HomeMy WebLinkAbout03-14-14 1505610105
REV-1500 a(e u)(R)
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN - ----
Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT /c
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
06/16/2013 - ----- '06/16/1930-
- — .. . -- -- -- -- —' -.- - -- —'
Decedent's Last Name Suffix Decedent's First Name MI
j Meluskey - -- - ;Andre--
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name — Suffix Spouse's First Name MI
; I
Spouse's Social Security Number
-_- -- THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
m 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 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
Steven J. Fishman, Esq. -J ---- ------- — - I (717)249-6873
REGISTER` nl_LS USE TgLY
W� - C7)
_ l�
First Line of Address �- ,�,�' �
119 W. South Street - — C/;
c.
(Second Line of Address.----
(City or Post Office '— _ - - LLState ZIP Code WATE FILED c O
Carlisle PA '17013
correspondent's e-mail address:steve-Fishman @comcast.net
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 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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
SIGNA ER OTHER THAN REFIRE T E ' r DATE
ADDRESS
19 W. South St., Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 \
J 1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
r. .�_- ---t
Decedent's Name: Andre J. Meluskey t
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1.4
2. Stocks and Bonds(Schedule B) ....................................... 2. .
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. I -�
4. Mortgages and Notes Receivable(Schedule D)........................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. ; 32,371.00
6. Jointly Owned Property(Schedule F) 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. 32,371.00
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 10,266.00
i
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 14,271.00
11. Total Deductions(total Lines 9 and 10)................................. 11. 24,537.00
n
12. Net Value of Estate(Line 8 minus Line 11).............................. 12.1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13. ± 7,834.00
t
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 0.00 j
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 1 �-
(a)(1.2)X.0_ 15.1
16. Amount of Line 14 taxable
at lineal rate X.0_ 16.1
17. Amount of Line 14 taxable
at sibling rate X.12 -__ 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.!
19. TAX DUE ......................................................... 19.E
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=)
Side 2
L 1505610205 1505610205
REV-1500 EX(Fl) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Andre J. Meluskey
STREETADDRESS
St. Patrick's Rectory
152 E. Pomfret Street
crry STATE 21P
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) 0) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
3. Interest Total Credits(A+B) (2)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (3)
Fill In oval on Page 2,Line 20 to request a refund. (4)
5. It Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
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.......................................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ 0
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?.............. ❑ E
4. Did decedent awn 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.
REV-iso6 IX+(oB-f2)
Is pennsylvania SCHEDULE E
P.� DEPARTMENT OF REVENUE CASH, BANK DEPOSITS &MISC.
RESIDENNCE TAX RETURN PERSONAL PROPERTY
RESIDFM DECEDENT
ESTATE OF: FILE NUMBER:
AndreJ.Meluskey 2113-0782
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-Orrstown Bank,Carlisle PA Acct.No146000840 16,650.00
2. Cash 68.00
3. Misc.Personal Property(clothing,books,etc.) 500.00
4. Auto:2002 Buick LeSabre(114,600 mi)sold to Gibson Auto Sales,Cadisle,PA 17013 4,500.00
5, Life Insurance Payable to Estate-Principal Life Insurance,Des Moines Iowa 8,136.00
6. Payment received from Diocese of Harrisburg 2,429.00
7_ Refund:Amber Enterprizes(pharmacy) 71.00
8_ Refund:Express Scripts(pharmacy) 10.00
9. Refund:Discover Card 7.00
TOTAL(Also enter on Line 5, Recapitulation) $ 32,371.00
If more space is needed, use additional sheets of paper of the same size.
-ans awes atg jo jaded to siaays leuoglppe asn'papaau sl aoeds ajow li
00'99Z'O L Y (uopelnlldmq '6 au.n uo jalua oslV)lVlol
'L
00'00£ :saai jajedwd wrgay xej .9
:saa3luelunmw .s
001764 :saa,{alegad 16
luapa3aa of Tuewmo)o dlgsuogelay
d1Z—MIS ATa
sswMlaa4s
luewlelo
(,uogeueldxa tpeue•sluewlep se awes agl lou sl mppe sluapww IT):uogdurax3 Ailwed �
00'00£ :saad AawolTV Z
:pled uolsslwwoO(s)jeaA
dlZ aTeTS Alp
ssajppV WAS
(s)angeluasajday leuoslad jo(s)aweN
:suolssrwwo:)angejuasauday leumad 'T
:S1S0)3N.Ltl81SINIWOV 9
00'9LL slsoo uogdaoal'os!W-Aa>snlayl sauler T
OO'LZO'4 +Iwn43 OnlIO(PRO uewo;d s)pPled IS Z
00'699'L Vd'uoII091S-awoHlejounjuewplaM T
:S3SN3dX3lV'Mn( T
iNnOWV NOLIANDS30 1139WnN
Wall
•i alnpa435 uo paljodaj aq lsnw slgap s,luapaaa0
ULO-£4 4Z Aamsmaw -r ajpuv
t omnN Slid do UViS3
S.LSO� 3AUVHJLSINIW{IV "ru vxviTrroui auN?
