The URL can be used to link to this page

Home My WebLink About04-19-13 (2) J 1505610105 REV-1500 Fx(02.11)(FI' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes of"p ` County Code Year File Number PO BOX 28o6o1 INHERITANCE TAX RETURN Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT 1 -13 -U iyo ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 02/06/2013 12/05/1928 Decedent's Last Name Suffix Decedent's First Name MI ROHM ANNA M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW dft 1. Original Return p 2.Supplemental Return C=) 3. Remainder Return(Date of Death Prior to 12-13-82) C=:) 4. Limited Estate p 4a. Future Interest Compromise(date of C=) 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate Cn 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) C=:) 9.Litigation Proceeds Received C=:) 10.Spousal Poverty Credit(Date of Death C=D 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 WILLIAM A ROHM (717)2P-7215 X m RE4i6Ti:R OF WILLZUSE 61iY, _..J First Line of Address 2977 ENOLA ROAD p: +..ti ;a _..l Second Line of Address 1 iI City or Post Office State ZIP Code DATE FILED u ..I CARLISLE PA 17015 Correspondent's e-mail address: 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 Willef, it is true,correct and corn te.Declaration of reparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE P RESPON IB R FILING RETURN DATE q �y E �J ADDRESS / / 1 /F40/A /' co CAt-L- 'r (fQ !rd 1 S SIGNATURE OF PREPARER OTHER THA PR ENTAT4V JE ATE AD RESS y t 99 CAMPGROUND ROAD CARLISLE PA 170 5 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: ANNA M ROHM RECAPITULATION 1. Real Estate(Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 6,000.00 2. Stocks and Bonds(Schedule B) 2. 21,866.66 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. . . 3. 4. Mortgages and Notes Receivable(Schedule D) . . .. . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 3,236.76 6. Jointly Owned Property(Schedule IF) O Separate Billing Requested . . . . . . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G; O Separate Billing Requested.. . . . . . . 7. 8. Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . .. . .. . .. . . . . . ... . 8. 31,103.42 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . . . .. . 9. 2,562.51 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1).. . . . . . . . . . .. . 10. 11 Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2,562.51 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . .. . . . . . . . . . . . . . 12. 28,540.91 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. 28,540.91 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._ 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0 45 28,540.91 16, 1,284.34 17. Amount of Line 14 taxable at sibling rate: X ,12 17. 0.00 18. Amount of Line 14 taxable at collateral rate X.15 18. 0.00 19. TAX DUE . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 19. 1,284.34 20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: _ DECEDENT'S NAME ANNA M ROHM STREETADDRESS 2977 ENOLA ROAD CITY - 1 STATE ?IP CARLISLE PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19; (1) _ 1,284.34 2. Credits/Payments A.Prior Payments B.Discount 64.22 Total Credits(A+B) (2) _ 64.22 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) _ 1,221.90 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 arid: Yes No 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 ............................................................................................................................ d. receive the promise for life of either payments,benefits or care?.................................................................... ❑ 0 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}]. • 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. pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNA M ROHM 21-13-0190 All real property owned solely or as a tenant in common 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1' 78 HOMELITE MOBIL HOME 6,000.00 TOTAL(Also enter on Line 1, Recapitulation.) $ 6,000.00 If more space is needed, insert additional sheets of the same size. REV-1503 EX+(8-12) I I pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNA M ROHM 21-13-0190 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER _ DESCRIPTION OF DEATH DWS INVESTMENTS ACCOUNT#26193183 21,866.66 i TOTAL(Also enter on Line 2:, Recapitulation) $ 21,866.66 If more space is needed, insert additional sheets of the same size REV-1508 EX+(11-1o) pennsylvania u SCHEDULE E DEPARTMENT Or RF-VENUE. CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ANNA M ROHM 21-13-0190 Include the proceeds of 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CHECKING ACCOUNT M&T Bank 1072102 2,304.27 i 2. PATRIOT NEWS PAPER REFUND 58.08 3. PERSONAL ITEMS 35.00 4. PMI LOT Security Deposit Refund 115.41 5 AUTOMOBILE 500.00 6 PERSONAL ITEMS 224.00 TOTAL(Also enter on Line 5, Recapitulation) $ 1 _ 3,236.76 If more space is needed, use additional sheets of paper of the same size. 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 ANNA M ROHM _ 21-13-0190 Decedent's debts must be reported on Schedule I. ITEM — NUMBER DESCRIPTION _ AMOUNT A. FUNERAL EXPENSES: 1. URN 93.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP vear(s)Commission Paid: Z. Attorney Fees: 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: 148.50 S• Accountant Fees: 500.00 6. Tax Return Preparer Fees: 7. UTILITY-PPL 87.14-PP&L 48.24-CENTURYLINK 31.43-COMCAST 30.90 197.71 B. PMI LOT RENT 403.59 9. HALTEMAN TREE SVC 70.00-STEVE ROHM 58.00 128.00 10. WILLIAM ROHM EXP 365.- BANK CHECKS 15.74-ROBERT CARNS TAXES 11.99 392.73 11. SARA TODD 270.00-West Shore Ambulance 385.32 655.32 12. MEDICAL SARA TODD 43.66 TOTAL(Also enter on Line 9, Recapitulation) $ 2,562.51 If more space is needed,use additional sheets of paper of the same size. named, as and for tier Last Will , in the presence of us , W110, at tier request, in her presence and in the presence of each other, have subscribed our names as witnesses thereto. ol COMMONWEALTH OF PENNSYLVANIA C011"rpy OF clit-IBFRIAND We, Anna 1,1. Rohm, Robert R. Blacj,,, and the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as tier Last Will , and that she had signed willingly (or willingly directed another to sign for tier) , and that she executed j-,t as her fr.-ee and voluntary act for the purposes therein expressed, and that each of the witnesses , in the presence and hearing of the Testatrix, signed the Will as witness, and that to the best of their knowledge the Testatrix was at the time eighteen years of age or older, of sound mind and under no constraint or undue influence . ,Ilestatrix Anna H. Rohm Witness Robert R. Black Witness Subscribed, Sworn to and acknowledged before me by Anna M. Rohi,,i, Testatrix, and subscribed and sworn to before me by Robert R. Black and witnesse.s, this Vil day