HomeMy WebLinkAbout10-01-14 J 1505610105
REV-1500 IX Ipavv>IFl>
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes " County Code Year File Number _
PO Box 28o6o1 INHERITANCE TAX RETURN
Harrisburg,PA 17728-o601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
{ (01119/2013 ( 07/1711927
lDecedents Last Name Suffix Decedent's First Name (MCI
Miller _A� F4 ��
Gloria I Y I
(If Applicable)Enter Surviving Spouse's Information Below _�J �1
Spouse's Last Name Suffix Spouse's First Name MI
_._� _
}
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
I _ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
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)
Ob 6.Decedent Died Testate O 7.Decadent Maintained a Living Trust B. Total Number of Safe Deposit Boxes
j (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 T0:
Name Daytime Telephone Number
William S. Daniels _ _ 1(717)243-3831 M
_ ry
REGISTSMOWLLS USE40NLY M rn
Q"o C3
FT a� t'r1
L
First Line of Address n --1 �]
I=)
f 1 West High Street rT` F ' Fri M
Second Line of Address o -n
Ile 205 ^�LL o
DMA FILED r-
City or Post Office State ZIP Code
Carlisle iP� 17013 a
Correspondent's e-mail address:humeranddaniels @outlook.com
Under penalties of perjury.)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 persona representative is based on all information of which preparer has any knowledge.
SIGNATU E OF PERSON RESP NSIBLE FOR FILING RETURN ATE
ADDRESS J T—
Kathryn M. Huntzinger, 584 C ad,Carlisle, PA 17 15 2-0/
SI AT E O ARER OTHER Tt RE S NTA E DATE .
ADDRESS
William S. Daniels, Hunter and Daniels Law Office, 1 W. High St.,Suite 205,Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
1505610205
REV-1500 EX(Fl)
RECAPITULATION
I
1. Real Estate(Schedule A). ........ .. .. . . . . . . . .. . . . . . ................. . 1. , 0.00
2. Stocks and Bonds(Schedule B) ............. 2, 0.001
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) 3. 1 0.00
4. Mortgages and Notes Receivable(Schedule D)........................... 4, 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 5,331.90
6. Jointly Owned Property(Schedule F) C= Separate Billing Requested ....... 6. 1 _90..00J
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property -
(Schedule G) DID Separate Billing Requested........ 7. 27,784.30
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 33,116.20 1
9. Funeral Expenses and Administrative Costs(Schedule H)........... 9, 3;423.50
10, Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)......... 306,625.87
11. Total Deductions(total Lines 9 and 10). . . ............ .................. 310,049.37
12, Net Value of Estate(Line 8 minus Lim 11) .............................. 12 -276,933-17
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ....... . . . . . . . . . . . . ..... 13,
0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14, , -276,933.17
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under See.9116 1
(a)(12)X.0- 15. 1 0.00
16. Amount of Line 14 taxable
at lineal rate X 0 16,i 0.00 i.
17. Amount of Line 14 taxable
at sibling rate X.12 1 17. j 0.00 I
18. Amount of Line 14 taxable
at collateral rate X.15 18.i 0.001
19. TAX DUE . . . . . . . ..... ......................... . . . . . . . . . .. . . 19. o.001
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=)
Side 2
1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number " / - a V3
Decedent's Complete Address:
DECEDENTS NAME
Gloria Y. Miller
STREETADDRESS
100 Claremont Road
CITY STATE 21P
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. CreditsfPayments
A.Prior Payments 0.00
B.Discount
Total Credits(A+B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 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.......................................................................................... El N
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N
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?.............................................................................................................. ❑ E
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 dales 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 lax 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 decedents 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.
I, GLORIA Y.MILLER,widow,of the Borough of Carlisle,Cumberland
County, Pennsylvania, declare this to be my last will and revoke any will previously
made by me.
I. I give and bequeath all of my estate of every nature and wherever situate in equal
shares to such of my grandchildren,NATALIE KAY WARK,and NATHAN
DARRELL MILLER,as survive me by thirty days.
11. Should my granddaughter,Natalie Kay Wark, or my grandson,Nathan Darrell
Miller,predecease me or die on or before the thirtieth day following my death, I
give and bequeath the share of such grandchild to her or his issue per stirpes
living on the thirty-first day following my death; and should either my said
granddaughter,Natalie Kay Wark,or my grandson,Nathan Darrell Miller, leave
no such issue living on the thirty-fast day following my death, I give and
bequeath the share of such grandchild to my other grandchild or to her or his issue
per stirpes living on the thirty-first day following my death.