(INV S3SN3dX3 IMNna ano-janaadom3wjavd3a
H 3-ina3H:)S eLueAIKsuuad
(EL-Sa)+X3 TtST-Aga
-azls awes aap)o sways leuopippe yasw'papaau st ands aaow)I
00'LLZ'K $ (uopelnTldeoea 'pT auk uo jam oslV)1V101
00'86 aoueingwV II 4xx)g puepagwn0 -8
00'06 L 6ulweid-euelleg s,wwels L
00.0£ uo.gmipaw-slduOS ssajdx3 g
00.00Z (l0ago pawmai eoeldai)sgdawr-IS;o sia)slS .g
00'£L£ (pmo)IparO)PRO JOA0si0 v
00'05 Ja)ua0leolpaw leuo168a als!pe0 £
00'9L )u9w86euew ueplsAyd HWH alslue0 Z
00'4L£'£L Vd'fungsweH-Vd IPWOO 10 03ldsOH
'i
H1V30 40 NOL dIHOS30 HIMN
31V0 1V 3nlVA W311
•sasuadxa Impaw pasmgwlaiun 6ulpnpul'apeap yo al,ep eta le pledun poulewai jega gl,eap oq ioud juapaoap eta Aq paimoul slgap yaoday
Z8LO-£LLZ AoAsnlay3 £ajpuy
M3emm 31Id AO 31ViS3
SN3Il$ S3IlIlI9VIl 39t/91aOW uaw u XVI3ai JRF3HM
'1N303:)3(l d0 SIM 3nN3n3aaoi a ,,"vdaa
I nnam:)s euleAlAsuuad GA
(ZT-ET)+X3 ZTSI-A3a
wis awes ag1)o laded)o slaaqs leuoNippe asn'papaou si weds aiow 11
00'48£'L S '133HS 113AOJ 00ST-A3N 90 ET 3NI1 NO SN011n9RLSIO 319VXVI-NON 1V101 N310-11 latld i0 1V101
0011£S'L Vd'(LngsweH pun j keu(wag-6ngsweH 10 8saooi0 ogolpeO uewoa
't
:SNOLn9ITLSIO IVIMN113AO9 ONV 319tlUMD '9
.T
:N3NV110N SI Xtl101 NOLO313 NV HJIHM 1103 ET16 NOL09S H3aNn SNOLn9nLSla lVSnOdS 'V
SNOLnSM-LS1a 319VXV1-NON II
3iMd011ddtl SV 133HS 113AOJ OOST-A3b d0 9T H9nONH1 ST S3NI1 NO 3AO9V NMOHS SNOLn9I111Sw WA slNnOWtl 11tl110a N31N3
.T
['(Z'T)(e)9116'3aS
uapun evalsuen pue suognqulsip lesnods 146ulno apnputl SN011fI9I111Sw 3l9Vxv 1 I
IALS3 30 (s)aalsnll lsn ION Oa AlSdONd 9NIA1309N(S)NOS113d d0 SS3110(Itl(INV 3WVN H39WnN
3WHS 1101NnOWtl JN303330 01 dIHSNOUV1311
ZSLO-£l l A9XsnjaVj T ajpuy
:7J39wnN 31H :d0 RVIS3
1N3aama m3msaa
S31HVINAM 38 MUM XV).MW 1tl3HNI
3nN3A3d d01N3WlHVd30
C 3-ina3H:)S ewen��Csuuad�i�
(OT-10)+X3 LTST-A311
q3!m paloeiluoo aneq I goiLim sessew ££ aql Aoid of ollgndeN LioazO aql u! jnnQ AAON
;o Ajalseuo&N aql as!npe of jolnoax3 Aw loamp osle I 'll!M sigl10 suolslnoid 6ululewai
aql of 6ulp000e hliadoid leuosiad Aw gleanbaq pue as!nap 'an!6 I :2InOd W311
•belay 1olno9x3 'elueAlAsuuad 'A4uno0 jalseouel ;o 'Ae)lsnlaVq
sawed jaglaq Aw lulodde I 'anus os of uoseai Aue jol alqeun si jolnaax3 pies Aw
Juana aql ul •luawelsol pue ll!m lsel Aw 'smp to jolnoax3 ,.dd 'alsiue0 'gojng0 s,51014ed
luieS to AaAod we!ll!M puajanaa tiara aql lulodde AgajaLi I :33bH1 W311
'III
sigl japun 6uissed lou Apadad jaglo jo eouemsui;o spaeowd uo g6nogl uana 'p!ed os
