HomeMy WebLinkAbout09-02-15 T'^" pennsylvania 1505618403
DEPARTMENT OF REVENtX(0314)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg PA 17128-0601 RESIDENT DECEDENT 21 15 0272
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
03 01 2015 07 18 1924
Decedent's Last Name Suffix Decedent's First Name MI
BURKETT JEANETTE E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q1. Original Return 2. Supplemental Return 3. Remainder Return(date of death 1:1
prior to 12-13-82)
4. Agricultural Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
R7. Decedent Died Testate ❑ 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
❑ 13. Business Assets ❑ 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT.THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
BRADLEY L GRIFFIE 717 243 5551
First Line of Address
396 ALEXANDER SPRING RO
Second Line of Address 4�
7:0 fil
G p Jy n G'
City or Post Office State ZIP Codern
(yi 3
CARLISLE PA 17015 N
c�
Correspondent's email address: bgriffie(cD_griffielaw.com
C f7 E 3
REGISTER 6F WILLS USE ONVY_
REGISTER OF WILLS USE ONLY ',_,,.� ..C• (�
DATE FILED MMDDYYYY "1
DATE FILED STAMP
Side 1
I I�II IIII I III IIII II II IIII IIII I II III IIII II I IIII
1505618403 1505618403 J
1505618411
REV-1500 EX
Decedent's Social Security Number
Decedents Name: Burkett, Jeanette E.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D).................................................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 74 , 454 - 33
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) F-] Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 74 -,454 - 33
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 8 -1626 - 59
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............................ 10. 1 ,053 - 77
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 9 -1680 - 36
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 64 -1773 - 97
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 6 4 ,7 7 3 - 9 7
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 641773 - 97 16. 21914 - 83
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 2 -,914 . 83
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT El
Under penalties of perjury,I declare 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 person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNA,TIRE OF PERSON Rj�SPON�S{BLE F FILI RETURN Richard L. Burkett I_DTE
1 �� '-67 -' /4
ADDRESS
8 Shippensburg Mobile Estates, Shippensburg, PA 17257
SIGN EPAR ESENTATIVE Bradley L. Griffie DA E
jr�
4;EQn
pring R ad, Suite 1, Carlisle, PA, 17015
11111111111311111111111111111111111111111 Side 2
1505618411 1505618411 J
REV-1500 EX Page 3 File Number 21-15-0272
Decedent's Complete Address:
DECEDENT'S NAME
Burkett,Jeanette E.
STREET ADDRESS
57 Shippensburg Mobile Estates
CITY STATE ZIP
Shippensburg PA 17257
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,914.83
2. Credits/Payments
A. Prior Payments 3,800.00
B. Discount 190.00
Total Credits(A +B) (2) 3,990.00
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 1,075.17
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
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;............................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ 0
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ 0
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ ❑x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is_0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1508 EX+(08-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
tel' DEPARTMENT OFPERSONAL PROPERTY
INHERITANCE TAXAXRETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Burkett, Jeanette E. 21-15-0272
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Comcast Premium Refund 19.52
2 F&M Trust- 23,455.25
Checking Account No. XXX8753
(See attached statement)
3 F&M Trust- 37,013.08
Savings Account No. XXX824
(See attached statement)
4 Personal Property(Auctioned)- 1,815.50
(See attached statement)
5 Mobile Home(Auctioned)- 9,800.00
(See attached statement)
6 State Farm Fire&Casualty Co. Refund 161.91
7 Social Security disbursement due at date of death 1,993.00
8 Adams Electric Cooperative, Inc. 147.54
9 Adams Electric Cooperative, Inc. 48.53
TOTAL(Also enter on Line 5, Recapitulation) 74,454.33
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 08-12)
