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HomeMy WebLinkAbout02-0981PETITION FOR PROBATE and GRANT OF LF,TTFRc Estate of ,~'e ~; ~~ `, ~-~-. ~. ~, ., - No, also known as To: Deceased. Social Security No. I ~ ~ - a- ~- - -=~ ~ '~ 3 21-OZ-981 Register of Wills for the County of _CiTMRFRLANiI in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut named in the last will of the above decedent, dated ~? ~~~ to ~ `) , 19 ' ~= and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~- `'~ '° ~' ~' 1~ ~ ~~ ~ ~ ~ County,%P~ennsylvania, wig h ~ ,- last family or principal residence at ~ 7U1 ~_ ,cA~tz; ~'~~,~, ,, ; ,-t M < 1~~:, ~ c s ~ „-vim A '~~ Sc~ ~~~ (i~st street, number and muncipality) Decendent, then ~ ~ y~years of age, died ' C ~ ~-~~ ~ `-~ 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: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: ~ 5 J~ 00~ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters theron. V C a ,-~- v ~ ~ c bo ~~ ^a ~w o m c op (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) L~pp, hc~~ ,~ L ~ >~~_. ~.O ~ ! ~ i !'~ ~ h ~ Gi I ~ C%C1 G s:> ~S OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss The petitioner(sl above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and ly administer the estate according to law. ~~ Sworn to or affirmed and subscribed -~~~ ''': 6:~~`-~ ~ before me this 4th day of oo• NOVEMBER ~ 002 ~ /~ „~~„ r~ 0~'~`~~-J i °~4~e~ Regis er No. Estate of 21-02-981 PEGGY A LONG Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NOVEMBER 4 ~9t 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 JULY 24th 1986 described therein be admitted to probate and filed of record as the last will of PEGGY A LONG _ . and betters TESTAMENTARY are hereby granted to LYNDA A LONG Register of Wills ~Q~~2k~y _ 1 FEES Probate, Letters, Etc. ......... ~ 80.00 Short Certificates( ) .......... ~ 1(5 ~. 0QQ0 )~enlzn~iation ................ $ JCP $ 5.00 TOTAL $ 111.00 Filed NOVEMBER 4 2002 ................................... ATTORNEY (Sup. Cc. LD. No.) ADDRESS PHONE ,, , < I$r.L~,~l 4. ~.:'y3~;"~?Iu:.~i~ ~iE'iaa L;tSs"~ ~=~i ;3~~i~tia~~iu~ ~a;" p'.,<° a~..I,~~g, . r 8643305 _ _ __ 21-02-981 3Ray. tie? COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH MATE FILE ~DMBER NAME OF DECEDENT (F~rsr. Mid«e. ~asl ~ - SEX SCGAL SECURITY NUMBER GATE OF EATH ,MCnm, Cay, rear) I ,. Peggy A. Long 2.~ema~e 3.182 - 22 - 9373~~ 'Vi`i _.~Jz. AGE (Last Bertnday) UNDER 1 YEAR UNDER t DAY ~ DATE OF BIRTH BIRTHPLACE ;C•ry era PLACE OF DEATH ifrecn only one - ,ee i~suuul~u.a on •rnei sidal -r- iMOrelh. Day. y~rl Months i Daya Moura : Minutes stile «FCreegn COU«ry) HOSPITAL. O7HER~ OlMr N 3-28-1929 73 Y" ~ ure•q ^ Readenu rye ^ Inpalee«~ EWOuWau•nt LJ DOA ^ Home ~ ,span P Haan-i~sbwt g , ~. ,. , f. COUNTY Of DEATH CCTV, BORO. TWP OF DEATH FAC/LRY NAME III nor insl•heudn. give vreel and number, WASIA~D~JECEDENT OF HISPANIC ORIGIN? RACE -American IrWian, Black, whrta. etc. ISPaph) ipacily CuDen No l;J y'9a ^ I, yH Penn~Jboao Tw ~ bexeand C , . `,I + d/ ~ oS i f,'~ >Mexran.PuertoRican,ac 1,. tUh~ete ed k. . ,,. um DECEDENT'S USUAL IDCCUPQION KINOOF BUSINESSrINDUSTRY . WAS ECEDEN EVER IN DECE ENT'S EDUCATION MARITAL STA7US~Marned SURVIVING SPOUSE Widowed III wee Jive malaen namal ni heal, ra~le com leled Never Married t ord F RCES9 S (Give Mrs d w«k done durmg most c~ of working kN; do rwt use reared 1 S~a.~e , . . I r v U.S. ARMED O ElemenlaryrSecondary Cortege Div«ced (Spearyl ^ ® Go~eanmen~ Y f Nd (D..2) 12 Il a«5.) (u~dow See~ce~tea ,,,. • ,,.. ,. ,,. ,3. 2 DECEDENT'S MAILING ADDRESS (Sven GryROwn. Stale. LiVCOdeI DECEDENT'S pA ~Yef aeceantlived ~n Ham~.ton twp t7c • 4701 Chcvc bey Raad ACTUAL RESIDENCE . . • Ve. Stare Did d•c•d•'ll PA 17050 b ~ h (See mNruchorla °"«naraedel liw m f Cumbea~and I°w^~"'p' wNd•dec.d.May.d 17d ^ shin acluallmlrts« crtylh«o u~c an .c~ Mec 11. . . 17h. Court ry _ FATHER'S NAME (First. Meddle. Last) C~aueea 2 ea E E MOTHER'S NAME iFnsl. MNdb. Maltlen Surname) Ne2~~e Jane Myene . . ,, m ,q. ' INFORMANT'S NAME (TypaPrmg S MAILING ADDRESS (Street, GryyTOwn, SWIe. Zip Cone) INFORMANT L nda Lon 4827 Via ~n~.a Road Mechan~c~sbu~c PA 17050 20D 2a. METHOD OF DISPOSITION DATE OF DISPOSITION (Mdnlh Year1 Day . PLACE OF DISPOSITION-Na+mg of Cemetery, Crgmalory LOCATION-CiryRdwn, Seals, Zp C^de «OlllerPWCe Caema~~con Soe~ e~y o{~ . Bunat^ Cremalion~• RemovallromSlale^ , . Don.,nrl^ aherlspaPMl ^ ~~- ~~~-~-~' Hcvca~.~buh PA 17109 PA Caema.toac 2,d 27h. Rte. „d. . ' SIGNATURE FUNERALSERVICEL SEE P NACTITJGASSUCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY nema ,LCIn OC•L.Q L! O ' L1 4100 Jone~s~own Road Haha~~Jbuh PA 17109 22c Yea. Complem s 23at o«y wMn wnitying . 22D. To lM Dssl of my knowledge. death occurred al me hme, dale aM place staled. LICENSE NUMBER DATE SIGNED (Monet. Day. Year1 physician a not available al Dme of death to ISIynaWre are T,De) ' cenily cause of death. 23a. 23h. 23c. Beets 20.28 must De compbted Dy TIME OF DEATH • person woo prorounces deaN. ~ DATE PRONOUNCED DEAD IManh. Day, year) WAS CASE REFER ~~ //,Y ( ? -~ ~ J RED TO MEDICAL,EX' A1MINERICORONER7 Yea ® ~'~` No ^ ( ~ ~ t ,_ rr vv ( 27. PART l: Enter lne diseases. injuries or wmpkcalans which caused lne deem. Do not enter Ina mode of tlying, such as cardiac or respiral ry ariasl, mock or head tenure. r Approumale imerval between PART II: Ollie! signiecard conditions comndning to death but not resuhinq m the und•Mi^9 cause given m PART I. List Dory orw cause on each line. I 1 oruel antl deem IMMEDIATE CAUSE (Final I ~ assess«contlneon R ) I ~ l~se~h -- ~ ~ e- ~~,.~~. • ~- result mdeaml-~ a~ OUE 70 (OR AS A~- CFiNSEOUENCE OF): l.-.' ~ l tx ~l.t Seguentiaay Nn condrtane 'I any, Wadnq W anmeeale D. ~'.'~ -LL`r ~"'~"^^ Y DUE TO (OR AS A CONSEO ENCE OF): I I caux. Enter UNDERLYING • ' CAUSE(Disease«mpiry • mat mnialed events c. DUE TOIOR AS ACONSEOUENCE OFI: resulting n deem) LAST d - ---- ~ WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE MOW INJURY OCCURRED. PERFORME07 AVAILABLE PRIOR TO (Monet. Day Year) COMPLETION OF CAUSE © ^ OF DEATH? Hom Nawral icide Yes ^ No ^ Academ ^ Pending Invesligalron ^ 30f M, 30 b. 70c. 30d. Ve ^ No~ Yes ^ No ^ Suk:lde ^ Could not De determined ^ _ _ . ___ _._ PUCE OF INJURY ~ AI soma, farm, sireel, lagory. oflice LOCATION (Sireel. CrtyR cart, $raW) s building, etc. 5panlvl 2M. 2BD. 29. 30e. 70,. CERTIFIER ICheCk aniy noel SIGNATURE ANO TITLE OF CERTIFIER 'CERTIFYING PHYSICIANIPnys~cean cennyiny<ause:r dram caner an<mee unvvv~an has wo To tM Daft o, mY knowledge, deem occulted Due to th• caua<(sl and manner of stated . nourx;ed seam and c«nuleled Item 231 -~ .................................................... - 71b. ~_~-"-"- ,; LICENSE NUMBER DATE SIGNEDIMUnm. Day. vean -PRONOUNCING AND CERTIFYING PHYSICIAN IPhvsx;wnr.nr:;e-;nuune.ne~deam and vriri ly,nyw~.;ause cl deems - ' ~ (~,~(~- p56T46 ~ 3td. i:': 'LI `~ I . 3,c _.___ ..- . - To 1M bast of my knowledge, dNth accurrad at lM elms, date. and place, and du• to lh• cauael•1 and manner a• slated .......................... ___ ___ ____ _ ________ ____ __. _ _ NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (IIenIL],TypadlPrin' Andhzej LUaXhen M.D. i 'MEDICAL EXAMINERICORONER On the basis of aaaminatton and/or investigation, in my opinion, death occurred al the time, data, and place, and due to the cauae(sl and ^ ..... .. ........ .. 1 0 ~ L ow~thea Stye ee.t, Lemoyne , PA 17 0 4 3 manner of steted .................................................... 31 a. . ............... ... .......... 32. REGISTRAR'S SIGNATURE AND NUMBER DATE FILED (MOnln Uay. mail Lr.ST '~ILT~ AND T~S`"Ai~`T~'~~r'' Or PuG~Y ~. LCPiG I, pT;~;^-Y A. r.~CNr, of the Township of ti~ampden, Caux~t;~ of C~.~.mberl<.nd and. State of vennszTlva.nia, being of so-~.nd. and di.spcsing mi.nd., ?r~emorg and understandin, do make, I;ublist~ ar~d declare this m.y Last +~~ill and Testament, her•e~>;,- revokix~~f-; and making; void. any a.nd al.l pr~_ar 'v~,ills by me at ar.y t~_.ie h~retof'o.re ~_nade. 1. i ~lii-Cct 1-nP ~ayrrent of a1_1. my just debts and f`~.zneral e.x,perses as soc+n after :~; decease as the same can ':~c conveY~ier~tl;y done. 2. I ~^•ive, devise and begt~ea.th all the res remainder of my estate, of whatsoever nature the s2.me may bF situate, tc my son, ':'~iAR'nIi~ E G"'T~Df~. a . l~OiiG, my son, JAi°".