HomeMy WebLinkAbout01-0760
"-'. oJ / ~ - c:2 6 --'(""J ~ / 3
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
IlEV-1607 EX iFP (01-02)
.02
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
~rt 7 :4E;OUNTY
-I.- ACN
03-04-2002
PLUTKO
05-18-2001
21 01-0760
CUMBERLAND
101
ROSE
M
RfJC.-'
GEORGE A VAUGHN III
3904 TRINDLE RD
CAMP HILL
APR -1
Allount Rellitted
PA 1701~;;S[;<
CllJnb~;
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLEI PA 17013
NOTE: To insure prqper credit to your accountl subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REY=i6"ifj-Ex--AFP--fol-:oi.r------...-iNirERITANCE--YAX-STAfEME-NY-ifF-AC-Couiif--...---------------------
ESTATE OF PLUTKO ROSE M FILE NO. 21 01-0760 ACN 101 DATE 03-04-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SU""ARY OF THE PRINCIPAL TAX DUEl APPLICATION OF ALL PAYMENTSI THE CURRENT BALANCEI ANDI IF APPLICABLEI
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-11-2002
P R I NC I PAL TAX DU E : ............._...................._.....................................................................................................................................................................................
1/867.53
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-16-2001 CDOOO169 93.38 2/300.00
02-14-2002 REFUND .00 525.85-
TOTAL TAX CREDIT 1/867.53
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATEI SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $11
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A ..CREDIT" (CR) I
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
/6-~t!?-/3
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BU~U OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
, DEPT. 280601
HARRISBURG I PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
ReC,ln:>.' ..
RE;'~_j'r,:
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
A 8 :4 ~OUNTY
ACN
02-11-2002
PLUTKO
05-18-2001
21 01-0760
CUMBERLAND
101
GEORGE A VAUGHN III
3904 TRINDLE RD
CAMP HILL
.02
FEB 19
PA 170Ulen~,
CUITlbc:- .
*'
REY-1S.7 EX AFP 112-01)
ROSE
M
Allount Rellitted
( X) CHANGED
ll)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
2,950.00
89,135.94
5,341.55
(8)
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REY=is4-j-ix-AFP-flz-:oo"r-NoY-ici--oF-'rNHiifiTAifci-YAX-APPRjrisiMENT~--Ai:l-owAiici-ifi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF PLUTKO ROSE M FILE NO. 21 01-0760 ACN 101 DATE 02-11-2002
TAX RETURN WAS:
) ACCEPTED AS FILED
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 B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
llO)
9,304.65
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
97,427.49
1;1;.9'6 91
41,500.58
.00
41,500.58
NOTE: If an assessment was issued previOUSly, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
lS. Allount of Line 14 at Spousal rate
16. Allount of Line 14 taxable at Lineal/Class A rate
17. Allount of Line 14 at Sibling rate
18. Allount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
46.622.26
lll)
ll2)
ll3)
ll4)
llS) .00 X 00 = .00
ll6) 41,500.58 X 045 = 1,867.53
ll7) .00 X 12 = .00
ll8) .00 X 15 = .00
ll9)= 1,867.53
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-16-2001 CDOOO169 93.38 2,300.00
TOTAL TAX CREDIT 2,393.38
BALANCE OF TAX DUE 525.85CR
INTEREST AND PEN. .00
TOTAL DUE 525.85CR
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT-- (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
REV.1470 EX (6-88)
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME
Rose M Plutko
REVIEWED BY
Deborah Washington
ITEM
SCHEDULE NO.
H A-2
INHERITANCE TAX
EXPLANATION
OF CHANGES
EXPLANATION OF CHANGES
Not an expense of this estate
ROW
FILE NUMBER
ACN
2101-0760
101
Page 1
George A. Vaughn, III
Attorney at Law
3904 Trindle Road
Camp Hill, Pennsylvania 17011
(717) 975-9102
FAX (717) 975-9105
ReCO[t)d.., \.
Rr;q;:;:c.
of
"01 ole 31 P12 :47
Clerk
Cumbeila: rJ.L\
c:!/-~{){j-~0 0
December 20, 2001
i'jp
~~
Mary C. Lewis, Register of Wills
Cumberland County Court House
Carlisle, P A 17013
RE: Estate of Rose M. Plutko
Dear Mrs. Lewis:
Enclosed please find two copies of the Pennsylvania inheritance tax return for the above-
referenced estate for filing. Also enclosed is a check in the amount of$15.00 paying the filing
fees. Should you have any questions, please contact me.