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
' DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAXTURN
RESIDENT_DECEDENT
T ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Burkett, Jeanette E. 21-15-0272
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 130.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees IS riff ie&Associates, P.C. 3,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 255.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 4,741.09
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 8,626.59
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Burkett, Jeanette E: 21-15-0272
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Eby Granite Works 130.00
H-A 130.00
Other Administrative Costs
2 Shippensburg Mobile Estates(lot rent) 382.54
3 CenturyLink 51.61
4 The Sentinel (advertisement) 169.30
5 Adams Electric Cooperative, Inc. 139.55
6 Cumberland Law Journal (advertisement) 75.00
7 Auctioneer's Commission (sale of personal property) 635.43
8 Auctioneer's Commission(mobile home) 980.00
9 Barry L. Negley,Tax Collector- 53.33
(Real estate taxes)
10 Barry Negley,Tax Collector(Real estate taxes) 53.33
11 Social Security Refund of Overpayment 1,701.00
12 Reserves 500.00
H-67 4,741.09
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-12)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF
AXEVENUE
RETURN
INHERITANCE TAX RETMORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Burkett,Jeanette E. 21-15-0272
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Centuryl-ink 51.61
2 Quantum Imaging&Therapeutic Assoc. 12.41
3 Carlisle Digestive Disease Assoc. 104.66
4 Hospitalists of Central PA 14.16
5 Masland Associates, Inc. 42.34
6 Highmark Blue Shield(Pro-rated insurance premium) 7.34
7 Timmons Oil, Inc. (Heating oil)- 364.10
(Paid pre-death; posted post-death)
8 Shippensburg Mobile Estates(Rent)- 377.24
(Paid pre-death; posted post-death)
9 Adams Electric 79.91
TOTAL(Also enter on Line 10, Recapitulation) 1,053.77
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-12)
REV-1513 EX+(01-10)
7 pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Burkett, Jeanette E. 21-15-0272
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trustee s
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Edward W. Burkett Son Twenty-five 16,193.49
9 Bridgewater Road percent of net
Newville, PA 17241 distributable
estate
Larry E. Burkett Son Twenty-five 16,193.49
303 W. Pine Street percent of net
Mount Holly Springs, PA 17065 distributable
estate
Richard L. Burkett Son Twenty-five 16,193.50
8 Shippensburg Mobile Estates percent of net
Shippensburg, PA 17257 distributable
estate
Nancy L. Burkholder Daughter Twenty-five 16,193.49
10 W. Main Street percent of net
Newburg, PA 17240 distributable
estate
Total 64,773.97
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
i
OF
JEANETTE E. BURRETT
I, JEANETTE E. BURRETT, of Newville, Cumberland. County,
Pennsylvania, being of sound and disposing mind, memory and
understanding, do make, publish and declare this to be my Last
Will and Testament, hereby revoking and making void all previous
Wills and Codicils heretofore made by me.
„ ..u. .,........... ...... ._ ,
FIRST
?,E, I:worder :and direct my personal representative' hereinafter
named to pay all of my just debts, funeral expenses and expenses
involved or connected with the administration of my estate as .
soon after my death as is reasonably possible. However, my
personal representative need not accelerate and pay those
unmatured obligations which, in his, her or its opinion, it might
be proper and more advantageous to retain or renew and pay as
they become due and payable. If I do not own a burial plot or a
grave marker at the time of my death, I authorize my personal
representative, in his, her or its sole discretion, to purchase a
burial plot and to erect a suitable grave marker at my grave, and
to expend sums from my estate for this purpose.
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
SUITE 307
•CARLISLE, PA 17013 PAGE 1 OF 4 CHAMBERSBURG, PA 17201
SECOND
I give, devise and bequeath the rest, residue and remainder
of my estate, together with all insurance proceeds thereon of
whatever nature and wheresoever situate to my beloved spouse,
CHESTER L. BURKETT, providing that he survives me by sixty (60)
days.