III. I appoint PHILIP J. HUNTZINGER and KATHRYN M. HUNTZINGER,
husband and wife, or the survivor of them, guardian of any property which passes
either under this will or otherwise to a minor and with respect to which I am
authorized to appoint a guardian and have not other specifically done so,provided
COPY
that this appointment of a guardian shall not supersede the right of any fiduciary
in its discretion to distribute a share where possible to the minor or to another for
the minor's benefit. Such guardian shall have the power to use principal as well
as income from time to time for the minor's support and education(including
college education,both graduate and undergraduate)without regard to his or her
parent's ability to provide for such support and education,or to make payment for
these purposes,without further responsibility,to the minor or to the minor's;..,;
parent or to any person taking care of the minor.
IV. All federal, state and other death taxes payable because of my death, with respect
to the property forming my gross estate for tax purposes, whether or not passing
under this will, including any interest or penalty imposed in connection with such
tax, shall be considered a part of the expense of the administration of my estate
and sbali be paid out of the principal of my estate without apportionment or right
of reimbursement.
V. I appoint PHILIP J. HUNTZINGER and KATHRYN M. HUNTZINGER,
husband and wife,co-executors,or the survivor of them executor of this my last
will. Should Philip J. Huntzinger or Kathryn M. Huntzinger, fail to qualify or
.; e'
, ; ,-
cease to act as executor, I appoint my granddaughter,NATALIE KAY WARK,
and my grandson, NATHAN DARRELL MILLER,co-executors, or the
survivor of them executor of this my last will.
VI. I direct that my executors or guardians shall not be required to give bond for the
faithfu} performance of their duties in any jurisdiction.
- f fjc
IN WITNESS WHEREOF,I have hereunto set my hand and seal this day
of 1PA4 4- 2006.
SEAL)
GLORIA Y ILLE
The preceding instrument,consisting of this and two other typewritten pages
identified by the signature of the testatrix, GLORIA Y. MILLER,was on the day and
date thereof signed, published and declared by GLORIA Y. MILLER, the testatrix
therein named,as and for her last will, in the presence of us,who,at her request, in her
presence, and in the presence of each other have subscribed our names as witnesses
hereto.
� �� tP -Z
REV-E508 EX+(o8-iz)
i pennsylvania SCHEDULE E
'f DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DKEDENT
ESTATE OF: FILE NUMBER:
Miller, Gloria Y. 21-13-0143
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
1.1 M&T Checking Account#7220055 11732.66
2? Claremont Nursing and Rehabilitation Center Refund — 3,599 24
!
I
TOTAL(Also enter on Une 5, Recapitulation) $ I 5,331.90 ,,
If more space is needed,use additional sheets of paper of the same size. -
1M&TBaiik On
VIIIPTRANSACTION DEBIT
�
ORIBINATMB C-0STfENf01 EMPLOYEE NUMBER \AU ORIZATiON DATE' .I
COUNTp I CUSTOMER NAME(PRINT) -
( . r
SCRIPTION: b PARnALWRHDRAWAL, [g'6OSINOWRHDRAWAL - -
iSMMER ID: - - '
A ,h 15 0 X 935 -
iginai-Processing Work -
,Py•Branch ' CUSTOMER SIGNATUR
SCO NO.
kz
MM&TBank
U1lckmid11dingwfik�limoftarif .
Spring Garden Office
If you have any questions, please
call our Telephone Banking Center
at 1-800-724-2440
Today's Date: Business Date:
02/15/2013 02/15/2013
Time: 12:20 PM
Checking Deposit $1,732.66 ✓" al
****1980
Total Balance: $1,732.66
4344/08 68 M
Thanks for visiting us today,
tie are happy to assist you!
,age: 1 Document Names untitled
STFD 1 THE TRANSACTION STMT FORMAT 13102/13 12ON.06-07
STMT CO 96 OP EBRN MS 50861 LAST PAGE OF TRANSACTIS
ACTION COLD SHORT NAME MILLER GLORIA Y
PROD CODE DDA ACCT 720054
PAGE I SEARCH FROM 112/12/18 THRUI 1,13/0AN1/17
CURB CODE BALCE
POST EFFECTIVE CHECK NUMBER IRAN AMOUNT D/C
ACTN DESCRIPTION 1,759 .78
,RACE ID 27.12 D
12/18 012352004700126 MONUMENTAL LIFE INSURANCE 1, 732 . 66 2712 D
01/17 013016006754719 MONUMENTAL LIVE INSURANCE
M&T Bank NMUZ 0467479
Diana Froker
Personal banker
Spring Garden
100 South Spring Garden Street —STS14
Carlisle,PA 17013 11—CIJTO
717 240 4525 Fu 717 240 4526
dfraker@mtb.wm
0:1105 2013 ;.'1722585151 ucr•wn wr.c; aa:
'a E3TA J OF GLORIA V MILLER
XATHRYN V HUI4TZtNGER.EXEC ,^ .
