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HomeMy WebLinkAbout02-0835 Estate o/William J. Ouinn Also known as PETITION FOR PROBATE and GRANT OF LETTERS No.: ~J--o~-~JS To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania , Deceased. Social Security No. 182-10-6861 The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older and the exectrix named in the last Will of the above decedent, dated 17 March 1?93 an~ coe~cil( s) dated ~. ~/j,f~ IJ~ ~ 7-/..a'9~ ~ I \ 7~ ~state relem!:nt ci tances, e.g. renu~iation, death of executor, etc.) _t.oA Decedent was domici d at dea in Cumberland County, P~~ylvania, with hi.,! last family or principal residence at 1305 King:slev Road. Camp Hill. PA 17011. ~~ 7f-;, ~ (list street, number and municipality) ~ Decedent, then 85 years of age, died September 5. 2002, at ManorCare. Allentown. P A. Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: N/A Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property (If not domiciled in P A) Personal property in Pennsylvania (If not domiciled in P A) Personal property in County Value of real estate in Pennsylvania Situated as follows: 1305 King:slev Road. Camp Hill. PA 17011. $ 3.000.00 $ $ $ 95.670.00 WHEREFORE, petitioner(s) respectfully request(s) the probate of the last Will and codicil(s) presented herewith and the grant of letters testamentary II 0 thereon. (",,,,,,,,,.,,; "'''''''",'00 ,.c.; -~~ .. ] '0 .-.. Marie "L Hocker .-.. -;;j'~ 10 Arthur Road ~'a:([) ~ g 5 HiIlsboroul!h. NJ 08844 a I)';: - - ~] 'il ~~"" OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYL VANIA COUNTY OF Cumberland } } ss 1 The petitioner(s) above-named swear(s) or affrrm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief ofpetitioner(s) and that as personal representative(s) of the above decedent petitioner( s) will well and truly administe the est~te acc in 0 law.., )C Sworn to or affrrmed and subscribed before { me this 17lth day of September { Marie ~~~ { /rJ. {.11..( ~/. Donna M. Otto.1st Depti Mer ~ /7-R~'lO No. 21-2002-835 Estate of William J. Quinn, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW, September .17,,2002, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 17 March 1993. Described therein be admitted to probate and filed of record as the last Will of William J. Ouinn; and Letters Testamentary are hereby granted to Marie 'K Hocker . FEES Probate, Letters, Etc. ..........$ 200.00 Short Certificates (~ ..........$ 15.00 Renunciation.. ... . .. .. .... .....$ x-Pages (2) $ ~.OO JCP TOTAL $ 5.00 $ 226.00 Filed. .S.e.p. terob.ex.. .17..r. 2.0.0.2. j}~,qz ~/a4-v.l~ ~/A/~ Register of Wills " 'J&. Donna M. otto, 1st DepIty , _~ . James M. Bach 18727 ATTORNEY (Sup. Ct. I.D. No.) 352 S. Sporting Hill Road, Mechanicsburg, P A 17050 ADDRESS 717-737-2033 PHONE 1\ILED LEITERS 'IO ATroRNEY ON 9/17/02 This is to certify that the information here given is correctly copied fro~ an original certificate of death dul~ filed with me as Local Registrar. The original certificate will be forwarded to the State VItal Records Office for permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. p 8387722 No. /j .,,;" <-" U;-ft,. ..,j~./ 7?? c:J;.'2 >>- t '~7." f1!.--- Jr ,,.- '." '~...... _'Ii'.... ,r' Local Registrar _ () Fee for this certificate, $2.00 Sf P--l 3 2002 Date 3 Rev, 2187 COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH SEX STATE m.E NUMBER SOCIAL SECURITY NUMeeR 2. MALE .. 182 - 10 6861 DATE OF DEATH \Mondl. 0&)'. 'l'8aI) 4. September 5, 2002 1711. Did - ~in. Cumberland _? 17..0 :...--===.. MOTHER'S NAME IF..51, Mld(Jle, MaicWlnSurnam.) ... Jennie O'Neill INFORMANT'S MAILING ADORESS lSU.... CilyIliMn. _. ''''~) 10 Arthur Road, Hillsborough, NJ 08844 PlACE OF OlSPOSlTION . N_ 01 Comet..... CIOlNlOry LOCATION. CitylliMn. St.... Zip ~ Of 0IIl<< PIoc:o Gate 21C". ="",0 5 85 CQUNTV OF OEAI'H BlRTtfPLACE (CIy aAd PLACE OF DEATH (Ct>eck 0f'It1 Ofoe -;ee .nstroct.of1s on Ofher s.ae. StateOlfcrQ\lC}C\Ccuouy) HOSPITAl: Philadelphia,PA ,_,....0 1, ... FACIUTY NAMe (If not InsNUtlOf\. 