THIRD
Should my spouse, CHESTER L. BURKETT, predecease me or die
on or before the sixtieth (60) day following my death, then I
give, devise and bequeath the rest, residue and remainder of my
estate together with all insurance proceeds thereon of whatsoever
nature and wheresoever situate in equal shares to my children
EDWARD W. BURKETT, NANCY L. BURKHOLDER, RICHARD L. BURKETT, LARRY
E. BURKETT and LESTER S. BURKETT who survive me by sixty (60)
days : ;per capita. I direct my personal representative to divide
among such beneficiaries all personal property of a sentimental
or family nature (excluding cash, stocks, bonds and the like) ,
including but not limited to jewelry, household goods, antiques,
furniture and memorabilia, in accordance with a separate
memorandum which I may place with my will or deposit with my
attorney. In the absence of such disposition of memorandum, I
direct that the said tangible personal property be divided
between my residual beneficiaries with due regard for their
personal preferences in as nearly equal shares as practical, with
the value of such dispositions being credited to the share of
each respective recipient. If the said beneficiaries do not
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
SUITE 307
CARLISLE, PA 17013 PAGE 2 OF 4 CHAMBERSBURG, PA 17201
agree to the division of the personal property provided for
hereunder, the decision of my personal representative, including
the decision to sell the property at public or private sale and
distribute the proceeds therefrom as provided hereinafter, shall
be final and conclusive on all parties.
FOURTH
I nominate, constitute - -and appoint my son, RICHARD L.
BURRETT, as Executor of this my Last Will and Testament. In * the
event my son is deceased, unable or unwilling to serve or . shall
cease to serve for any reason whatsoever, then I nominate,
constitute and appoint my son, EDWARD W. BURRETT, as personal
representative of this my Last Will and Testament. I direct that
my personal representative shall not"-be required to give or post
bond for the faithful performance of his, her or its duties in
I
this or any other jurisdiction.
FIFTH
I hereby declare it to be my . expressed desire that my
personal representative employ the lava' firm of . Griffie &
Associates, of Carlisle, Pennsylvania, for legal advice and
assistance regarding this my Last Will and Testament, they having
considerable knowledge of my affairs, views and wishes respecting
any matters that may arise at the probate of this instrument, the
administration of my estate, and the execution of the powers
herein mentioned.
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
CARLISLE, PA 17013 PAGE 3 OF 4 SUITE 307
CHAMBERSBURG, PA 17201
IN WITNESS WHEREOF, I have hereunto set my hand to this my
Last Will and Testament this a5tl1 day of Rpt 1
19�(�.
WITNESS:
ANETTE E. BURKETT
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
SUITE 307
CARLISLE, PA 17013 PAGE 4 OF 4 CHAMBERSBURG, PA 17201
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
: SS
COUNTY OF CUMBERLAND
I, JEANETTE E. BURKETT, the Testatrix whose name is signed
to the attached or foregoing instrument, having been duly
qualified according to law, do hereby acknowledge that I signed
and executed the .instrument as my Last Will and Testament; that I
signed it willingly, and that I signed it as my free and
voluntary act for the purposes therein expressed.
ANETTE E. BURKE T
Sworn or affirmed and acknowledged before me by JEANETTE E.
BURKETT, the Testator, this c ,y day of
.fit J'
1996.
I
Notarial Seal '
Robin J.Goshorn,Notary Public
Carlisle 0oro,Cumberland County
My Cornmlgsion Expires April 17,1999
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
SUITE 307
CARLISLE, PA 17013
CHAMBERSBURG, PA 17201
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
: SS
COUNTY OF CUMBERLAND
We, t dei to . Ca I Vff and
the witnesses whose names are attached to the foregoing document,
being duly qualified according to law, do depose and say that we
were , present. . and .saw-JEAKET:!E E. BURKE'rT sign_ and execute the
instrument as her ' Last Will and Testament; that she signed
willingly and that she executed it as a free and voluntary act
for the purposes therein expressed; that each subscribing witness
in the hearing and sight of the Testatrix signed the Last Will
and Testament as witnesses and that to the best of our knowledge
the Testatrix was at the time 18 or more years of age, of sound
mind and under no constraint or undue influence.