~S A. L,~I~r , and my ~':. LC:I`~G, share and share alike, per sti ryes. t, resi d~Ae and a:nd ~~heresoecTer grandscn9 ~ (J.~;~, ~'r:~I~ a.) In the event t`~zat my grandson, JG~~?T-~:AI~? L. I~Oitia, h~::s r.ot attained the age of eimhteen. (18) tiears at the tir;e of r~a~- decease, tier, in suer eveYzt, T ~°ive, devise and bequeath h?s share in ~~,`r estate tc his father. , ~~:%~RTIP E. L~JIvr, in trust, neverthel,~ss, to hold, manage, invest and reir_vest the sar2e, ,f~.r.+d to use and aprly the inccme and principal thereof, as in said -1- Tr.ustee's sole discretion may be necessary or appro~_riate tar mfr grandson's education, including trade sc'nool and ccllege education, both graduate and undergraduate, without further »espons.bility to such beneficiary or to such ~~erie'icia~°y' s guardian and/or to any person taking care of such beneficiar~,r. An~J income .not so used or a~~p~lied shall be accumLulated and. added to and t_~ereafter be treated as part o:f the z;rincipal. ~rher~ m,r said grandson attains the a.ge of eighteen (la} years, his trust V s!~.all ter~~i.rate and the p.r.incipal and. any accrued income therecr s~~all be paid over and distributed to him absolutel~~. "'he interest of may said mrandson hereunder shall _.ot be subject to anticipation or voluntary or invo~=untary al~_enation. Further direct that my son, ~~~~ARTI~ ~~". LCNG, be perraitted- to serve as ^rustee of the ~,sta.te of my grandson, J:?P.~T,~.:A'~ :=~. i_ O3", without post.nG bond or other securit~r ar.d that he 'oe exc:useU from filing an Accounting of h_s ~'rus tees'nip. ~i=i`.~`~'T.,~'_', T nOmi Hate, COnStl tU.tedr:C'. appC1.:CJt "i1~:' SCT2 _'1-.~t~ ii ~'~. T,CTvCi, and rn.y dau ;titer, ~~VrvD'~ A. LONG, Co-executors off' t.: is ~,~5. east `ri11 and testament. IT; ~~.'~TP~~SS ~•:rER~'CF, ~ have hereunto set Wry hand and seal. t~'i.i s ~~-- day of July, A . D . , 196 , __. p v,£,; A. Long -2- :~ir~°ned, sealed, published and. declared by the above named, Pe{_:.~y A. L.on~;, as and ~'or :per Last ~r~ill a.n~~ ~iestarr:ent, -± n the presence of us, whc ha.~e s~absc.ribed our naL~~es hereto ail ~f».tnesses, at the request of said t~~~statrix, ira rer presence -:nd in tre nresence of each other. t~ ~ G' // t`, ~. / -~- 21-02-981 REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS (each) a subscribing witness to the law, depose(s) and say(s) that codicil will presented herewith, (each) being duly qualified according to the testat ,sign the same and that present and saw signed as a witness at the request of testat in h presence and (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this day of 19 Register (Name) (Address) (Name) (Address) REGISTER OF WILLS OF CUMBERLAND COUNTY OATH OF NON-SUBSCRIBING WITNESS LYNDA A LONG and MARTIN A LONG (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that that are familiar with the signature of pEG y a T f1N(' I~>~ testator of (one of the subscribing witnesses to) the will presented herewith and ~R that they believed the signature on the will is in the handwriting of PEGGY A LONG to the best of r_hF~; r ._ knowledge and belief. Sworn to or affirmed and sabs;;ribed before me this 30th __ day of OCTOBER~.~~ ' _, ~~ 2002 ~ ~~ I~6~r i ~'~2 -t ~ !N ~~~ ~ dress) n 1b..c ,,, RENUNCIATION In Re Estate of 21-02-981 deceased. To the Register of Wills of ~ ~% ~ •~~~ t G' ~'~ County, Pennsylvania. The undersigned ~ ~ ~'~ ~' ~ ~ ~ ~ ~ '~ S crvi of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters -~ i ~~ Wl //r t''1 ~ c~ V' ~s be issued to ~- ~l V~ ~,A G ~' ~- G /1 Gl WITNESS r ,n ~ ~~''l U /',~zr~ ~,~. ( dd;ess) ~~ rr~~, ~~ y ~~-~~ (Signature) (Address) (Signature) hand this day of , 19 l ~ (Signature) (Address) ~~ Name of Decedent: CERTI/F~ICATION OF NOTICE UNDER RULE 5.6(a) Date of Death: ~ (' ~ ~'~~~ ~~ Will No. ~' ~ ~ `~ ~~~~ ~~ Admin. No To the Register: I certify that notice of (beneficial interest) estate administration 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 ~ ~~~ ~ Name CG r ~+ s~ G . _~~t/ v~~ t I SU 5~;,,,~ ~. Lvt.. ~~~~~ ~u~ L~> Address ~~~~~I~ f-~ l.ti~~r~ y ~~~3 ~{ `101 CV~.r-Iz.s ~-UCi~ I~~c ~~c~ v. ~ c. S ~, ~~ v~ ~~~~~ Notice has now been given to all persons entitled thereto under Rule 5.6(a) except r ~~ i Date: Signature Name L,~ v~C~G l~-OInC Address ~g~~ ~ 1 ,(~~ ~ ~,. i C-t IC C ~~-~ ~~,~;~ _ P~- ~s ~ __ ~~s Telephone (~~~) ~ j7 ~ - I ~--(y Capacity: Personal Representative Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: REV-1162 EX111-961 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT LONG LYNDA A 4827 VIRGINIA ROAD MECHANICSBURG, PA 17050-3075 ACN ASSESSMENT CONTROL NUMBER fold ESTATE INFORMATION: ssrv: ~s2-22-x373 FILE NUMBER: 2102-0981 DECEDENT NAME: LONG PEGGY A DATE OF PAYMENT: 01 / 24/ 2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 10/29/2002 AMOUNT 101 ~ 55,000.00 TOTAL AMOUNT PAID: REMARKS: LYNDA A LONG SEAL CHECK# 105 INITIALS: CW RECEIVED BY: DONNA M. OTTO 55,000.00 DEPUTY REGISTER OF WILLS NO. CD 002086 REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 002514 LONG LYNDA A 4827 VIRGINIA ROAD MECHANICSBURG, PA 17050-3075 fold ESTATE INFORMATION: ssN: 182-22-s3~3 FILE NUMBER: 2102-0981 DECEDENT NAME: LONG PEGGY A DATE OF PAYMENT: 05/01 /2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 10/29/2002 REMARKS: LYNDA A LONG CHECK#109 SEAL 5818.60 DEPUTY REGISTER OF WILLS ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5818.60 REV-1162EX(11-96) TOTAL AMOUNT PAID: INITIALS: JA RECEIVED BY: DONNA M. OTTO CERTIFICATE ION OF NOTICE UNDER RULE 5 6(a) Name of Decedent: t~~-~ ~' ISO v1~ /?- Qd? ~3 COMMONWEALTH OF PENNSYLVANIA ~, BUREAU OF INDIVIDUAL Taxes DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280bCi HAfaicISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX aev-isa~ ex -FV eoi-oar ~.~ - _ DATE 06-03-2003 <~„ ESTATE OF LONG PEGGY A DATE OF DEATH 10-29-2002 FILE NUMBER 21 02-0981 ~Q3 `'IFS -s ~" I ~'~~ COUNTY CUMBERLAND LYNDA A LONG ACN 101 4827 VIRGINIA RD Amount Remitted MECHANICSBURG PA ~7;[t50 -3075 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (O1-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF LONG PEGGY A FILE N0. 21 02-0981 ACN 101 DATE 06-03-2003 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule Bl 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/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) 120,000.00 (2) .00 (3) .00 (4) .00 (5) 14,146.27 (6) .00 (7) 15,383.85 (8) NOTE: To insure proper credit to your account, submit the upper portion of this fora with your tax payment. 149,530.12 APPROVED DEDUCTIONS AND EXEMPTIONS: 9,147.06 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 5,387.7 6 11. Total Deductions (11) 14.534.82 12. Net Value of Tax Return (12) 134,995.30 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 134,995.30 NOTE: If an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15 . Amount ofi L ine 14 at Spousal rate (15 ) . 0 0 X 0 0 = . 0 0 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 134,995.30 x 045 = 6,074.49 17. Amount of Line 14 at Sibling rate (17) • 00 X 12 = . 00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 = .00 19. Principal Tax Due (19)= 6,074.49 TA.Y 1'DCTTTC• DATE NUMBER + INTEREST/PEN PAID (-) AMOUNT PAID 01-24-2003 CD002086 263.16 5,000.00 05-01-2003 CD002514 .00 818.60 TOTAL TAX CREDIT 6,081.76 BALANCE OF TAX DUE 7.27CR INTEREST AND PEN. .00 TOTAL DUE 7.27CR * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1470 EX (6-88) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 DECEDENT'S NAME REVIEWED BY PEGGY A LONG FILE NUMBER 2102-0981 John Kealy ~~~~ 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES H ~ ~ Included additional probate fees in the amount of $155.00. INHERITANCE TAX EXPLANATION OF CHANGES Row Page 1 ..REV-'500EX(6~1 . COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 Il-q8-3 REV-1500 - INHERITANCE TAX RETURN RESIDENT DECEDENT ~ Z W C W (,) W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) LONG, PEGGY, A. u___ ----..------ --1-"--'--'---- DAlE DF DEATH (M!.HJD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 10/29/02 03/28/29 --------- j ----.