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Home My WebLink About08-06-14 1 1505611101 -I REV-1500 Ex(02-11) ' ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania mm• »n•x County Code Year File Number Bureau 2Individual Taxes INHERITANCE TAX RETURN 1111' PO Box rg,PA 1 -2 / Harrisburg,PA xpi2R-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMODYYYY Decedent's Last Name _ Suffix Decedent's First Name MI UJ FL1Z / 1�1 (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name �'�''�� Suffix Spouse's First Name MI=1 11 171111] [3 Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE �� REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t� 1. Original Return 2.Supplemental Return O 1 Remainder Return(Dale of Death Prior to 12-13-82) G3 4.Limited Estate O 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12.82) . O 6. Decedent Died Testate en 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 y( c rN �N G AtTG L / r1y 7 7iI � *7; .� / i J REGISTER OF WILLS USE ONLY N_ First Line of Address MC' C 7 Second Line of Address city or Post Office State ZIP Code 1iyiLEO I - m r 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 belief, It is true,correct and complete.Declaration of preparer other than the personal presentative ia based on all information of which preparer has any knrnWedge, SIG ESS PERS ESPONSIBLE FOR RETVR � 5 AO � SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side t 1505611101 1505611101 J 1505611201 REV-1500 EX Decedent's 4Social Security Number Decedent's Name: RECAPITULATION J " 1. Real Estate(Schedule A). .. ...14111,�/. . 1 _ r 2. Stocks and Bonds(Schedule B) . ./.'� .... ... ........ .... ... .... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)/"1� 3. �� • 4. Mortgages and Notes Receivable(Schedule D) .. A1/�. .... ... ... . .. . ... 4. _u�� n•� 5. Cash, Bank De p osits and Miscellaneous Personal Property(Schedule E).. ... .. 5. �� a•� -r 6. Jointly Owned Property(Schedule F) O Separate Billing Requested. 6. _ ' ��.4��,• 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property /��q - - r)•� (Schedule G) O Separate Billing Requested."1., !.. 7. - �� L 8. Total Gross Assets(total Lines 1 through 7). . .... .... ... ... . ... ... .... .. 8. _L_�".TJ- -�'��`�-•t��a _ f 9. Funeral Expenses and Administrative Costs(Schedule H).. ... .... ... ... .... 9. �� U.-�12�yi�j�`•�r�o 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)...!C�. 1 • 11. Total Deductions(total Lines 9 and 10).. . ... . ... . ... ..... ... ... ... . .... 11. 12. Net Value of Estate(Line 8 minus Line 11) . . ... .... . ... . ... .. . ... . .. 12. 13. Charitable and Governmental BequestslSec 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. 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. _. _ 16. Amount of Line 14 taxable - 1' at lineal rate X,.0_ , _L1•! 16. _ �� • - 17. Amount of Line 14 taxable - at sibling rate X.12 •�1 17. �_ r�, �• 18. Amount of Line 14 taxable at�collateral rate X.15 (•� 18. 19. TAX DUE .. .. . ... .... ... . ... ..... .... .. . ... ..... ... . ...... .".. .:. 19. Qd� x 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT .O Side 2 1505611201 1505611201 J REV-1500 Ex Page 3 File Number Decedent's Complete Address: DECEDENTS N ME STREET ADD j //k CITY .• � � STATE TIP Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 2. Credits/Payments A.Prior Payments S.Discount Total Credits(A+8) (2) 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) v/T Make check payable to: REGISTER OF WILLS,AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS f. Did decedent make a transfer and: 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 ...........................................................................................................................I., ❑ Q i d. receive the promise for life of either payments,benefits or care?...................................................................... 2. it death occurred after Dec.12,1902,did decedent transfer property within one year of death without receiving adequate considerat ion?............................................................................................................ ❑ �'' 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. Il E? 