!rulY YO,r:;ts,
() lilt &
e rge A. Va, III
Attorney at Law
GA V /dj
Enclosures
George A. Vaughn, III
Attorney at Law
3904 Trindle Road
Camp Hill, Pennsylvania 17011
(717) 975-9102
FAX (717) 975-9105
August 16, 2001
HAND DELIVERED
Mary C. Lewis, Register of Wills
Cumberland County Court House
Carlisle, P A 17013
RE: Estate of Rose M. Plutko
Date of Death: May 21, 2001
Mrs. Lewis:
It has not yet been necessary to proceed with probate for this estate, but a Pennsylvania
inheritance tax return will certainly be required. Accordingly, a prepayment of the estimated
inheritance tax liability for the estate is now being made to secure the early payment discount. A
check in the amount of$2,300.00 is enclosed for this purpose. Kindly process this payment and
issue your receipt for it in due course.
Since this is also the first documentary filing in your office for this estate, I am also
enclosing a complete Estate Information Sheet.
If you require anything further at this time, please let me know.
Very truly yours,
~tl U~
~rge Aqaug~~ III
Attorney at Law
GA V/gav
Enclosures (2)
cc: Mrs. Suzanne M. Jones
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
VAUGHN GEORGE A III ESQ
3904 TRINDLE ROAD
CAMP HILL, PA 17011
__nn__ fold
ESTATE INFORMATION: SSN: 181-24-9171
FILE NUMBER: 21-2001- 0760
DECEDENT NAME: PLUTKO ROSE M
DA TE OF PAYMENT: 08/16/2001
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 05/18/2001
NO. CD 000169
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,300.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,300.00
REMARKS: SUZANNE M JONES
C/O GEORGE A VAUGHN III ESQ
CHECK# 3439
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-1500 EX. (6-00)
CAPB
HpRL
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CRAC
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
P1utko Rose M.
DATE OF DEATH (MM-DD-YEAR)
.~~
OFFICIAL USE ONLY
/b-d5().-/3
FILE NUMBER
COUNTY CODE
21-01-760
YEAR
NUMBER
SOCIAL SECURITY NUMBER
N':irie
~~.
NOne
None
2,950~00
89,135':":94
);, , '
5,341. 55
9,457.31
46,622.26
x
X
X
X
.0 0
.0 45
.12
.15
DATE OF BIRTH (MM-DD- YEAR)
1. Original Return
4. Limited Estate
6. Decedent Died Testate
2. Supplemental Return
4a. Future Interest Compromise (date of death after 12-12-82)
7. Decedent Maintained a Living Trust
181-24-9171
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o
o
3. Remainder Return ~f~; fc,f 12e~}~ -82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch 0)
(Attach copy of Will) (Attach copy of Trust)
o 9. Litigation Proceeds Received 010. Spousal Poverty Credit
(date of death between 12-31-91 and 1-1-95)
P NAME COMPLETE MAILING ADDRESS
C
0 0 III
R N 3904 Trind1e Road
R D
E E Camp Hill, PA 17011
N
S T TELEPHONE NUMBER
9 5-9102
Real Estate (Schedule A)
Stocks and Bonds (Schedule B)
Closely Held Corporation, Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, 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 Bequests/See 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)
(1)
(2)
(3)
c:5 OFFICI~. ONLY
-"*!"'C' -:'......
(r"~ 'I::i
c;::J
c-::;
w
:g
N
.p;.
-.J
(8) 97,427.49
(11) 56,079.57
(12) 41 ,347. 92
(13)
(14) 41,347.92
(15)
(16)
(17)
(18)
(19)
0.00
1,860.66
0.00
0.00
1,860.66
R
E
C
A
P
J
T
U
L
A
T
I
o
N
(4)
(5)
(6)
C
o
M
T ~
A T
X A
T
I
o
N
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. X
41,347.92
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
5 Wheatfield Drive
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
1,860.66
2,300.00
93.03
Total Credits ( A + B + C) (2)
2,393.03
3. Interest/Penalty if applicable
D. I nte rest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line S + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
532.37
0.00
0.00
0.00
iii:::iW~:t~~~,~i~~~!~~iy~~il~:~tt~!I'~~:!:~~~~y~~i~~m~~:::~~~6:1:!~:~~il:"'~:,,m~~li:+~~i:i~~~~i~~i~:li~y~~t~~~~WiiW:iii
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; .
c. retain a reversionary interest; or. . . . . . . . . . . . . .. ..........
d. receive the promise for life of either payments, benefits or care? . . . . . . . . .
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . " ...... [K] 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
[K]
o
o
IT!