xel Lions Aue jol luawas.ingw!aj ulelgo of uoge6iigo jo lilnp ou aneq pegs jolnoaxa Ayq
•alelsa Aw jo uopilsluiwpe agl to lied se pue aseaoap lbw jaue algeoiloeid se uoos
se alelsa tienp!saj Aw wal pled eq !legs (Apadad Aue;o lualdloei Aue Aq jo alelsa
2Aw �(q algeAed eq saxel Lions jaglagm) saxel gleap lie pue sesuadxa tieluawelsel
o <�i c�
'sasuadxalejaun; 'slgap algeeojolue Alle6al Aw Ile leg!pomp I :OM1 IN311
� U
-spew aneq I sluawa6mie-aid all ql!m aouepi000e
Ld T
v, wlTpsunq aq sulewai Allpoq Aw leg! ailsep Aw leg!loajip I :3NO IN311
n
U c9 U
LU
W v ; •aw Aq apew
Alsnoinaid slloipo0 pue sll!M lie ajonaj AgajaLi pue luawelsal pUe II!M isel Aw eq of
sigl ejeloap Rgajeq op 'eluenlAsuuad 16mgsijJeH 10 asaoold aql;o lsaud 'Aa)lsnlalN 'f
aipuy puaaanab 'I '111:1IdS AIOH ONb 'NOS '213Hldd 31-11 d0 3V4VN 31-11 NI
A3NSflI31N 'f 3HONV
Z10
WOUM4891 pus TTTA 48VU
`)oaiall uogeo11dde all of eas of siapual all to lied ay) uo A)Illgell )notgm 'eslmiaLi)o io
'sluawlsanw jo a6pald 'Aliadad leuosiad Aq luawAed sp amoes of pue Aauow maioq
of 'uopjaplsuoo Rue}o uogeo11dde ay)aol jase4oind Aue}o A)glgell lnotipm 'Apedoid
all to sja;suejl pue sluawu6lsse 'saoueAanuoo lualol}ns pue pooh jaA11ap pue a)noaxe
of pue 'auluualap llegs joinoexe Aw se suolllpuoo pue swial Lions uo pue 'seoud jo
aoud Lions jol pue 'jauuew Lions w 'awll jo awll Lions le 'AlJadad leuosiad Aue lJanuoo
aslmiaLilo jo Iles of jg6u aLil xulnoaxapo)noaxa Aw uodn ialuoo I :3NIN W311
•Aielogauoq Lions Aue jo sioppajo all Aq laluoo caw; aai} pue 'a6pald
PUB 'Iuewgoe4e ')uawuftse uopualle 'uo1)edlogue wog; aaj; pue 'apew sI luawAed
all wogm of lenPlAlpul angoadsaj aq4 jo ldlam aloe 9qj uodn apew aq lle4s 'way)
to Aue jo 'snaq Aw of algeAed 'awooul jo ledloulid jol jeglagm pue pwN w J0 4sea uI
jallagm 'scans io wns Aue)o sluawAed jo luawAed Ile pue Auy :1HJ13 W311
quawmisul S141 10 A)IpgeA ay);o uolleolldde jo uo13e)aidjalul Aue of
Aldde 11e4s e1ueAJAsuuad;o 431e9muowwoa all;o m8l all)eLil)oaalp 1 '6u1Pue)slllm)0u
Ajejluoo all of uollolpsun(jaLi)o Aue jo elueAlAsuuad ;o Li)leamuowwoa all jo linoo all
to alru jo mel Aue 'janaosjegm asodind Aue jol adfq Aue to Alunoes Aue aA16 jo puoq Aue
lsod of pajinbaj aq IIe4s luewelsal pue IIIM)set Aw s14)Aq palulodde jo 'pa)eulwou
'poweu Ajelonpg j9410 jo siolnoaxe '(s)aa)snul ou )eqj loamy I :N3A3S IN311
•pun3
AieulwaS asaoola 6ingsljJeH 9qj of alenlls jama lm pue amleu aana)egm{o 'a)else