91\18 street and number! .... Lehigh ManorCare WAS DECEDENT EVER ". u.s. ARMED FORCES? ....0 ...00 S r_WyISec<l...... 12 (().'ZI ... Pennsylvania SURVIVING SPOUSE (It _.. 91'18 maKi8n n.wne) 1305 Kingsley Road ". Camp Hill, PA 17011 FATHER'S NAME (First Middle. Last) ... Christopher Quinn INFORMANT'S NAME (T 1","P,ioI) _. Marie T. Hocker METHOOOF DISPO~ O -~ c,.-o _..,...._.0 llonolion 0IIl<< (~, 1'" SIGNATURE OF FUN ENSEE OR PERSON ACTING AS SUCH 17.. Slate ... l1..o.._w..". Twp. ""P. COy_. DATE OF DISPOSITION <_.001, _, o September 7, 2002 21.. PA 17055 ComllIota ..... 230-<> .................- . <*Ufy cauM at deaU.. II.... ZHI..... be ~b't . ~ whO ptOnQUnC8f..dNth. ify;"g oIdHlhlO _lllATE CAlISE {F.... dl5eaM or condition r~lf\dMth)----... .. H. l~""'" &inl8t'WIf~ : onHf and dlId\ I I , PART.: OII1eroignillconl~"""'""'""vlO_.... nor ,,",,"ing in tbt undeftytnQ ca\M gr...n in PART I. SequonhoIIy"'- I.' ~lln1,-.gIO_ _. em. UNllERLYINQ CAUSE (DiMaM OIIOflJfY c. . thai ntiated..", IliI8tIIIlng In dMf'l) LAST .. Hat..... Accident 00 o o DATE Of INJURY (Moo". OaY. _I TIME ~ INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. WAS AN AUlOPSY . PERFOR"'ED? WERE JoUlOf'SY FINDINGS -.lMIl.E PAtOR 10 COMPLETION OF CAUSE OF DERH? "'AHNER OF DEATH P_ndiog 1nvtI..igation o o o PUlCE OF INJURY. Al ho.... "'m. ''''''. ..ct....._ .... _ ....ISpec.y) _. .... 0 NoD HomIc:Jde o ...4. a. Ye. 0 No I1l. _0 ...0 Suicide Coutd not be ~ermined _. 2.... CEATtFlEA {Check only one. .ceRTIFYING PHYSICIAN (Phys.c.an C8t'11Iyu1g cause at c;leaU1 'Irttlerl,.nother p/l'w'SlClao has pfonounceo ooalh ana comPleted nern 23) To the...... ot tny knowtedOe, ...,. occUllWd diu. to u-. c:MlHi.) and matNler.. .ta'ed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . >t. .PAONOUNCIHG AND CERTIFY.NO PHYSICIAN (Pt\Y5'C~(t bOItl pronOUflClI19 death and ceftlfylnQ to. cause of dealh) To the best of my knowredg_, death occurred.t the tlm., d.~. .nd pI",., and due to U\ta cauu(.) and manne' ita stated., . . . . . . . . . . . . . . . . . . . . . . . . '..EDlCAL EXAMINER/CORONER On the baI.l. 0' examination and/or inv..tlgation, in mv opinion, d..th occ;u".d It the time, dlt.. and place. and due to the CIUse(., and mann.,.. s.,ted.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .............,.................................................. ". REG'STRAA;:>Sl6NATURE AN~IiU"BE~_..{...--' C..;0,,:,,'J(;/ ./'/;'J '~7.,;, .' " t... .."..1,..'J_~i:.~<~.~ j:.'!..___ ;- (J 1"<1 /id..1 /1/ I LAST WILL AND TESTAMENT OF WILLIAM J. QUINN 21-2002-835 I, William J. Quinn, of the Township of Lower Allen, County of Cumberland, and state of Pennsylvania, being in good bodily health and of sound and disposing mind and memory, and not acting under duress, menace fraud, or undue influence of any person whomsoever, merely calling to mind the frailty of human life, and being desirous of disposing of my worldly goods while I have the strength and capacity so to do, I do make, publish and declare this my LAST WILL AND TESTAMENT. I hereby revoke, cancel and annul all my former Wills and Testaments, including codicils thereto, by me at any time made, and declare this alone to be my LAST WILL AND TESTAMENT. AS TO SUCH ESTATE AS IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ: ITEM 1. I direct that my Executors hereinafter named pay and discharge all of my just debts, funeral and testamentary expenses. ITEM 2. All the rest, residue and remainder of my entire estate, wheresoever situate, and whatsoever it may consist of, I give, devise, and bequeath, absolutely, and in fee, to my dearly beloved wife, Mildred M. Quinn. In the event that my dearly beloved wife dies with me in a simultaneous disaster, or fails to survive my death by thirty days, then I give devise and bequeath, my entire estate, wheresoever situate, whatsoever it may consist of, to my dearly beloved children, share and share alike, per stirpes. ... 