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
Suzanne M. Jones
5 Wheatfie1d Drive
-----------------------------------------------------
Carn Hill, PA 170113
George A. Vaughn III
3904 Trindle Road
- - -cro;- - -Hi ri - - PA - - rid ir - - - - - - - - - - - - - - - - - - - - - - - - -
DATE
1~113/{) I
DATE
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 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%
[72 P.S. 9116 (a) (1.1) Oi)]. 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 twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 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.S%, except as noted in 72 P.S. 9116(1.2)
[72 P.S. 9116(aX1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 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.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
REV-1508 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Rose M. Plutko
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
SS11 181-24-9171
05/18/2001
FILE NUMBER
21-01-760
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
DESCRIPTION
1984 Cadillac Coupe DeVille
VALUE AT DATE
OF DEATH
2,450.00
2
Miscellaneous household and personal effects
500.00
TOTAL (Also enter on line 5, Recapitulation) $ 2,950.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSyslems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1509 EX . (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Rose M. Plutko
SCHEDULE F
JOINTL V-OWNED PROPERTY
55/; 181-24- 9171
05/18/2001
FILE NUMBER
21-01-760
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
A.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
Suzanne M. Jones
B.
c.
5 Wheatfield Drive
Carlisle, PA 17013
RELATIONSHIP TO DECEDENT
Daughter
JOINTLY -OWNED PROPERTY:
LETTER
ITEM FOR JOINT
NUMBER TENANT
1 A
2
A
3
A
4
A
5
A
DATE
MADE
JOINT
06/30/99
DESCRIPTION OF PROPERTY
Include name of financial institution and bank
account number or similar identifying number.
Attach deed for joinlly- held real estate.
Commerce Bank, N.A.;
Checking Account #513088666
- Balance as of date of
death
DATE OF DEATH
VALUE OF ASSET
12,163.43
06/30/99 Commerce Bank, N.A.; Time
Deposit Account #23403 -
Balance as of date of death
% OF DATE OF DEATH
DECO'S VALUE OF
INTEREST DECEDENT'S INTEREST
50.00% 6,081.72
50.00%
5,019.06
10,038.12
06/30/99 Commerce Bank, N.A.; Time
Deposit Account #23404 -
Balance as of date of death
10,038.12
07/03/00 Commerce Bank, N.A.; Time
Deposit Account #301137 -
Balance as of date of death
10,032.20
08/14/98 Residential real estate
located at 5 Wheatfield
Drive, Carlisle, PA;
improved with one story
brick and vinyl ranch
dwelling (1,248 sq. ft.)
136,000.00
50.00%
5,019.06
50.00%
5,016.10
50.00%
68,000.00
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
89,135.94
Form REV-1509 EX (Rev. 1-97)
SCHEDULE F - Exhibit
CENTRAL PENN APPRAISALS, INC.
File No. WHEATFI5
APPRAISAL OF
Single Family Residence
LOCATED AT:
5 WHEATFIELD DRIVE
CARLISLE, PA 17013
FOR:
FIRST UNITED MTG. SERVICES
4931 CARLISLE PIKE
MECHANICSBURG, PA 17055
AS OF:
APRIL 9, 1999
BY:
ROBERT K. BANZHOFF
PACERT RL-001231-L
Pronertv Oescrintlon Uk-.. - ORM RESIDENTIAL APPRAISAL h_~ORT File No. WHEATFI5
Prooertv Address I) WHEATFIELD DRIVE Citv CARLISLE State PA Zio Code 170n
Leoal Descriotion DEED BOOK W1l). PAGE 1074 CounlvCUMBERLAND
Assessor's Parcel No. SEE MAP REFERENCE NUMBER Tax Year 1998 R.E. Taxes $1 . SO 1 .00 Snecial Assessments SNONE
Borrower JONES R&:S/PLUTKO R. Current Owner BORROWER Occuoant: r xl Owner I I Tenant r l Vacant
.. Prooertv riohts anoraised 1 xl Fee Simole f l Leasehold I Proiect Tvoe I I PUD fl Condominium IHUDIVA onlv\ HOAS NONE/Mo.