- - ----, (IF APPLICABLE) SURViVING SPOUSE'S NAME (lAST. FIRST AND MIDDLE INITIAL) FILE NUMBER EJ..-Q:l COONTY COOE YEAA SOCIAL SECURITY NUMBER 182-22-9373 CJiL__ "-'- -+' THIS RETURN MUST BE FILED IN DUPlICAlE WITH THE REGISTER OF WILLS -...... ---.. -.. --'-'. .- SOCIAL SECURITY NUMBER W t- :.c:S~ ofo woo :",-, ".... .. " [!] 1. Original Return o 4. Limited Estate [!] 6. Decedent Died Testate fAllach copy ol Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 43. Future Interest Compromise (date of deaIh after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach ropyolTrust) o 10. Spousal Poverty Credit (d&te ctdellll'lbetween 12--31-91 lrld H-9S) o 3. Remainder Return (dateofdealhpriorfDI2-1U2) o 5. Federal Estate Tax RebJm Required -L. 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AttachSdJO) I- Z w Q Z ~ .. w '" '" o " THIS $ECTlOH MtIST BE COMPliE1'ED. ALL COAAESPOHQIiNClt _COI!lFfDElrt/A.LtAXINl'Ol'lM ~ft O_C1'EIl.TO: NAME COMPLETE MAILING ADDRESS LYNDA A LONG__ 4827 VIRGINIA ROAD FIRM NAME '''^",,,,",} MECHANICSBURG, PA 17050-3075 lELEPHONE NUMBER (717) 737-9265 0(') 120,000.Oi ;~ \1)' z o S :) ~ ii: c( (,) w Ill:: 1_ Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnefship or SoI&flroprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. JoinUy Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedu~ G or l) 6_ Total Gtoo, _ (total lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) (1) (2) (3) (4) (5) \J.l ~~" r~ :::3: =.:: I ~ C' l~t " 14,146.27 ~, :-or.: :l>' (6) (7) 10. Debts of Deoeden( Mortgage Liabilities, & liens (Schedule I) (10) 11_ Total Deductions (total lines 9 & 10) 12. Net Value of Estate (line 8 minus Line 11) 13. Charitable and Governmental BequeslslSec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (line 12 minus line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RAlES z o ~ .... :) Q. ::E o (,) ~ 15. Amount of line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) u_ , .0 __ (15) _13~ 150,30. , 045 (16) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate '.12 (17) , .15 (18) 18. Amount of line 14 taxable at coIlaleral rate 19. Tax Due 20.0 CHECK HERE IF YOU ARE REOUESTING A REFUND OF AN OVERPAYMENT 15,383.85 :J;;> 0:> Vi Ul (8) 8,992.06 5,387.76 (11) (12) (13) (14) (19) 1'lIlllIIICK MATH"" ell (0 {f ,', 149,530.12 14,379.82 135,150.30 135,150.30 6,081.76 6,081.76 , OeceElent's Complete Address: STREET ADDRESS _--AZQJ CHARLES ROAD _ ciTY MECHANICSBURG STATEpA ..... Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spoosal Poverty Credit B. Prior Payments C. Discount (1) ZIP 17050 6,OB1.76 .. .5,000.00 263.16 3. InleresUPenal1y ~ applicable D.lnterest E. Penalty Total Credits (A + B + C) (2) 5,263.16 TotallnteresUPenal1y ( 0 + E ) 4. II Line 2 is greater than Line 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Pagel Line 20 to request a refund (3) (4) (5) (SA) 5. W Une 1 + Line 3 is grealer than Une 2, enter the difference. Th~ is the TAX DUE. B1B.60 A. Enter the interesl on the tax due. B. Enter the total 01 Une 5 + SA. This is the BAlANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT B1B.60 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN ''X''IN THE APPROPRIATE BLOCKS No ~ ~ ~ ~ 1. Did decedenl make a transfer and: Yes a. retain the use or income of the property translerred;.......................................................................................... D b. retain the righl to designate who shall use the property lransfenred or its incorne; ............................................ D c. retain a reversionary interest; or...................................................."",.....................,........................................... D d. receive the promise lor Ine of either payments, benefits or care? ...................................................................... D 2. W death occunred after December 12, 1982, did _nltransfer property within one year of death withoul receiving adequate consideration? .............................................................................................................. D 3. [Jjd decedenl own an 'in lrustfof or payable upon death bank accounl or securily al his or her death?.............. D 4. Did decedenl own an Individual Retiremenl Accounl, annuity, or other non-probate property which contains a benefidary designation? ........................................................................................................................ ~ ~ ~ D 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 !hat I have eX8l1"ined this retum, induding accompan)YIg sdledules and statements, and to the besl of my kno-.1edge and belief, it Is true, correct and COfl1llete. Dedarationofpreparerolherltlanthepersona/represenfativeisbased on allnfonnationof\llt1lch preparerhas any kno>Medge. SIG~TU FPERSONREaBLE,~RETU:~ u___ ...__ DA~ Sf! /03 ADDRESS 4B27 VIRGINIA ROAD, MECHANICSBURG, PA 17050-3075 -- ------ ----..-------- -."------_._- SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS DATE For dales of death on or after July 1, 1994 and before January 1, 1995, the tax rale imposed on the net value of transfers to or for the use 01 the surviving spoose is 3% [72 P.S. ~9116 (a) (1.1) (ill. For dales 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 spoose is 0% [72 P.S. ~9116 (a) (1.1) MI. The staMe does not exemot a transfer to a surviving spouse from tax, and the stalutory requirements for d~osure of assets and filing a tax retum 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 nel value of transfers from a deceased child twenly-ooe years of age or younger at death to or for the use of a natural parenl, an adoptive paren~ or a stepparenl of the child is 0% [72 P.S. ~9116(a)(1.211. The tax rate imposed on the net value of ~ansfers to or for the use of the decedenfs lineal benefidaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)J. The tax rate imposed on the nel value of transfers to or lor the use of the decedenfs siblings is 12% [72 P.S. ~9116(a)(1.311. A sibling is defined, under Section 9102, as an individual who has al ieasl one parenl in common with the deceden~ whether by blood or adoption. REV"502 EX+ 16-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF PEGGY A. LONG FILE NUMBER All real property owned solely or.. a tenant in common InUIt be reported It fair martet value. Fair mar1l:et value is defined as the price at whtch 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 I, jointly-owned with right of lurvlvorshlp must be dllclond on Schedule F. ITEM NUMBER ,. DESCRIPTION PROPERTY LOCATED AT 4701 CHARLES ROAD, MECHANICSBURG, PA 17050-7701 (RECORDED IN THE OFFICE OF THE RECORDER OF DEEDS IN AND FOR CUMBERLAND COUNTY, PA IN DEED BOOK oW," VOLUME 14, PAGE 82) VALUE AT DATE OF DEATH 120,000 TOTAl (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 120,000.00 REV.1508 EX+ (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAl PROPERlY ESTATE OF PEGGY A. LONG FILE NUMBER Include '!he proceeds of Utigation and the date the proceeds were received by the estate. All property Jolntly..owntd wfth right of survivorship mUM be dlacloHd on Schedule F. ITEM NUMBER DESCRIPTION 1. PENNSYLVANIA STATE EMPLOYEES CREDIT UNION, ACCOUNT #182229373 (FROM 10/31/02 STATEMENT: SAVINGS-31.57, CHECKING-3,914.98) VALUE AT DATE OF DEATH 3946.55 2. PERSONAL PROPERTY (PER AUCTION HELD 1/11/03 AT YINGLING'S AUCTION, GETTYSBURG, PAl 8090.00 3. 1990 PONTIAC GRAND AM LE (PER SALE TO MARK FUNKHOUSER ON 1/18/03) 400.00 4. OTHER PERSONAL PROPERTY 700.00 5. PRORATED TAXES (2/14/03) 800.12 6. PRORATED SEWER (2/14/03) 50.60 7. HOMEOWNERS INSURANCE REFUND (3/4/03) 159.