0-t-Lf.,. ~-u-/ WILLIAM J. 1 ITEM 3. I nominate and appoint MILDRED M. QUINN as Executrix of this my Last Will. Should the Executrix named fail to qualify or cease to act as Executrix, then I appoint MARIA HOCKER as Executrix in her stead. ITEM 4. I direct that my personal representatives, as well as their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM 5. I direct that all estate, succession, legacy, inheritance or other transfer taxes, however designated that shall become payable by reason of my death in respect of all property comprising my gross estate for tax purposes, whether or not such property passes under this Last Will, shall be paid by my Executor out of my residuary estate. ITEM 6. I grant to my personal representatives herein named, in addition to, but not in limitation of those powers vested by law, to be exercised without prior application to or approval of any court, the power and authority to retain indefinitely any property, to invest and reinvest any assets or the proceeds derived from the sale of assets, although said investments may not be of the character prescribed by law, to sell, convey, assign, transfer and encumber any property, to pay, settle or compromise all claims, to make distribution or divisions in cash or in kind, and in general to exercise all powers in the management of any property hereunder which any individual could exercise in the management of similar property owned in his own right, and to execute and deliver any and all instruments and to do all acts which may be deemed necessary and proper. , f{J //_- ~~~ ,. --J WIL lAM J. QU _______________________________END______________________------- 2 COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND I, WILLIAM J. QUINN ,TESTATOR, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby 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 purpose therein expressed. Sworn or affirmed to and acknowledged before me, by WILLIAM J. QUINN , the TESTATOR, this 17th day of March , 19JL3. " ~lI!n _I~~ NOTARIAL SEAL . ~ORNEY JAMES M. BACH. N,tary Public "~f Cumberland County . Commission Ellpires May 13, 1995 I#~,... ~ ~ ~TARY PUBLIC Mechanlcsburg, PA My Commission Expires: 05/13/95 The preceding instrument consisting of this and two (2) other typewritten pages, identified by the signature of the TESTATOR, was on the date thereof signed, published and declared by WILLIAM J. QUINN , the TESTATOR therein named as and for his LAST WILL AND TESTAMENT. ~~~jJ.u ~ GLA S B. SPRAMELLI Residing at 352 S. Sporting Hill Road Mechanicsburg, PA 17055 Residing at 352 S. Sporting Hill Road Mechanicsburg, PA 17055 A F F I D A V I T COUNTY OF CUMBERLAND } ) } ss COMMONWEALTH OF PENNSYLVANIA We GLADYS B. SPRAMELLI and DANA L.MIDDLEKAUFF , 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 TESTATOR sign and execute the instrument as his LAST WILL: that he signed willingly and that he executed it as his free and voluntary act for the purpose therein expressed: that each of us in the hearing and sight of the TESTATOR signed the WILL as witnesses: and that to the best of our knowledge the TESTATOR was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by GLADYS B. SPRAMELLI and DANA L. MIDDLEKAUFF, witnesses, this 17th day of March , 1993. .. ',' 'j.,"" :.'...:t 1"-;tA4,- ~ ~ARY PUBLIC echanlcsburg, PA My Commission Expires: 05/13/95 " _AAMES"t{ BACti' ATTORNE:V AT LAY/, !~I $, SPO,RTiNG HILL fHl Met"ANlCS8URG. fA t105z~ ~" NOTARIAL SEAL 3 'AllORNEY JAMES M. BACH, N:'~afY Public .' Cumberland CCP!:tj " My Commission Expires Me}' 13. 1995 cP CERTIFICATION OF NOTICE UNDER RULE 5,6(a) Name of Decedent: William J. Ouinn Date of Death: Seotember 5. 