Neiahborhood or Proiect Name THE MEADOWS Maa Reference 21-011-04 ":l.":l.-I) 1 Census Tract 0118
Sale Price $ REFINANCE Date 01 Sale 4-qq Descrintion and $ amount of loan charaes/concessions to be oaid bv seller N 1 A
Lender/Client FIRST UNITED MTG. SERVICES Address 4q11 CARLISLE PIKE. MECHANICSBURG. PA 1701)11
ADDraiser ROBERT K. BANZHOFF Address 24 WEST MAIN STREET SHIREMANSTOWN PA 17011
Location 0 Urban l1J Suburban LJ Rural Predominant Single family housing Present land use % land use change
Built up 0 Over 75% 'XI 25-75% 0 Under 25% occupancy PRICE AGE One family 60 0 Not likely 0 liKely
,LA! , $ (000) (yrs)
Growth rale 0 Rapid W Stable 0 Slow CXJ Owner 80 Low NEW 2-4 family 0 CXJ In process
Property values 0 IncreaSing W Stable 0 Declining 0 Tenant MOO Hiah .Mulli-famIIY 0 To: 1 F AMIL Y
Demand/supply q Shortage W In balance q Over supply ~ Vacant (0-5%) Predominant Commercial 5
MarKetinatimeIIUnder3mosIXI3-6mos.IIOver6mos. IIVacanlfover5X\ 12'5 I 10 VACANT, ~
Note: Race and the racial composition of the neighborhood are not appraisal factors.
Neighborhood boundaries and characteristics: See Attached Addendum.
. Factors that affect the marketability 01 the properties in the neighborhood (proximity to employment and amenities, employment stability, appeal to market. etc.):
. This suburban neiahborhood has most DubHc utilities available. relativelv easv access to
.. emolovment and services. and is comoetitive with other nei12hborhoods in the aeneral area. Most
have similar amenities. No unfavorable factors were observed which would adverselv effect
marketabili tv.
Market conditions in the subject neighborhood (including support lor the above conclusions related to the trend of property values, demand/supply, and marketing time
- - such as data on competitive properties for sale in the neighborhood, description 01 the prevalence of sales and financing concessions, etc.):
There are no foreseeable economic trends which miaht sianificantlv influence market conditions
in this area. The current mort12a12e market offers a wide varietv of conventional loans with
competitive rates. As a result. the terms of financin12 have little if any. imoact on sales
orices. If interest rates remain reasonable. orooertv values and marketabilitv should be 12ood.
Project Information for PUDs (11 applicable) - - Is the developer/builder in control of the Home Owners' Association (HOA)? U YES 0 NO
. Approximate total number 01 units in the subject project N 1 A Approximate total number 01 units for sale in the subject project N 1 A
Describe common elements and recreational facilities: N 1 A
Dimensions SEE LEGAL DESCRIPTION Topography SLIGHT SLOPE
Sile area . 51 AC Corner Lot U Yes lxJ No Size TYPICAL FOR AREA
Specific zoning classification and description RESIDENTIAL Shape RECTANGULAR
Zoning compliance CXJ Legal 0 Legaloonconforming(Grandfalhereduse) 0 Illegal U No zoning Drainage APPEARS ADEQUATE
Hiahesl & best use as imoroved: rXlPresent use-Fey Other use lexr\lain\ View AVERAGE
Utilities Public Other Off-site Improvements Type Public Private Landscaping AVERAGE
Electricity [Xl Street ASPHALT W 0 Driveway Surtace ASPHALT
Gas W Curb/guller NONE 0 0 Apparent easements NONE OBSERVED
Water W Sidewalk NONE 0 0 FEMA Special Flood Hazard Area U Yes (Xl No
Sanitary sewer CXJ Streetlights NONE Q Q FEMA Zone C Map Date 6-11)-81
Storm sewer !Xl AIIev NONE i I I I FEMAManNo. 420":l.61/0010B
Comments (apparent adverse easements, encroachments, special assessments. slide areas, illegal or legal nonconlorming zoning, use, etc.): Site has
avera12e site imorovements. avera12e landscaoin12. and tvoical maintenance. There are no apparent
adverse easement encroachments. or other adverse conditions on this site.
GENERAL DESCRIPTION EXTERIOR DESCRIPTION FOUNDATION BASEMENT
No. 01 Units 1 Foundation CONC. BLOCK Slab NONE Area Sq.Ft. 1248
No. 01 Stories 1 Exterior Walls BRCK/VINYL Crawl Space NONE % Finished 90%
Type (Det./AIl.) DETACHED Roof Surtace SHINGLE Basement YES Ceiling DRYWALL
Design (Style) RANCH Gullers & Dwnspls. ALUMINUM Sump Pump NONE Walls WD PNL
Existing/Proposed EXISTING Window Type DB HG THRM Dampness NONE OBSER. Floor CARPET
Age (Yrs.) 10 Storm/Screens NO/YES Se\tlement NONE OBSER. Outside Entry NO
Effective Aoe Yrs\ ~. Manufactured House NO Infestation NONE OBSER.