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 14,146.27 RE\f..1510 EX+ (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF PEGGY A. LONG FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the RE\l-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECO'S EXClUSION INClUDE THE NAME OF THE TRANSfEREE, TliEIR RE1..ATIONSHIP TO DECEDENT AND TAXABLE NUMBEF '!ME lW'E OFiRANSFER. ATTACHACOPYOf M DEED FOR REALESTATE. VALUE OF ASSET INTEREST IIFAPPUCA8I.E VALUE 1. PRINCIPAL LIFE INSURANCE COMPANY: 11,917.50 MARTIN E. LONG (SON) 1/3 3,972.5 LYNDA A. LONG (DAUGHTER) 1/3 3,972.5 JAMES A. LONG (SON) 1/3 3,972.5 2. JACKSON NATIONAL LIFE INSURANCE COMPANY: 3,466.35 MARTIN E. LONG (SON) 1/3 1,155.4 LYNDA A. LONG (DAUGHTER) 1/3 1,155.4 JAMES A. LONG (SON) 1/3 1,155.4 TOTAL (Also enleron line 7 Recapitulation) S 15,383.8 o o o 5 5 5 5 (If more space is needed, insert. additional sheets of the same size) REV:1511 EX+ (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF PEGGY A. LONG FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. CREMATION SOCIETY OF PENNSYLVANIA 1,312.00 2. SHOOPS CEMETERY ASSOCIATION 220.00 3. BAUGHMAN MEMORIAL WORKS 535.80 5. FUNERAUMEMORIAL COSTS 262.34 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Address City State_Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant JAMES A. LONG Street Address 4701 CHARLES ROAD City MECHANICSBURG State~Zjp 17050 Relationship of Claimant to Dececlent SON 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 60.00 7. PROBATE FEES: REGISTER OF WILLS, DEATH CERTIFICATES, SHORT CERTIFICATES, REV-15oo FILING FEE 135.00 FEDERAL TAX RETURN 113.00 ADMINISTRATIVE COSTS: AUCTIONEER COMMISSION 2,427.00 STATE/LOCAL REALTY TRANSFER TAXES, DEED PREPARATION, NOTARY FEE 426.92 TOTAL (Also enter on line 9, Recapitulation) $ 8,992.06 (If more space is needed, insert addttional sheets of the same size) REV-"1512 EX+ (6-98) *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIUTlES, & UENS COMMONWEAlTH Of PENNSYLVANIA INHERIlANCE TAX RETURN RESIDENT DECEDENT ESTATE OF PEGGY A. LONG FILE NUMBER Include unrelmbul"Hd med1ca1expenses. ITEM NUMBER DESCRIPTION 1. PENNSYLVANIA STATE EMPLOYEES CREDIT UNION (STATEMENT DATE 10/31/02) - HOME EQUITY LOAN VALUE AT DATE OF DEATH 5,115.48 2. UTILITY BILLS (HEATING OIL-152.19, PENNSYLVANIA WATER COMPANY-40.44, PPL-56.10) 3. OTHER BILLS (VERIZON-9.55, WALKER POUCH-14.00) 248.73 23.55 TOTAL (Also enler on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5,387,76 REV.1513 EXt (9-00) .. SCHEDULE J BENEFICIARIES COMMONV\QLTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF PEGGY A. LONG FILE NUMBER RElATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List TIU_tll OF ESTATE I TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)1 1. MARTIN E. LONG SON 1/4 11501 BRIARCLlFF WARREN, MI 48093-2581 2. LYNDA A. LONG DAUGHTER 1/4 4827 VIRGINIA ROAD MECHANICSBURG, PA 17050-3075 3. JAMES A. LONG SON 1/4 4701 CHARLES ROAD MECHANICSBURG, PA 17050-7701 4. JONATHAN LONG GRANDSON 1/4 11501 BRIARCLlFF WARREN, MI 48093 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REY-1500 COVER SHEET IT 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 11- 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) COMMONWEAL"TH Of PENNSYLVANIA DEPAR.TMENT OF REVENUE BUREAU OF INOlVIDUAl TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-l1G2 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT LONG LYNDA A 4827 VIRGINIA ROAD MECHANICSBURG, PA 17050-3075 _"_n___ fold ESTATE INFORMATION: SSN: 182-22-9373 FILE NUMBER: 2102-0981 DECEDENT NAME: LONG PEGGY A DATE OF PAYMENT: 01/24/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 10/29/2002 NO. CD 002086 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $5,000.00 I I I I I I I I TOTAL AMOUNT PAID: $5,000.00 REMARKS: LYNDA A LONG CHECK#105 SEAL INITIALS: CW RECEIVED BY: TAXPAYER DONNA M. OTTO DEPUTY REGISTER OF WILLS r---- j , i ;i I I I ! , -'~'"~~".".., -,..... "'". ~ 10" .~. ,: -"r. ...,_,,:1 ,.,~';, ~ ~_... 1: \1 f';' 'r \, \ l ,~ ...-\ } 1 " " d ~..: ~./ ,> .,,?.,I{ t ,. '.H.....'~'.,.~ , ,~;:~~,:~:\~:\.:.;.., Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2002-00981 PA No. 21-02-0981 ESTATE OF LONG PEGGY A iLAb'l', t'iKbl, 1"111111LI>) Late of HAMPDEN TOWNSHIP CUMJ:ll>KLAJ)J11 CUUN l'Y , Deceased Social Security No. 182-22-9373 day of November 2002 an instrument WHEREAS, dated July was admitted on the 4th 27th 1986 to probate as the last will of LONG PEGGY A (LAb'i, tl.Kbi, jVjl.UULl>i late of HAMPDEN TOWNSHIP 29th day of October 2002 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, MARY C. LEWIS , Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to LONG LYNDA A who has duly qualified as Executor (rix) and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA, IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office the 4th day of November 2002. CUMBERLAND County, who died on the &"'N..J h7, /)~#l'!' ~fi'fr Kegls 0 ~ s ~~~ **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) LAST WILL AND TESTAMENT OF PEGGY A. LONG I, PEGGY A. LONG, of the Township of Hampden, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I uL.ocu r.hA vayment of all my just debts and funeral expenses as soon after my decease as the same can be conveniently done. 2. I give, devise and bequeath all the rest, residue and remainder of my estate, of whatsoever nature and wheresoever the same may be situate, to my son, ~~RTIN E. LONG, my daughter, LYNDA A. LONG, my son, JAMES A. LONG, and my grandson, JONATHAN A. LONG, share and share alike, per stirpes. a.} In the event that my grandson, JONATHAN A. LONG, has not attained the age of eighteen (18) years at the time of my decease, then in such event, I give, devise and bequeath his share in my estate to his father, MARTIN E. LONG, in trust, nevertheless, to hold, manage, invest and reinvest the same, and to use and apply the income and principal thereof, as in said -1- Trustee's sole discretion may be necessary or appropriate for my grandson's education, including trade school and college education, both graduate and undergraduate, without further responsibility to such beneficiary or to such beneficiary's guardian and/or to any person taking care of such beneficiary. Any income not so used or applied shall be accumulated and added to and thereafter be treated as part of the principal. When my said grandson attains the age of eighteen (18) years, his trust shall terminate and the principal and any accrued income thereon ghRll be paid over and distributed to him absolutely. The interest of my said grandson hereunder shall not be subject to anticipation or voluntary or involuntary alienation. I further direct that my son, MARTIN E. LONG, be permitted to serve as Trustee of the Estate of my grandson, JONATHAN A. LONG, without posting bond or other security and that he be excused from filing an Accounting of his Trusteeship. LASTLY, I nominate, constitute and appoint my son MARTIN E. LONG, and my daughter, LYNDA A. LONG, Co-Executors of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this .;?.Jjfd- day of July, A. D., 1986. I1ttr (( ~;f:~t- P g A. Long (SEAL) -2- -~~.~--~_...- . Signed, sealed, published and declared by the above named, Peggy A. Long, as and ror her Last Will and Testament, in the presence or us, who have subscribed our names hereto as witnesses, at the request or said testatrix, in her presence and in the presence of each other. c::- ^ ~/-""~-<;?-J-. e C0- ,,-/~~- ,/ v ~,(~ /{(~/_'<L / -3- .f6~0 DECEASED PEGGY A LONG 10/29/02 2002 . u.s. Individual Income Tax Return I '99\ IRS Use Onlv. 00 not write at staole In thi5 :SDace. ~ Label Forthe vear Jan. 1-Dec. 31 2002 or other tax vear beainnina endina I OMS No. 1545-0074 Your first name M.1. Last name Suffix , Your social security no. (See PEGGY A LONG , 182-22-9373 inslruclionson , page21.) If a joint return, spouse's first name M.1. Last name SuffIx , Spouse's social security no. Use the IRS , , label. Horne address (number and street). If you have a P. O. box, see page 21. IAPt. no. A. IMPORT ANTI A. Otherwise. 4701 CHARLES RD You MUST enter please print City, town or post office State ZIP code your SSN(s) above. or type. MECHANICSBURG PA 17050-7701 Presidential .... NOTE. Checking "Yes" WIll not change your tax or reduce your refund. You Spouse Election Campaign r Do you, or your spouse if filing a joint return, want $3 to go to this fund? . ~ 0 Yes 0 No 0 Yes 0 No 1 !]] Singie 4 0 Head of household (with qualifying person). (See 2 0 Married filing jointly (even if only one had income) page 21.) If the qualifying person is a child but not your dependent, enter this child's name here. 3 0 Married filing separately. Enter spouse's SSN above and full name here. Filing Status ~ Check only one box. ~ first name: Last name: Name SSN: 5 0 Qualifying widow(er) with dependent child (year spouse died ~ ). (See page 21.) 