Aw jo japulewai pue enplsaj 'lsaj all gleanbeq pue eslAap 'aA!6 I :XIS W311
•jolnoex3 Aw of umou)l apew uaag aneLi go14m 'sa4slm Aw 431m aouepJ000e
u1 suolssessod leuosiad Aw aingplslp of jolnoax3 Aw loanp l :3/U3 W31l
•aw Jo}sago of waLi)
If 2'
I, ! 33 j -rpT SS3UGClV ,7Q5
j� •sessaupm se saweu mo pagtaasgns olunaiay
aney `ioglo yoea to aouasaid pue ly8ts ay; ut pue 'aouasaid pue lg6ts sty ut 'lsenba3
sty le 'oup 'sn jo aouasaid ayl ut 'luawelsa,L pue Ip AA Ise-1 sty jol pue se 'Aa)lsnlayq
.r ajpuy 'jolelsal peweu anoge ay;Aq paieloap pue paystlgnd 'Paleas 'pauBiS
Aa�lsnl uy
(Td3S)
"£60Z
r
'AaW jo Aep r t 0 otl . 'tluapi;o asodind ayl iol u0jew ayl ui asnleuBts Aw jeaq
yotynn;o (t;) aaayl lsIg 9141 'sOad uallpmedAl (y).mol jo 6uilstsuoo 'luaweiso i Pue IIIM
lsel Aw 'sty;of teas pue puey Aw las olunalay aney I '3O3a3HM SS3N11M NI
•alelsa Aw jo uotlnqulstp pue
uotlejlstutwpe juawg6euew ayl ut aleudoidde jo Aiesseoau s6ut4l pue sloe Jaylo fie
op of pue : pea ut Allied io 'pupl ut Jo aseo ul 'sauetoyauaq 6uowe Aliadoid ut slsa olut
paptntpun jo A4jadoid to sajeys aleuopodoadstp jo sputm luaaapp alnqulstp pue aleoolle
of 'put ut io yseo ut uotingulstp aatew of '„sluaugsanut le6al. Polleo-os of uotloulsaa
lnoy `uog9iostp le lsanulaa Pue lsanut al :uotlaaastp le sluewlsanut Aue ulepJ of
SMVI N 40 NOMOOS y VMtlA97SNN3d*MSNM
=/4uZnco
mw4 S jJNua[
Was aN
N
MNVAUSNN3d d0 HLIV3MNOWWO]
1
-uoz ' 4W to Aep�slgl ow aiolaq pequosgns pue of rooms
eouenllui anpun jo luiejisuoo ou aapun pue puiw
punos to 'japlo jo a6e to sieaA (9i ) uaalg6ie awl; eql le sem Joleisal agl `a6palmouN
jlagl to lsaq eql of legl pue 'sessoullm se IIIM eql pau6is 'jolelsal aql 10 6uueaq pue
aouesaid aql ui 'sassaupm eqi to goea iegi pue `possajdxa uiajagi sasodind aqi jol ioe
fuelunlOA pue aail sig se painoaxa aq iegi pue AlBuipim pau6ls aq legi pue 'luewelsal
pue li!M isel sly to luawnilsul aqi painoaxa pue poubis lolelsel agl leyl A4uogine
pou61siepun eql of ajeloap Agajaq op 'rooms Alnp lsjg 6uiaq 'ivawnilsui 6uio6ajol
jo pagoel;e aql of pau61s aie seweu asogm 'AleAgoodsai 'sassaupm agi pue Joielsel aql
pue •rou�v s 1 " `/Ca)lsnlayq [ ajpuy `aM
ONHlU3evvno 30 il1Nnoo
'SS
VINVAIASNN3d d0 HIIV3MNOWWOO
•pagslull U0 14M wio; agl jo Mopq aql alep pup u6ls espald
saxoq iaglo due 1loago iou op •asianaj uo Z dais of peaowd OOS t 3
an4eluasaidai alelsa ay16q paly wnlaa uuo;xel souelu yu!