. ROOMS Fover Livino Dinino Kitchen Den Familv Rm. Rec. Rm. Bedrooms # Baths
~~n~ 2 1
Level 1 1 AREA 1
. Level 2
INSULATION
Root
Ceiling AVE
Walls AVE
Floor AVE
None
Unknown
o
CXJ
CXJ
CKJ
o
o
Laundrv
X
Other
Area So.Ft.
1.248
1.248
":l.
2
. 0
Finished area above nrade contains: ~ Rooms' 1 Bedroomls\' 2 Bathls" 1 _ 248 Souare Feet 01 Gross Uvino Area
INTERIOR Material s/Condilion HEATING KITCHEN EQUIP. ATTIC AMENITIES CAR STORAGE:
Floors CPT/VIN/BTRAVE Type FA Refrigerator 0 None 0 Fireplace(s) # L- CXJ None 0
. Walis DRYWALL/BTR AV Fuel GAS Range/OVen (X) Stairs 0 Patio 0 Garage # of cars
Trim/Finish WOOD/BTR AVE Condition AVE Dispusal CXJ Drop Stair 0 Deck 1 CXJ Attached 2
Bath Floor VINYL/BTR AVE COOLING Dishwasher CXJ Scuttle CXJ Porch 1 CXJ Delached
_...._. _ ,.....~'r'Io A'lI"_ - . \.1..-,.. ~ '" I,;'i - ,--,
V I ;t
U~ ORM RESIDENTIAL APPRAISAL ~ t>>ORT
a ua ion Section ~ .- File No. WHEATF'IJ:}
ESTIMATED SITE VALUE ..,.. . .......,.. . " $ 11 000 Comments on Cost Approach (such as. source of cost estimate,
ESTIMATED REPRODUCTION COST -NEW OF IMPROVEMENTS: site value, square foot calculation and for HUD, V A and FmHA, the
Dwelling 1 .248 Sq. FI. @ $ 62.45 " $ 77 . 938 estimated remaining economic life of the property): See Attached
Bsmt. 1248 Sq. Ft. @ $ 1l1. 00 " 17.472 Addendum.
. FP/PORCH/DECK " 9.000
. Garage/Carport ~ Sq. Ft. @ $ 14.00 6.468
"
Total Estimated Cost New. .. ............ = $ 110.878
. Less Physical I Functional I External
Depreciation 8.870 $0 $0 " $ 8.870
Depreciated Value of Improvements. " $ 102 008
"As-is" Value of Site Improvements. . . = $ 1 000
INDICATED VALUE BY COST APPROACH " s 138 000
ITEM I SUBJECT COMPARABLE NO.1 COMPARABLE NO.2 COMPARABLE NO.3
5 WHEATF'IELD DRIVE 2 CONIFER LANE 423 BERNHEIZEL BRIDGE 34 TEABERRY DRIVE
M~_CAAUS
Proximitv to Subiect MILES 2 BLOCKS BLOCKS
Sales Price $ REF'INANC $ 140 0 1 00 $ 1 8 000
Price/Gross Uv. Area $ O.oOtllls 81.'18~ $ 104.4'1 $ 107.14
Data and/or INSPECTION ASMT RECORDS/MLS/ ASMT RECORDS/MLS/ ASMT RECORDS/MLS/
Verilication Sources N/A AGNT/STTMNT DEPT. AGNT/ST'I'MNT DEPT. AGNT/STTMNT DEPT.
VAlUE ADJUSlMENTS DESCRIPTION DESCRIPTION I '(-)$ Adju.tm.nt DESCRIPTION I '(-)$ Adiu,tmen! DESCRIPTION I .1-) S Ad",.tment
Sales or Financing CONVENTIONAL , CONVENTIONAL , CONVENTIONAL 0
0 , ,
Concessions NONE , NONE , NONE
, .
Date of Sale/Time 1-12-g8Fn , 4-10-98/45 , 19-16-q8/41
, ,
Location AVERAGE AVERAGE 0 AVERAGE , AVERAGE ,
, 0
Leasehold/Fee Simole FEE FEE , FEE 0 FEE 0
, ,
Sife .J:}1 AC .ljq AC .74 AC , .48 AC
, 0 ,
View AVERAGE AVERAGE , AVERAGE 0 AVERAGE ,
Desion and Aooeal RANCH/AVE RANCH/AVE 0 BI-LEV/AVE , BI-LEV/AVE
. ,
CUalitv of Construction AVERAGE AVERAGE 0 AVERAGE . AVERAGE 0
, , ,
Aoe 10/lj 5/3 . -4.000 13/2 , -4.000 4/2 -4.000
, ,
Condition AVERAGE BTR THN AVE , -2 000 BTR THN AVE , -2 000 BTR THN AVE -2 000
, 0 ,
Above Grade T etal : 8drms : Total: Bdrm, . , Total : Bdrms l 0 Total: Bdrms . Bath.