6a [KIYourself. Exemptions b 0 Spouse c If your parent (or someone else) can claim you as a dependent On his or her tax return, DO NOT check box 6a. . . . . . . .} No. of boxes checked on 6a and 6b ----L- No. of children on 6c who: -lIvedwilhyou ~ . did oot live with you due to divorce or seperation ~ Dependents on 6e not entered above ~ If more than five dependents, see page 22. , " ' Dependents: (2) Dependent's (3) Dependent's (.01) VifqUal. social security number relationship ifying child for (11 First name Last name lovou child taxaedil 0 0 0 0 0 [2] Add numbers on d Total number of exemptions claimed . . . , . . . . . . , , . . . . , , . . . lines above .... Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 7 0 8a TAXABLE interest. Attach Schedule B if required . .i 8b" oi 8a 42 Attach b TAX-EXEMPT interest. DO NOT include on line 8a Forms W-2 and W-2G here. 9 Ordinary dividends. Attach Schedule B if required 9 0 Also attach Form(s) 10 Taxable refunds, credits, or offsets of state and local income taxes (see page 24) 10 0 1099.R Iftax 11 Alimony received 11 0 was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ ~tj 12 0 If you did not get a 13 Capital gain or (loss). Attach Sch. 0 if required. If not required, check here 13 0 W-2, see page '23. 14 Other gains or (losses). Attach Form 4797 14 0 15a IRA distributions . . . . . . . ~ otj b Taxabie amount 15b 5000 16a Pensions and annuities . . ., 16a o b Taxable amount 16b 5103 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17 0 18 Farm income or (loss). Attach Schedule F 18 0 Enclose, but do 19 Unemployment compensation .~'b 'T~x~bl~ a~o~ni 19 0 notattach,any 20a Social security benefits 20b 0 payment. Also, 21 Other income. List type and amount (see page 29) ...---.-....----....----.....-. please use .-.--------.-----------.---------------.--.------.-----._-_......_-~-----------_._-- 21 0 Form 1040.v. 22 Add the amounts In the far riaht column for lines 7throuah 21. This is your TOTAL INCOME .~ 22 10145 23 Educator expenses (see page 29) 23 0 Adjusted 24 IRA deduction (see page 29) 24 0 25 Student loan interest deduction (see page 31) 25 0 Gross 26 Tuition and fees deduction (see page 32) 26 0 Income 27 Archer MSA deduction. Attach Form 8853 27 0 28 Moving expenses. Attach Form 3903 28 0 29 One-half of self-employment tax. Attach Schedule SE 29 0 30 Seif-employed health insurance deduction (see page 33) 30 0 31 Self-employed SEP, SIMPLE, and qualified plans 31 0 32 Penalty on early withdrawal of savings 32 0 33a Alimony paid b Recipient's SSN ~ 33a 0 34 Add lines 23 through 33a 34 0 35 Subtract line 34 from line 22. This is vour ADJUSTED GROSS INCOME ~ 35 10145 /lIT^\ For I1I!'H"nSllro rrivnrv ^rt nil t Pnl1p.l1~t')r\l Rf'dlwlln'\ Arl Nnllrn r,nn 11:10" 7" t- 1n1n ,.".,," $m 104012002\ PEGGY A LONG 182-22-9373 Po. , ? Tax and 36 Amount from line 35 (adjusted gross income) tjs"P~USE "'a~ 65 ~r ~Id~r: '[j BIi~d' 'I 36 10145 Credits 37a Check if: [R]vou were 65 or older, DSllnd; Standard Add the number of boxes checl<.ed above and enter the total here ,.. 1 Deduction 37a for. b If you are married filing separately and your spouse itemizes deductions, - or you were a dual.status alien, see page 34 and check here ,.. 37bD . People who 38 ITEMIZED DEDUCTIONS (from Schedule A) OR your STANDARD DEDUCTION (see left margin) 38 5850 checked any box - 39 Subtract line 38 from line 36 39 4295 on line 37a or 37b OR who can 40 If line 36 is $103,000 or less, multiply $3,000 by the total number of exemptions be claimed as a claimed on line 6d, If line 36 Is over $103,000, see the worksheet on page 35 40 3000 dependent, see page 34. 41 TAXABLE INCOME, Subtract line 40 from line 39, If line 40 is more than line [jenter -0- , 41 1295 42 TAX (see pg 36), Check if any tax is from: a o Form(s) 8814 b Form 4972 42 129 . AU others: Single, $4,7DC 43 ALTERNATIVE MiNIMUM TAX (see page 37), Attach Form 6251 43 0 44 Add lines 42 and 43 ,.. 44 129 Head of 45 Foreign lax credit A\lach Form 1116 if required 45 0 household. $6,900 46 Credit for child and dependent care expenses, Attach Form 2441 46 0 47 Credil for the elderly or the disabted, Attach Schedule R 47 0 Married filing 48 Education credits, A\lach Form 8863 48 0 joinllyor Qualifying 49 Retirement savings contributions credit Attach Form 8880 49 0 wldow(er), 50 Child tax credit (see page 39) 50 0 $7,850 51 Adoption credit. Attach Form 8839 , 51 0 Married filing 52 Credits from: a 0 Form 8396 b d F'or;" 8859 52 0 separately, 53 Other credits, Check applicable box(es): a 0 Form 3800 $3,925 b o Form 8801 c 0 Specify 53 0 54 Add lines 45 through 53, These are your TOTAL CREDITS 54 0 55 Subtract line 54 from line 44, If line 54 is more than line 44 enter -0- .. 55 129 56 Self-employment tax, Attach Schedule SE 56 0 Other 57 Social security and Medicare tax on tip Income not reported to employer. Attach Form 4137 57 0 Taxes 58 Tax on qualified plans, Including IMs, and other tax-favored accounts. Attach Form 5329 if required 58 0 59 Advance earned income credit payments from Form(s) W-2 59 0 60 Household employment laxes, Attach Schedule H 60 0 61 Add lines 551hrouDh 60, This is your TOTAL TAX ' .. 61 129 Payments 62 Federal income tax withhetd from Forms W-2 and 1099 62 16 63 2002 estimated tax payments and amount applied from 2001 return 63 0 If you have a 64 Earned income credit (EIC) 64 0 qualifying child, 65 Excess social security and tier 1 RRTA tax withheld (see page 56) 65 0 attach Schedule EIC, 66 Additional child tax credit. Attach Form 8812 66 0 67 Amount paid with request for extension to file (seeefte 56) , , 67 0 68 Other payments from: a OForm 2439 b Form 4136 c OForm 8885 , , ' , ' , ' , , , ' , ' , ' , , , ' 68 0 69 Add lines 62 throuch 68, These are vour TOTAL PAYMENTS .. 69 16 Refund 70 If line 69 is more than line 61, subtract line 61 from line 69, This is the amount you OVERPAID. 70 0 71a Amount of line 70 you want REFUNDED TO YOU ' , , , ' , ' , ' , t:i S~vi~gS .. 71a 0 Direct deposit? b' C 1___ 0' See page 56 and --- Routing number C Type: Checking fill in 71 b, 71c, .... d Account number I I 0/ ~~ ~ 72 Amount of line 70 vou want APPLIED TO YOUR 2003 ESTIMATED TAX ,~ 72 Amount 73 AMOUNT YOU OWE, Subtract line 69 from line 61, For details on how to par see lage 57 'o't 73 113 You Owe 74 Estimated tax oenaltv (see paDe 57\ , , , , , , , ' , , , ' , 74 Third Party Designee Sign Here Do you want to allow another person to discuss this return with the IRS (see page 58)? 0 YES, Complete the following, 0 NO Designee's Phone Personal identification name .. no, .. number (PiN) .. Joint return? ~ See page 21. Keep a copy for your records. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete, Declarallon of preparer (other than taxpayer) Is based on aU information of which preparer has any knOWledge. Your signature Date Your occupation Daytime phone no, RETIRED Paid Preparer's Use Only Spouse's signature, If a joint return, BOTH mu.;;t sign, Date Preparer's signature Firm's name (or yours if self-employed), address, and ZIP code ~ RY BILLER 410 EAST MARBLE STREET MECHANICSBURG Date 4/5/2003 Spouse's occupation Stale P A Home phone no, Preparer's SSN or PTIN 166-46-41 03 717-795-8993 17055 Form 1040 (2002) ,..... OMB NO. 2502-0265 .,r A. B. TYPE OF LOAN: U.S. DEPARtMENT OF HOUSING & URBAN DEVELOPMENT 1DFHA 2.QFmHA 3. [RJCONV. UNINS. 4.0VA 5. OCONV. INS. SETTLEMENT STATEMENT 6 FILE NUM~~A'i; 17. LOAN NUMBER: 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is furnished to give you a statement of actual set({emenf cosls. Amounts paid to and by the settlement agent are shown lIems marked "[POC)" were paid outside the closing; they are shown here for informational purposes and are not included ill the totals. 