2002 Will No.: 11- ()OfI~ Admin. No.: To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above- captioned estate on Seotember 19.2002: Name Address Marie T. Hocker 10 Arthur Road, HiIlsborough, NJ 08844 Mildred A. Gugger 523 Colonial Road, East Greenville, PA 16125 Kathleen M. August 88 Avondale Road, Manchester, CT 06040 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except (None). Date: September 19.2002 ~",~ Signature Name: James M. Bach. Attorney-at-Law Address: 352 S. Sporting Hill Road Mechanicsburg. P A 17050 Telephone: 717-737-2033 ,'....1 P Capacity: 0 Personal Representative r8J Counsel for Personal Representative " ',:" ,-",' '~....'" :~' ii" . , , ' : \', i\\ ,,: I " i',' ....... / i\ .......... JAMES M. BACH Attorney At Law '~" ; r, \ :\ , , . " , ':,'.' . . . . . ' , ; , .,' . , . . ""-*'" I ' '. ""-*'" 352 S. Sporting Hill Rd., Mechanicsburg, PA 17050, Tel: (717) 737-2033 July 16, 2003 cJ I., OJ- <g J5 Register Of Wills Cumberland County Court House One Court House Square Carlisle, P A 17013 Dr: ::::: (:' :::3:;, t:J ' cr d w r: L r;; -... ......, RE: ~ Estate of William J. ~uinn CI SSN: 182-10-6861 -" ~ Dear Register of Wills: Enclosed herewith please fmd a check in the amount of $15.00 which represents filing fees; and a check in the amount of $3,639.90, which represents full payment of Pennsylvania Inheritance Tax. You will also find an original inheritance tax return and one copy. Kindly process these in your normal fashion, and return to me an official receipt. Respectfully, ~M':: :Attorney-at-Law JMB / thl Enclosure: Check No. 125 - $15.00 Check No. 126 - $3,639.90 Inheritance Tax Return (Original and One) CC: Marie T. Hocker COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BACH JAMES M ESQUIRE 352 S SPORTING HILL ROAD MECHANICSBURG, PA 17050 n____n fold ESTATE INFORMATION: SSN: 182-10-6861 FILE NUMBER: 2102-0835 DECEDENT NAME: QUINN WILLIAM J DATE OF PAYMENT: 07/17/2003 POSTMARK DATE: 07/16/2003 COUNTY: CUMBERLAND DATE OF DEATH: 09/05/2002 NO. CD 002813 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,639.90 I I I I I I I I TOTAL AMOUNT PAID: $3,639.90 REMARKS: MARIE T HOCKER C/O JAMES M BACH ESQUIRE CHECK#126 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS REV-1JOO EX 16-00 I> COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT /1-J""t- If) REV-1500 I- Z W C W U W C DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) Quinn, william J. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 09-05-2002 01-04-1917 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) w "' ::.::~(I) u .", w"-u ,,00 uO:-' ,,-Ill "- '" N/A [X] 1. Original Return D 4. limited Estate D 6. Decedent Died Testate {Attach copy of Will) D 9. litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise {date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy o/Trust) o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CJFF1C!AL USE OhJ:L''Y () ~/ FILE NUMBER J.L--D-~ COUNTY CODE YEAR fltLX-E....5. NUMBER SOCIAL SECURITY NUMBER 182 10 - 6861 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 3. Remainder Return (dateo/death prior to 12-13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) "' Z W " Z o "- '" w 0: 0: o U NAME James M. Bach FIRM NAME (I/Applicable) Attorne at Law TELEPHONE NUMBER 717-737-2033 COMPLETE MAILING ADDRESS 352 S. Sporting Mechanicsburg, (1) 101,558.19 (2) -0- (3) 0 (4) -0- (5) 3,298.23 (6) -0- (7) (8) (9) 23,909.77 (10) -0- 13, Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) Hi 11 Road PA 17050 OFFiciAL usi"ofJ IY , ~CI :c (';'i -=5 -I 63 r"; . " c E r- 6.42 (11) (12) (13) 23,909.77 80,886.65 -0- 1. Real Estate (Schedule A) 2. Slacks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property Z (Schedule E) 0 6. Jointly Owned Property (Schedule F) !cc D Separate Billing Requested ...J ::::l 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property !::: (Schedule G or L) ll. <C 8. Total Gross Assets (total Lines 1-7) U 9. Funeral Expenses & Administrative Costs (Schedule H) W c::: 10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I-' :J ll. :i o u ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under See, 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17, Amount of Line 14 taxable at sibling rate 18, Amount of Line 14 taxable at collateral rate 19. Tax Due 80,886.65 '.0_ (15) , .04.5%(16) , 12 (17) '.15 (18) CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT (14) 80,886.65 20.0 -0- 3,639.90 -0- -0- (19) 3,639.90 Decedent's Complete Address: STREET ADDRESS 1305 Kingsley Street CITY Camp Hill I STATE I ZIP PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount 3,639.90 Total Credits (A + 8 + C) (2) -0- 3. tnteresUPenatty if applicable D. Interest E. Penalty TotallnteresUPenally ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a relund (4) -0- -0- 3,639.90 -0- 5. II Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. 