xel aoueluayul Vd a41 411m pied kel pue paliodai aq 0im io uaaq,sey lgspe pququapl-anoge ayl uo pouodai eq 0!m joss
y 3 ;
-uuol slgi jo iloeq agi uo aleudwdde se£lied pue d pad alajdwoO lsil
-pied aiam suoponpop pue slgep jo/pue loanoom si anoge uo!lawo;ui aqi suo!lonpop io sa6uey6 4
-(auou 6ulpniow)sd!4suollelai iaylo pV %9 L ❑
paseaoop a41 10 6uilq!s a we I %Z L (-asianai uo£
❑ ued alaldwoo pue'ly6u
le ales Xel loeim polas)
•paseaoep ayl jo(•ola'pliy3puei6'P1!43 yuaied)6ie!ogauaq leoull a we 1 'Lo4'V ❑ -loaiiooui sl ales xe1841❑ O
-saxoq iaglo due 1loago iou op "asianai uo Z dalS of paaowd
asuodsai Aw yLm •loaiioo
lugs aq plm luaw6ed pue'uallel 6u!aq aie suollonpop ou'10aL00 sl uollEwio;ul anoge ayl si uogewio;u!a4l 8
-an f7 xel le'lualod se anoge umogs
lunowe aqi pieBeisip pue sexoq jagio due 1loago iou op •asianai uo d daiS of paaawd
•tileop;o alep le aa6unoA ao plo sjeoA lZ
sem ogm luapaoap a jo luaied aqj we 1 ao poseaaap aql to asnods ayl we 1 anp s1 xel ON F V
•molaq saxoq oleljdoldde 841 310040 aseald :L da1S L
land
•yleap 10 alep 841 Jage
syluow awu luenbupap awooaq plm anp xel aoueppaqu!AuV •anp ,31ON aas $ (96.0 x xul)WOW'(]%9 43!M
xel ayl.uo lunoos!p luawad g enpap'yleap 10 alep s,luapaoap LL'9bZ'L$ anp xel le!lualod
a4110 syluow amyl u!411m apew am,s3uawAud xel11 :A-LON OS l'0 X aiea xel
Z VgcZS'8$ xel of loefgns lunowV
£LOLL Vd 31sliuvo 09 X olgexelluawad
3
3aynosSnOH1anoo L £3'099'9L$ aoueleg 3un000V
SIIIM dO a31S103a LOOZ-6O•LO pagsllgels3 aiea
:ol swjo3 pue luewAed l!waa M0009VL'oN lun000y
pal pep!lun000e oql;o i(1eloljauaq 10 iaumo julof a aiam noA luapaoap paweu-anoge
aqi jo Uluep all le leyl 6ulleo pul moleq uollewlojul aqi ql!m luawliedep ayl paplAoid -ANVfl NNOlsilao
1099-0SOLT Vd 9HnffsoINVH03W
13 lIVIXDA Z
aleouRiao aNVl83giNno/yunoo INIS09 6 Hd3SOf
lsnil £LOZ-9L-90 41ea(I 10 alea
6u!lloogo L6£O-YZ-8L L NSS
s6u!AeS u)isnl3W f 3aoNV 10 alels3
luno00V 10 a&_L
£LOZ-ZO-90 31V1]
609 LbL£L NOV
Z9LO-£L LZ'ON 311j asuodsod jeAudxel puV
ao-va>33n,-Q x3 csse-na
3nN3A3H 301N3W1HYd30 { 00110N uOl3ewiO;ul 1090-OZILI vi aanesiUM
�LUBA�ASUUad ICU ire aou ua u elupn,tsuua 1Hl JO xos 0d
1 pl. 4 1 I d s3xvi 1ma1A1ani do nnana
LLrt 44LLV 414J Wl(Crt11[ t�I GL IIWJ LLOLGLV
YJBLBa:
ZZST—SVZ-008—T lVD01
0594—Z6EO9VMOI sHNION saa
sNIH'IO AS'I'IIaysI0 �3 Safi f
:11V3 3SV31d - SNOI1S3flb ANV 3AVH nOA dI
Saa0O3a1unOA HOA NIV138
's79eueQ l0 wawesJngwmi IIN Bulpnl0w sagleuad paulwu0 Pue Ilnn ul llnSW P1n00 su0lleluasaidaf aSled 7uawAed
iol wlep eta to lwddns ul epees uaeq eneq suogeWesa,de, 6upselslw jd slueutoM esM ou Pue Pe6uego lou eneq luewapgue gone 6ugoe4e
Smuelswn;uq IMP Saleolpul u04UD4w o Slg1 'Sy}auaq poi luswAed S.M of IMMMUD sa49Jw OBftd e4l VMP s!W W luewesJWUG AS :30IlON
/r1
SNatlN3a
Z9' S£T'8 S1V1o1
Z9'S£T'8 33I't xHHIdB OT9KH
-µ _. S033OONd
:_-.Lf#ilNlll'fd. =: -.- QFYaH1 3,3" dli'3fCAi- 3dI1
116—XXXXXXXXX—T-4ZLL9H ON NITIO
Z9'S£T'8$ INnONV 92iIl8s IHHHH d0 Ts3O0I0 a3010HAOI10d
ET-ST-01 31va arias iNvwrVI3
94L98L-69 '0N )03H3 AaxsnrlHN H2IaNS a3ew3p
♦A71dWOad HSVO 0NV NOIlVUOAod 1V H=30 3SMd V