10 3/9B (PH03024 SMRPrOIPH0302A SMRl12\ D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER: JAMES A. LONG ESTATE OF PEGGY A. LONG CONSUMER MORTGAGE SERVICES INC 999 WEST CHESTER PIKE, STE 200 WEST CHESTER. PA 19382 G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 25-1648139 \. SETTLEMENT DATE: 4701 CHARLES ROAD PENN HERITAGE TRANSFER COMPANY MECHANICSBURG, PA 17050 February 14, 2003 CUMBERLAND County, Pennsylvania PLACE OF SETTLEMENT 3464 TRINDLE ROAD CAMP HILL. PA 17011 J. SUMMARY F BORROWER'S TRANSACTION K. U MARY OF SELLER'S TRANSACTION 101. Contract Sales Price i 120,000.00 401. Contract Sales Price 120,000.00 102. Personal Property I 402. Personal Pronertv I 103. Settlement Charges to Borrower lLine 140m I 4,201.94 403. i 104. i 404. I 105. I 405. i en s or I en v n m I (If V n 106. Citv/Borou h Taxes to 406. Citv/Borouah Taxes to 1 107. Countvrrwo Taxes 02/14/03 to 01/01/04 305.94 407. CounlvfTwo Taxes 02/14/03 to 01/01104 1 305.94 .108. School Taxes 02/14/03 10 07/01/03 494.18 408. School Taxes 02/14/03 10 07/01/03 494.18 109. Sewer/Refuse 02/14/03 to 04/01/03 50.60 409. Sewer/Refuse 02/14/03 to 04/01/03 I 50.60 110. 410. 1 111. 411. I 112. 412. i 120. GROSS AMOUNT DUE FROM BORROWER I. 125,052.66 420. GROSS AMOUNT DUE TO SELLER I 120,850.72 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. Deoosit or earnest monev , 501. Excess Oenos\t (See Instructions) 202. Pr\nc\oal Amount ot New loan(s} I 96.000.00 502. Settlement Charoes to Seller IUne 14001 , 90,850.72 203. Existina loanfs) taken subiect to I 503, Existing loan{s} taken subject to 204. 504. Payoff of first Mortgage I 205. 505. Pavoff ot second Mortnane i 206. 506. I 207. 507. I 208. Gift From Estate 30,000.00 508. Gift From Estate I 30,000.00 209. I 509. I ustments or Items !i"nain Rv Se1ler ustmenis or lems /7mll TRIi-SeRer 210. Citv/Borouah Taxes to I 510. Citv/Borouah Taxes 10 211. CounlvfTwo Taxes to 511. CountvfTwD Taxes to 212. School Taxes to 512. School Taxes to , , 213. 1 513. I 214. 514. I 215. I 515. I 216. , 516. I 217. I 517. i 218. ! 518. I 219. , 519. , I I 220. TOTAL PA/D BY/FOR BORROWER I 126,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER , 120,850.72 300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 301. Gross Amount Due From Borrower (line 120) I 125,052.66 601. Gross Amount Due To Seller (Line 420) I 120,850.72 302 Less Amount Paid By/For Borrower (line 220) '( 126,00000) 602. Less Reductions Due Seller (Line 520) ( 120,850.72 303. CASH ( FROM) ( X TO) BORROWER , 947.34 603. CASH( TO) ( FROM) SELLER 000 The underSigned here~CknOWledge receipt of a completed copy of pages 1 &2 ollhis stalement & ~enlS referred to here,n Borrower /V ~ ,~./ Seller . 4': ~ g-0~ c-..rI,.. ''>r- J ES A. LO G V" TATE OF PEGGY A.,{ONG HUD.l (3.8G) RESPA, H84305.2 1 .. --~- --- ..--- 700. TOTAL COMMISSION Based on Price < (ij) Of. PAID FROM PAID FROM . Oi~'isiun of Commission-rline 7001 as Follows: BORROWER'S SELLER'S 701.$ 10 FUNDS AT FUNDS AT 702.$ 10 SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 704. 10 800. ITEMS PAYABLE IN CONNE ION H LOAN 801. Loan Oriqinalion Fee 1.0000 % 10 CONSUMER MOR I GAGE SERVICES INC 960.00 802. Loan Dlscount % \0 803. Underwriting Fee 10 CONSUMER MORTGAGE SERVICES INC 240.00 804, Document Preparation \0 CONSUMER MORTGAGE SERVICES INC 160.00 805. Processing Fee 10 CONSUMER MORTGAGE SERVICES INC 180.00 806. Courier Fee \0 CONSUMER MORTGAGE SERVICES INC 20.00 807. Application Fee 10 CONSUMER MORTGAGE SERVICES INC POC $350.00b 808. 809. 810. 811. 900. ITEMS REOUIRED BY LE DER T"RE PAID IN ADVANCE 901. Interest From 02/14/03 to 03/01/03 @ $ 17.095900/day ( 15 days %) 256.44 902. Mortgaae Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 veafS 10 904. 905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance 3.000 months (a) $ 31.42 per month 94.26 1002. Mortqage Insurance months @ $ per month 1003. Cilv/BorouQll Taxes months @ $ per month 1004. Counlyrrwo Taxes 2.000 months @ $ 28.99 oer month 57.98 1005. School Taxes 9.000 months @ $ 109.72 per month 987.48 1006. months ((j) $ per month 1007. months (ij) $ oer month 1008. Armreqate A(fustment months @ $ oer month .333.47 1100. TITLE CHARGES 1101. Closing Service Letter to FIRST AMERICAN TITLE INSURANCE COMPANY 35.00 1102. Courier Fee 10 PENN HERITAGE TRANSFER COMPANY 15.50 1103. Wire Transfer Fee 10 1104. Title Insurance Binder \0 1105. Deed Preparation to LAW OFFICES OF CRAIG A. DIEHL 80.00 1106. Notarv Fees \0 CASH 12.00 6.00 1107. Attorney's Fees 10 (includes above item numbers: T 1108. Title Insurance to PENN HERITAGE TRANSFER COMPANY 958.75 (includes above item numbers: i 1109. Lender's Coverage $ 96,000.00 1110. Owner's Coverage $ 120,000.00 1111. Endorsements 1 DO, 300, 8.1 10 PENN HERITAGE TRANSFER COMPANY 150.00 1112. 1113. 1200. GOV RNMENT RECORDING AND TRANSFER "HARGE 1201. Recording Fees: Deed $ 39.50; Morlgage $ 58.50; Releases $ 98.00 1202. Citv/Countv Tax/Stamos: Deed 300.00. Mortaaae 300.00 1203. State Tax/Stam s: Revenue Stamos 300.00; Mortaaae 300.00 1204. 1205. Recording Service Fee 10 PENN HERITAGE TRANSFER COMPANY 10.00 1300. ADDITIONAL SE rTLEMENT CHARGES 1301. SurveY la 1302. Pestlnspeclion 10 1303.2003 Count\lrrownshin Taxes \0 KATHRYN FETROW, TAX COLLECTOR 340.92 1304. Escrow For Possible DPW 10 PENN HERITAGE TRANSFER COMPANY 90,123.80 1305. 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) 4.201.94 90,850.72 By signing page 1 of this statement, the signatories acknowledge receipt of a completed copy of page 2 of thl j , , , Certified to be a true copy. \ PH030Z4_SMR I PHG3GZ"_SMR I 12 \ 1100i\ ~ol PAGE liOO BEGINNING at a point at the intersection of the 'HSstern line of a fifty (50) feet lvide street with the northern line of a proposed thirty-three (33) feet wide street, said point bein~ North 7 degrees 16 minutes :~st Seven Hundred Fifty-Seven (757) feet, more or less, from t he intersection of the aforementioned western line of said fifty (50) feet ,vide street with the center line of the Trindle Road; thence along the l~stern line of said fifty (50) feet wide street~ north 7 degrees 16 minutes V~st one hundred fifty (150) feet to a po~nt on the line of lands now or fonnerly of Harry M. :',e i tzel and In ldred E. \~i tzel, hiS wife; thence along the line of said last mentioned lands South 85 degrees 04 minutes .'est one hundred (100) feet to a point; thence along, the line of lands' " now or formerly of the same, Soutll 7 degreos 16 minutes East one hundred fifty' (150) foot to a point on the northern line of the proposed thirty-three (33) , feet wide street, aforesaid; thence along said northern line of said proposed thirty-three (33) feet wide street, North 85 degrees 04 minutes E~st One hundred (lGO) feet to a point, at the place of BEGDnIING. BEllm the same premises which HarI"'J 11. :'Iei tzel and 1,Iildred E. ';Ie i tzel, his wife, by their Deed dated Hovember 5, 1'351, and recorded in the Office of the Recorder of Deeds in and for Cumberland County, Pennsylvania in Deed Book "'VI ", Volume l't ' Pa~e i"" ~ ' granted and eonveyed unto Chester M. Lon~ and Peg~ A. Long, hi s wife, the MortGagors herein. llft.1: NUMBER }f .,{ ;~ . ": o UOOM SfATUS .\~ f f' l i't '!, ,) ,\ 4. ~ t, i ijJf ,1\ 'l, \'BJ4 ",%\<V 'I '. ~ "'~ '\ ,t "\" ytl": \~?l' )' j Ilf\'IS1fl"'~'r~y.'NH1{f!iJ I'~ [~f~ I ~~~ '.1 ;, Jb:~ ' ~\ PEGC;;';', "^'~'-~N~~ J~i", "~'v I .~. ~i1iii' ~::J)" _ ,. 1Ii>,':::',' "....tl1:1CHI\R'CESho./i ~.[~')",.\t.'IW ~:~l n.,' i, nr:CHANICSBURG' PA ."......",.... .. .. lIliEBAANDS '\":DUOMETEI1STATlJS O..,ACTVALMllEAGE 1 .. !olILEAaiO eXCEEDS THE MECl:fANICAl. '-UMlT8 2 "t<<)T'IlIE ACTUAL MIlE:AOE c''-' ~~,~~';I:~:~~~r~E~EAGE'O~ErEA 4.. EXEt,1PT tFIC/M ODOMETER VlSCLOSURE (':\ ,,- '''':1'' 11llE BnANQ~, ..".',,,"F,,X:':" .."~,t1UEIIE!IICLl!,"::',",',','.,.','."',,,.:',",':::;:'"":~:". ',:' ,: SIC,Vt'HIGLIj"., ,:,:j:,:':,,,;,",,,!,;,:,:;, ..: EOTlll.u'VEfHM 'I",,'" ",,' "r, .IOU OFCt1tJl'H~Y, ::!,',:,'I',,';' ,""QAIGlNAltI'MF~",,'.fU, """'" ,',"".$,,:, ~'XJ:Jfs'fr.:atJr:o'; 'r" '. ""'. ':':\ H _'AGRtC!JLTllfMI.VEl,IIClE%':,:",:,:>, l _lddGINo:lVEI"CL@' '" "',-,',W",,." P ~ I$IW^~ A rOIJGEVEIIlCU=: R"AECC"lS/AUt;lEIl S ~S'tREHROO ~ T "RECOVEI1W1HEFrVEHICle v ",\(l!HICU'COMTMNSflE\S$UEU'JlN {W~'L()orJVl;HIr::LE )( ~ i!lM'A-'> " ,"'1.;, }"t, (,::::;::'(:k~, \'~":;:;::~~h ~, 1\ <"!ilUt:NRElE:ASIW .1, O,o.,TE " 1'; _1~' U:"i.INGADDRESS ,', I.i l' Jl * , AUTHORIZED,f'lEF'AESENTATlIfE ~':::~ ,:':I'I:i',\~':'~' 'r ',", ',' ;'~'i ':?!.':, ~E;G~YA LONG ,; 4'10'jj'~ CHA!i(~'S' RD. MECHANICSBURG PA 17055 @~iilli :":'II!,'" 'i'~I'IJI;'~ ";',"'",',' ;,,,JI, ,:w.,.",,""III'..:;) "r~ l.