8. Enter the total of Line 5 + 5A. This is the 8ALANCE DUE. (5A) (58) 3,639.90 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 and: Yes No a. retain the use or income 01 the property transferred; ....................................... .......... D KJ b. retain the right to designate who shall use the property transferred or its income; ............................... .... D I[] c. retain a reversionary interest; or ........................ ................................ ......................... D IX] d. receive the promise for life of either payments, benefits or care? ....................... 0 [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................ .................................................................................... D IX] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. D IX] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........... ................................................................. ................... ...................... D KJ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, 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 informationofwhi preparerhas any knowledge SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN James M. Bach ADDRESS 352 S. S ortin Hill Road SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE Marie T. Hocker ADDRESS 10 Arthur Road, #/ DATE ~-~> PA 17050 DATE '7-/1-03 Hillsborough, NJ 08844 11lIllI__IW 1IIIIIIIIIUIL. II _.lW _.1111 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 PS. 99116 (a) (1.1) (ill. "_ III For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (iill. The statute does not exemot 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 twenty-one 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% [72 P.S. 99116(a)(1.211. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(111. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is deftned, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV,!502 EX+ 16'9. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Quinn, William J. 21-02-0835 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 which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 1305 Kingsley Street, Camp Hill, PA 17011 VALUE AT DATE OF DEATH $101,558.19 This property was sold on or about December 13, 2002 for $101,000.00. See settlement statement attached hereto. TOTAL (Also enter on line 1, Recapitulation) $ 1 0 1 , 558 . 1 9 (If more space is needed, insert additional sheets of the same size) j A. SETTLEMENT STATEMENT u.s. I>EPARTMENT OF \lOUSING ANI> (JlWAN I>EYELOPMENT .-lLJU-J OMB No. 2502-0265 B. Type of Loan. L FHA = FmHA gConv Unins. 6. File number. 7. Loan number. 18. Mortgage Insurance case No. r- VA X Cony Ins. I I Cash 02-100 2177152 0232316010 C. Note: This form is furnished to give you a statement of actual settlement cost. Amounts paid to and by the settlement agent are shown. Items marked "(poc)" were paid outside the closing; they are shoWTl here for information purpuses and arc not included in lotals. D. Borrower Luke Smalley, .,... Tara Smalley name/address. 19 Wild Rose Lane 19 Wild Rose Lane 001 54 1265 Mechanicsburg, PA 17050 004 80 8722 Mechanicsburg, PA 17050 E. Seller Willaim J. Quinn, Estate name/address. 10 Arthur Road 81 6105 635 Camp Hi11,PA 17011 F. Lender namc/adr Citizen I s Mortgage Corp 10 Tril'Ps Lane Riverside, RI 02915 H. Settlement Agent Bratic & portko enone NO. 1101 South U. S. Route 15 IDi11sburg, PA 17019 J. SUMMARY OF BORROWER'S TRANSACTION 100 . GROSS AMOUNT I>UE FROM BORROWER G. Property Location 1305 Kingsley Street, C~ Hill, Zip Code 17011 I. Settlement Dale 12/13/2002 Place of Seulement ReMax Real ty Camp Hill, PA 17011 K. SUMMARY OF SELLER'S TRANSACTION 400 .GROSS AMOllNT I>lIE TO SELI_ER , , , 101,000.00 1. 