Baths Bath. 0 Bath. ,
5 : 1: ~ 6 1: 2.5: -500 6 0 1: 2: 6 , ':l: 1 . Ij : +500
Room Count 0 ,
Gross Livina Area 1 .248 Sa. Ft. 1 .684 Sa. Ft. : -6 000 1 282 Sa. Ft. : 1 288 So. Ft. ,
,
. Basement & Finished FULL BASEMEN1 FULL BASEMENT : PART BASEMENT : +2,000 PART BASEMENT : +2,000
DEN~ 0
Rooms Below Grade REC RM/2 UNFINISHED 0 +6 000 REC ROOM , +2.000 REC ROOM +2.000
, ,
Functional Utilitv AVERAGE AVERAGE , AVERAGE 0 AVERAGE ,
0
Heatina/Coolino FA/CN AIR HP/CN AIR , FA/CN AIR , FA/CN AIR ,
. , ,
Enerav Efficient Items TYP FOR AREA lTyP FOR AREA , TYP FOR AREA . TYP FOR AREA
,
Garaae/Caroor! 2CAR GAR/ATT 2CAR GAR/ATT 0 2CAR GAR/INT , 2CAR GAR/INT 0
, , ,
Porch, Patio. Deck, PORCH/DECK DECK , +500 DECK , +500 DECK , +500
0 . ,
, 0
Fireolacels\, etc. 1 FP NONE , +2.000 NONE . +2 000 1 FP
.
NONE NONE , NONE , NONE ,
Fence, Pool. etc. , , ,
NONE NONE , NONE , NONE 0
0 ,
Net Ad/. Itolall r l + [xl - :$ 4.000 lxl+ l J- :$ 500 I I + rxl - :$ 1 000
Adjusted Sales Price 1~~~Illj~1111 $ ii.~J~i:~i:i!~~~ii $ i~IJ~i;.~~~~I\ $
of Comoarable 116.7'30 134 400 117 000
Comments on Sales Comparison (including the subject property's compatibility to the neighborhood, etc. ): See Attached Addendum.
ITEM SUBJECT COMPARABLE NO.1 COMPARABLE NO.2 COMPARABLE NO.3
Date. Price and Data HAS NOT NONE KNOWN TO EXIST NONE KNOWN TO EXIST NONE KNOWN TO EXIST
Source for prior sales TRANSFERRED PTHER THAN LISTED OTHER THAN LISTED OTHER THAN LISTED
wilhin vear of aooraisal IN PAST YEAR. ABOVE. ABOVE. ABOVE.
Analysis of any current agreement 01 sale, option. or listing ot the subject property and analysis of any poor sales at subject and comparables within one year of the date of appraisal:
PROPERTY TRANSFERRED 8-14-q8 FOR $127.'300.
INDICATED VALUE BY SALES COMPARISON APPROACH. $ n6 000
INDICATED VALUE BY INCOME APPROACH (If Applicable) Estimated Markel Rent $ N / A /Mo. X Gross Rent Multiplier N/ A : $ N/A
This appraisal is made LXJ "as is" U subject to the repairs, alterations. inspections or conditions listed below U subject to completion per plans and specifications.
Conditions at Appraisal: Th is aODraisal report has been prepared with the property in "as is" condition. No
Inersonal nronertv has been included in this valuation.
Final Reconciliation See Attached Addendum.
REV-1510 EX + (1-97)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Rose M. P1utko
05/18/2001
FILE NUMBER
21-01-760
5511 181-24-9171
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
DESCRIPTION OF PROPERTY %OF
ITEM RELA~~8~M~I~ 1Wb~~~5~M.t;WJ~~~b"fl~EJF 1~~~SFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE)
1 M&T Bank; Certificate of 5,341. 55 100.00% 5,341. 55
Deposit 1131003910874211 -
Balance at date of death
(joint ownership created
within one year of date of
death)
TOTAL (Also enter on line 7, Recapitulation) $ 5,341. 55
(If more space is needed, insert additional sheets of the same size)
Copyright (c) t996 form software only CPSystems, Inc.
