOR N T BOX NUMBER OF BOX 1 TITLE NDER RICH B X IS REQUESTED JU NKVV AM ADDRESS OF PERSON(S)HAVING ACCESS TO BOX a N b. NAME: � ID � $TREETA, RESS: STREET ADDRESS: iolih f Y _t# STATE: IP C DE: CITY: - --- STATE: ZIP CODE: NAM D TITLE OF EMPLOYEE TAKING THE INVENTORY OL.c(S -- o L �✓ in WAS WILL IN THE BOX? ❑ YES ❑ NO if yes, a. Date of will: b. Name and address of personal representative,if named in the will NAME: S RE DID RS SS; � CITY: STATE: ZIP CODE: C. Name and address of attorney,if any STREET ADDRESS: CITY: STATE: ZIP CODE: 48500041046 48500041046 4 rx �i .G �'1 h cz C LO C o v 00 r C N Ch LO Ulan° o ° IUD. a CJ gr r N >s p o a 0 tm 0 ° o >,ti vg° t a co W �c a C') o eL 93 0 4.� V c co A � LO q a m.II cc� c� a w � ° M o LO LO r�O iN N 4. G O a) FY �O+ 00 O NG +� tz w o i w C', G -11.2 t1} c x ° w ° . .0 'o ' Pa. c!� N � � C LZI CCU o a O 'b w LLS a a a •E 0 3r o ao o a o fj O p Q) 3 r. o A a A H w o . me U) z > D C: U) O cn m O � mD � � n o = = -n On O N n 0 CU = 0 c co = cn' in' = lD � `< N > 0 -h0 h _ v Cn 14 _ � c = o w Cl) a — � (1) _ � rn — o rn a O 30383 �3���4 ZZ9b999000SZ90