of - -- 1993 . Notary Public NoiariaE X31 AM-1 L Wit�Cf,Notary PUUiC cars-,ie Ficfo,Cumbeil.arki County F.t/Clmrr.7wn Fxijies Sept 9,19% r t�' ! EMFNT' PERIOD PAGE _. .JAh!.. 4-FEB 22,201_H1 OF 3 )0 0 0431+414 Nil 01:' 00000443 F1DS1549D01;0'2`Z)13U, Ct`000 40284 ANNA ICI ROHM WI -L I AM A ROHM 901 SOUTH SPRING GARDEN ST LOf 85 CARLISLE PA 17015 SELECTED ACCOUNT SUMMARY __ J ACCOUNT ACCOUNT INTEREST EARNED MATURITY ENDING TYPE NUMBER "EAR-TO-DATE DATE BALANCE CLASSIC CHECKING 000000001072102 0.00 1,339.12 RELATIONSHIP SAI/INGS 015004200944715 0.05 0.00 TOTAL DEPOSITS 1,339.12 r rr� -----_ ----_��_._ r- C uUf'aT T i,t A M ROHM CLASSIC CFiECKINi�' �LTLE ! WILLIAM A ROHM ACCOUNT NO. 1072102 SPRING GARDEN INTEREST EARNED FOR STATEMENT PERIOD 0.00 ACCOUNT SUMMARY _ BEGINNING DEPOSITS & OTHER 4 CVRRENT ENDING BALANCE OTHER ADDITIONS _ CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE N0. I AMOUNT - NO. AMOUNT N0. AMOUNT 1,585.68 4 2,072.43 5 2,030.41 4 288.58 0.00 1,339.12 ACCOUNT_ ACTIVITY POSTING - DEPOSITS,INTEREST CHECKS & OTHER DAILY DATE TRANSACTION DESCRIPTION & OTHER ADDITIONS SUBTRACTIONS BALANCE 01-24-13 BEGINNING BALANCE $1,585.68 01-25-13 CHECK NUMBER 2337 403.59 1,182.09 02-01-13 SSA TREAS 310 XXSOC SEC 1,088,00 02-01-13 CARLISLE CORPORA PENS PMTS 260.43 02-01-13 AARP AARP 000000000002338 16.00 2 514.52 02-05-13 UnitedHealthcare PREMIUM 210.25 2 304.2 7 02-07-13 COMCAST CENTRAL CENTRAL. PA 30.90 2, 37 02-11-13 DEPOSIT 500.00 02-11-13 DEPOSIT 224,00 02-11-13 CHECK NUMBER 2340 93.00 02-11-13 CenturyLink SPEEDPAY 31.43 2,872.94 02-14-13 CHECK NUMBER 2339 _ 385.32 2,487.62 ENFIA f PF-R l0?'. PAGE 2 OF 3_ ANNA M RUH14 WILL: M A ROHh V,:COJNT II:;TIVIT _ POSTING -" p .PCSI VT(REST ---CHECKS 6 OTHER DAILY DATE TRANSACTION DESCRIPTION 6 OTHER ADDI1I(iNS SUBTRACTIONS BALANCE 02-15-13 +:NECK NJMBER 2342 1,000.00 1,487.62 02-20-13r:HECK NJMBER 2,341 148.50 1,339.12 �- ENDING 13ALANCf — _-_ _ _ _-_--_-- _. $1,339.12 - — — ---- - -:NECKS PAID_SUMMAR).- -`— 2337 01-25-13 4C3.59 23304 02-14-13 185.32 2340 02-11-13 93.00 2341 02-20-13 7.48.50 2341: 02-15-13 1 000.00 YOU HAVE THE FREEDOM 70 USE YOUR M3T CMECt: CARD THE WAY YOU WANT AT THE PEGISTER- CHOOSING EITHER "CREOTT" OR ,DEa:f"- AND YOU WILL NOT BE CHARGED ANY TRANSACTION FEES* ON YOUR PURCHASES IN 'THE EJ.S_, EVEll WHEN YOU GET CASH BACK! rM&T DOES NOT CHARGE FETES FOR USING YOUR MkJ CHECK C44RD FOR PURCHASES IN THE L.S.; HOWEVER, FEES WILL APPLY LF YOU USE A)UR CARD OUTSIDE THE U.S. , INCLUDING ONLINE PURCHASES WITH A. MERCHANT LOCATED 01,17SIDE O= 'iHE U.S. IN ADDITION, OTHER FEES, INCLUDING OVERDRAFT FEES, APPLY TO YOUR DEPO'ill ACCOUNT ACCORDING TO THE TERMS OF YOUR ACCOUNT. - ---� -- ACCOUll4- ANNA-M—ROHM _. RELATIONSHIP_SAVINGS Ti'r�i__-L ACCOUNT NO 15004200944715 SPRING GARDEN INTEREST EIRNED FOR STATEMENT PERIOD 0.01. _ ACCOUNT SUMMARY F—B EG—INN I DEPOSITS & - WITHDRAWALS & OTHER--- CURRENT ENDING BALAN{:E OTHER ADDITIONS SUBTRACTIONS INTEREST PAID BALANCE NO. AMCiUNT NO. I— AMOUNT' 1,073.67 1 _ 124.53 .l — n ,198.21 0.0L 0.00 ACCOUNT ACTIVITY POSTING - �— -� DEPOSITS,:lNrEREST W/DRAWALS & OTHER DAILY DATE _. TRANSACTION DESCRIPTION _ & OTHER ADDITIONS SUBTRACTIONS BALANCE 01-24-13 BECSNNING BALANCE $1,073.67 01-29-13 DEPOSIT 1?4.53 1,198.20 r' TT'"Iw 1 m " ^ j S � , � lw 4p s '{lal o I m C r t 0F' 7 J(1( 061 Fi[' -,I iEX, - INTEREST EIRNED FOR f.'r'F: I ( E !I;D )o SPRING GiaROLN BEG: ):1 i IIS CHEI i F'! -- — - - - — -- - - _- !; 77171ACTIONS I ILi__Rt S17 E'E)� BN4i7LdG A.ANC E ).