Form REV-1510 EX (Rev. 1-97)
REV-1S11 EX+(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Rose M. Plutko
SS1t 181-24-9171
05/18/2001
FilE NUMBER
21-01-760
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES:
Allegro Restaurant - Funeral luncheon
431.15
2
Charge for hotel room for funeral attendance (2 nights)
152.66
3
Krish Funeral Home - Professional funeral services
5,081. 00
ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees George A. Vaughn III
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Suzanne M. Jones
Street Address 5 Wheatfield Drive
City Carlisle State PA Zip 17013
Relationship of Claimant to Decedent Daughter
832.50
2,945.00
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Register of Wills - Reserve for inheritance tax return and
inventory filing fee
15.00
TOTAL (Also enter on line 9, Recapitulation) $ 9 ,457 . 31
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
Estate of: Rose M. Plutko
Soc Sec #: 181-24-9171
Date of Death: 05/18/2001
Item
#
Description
Continuation of Schedule H-B3
(Family Exemption)
Amount
1
Suzanne M. Jones - Family Exemption
2,945.00
2,945.00
Estate of: Rose M. Plutko
Soc Sec #: 181-24-9171
Date of Death: 05/18/2001
Continuation of Schedule H-B2
(Attorney's Fees)
Item
if
Description
Amount
1
George A. Vaughn, III - Payment of interim attorney's fee
George A. Vaughn, III - Payment of interim attorney's fee
George A. Vaughn, III - Reserve for payment of final attorney's
fee
295.00
2
237.50
3
300.00
832.50
REV-1512 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Rose M. Plutko
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
55!! 181-24-9171
05/18/2001
FILE NUMBER
21-01-760
Include unreimbursed medical expenses.
ITEM
NUMBER
1 AT&T - Final bill
DESCRIPTION
AMOUNT
10.10
2
Cumberland Family Practice - Medical services - final bill
9.64
3
Holy Spirit Hospital - Medical services - final bill
12.72
4
Moffit Pease & Lim - Medical services - final bills
34.21
5
National City Mortgage Co. - One-half of mortgage debt
encumbering 5 Wheatfield Drive, Carlisle, PA (total debt is
$92,855.24)
46,427.62
6
Verizon - Final bill
8.42
7
West Shore EMS - Ambulance services
119.55
TOTAL (Also enter on line 10, Recapitulation) $ 46,622.26
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
v
SCHEDULE I
Exhibit
.
> '.7~. -1 (~
~::> '-.---
r; C ;; E r1":' : . :. I f.: ~ I. r: n
1\ I: G n r it.::. n~' ,. ~ ~~ ~ S
'~L'r,~O~f\L/i.~:'~: r:~~J:!~;'.'-~,~~
'89 nrR 19 Prl 1 23
ISpace Abov. Thi. Un. For Recording Data'
LOAN NO.
0000617446
The mortgagor is
MORTGAGE
THIS MORTGAGE ("Security Instrument") is given on APRIL 14
RONALD M JONES AND SUZANNE M JONES
1999
AND ROSE M. PLUTKO
(" Borrow~r").
This Security Instrument is given to FIRST UNITED MORTGAGE SERVICES, INC.,
which is organizeu anu existing unuer the laws of COMMONWEALTH OF PENNSYLVANIA
auuress is 4931 CARLISLE PIKE,
MECHANICSBURG, PA 17055
Borrower owes Lenuer the principal sum of NINETY-FIVE THOUSAND AND 00/100
, amI whose
(" L~nuer").
.
Dollars (U.S. $ 95,000.00 ). This u~ht is eviuenc~u hy Borrow~r's not~ uat~u Ihe sam~ uate as Ihis Se<:unl\
Instrument ("Nok"), which provid~s tilr monthly payments, wilh th~ full deht, if not paid ~arlier, tlue anu payahle on
MA Y 1, 2029 . This Se<:urily Instrument secures to Lenuer: (a) the repayment of the ueht "vluen<:~u hy th" Nole.
with interest, anu all renewals, ~xtensions anu moditications of the Not~; (h) the payment of all other Sllll1S, with int~r"st. auvan,eJ
under paragraph 710 prolectthe security oflhis Security Instrument; anu (cl Ihe performance of Borrow~r's <:ovenanls anu agreemenls
umler Ihis Security Instrument anu the Note. For this purpose, Borrower uoes herehy mortgage, grant anti <;onvey to L"nJer Ihe
following uescrihed property localeu in Cumber land Counly. PennsylvaOla:
SEE ATTACHED DESCRIPTION
which has lh~ atldr~ss of
5 WHEATFIELD DRIVE
Carlisle
Pennsylvania
17013
ISI,..tl
("Properly Address");
lellvl
IZip Codel
TOGETHER WITH all the improvements now or hereafter erecl~d on the properly, and all easements, appurt~nan<;es. anJ fixlure'
now or hereaner a parI of the property. All replac~m~nls and auditions shall also he <:overed hy thiS Se<;urily Instrument. AII..I
the foregoing is referred to in this Security Instrument as the "Property".