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ pl� 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-1508 EX+(o&- ) Tpennsytvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX PERSONAL PROPERTY ESTATE OF: FILE NUMBER: RK��wY � 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. T'ITEM DESCRIPTION VALUE AT DATE OF DEATH ovvw TOTAL(Also enter on Line 5, Recapitulation) $ pr If more space is needed, use additional sheets of paper of the same size. REV-gag EX+(oi-io) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: If an asset became Iointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) N AME(S) ADDRESS RELATIONSHIP TO DECEDENT e�41wp1411Z Z-, B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR]OINRY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL(Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. INHERITANCE TAX RECORD ADJUSTMENT pennsylvania BUREAU OF INDIVIDUAL TAXES JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION REV-1604 IX AFP (12-13) PO BOX 280601 HARRISBURG PA 17328-0601 DATE 05-16-2014 ESTATE OF CIGARAUSKAS KATHERINE DATE OF DEATH 05-10-2013 FILE NUMBER 21 13-0854 COUNTY CUMBERLAND SSN/DC HELENA RATCLIFF ACN 13130926 38 SUNFIRE AVE CAMP HILL PA 17011-1020 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS F REV-1604 EX AFP (12-13) ■■ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS x■ DATE: 05-16-2014 ESTATE OF: CIGARAUSKAS KATHERINE DATE OF DEATH: 05-10-2013 COUNTY: CUMBERLAND FILE NO. : 21 13-0854 S.S/D.C. NO. : 170-28-5226 ACN: 13130926 ADJUSTMENT BASED ON : ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: PSECU ACCOUNT NO. : 0170285226-Sl TYPE OF ACCOUNT: ( X) SAVINGS C ) CHECKING ( ) TRUST ( ) TIME CERTIFICATE DATE ESTABLISHED 06-01-1999 Account Balance 552.72 NOTE: TO ENSURE PROPER CREDIT TO YOUR Percent Taxable X 0.500 ACCOUNT, SUBMIT THE UPPER PORTION Amount Subject to Tax 276.36 OF THIS NOTICE WITH YOUR TAX Debts and Deductions - . 00 PAYMENT TO THE REGISTER OF WILLS Taxable Amount 276.36 AT THE ADDRESS SHOWN ABOVE. Tax Rate X .045 MAKE CHECK OR MONEY ORDER PAYABLE Tax Due 12.44 TO: ^REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-18-2013 CDO17984 .62 11.82 TOTAL TAX PAYMENT 12.44 BALANCE OF TAX DUE D INTEREST AND PEN. .00 TOTAL DUE • IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST- IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. INHERITANCE TAX RECORD ADJUSTMENT pennsylvarna JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE BUREAU OF TX DIVISION TAXES INHERITANCE TAX pZYIBZON REV-1604 IX AFP (12-23) PO BOX 280601 HARRISBURG PA 17128-0601 DATE 05-16-2014 ESTATE OF CIGARAUSKAS KATHERINE DATE OF DEATH 05-10-2013 FILE NUMBER 21 13-0854 COUNTY CUMBERLAND HELENA RATCLZFF SSN/DC ACN 13130927 38 SUNFIRE AVE Amount Remitted CAMP HILL PA 17011-1020 .-...� MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS 4--- REV-1604 EX AFP (12-13) ■ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS �(1( DATE: 05-16-2014 ESTATE OF: CIGARAUSKAS KATHERINE DATE OF DEATH: 05-10-2013 COUNTY: CUMBERLAND FILE NO. : 21 13-0854 S.S/D.C. NO. : 170-28-5226 ACN: 13130927 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: PSECU ACCOUNT NO. : 0170285226-S4 TYPE OF ACCOUNT: ( X) SAVINGS ( ) CHECKING t ) TRUST t ) TIME CERTIFICATE DATE ESTABLISHED 06-01-1999 Account Balance 515.42 NOTE: TO ENSURE PROPER CREDIT TO YOUR Percent Taxable X 0.500 ACCOUNT, SUBMIT THE UPPER PORTION Amount Subject to Tax 257.71 OF THIS NOTICE WITH YOUR TAX Debts and Deductions - •00 PAYMENT TO THE REGISTER OF WILLS Taxable Amount 257.71 AT THE ADDRESS SHOWN ABOVE. Tax Rate X •045 MAKE CHECK OR MONEY ORDER PAYABLE Tax Due - .. ..,.11.60 _ ..TO.: ^REGISTER OF _WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+7 AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (J 07-18-2013 CDC17984 .58 11.02 TOTAL TAX PAYMENT 11.60 BALANCE OF TAX DUE .00 INTEREST AND PEN. 00Y TOTAL DUE nn £ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. INHERITANCE TAX RECORD ADJUSTMENT - pennsylvania BUREAU OF INDIVIDUAL TAXES JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION REV-1604 IX AFP (12-13) PO BOX 280601 HARRISBURG PA 17128-0601 DATE 05-16-2014 ESTATE OF CIGARAUSKAS KATHERINE DATE OF DEATH 05-10-2013 FILE NUMBER 21 13-0854 COUNTY CUMBERLAND SSN/DC HELENA RATCLIFF ACN 13130928 38 SUNFIRE AVE - CAMP HILL PA 17011-1020 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS 4— REV-1604 EX AFP (12-13)� INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ■■ DATE- 05-16-2014 ESTATE OF: CIGARAUSKAS KATHERINE DATE OF DEATH: 05-10-2013 COUNTY: CUMBERLAND FILE NO. : 21 13-0854 S.S/D.C. NO. : 170-28-5226 ACN: 13130928 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: PSECU ACCOUNT NO. : 0170285226-S7 TYPE OF ACCOUNT: ( X) SAVINGS ( ) CHECKING ( ) TRUST ( ) TIME CERTIFICATE DATE ESTABLISHED 06-01-1999 Account Balance 3,470.34 NOTE: TO ENSURE PROPER CREDIT TO YOUR Percent Taxable X 0.500 ACCOUNT, SUBMIT THE UPPER PORTION Amount Subject to Tax 1,735. 17 OF THIS NOTICE WITH YOUR TAX Debts and Deductions _ - •00 PAYMENT TO THE REGISTER OF WILLS Taxable Amount 1,735.17 AT THE ADDRESS SHOWN ABOVE. Tax Rate X .045 MAKE CHECK OR MONEY ORDER PAYABLE Tax Due 78.08 TO: "REGISTER OF WILLS, AGENT." TAX CREDITS : PAYMENT RECEIPT DISCOUNT (t) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-7 07-18-2013 CDO17984 3.90 74. 18 TOTAL TAX PAYMENT 78.08 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. pennsylvania BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX 'E.�' DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX APP (12-13) HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 05-26-2014 ESTATE OF CIGARAUSKAS KATHERINE DATE OF DEATH 05-10-2013 FILE NUMBER 21 13-0854 COUNTY CUMBERLAND SSN/DC HELENA C RATCLIFF ACN 14124823 38 SUNFIRE AVE APPEAL BY DATE:07-25-2014 CAMP HILL PA 17011-1020 (See reverse side underObjecdons) Amount Remitted F MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS 4— --____________________________________________________________""---- REV-1548 EX AFP (12-13) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 05-26-2014 ESTATE OF: CIGARAUSKAS KATHERINE DATE OF DEATH:05-10-2013 COUNTY:CUMBERLAND FILE NO. : 21 13-0854 S.S/D.C. NO. : 170-28-5226 ACM: 14124823 TAX RETURN WAS: C ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: WELLS FARGO ACCOUNT NO. : 001010030760406 TYPE OF ACCOUNT: ( )SAVINGS ( X) CHECKING ( )TRUST ( )TIME CERTIFICATE DATE ESTABLISHED 09-27-2002 - Account Balance 11005.81 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0.500 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 502.91 UPPER PORTION OF THIS NOTICE Debts and Deductions .00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 502.91 REGISTER OF WILLS AT THE Tax Rate X .045 ABOVE ADDRESS. MAKE CHECK Tax Due 22.63 OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-18-2013 CDO17984 1.13 226.36 TOTAL TAX PAYMENT 227.49 BALANCE OF TAX DUE 204.86CR INTEREST AND PEN. .00 TOTAL DUE 204.86CR rt IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. rt IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. REV-1511 EX+ (10-09) 10 pennsylvania * SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ;RnolNp- C)c6gy4 l"Isga1 21/3- DAN Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. v J D Ivl L1 5Z�XL �= /d C B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: d� Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: C2, RP 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explan6tion.) Claimant Ik L)�,7W_ �C Z. 1 Street Address City GfrMV ��— ' State W/'1 ZIP 17bzj-- Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: O� 1v 7. TOTAL (Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. Established in 1895 By Samuel D.Myers May 901 ' Helena Ratcliff Dolan IN ACCOUNT WITH 3.oo.ao DAVID M. MYERS FUNERAL HOME, INC. SECOND AND WALNUT STREETS NEWPORT,PENNSYLVANIA 17074 PHONE(717)567-3138 SALLY A.MYERS-SUPERVISOR,FUNERAL DIRECTOR JACK M.MYERS-FUNERAL DIRECTOR 10 May 2013 Complete funeral expenses for : Katherine Cigarauskas Traditional funeral with Columbia 18 gauge metal $ 6 , 750.00 casket , protective, with velvet interior Evans-Wilbert Monticello Burial Vault , grave 1 , 395 .00 casket placer , and tent Grave opening- Resurrection Cemetery 1 ,060. 00 Clergy honorarium 500 .00 (5) Death Certificates 30.00 Spray of flowers- Lana' s Flowers 408 .00 $ 10, 143 .00 ID- SALES CONTRACT Office of Catholic Cemeteries N°_ 4400 Diocese of Harrisburg DATE /,0/7 3 f r of 4800 Union Deposit Road CEMETERY/;e CEMETERY# / Harrisburg, Pennsylvania 17111-3710 Phone(717)657-4804 A!N ?< P1N A/R NAME //r'. 1 . r# tr3s7 fit'Z � F PHONE ADDRESS � '�«' ✓ CITY e3y-1f,�', 14e. STATE ZIP CODE /9e Yf Interment Spaces . . . . . . . @ $ 1. Price. . . . . . . . . . . . . . . . . $ ,?-1 eon . . . . . . . @ $ f Bronze Memorials. . . . . @ �2?^ cr!$ 29 37,i oo 2. Down Payment. . . . . . . . . Size 1' £.) Granite Foundation. , . .,�Q c?S`l+.ac+ $ *5cYJ•rrr 3. Unpaid Balance(1-2} . . . . . Burial Vaults. . . . . . . . . . . $ 4. Finance Charge. . . . . . . . . Crypt Spaces . . . . . . . . . . @ $ 5. Deferred Payment (3+4) . . Niche Spaces . . . . . . . . . . @ $ 6. Total Price (1+4) . . . . . . . . 5� 5 Other $ 7. Approx. Monthly Payment Section � Lot2Z3�6rave(s) 4 8. Number of Payments . . . . Building Side Crypt or Niche 9. First Monthly Payment Due Selection must be made within 30 days or cemetery will make choice. 10. Annual Percentage Rate ` The payment is due on the date stated above and the remaining payments on the same day of each succeeding month. Buyer may prepay in advance the full amount due without penalty and will be entitled to a proportionate refund of the unearned finance charge. Upon default in the payment of any installment due hereunder for a period in excess of one hundred twenty (120) days, Seiler may, at its option, void this agreement and retain all payments made by Buyer as liquidated damages. Buyer hereby acknowledges receipt of an exact executed copy of this agreement at the time of execution hereof. Before any burial is permitted in this lot, or any memorial placed on this lot, the price of the grave and memorial must be paid in full. The Purchaser(s)agree(s)to abide by all rules and regulations of the cemetery now in force as well as any rules and regulations which may hereafter be adopted. Said rules and regulations may be seen upon request at the Seller's office. Upon fulfillment of the conditions of this agreement and receipt of all the above described payments, Seller agrees and binds itself to convey to the Buyer, by its cemetery easement, for interment purposes only, the above mentioned number of sites. YOU, THE PURCHASER, MAY CANCEL THIS TRANSACTION BY WRITTEN NOTICE AT ANY TIME PRIOR TO MIDNIGHT OF THE T JRD3 BUSINE�AFTER THE DATE OF THIS TRANSACTION. BY- (Autloe Representative) (Purcha`ser's`Signature)�)) ?„ „. NOTICE: See other side for additional information. (Co-purchaser's Signature)