0 1 . Contract sales price 1. 0 2 . Personal property 1Q~". Settlement charges to borrower (1111400) 104. 105. Adiustments for items oaid bv seller in advance 106.crrT" 12/1JaJll!2 To, 12/3.1aJl~_ 107 . Coo"" T" lZLU12002 To lZLJl1200L- 1. 0 8 . Assessment To ~~~-_.~. ...--- 109.Schoo1 Tax 12/13/02 To 06/30/03 110.Sewer 12/13 - 12/31/02 111.Trash 12/13 - 12/31/02 112. , _!Q1,OOQ. q~ 4,486.8 8.2,;1 9.65 ~ 91 ~5'(lnlrac~E.~~ ~~~____ 402 . Personal property 403. 404. 405. Adjustments for items naid bVseller in advance 406.CrrT" 1211JLW02 To 12lJ1L1l1ll~ 407.Cm,".,T" 12/1312002 To 12/311200L- 408.Assessment To 409. School Tax 12/13iO:lTO 06/30i03 410. Sewer 12/13 - 12/31/02 411. Trash 12/13 - 12/31/02 412. 8.2 9.6,S 526.82 4.80 8.70 526.82 4.80 8.70 120 .GROSS AMOlINT I>lIE FROM BORROWER 200 .AMOllNT PAm BY OR IN BE\lALFOF BORROWER ..201. . Deposit or camest money ___ _ __. 1, 000 . 00 202 . Principal amounlofnew loan -9-5~-ooO:-cfQ 203 . Ellisting 1031\(5) taken subject to 204. 20S.Citizens Grant 206. 207. 208. - --------- 209. Adjustments for items llnnaid bv seller in advance :'LLU .CrrTax To 106,045.0' 420 .GROSS AMOllNT I>UE TOSELI.ER 500 .REI>l!CTION IN AMOUNT I>lIE TO SELLER 101,558.19 3,030.00 501. . Excess deposit SO 2 . Settlement charges 10 seller ih~-i4ooi ._n _ 50~ . Exisling ]oan(s) taken s~~. 10 504 .Payoffof 1st mortgage loan 505 . Payoff of 2nd mortgage loan 506 . Deposit or eamesl money 8,5.21.03 T 507. 508. 509. Adiustments for items unnaid bv seller in advance I 510 .err Tal( To I L SETTLEMENT CHARGES I. {'""'7W. TOTAL SALESIRROKER'S COMMISSION based on price 101,000.00 7.000 - 7,070.00 nivisioll ofcomrnissioll (line 700) as follows: PAID FROM PAID FROM __ZP_!:._~_~_~2~_Q.!..Q.Q.~~Max _:Bea~_!::Y.- A~~Q~~._______~ UORROWI<:R'S S":U.ER'S ...__~ ._n_ .___~___. ,...__._ ------ -FUNDS AT-- ------- 702. 3,510.00 To ReMax Realty Prof. FUNDS AT SETILEMENT SETTLEMENT _~.Q_~.~~ositof ____1-_LQQQ~Q_Q,_~I~~~~~~ Re~_!!y__~!,~,~=_~______._____ _._-_._~---- _._------~ ~_._-,_..._--- 704 . Commission paid al settlement . 7,070.00 800 . ITEMS PAYAIILEIN CONNECTION WITH I.(lAN __~~~;~_-.!.-..oan orig!~li~'1l1 Fc~______ -----~--- ..._---.-------- - ----- - - ---_.'------ u ~,_.- -----~.- -- - 802 . loan discount _~___ ___._______ _ u_~_!L.QJl_"'~ --_.~ - ---.------- .--.!o 3 . ApP!3isallCc Nat. RE Inf9...J3v~~2 9 QPO~__~__ 80.4 . Credit report ___~g..!i'~!.t:_~!!]:~Q.~~15...!'QQ____.___~__ --~---- 80S . Lender's inspection fee .._--_.~-~_...__...._--~-- 806 0 Mortgage ins. appl. fee 807 . ^~~mption~~e . --...-'.-- - - ~--- U..__ . -- - -------" --..... -~_._- -- .---.-..---.- ~~ot\pplil:ationll:e Citizenfs Mortgage 325.00 809 . Underwriting fee Citizen's Mortgage 300.00 810. Tax Service fee 1st American Tax Sve 12.00 811 0 Flood Cert fee 1st Amero Flood Data Sve 16.00 - 812. 813. 814. 900 . ITEMS REQUIRED BY LENDER TO liE PAIIlIN ADYANCE 901. Interest from 12LlJL2.ll02 To OlLllILzOO3 0J 13.664384 per/day __1~!.62 ~- 902 0 Mortgage insurance Months to; 903 0 Hazard insul1lnce Months to: 1 Year $198 poe 904. Months to; 905. Months to: 1000. RESERYES DEPOSITED WITH I.ENDER ~.Q.01o Mortgagc Insura~~~_ 2.00 Months:@ 71. 25 pcr/Mollth --~-- 142.50 1002 . Hazard insurance 2.00 ~Olllhs:(t!l 16o_?Q.--E:r/Month -- 33. Q.Q 1003 . City property tax 13.00 MOllths:@ 13 ~~.pcrfMonlh 173.29 _10040 Co. property tal[ 13.00 Months:@ 17.13 per/Month 222.69 10050 Annual assessments Months:@ per/Month 10060 School Tax 8.00 Monlhs:@ 80.52 pcr/Mollth 644.16 1007. Months:@ perfMonth 1008. Months:@ per/Month 1009. 1010 0 A2JUe2ate Escrow Adiustment -251.19 1100. TITLE CHARGES .1-_101 0 Settlement or c1os!ng fee Bratic & Portko , 35.00 .--- 1102 0 Abstract or title search 1103 0 Title examination 1104 0 Title insurance binder ----- 1105. Document preparation -. 