Sworn or affirmed and subscribed before me by
Cyd / _
c ,/�-tom ril,rC�and Cc.�i � .�� this a:5*6L day
of %� , 19 '7
Notarial Seal
Robin J.Goshorn,Notary Public
Carlisle Boro,Cumberland County
My Commission Expires April 17,199
GRIFFIE & ASSOCIATES
ATTORNEYS AT LAW
14 NORTH MAIN STREET
200 NORTH HANOVER STREET
SUITE 307
CARLISLE, PA 17013 CHAMBERSBURG, PA 17201
Attachment to Schedule "E"
F&M TRUST
Date of Death Valuations
Customer Name: JEANETTE E.BURKETT
Date of Death March 1,2015
Total Balance
as of Date of
Acct Type Account Number Open Date Close Date Balance Accrued Int Death Interest YTD Account Owners/Title Joint Established
Savings 811824 12/5/2001 4/212015 $37,013.03 $0.05 $37,013.08 $2.99 Jeanette E Burkett
Checkingi 3428753 3/18/2002 4/1/2015 $23,455.25 $0.00 $23,455.25 $0.00 Jeanette E Burkett
DAN HERSHEY' AUCTION SERVICE, LLC
790 West High Street
Carlisle, PA 17013
(717) 532-4647
Steve Ege 717-385-5438 Cell Chris Bream 717-226-1920 Cell
'N Tf— DA -
SELLERS NAME xf�f tLld KD' TE
L
ADDRESS PHONE 00yH
OTHER ^IIAUCTIONEER %
AUCTION DATE/LOCATION Ah CLERK %
DESCRIPTION OF MERCHANDISE
is ((I
Vj J?
-k"[f 110 14LAC w sr,
4A lrlf_fi61'1'+I qncrt I I slik'-wev 601'V o
4 t
�v P
A ��Pkf'k 1�
4� i:� 1" ki" t
r �1
C, 0( `
v
<k
ac C, .613('5,
j_,) r PC,�
U ly� '0
I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized representa-
tive of the merchandise, goods and/or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement. Trash fee applied if applicable.
AUCTION SIGNATURE SELLERS SIGNATURE
,�ed* ) $
Total: les (Clerking Tick tsUiit
Less Sale Expense:
C,3C; Ll 7
% Comm'is.sion Auctioneer $
%Commission Clerks $
OTHER:`
TOTALSALE,EXPENSE DEDUCTED $
SELLERS NET $
AV
AUCTION SIGNATURE
DAN HERSHEY AucTioN SERVICE, LLC
790 West High Street
Carlisle, PA 17013
(717) 532-4647
Steve.-Ege 717=385-5438 Cell Chris Bream 717-226,1920 Cell
SELL EI2S.NAME ;-:.�i C��,. C�' \' -. �.c tj <t '5 �
�1 t' DATE.
ADDRESS C:, �} i -L Y\y'+�� « 5` i PHONE{(i t
OTHER r�=kx��� a' ; !`���f, o CJ
AUCTIONEER /o
AUCTION DATE/LOCATION ;ti(t oft `o"r,11') CLERK %
DESCRIPTION OF.MERCHANDISE
i .
I'Commission the Auctioneers to.sell the merchandise:to the.highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids.I certify that I am the owner or authorized representa-
tive of the merchandise, goods and/or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement. Trash fee applied if applicable.
�:.':.SELLERS::SIGNATURE SIGNATURE...
-:
AUCTION SIIATU'RE -
2-7
Total Sales (Clerking Tickets Attached) $
Less Sale Expense:
-L % Commission.Auctioneer
% Commission Clerks $
OTHER:
-:TOTAL SALE EXPENSE:DEDUCTED $.
SELLERS NET
AUCTION SIGMATUR E-