BORROWER COVENANTS that Borrowt:f is lawfully s~ised of th~ ~stale h~rehy conveyed and has Ihe right to lIlorlgage, !,lranl
and convey the Property and that the Property is unencumh~reJ, except Illr enculllhrances of reconl. Borrower warrants Rnd will
Jefellll generally Ihe litle to the Prop~rty against all claims and demands, suhi~cl to any encumhran<;es of record.
.
PENNSYLVANIA. Single Familv. Fannie Mae/Freddie Mec U~IFOR INSTRUMENT
Form 30399/90 Page ~o 6
La.., Fooms Inc. 18001 446.3555 . . ~ 9 BOUK 1535 rAGE of 95
LIFT '3039 9193 Initials: _ ~
~ ,,\ ~ ,~ l:l~; fl.! : (I, ~ 'i: .S
NationaICity@
Mortgage
National City Mortgage Co.
3232 Newmark Drive. Miamisburg, Ohio 45342
Telephone (937) 910-1200
Mailing Address:
P.O. Box 1820
Dayton, Ohio 45401-1820
CUSTOMER ACCOUNT ACTIVITY STATEMENT
RONALD M JONES
SUZANNE M JONES
5 WHEATFIELD DR
CARLISLE PA 17013
DATE 06/08/01
PAGE 1
LOAN NUMBER: 0617446
REQ BY EST
IF YOU HAVE QUESTIONS REGARDING THIS STATEMENT,
PLEASE CONTACT OUR CUSTOMER SERVICE DEPARTMENT
AT 1-800-822-5626 OR VISIT US AT OUR WEBSITE AT
WWW.NATIONALCITYMORTGAGE.COM.
*******************************************************************************
-------------------------- CURRENT ACCOUNT INFORMATION ------------------------
DATE TOTAL PRINCIPAL LOAN CURRENT
PAYMENT PAYMENT & INTEREST INTEREST PRINCIPAL ESCROW
DUE AMOUNT PAYMENT RATE BALANCE BALANCE
06-01-01 773.79 608.30 6.62500 92,855.24 1,199.89
*******************************************************************************
PROCESS
DATE
DUE
DATE
ACTIVITY FOR PERIOD 06/08/00 - 06/08/01
TRANSACTION TRANSACTION
CODE DESCRIPTION
EFFECTIVE DATE
OF TRANSACTION
-------------------------------------------------------------------------------
TRANSACTION
AMOUNT
PRIN. PAID/
BALANCE
ESCROW PAID/ ------------OTHER-------------
INTEREST BALANCE AMOUNT CODE/DESCRIPTION
-------------------------------------------------------------------------------
05-15-01 05-01 171 PAYMENT
773.79 95.14 513.16 165.49
92,855.24 1199.89 NEW PRINCIPAL/ESCROW BALANCES
04-13-01 04-01 171 PAYMENT
773.79 94.61 513.69 165.49
92,950.38 1034.40
04-03-01 04-01 313 CITY TAX DISBURSEMENT
328.27- 0.00 0.00 328.27-
868.91
03-19-01 03-01 172 PAYMENT
773.79 94.09 514.21
93,044.99
02-16-01 02-01 171 PAYMENT
773.79 93.58 514.72
93,139.08
01-12-01 01-01 171 PAYMENT
773.79 93.06 515.24
93,232.66
12-11-00 12-00 173 PAYMENT
765.81 92.55 515.75
93,325.72
165.49
1197.18
165.49
1031.69
165.49
866.20
157.51
700.71
NEW PRINCIPAL/ESCROW BALANCES
NEW PRINCIPAL/ESCROW BALANCES
03-16-01
NEW PRINCIPAL/ESCROW BALANCES
02-15-01
NEW PRINCIPAL/ESCROW BALANCES
NEW PRINCIPAL/ESCROW BALANCES
NEW PRINCIPAL/ESCROW BALANCES
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIAR IES
ESTATE OF
Rose M. P1utko
SSfI 181-24-9171
05/18/2001
FILE NUMBER
21-01-760
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
1 Suzanne M. Jones
5 Wheatfie1d Drive
Carlisle, PA 17013
Daughter Residue
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 2000 form software only The Lackner Group, Inc.
0.00
Form REV-1513 EX (Rev. 9-00)