1106. NOlaryfees ---~---_._---_._--_._._-- -~------- - - -.::;;;; Cash 14.00 1107. Attorney's fees - - -- - - (includes above items; ~ ~ -- -... - d - ----...,- REV.1508 EX: (1-97) '*' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Quinn, William J. FILE NUMBER 21-02-0835 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Checking account and/or cash on hand at date of death. VALUE AT DATE OF DEATH $3,238.23 TOTAL (Also enter on line 5, Recapitulation) $3, 238.23 (if more space is needed, insert additional sheets of the same size) REV~1511 EX+ (12-99) . ~j- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF QUinn, William J. FILE NUMBER 21-02-0835 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Gate of Heaven Cemetery (Grave Flowers) 24.50 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Marie T. Hocker 5,239.82 Social Security Number(s)/EIN Number of Personal Representative(sl Street Address 10 Arthur Road City Hillsborouqh State ~ Zip 08844 Year{s) Commission Paid: 2003 2. Attorney Fees - James M. Bach, Attorney at Law 6,287.79 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 226.00 - Cost to file tax return 15.00 5. Accountant's. Fees 6. Tax Return Preparer's Fees 7. See Sheet Attached. 12,116.66 TOTAL (Also enter on line 9, Recapitulation) $23,909.77 Debts of decedent must be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Estate of Quinn, William J. File Number 21.02.0835 PP & L Electric Utilities Patriot News Legal Ad Greg Fuller (Carpet @ 1305 Kingsley Road) Mildred Gugger (Bathroom Fixtures for 1305 Kingsley Street) William Gugger (Services Rendered at 1305 Kingsley Street) Susquehanna Internal Medicine Lehigh Valley Physicians Group Pennsylvania American Water Company UGI Utilities Radiology & MRI of Bethlehem Lehigh Valley Cardio Diagnostics Holy Spirit Hospital Waste Management (Dumpster) Silver Spring Ambulance $95.75 $108.43 $1,400.00 $72.32 $300.00 $24.51 $28.02 $44.09 $155.13 $1.75 $1.74 $88.12 $647.27 $622.50 Settlement Charges for Sale of 1305 Kingsley Street, Camp Hill, PA 17011: Commission Paid at Settlement Settlement Fee Realty Transfer Tax Electric Repair Processing Fee Deed Preparation Fee Total $7,070.00 $35.00 $1,010.00 $62.03 $250.00 $100.00 $12,116.66 . REV-\'313 EX+ 19-00* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Quinn, William Jo FILE NUMBER 21-02-0835 1. RELATIONSHIP TO DECEDENT NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trusteels) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Marie.To Hocker Daughter 10 Arthur Road Hi11sborough, NJ 08844 AMOUNT OR SHARE OF ESTATE NUMBER I 1/3 2. Mildred A. Gugger 523 Colonial Road East Greenvi11e, PA 16125 Daughter 1/3 30 Kathleen M. August 88 Avondale Road Manchester, CT 06040 Daughter 1/3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH lB, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE ,. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ,. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) I~-RJ'-/O '\; BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '* NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP \11-05) JAMES M BACH ATTY 352 S SPORTING HILL RD MECHANICS BURG PA li050 '03 SCP - 2 /~11 :(;9 DATE ESTATE OF DA TE OF DEATH FILE NUMBER COUNTY ACN 08-25-2003 QUINN 09-05-2002 21 02-0835 CUMBERLAND 101 Allount Rellitted WILLIAM J f'~ Ii ','I '. MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=i54-.rix-AFP-coT=o3Y-NOYiCi--oF-YNHiifiTANCi-YAx-A'PPRAISiMENT~--ALi-oWANCi-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF QUINN WILLIAM J FILE NO. 21 02-0835 ACN 101 DATE 08-25-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgeges/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) 101.558.19 .00 .00 .00 3.238.23 .00 .00 (8) NOTE: To insure proper credit to your account, sub.it the upper portion of this forll with your tax paYllent. 