(10 5 _ NICM. --- S 10L I 10 AMOUNT --- — k ANCc-- -- ��- - 28,900.34 POST INi T3DEF'OSIT .[ r/ :: l DALE I 'OS (1S, IEREST CHECKS 8 O7HER DAILY —` - ---- fRA'd( t : III: L'�1 h.:PTIOhI - - -- -- - --- _-. SU3TRACTIONS -_--- 1)2-15-: E6',INNING - )2-15-: $0.00 12-25-13'DE-us IT 1 oII.co 1,000.00 )3-04-13 DIE'DS:IT 3''. .60 1,035.00 1)3-03-13 DIE 113S:(T F''I 03 1,093.08 03-1 ?-13 Df_LUXE: CHECk, CflEE r,l 5, .00 J 7,093.08 03-1:;-13 CHI.I:K NUMBER CI171 15.74 7,077.34 (3-1!;-13 DEF'I)S]T 43 66 7,033.68 ': ,Ilibt .c,6 _—_-_ ENE I:NG BALANCE ----- E'EC, 11 � ---- --- LET 111 iRE I`51ISO'H LITY 10W F -NI,'1 (4G ICrUR 1181 CHECK CARD +711;4 YFlE PICTURI Of.' 1 [:; (i' YOIIIR Ch10a :',:, V:I [f I"lI .C)M,CL'ST0hIC,i"..RD TO VIEW OUR GALLERY' USE ORI IIE :; q; :LVE LEMON:S 'e(ATI(' TOCI h4D [,E'T ".IAI;'TED. USE E 11{E Ml rlrD IIE:SIGN :.I RVIC :S : ILLt,1.CT TO F r'OCRAM TERMS 8 LONDLTIONS, IMAGE (lq C IE III .; # I A t ;'.95; :IEIi CIE 5 UP IF l E' FOR FA( -', f EWLY AF'PROVEO CUSTOM CARD DESI:GIV Illl :1 ':[S I AVING 11: S,A,' li NU1'IBLs' DI'dE E.Ii' 4tEWL BE PROVEDD PER APPROViD ClJ ( 11 1 _'i B:,N, REGARDI 1:3S 0 THE IV.6'II91ER 01= C,,".iR[)S ISSUED. REPLACE=MENT CARDS DILL I I 1 .f :11 p, T-111:3 FEE :'F 'rim- I LISTC113 11 SI(',JN REIIA]I:NS UNCHANGED. REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA, 1 i 11n- 20 13- 00190 2 . ?- 1'3 0190 Estate CO`: ANNA M ROHM - L-at 0 SOL/TH MIDDLET()N TOV/NSf-IIP CUMBERLAND COUNTY Degeasej 780-265191--' i , L , .._. ANNA M ROHM SOU!H IWDDLETON TOWNSHIP, CLIMBF--RI AND Cour,:'y 1,2- - L GLF_NDA FARNER STRASBAUGH ER Vl- (2 r _i�Ye S av g;�� terz �t 1-FSAlv9ENT," RY" to: WILLIAM A ROHM who _as ciul z i ed as EXECUTOR(RIX1 X37 �IaS '1�7 - r°�i ��% �� I71 S L e__" E,'2e c,s a .' ii.i-f?rr F J m,, --.�e a C(/MBi-RLYiiVD COUIIT� - r . Uf-i 1- HOUSE, SE, CARLISLE, PENNSYj_ V-1 NIA. VV h da �� _ .1.. e 95t y o f February 3. INVENTORY Rl",G[, TFR OF' WILT S 0 F c PENNSYLVANIA umRF.RT,ANn C01_11N CONINIONW EALTI I OFf'ENNSYINANIA SS COUNTY OF Fiic Number -2 0 1 3--0 0 1 9 0 Personal Rc[)reselliativc(s) of the Estate of' ANNA. M ROHM deceased,depose(s) and say(s)that the Items appearin',III the f011ow-11111 IFIVCIAOIy 111CILICIC 211 Ofll-C personal assets wherever situate C r- drid all of the real estate in the Commonwealth of Pennsylvania of said Decedent,that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the decedent's death, and that [)cCederit ov,lied no real (-,state outside oftlic C0,111,10"wealtli of Pennsylvania except that which appears in a memorandum at the C-I-Id of this I verify that the statements made in this Inven- tory are lFtle and correct I understand that false state- 111clits herein are niade subject to the penalties of IS Pa.C.S. § 4904 11datI171- to LHIYwOrtl falsification to — authorities. f Attorney (Sup coax Court 11). ('Address)_____ (Tclephorw)__ CAl I OF DEATi f I-AST R[.'_SIDENCe soc SEC No CHECKING ACCOUNT 2304 . 27 AUTOMOBILE :500 . 00 MOBILE HOME 6000 . 00 DWI STOCK 21866 . 66 PERSONAL ITEMS 259 . 00 NEWSPAPER REFUND 58 . 08 LOT RENT SECURITY DEP REFUND -115 . 41 -(Attach additional sheets as needed) 31103 . 42 NOTE The Mejjc)jjjjjd,,-, of,col estate outside [Ile Common"ealth of Pennsylvania may, it [11c' euion of the PV'So?i" the viflLjc of'each � tent,but such f ig,m s d;lot be cx tended S ei o the total of the Inventory (See 30 pa ("S I-c"m pi� o9 r', 10/3(jo