-\ ".:;'; ~~.:,:~ "'<'.. lIwI offlclll raoords ot'lh" P....sylYlnlll OlIparlm~nl,..il:' peIBon(BI"'C<lmpG.n'lnl.loll'>'&rl~i~1htt.18w'ul':ll""llr: , , i I " '\ir. n.m It>'' 'Mpol1~lion , ~~ld vahicla. ~;j :~-: APPllC ION FIlR TITL~ AND L1E~ INFORMATIO . 11111 co-purchaS6r olher Ihon your spouse 1$ 1l~9d and you want the tllln 10 be IlsW:! 85 "Joint Ten8nl$ WIth Right 01 Sl,!rvlvOIShip" (On dealh q~, one owner, title goer. 10 r.urvwlTlg owner,)CHE~\< HERE [J.,Otherw!~tl.:t~1;j litle will be Issued as "T6flanls In Commo~~ (rj~,:,dtlat~;,~1 o~t>:Nnef,j(ln\~lttll ,~t decea$oo owner g08S 10 hl~er heir,' or.~ll'lAje).,: ",,',:':,:,::',' :''-j''',:Y' :~:: 1ST LiEN DAfE: 1e~ !~Nb lIE'~;"CH~~t~/'\\:;... ".."CilltlEPANUS....OON j ," ..-.. ,I I ,1'LfORE,Me:: ..,~.'~~ o:~" Joi:/ ~~~~ 1[~~ c-t.z~,o:h:;r",~~~ZW - 'if""'" 1!';:::;jFi > ~"'vn<d h...bJ....... .Pfl4l<;ol"'" lor, ~;lits,. "' lQ,_ \Q.,,,,_~:""_ ""..~IIl.11...~''''"...J<lII,..~~i!''..tIo~h_... ' ;>',-_. (JIl i'HINT) Cellihcato ul "tille must be submit\nu wilhin 2u uay,;, unless Ihe purchaser is a n~yislered dealer holding IIle vehicle lor JeS<tlo r\N. A'-- -8- ~J I N G '~,;':FEDER^L,,^ND STATE LAWS REQUIRE THAT YOU nATE lHE MilEAGE IN CONNECTION" WITH. (THE ,T~N5FEI=I OF OWNER~HIP.. FAILURE L _ ,- . F ' :h''':'''' 'lOCOMPlETE OR "nOI/IUING A. rALSe STATEMENT "MY RESULT IN FINES AND/OR IMPRISONMENT. i':' ::' "';"':( , ,','", ' ,':"'."'~'"'f''''''''' ''';''':l',,~:Reg'oUlietldol''~ ~l ~~ 101...,. l.wnA <i ""'21\\ i >: 'J ::;,}!ff;; LAPt",,)~ :~],:~::~, :.:. ",'" FIRST::..: ',,:"::i':., M,I. . 'Ie '~MEl'n ',Q '",'I:l1LE~;':"'1'1:.' '.,q.JtlJd b)o:-r~"'- II purctlhef 1.f:i.Q[ A' .-glSln,..;._lel. . .'.., ":,~".~\ ,it:,:,,:':~:t ,,~j':i:?:"::'" ""':",:': \-, ',I"~ ',I'fy. 1~,.~,~,;~:~,:;'.o~"~.:,:";;:;;i;;:;~;I~~~'~ b8 ~lnd,l' :tl~~~~E~II~~FI1I;F/{ N J:.tk>71' ,,~,:,::,.::~..:,.~.,,:..:'~~~':':" ,_' ~ A~K''',:'':' :"-.':~ '1 ').".,FDJY,tffi" . "." ,", . co',"",",,,, nAif As ',I.'."'.'. c.Y,'irN.-rA- .... I _'eoe..::::j;l'ii;~Li"'>,<.mlln'llI1drenec:tSlhellel"'BlmllllllgeOllheVllhicle. ',(,)'-1.. ';,"''''':'.'' ," M ;;.L"."", 4.r-- \Jl' o"eOl~JOII;;~;i.f~e~'lilctJedI;~;1 ;..:,' ,,"'~'- ....::',,:, ',r;:, ~,', ,~b~~~1s'" 3't':,~, ;'y~It-XR'llb l tle1lf1ct.lhOlllTlOlIl11oII'l1llllBgO") ',;,..f'ti 18NOTthoBdualmllli~gB'" i'''' '~"~ ,I::',..;;,,;,:'''''''':,' " _ "\01~Mloflts~!lJllClllllmlts ~~', '."L.J .....ARNING:~~'..I"',~"dI8t'epari~ ,:r;,~",: .J...!.~ ' ,~&J::: _~____~ 1'-1\1" 1"'lhft'CII.tilYlhot,lhe. yo. hlcktIS.'. &01 "."' 1IOdu.' mbrancellrld.'llat o~,~'..'"le;,Ilii,r"I"'. '1'(". .."~ .tJ!fA;\". ,-'.tl'''.~.''. < 1";"~:;'.I"'\'../~.5. <:> f..': PO". C..~I ~.1'h Jr,,,. "~Jt~~~'OI'1he(/jlotlerll'lell, ',;'i '" ',,,'N"w, ""!iJ!A~, ,-,,":"':',.- ~"~_E,,, ~,,>',r "~,i,;,"Z\P_..:..-c-- --:-' OflO_~O L-:>.~ r';"IBEo':ANO\S"ORN)i;, ";4+" ,'-.:;. "II,',:'",'I!,I"", ,r" 'fiii';':':'I':;:i,", 'j',',1.!J. : ,'" ;'~'\i,l'" ,. '.;C7 ~7~"'" I.";;" , ': ..'.0"'1',..... ',., ,,';,' ',", ',,' "',,' -',,'J;.' ~' '. .;?di::>'"'' ."" ~,." ~ .1"'1"1" "~,,l-~' "~Ii'l" ',' "~) ,,'t; ""V'""';, ,',,-; , , ,~ I:,~', I ," "":w ",' .... ~ ,"" ""J'~'" ij 1111 II,' ,',", ': . .... 'MO.~;.'. ~.. ....'.. .,..A" '-, '," , '." :' "";G.~tASERSIGN".TuRe _ f'" ,~,.q:'''''.''.':'''' ":"r",,, "',1,,'. ",.f; '" ,;,,' I",. ,,'" :)12-" ;',> L i -i "~;~:~~~!E~: ~.~' ':COi.~~:S~~::;.I".'~,,-;~.'..~... .~..1:~~:iLf~ /'~)rq ,i;~ ,130BERTA'E, B1ESECKEFl, No!afY,Pl' .' ;'~X-0~C:;" .... ~ JV.xec il!.;'.' ':. /1 Camp Hili BotQ. Cumbllrllll)d C()(JI1 . '_ S~""""'O","," /~ :'! ,;'ijy/ ~ O?",millolonExplro8 .Iuly 4j, 20 "y.., ,:,:~,'"', ,,;~'iffM"I';"'''' ,'I, ' ,., '''''1'.'1'''' \, "'Y"'I"::, ""'i":'''''''.'\,'' 1~"J"""il'\'.;Y:ii";'I:",*',";i;:,'t,i,:'~,:il:',,: .':";,;,',!;:,:,~,,;,!, . :: ,~~'t!:,; '. ", ::{:lk!f: ,!,i,:, ,', '~t~ ~',i~I:' ',<:, ,,1' ,"111(1','" 11:,/,:, ':,:,i,:,:fri:": " t:} lid .IISSIGNMENT OF TITLE BY REGISTERED DEALER. V 1/,. rCl'!.ly:,\_o..~.~,~,';.~r'.()\J' knOWledge Ihal~ odom8\~' readjnl,l Ill;. ~ ,"- ~::J2i~~j~Ti~~~s '~,~ .'~\fi$ 11'0 oeluel rrMl~,~';,;,~I l'1iti~:~i0',:~ \I '1"'", One 01 IhlllollyW~lQbo~e,.,1f chocked_;;, :';' , "d"",I:~ ::r!l!t,!"" ~I:':,',',','/r::," , J l1efl9C\l. U,., lIt(lOIJnI. 01 mlleeg&,!,',+<:;rr1 1. NOr '''a al:1.WiI."'~.''''. ,I''''''j','':':', L ,in~oI,~~~I,~!II A1iN'~, W"RNINO; ~~~t:~,f!c(otj,Mr'I(y II':" r"'lharCllrllfy!l'l.lllltKlVllhlcl.,!ElI.....olll~~'~~\I\a1n.;;l'J,fwil'~rlpl.'ln'rl!by " '",' r~,.~~ 10 ~1' fI(Irson(s) or the ~al., lIated: ":";.", " 'II:!';-"""":",'I "<':,"'," "r! "HIDED AND SWORN ',;J:aHE ME:;~ sr"H, ,,'j li' PUflCIllISEPRICE OROlN OAY yfAIl MO. I.., ~'i :(0 !, ~I,GNATURE Of ff.li-SOH ADMINiStERING OA1H IGNMENT OF TitLE BY REOISTEIlED DEALER. II pUtChl!.Mt \9 OT \\ reglsteT d tleal[!T SectIon D on t e fron 0 this lorm mU!I becompfeldd -- To} tI~~, ~:a~,:~:'F~~~~~:I~~~~d!le;~llat th:,romtt18' tt~I"!I"~;,,',:,t"i,#.,":;,,,: ";:"( __'.~~:.lli2~X m\lenancl re"8l."\t the elrl...almllea~,?llt,.'~ehlcle.I";;:':, ,w,> ~lt;'.. fullowlnQ b01es li'e'hecked:lt, '(:Wi '<:,::" "::;:\" i'~';')":':',I:~r, ,,'::ri::fi:'lii' .j',,;,:/):i',:,:,:,:,:, .11!ell""I~II'lI11mou'llolmll~ge '>; rl JsNOTlhellCllJ,IUjllo~gll ,',',:',",":':', '" erC('1l6 <llttr; meclwJicalllinllll U W"RNlNG: OdomoIO',dlllC''PariCy' ,':':/~',~r,~;!~~Yp~:::,:,'{:/g~~~ ~~~:~I~t~~ .neu,',-nb,allC;' arld Ihel1h& ,~,~~~,(tl"1p laih'~!!.by ,'f :"~'ij';:"""",,"';',f."'\ ",',1':, ,:i,,:~,,'r;'" """,:,,\'~~'I;','::, ':""'," .' "~' ,e ',~.~l' 1 '" CU~CHAiI" bfl F,':!1ol';""""I'd,!,I'i~"',',',,J"I" U INESS' AMEI...--',:" ",,,,,,,'1'"'' ~UFI~~!i3ER ~Y~'i::':'t, ':,J~':i';~:'Nl:;i', smEET ""~'i<<',',...,', ',':,1"::'1; ""II'W;~~"'''' 'I,t" ~ ,~Es~',F" ~''';''''':'"i,;I,'":,'','";,:,,,, CITY c,LAST FIRST " ,';.'> >1< ':\ d<'p 1\"-~C\\lBEl) AND SWORN , 11U'UHE ME: ~ STATE '",n',' li' PUnClJASEPfllCE OAOIN MO. DAY YEAR;, :it.~:;" PtJACH.0\5EflSIGNATUflE +)0 ;,:i r'U '. SIGNIITURE OF PERSON "OMINI9tEfltN13 OA1H ';;~.';.:;.,',; 'I , ~' , ',; >,. . '\'.;lii.'j~.., ,':)\\/!,::::!:,;,..:;.,,)t", C:~PUAC~~,ER ~IG~,~TUfl~, '/' '-1A1:\>~IW:Y" ",.::ft/kix:, :':l, .1 ,(b." ".,' ", (J:b,;,,;,0,*lf~,' ':,,:::,;:9:4:: ,,;;:::: 'SIGf,lAru~eO/lSE\,U:R 'ijf{/l/#;::,)y ", 'i~~M!::U,,:,:::::':~\ ..,.:.;:::(iWi:::....;' PUfl,Cl-lAsep.I\WOfOp. , ~~UF'tCHA~ER MUf I,' ~. _'NT "':'E" A' " SElLEAMUST ),. HANOPR/t-lTN!\Ml:: IlEne ,\"',' ,Iii ",,:,:,:~,~i', ,--, ';.-,,',,;!-,,,:,,,,::,,,:,, <:'1:': ~l)' ,- , purc aset Is t:!Q _ a U!glsler d dea er ecllcn on e ron 0 I 19 otm !11us be completed . . . rl"\"tolhObestor,i11yfoor1..-.owlodgelllalthe odometer readlng,'-" " ",:", ., ":_:::ITHIltIS ',1',',' '," __'-"-'-_ ~ ~r X ml~s arid lallecl$ lloe QetlJal mllaageof Ihe'lItIhicle,':'" rUI1CIIIISEfl6n FUll "01 1;,elollowlnll bo~esllJ Checlcod:",'::"':_ :::,,;:,[',!,: 2,:';':':\" ,~~,SINE~,S,,~~E '::":"'J':' I ] n"lled$ th.. amoUnl 01 mileage' fT1 la NOT the ACIU.'.' m. ""'8.110'. ";:","::,,',,:,',,;: ',~RC~~,ER :,~;(,',:::," I ,- - '" a~ce~~ 01 lI:s 1neCh8nlealllrnlts LJ WARNING; odomet~r d!sI:'llpaliC)' SlRI!!Ed',W,'I,M,li I.I.,,,,:,!,, : ",p""lh~,r.ell!tylhAllhAvehlaloI8rreeolally'ncumbrancenl1dthetlhlf~iltJi1li.'" 'Ill."."." e,tll:by AdORESSJ-" ',,:1' "."'11 ." '""...llo!hI! p~l~on(sl Of1hA dtalfl' lisle<!. 'X" ,',". '~,":':':,~~~"f.'('~;~'I~"1' _,' , " ~ ", .,,~ .,. ',' ~ITV , ',:~,( 'IIrJ[O AND SWORN ',J'''~',~;''\i-I.Jt;;tj'~II'-'; "',<' lllE ME: DA ", Y~~R"':~~'" ,~jllt(it'i' 'j?~r.' ~;:~; CAST fIRst ,;,:,:,;::,:::", ''''':':''''''','' \'11''''''1 1,'1",:::::::, "ii' ,--x"~ '>i <'i \\:'i/ ,"',) "' ,"P\lAC\1I\SE1"FIlCE OI\UIN ",.,-,.." :if::; <,,;; 't'" SIGNA luRE OF PERSON AOMrNISTEHlNG O^ HI PUIlCHA9ERSlGfltATURE : k" I<,j;:~ \1/1 >Y~ co-PURCHASER SlGHATURt' ',";",''''';:i:/0'' ,,!" !;;i;; ~",~:~it):t;, ,::+}i" \ ,.'~,,:, ","'*f ,~~:\,;!'::' ", ,," SIl1AAtlme.oF BEl.l.ER . 'l':"~",:'i':"f' ,; ::'.';"":', i':::~"rih.',i/t . "'\i:'i,~"'~' ",'" :'",y:'-',:'" \\' ",:,,:', ','" ,'>' ] CHECK HERE IF APPUCATIOKfOR DEALER TIT~E AND C9111~~I'T~l'E!<TIOIj..P,IUl!.1j9...~E~S ~ ~ ---'~cl""_'",..'",,",..,&'1 M.l. '" ,- ~ "' pJ ,- In JJ "' 0, G5 '< " 2 JJ '" <n o /~ ~i) 0, G 'I> > c~ 0, '-i "' '0 Q i-:! '" f~ '" fJ 0, Ci <: o '< ,- -< ;;: ~ '" -0 JJ 'I> "' '" '< () '" o " '" '< o 'I> :!1 () '" JJ "1 1:: <J o ~ JJ i!l d '" fJ ~ 0, rr1 JJ ~ :I! "' M.L PSEOt:: P.O. Box 67013 (717) 234-B4B4 (Harrisburg) Harrisburg, PA 17106-7013 (BOO) 237-7328 (Nationwide) website - http://www.psecu.com Pcnnlylvolllo Slote Employecs Credit Union VISA" PAGE 1 0.00 1",11""111""1,1,11...,.,."".,,1......1111.,,,,,11",111 PEGGY LONG 4701 CHARLES RD MECHANICSBURG PA 17050-7701 Wny waste time & money on writing checks and paying postage? 