104,796.42 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts 14. Net Value of Estate Subject to Tax (9) (10) 23,909.71 .00 (11) (12) (13) (14) 23.909 17 80,886.65 .00 80,886.65 (Schedule J) I~ an assessmen~ was issued previoUSly, lines 14, IS and/or 16, 17, 18 and 19 will r~lect ~igures ~ha~ include ~he ~o~al o~ ~ re~urns assessed ~o da~e. ASSESSMENT OF TAX: 15. A.ount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due AX CIS: NOTE: .00 X 80,886.65 X .00 X .00 X 00 = 045 = 12 = 15 = (19)= .00 3,639.90 .00 .00 3,639.90 DATE 07-16-2003 NUMBER CD002813 + INTEREST/PEN PAID (-) .00 AMOUNT PAID 3,639.90 BALANCE OF UNPAID INTEREST/PENALTY AS OF 07-17-2003 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 3,639.90 .00 20.45 20.45 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BACH JAMES M ESQUIRE 352 S SPORTING HILL ROAD MECHANICSBURG, PA 17055 4_______ fold ESTATE INFORMATION: SSN: 182-10-6861 FILE NUMBER: 2102-0835 DECEDENT NAME: QUINN WILLIAM J DATE OF PAYMENT: 09/17/2003 POSTMARK DATE: 09/16/2003 COUNTY: CUMBERLAND DATE OF DEATH: 09/05/2002 NO. CD 003021 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $20.45 I I I I I I I I TOTAL AMOUNT PAID: $20.45 REMARKS: MARIE T HOCKER C/O JAMES M BACH ESQUIRE CHECK# 203 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS C H Z C >111 ...~ >Z 0111 Z> ZIII ilia:: a. IL ILO o ... :E:Z ...111 ...E C'" ilia:: 3:C za. 0111 Ea E Q U W U ZX CC ZI- o ....... X"" 0 CC I-CIlI- MZ WClW U :II: ZlIl:CIl COCll I- W MWCIl lIl:UCIl WZC :Z:C ZZCI MOZ ....C ....... 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Z(!) ::CI-Illl: U...:::::t ClIl:lQ lQQCI) Q.,U :ECI)I-I Z Cl)CI)C W ::c :ENU CIl'lW ..,...,:1: , , \ l ' { \( ( \\\ \ \ .0.1 c."- CUI u: Q ! U III a:: a:: ~ o > a:: o IL Z o H ... a:: o a. a:: III 3: o ... Z H C ... III a:: , , III Z H ... o H :E: ... e:>> Z o ... cr. ... ~ u ~~ ~~ ...I'"" ...Ie( ....a. ~x .... ~CJ~ X.J!:) ~~~~ ca~Ou . w a. .... S.Z~Z ~ct .e( WO~X e'~NU . ",u.I ~ict~~ 17 . :53 Q) (/) ::3 o :c t ::3 o <.) ~('i) C..- (/)::30 _01"- ==<.)..- 3:"0<( o~o.. ~-ca> ....Q)- (/).D (/) E'- '0, ::3 ~ &<.)<.) - - - - - - - - - ~ - - - - (';1 (,'.1 1"0:' ,":' "* ,.,:- ..... .::;. I'" ..... ()~t- STATUS REPORT UNDER RULE 6.12 Name of Decedent: William J. Quinn Date of Death: September 5. 2002 Will No.: 2002-00835 Admin. No.: 21-02-0835 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: IZl Yes 0 No 2. If the answer is to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? DYes IZl No b. The separate Orphans' Court No. (if any) for the personal representative's account is: N/A (Not Applicable in Dauphin County) c. Did the personal representative state an account informally to the parties in interest? C8:I Yes 0 No c. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: S~tember 19. 2003 James M. Bach. Attorney-at-Law Name (Please type or print) 352 S. Sporting Hill Road. Mechanicsbur~. P A 17050 Address \.0 :-~ 717-737-2033 Phone No. Capacity: Personal Representative N N --X- Counsel for Personal Representative 0"'1'-' (:.; -' ~ /" .... .....~ ~...... /7-cP?- /0 I/' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '*' IEV-1607 EX AFP lUl-05) JAMES M BACH ATTY 352 S SPORTING HILL RD MECHANICSBURG PA 1V~50 \..).) 1 . i I) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-29-2003 QUINN 09-05-2002 21 02-0835 CUMBERLAND 101 WILLIAM J Amount R_itted (C', , .~, - ' '~ MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ii"Ei=i6'ifi-EX--AFP-('OY:oiY------...-iNHiiiiTANC'E--fAX-ST'AYEMEtif-cfF-ACCOUN"y--.i.------------------ --- ESTATE OF QUINN WILLIAM J FILE NO.21 02-0835 ACN 101 DATE 09-29-2003 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 08-25-2003 P R I NC I PAL TAX DUE: ...n...nn.....nm".n..n."""'..."'._nn....n...n...m....n...m......................"...".."'''m''_..''.''..n...n..''....".........".............."'......"_.n........."'mn..."'''. . 3,639.90 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-16-2003 CD002813 .00 3,639.90 09-16-2003 CD003021 20.45- 20.45 TOTAL TAX CREDIT 3,639.90 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 If SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A '"CREDIT'" (CRl, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. l