6a1 tiREA5nN Ra.
CAR115t6.PA 17015
Vi ✓/
aA'E.r7011 �iJR lbbr4ttlE WIiMD N�� EUY TOI�L �
• "POSIT$uPV NOT B-AVfRP84 —'_-
iw- IvnEUUneq. __
I MM&IrBank
r:50 10000 5 90: gR611. 319$D11'
. I �
I
6p
O �
Batik
/\
h^
m
Chxiers'tOD,�
sp'ir'A Garden
LJ V
bN rD E A25
f you have anY 4ue5t1cns. Please > g 1 10 n y
Banking Center x x ; ° m M�
Salephone o° �_ i°"
at 1'900-724.2440 w� ' :3'
aday's Date: Business Date. o } 1 y sl
13104/2013 03/04/2013
1me: 12:07 PM
Q
• 53.599.24 � g�
;narking Deposit
w*1980
n r:
55.331.90 or I Q
,,.tai Balance: $1,732,66
kaTlehle Balance:
or
4344114 179 �1
+ I K
En.y{
ru «
ruf ar 11 \JA
lha.*s for visiting us today.
ne are h&DDV tD assist YOU,
o ,
+ w I r5
x
! s o
N
REV-1510 EX+(08.09)
pennsytvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Miller, Gloria Y. 21-13-0143
This schedule must be completed and riled if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM
INaM RHE NVIE OF THE TRUS61ff.THEIR REwnON"To DEOMET MD .DATE OF DEATH % DECD'S EXCLUSION TAXABLE
NUMBER PIE CATE OF TRANSFEK AnACH A COPY OF n1E D®FOR REAL ESTA,E VALUE OF ASSET INTEREST OFAR'II VALUE
1. ((Lincoln Benefit Life,#LBF108837fi-Annuity
^
I -Beneficianes:
INathan Mil elµ rr randsan ghter 27,784.29� I M 27,78A.29 Vi
3 ,
L
i
L.«. _..-�_-.,mac:^=�---- _ •-" =•a-----°-�.._ � ..j t
5
f
LJ
it
TOTAL(Also enter on Line 7, Recapitulation) $ f,' 27,784.29
If more space is needed,use additional sheets of paper of the same size.
�,.
l
1
LINCOLN BENEFIT LIFE
AN ALLSTATE CO M MA NY
January 25,2013
Natalie K.Singer
8 Lebo Rd.
Carlisle, PA 17015
Re: Gloria Y. Miller,deceased
Contract No: LBF1086376
Claimant's); Natalie K.Singer and Nathan Miller
Dear Ms.Singer.
We are very sorry to learn of your loss and extend our sincere condolences, We understand this may be
a difficult time for you.
The contract owner was receiving a series of payments spread over a period of time under this annuity.
The beneficiary is now entitled to receive the remaining guaranteed payments described below. Any
payments due a beneficiary will be paid on the specified due dates,and they will not be commuted or paid
in a lump sum. If there are multiple beneficiaries,each beneficiary will receive their respective share of
any payment.
Frequency of payments: Monthly
Amount of each payment: $178.97
Last payment date: February 1,2026
We Need Some Information to Process Your Claim
In light of this loss,we need some additional information from you to help us process your claim. At your
earliest convenience, please send us the following documents in the enclosed postage-paid envelope:
• Claimant's Statement(fully completed and signed)
• Certified copy of death certificate("certified"means an original document or copy with raised seal
or original stamp). Unfortunately,we are unable to return an original death certificate submitted to
us for this claim.
The Internal Revenue Service requires that when the owner dies and we pay the remaining guaranteed
payments to a beneficiary,we must pay out the remaining cost basis first. Therefore,the taxable portion
of each payment to the beneficiary may differ from what applied to the owner during their lifetime,and it
may change over the remainder of the guaranteed period.
Lincoln Benefit Life Company
Life and Annuity Claims
P.O. Box 94212, Palatine, IL 60094.4212 Phone 877.499-6418 Fax 866-6354523
January 25,2013
Page 2
Additional Tax Information
Payments from an annuity may be taxable to the recipient. Please consult with your tax advisor or
attorney prior to making any decisions concerning the claim. If you have any questions,or if you need
assistance in completing the forms,please contact me at 1-877.499-6418, Ext.24677.
Again,we extend our sincere condolences on your loss. Thank you for your assistance.
Sincerely,
Nicole D.!_evas
Sr. Claims Examiner
Enclosures
REV-1511 EXt(08-13)
pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX REVURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Miller, Gloria Y. 21-13-0143
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
1.
0.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 1,000.00
Name(s)of Personal Representative(s) Kathryn M. HUnt7inger
Street Address 584 Greason Road
City Carlisle State PA ZIP 17015
Year(s)Commission Paid:
2. Attorney Fees:
1,500.00
1 Family Exemption:(if decedent's address is not the same as daimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. probate Fees: 103.50
S. Accountant fees: 0.00
6. Tax Return Preparer Fees: 0.00
7. Register of Wills,Filing Family Agreement 20.00
B. Cumberland Law Journal,Advertising 75.00
9. The Sentinel-Legal,Advertising 300.00
to. Additional Probate 25.00
it. Reserve 400.00
TOTAL(Also enter on Line 9, Recapitulation) $ 3,423.50
If more space is needed,use additional sheets of paper of the same size.
RECEIPT FOR-PAYMENT
Receipt Date: 2/05/2013
17 : 08
Receipt Time: 10.72965
Cumberla County SBAUg'
Of Wills Receipt No' :
- Register
are
One CourthpuuselTs.
Carlisle,
MILLER GLORIA Y ---
2013-00143
Estate File WILLIAM S DANIELS --------------
paid By Remarksarks : ----------HKW
________ Receipt Distribution
------------------------
----- payment Amount Payee Name GENERAL FUN
Fee/Tax Description
CUMBERLAND COUNTY GENERAL FUN
20 .00 CUMBERLAND
15 . 00 CUMBERLAND COUNTY GENES FUN
PETITION LTRS TEST 5 . 00 CUMBERLAND CONY CNTR M--
WILL 5 . 00 BUREAU OF RCQ SCRIPTS FUN
RENUNCIATION 23 . 50 Ct7MBERLANI7
SHORT CERTIFICATE 5 , 00 CUMBERLAND COUNTY GENERAL FUN
SCS FEE 15. 00 UMBERLAND CONY GENERAL FUN
AUTOMATION FEE 15 .00 C
INVENTORY ----------------
INH TAX RETURN -----'-103 . 50
Check# 1117 103 .50
Total Received- - - - - -
REV-1512 Ex+(12.12)
pennsylvania SCHEDULE I
W' DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Miller, Gloria Y. 21-13-0143
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
STEM I VALUE AT DATE
NUMBER DESCRIMON OF DEATH
1 Commonwealth of Pennsylvania,Third Party Liability,Statement of Claim Summary �i 306,625.87!j
[ i
r I
+ k, <
1414 t
- -
El
v ;
L
-TOTAL(Also enter on Line 10, Recapitulation) $ mm 306,625.67
If mom space is needed,Insert additional sheets of the same size.
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 84%
HARRISBURG,PA 171058486
May 27,2014
STATEMENT OF CLAIM SUMMARY
F AME - Estate of MILLER,GLORIA
; • 280 204 461
MEDICAL CLASS 3 CLASS 5.1 - TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 166.91 166.91
LONG TERM CARE 27,580.24 278,522.09 306,102.33
DRUG 13.49 343.14 356.63
REIMBURSEMENT TO DPW 27,593.73 279,032.14 306,625.87
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 22
I
i
i
� 3
i
� .�
�, � � . t .
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Miller, Gloria Y. 21-13-0143
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under
.Sec.9116(a)(1.2).]
I. Nathan D.Miller,142 Jamestown Road,Unit C,Ocean City,MD 21842 Grandson 50%
F2] Natalie Kr-'^_Singer,83 Lebo Road,Carlisle,PA 17015 T 1 Grandaughter 50%
El E-
-- - --❑ �❑�
❑ ❑=
❑ �_ ❑
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 16 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
El I
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,use additional sheets of paper of the same size.
r
t
f
4
V
w .. � } . .
°t.p .,
.� �� ' ..
�� .. _ � ,.
. . ' v,
."
T
M
/n� � - _ . .
"_V