1f)'OU are gotng to make )'OUf VIsa peyment using. PSECU ch.ck, log lnb onIne banking end ..anater your VJaa paymentl Or, callus at (eoo) 237.7328 nationwide or (717) 234.8484 In Harrlsburg. A. the menu starts, enter 44. Usten b the .electlon and follow tIw Instrucllone. ('rou'. need your account number and PIN handy.) Either Way - No eo.t, Quick & easy. Available 2"-hou... . Oayl 3090182229373 TO REPORT A LOST OR STOLEN CARD" CAu.. OUR BUSINESS NUMBERS LISTED ATTHE TOP OF EACH STATEMENT PAGE FROM 7 AM - 5 PM MONDAY 10 FRIDAY AND 8 NIl 10 12 PM SAnJRDAY, OTHERVVISE CAU, 801}.556-5678 :~:PA~-'-" 0182XXXXXX 10/31/02 11/25/02 9125.00 QELEASE BEFORE j, DETACHING HERE T "';:-,:':;,:':':-:-;-";-'-'-;":':':-:'---:':.""", ",~.".. "~~'~..'~~~"~,~- 0.00 0.00 9125.00 ID 09 VISA LOAN POST TRAN REFERENCE DESCRIPTION AMOUNT YTD FINANCE CHARGE, YEAR TO DATE 1.60 'IOTA!. FINANCE CHARGE 0.00 0.00 0.00 0.00 ANNUAL PERCENTAGE RATE !Ir:>lB:i~::I~~:~ PER~l>C + f1";'~= _ 'IOTA!. -~:-~~I~~~-- ---~:[J-----~:~~ -I---~~ -:~~~_~~[ ~: ~~ 2'1611511 9.900% 12.900% PSECt: P.O. Box 67013 (717) 234-8484 (lIurrisuury) Harrisuurg, PA III 06-7013 (800) 237-7328 (Nationwide) website - http://www.psecu.com PennsylvanlO Stale Employees Credit Union TAKE THE HASSLE OUT OF HOLIDAY SHOPPING. USE YOUR PSECU VISA. PEGGY LONG JOINT OWNER HARTIN E LONG PAGE 2 I I ?1 (.0"1? p.o. Box 67013 (717) 234.8484 (tlorr~burg) Horrisburg, PA 17106.7013 (600) 237-7326 (Nofionwide) website - hltp://www.psecu.com TAKE THE HASSLE OUT OF HOLIDAY SHOPPING. USE YOUR PSECU VISA. PEGGY LONG JOINT OWNER HARTlN E LONG PAGE 3 Z160513 PSEce P.O. Box 6701 J (717) 134-8484 (Hurrisburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Naliarrwiue) website - h"p:/ /www.psecu.com Pennsylvania State Employees Credit Union TAKE THE HASSLE OUT OF HOLIDAY SHOPPING. USE YOUR PSECU VISA. PEGGY LONG JOINT OVIINER HARTIN E LONG PAGE 4 2160514 Baughman Memorial Works, Inc. DESIGNERS AND BUILDERS OF eemete'Uf M~ 23-25 South Main Street PrIce Lf 3.:) 99- ... }ObiS..... DOVER, PA. 17315 Telephone 292-2621 P :13' . ~;!i6 . Total rice..). ........... Please design and build the following memorial DATE . ~1J' ~..... h.,. (k:..... .}~I. 7.$~.~...... 'A'..... ',j'" '1\ .,.... Address... ~~:i' .~..: -f7o \..... .~~. M... .f.Y.h:Jl.a1"",C~~. ""j' A... .{~().. Design No. l.'~~-'t n4l! . W1 ~r.1 ~ L.. U ~ Material f..n. ('~~~. . . . . (Y\. r/v'O \ ~ r l'Y\aA- \tJt . Die U For Base Posts Pt:J~~ rl. \~fJOV2.t Lv; tZ Lo (\) J 'AN!::l rno'thz (' Markers . d ~~ .4 j.~ . . . . . . . . . Price . . . . . . . . . . . . . Tax.... 'J 00 Deposit .::>OD.~............ Balance Due. d.3,{...80. . . . -Ff;olaJ Family Name. . . . . . . . . . . . . *ctl4:/r<-{,.K Inscription ............. :.'>. . . . j 101 rrq:\C' ~ g, \qd1 Del d~ I de.)) d. '~.f6. .fp~~.. .It.~9..!)t B. .~. Malerial to be best selected monumental gr~ \rd to, ~e free fro~' ~:;'E~tns and first class in every way. Work to be :~e:e:o:ia~:~~~::~:a:~~......... ..~.~U).. ~~~.~................ ,................... Cemetery :::'l~~s n':~V~id~bt \~~""::\'b-~;;be-!i\"~ih~~ . ~~~ii';~~~~:s t:y:;;'O,t\1,:f ";;'b-o' nd the .. ~~~;; .~~ . p;,;;~ible" Addi: tional lettering and other work o~is memorial in the future is not included in the Contract Pri Style of Letters ............... Foundation to be furnished by .. . . Title and right of possession and removal of said stone, monument or appurtenances shall remain for all purposes in Baugh- man Memorial Works Wltil work and materials ordered are fully paid by purchaser or purchasers. In consideration of the ac- ceptance by Baughman Memorial Works of this order, the Wldersigned (hereinafter known as the purchaser) agrees to pay Baughman Memorial Works .... ........... ..................... ........ ...... ......... ....... ....Dollars on or before the 15th day following the billing of the work or job upon completion thereof by Baughman Memorial Works, said billing to be notice of completion thereof, this order shall become a crmtract between the purchaser and Baughman Memorial Works upon acceptance thereof in' the space below by a quly authorized representative of said Baughman Memorial Works; it being underswod that this instrument upon such acceptance covers all of the agreement between the purchaser and Baughman Mt!morial Works and that no agent or representative of Baughman Memorial Works has made any statements or agreements, verbal or written, modified or adding to the terms and conditions herein set forth. It is further Wlderstood that upon the acceptance of this order the contract so made cannot be cancelled, altered, or modified by the purchaser or by any agent of Baughman Memorial Works or in any manner except by agreement in writing between the purchaser and Baughman Memorial Works, and it is hereby understood and agreed by all parties involved that in case of de- ' fault by purchaser or purchasers, twenty-five per cent of the total original cost of the work or. work and materials ordered, as " the case may be, shall be a specified correct sum as liquidated damages which purchaser shall owe Baughman Memorial Works, less any payment on account made prior to such default, this specification of damages to be due regardless of removal and taking possession of stone, monument or materials from purchaser or purchasers by Baughman Memorial Works upon following such default. \ ............................................................... ...................................................... . (SEAL) ~~~~~~~~. '~e'~~~;~' ~~~~~. .~~~:~~~; .~;. }S~1)1r.~~: ::::::::::: ::::::: ::.... .::::::::::::::: ::::: 'II;, nrr; r.". ,.~". . r. ",. r;.1 ~_'IA ". r. t", c /l) .. CD " o ... ~ ~ ~ '" 't' III '< ~ z " r- m /l) )> ::E '< (J) 3 -f III CD III )> ::I ~ r- .. )> )> r- Z )> 0 z ~~ m 0 m V) V) ~ \ '- ~ \.}j - \;'l ~ "- ~ ~ ... C c \ c C, Q. iil ... CII o o " ~ -< z )> " .!!l ~ o o C- o iilr ~ o :;; " :D ~p z !::l ).- .,., ~ " "- ~. l;' ~ ; ,. i \~ " , 'j "- ......---. '" "- '? --- '\"" ,.. I '- \~ ;I;;. ., , f TAX TOTAL _Q011324 Rec'd by .iI "1)"r1~ MtJST h,~ ;lccorn ;inied by this:/;i.ifl. d~/ STATUS REPORT UNDER RULE 6.12 Name of Decedent:__~.~ ~, i~-v Date of Death: ~t~`c3-G11(1 ~- Will No. ~~.UOJ~ - ~~~( ~ Admin. No. ~l' ~a - U ~ ~~ 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: Yes~_ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal rep sentative file a final account with the Court? Yes No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ,~ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date: ~~~~ ~d3 . Signature =~~ ~ ~~~ (~ L~ ~~ Name (Please type or pri t) ~i ~ a -~ v~ ; f~ ,~. ; « ~~ ~ ~, d Address ('t [ ~) '7 3 ~~ - ~~ a ~ Tel. No. Capacity: / Personal Representative Counsel for personal representative (MAH:rmf/AM3) BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRI58URG, PA 17128-0601 LYNDA A LONG 4827 VIRGINIA RD MECHANICSBURG COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT REV-1607 E% AFP (01-03) DATE 08-04-2003 ESTATE OF LONG PEGGY A DATE OF DEATH 10-29-2002 FILE NUMBER 21 02-0981 ' •• _-=• COUNTY CUMBERLAND ACN 101 • Amount Remitted PA 170.50-3075 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion ofi this fora with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~1 ------------------------------------------------------------------------------------------- REV-1607 EX AFP (01-03) ~(** INHERITANCE TAX STATEMENT OF ACCOUNT *~(~( ESTATE OF LONG PEGGY A FILE N0. 21 02-0981 ACN 101 DATE 08-04-2003 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: 06-03-2003 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 6,074.49 PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID 01-24-2003 CD002086 263.16 5,000.00 05-01-2003 CD002514 .00 818.60 07-21-2003 REFUND .00 7.27- TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. TOTAL DUE 6,074.49 .00 .00 .00 IF TOTAL DUE IS REFLECTED AS A "CREDIT•• (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )