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Home My WebLink About01-31-06 REV-1500 EX + (6-00) REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-{)601 OFFICIAL USE ONLY FILE NUMBER 2 1 -0 5 0 4 5 5 ""'COuNTY"'CoiiE -VEAR- - - NuMeER- - DECEDENTS NAME (LAST, FIRST, AND MIDDlE INITIAL) SOCIAL SECURllY NUMBER ~ Z W C w o w C BOWMAN D. WILLIAM DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) 04/08/2005 10/05/1954 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) BOWMAN MICHELE 2 0 2 - 4 2 - 7 375 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURllY NUMBER 1 83- 4 4 - 2 392 W I- ~ ~en OO::~ wD.O :x;oo 00::...1 D.m D. 0( 00 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Attach copy of WIll) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach copy ofTrusl) o 10. Spousal Poverty Credit (dal8ofdeath between 12-31-91 and 1-1-95) o 3. Remainder Return (daleofdeathpriorlD 12-13-82) o 5. Federal Estate Tax Retum Required _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113{A) (Attach Sch 0) I- Z W C Z o D. en w 0:: 0:: o o THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS SUSAN J. HARTMAN 1 IRVINE ROW FIRM NAME (If Applicable) DUNCAN & HARTMAN P.C. TELEPHONE NUMBER 717-249-7780 CARLISLE PA 17013 z o i= <C ..J ::J ~ ii: <C o W 0::: 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposils & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) {6} 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) OFFICIAL USE ONLY 2,290.42 -'J 10,116.98 } ~<. r , '_.:'.~' 3,919.31 34,668.56 ',-_J Cl 0.00 14. Net Value Subject to Tax {Line 12 minus Line 13} SEE INSTRUCTIONS ON REVERSE sIDe FOR APPLICABLE RATES z o i= <C ~ ::J D.. :! o o >< <( ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a}(1.2) 19. Tax Due 9,112.71 X .000 (15) 4,168.86 X .045 {16} X .12 {17} X .15 (18) {19} 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 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT (8) 50,995.27 7,214.00 30,499.70 (11) {12} (13) 37,713.70 13,281.57 0.00 {14} 13,281.57 0.00 187.60 187.60 :> > RF ~IIRF Tn AN~WFR AI I (,)IIF~TlnN~ nN RFVFR~F ~mF ANn RF~~F~K MA T~ < < 6 C;- L/ rr-- . 4' C f Cd [,1 0~ dJ,if _.~ 1/3{ J 5 diYf/l'1 Decedent's Complete Address: STREET ADDRESS 603 S. SPRING GARDEN STREET CITY I STATE I ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 187.60 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 5. Total Interest/Penalty (D + E) If Une 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) 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. (5A) B. Enter the total of line 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT (3) 4. 0.00 187.60 187.60 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; ........................ ............ ....................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00 c. retain a reversionary interest; or ...................................................................................................... 0 00 d. receive the promise for life of either payments, benefits or care? ........................... ...... ............................ 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?..................... ............. ........... .......... ......... ............ .................. 0 00 3. Did decedent own an oin trust for" or payable upon death bank account or security at his or her death? ................. 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............... ............... ................ ...... ................. .................................. 00 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. (J >> 11A..7,,\.._ ADDRESS 603 S. SPRING GARDEN STREET CARLISLE SIGNATURE OF PREPARER OTHER THAN REPRES ...LJ.t '- ) ADDRESS "' 1'IRVINE ROW" J CARLISLE PA 17013 DATE PA 17013 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 oftransfers to or for the use ofthe surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)l. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)J. 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 in...4iui...4. ......1 u.,h,... hO"'\C" ...,,+ l....."ro... "1"'0" n.......,...n.. ir"l ,...........u'Yv."""- ,,,if.h +hn ,.a",.."...I"". n,h",+hnr """,, ......",,1"4 "r .....rlru."..inn - ; Federal Tax Return for EASTERN STATES CLAIMS SERVICE, LLC 2003 GROUPS TAX AND PAYROLL 524 SOUTH PITT STREET CARLISLE, PA 17013 GROUPS TAX AND PAYROLL 524 SOUTH PITT STREET CARLISLE, PAl 7013 April 1, 2004 EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 Dear Sir, The 2003 federal income tax return for EASTERN STATES CLAIMS SERVICE, LLC has been successfully efiled. Enclosed is a copy of the return for your records. We have prepared your 2003 returns based on the information you have provided. Please review the returns carefully. If you have questions about these returns or about EASTERN STATES CLAIMS SERVICE, LLC's tax situation during the year, please call us. We appreciate this opportunity to serve you. Sincerely, SUZETTE CASE GROUPS TAX AND PAYROLL u.s. Partnership Declaration and Signature for Electronic Filing OMS No. 1545-0970 Form 8453-P Department of the Treasury Internal Revenue Service For calendar year 2003, or fiscal year beginning , and ending 2003 .. See instructions on back. Employer identification number 25-1884414 Name of partnership EASTERN STATES CLAIMS SERVICE LLC Number, street, and room or suite no. (or a P.O. box if mail is not delivered to a street address) 603 SOUTH SPRING GARDEN STREET City or town, state, and ZIP code CARLISLE PA 17013 Partnership Return Information Telephone number Gross receipts or sales less returns and allowances (Form 1065, line 1 c) 249,399 2 248,284 2 Gross profit (Form 1065, line 3) . . . . . . . . . 13,521 3 Ordinary income (loss) from trade or business activities (Form 1065, line 22) 4 3 4 Net income (loss) from rental real estate activities (Form 1065, Schedule K, line 2) 5 Net income loss from other rental activities Form 1065, Schedule K, line 3c Transmitter Information 6 Transmitter's name SUZETTE CASE Declaration of General Partner or Limited Liabilit Member Sign Here ERO's Use Only Paid Preparer's Use Only Under penalties of perjury, I declare that the above amounts (or the amounts on the attached listing) agree with the amounts shown on the corresponding lines of the electronic portion of the 2003 U.S. Return(s) of Partnership Income. I have also examined a copy of the return(s) being filed electronically with the Internal Revenue Service, and all accompanying schedules and statements. To the best of my knowledge and belief, they are true, correct. and complete. If I am not the transmitter, I consent that the return(s), including this declaration and accompanying schedules and statements. be sent to the Internal Revenue Service by the return transmitter. I also consent to the IRS' sending the transmitter an acknowledgment of receipt of transmission and an indication of whether or not the return is accepted, and, if rejected, the reason(s) for the rejection ~ Date and Paid Pre I declare that I have reviewed the above partnership return(s) and that the entries on Form 8453-P are complete and correct to the best of my knowledge. If I am only a.collector, I am not responsible for reviewing the return(s), and only declare that this form accurately reflects the data on the return(s). A general partner or limited liability company member will have signed this form before I submit the return(s). I will give the general partner or limited liability company member a copy of all forms and information to be filed with the IRS, and have followed all other requirements described in Pub. 1524, Procedures for the 1065 e-file Program, U.S. Partnership Return of Income for Tax Year 2003. If I am also the Paid Preparer, under penalties of perjury I declare that I have examined the above partnership return(s) and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete, Declaration of preparer is based on all information of which the preparer has any knowledge, Date Check if Check ERa's SSN or PTIN ERa's ~ also paid if self- signature , 4/1/2004 pre parer ~ D employed ~[R] P00056641 Firm's.name (or ~ GARY GROUP EIN ~ 23-2933778 yours If self-employed), , and address 524 SOUTH PITT STREET CARLI SLE PA ZIP code .. 17013 Under penalties of perjury, I declare that I have examined the above partnership return(s) and accompanying schedules and statements, and to the best of my knowledge and belief. they are true. correct. and complete. Declaration of preparer is based on all information of which the preparer has any knowledge, '1 If :\(/ ~. Lft),~-- Firm'sname (or J~ GROUPS TAX AND PAYROLL yours If self-employed), , address. and ZIP code 524 SOUTH PITT STREET CARLI SLE PA 17013 Pre parer's signature ~ Preparer's SSN or PTIN P00056645 23-2933778 717 -245-8581 Form 8453-P (2003) For Paperwork Reduction Act Notice, see instructions. (HTA) 1065 u.s. Return of Partnership Income I OMB No 1545-0099 Form Department of the Treasury For calendar year 2003, or tax year beginning , and ending _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _' 2003 Internal Revenue Service ~ See seoarate lnstri.ictlons.- - A Principal business activity Use the Name of partnership o Employer identification no. HEAVY EQUIPMENT API IRS EASTERN STATES CLAIMS SERVICE LLC 25-1884414 B Principal product or service label. Number, street, and room or suite no. If a P.O. box, see page 14 of the instructions. E Date business started APPRAISAL Other- 603 SOUTH SPRING GARDEN STREET 4/1/2001 C Business code number wise, City or town State ZIP code F Total assets (see page 14 print of the instructions) or type. PA 6,1301 541990 CARLISLE 17013 $ G Check applicable boxes: (1)Dlnitial return (2)DFinal return (3)DName change (4)DAddress change (5)DAmended return H Check accounting method: (1 )[K]Cash (2)DAccrual (3)DOther (specify) ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I Number of Schedules K-1. Attach one for each person who was a partner at any time during the tax year ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ? Caution: Include only trade or business income and expenses on lines 1a through 22 below. See the instructions for more information 1 a Gross receipts or sales 1a 249,399 ~ b Less returns and allowances 1b 1c 249,399 2 Cost of goods sold (Schedule A, line 8) 2 1,115 QI 3 Gross profit. Subtract line 2 from line 1 c 3 248,284 E 0 4 Ordinary income (loss) from other partnerships, estates, and trusts (attach schedule) 4 u -= 5 Net farm profit (loss) (attach Schedule F (Form 1040)) 5 6 Net gain (loss) from Form 4797, Part II, line 18 6 7 Other income (loss) (attach schedule) 7 8 Total income (loss). Combine lines 3 throuah 7 8 248,284 W 9 Salaries and wages (other than to partners) (less employment credits) 9 10 Guaranteed payments to partners 10 213,500 19 11 Repairs and maintenance 11 :s E 12 Bad debts 12 ~ 13 Rent 13 ~ 14 Taxes and licenses 14 60 .~ 15 Interest '116~ f 43'11 15 ~ 16 a Depreciation (if required, attach Form 4562) ~ ~ b Less depreciation reported on Schedule A and elsewhere on return . r 16b 1 16c 431 ~ ~ 17 Depletion (Do not deduct oil and gas depletion.) 17 18 Retirement plans, etc. 18 ! 19 Employee benefit programs 19 ~ 20 Other deductions (attach schedule) 20 20,772 g -g 21 Total deductions. Add the amounts shown in the far riqht column for lines 9 throuah 20 21 234,763 c 22 Ordinary income (loss) from trade or business activities. Subtract line 21 from line 8 22 13,521 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge Sign and belief. it is true. correct, and complete. Declaration of preparer (other than general partner or limited liability company member) is baseo on all information of which preparer has any knowledge. May the IRS discuss this return With Here ~ the preparer shown below (see ~Date instructions)? Wves DNo Signature of general.partner or limited liability company member Pre parer's ~ UJ (\ I Date I Check if Ipreparer's SSN or PTIN Ii , \ Paid signature j/0~- 4/1/2004 self-employed .D POO056645 Preparer's Firm's name (or yours J ~ 'GROUPS TAX AND PAYROLL EIN . 23-2933778 Use Only if self-employed), 524 SOUTH PITT STREET Phone no. 717-245-8581 address, and ZIP code CARLISLE State PA ZIP code 17013 For Paperwork Reduction Act Notice, see separate instructions. (HTA) Form 1065 (2003) 25-1884414 Pa e2 1 Inventory at beginning of year . . . . .. ...................... 1 2 Purchases less cost of items withdrawn for personal use 2 3 Cost of labor . . . . . . . . . . . . . . 3 1,115 4 Additional section 263A costs (attach schedule) . . . 4 5 Other costs (attach schedule) . . . . . . . . . . 5 6 Total. Add lines 1 through 5 . . . . . . . . . . . . . . . . . . . . 6 1,115 7 Inventory at end of year . . . . . . . . . . . . . . . . . . . . . . 7 8 Cost of goods sold. Subtract line 7 from line 6. Enter here and on page 1, line 2 8 1 ,115 9 a Check all methods used for valuing closing inventory: (i)DCost as described in Regulations section 1.471-3 (ii)DLower of cost or market as described in Regulations section 1.471-4 (iii)DOther (specify method used and attach explanation) ~ __ __ __ __ _ __ _ __ __ __ __ _ _ _ _ _ _ _ _ __ __ __ _ __ _ _ _ _ _ _ _ _ _ _ _ __ _ __ __ __ __ b Check this box if there was a writedown of "subnormal" goods as described in Regulations section 1.4 71-2(c) . . . . . . ~ 0 c Check this box if the LIFO inventory method was adopted this tax year for any goods (if checked, attach Form 970) . . . ~ 0 d Do the rules of section 263A (for property produced or acquired for resale) apply to the partnership? . . .. DVes ONo e Was there any change in determining quantities, cost, or valuations between opening and closing inventory? DVes ONo If "Ves," attach explanation. Other Information 1 What type of entity is filing this return? Check the applicable box: a DDomestic general partnership b DDomestic limited partnership c ~Domestic limited liability company d DDomestic limited liability partnership e DForeign partnership f DOther ~ _ __ __ _ _ _ _ __ __ __ _ _ _ __ __ __ __ __ _ __ __ __ _ __ ____ 2 Are any partners in this partnership also partnerships? . . . . . . . . . . . . . . . . . . . . . . 3 During the partnership's tax year, did the partnership own any interest in another partnership or in any foreign entity that was disregarded as an entity separate from its owner under Regulations sections 301.7701-2 and 301.7701-3? If yes, see instructions for required attachment . . . .. ...... . . . . . 4 Is this partnership subject to the consolidated audit procedures of sections 6221 through 6233? If "Yes," see Designation of Tax Matters Partner below . . . . . . 5 Does this partnership meet all three of the following requirements? a The partnership's total receipts for the tax year were less than $250,000; b The partnership's total assets at the end of the tax year were less than $600,000; and c Schedules K-1 are filed with the return and furnished to the partners on or before the due date (including extensions) for the partnership return. If "Ves," the partnership is not required to complete Schedules L, M-1, and M-2; Item F on page 1 of Form 1065; or Item J on Schedule K-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Does this partnership have any foreign partners? If "Ves," the partnership may have to file Forms 8804, 8805 and 8813. See page 20 of the instructions ... ....... ... .... .. .. .... .. 7 Is this partnership a publicly traded partnership as defined in section 469(k)(2)? . . . . . . . . . . . . 8 Has this partnership filed, or is it required to file, Form 8264, Application for Registration of a Tax Shelter? . . 9 At any time during calendar year 2003, did the partnership have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? See page 20 of the instructions for exceptions and filing requirements for Form TO F 90-22.1. If "Ves," enter the name of the foreign country. ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. 10 During the tax year, did the partnership receive a distribution from, or was it the grantor of, or transferor to, a foreign trust? If "Ves," the partnership may have to file Form 3520. See page 20 of the instructions . . . . . 11 Was there a distribution of property or a transfer (e.g., by sale or death) of a partnership interest during the tax year? If "Ves," you may elect to adjust the basis of the partnership's assets under section 754 by attaching the statement described under Elections Made By the Partnership on page 9 of the instructions . . . . 12 Enter the number of Forms 8865, Return of U.S. Persons With Respect to Certain Foreign Partnerships. attached to this return . . . . . . . . . . . . . . . . . . . . . ~ Designation of Tax Matters Partner (see page 20 of the instructions) Enter below the general partner designated as the tax matters partner (TMP) for the tax year of this return: Name of desiqnated TMP Address of desiqnated TMP ~ D. WILLIAM BOWMAN lil... 603 SOUTH SPRING GARDEN STREET ,. CARLISLE Identifying lil... number of TMP ,. 202-42-7375 PA Ves No ~ X X X ~ X X X X X X X / 17013 Form 1065 (2003) Form 1065 (2003 EASTERN STATES CLAIMS SERVICE, LLC Partners' Shares of Income. Credits Deductions etc 25-1884414 Pa e 3 Schedule K u ;:, en "tl C Q) 0 C" .. .. III = C ~ > CD .. .EE.E >. o ~ a. c ~ ~ E -0 i B III C E ~ III III III E '; E en D:. ! ~~- <l: ... (b) Total amount 13,521 Ui en o d. Q) E o () .E (a) Distributive share items 1 Ordinary income (loss) from trade or business activities (page 1, line 22) 1 2 Net income (loss) from rental real estate activities (attach Form 8825) 'I' '," I v//~/./; 3 a Gross income from other rental activities , I 3a V////h b Expenses from other rental activities (attach schedule) .I 3b I I v////"";; c Net income (loss) from other rental activities, Subtract line 3b from line 3a ~~~ 4 Portfolio income (loss) (attach Schedule D (Form 1065) for lines 4d and 4e): , ~~l<0: a Interest income 4a 131 b Dividends: (1) Qualified dividends ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _' _ _ _ (2) Total ordinary dividends ~ 4b c Royalty income 4c d Net short-term capital gain (loss): (1) post-May 5, 2003 ~ _ _ __ _ __ . __ . . _ _ _ _ _ (2) Entire year ~ 4d(2) e Net long.term capital gain (loss): (1) post-May 5, 2003 .. .. _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ (2) Entire year .. 4e(2) f Other portfolio income (loss) (attach schedule) 4f 5 Guaranteed payments to partners 5 6 a Net section 1231 gain (loss) (post-May 5,2003) (attach Form 4797) 6a b Net section 1231 gain (loss) (entire year) (attach Form 4797) , 6b 7 Other income (loss) (attach schedule) 7 8 Charitable contributions (attach schedule) 8 9 Section 179 expense deduction (attach Form 4562) 9 10 Deductions related to portfolio income (itemize) 10 11 Other deductions (attach schedule) 11 12 a Low-income housing credit: (1) From partnerships to which section 42(j)(5) applies, 12a(1) (2) Other than on line 12a(1) 12a(2) b Qualified rehabilitation expenditures related to rental real estate activities (attach Form 3468) 12b e Credits (other than credits shown on lines 12a and 12b) related to rental real estate activities 12c d Credits related to other rental activities 12d 13 Other credits 13 14 a Interest expense on investment debts 14a b (1) Investment income included on lines 4a, 4b(2), 4c, and 4f above 14b(1) (2) Investment exoenses included on line 10 above 14b(2) 15 a Net earnings (loss) from self-employment 15a b Gross farming or fishing income 15b c Gross nonfarm income 15c 16 a Depreciation adjustment on property placed in service after 1986 16a b Adjusted gain or loss 16b c Depletion (other than oil and gas) 16c d (1) Gross income from oil, gas, and geothermal properties 16d(1) (2) Deductions allocable to oil, gas, and geothermal properties 16d(2) e Other adiustments and tax preference items (attach schedule) 16e 17 Name of foreign country or U.S. possession ~ _ _ _ __ _ _ __ _ _ __ __ _ __ __ _. _ __ __ _ __ _ _ _ _ _ _ _ __ _ ~ b Gross income from all sources 17b c Gross income sourced at partner level 17e d Foreign gross income sourced at partnership level: ~ (1) Passive __._________ (2) Listed categories (attach schedule) ,__._______ (3) General limitation ~ 17d(3) e Deductions allocated and apportioned at partner level: ~ (1) Interest expense ~ (2) Other 17e(2) f Deductions allocated and ~'~;portio~ed- at p-';rt~e~~hip level to foreign source income: ~ (1) Passive __ _ _ _ _ __ _ __ _ (2) Listed categories (attach sched/:!f!!). . __ _ _ _ __ __ _ (3) General limitation ~ 17f(3) I 9 Total foreign taxes (check one): ~ PaidD AccruedU. 17g h Reduction in taxes available for credit (attach schedule) , , 17h 18 Section 59(e)(2) expenditures: a Type ~ _____u____u_u________. b Amount ~ 18b 19 Tax-exempt interest income 19 20 Other tax-exempt income 20 21 Nondeductible expenses 21 22 Distributions of money (cash and marketable securities) 22 23 Distributions of property other than money 23 24 Other items and amounts required to be reoorted separate Iv to oartners (attach schedule) 213,500 2 'C Q) L- U 131 227,021 248,284 -135 en Q) >< III ~ l: Cl '(jj L- o LI.. L- Q) .s::. 5 1,088 11,712 ?:; Form 1065 (2003) Form 1065 (2003) EASTERN STATES CLAIMS SERVICE, LLC Paqe 4 Analvsis of Net Income (Loss) 1 Net income (loss). Combine Schedule K, lines 1 through 7 in column (b). From the result, subtract the sum of Schedule K, lines 8 throuqh 11, 14a, 17q, and 18b 2 Analysis by (i) Corporate (ii) Individual partner type: (active) a General partners b Limited partners 25-1884414 . I 1 227,1521 (iii) Individual (passive) (v) Exempt organization (iv) Partnership (vi) Nominee/Other 227,016 136 Note: Schedules L, M-1 and M-2 are not required if Question 5 of Schedule B is answered "Yes. Balance Sheets per Books Beginning of tax year Assets (a) (b) Schedule L 1 2a b 3 4 5 6 7 8 9a b 10 a b 11 12 a b 13 14 15 16 17 18 19 20 21 22 Cash . Trade notes and accounts receivable Less allowance for bad debts Inventories U.S. government obligations Tax-exempt securities Other current assets (attach schedule) Mortgage and real estate loans Other investments (attach schedule) Buildings and other depreciable assets Less accumulated depreciation Depletable assets Less accumulated depletion Land (net of any amortization) Intangible assets (amortizable only) Less accumulated amortization Other assets (attach schedule) Total assets Liabilities and Capital Accounts payable Mortgages, notes, bonds payable in less than 1 year. Other current liabilities (attach schedule) All nonrecourse loans Mortgages, notes, bonds payable in 1 year or more. Other liabilities (attach schedule) Partners' capital accounts Total liabilities and capital Schedule M-1 Reconciliation of Income Loss 1 Net income (loss) per books . . . . . . 2 Income included on Schedule K, lines 1 through 4, 6b, and 7, not recorded on books this year (itemize): _ __ __ __ __ __ __ __ __ _ ___ 3 Guaranteed payments (other than health insurance) . . . . . . . . . . . . . 4 Expenses recorded on books this year not included on Schedule K, lines 1 through 11, 14a, 17g, and 18b (itemize): a Depreciation $ __ _ __ __ __ __ __ __ __ __ __ __. b Travel and entertainment $ . _ _ __ __ _ __ J ,_Q~~ c ~ - -------- --- - --- - - -- ---- ---- -- - ---------. 5 Add lines 1 throu h 4 c e u e - Analvsls of Partners' Caoital A 1 Balance at beginning of year 2 Capital contributed: a Cash b Property 3 Net income (loss) per books 4 Other increases (itemize): . __ __ __ _ __ ___ Shdl M2 5 Add lines 1 through 4 2,782 End of tax year (c) (d) 5,168 ij'/1;:% 11 ,298 11,298 Y///~ 9,038 ~ 2,260 10,499 799 /~ 363 363 /~ 127 236 200 163 ~ 5,278 6,130 ., /~ 5,278 5,278 6,130 6,130 er Return Income recorded on books this year not included on Schedule K, lines 1 through 7 (itemize): Tax-exempt interest $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 213 500 a b 7 Deductions included on Schedule K, lines 1 through 11, 14a, 17g, and 18b, not charged against book income this year (itemize): a Depreciation $ _ _ __ _ _ _ __ _ _ __ __ _ _ _ 1,088 227,152 ccounts 5,278 b c 8 9 Add lines 6 and 7 . . . . . . . . . Income (loss) (Analysis of Net Income Loss , line 1 . Subtract line 8 from line 5 227,152 6 7 Di~ributions: a Cash b Property Other decreases (itemize): 11,712 12,564 8 17,842 9 Add lines 6 and 7 Balance at end of year. Subtract line 8 from line 5 11,712 6,130 Form 1065 (2003) EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 4/1/2004 D. WILLIAM BOWMAN 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 RE: EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Schedule K-1 from Partnership's 2003 Return of Income Dear: D. WILLIAM BOWMAN, Enclosed is your 2003 Schedule K-1 (Form 1065) Partner's Share of Income, Credits, Deductions, Etc. from EASTERN STATES CLAIMS SERVICE, LLC. This information reflects the amounts you need to complete your income tax return. The amounts shown are your distributive share of partnership tax items, including income/loss, credits and deductions, and other information to be reported on your tax return. This information may not correspond to actual distributions you have received during the year. This information is included in the Partnership's 2003 Federal Return of Partnership Income that was filed with the Internal Revenue Service This Schedule should be retained with your tax records and documentation. If you have any questions concerning this information, or if we can be of assistance in any way, please do not hesitate to contact us. Sincerely, EASTERN STATES CLAIMS SERVICE, LLC 6511 Partner's Share of Income, Credits, Deductions, etc. . See separate instructions. OMS No. 15450099 SCHEDULE K.1 (Form 1065) Department of the Treasury Internal Revenue Service Partner's identi in number .202-42-7375 Partner's name, address, and ZIP code Partner: 1 D. WILLIAM BOWMAN 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 A This partner is a 0 general partner 0 limited partner llillimited liability company member B What type of ent,!!Y..Js this partner? . _~\?~iy~_I_~qiY!~':l9! _ _ __ C Is this partner a ~ domestic or a 0 foreign partner? (i) Before change (ii) End of or termination year D Enter partner's percentage of: Profit sharing . . . __u____u_____ ___u___u~~._o~ H Loss sharing . . . . . . .u_u____u___ u_uu___~~._o~o Ownership of capital . . . _ u _ _ __ u _ u _ u _ _ _ u _ U u~~'_~o E IRS Center where partnership filed return: Cincinnati, OH J Analvsis of partner's capital account: 1 Ordinary income (loss) from trade or business activities. 2 Net income (loss) from rental real estate activities. 3 Net income (loss) from other rental activities. 4 Portfolio income (loss): a Interest income b (1) Qualified dividends. (2) Total ordinary dividends c Royalty income . d (1) Net short-term capital gain (loss) (post-May 5, 2003) . (2) Net short-term capital gain (loss) (entire year) . e (1) Net long-term capital gain (loss) (post-May 5, 2003) . (2) Net long-term capital gain (loss) (entire year) . f Other portfolio income (loss) (attach schedule) . 5 Guaranteed payments to partner. 6 a Net section 1231 gain (loss) (post-May 5,2003) . b Net section 1231 gain (loss) (entire year) . 7 Other income (loss) (attach schedule) . 8 Charitable contributions (see instructions) (attach schedule) . 9 Section 179 expense deduction. 10 Deductions related to portfolio income (attach schedule) . 11 Other deductions (attach schedule) . 12 a Low-income housing credit: (1) From section 420)(5) partnerships. (2) Other than on line 12a(1) b Qualified rehabilitation expenditures related to rental real estate activities c Credits (other than credits shown on lines 12a and 12b) related to rental real estate activities d Credits related to other rental activities. 13 Other credits. For Paperwork Reduction Act Notice, see Instructions for Form 1065. (HTA) g Ul -g .~ c - 2003 20 603 SOUTH SPRING GARDEN STREET CARLISLE PA F Partner's share of liabilities (see instructions): Nonrecourse . . . . . . . . .. $ Qualified nonrecourse financing .. $ Other . . . . . . . . . . $ 17013 G Tax shelter registration number . Check here if this partnership is a publicly traded partnership as defined in section 469(k)(2) . . . o Check applicable boxes: (1) 0 Final K-1 (2)0 Amended K-1 (a) Capital account at beginning of year (b) Capital contributed during year (c) Partner's share of lines 3,4, and 7, Form 1065, Schedule M-2 (e) Capital account at end of year (combine columns (a) through (d)) (d) Withdrawals and distributions 4,829 12.438 11 712 5555 (c) 1040 filers enter the amount in column (b) on: } See page 6 of Partner's Instructions for Schedule K-1 (Form 1065). (a) Distributive share item (b) Amount 1 2 3 13,386 Cii" ~ :::!.. 4a 4b( 1) 4b(2) 4c 4d~ 1) 4d12) 4e(1) 4e(2) 4f 5 6a 6b 7 8 9 10 11 12a 1) 12a 2) 130 Form 1040, line 8a Form 1040. line 9b Form 1040, line 9a Sch. E. Part I. line 4 Sch. D. line 5, col. (g) Sch. D. line 5, col. (f) Sch. D, line 12. col (g) Sch. D, line 12. col. (f) } See pages 6 and 7 of Partner's Instructions for Schedule K.1 (Form 1065) Q) 6 ~ 213,500 Sch. A, line 15 or 16 } See page B of Partner's Instructions for Schedule K-1 (Form 1065) } Form 8586, line 5 ~ "C Q) ... U 12b } See page 9 of Partner's Instructions f.or SChedule K-l (Form 1065) 12c 12d 13 Partner: 1 Schedule K-1 (Form 1065) 2003 6512 Schedule K-1 (Form 1065) 2003 EASTERN STATES CLAIMS SERVICE, llC 25-1884414 Paoe 2 (a) Distributive share item (b) Amount (c) 1040 filers enter the amount in column (bl on: .... c: Form 4952, line 1 ell i 14 a Interest expense on investment debts 14a E Hi ,f! b (1 ) Investment income included on lines 4a, 4b(2), 4c, and 4f . 14b(1 ) 130 } See page 9 of Partner's > .E Instructions for Schedule K-1 .E (2) Investment expenses included on line 10 . 14b(2) (Form 1065). ~ i 15 a Net earnings (loss) from self-employment. 15a 226,886 Sch. SE, Section A or B E b Gross farming or fishing income. 15b } See page 9 of Partner's ~ >- J1J.S2 Instructions for Schedule K-l Q. e Gross nonfarm income. 15e 245,801 (Form 1065). 1;1 16 a Depreciation adjustment on property placed in service after 1986 . 16a -134 I- III b Adjusted gain or loss. 16b " ! } S" P'9" 9 '" W p' c "' e Depletion (other than oil and gas) . 16e Partner's Instructions III B for Schedule K-1 C 16d( 1) .. c d (1 ) Gross income from oil, gas, and geothermal properties, (Form 1065) and E ~ - .. (2) Deductions allocable to oil, gas, and geothermal properties _ 16d(2) Instructions for Form 6251 III -- :ij-~ <I: e Other adiustments and tax preference items (attach schedule) . 16e 17a Name of foreign country or U.S. possession ~ . .--------------. b Gross income from all sources 17b e Gross income sourced at partner level 17e d Foreign gross income sourced at partnership level: (1 ) Passive . 17d(1 ) III (2) Listed categories (attach schedule) . 17d(2) Q) (3) General limitation . 17d(3) ~ l- e Deductions allocated and apportioned at partner level: ~ Form 1116, Part I ~ (1 ) Interest expense 17 e( 1 ) 'Q) L- ~ (2) Other ~~ f Deductions allocated and apportioned at partnership level to foreign source income: (1 ) Passive . 17f(1 ) (2) Listed categories (attach schedule) . 17f(2) (3) General limitation . 17f(3) ~ 9 Total foreign taxes (check one): ~ tf P~id [j' A~cr'ue~ 17g Form 1116, Part II h Reduction in taxes available for credit (attach schedule) 17h Form 1116, line 12 18 Section 59(e)(2) expenditures: a Type ~ '1 See page 10 of Partner's ------~------- > InstruCllons for Schedule K-l b Amount. 18b , (Form 1065) 19 Tax-exempt interest income. 19 Form 1040, line 8b 20 Other tax-exempt income. 20 ~ 21 Nondeductible expenses. 21 1,077 } S" P'9" 0 01 ~ ~ 22 Distributions of money (cash and marketable securities) _ 22 11,712 Partner's Instructions for 23 Distributions of property other than money. 23 Schedule K-1 (Form 1065) 24 Recapture of low-income housing credit: a From section 42U)(5) partnerships 24a } b Other than on line 24a 24b Form 8611, line 8 25 Supplemental information required to be reported separately to each partner (attach additional schedules if more space is needed).- --------------------------------------------------------------------------------------------------------------------- s::: .S! iQ -- --- - -- - - - - -- -- - --- - ----- - - -- -- - - - - -- - ---- - -- - - - - - -- - - - - -- - -- - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- ------------------- - - -- -- E L- 0 - .E --- --- --- - -- -- - - ---- - - - --- - ---- -- --- --- -- - ---- - - - -- --- - - - - - - -- - - -- - - --- - -- - - - -- - -- - - - - - - - - - - - - - - - - - -- - - - -- - - - - - - - - - - - iii "E Q) ---- -- ----- - - - - -- --- -- ---- - -------- --- - - --- --- - - - - - -- ---- - - --- - - --- ---- -- -- - - - - - - --- - - - - - - - - - - --- ------------------ -- E Q) a. Co -------------------------------------------------------------------------------------------------------------- --- - -- ::J en - - - - - - - - - - --- -- -- - --- - - - -- -- --- -- --- -- - - - - - - - - - - - - - - -- - - - - - - -- - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - -- -------------- Partner: 1 D_ WilLIAM BOWMAN - 202-42-7375 Schedule K-1 (Form 1065) 2003 Form 1065 Partner's Basis Statement Note to Partner: Keep for your records 2003 Partner's name D. WILLIAM BOWMAN Partnership's name EASTERN STATES CLAIMS SERVICE LLC Summary Partner: 1 Identifying Number 202-42-7375 Employer 10 Number 25-1884414 Beginning Share of Other Other Withdrawals, End of of Year Taxable Income Increases Decreases Distributions Year 3999 13516 1077 11 712 4,726 Basis Computation 1 Beginning Basis . . 2 Contributions . . . 3 Increase in share of liabilities 4 Other Adjustments . . . . 5 Share of taxable income . . 6 Share of tax-exempt income . . . . . . . . . . . . . . . . . . . . . . . 7 Add lines 1 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Decrease in share of liabilities (not to exceed 7) . . . . 9 Subtract line 8 from line 7 . . . . . . . . 10 Distributions (not to exceed line 9) . Distributions in excess of basis . . . . . . 11 Subtract line 10 from line 9 . . . . . . . . . . 12 Share of nondeductible expenses (not to exceed line 11) 13 Subtract line 12 from line 11 . . . . . . . . . . . . . . . . . . 14 Share of deductions not subject to basis limitation (not to exceed line 13) . . . . . . 15 Subtract line 14 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . 16 Share of taxable losses and deductions subject to basis limitation (not to exceed line 15) 17 Ending basis, subtract line 16 from line 15 . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 6 7 8 9 10 3,999 13,516 17.515 17,515 11,712 11 12 13 14 15 16 17 5,803 1,077 4,726 4,726 4,726 Alternate Basis Computation DCheck to use the alternate computation. 1 Capital account balance . . . . . . . . . . .. 1 2 Share of liabilities . . . . . . . . . 2 3 Accumulated tax/book timing differences . . . . . . 3 4 Carryover nondeductible expenses . . . . . . . . 4 5 Excess deductions not subject to basis limit 5 6 Carryover losses and deductions 6 7 Distributions in excess of basis . . . . . 7 8 Other differences . . . . . . . . . . . . . . . 8 9 Alternate basis. Combine lines 1 - 8 . . . . . .. 9 Beginning Increase (decrease) Ending EASTERN STATES CLAIMS SERVICE, LLC Share of Taxable Income 1 Ordinary income from trade or business activities . . . . . . 2 Net income from rental real estate activities 3 Net income from other rental activities 4 Portfolio income: a Interest . . . . . b Ordinary dividends . c Royalties . . . . d Net short-term capital gain e Net long-term capital gain . . . . . . . . . . . . . . . . . . f Other portfolio income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Net section 1231 gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total - Share of Taxable Income . . . . . . . . . . . . . . . . . . . . . . . . . . 25-1884414 1 2 3 13,386 4a 4b 4c 4d 4e 4f 6 7 130 13,516 Share of Taxable Losses and Deductions 1 Ordinary loss from trade or business activities . . . . . . . . . . . . . . . . . . .. 1 2 Net loss from rental real estate activities 2 3 Net loss from other rental activities 3 4 Portfolio loss: d Net short-term capital loss . . . . . . . . . . . . . 4d e Net long-term capital loss . . . . . . . . . . . . . 4e f Other portfolio loss . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4f 6 Net section 1231 loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Other loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7 9 Section 179 expense deduction . . . . . . . . . . . . . . . . . . . . . . . . . . 9 10 Deductions related to portfolio income 10 11 Other deductions . . . . . . . . 11 12 Interest expense on investment debts 12 13 Section 59(e)(2) expenditures . . . 13 CF Carryforward of Taxable Losses and Deductions from prior year CF Total - Share of Taxable Losses and Deductions . . . . . . Loss Carrvovers Loss items carried over to next year . . . . . . . . . . . . . . . . . . . . . . . . . . Nondeductible expense items carried over to next year . . . . . . . . . . . . . . . . . . . D. WilLIAM BOWMAN 202-42-7375 EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 4/1/2004 MICHELLE E BOWMAN 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 RE: EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Schedule K-1 from Partnership's 2003 Return of Income Dear: MICHELLE E BOWMAN, Enclosed is your 2003 Schedule K-1 (Form 1065) Partner's Share of Income, Credits, Deductions, Etc. from EASTERN STATES CLAIMS SERVICE, LLC. This information reflects the amounts you need to complete your income tax return. The amounts shown are your distributive share of partnership tax items, including income/loss, credits and deductions, and other information to be reported on your tax return. This information may not correspond to actual distributions you have received during the year. This information is included in the Partnership's 2003 Federal Return of Partnership Income that was filed with the Internal Revenue Service. This Schedule should be retained with your tax records and documentation. If you have any questions concerning this information, or if we can be of assistance in any way, please do not hesitate to contact us. Sincerely, EASTERN STATES CLAIMS SERVICE, LLC 6511 SCHEDULE K.1 (Form 1065) Department of the Treasury Internal Revenue Service Partner's identif in number ~ 183-44-2392 Partner's name, address, and ZIP code Partner: 2 MICHELLE E BOWMAN 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 1 Ordinary income (loss) from trade or business activities. 2 Net income (loss) from rental real estate activities. 3 Net income (loss) from other rental activities. 4 Portfolio income (loss): a Interest income b (1) Qualified dividends. (2) Total ordinary dividends c Royalty income . d (1) Net short-term capital gain (loss) (post-May 5, 2003) . (2) Net short-term capital gain (loss) (entire year) . e (1) Net long-term capital gain (loss) (post-May 5,2003) . (2) Net long-term capital gain (loss) (entire year) . f Other portfolio income (loss) (attach schedule) . 5 Guaranteed payments to partner. 6 a Net section 1231 gain (loss) (post-May 5,2003) . b Net section 1231 gain (loss) (entire year) . 7 Other income (loss) (attach schedule) . 8 Charitable contributions (see instructions) (attach schedule) . 9 Section 179 expense deduction. 10 Deductions related to portfolio income (attach schedule) . 11 Other deductions (attach schedule) . 12 a Low-income housing credit: (1) From section 420)(5) partnerships. (2) Other than on line 12a(1) b Qualified rehabilitation expenditures related to rental real estate activities c Credits (other than credits shown on lines 12a and 12b) related to rental real estate activities d Credits related to other rental activities. 13 Other credits. For Paperwork Reduction Act Notice, see Instructions for Form 1065. (HTA) ~ rJ) i .~ o - Partner's Share of Income, Credits, Deductions, etc. OMS No 1545.0099 .. See separate instructions. 2003 ,20 o limited partner 603 SOUTH SPRING GARDEN STREET CARLISLE PA F Partner's share of liabilities (see instructions): Nonrecourse . . . . . . . . .. $ Qualified nonrecourse financing .. $ Other . . . . . . . . . . $ 17013 A This partner is a 0 general partner ~ limited liability company member B What type of ent,!.!Y,is this partner? .. J~~~~i~~ _1~I~l~i_d_l!~I_ __ C Is this partner a l1SJ domestic or a 0 foreign partner? (i) Before change (ii) End of or termination year G Tax shelter registration number .. D Enter partner's percentage of: Profit sharing . . . . __ _ _ _ _ _ _ _ __ _ __ __ _ __ _ __ _ __ 1..0(0 Loss sharing . . . . . _ __ __ __ _ __ __ __ _ _ _ _ _ _ _ __ __ 1.0(0 Ownership of capital . _ __ __ _ __ _ _ __ __ _ _ _ _ _ __ __ _ __ LO~o E IRS Center where partnership filed return: Cincinnati, OH J Analvsis of partner s capital account: H Check here if this partnership is a publicly traded partnership as defined in section 469(k)(2) o Check applicable boxes: (1) D Final K-1 (2)0 Amended K-1 (a) Capital account at beginning of year (c) Partner's share of lines 3,4, and 7, Form 1065, Schedule M-2 (d) Withdrawals and distributions (e) Capital account at end of year (combine columns (a) through (d)) (b) Capital contributed during year 449 126 575 (c) 1040 filers enter the amount in column (b) on: } See page 6 of Partner's Instructions for Schedule K-1 (Form 1065). (a) Distributive share item (b) Amount Ul 19 ::::!. Q) 6 ~ 1 2 . 4a 4b(1 ) 4b(2) 4c 4d(1) 4d(2) 4e(1 ) 4e(2) 4f 5 6a 6b 7 8 9 10 11 12a(1) 12a(2) Sch. A, line 15 or 16 } See page 8 of Partner's Instructions for Schedule K-1 (Form 1065) } Form 8586. line 5 135 Form 1040, line 8a Form 1040, line 9b Form 1040, line 9a Sch. E, Part I, line 4 Sch. D, line 5, col (g) Sch. D, line 5, col. (f) Sch. D. line 12, col. (g) Sch D, line 12, cOI (i) } See pages 6 and 7 of Partner's Instructions tor Schedule K-1 (Form 1065) rJ) :t:! 't:I Q) ... U 12b } See page 9 of Partner's instructions f.or Schedule K-1 (Form 1065) 12c 12d 13 Partner: 2 Schedule K-1 (Form 1065) 2003 Schedule K-1 (Form 1065) 2003 EASTERN STATES CLAIMS SERVICE, LLC (a) Distributive share item 14 a Interest expense on investment debts b (1) Investment income included on lines 4a, 4b(2), 4c, and 4f . (2) Investment expenses included on line 10 . 15 a Net earnings (loss) from self-employment. b Gross farming or fishing income. e Gross nonfarm income. 16 a Depreciation adjustment on property placed in service after 1986 . b Adjusted gain or loss. e Depletion (other than oil and gas) . d (1) Gross income from oil, gas, and geothermal properties. (2) Deductions allocable to oil, gas, and geothermal properties. e Other adiustments and tax preference items (attach schedule) . 17 a Name of foreign country or U.S. possession ~. __ _ _ _ _ _ _ _ _ _ _ _ _. b Gross income from all sources e Gross income sourced at partner level d Foreign gross income sourced at partnership level: (1) Passive. (2) Listed categories (attach schedule) . (3) General limitation . e Deductions allocated and apportioned at partner level: (1) Interest expense (2) Other f Deductions allocated and apportioned at partnership level to foreign source income: (1) Passive. (2) Listed categories (attach schedule) . (3) Genera/limitation. . . . . . 9 Total foreign taxes (check one): ~ D Paid D Accrued h RedLJction in taxes available for credit (attach schedule) 18 Section 59(e)(2) expenditures: a Type ~ __ __ __ __ __ __ __ b Amount. 19 Tax-exempt interest income. 20 Other tax-exempt income. 21 Nondeductible expenses. 22 Distributions of money (cash and marketable securities) . 23 Distributions of property other than money. 24 Recapture of low-income housing credit: a From section 42(j)(5) partnerships 24a} Form 8611, line 8 b Other than on line 24a 24b 25 Supplemental information required to be reported separately to each partner (attach additional schedules if more space is needed): +- c: E i Xi .f! > .5 .5 'i i E ~ >- Jj,,!;l Co r.l t- .. ~ ~ ~ 8 CIl c: E t .. ... ~~ <( Kl ~ l- S, 'ijj & .... III J:: i5 c: o ~ E .... .E .E Iii 'E III E III Q. a. :J en Partner: 2 MICHELLE E BOWMAN - 183-44-2392 25-1884414 6512 Page 2 (c) 1040 filers enter the amount in column (b) on: (b) Amount ///// 14a 14b(1) 14b(2) 15a 15b 15e 16a 16b 16e 16d (1 ) 16d(2) 16e Form 4952, line 1 1 } See page 9 of Partner's Instructions for Schedule K-1 (Form 1065). 135 2,483 } Sch. SE, Section A or B See page 9 of Partner's Instructions for Schedule K-I (Form 1065) -1 } See pages 9 and 10 of Partner's Instructions for Schedule K-1 (Form 1065) and Instructions for Form 6251 , 17b 17e 17d(1 ) 17d(2) 17d(3) )> Form 1116, Part I 17e(1\ 17e2 17f{1 ) 17f(2) 17f(3) 170 17h , Form 1116, Part II Form 1116, line 12 18b 19 20 21 22 23 '1 See page 10 of Partner's ~ Instruclions for Schedule K-1 j (Form 1065) Form 1040, line 8b 11 }see page 10 of Partner's Instructions for Schedule K-1 (Form 1065) Schedule K-1 (Form 1065) 2003 Form 1065 Partner's Basis Statement Note to Partner: Keep for your records 2003 Partner's name MICHELLE E BOWMAN Partnership's name EASTERN STATES CLAIMS SERVICE LLC Summary Partner: 2 Identifying Number 183-44-2392 Employer 10 Number 25-1884414 Beginning Share of Other Other Withdrawals, End of of Year Taxable Income Increases Decreases Distributions Year 441 136 11 566 Basis Computation 1 Beginning Basis . . 1 2 Contributions . . . 2 3 Increase in share of liabilities 3 4 Other Adjustments . . . . 4 5 Share of taxable income . . 5 6 Share of tax-exempt income . . . . . . . . . . . . . . . 6 7 Add lines 1 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 8 Decrease in share of liabilities (not to exceed 7) . . . . . . . . . . . . . . . . . .. 8 9 Subtract line 8 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9 10 Distributions (not to exceed line 9) . 10 Distributions in excess of basis . . . . . . . . . 11 Subtract line 10 from line 9 . . . . . . . . . . . . . 11 12 Share of nondeductible expenses (not to exceed line 11) . 12 13 Subtract line 12 from line 11 . . . . . . . . . . . . . . . . . . 13 14 Share of deductions not subject to basis limitation (not to exceed line 13) . . . . . . 14 15 Subtract line 14 from line 13 ............. . .... 15 16 Share of taxable losses and deductions subject to basis limitation (not to exceed line 15) 16 17 Ending basis, subtract line 16 from line 15 . . . . . . . . . . . . . . . . .. 17 441 136 577 577 577 11 566 566 566 Alternate Basis Computation DCheck to use the alternate computation. 1 Capital account balance . . . . . . . . . . .. 1 2 Share of liabilities . . . . . . . . . 2 3 Accumulated tax/book timing differences . . . . . . 3 4 Carryover nondeductible expenses . . . . . . . . 4 5 Excess deductions not subject to basis limit 5 6 Carryover losses and deductions 6 7 Distributions in excess of basis . . . . . 7 8 Other differences . . . . . . . . . . . . . . . 8 9 Alternate basis. Combine lines 1 - 8 . . . . . .. 9 Beginning Increase (decrease) Ending EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Share of Taxable Income 1 Ordinary income from trade or business activities . . . . . . 2 Net income from rental real estate activities 3 Net income from other rental activities 4 Portfolio income: a Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b Ordinary dividends . . . c Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d Net short-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . e Net long-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . f Other portfolio income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Net section 1231 gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total- Share of Taxable Income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 135 2 3 4a 4b 4c 4d 4e 4f 6 7 136 1 2 3 4d 4e 4f 6 7 9 10 11 12 13 CF Share of Taxable Losses and Deductions 1 Ordinary loss from trade or business activities . . . 2 Net loss from rental real estate activities 3 Net loss from other rental activities . 4 Portfolio loss: d Net short-term capital loss . . . . . . . . e Net long-term capital loss . . . . . . . . f Other portfolio loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Net section 1231 loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Other loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Section 179 expense deduction . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Deductions related to portfolio income 11 Other deductions . . . . . . . . 12 Interest expense on investment debts 13 Section 59(e)(2) expenditures . . . CF Carryforward of Taxable Losses and Deductions from prior year Total - Share of Taxable Losses and Deductions . . . . . . Loss Carrvovers Loss items carried over to next year . . . . . . . . . . . . . . . . . . . . . . . . . . Nondeductible expense items carried over to next year . . . . . . . . . . . . . . . . . . . MICHELLE E BOWMAN 183-44-2392 Form 1065 EASTERN STATES CLA Basis Summary 25-1884414 2003 Keen for vour records Grand Totals: 4.440 13.652 1 088 11 712 5292 Paqe Totals: 4440 13 652 1 088 11 712 5,292 Partner Partner (a) (b) (c) (d) (e) (f) Number Name Beginning Share of Other Other Withdrawals. End of of Year Taxable Income Increases Decreases Distributions Year 1 D. WILLIAM BOWMAN 3999 13 516 1 077 11 712 4726 2 MICHELLE E BOWMAN 441 136 11 566 Form 1065 EASTERN STATES CLA Capital Account Summary 25-1884414 2003 Keen for vour records Grand Totals: 5278 12 564 11712 6,130 Paoe Totals: 5278 12.564 11 712 6,130 (a) (b) (c) (d) (e) Partner Partner Capital Account Capital Partner's Share of Withdrawals Capital Account Number Name at Beginning Contributed Schedule M-2 and at the of Year DurinQ Year lines 3 4 & 7 Distributions End of Year 1 D. WILLIAM BOWMAN 4.829 12 438 11.712 5.555 2 MICHELLE E BOWMAN 449 126 575 Form 4562 Depreciation and Amortization (Including Information on Listed Property) OMS No 1545-0172 2003 Department of the Treasury Internal Revenue Service ~ See se arate instructions. ~ Attach to our tax return. Name(s) shown on return Business or activity to which this form relates EASTERN STATES CLAIMS SERVICE LLC HEAVY EQUIPMENT APPRAISALS Election To Expense Certain Property Under Section 179 Note: If au have an listed ro eri , com lete Pari V before au com lete Pari I. 1 Maximum amount. See page 2 of the instructions for a higher limit for certain businesses . . . . 2 Total cost of section 179 property placed in service (see page 2 of the instructions). . . . . . . 3 Threshold cost of section 179 property before reduction in limitation . . . . . . . . . . . . 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0- . . . . . . . . . . . . 5 Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing se aratel ,see a e 2 of the instructions . . . . . . . . . . . a Descri tion of ro ert Attachment Se uence No. 67 Identifying number 25-1884414 1 2 3 4 100,000 400,000 6 5 100,000 c Elected cost . 7 Listed property. Enter the amount from line 29 . . . . . . . . . . . . . . . . . . .. 7 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 9 Tentative deduction. Enter the smaller of line 5 or line 8 . . . . . . . . . . . . . . . . . 10 Carryover of disallowed deduction from line 13 of your 2002 Form 4562. . . . . . . . . . . . 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 (see instructions) 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 13 Car over of disallowed deduction to 2004. Add lines 9 and 10, less line 12 . . . . . . . . ~ Note: Do not use Part II or Part III below for listed ro ert . Instead use Part V. S ecial De reciation Allowance and Other De reciation Do not include listed 14 Special depreciation allowance for qualified property (other than listed property) placed in service during the tax year (see page 3 of the instructions) . . . . . . . . 15 Property subject to section 168(f)(1) election (see page 4 of the instructions) . . . . . 16 Other de reciation includin ACRS see a e 4 of the instructions . . . MACRS De reciation Do not include listed ro ert. See a e 4 of the instructions. Section A 17 MACRS deductions for assets placed in service in tax years beginning before 2003 . . . . . . . . . . . . . . 18 If you are electing under section 168(i)(4) to group any assets placed in service during the tax year into one or more general asset accounts, check here . . . . . . . . . . . ~ D S B A PI d' SO' 2003 T Y U' th G 8 9 10 11 12 14 15 16 17 'i: ectlon - ssets ace In ervlce unn ax ear sing e enera epreclatlOn iystem (b) Mo nth and (c) Basis for (d) Recovery (e) (f) (9) (a) Classification of property year p laced depreciation period Convention Method Depreciation in se rvice (busi ness/i nves tmen!' deduction 19 a 3-year property b 5-year property c 7-year property d 1 O-year property e 15-year property f 20-vear property g 25-year property 25 yrs. S/L h Residential rental 27.5 yrs. MM S/L property 27.5 yrs. MM S/L i Nonresidential real 39 yrs. MM S/L property MM S/L 10 S Section C - Assets Placed in Service Durin 2003 Tax Year Usin the Alternative De 20 a Class life b 12- ear c 40- ear Summa see a e 6 of the instructions 21 Listed property. Enter amount from line 28 . . . . . . . . . . . . . . . . . . 22 Total. Add amounts from line 12, lines 14 through 17, lines 19 and 20 in column (g), and line 21. Enter here and on the appropriate lines of your return. Partnerships and S corporations - see instructions . . . . . . 22 23 For assets shown above and placed in service during the current year, enter the portion of the basis attributable to section 263A costs . . . . . . . . . . . . . . . . . . . . . 23 12 rs. 40 rs. MM 21 431 431 For Paperwork Reduction Act Notice, see separate instructions; (HTA) Form 4562 (2003) 2003) EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Page: Listed Property (Include automobiles, certain other vehicles, cellular telephones, certain computers, and property used for entertainment, recreation, or amusement.) Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a, 24b, columns (a) through (c) of Section A, all of Section 8, and Section C if applicable. Section A - De reciation and Other Information Caution: See a e 7 of the instructions for limits for assen er automobiles. 24a Do you have evidence to support the business/investment use claimed? [R]ves DNo 24b If "Yes," is the evidence written? 0Ves DNo (a) (b) (e) Business/ (d) (e) Basis for (f) (g) (h) (i) Elected Type of property Date placed investment use Cost or depreciation Recovery Method/ Depreciation section 179 list vehicles first in service ercenta e other basis business/investment eriod Convention deduction cost 25 Special depreciation allowance for qualified listed property placed in service during the tax ear and used more than 50% in a ualified business use see a e 6 of the instructions 25 26 Property used more than 50% in a aualified business use (see GaGe 6 of the instructions: DIGITAL CAMERA 12/17/1999 100.00% 3943 3943 5 20008 MQ 431 27 Property used 50% or less in a aualified business use (see paqe 6 of the instructions): S/L- S/L- S/L- 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 .1 28 431 29 Add amounts in column (i), line 26. Enter here and on line 7, paqe 1 29 Section B - Information on Use of Vehicles Complete this section for vehicles used by a sole proprietor, partner, or other "more than 5% owner," or related person. If you provided vehicles to vour emolovees first answer the auestions in Section C to see if yoU meet an exceotion to comDletina this section for those vehicles. 30 Total business/investment miles driven during (a) (b) (c) (d) (e) (f) the year (do not include commuting miles - Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 see page 2 of the instructions) 31 Total commuting miles driven during the year 32 Total other personal (noncommuting) miles driven 33 Total miles driven during the year. Add lines 30 through 32 34 Was the vehicle available for personal Ves No Ves No Ves No Ves No Ves No Yes No use during off-duty hours? 35 Was the vehicle used primarily by a more than 5% owner or related person? 36 Is another vehicle available for personal use? Section C - Questions for Employers Who Provide Vehicles for Use by Their Employees Answer these questions to determine if you meet an exception to completing Section 8 for vehicles used by employees who are not more than 5% owners or related ersons see a e 8 of the instructions. Ves No 37 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your employees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your employees? See page 8 of the instructions for vehicles used by corporate officers, directors, or 1 % or more owners . 39 Do you treat all use of vehicles by employees as personal use? 40 Do you provide more than five vehicles to your employees, obtain information from your employees about the use of the vehicles, and retain the information received? 41 Do you meet the requirements concerning qualified automobile demonstration use? (See page 9 of the instructions.) Note: If our answer to 37, 38, 39, 40, or 41 is "Yes," do not com lete Section B for the covered vehicles. Amortization (a) (b) Date (e) (d) Code (e) (f) Amortization for this ear Description of costs amortization Amortizable Amortization period 42 43 73 44 73 Form 4562 (2003) 43 Amortization of costs that began before your 2003 tax year . . . . . . . . . . 44 Total. Add amounts in column f . See a e 9 of the instructions for where to re art EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Line 20 (Form 1065) . Other Deductions 1 Travel. Meals and Entertainment a Travel . . . . . . . . . . . . . . . 1 a b Total meals and entertainment . 1 b 2,176 c 50% of line b . . . . . . . . . . . . . 1 c 1,088 d Subtract line c from line b . . . . . . . . . . 1 d 2 From Form 4562 - Amortization . . . . . . . . . . . . . . . . . . . . . . . 2 3 Ac!l(~I}!~i!1.ll. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3 4 .R~(fl~_~1]9_~LJ~~~!i.Rt!ql]~_ _ _ _ _ _ __ ___ _ _ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ __ _ _ ___ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4 5 !I]~~!~~~~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5 6 Qf:fL~~ ~~.R~li~~ _~Qg _~~I?~!1.:>_~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6 7 p_q~t?_g~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7 8 p_r9!~~~iqJ)9! f~~~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 8 9 ~l!P.l?U~~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 9 1 0 !_~I~p_h_ql]~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 10 11 Total other deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1,570 1,088 73 3,032 174 1,831 199 1,009 480 5,123 6,193 20,772 .... .... 0 0 .... '$ '$ 0 ~ lO C'I I"- C"i c .- .- <"> <"> .... <"> <"> l"- I"- 0 .... .... l!) E ~ ~ 3 u C .2 ~S" gO?! is:. .- ~~ '(::j'(::j ~..- -..::-~ C"ic<"> <,,><'> ........ lO<.O cr>cr> <,><"> c<ic ~ U1 II) II) ~ a ~ (,) II) U1 ~ ~ ffi ~ 4- U1 <,,><"> ~~ C"ic '&~~ a:(/) (j) u.J 'r ~~~ cO? 0 <E C'I..J Q) c; '5 -' cr> ,!: '" $ W, ~ ~.~ ~~ 0",0)"''- [. (/) ,~~ '" :::l ~ a; 0) ",-0 ~8 N '" t.n ~ o u- t: o 0- ~ C- o .;; II) '0 Q) 0- Q) o ia ... Q) "0 Q) 'L c .g t:: -~o g '" ~ Q) 0.. o o lO C'I <'> c:')c:') <g<g -R o o o ~ ..,e. o l!) c: .... -R 'b o o o .- N o o ..-- C'I <'>- .....- Q).... c: '2- 'iii ~(j) :><t) gO cO Q)..J t<:( 52 Q)Q 01;;( QiN ~- c:~ .g '" ~ct: '€o o ElO 4. <l) 0> '" 0.. lri '" "0 I- ~ 0305917114 PA-20S/PA-65 (09-03) 2003 Pennsylvania PA 5 Corporation/Partnership Information Return ENTER ONE lETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted label Filing Status: PA.20S N y PA-65 251884414 C EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE PA 17013 Amended Information Return N SUBMIT ALL SUPPORTING SCHEDULES L Fiscal Year N Extension Requested N Final Return N Do you want to receive a 2004 Y PA.20SfPA-65? EIN/Name/Address N Change ENTER ONE NUMBER IN EACH BOX 1a 1b 1c 1d 1e 12433 o 12433 o 12433 12433 o o o o o 12433 o 131 o o o o o 131 0305917114 ~ PA Sources ~ 2a Outside PA 2e PA Sources 2b Outside P A 2f PA Sources 2c Outside PA 29 PA Sources B 2d Outside PA 2h 3 4 B 5 6 7 8 0 9 If a loss place an X in the box Part I. Total PA Taxable Business Income (Loss) from Operations Everywhere 1a PA Taxable Business Income (Loss) from its Operations Everywhere ~ 1 b Share of Income (Loss) from All Other Entities 1c Total Income (Loss). Add Line 1a and Line 1b 1d Previously Disallowed CNI Deductions - PA S only 1e Total Adjusted Business Income (Loss). Subtract Line 1d from Line 1c 0 Part II. PA Taxable Business Income (Loss) Allocable to PA 2 Net Operating Income (Loss) from Line 7 PA Schedule H 2 Net Income (Loss) from Other Entities 2 Previously Disallowed PA Source CNI Deductions - PA S corporations only 2 Compute Adjusted/Apportioned Net Operating Income (Loss)- Total each column Part III. Other PA PIT Income (Loss) 3 Interest Income 4 Dividend Income 5 Net Gain (Loss) from the Sale, Exchange, or Disposition of Property 6 Net Income (Loss) from Rents, Royalties, Patents, and Copyrights 7 Income from Estates or Trusts 8 Gambling and Lottery Winnings 9 Total Other PA PIT Income (Loss) - Add Lines 3 through 8 EC FC Page 1 of 3 L DDDDDDDDDD 0305917114 .-J 0306017112 PA-20S/PA-65 - 2003 (09-03) L 251884414 c EASTERN STATES CLAIMS SERVICE, Ll If a loss place an X in the box Part IV. Other PA PIT Income (Loss) Allocable to Pennsylvania 10 Net Gain (Loss) from the Sale, Exchange, or Disposition of Property 11 Net Income (Loss) from Rents, Royalties, Patents, and Copyrights 12 Income from Estates or Trusts Part V. Total PA S Corporation or Partnership Income (Loss) 13 Total Income (Loss) per Underlying Pennsylvania Books and Records 14 Total Reportable Income (Loss) (Add Line 1e and Line 9) or (Add Line 2h, 10. 11, and 12) 15 Total Nontaxable/Nonreportable Income (Loss) - Subtract Line 14 from Line 13 Part VI. Pass - Through Credits - see instructions for each credit 16a Resident Shareholders Tax Credit - PA S corporations only 16b PA Employment Incentive Payments Credit 16c PA Jobs Creation Tax Credit 16d PA Research and Development Tax Credit 17a PA 2003 Tax Withholding Payments from Nonresident Shareholders and Partners 17b Final Payment of Nonresident Withholding Tax 17c Total PA Income Tax Withheld - Add Lines 17a and 17b Part VII. Distributions - see instructions Partnerships Only 18 Distributions of Cash, Marketable Securities, and Property 19 Guaranteed Payments for Capital 20 Guaranteed Payments PA S Corporations Only 21 Distributions from PA Accumulated Adjustment Account (AAA) 22 Distributions of Cash, Marketable Securities, and Property B 10 0 11 0 12 0 ~ 13 12564 14 12564 15 0 16a 0 16b 0 16c 0 16d 0 17a 0 17b 0 17c 0 18 19 20 11712 o 213500 21 22 o o Signature and Verification 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. (FILE ALL 3 PAGES) Preparer Name, based on all information of which preparer has any knowledge - Date Daytime Telephone Number Please print GROUPS TAX AND PAYROLL 040104 717-245-8581 For the PA S Corporation or Partnership Name - Please print Date Daytime Telephone Number EASTERN STATES CLAIMS SERVICE (717) 241-9514 Signature Title PARTNER Street Address City, State, ZIP Code: 524 SOUTH PITT STREET CARLISLE, PA 17013 Page 2 of 3 EC FC L 0306017112 DDDDDDDDDD 0306017112 --.J -.J 0307117119 PA-20S/PA-65 - 2003 (09-03) 251884414 c EASTERN STATES CLAIMS SERVICE, LL L Part VIII. Shareholders and Partners Summary Enter the total number of owners of the PA S corporation or partnership, and the number for each type of owner. The entity must provide a PA Schedule RK-1 to each resident individual owner and a PA Schedule NRK-1 to each non-PA resident individual. The entity must provide each owner that is not an individual with both a PA Schedule RK-1 and a PA Schedule NRK-1. Read the instructions. Total shareholders or partners Type of Shareholder or Partner Individuals Partnerships Estates Trusts PA S corporations All other corporations Part IX. PA S Corporations Only - Accumulated Adjustment Account 1 Balance at the beginning of the taxable year 2 Total reportable income from Part V, Line 14 3 Other additions - Submit an itemized statement. 4 Loss from Part V, Line 14 Place an X in the box 5 Other reductions. Submit an itemized statement. 6 Add Lines 1 through 5 7 Distributions other than dividend distributions 8 Balance at taxable year end - Subtract Line 7 from Line 6. o PA Resident Non PA Resident 1 2 3 04 5 6 7 8 o o o o o o o o Part X. Nonresident Withholding Payments PA S Corporations and PA Partnerships Use this part to list all the withholding payments that the PA S corporation or partnership made on behalf of shareholders or partners that were not residents of Pennsylvania during the taxable year. A PA Tax Due on PA Taxable Income to Nonresidents. Enter on Line 17c B NOTE. The amount on Line A must equal the total from all PA Schedules NRK-1 and the Total PA Income Tax Withheld, Line 17c. Nonresident Withholding Payments during the Entity's Taxable Year: Date Amount Total Nonresident Withholding Payments. Enter in Part VI, on Line 17a C Date Amount o Reconciliation Payment. Subtract B from A, and enter in Part VI, on Line 17b Pay any balance due with: The PA-20S/PA-65 Information Return, or The PA-40NRC, Nonresident Consolidated Tax Return, if all the nonresident owners elect to participate in a group return. EC FILE ALL 3 PAGES Page 3 of 3 FC L 0307117119 DDDDDDDDDD o 0307117119 ---1 --.J 0307910018 PA SCHEDULE M Reconciliation of Federal Taxable Income to PA Taxable Income (09-03) PA-20S/PA-65 Schedule M Name as shown on PA-20S/PA-65 Information Return 2003 Federal Identification Number OFFICIAL USE ONL Y PA Sales Tax License Number EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 PA Schedule M Part A Classifying Federal Income (Loss) for PA Personal Income Tax Purposes Classify without adjustment for PA PIT rules, the federal income (loss) from the Schedule K of Federal Form 1120S or from Federal Form 1065. The entity must allocate or apportion the amounts from the federal categories to the reportable PA PIT classes. The total of the PA-classified amount should equal the total of the federal schedule. Federal Form Classified for Pennsvlvania Personal Income Tax DurDoses Form 1120S, Schedule Kline (a) (b) (c) (d) (e) (f) description Federal PA Business Interest Dividend Gain (loss) Rent & royalty Form 1065, Schedule Kline Income income Income income from sales income (loss) description (loss) (loss) PA Schedule A PA Schedule B PA Schedule D PA Schedule E 1. Ordinary income (loss) from trade or business activities 13521. 13521. 2. Net income (loss) from rental real estate activities O. 3. Net income (loss) from other rental activities O. 4. Portfolio income (loss) 131. 5. Interest income 131. 6. Ordinary dividends O. 7. Royalty income O. 8. Net short-term capital gain (loss) O. 9. Net long-term capital gain (loss) O. 10. Other portfolio income (loss) O. 11. PA S corporations ONLY Net section 1231 gain (loss) from Form 4797 for Form 1120S O. 12. Partnerships ONLY Guaranteed payments to partners from Form 1065 213500. 13. PA S corporations ONLY Other income (loss) from Form 11205 O. 14. Partnership ONLY Net section 1231 gain (loss) from Form 4797 for Form 1065 O. 15. Partnerships ONLY Other income (loss) O. 16. PA Income (loss) by classification. Total the amounts in each column. 13521. O. O. o. o. Please enter losses in parentheses ( ). Columns (c) and (d) can never result in a loss. The respective Federal Schedule K for partnerships and PA S corporations were not available when the Department printed PA Schedule M. After the release of the federal schedules the Department will update PA Schedule M. See the PA PIT Guide for the cross-references to the Federal Schedule K. L 0307910018 SIDE 1 0307910018 -1 ---.J 0308020015 PA SCHEDULE M Reconciliation of Federal Taxable Income to PA Taxable Income (09-03) 2003 OFFICIAL USE ONL Y Federal Identification Number 25-1884414 PA-20S/PA-65 Schedule M Name as shown on PA-20S/PA-65 Information Return EASTERN STATES CLAIMS SERVICE, LLC PA Schedule M Part B. Determining PA Reportable Income or Loss by Classification The entity may need to prepare a PA Schedule M, Part B. for each PA income class if it must make adjustments to properly determine its reportable classified income for its PA-20S/PA-65 Information return. This specific list of adjustments primarily applies to ordina Income from a business or farm Section 1. Federal Classified Income Loss. Income class from Part A, Column: (b ) Enter the initial of the column. 1. 13521. Section 2. Itemize income adjustments that increase PA reportable income (reduce the loss). a. Deferred income relating to advance payments for goods and services ................... a. b. Difference in gain (loss) for each sale of property where PA basis is lower than federal basis b. c. Gain from like-kind exchanges, other than transactions qualifying as PA allowable like-kind exchanges -IRe Section 1031 c. d. Gain (loss) on involuntary conversions -IRC section 1033 .............................................. d. e. Income from cancellation of debt that PA treats differently from federal rules ................................ e. f. Increases in income in the year of change resulting from spread in the year of change associated with IRC Section 481 (a) adjustment ......................................................... f. g. Income from obligations of other states and organizations that is not exempt for PA purposes h. Other taxable income for PA ur oses that the enti does not re art for federal ur oses - submit statement h. 2. Total Lines a throu h h 2. Section 3. Itemize income adjustments that decrease the PA reportable income (increase the loss). a. Decrease in gain for each sale of property where PA basis is higher than federal basis ........................ a. b. Income from obligations of the U.S. Government and other organizations that is not taxable for PA purposes b. c. Decreases for previously reported income in prior year resulting from spread associated with I RC section 481 (a) c. d. Other PA nontaxable income that the enti re orted for federal ur oses - submit statement ................... d. 3. Total Lines a throu h (d 3. Section 4. Ad'usted PA Re ortable Income. Total Lines 1 Ius 2 minus 3. 4. Section 5. Itemize those expenses that PA law does not allow that the entity deducted on its federal form. These adjustments increase PA reportable income (reduce the loss). o. o. o. O. 13521. a. Taxes paid on income from the worksheet in the PA PIT Guide ... . .... . ...... . ........ . ,.. . .. . a. b. Differences in depreciation taken for PA and federal purposes .. . ...... . ... . .. . ... . ,... . -.... . b. O. c. Key man life insurance premiums (owners as beneficiaries) . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . ......... . c. d. Differences in PA treatment of guaranteed payments for capital . . .. . .......... . ...... . ,.. . d e. Differences in depreciation for bonus depreciation PA law does not allow bonus depreciation ............ . ..... . e. f. Expense adjustments to qualify for the PA credits claimed in Part VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . ... . f. Q. Other expenses that the entity took on its federal return that PA does not allow - submit statement .......... . ... . g. 5. Total Lines (al throuah (al 5. O. Section 6. Itemize those expenses that PA law allows that the entity could not deduct on its federal form. These adjustments decrease PA reportable income (increase the loss). a. 50 percent of business meals and entertainment that the entity could not deduct and club dues ....... . ..... . .. . a. 1088. b. Sales tax on depreciable assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... . . . . . . . . ......... . b. c. Qualified charitable contributions that the entity made ................ ................................ . . c. O. d. Differences in depreciation taken for federal and PA purposes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . d. e. IRe section 179 expenses - the maximum for PA purposes is $25,000. . . . . ................................ . e. f. Differences in depreciation for bonus depreciation .................. . ................................ . f. g. Expenses for employees, including PA S corporation shareholder-employees .............................. . a. h. Life insurance premiums (PA S corporation or partnership as beneficiary) ................................ . h. i. Expense adjustments to qualify for federal credits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . ... . I. j. Other expenses that PA allows that the entity did not deduct on its federal return - submit statement ....... . .. . j. 6. Total Lines (al throuah (j) 6. 1088. Section 7. PA Classified Taxable Income (Lossl. Total Lines 4 plus 5 minus 6. If a (Iossl. fill in the oval. I I 7. 12433. L 0308020015 SIDE2 0308020015 ---.J -.J 0306517111 L PA Schedule RK-1 (09-03) 2003 Resident Schedule of PA S Shareholder/Partner Pass-Through Income, Loss, and Credits 202427375 BOWMAN c 603 SOUTH SPRING GARDEN STREET Owners 1 Amended N CARLISLE PA 17013 Stock Ownership % EASTERN STATES CLAIMS SERVICE LLC CARLISLE PA 251884414 c 17013 Part II. Owner's Distributive Share of Income and Loss Shareholders and partners enter the amounts from this schedule on the corresponding lines of the Pennsylvania Income tax or information returns they must file. Read the instructions for completing the PA. 40, PA-41, or PA20S/PA-65. PA Taxable Business Income (Loss) from Operations Interest Income Dividend Income 1 2 3 4 5 6 7 o If a loss, place an x in the box. Net Gain (Loss) from the Sale, Exchange, or Disposition of Property Net Income (Loss) from Rents, Royalties, Patents, and Copyrights Income from Estates or Trusts Gambling and Lottery Winnings If a loss, place an x in the box. If a loss, place an x in the box B Part III. Owner's Share of PA Credits 8 PA Resident Credit - PA S Shareholders only 9 PA Employment Incentive Payments Credit 10 PA Jobs Creation Tax Credit 11 PA Research and Development Tax Credit Part IV. Distributions from Partnership 12 Distributions of Cash, Marketable Securities, and Property - not including guaranteed payments 13 Guaranteed Payments for Capital 14 Guaranteed Payments Part V. Distributions from PA S Corporation 15 Distributions from PA AAA 16 Distributions of Cash, Marketable Securities, and Property Part VI. Nontaxable PA S Corporation Income or Loss 17 Nontaxable PA S corporation income (loss) If a loss, place an x in the box. Do not report this income or loss on your PA-40 Tax Return Part VII. Supplemental Information 18 Member's Share of Depreciation Expense 19 Member's Share of Straight-Line Depreciation o EC FC L 0306517111 rnITIIIIJITJ D. WILLIAM (Individual=1, S Corp=2, All Other Corp=3, Estate/Trust=4, Partnership=5) Partner's % of: Profit sharing 0 . 990 0 0.9900 Loss sharing 0.9900 N Capital 0 . 9 9 0 0 Ownership PA S Corp Y Partnership 1 2 3 4 5 6 7 12309 130 o o o o o 8 9 10 11 o o o o 12 13 14 11712 o 213500 15 16 o o 17 o 18 19 o o 0306517111 -' ~ 0306517111 L PA Schedule RK-1 (09-03) 2003 Resident Schedule of PA S Shareholder/Partner Pass-Through Income, Loss, and Credits 183442392 BOWMAN c 603 SOUTH SPRING GARDEN STREET Owners Amended CARLISLE PA 17013 Stock Ownership % EASTERN STATES CLAIMS SERVICE LLC CARLISLE PA 17013 251884414 c Part II. Owner's Distributive Share of Income and Loss Shareholders and partners enter the amounts from this schedule on the corresponding lines of the Pennsylvania income tax or information returns they must file. Read the instructions for completing the PA- 40, PA-41, or PA20S/PA.65. PA Taxable Business Income (Loss) from Operations Interest Income Dividend Income 1 2 3 4 5 6 7 If a loss, place an x in the box. Net Gain (Loss) from the Sale, Exchange, or Disposition of Property Net Income (Loss) from Rents, Royalties. Patents, and Copyrights Income from Estates or Trusts Gambling and Lottery Winnings If a loss, place an x in the box If a loss, place an x in the box Part III. Owner's Share of PA Credits 8 PA Resident Credit - PA S Shareholders only 9 PA Employment Incentive Payments Credit 10 PA Jobs Creation Tax Credit 11 PA Research and Development Tax Credit Part IV. Distributions from Partnership 12 Distributions of Cash, Marketable Securities, and Property - not including guaranteed payments 13 Guaranteed Payments for Capital 14 Guaranteed Payments Part V. Distributions from PA S Corporation 15 Distributions from PA AAA 16 Distributions of Cash, Marketable Securities, and Property Part VI. Nontaxable PA S Corporation Income or Loss 17 Nontaxable PA S corporation income (loss) If a loss, place an x in the box Do not report this income or loss on your PA-40 Tax Return Part VII. Supplemental Information 18 Member's Share of Depreciation Expense 19 Member's Share of Straight-Line Depreciation EC 1 N FC L 0306517111 rnmITJ MICHELLE E (Individual=1, S Corp=2, All Other Corp=3, EstatelTrust=4, Partnership=5) Partner's % of: Profit sharing 0 . 0 1 0 0 0.0100 0.0100 Loss sharing N Capital 0 . 0100 Ownership PA S Corp Y Partnership D 1 2 3 4 5 6 7 124 1 o o o o o B 8 9 10 11 o o o o 12 13 14 o o o 15 16 o o o 17 o 18 19 o o 0306517111 ---1 I 10100031545 RCT -101 PAGE 1 OF 6 STEP A Tax Year Beg. Tax Year End. STEP C PA Account 10 Federal EIN Corporation Name Address Line 1 Address Line 2 City State Zip STEP 0 A. Tax Liability from Tax Report CS/FF LOANS CNI TOTAL xx xx xx XX XX XX XX XX XX XX I DEPARTMENT USE ONLY PA CORPORATE TAX REPORT 2003 STEP B 01012003 12312003 XX XX XX First Report Koz/EIP Credit File Period Change N Y N XX XX XX N N N Regulated Inv. Co. 52-53 Week Filer Address Change 251884414 EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN CARLISLE PA 17013 B. Estimated Payments & Credits on Deposit C. Restricted C red its STEP E: Payment Make check for this amount payable to "PA Dept of Revenue" Calculation: A minus B minus C o o o o 0 0 0 0 0 0 0 0 0 0 0 0 Made Payment Via EFT N o o o o STEP F: PAYMENT RefundlTransfer Method Select one of the following options: A N Total transfer of credit B N Combination Transfer/Refund. Enter transfer amount to right7 o C N Total refund of credit TRANS AMT STEP G: Affirmation and Signature of Corporate Officer NAME PHONE E-MAIL D. WILLIAM BOWMAN 7172419514 1015 FORM I hereby affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete report. If prepared by a person other than the taxpayer, his declaration is based on all information of which he has any knowledge. Corporate Officer SignaturelDate I 10100032546 I NAME ACCOUNT 10 EASTERN STATES CLAIMS SERVICE, TAX YEAR END 12312003 RCT -101 PAGE 2 OF 6 PA CORPORATE TAX REPORT 2003 SECTION A: CS/FF OLDEST PERIOD FIRST TAX PERIOD BEGINNING TAX PERIOD ENDING BOOK INCOME YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 CUR YR 04012001 01012002 01012003 12312001 12312002 12312003 11959 -10093 721 o o o o o 2. TOTAL BOOK INCOME (sum of income for all tax periods up to, but not over 5 years total) 3. DIVISOR (In years and in part years rounded to three decimal places) See Instructions 4. Divide Line (2) by Line (3) 5. AVERAGE BOOK INCOME - Enter Line (4) or if Line (4) is less than zero enter "0" 6. Divide Line (5) by 0.095 1. Shareholders' equity at the END of the current period B. Shareholders' equity at the BEGINNING of the current period 9. If Line (7) is more than twice as great or less than half as much as Line (8), add Lines (7) and (8) and divide by 2. Otherwise enter Line (7). 10. NET WORTH - Enter Line (9) or if Line (9) is less than zero enter "0" 11. Multiply Line (10) by 0.75 12. Add Lines (6) and (11) 13. Divide Line (12) by 2 14. $125,000 valuation deduction 15. CAPITAL STOCK VALUE - Line (13) less Line (14) but not less than "0". If 100% Taxable, enter Line (15) on Line (17). 16. Proportion of taxable assets or apportionment proportion (From Schedule A-1, Line 5) 17. TAXABLE VALUE - Multiply Line (15) by Line (16). If less than zero, enter "0". 18. CAPITAL STOCK/FOREIGN FRANCHISE TAX - Multiply Line (17) by 0.00724 L Investment in LLC X X Holding Company X X Family Farm X X N N N WHOLE DOLLARS ONLY 2 3 4 5 2587 2.753 940 940 6 7 8 9 9895 6130 5278 6130 10 11 12 13 14 15 6130 4598 14493 7247 -125000 o 16 17 18 0.000000 o o ~ I NAME ACCOUNT ID EASTERN STATES CLAIMS SERVICE, TAX YEAR END 12312003 I 10100033547 RCT-101 PAGE 3 OF 6 PA CORPORATE TAX REPORT 2003 SECTION B: Bonus Depreciation 1. Current Year Fed. Depree. of 168k Prop. 2. Current Year Adj. for Disp. of 168k Prop. 3. Other Adjustments (Must Attach Schedule C-3 if claiming bonus depreciation) Business Trust XX N 1 0 Solicitation Only XX N 2 0 LLC XX Y 3 0 PA-S XX N Taxable Built-In Gains XX y SECTION C: CORPORATE NET INCOME TAX 1. Income or Loss from federal return on a separate company basis TOTAL ADDITIONS. Sum of (A) through (E) 1 0 2A 0 28 0 2C 0 2D 0 2 0 3A 0 38 0 3C 0 3D 0 3E 0 XX 3 0 4 0 5 0 6 0 7 0.000000 8 0 9 0 10 0 11 0 12 0 13 0 2. DEDUCTIONS: A. Corporate Dividends Received (From Schedule C-2, Line 6) B. Interest on U.S. Securities (GROSS INT less EXPENSES) C. Curro Yr. Addtl. PA Depree. plus Adjust. for Sale (Attached Schedule C-3) D. Other (Attached Schedule). See Instructions TOTAL DEDUCTIONS - Sum of (A) through (D) 3. ADDITIONS: A. Taxes imposed on or measured by net income (Attached Schedule) B. Tax Preference Items (Attached copy of Federal Form 4626) C. Employment Incentive Payment Credit Adjustment (Attached Schedule W) D. Current Year Bonus Depreciation (Attached Schedule C-3) E. Other (Attached Schedule) See Instructions 4. Income or Loss with Pennsylvania Adjustments (Line 1 - Line 2 + Line 3) 5. Total Nonbusiness Income (or Loss) 6. Income (or Loss) to be Apportioned (Line 4 - Line 5) 7. Apportionment Proportion (from Schedule C-1 Line 5) 8. Income (or Loss) Apportioned to PA (Line 6 x Line 7) 9. Nonbusiness Income (or Loss) allocated to PA 10. Taxable Income (or Loss) after Apportionment (Line 8 + Line 9) 11. Total Net Operating Loss Deduction (from RCT-103) can not exceed $2,000,000 12. PA Taxable Income (or Loss) after Apportionment (Line 10. Line 11) 13. Corporate Net Income Tax (Line 12 x .0999) L ~ USE WHOLE DOLLARS ONLY NAME ACCOUNT 10 EASTERN STATES CLAIMS SERVICE, TAX YEAR END 12312003 I I 10100034548 RCT-101 PAGE 4 OF 6 PA CORPORATE TAX REPORT 2003 SECTION 0: LOANS TAX 1. Did this corporation have a fiscal officer resident in PA and paying interest on indebtedness of the corporation? 2. Did this corporation have indebtedness outstanding to individual residents and/or partnerships resident in Pennsylvania? 3. Did this corporation have indebtedness outstanding held by a trustee, agent or guardian for a resident individual taxable in its own right or by an executor or administrator of an estate wherein the decedent was a resident of Pennsylvania? xx XX XX N N N List outstanding indebtedness. Attach separate schedule if additional space required. o o o Interest Rate 00.000 00.000 00.000 Taxable Value Interest Amount o o o TAX INOEBT X X o LOANS TAX X X o SCHEDULE A-1: Apportionment Schedule For Capital Stock/Foreign Franchise Tax (Include Form RCT-102, RCT-105, or RCT-106) Three Factor Single Factor Property-PA 1A 0 1C 0.000000 Numerator 4A 0 Property-Total 18 0 Denominator 48 0 payroll-PA 2A 0 2C 0.000000 Payroll-Total 28 0 Sales-PA 3A 0 3C 0.000000 Apportionment 5 0.000000 Sales-Total 38 0 Proportion SCHEDULE C-1: Apportionment Schedule For Corporate Net Income Tax (Include Form RCT -106) Three Factor Single Factor Property-PA 1A 0 1C 0.000000 Numerator 4A 0 Property-Total 18 0 Denominator 48 0 Payroll-PA 2A 0 2C 0.000000 Payroll-Total 28 0 Sales-PA 3A 0 3C 0.000000 Apportion ment 5 0.000000 Sales-Total 38 0 Proportion L ~ USE WHOLE DOLLARS ONLY NAME ACCOUNT JD EASTERN STATES CLAIMS SERVICE, TAX YEAR END 12312003 I I 10100035549 RCT-101 PAGE 5 OF 6 P A CORPORATE TAX REPORT 2003 SECTION E: CORPORATE STATUS CHANGES Out of Existence X X N Out of Existence Date X X (Final Report) . Date of Distribution of X X OR No Assets X X Assets to distribute PA Corporations: Report date business activity ceased and date assets were distributed. Foreign (Non-PA) Corporations: Report date business activity in PA ceased and date PA assets were distributed. . Schedule of Disposition of Assets MUST be completed and filed with the PA Corporate Tax Report. Has the corporation sold or transferred in bulk 51 % or more of any of the following classes of assets: X X N any stock of goods. wares, merchandise of any kind, fixtures, machinery, equipment, buildings or real estate. If so, please provide the name and address of the purchaser. (Attach separate schedule if additional space required.) Purchaser Name X X Address Line 1 X X Address Line 2 X X City X X State X X Zip XX SECTION F: GENERAL INFORMATION QUESTIONNAIRE Brief Description of corporate activity in PA HE A V Y E QUI P MEN TAP P R A I S A L S Brief Description of corporate activity outside of PA List other states in which taxpayer has activity State of Incorporation Incorporation Date XX XX 04012001 If incorporated outside of PA, does the corporation solicit sales in Pennsylvania? If yes, does the corporation use: Employee X X Exclusive Sales Representative X X Independent Sales Representative X X XX N 1. Has federal government changed taxable income as originally reported for any prior period for which reports of change have not been filed in PA? XX N If yes: First Period End Date: Last Period End Date: XX XX L 2. Does any corporation hold all or a majority of the stock of this corporation? 3. Does this corporation own all or a majority of stock in other corporations? If yes. complete Schedule X. N N --.J I 10100036540 RCT-101 PAGE 6 OF 6 NAME EASTERN STATES CLAIMS SERVICE, ACCOUNT 10 TAX YEAR END 12312003 PA CORPORATE TAX REPORT 2003 SCHEDULE OF REAL PROPERTY IN PA (Attach separate schedule if additional space required.) Own/Rent Street Address City CORPORATE OFFICERS President X X Vice President X X Secretary X X Treasurer X X TAX PREPARER'S NAME AND ADDRESS Mail to Practitioner X X Federal EIN X X Name XX Address Line 1 X X Address Line 2 X X City X X State X X Zip XX NAME PHONE E-MAIL County Last Name First Name MI Y 232933778 GROUPS TAX AND PAYROLL 524 SOUTH PITT STREET CARLISLE PA 17013 04/01/04 SUZETTE CASE 7172458581 GROUPTAX@EARTHLINK.NET L I KOZ/KOEZ N N N N SSN ~ EASTERN STATES CLAIMS SERIVCE, LLC 2002 RCT-101 EIN: 25-1884414 ACCOUNT 10: 4710-494 BOOK INCOME ADJUSTMENTS FOR CAPITAL STOCK TAX BOOK INCOME PER LINE 1 OF SCHEDULE M-1 OF FORM 1065 $12,433.00 lESS: DISTRIBUTIONS TO MATERIAllY PARTICIPATING MEMBER' PER LINE 22 OF SCHEDULE K-1 OF FORM 1065 FOR D. WilLIAM BOWMAN. MR. BOWMAN WORKS MORE THAN 2000 HOURS PER YEAR IN FUll-TIME EMPLOYMENT FOR THE TAXPAYER. -$11,712.00 BOOK INCOME FOR CAPITAL STOCK TAX $721.00 Eastern States Claims Service, LLC business expo 2003 and int. Business Exp. 2003 expo 2003 Interest Supplies $4,612.54 130.56/members first checking postage/fed-ex $1,009.48 booksJ magazines $24.00 sub-contractors $1,115.00 cell phone $3,102.42 local phone $1,421.95 long dist. $1,668.60 sponsorship $1,049.50 Little leag.lsoftball Teams Advertisment $625.00 Membership $150.00 tara License $60.00 PA AND CT dining $2,175.55 Internet $199.00 Car Rental $0.00 Hotels $1,569.38 NEW EQUIPMENT $509.80 CAMERA legal feesJT AX ins. E &0 $1 ;831.00 E&O COVERAGE $23,126.22 total ..-- o o N ci ..... .!:: >< 1!! g c '- Q) (j) ro Q) I CO 0 ~ I j"": --+- i ~ I ~II, 0/ 0 0 0 ...... I ..-- ~ '<;t 0 I 0 0 ~Ioi'--I 0> 0> / 0> CO / C") (/)1 "'" ~I/i ~I~ ""~ ~ ~ II.{) ...... 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N <0 V LO N :~ I~ ~ gj g g ~ ~ ~ gj gj gj ~ i~l~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ M I I I ~ OOCOooOOOOO>(oI'--IO...... <": 01'--0>0>0>0> 1'--00 1'--0> '<;to> cg~~~~~~~~~~~~~ ....t' ci CO- 1'--- .....: ....t' 00- a:i cO M M M 10- ..--N..--..--........--........--......NNNN t5~~~~~~~~~~~~N :0 ~ NOO'<;tCOOLO'<;t..--ON'<;t......I'-- /'-NCC!OOO>......O>/'-......(V')(V')~I'-- ....t....tlX)Lr:icri..-:MNOo)~......a:i '<;t/'-(V')Noooo'<;tLOO>Ooo(Oo> Q> '<;t_ V_ q M_ ~ ..--_ (0_ I'-:. ~ q 00 ...... (V') E co N 0> 0 0> co 0 0> 00 co ....t' 10- 0)- O..--N......N..--......N........--NNN'<;t U N C~~~~~~~~~~~~~ co (V') 010 ,,<0 10 (V') ~~~~ ~I I .c en .I U :J..... ..J '- 'C ~ ~ ~ C) Q...... > U Ctl ;.~~ E g. E .a.a ~ ~ g g ~:8 .c en ..J U :J . ~ C .0 .... 'C ~ ~ ~ C) 15...... > U r- roQ)roEQ.E :JQ>UOQ>O .~ ..... ro .a.a ro (/) 0 C "'0 ~ LI,,! 81 ilfnnii-- g I' N ~ o o Lr:i N (0 ~ o 00 Ooo~ O~U)N I.{) 0 1'--00 01O(V')...... ......~~~ ~ ~ Ctl ocn= (/) .0 ro C >..0 OE.:= ~(/)~ ~~ el!:::: .c~ E~ o o c:i o M ...... ~ I o o o o 10 M ..-- ~ I I I I "0 Q> '+- 1 I IT . I I ,--- ~-t-- I 1 I ' ! I I '[ )1.:1 I It! I I I -- JJ\r'TIst ~~~~fo~~ll: - - ---- ,- ~ ,- ,- ,- - .- Instructions for Recipient Box 1. Shows interest paid to you during the calendar year by the payer. This does not include interest shown in box 3. If you receive a Form 1099-INT for interest paid on a tax- exempt obligation. see the instructions for your income tax return. Box 2. Shows interest or principal forfeited because of early withdrawal of time savings. You may deduct this on the "Penalty on early withdrawal of savings" line of Form 1040. Box 3. Shows interest on U.S. Savings Bonds, Treasury bills, Treasury bonds, and Treasury notes. This mayor may not be all taxable. See Pub. 550, Investment Income and Expenses. This interest is exempt from state and local income taxes. This lnter.,st i= :;ot inch,:ded in box 1. Box 4. Shows backup withholding. Generally. a payer must backup withhold at a 30% rate if you did not furnish your taxpayer identification number to the payer. See Form W-9, Request for Taxpayer Identification Number and Certification, for information on backup withholding. Include this amount on your Income tax return as tax withheld. Box 5. Any amount shown is your share of investment expenses of a single-class REMIC. If you file Form 1040, you may deduct these expenses on the "Other expenses" line of Schedule A (Form 1040) subject to the 2% limit. This amount is included in box 1. Box 6. Shows foreign tax paid. You may be able to claim this tax as a deduction or a credit on your Form 1040. See your Form 1040 instructions. Nominees. If this form includes amounts belonging to another person(s), you are considered a nominee recipient. Complete a Form 1099-INT for each of the other owners showing the income allocable to each. File Copy A of the form with the IRS. Furnish Copy B to each owner. List yourself as the "payer" and the other owner(s) as the "recipient." File Form(s) 1099-INT with Form 1096, Annual Summary and Transmittal of U.S. Information Returns, with the Internal Revenue Service Center for your area. On Form 1096 list yourself as the "filer." A husband or wife is not required to file a nominee return to show amounts owned by the other. IMPORTANT - TAX DOCUMENT ENCLOSED D CORRECTED (if checked) PAY[R'S name, ~..reet address, city. state, and ZIP code Payer's RTN (optional) OMS No. 1545-0112 MEMBERS 1ST FEDERAL CREDIT UNION 5000 LOUISE DRIVE ~@O3 Interest Income MECBANICSBURG PA 17055 1-800-283-2328 14706 Form 1099-INT PAYER'S Federal identification number I RECIPIENT'S identification number 1 Interest income not included in box 3 Copy B 23-1360906 251-88...4414 $ 130.56 For Recipient RECIPIENT'S name Street address (including apt. no.) City, state.arldZIP code 2 . Early withdrawal penalty 3 Interest on U.S. Savings This is important tax EASTERN STATES CLAIM SVCS LLC Bonds and Treas. obligations information and is $ 0.00 $ 0.00 being furnished to the Internal Revenue PO BOX 864 4 Federal m:ome tax wIIhheJd 5 Investment expenses SelVice. If you are $ 0.00 $ 0.00 required to file a return, a negligence penalty or 6' Foreign tax paid 7 Foreign country or U.S. other sanction may be CARLISLE PA 17013-0864 possession imposed on you if this income is taxable and Account number (optional) the IRS determines that it has not been 204697-00 $ 0.00 reported. Form 1099-INT (keep for your records) Department of the Treasury . Internal Revenue Service Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org Main SWitchboard: (717) 697-1161 or (800) 283-2328 EZCall: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 MEMBERS 1st FEDERAL CREDIT UNION ~- ~ ----- ~ "- D :.- ::>- ~ 5690 1 AV 0.278000 11379-5690 1...11111.111'1'1..11..11.11...11.1..11"111.1.11...1..111'1.1 EASTERN STATES CLAIM SVCS LLC PO BOX 864 CARLISLE PA 17013-0864 Statement of Accounts Apr 01, 2005 thru Apr 30, 2005 Account Number: 204697 Account Balances at Checking: Savings: Certificates: Loans: Money Management: a Glance: 9,089.04 1,002.69 0.00 0.00 0.00 Page: 1 of 2 Join the Hap E. Traveler's club on a trip to New York City on Saturday, June 18, 2005. See the enclosed insert for more information. CHECKING ACCOUNTS 11 - CHECKING Date Transaction Description Apr 01 Balance Forward Apr 30 Deposit Dividend O. 2SOOlo Annual Percentage Yield Earned 0.250% from 04/01/2005 through 04/30/2005 Based on A verage Daily Balance of 9, 087. 17 Apr 30 Ending Balance DEPOSITS AND OTHER CREDITS Date Apr 30 Amount Description 1 .87 Deposit Dividend Date Amount Description SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Apr 01 Apr 06 Transaction Description Balance Forward Withdrawal Transfer To BOWMAN,D W XXXXXXXXXX Share 00 Apr 30 Deposit Dividend 1.000% Annual Percentage Yield Earned 1.010% from 04/01/200$ through 04/30/2005 Apr 30 Ending Balance Additions Subtractions Balance 9,087.17 9,089.04 1.87 9,089.04 Additions Subtractions Balance 14,611.83 1,000.00 13,611.83- 2.69 1,002.69 YTD SUMMARIES 1,002.69 TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 11 CHECKING 26.60 7.33 ~INI/ st Send In o"Jlres to: 5000 Lo~ise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org Main Switchboard: (717) 697~1161 or (800) 2B3~2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697~5312 or (800) 283-2328 ex!. 5312 TeleBranch: (717) 795~6049 or (800) 237~7288 . f-.. 1'1'. ~----. -- I ~;;; '\..J 03.1$/7 r- ~~ _lVHJ. s.'>I:::xiHuN 3~VH::J{ ::J 9NlalVv.. =:::$,_<oc_.......... ~,..~. --<:.c;;;.~......:.ri:.:.-s. Apr 01. 2005 thru Apr 30, 2005 Account Number: 181079 MEMBERS 1st FEDERAL CREDIT UNION *- ..... - .....= ...- -.j 0- * 2725 1 AV 0.278000 2725-2725 1...11 1111111111111111111.111111 11111/1111111111111.1111111111 D WILLIAM BOWMAN DBA EASTERN STATES CLAIMS SERVICE PO BOX 864 CARLISLE PA 17013-0864 Account Balances at a Checking: Savings: Certificates: Loans: Money Management: Glance: 0.00 25.25 0.00 0.00 0.00 Page: 1 of 1 Join the Hap E. Traveler's club on a trip to New York City on Saturday, June 18, 2005. See the enclosed insert for more information. CHECKING ACCOUNTS 11 - CHECKING Date Apr 01 Apr 30 Transaction Description Balance Forward Ending Balance Additions Subtractions Balance 0.00 0.00 SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Apr 01 Apr30 Tr.ansaction Description Balance Forward Ending Balance Additions Subtractions Balance 25.25 25.25 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 11 CHECKING 62.39 2.83 Total Year To Delte Dividends Paid NOTE: Total includes closed shares 65.22 REV-1508 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF BOWMAN D. WILLIAM FILE NUMBER 21 05 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0455 ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 800.00 Refund - ISP 2. Murdock Claim Management - payment to Eastern States Appraisal, LLC 2,525.37 3. Federated Insurance - payment to Eastern States Appraisal, LLC 593.94 TOTAL (Also enter on line 5. Recapitulation) $ !If more soace is needed. insert additional sheets of the same size) 3919.31 REV-1509 EX + (6-98) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF BOWMAN D WILLIAM FILE NUMBER 21 05 0455 If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G. SURVIVING JOINTTENANT(S} NAME ADDRESS RELATIONSHIP TO DECEDENT A. Samuel Hunter, IV 2526 Jefferson Drive West Mifflin, PA 15122 step-son B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 4/21/04 Property situate at 2526 Jefferson Drive, West Mifflin, 69,200.00 50. 34,600.00 Allegheny Co., PA recorded to document#2004-12792 2. A. Atlanta Postal Credit Union 137.11 50. 68.56 Acct. #0000026682 TOTAL (Also enter on line 6, Recapitulation) $ 34.668.56 IIf morp. !'milr.p. i!'\ np.p.rlp.rl. in!,;p.rt ilrlrlitionill !'\hp.p.t!'\ of thp. !'\ilmp. !'\i7P.\ SEND INQUIRIES TO: ~ ~A~1fA · ~. ~UNgOiNl 3900 Crown Road. Atlanta, GA 30380-0001 (404) 768-4126' (800) 849-8431 Web Site: www.apcu.com . E-mail: info@apcu.com as S"fATEMENT OF ACCOUNT r--MEMBER NUMBER SOCIAL SECURITY NUMBER STATEMENT PERIOD PAGE 17441 '"1"11111111111111111111111111111 For the first quarter of 2004 APCU share accounts paid 2.00% with an Annual Percentage Yield (APY) of 2.010%, IRAs paid 2.96% with an APY of 3.00% and share draft accounts paid 1.490% with an APYof 1.50%. Deposits start to earn dividends on the day of deposit. SAMUEL HUNTER IV 603 S SPRING GARDEN ST CARLISLE PA 17013-9264 Posting Date ID#/ Effective Date Transaction Description Payment Credits or Debits FINANCE CHARGES Fees or Charges Transaction Amount NEW BALANCE ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- 01/01 10 01 PRIMARY SHARE BEGINNING BALANCE 1,132.18 Joint Owners: o W BOWMAN 03/19 Withdrawal Shared Branch #214448 1,000.00- 132 . 18 SHBN SB Omega FCU Sieber 206 Siebert Rd. , # 20 Pittsburgh PA 03/31 Deposit Dividend 2.000% 4.93 137 . 11 Annual Percentage Yield from 01/01/04 through 03/31/04 03/31 Ending Balance 137 . 11 YTD Dividends Paid 4.93 --------------------------------- --------------------------------- END OF STATEMENT --'~~~~~~~----'---------------------------- ...---.---__~--,- _'iI'""-___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ iOU0040400)0701,17441 j\:;.nT~,:_~:~;-:: FiEGUL/-\fi ~:~,H/U-j;:': t\Cj=nu[\rr:; ).ri(:: :j'i'i :';-~i~T:\fU\.rl"ITfW"l.~. uf'! 'ni,.: nl:;conDS or: THIS CflEDIT UNION. Welcome to the Allegheny County Recorder of Deeds Online Search Page 1 of2 Tuesday, April 19, 2005 Home Free Search Search Help Feedback Contact Us Register Login [Back I Town: WEST MIFFLIN Number File Date Type Desc. Inst. Date # Pgs. Book/Vol/Pag 12792 04/26/2004 DEED 4 DE/12022/499 Property Details Lac Block/Lot Street # I StreE W MIFFLIN 240P71 Grantor ~QLl!;R ~IjjERINJ;.J::t KOLLER JOSEPH E KOLLER JOHN A KQl"L,!;R C8LI-:L~JI\JUJ_ Grantee HLJNTER SAJ'1UJ;.L ~QWM8NlL~ I Document Status I Complete I .. QlJic:J5J2QC:LJmeJ:1!-"!J~~~r (Not recommended for printing) .. ViE!~/SQVE!__printitQJE!QQ.c:.l,JmE!nt (Requires TIFF Plugin) gickiLeI~ for Instructions. ALLEGHENY COUNTY RECORDER OF DEEDS DISCLAIMER The Allegheny County Recorder's Office present the information on this web site as a service to the public. We have tried to ensure that the information contained in this electronic search system is accurate. The Recorder's Office makes no warranty or guarantee concerning the accuracy or reliability of the content at this site or at other sites to which we link. Assessing accuracy and reliability of information is the responsibility of the user. The user is advised to search on all possible spelling variations of proper names, in order to maximize search results. The Allegheny County Recorder's Office shall not be liable for errors contained herein or for any damages in connection with the use of the information contained herein. If you choose not to accept the conditions above please click HERE to exit this site. ATTENTION Documents recorded in the Recorder's Office are available to the general public for inspection and for copies. Copyright @ 2004 ACS. All rights reserved. LE!rIT1..?_9I-S_eevl<;;g NOTICE: We collect personal information on this site. To learn more about how we use your information, see our P.liYCl~Y_PQUc:Y. Contact us by phone or email at one of the listings below for further information or support. 1(800)782-5652 - Il}fQ!.rDCltJ911 - ;>!!RJloCt - W_e12mCl~J~r: https://www.recorder.county.allegheny.pa.us/palrlcontroller?commandf1ag=getDetails&op. .. 4/19/2005 Welcome to the Allegheny County Recorder of Deeds Online Search Page 1 of2 Tuesday, April 19, 2005 Home Free Search Search Help Feedback Contact Us Register Login [Back I Town: WEST MIFFLIN Number File Date Type Desc. Inst. Date # Pgs. Book/Vol/Pag 88797 04/26/2004 Mortgage 23 M/27670/386 Property Details Loc Block/ Lot Street # Street W MIFFLIN 2526 JEFFERSON Mortgagor HUNTER SAMUEL BOWMAN D W Mortgagee mJJ2.w_I;!,,!,,_BAt~tKj:E_.l1"ffi_ I Document Status I Complete I .. QlJJ<;KQQc::.lJn:H~l1tVi~\I'I~r (Not recommended for printing) .. View/Save Printable Document (Requires TIFF Plugin) Click Here for Instructions. ALLEGHENY COUNTY RECORDER OF DEEDS DISCLAIMER The Allegheny County Recorder's Office present the information on this web site as a service to the public. We have tried to ensure that the information contained in this electronic search system is accurate. The Recorder's Office makes no warranty or guarantee concerning the accuracy or reliability of the content at this site or at other sites to which we link. Assessing accuracy and reliability of information is the responsibility of the user. The user is advised to search on all possible spelling variations of proper names, in order to maximize search results. The Allegheny County Recorder's Office shall not be liable for errors contained herein or for any damages in connection with the use of the information contained herein. If you choose not to accept the conditions above please click HERE to exit this site. ATTENTION Documents recorded in the Recorder's Office are available to the general public for inspection and for copies. Copyright @ 2004 ACS. All rights reserved. I~LmS__QLSeQ(Lc:e NOTICE: We collect personal information on this site. To learn more about how we use your information, see our rr!ygc:;vP'Qlic:y. Contact us by phone or email at one of the listings below for further information or support. 1(800)782-5652 - InforOlgJigD - ~I,lQQort - WgQm(}~1er https ://www.recorder. county. allegheny.pa.us/palr! contro ller?commandflag=getDetails&op... 4/19/2005 Allegheny County Assessment Page 1 of 1 ALLEGHENY COUNTY REAL ESTATE WEB SITE Parcel 10: 0240-P-00071-0000-00 School District: Neighborhood Code: West Mifflin A rE>()..., 87015 Owner Name: Property Location: HUNTER IV SAMUEL 2526 JEFFERSON DR WEST MIFFLIN, PA 15122 Tax Code: Owner code: State Code: Use Code: Homestead: Farmstead: Taxable Regular Residential Single Family No No Sale Date: Sale Price: Deed Book: Deed Page: Abatement: Lot Area (SQFT): 4/26/2004 $1 12022 499 No 15,421 $69,200 2004 Market Value: 2005 County Assessed Value Total Land Value $14,500 Total Building Value $54,700 Total Market Value $69,200 2005 Full Market Value Total Land Value $14,seJO Total Building Value $54,"700 Total Market Value $69,:Z..OU 2006 Un-Certified 2006 Base Value $75,200 Certified 2006 Taxable Value $ To be determined NOTE: This is the only 2006 information for this property. It should be used for informational purposes only. Address Information Tax Bill Mailing: CENoANT I MORTGAGE SERVICE CNTR 95 METHODIST HILL DR STE 100 ROCHESTER, NY 14623- Change Notice Mailing: 2526 JEFFERSON DR WEST MIFFLIN, PA 15122- Legal Disclaimer http://www2.county.allegheny.pa.us/Rea1Estate/General.asp?HouseN um=2526&Street=j ef... 4/19/2005 111111111111111111 60 2004 00012792 Allegheny County Valerie McDonald Roberts Recorder of Deeds Pittsbul'gh, PA 15219 Oqc -,-/-j(( Recorded On: April 26, 2004 Instrument Number: 2004-12792 As Deed Parties: KOLLER JOSEPH E JR TRSTE To HUNTER SAMUEL 4TH Number of Pages: 4 Comment: **00 NOT REMOVE-THIS PAGE IS PART OF THE RECORDED DOCUMENr Deed 45.00 Total Recording: 45.00 ,Realty Transfer Tax Stamp ! Affidavit Attached-No Stamp Num- T179782 WEST MIFFLIN Ward-99-NO WARD BIk/Lot-240 P 71 Value Deed Registry Stamp Commonwealth of Pennsylvania Munic-West Mifflin Boro School District-West Mifflin 64,750.00 647.50 323.75 323.75 1,295.00 **00 NOT REMOVE-THIS PAGE IS PART OF THE RECORDED DOCUMENT' I hereby certify that the within and foregoing was recorded in the Recorder's Office in Allegheny County, PA File Information: Document Number: 2004-12792 Receipt Number: 207220 Recorded DatelTime: April 26, 2004 02:54P Book-VoIIPg: BK-DE VL-12022 PG-499 User I Station: J Clark - Cash Super 06 Record and Return To: AMERICAN GENERAL SERVICES CORP WILL CALL PITTSBURGH PA 15219 Valerie McDonald-Roberts Recorder of Deeds DEED I THIS DEED, made the 21st day of April I IJoseph E. Koller Jr., Successor Trustee and John A. Koller, Successor Trustee, I jSuccessor Trustees in the Trust of Catherine H. Koller, late of Allegheny County, I Pennsylvania, Grantors; I I I I , 2004, between -AND- i I "Samuel Hunter IV, single, and D.W. Bowman, step-father, Grantees; ,cu raIN. 1r=J.,.:)A.'\')"l':':) i'-' iTl\ Tt1-E. f(.\G-l-\T Or .s;'L,~v,v.Ot2.Sl-\i~ PrNO I -r-C('J,"h..:Ji5 ,,~ C"c;"',f.'\.\},1J ~ NeT ,1:5 I WITNESSETH: I I I That in consideration of the sum of ONE ($1.00) DOLLAR, and Other Good and IValuable Consideration, in hand paid, the receipt whereof is hereby acknowledged, the said ,Grantors do hereby grant and convey to the said Grantees, their heirs and assigns: i I IPARCEL NO: #1~D .-p.-- r"J { I ALL that certain lot or piece of ground situate in the Borough of West Mifflin, !formerly Township of Mifflin, County of Allegheny, and State of Pennsylvania, being Lot No. 147 in the Duquesne Village Plan No. 2 as recorded in the Recorder's Office of Allegheny !County, Pennsylvania, in Plan Book Volume 39, Pages 80 and 81, bounded and described ias follows: I ! ! BEGINNING at a point on the Northerly line of Lincoln Drive at the dividing line Ibetween Lots Nos. 46 and 47 in said plan; thence continuing along the northerly line of [Lincoln Drive, South 720 5' West 50 feet to the dividing line between Lots Nos. 47 and 48 in !said plan; the~ce along s~id dividing line North 1?0 55' W~st, 259 feet to a point; ~hence by (the areaf a CIrcle deflecting to the left and haVing a radIUS of 1196.14 feet a distance of 161.45 feet tot he dividing line between Lots Nos. 46 and 47 aforesaid; thence along the last (mentioned dividing line South 170 55' East, 294.49 feet to the northerly line of Lincoln rDrive at the place of beginning. HAVING erected thereon a one and one-half story brick dwelling. , i I Being the premises which Catherine H. Koller by deed dated November 15, 1991 land recorded in Deed Book Volume 8643 Page 53 granted and conveyed to Catherine H. I lKoller Trust. The said Catherine H. Koller died January 21, 2004. Pursuant to the terms and . '" (conditions of her Trust dated November 15, 1991, specifically, in paragraph ONE her sons ~oseph E. Koller Jr. and John A. Koller are the Successor Trustees and as such have signed ~his agreement. \\ ii II [I i! The actual consideration for this conveyance is the sum of SIXTY-FOUR THOUSAND, II SEVEN HUNDRED, FIFTY ($64,750.00) DOLLARS ,I Ii ;i if ~ J II I! HAS, TO THEIR KNOWLEDGE, NEVER BEEN USED FOR HAZARDOUS WASTE II DISPOSAL AS THAT TERM IS USED IN SOLID WASTE MANAGEMENT ACT NO. 97 !IOF 1980. (This Notice is given pursuant to the requirements of Section No. 405 II of said Act - 3S P.S. 6018-101, et seq. Ii I! THIS DOCUMENT MAY NOT SELL, CONVEY, TRANSFER, INCLUDE OR !l INSURE THE TITLE TO THE COAL AND RIGHT OF SUPPORT UNDERNEATH THE !I SURFACE LAND DESCRIBED OR REFERRED TO HEREIN, AND THE OWNER OR UOWNERS OF SUCH COAL MAY HAVE THE COMPLETE LEGAL RIGHT TO REMOVE ilALl OF SUCH COAL AND, IN THAT CONNECTION, DAMAGE MAY RESULT TO THE i! SURFACE OF THE LAND AND ANY HOUSE, BUILDING OR OTHER STRUCTURE ON ri OR IN SUCH LAND, THE INCLUSION OF THIS NOTICE DOES NOT ENLARGE, II RESTRICT OR MODIFY ANY LEGAL RIGHTS OR ESTATES OTHERWISE CREATED, II !! TRANSFERRED, EXCEPTED OR RESERVED BY THIS INSTRUMENT. (This Notice is 'I ii set forth pursuant to Act No. 255, approved September 10, 1965, as amended.) AND the said Grantor does hereby warrant generally the property hereby conveyed. THE GRANTORS HEREIN CERTIFIES THAT THE LAND HEREBY CONVEYED 11 ;1 NOTICE .-., _..-" ,..,.,- . -- -,' ,':::. ,'-, ::~"--- '., " The undersigned, as evidenced by the signature(s) to this Notice and the acceptance f! and recording of this deed, (is/are) fully cognizant of the fact that the undersigned may not 11 be obtaining the right of protection against subsidence, as to the property herein conveyed, iI II resulting from coal mining operations and that the purchased property, herein conveyed, Ii may be protected from damage due to mine subsidence by a private contract with the if owners of the economic interest in the coal. This Notice is inserted herein to comply with II the Bituminous Mine Subsidence and Land Conservation Act of 1966, as amended 1980, il 1\ Oct. 10, P.L 874, No. 156 1. I; if ;\ II p I' Ii and year first above written. ~ i il i! Signed, sealed and delivered II II in the presence of: il Ii _../"') /' -' !: . -~.:.""~-~-_,~Z: .~;~/- liZ:;- ,.. ~ ii. -,,,,,>/'. I.'i:., Wltne5rM. .' ./.~ i! .~~ p IN WITNESS WHEREOF, said Grantor has hereunto set her hand and seals the day 1- \ 1 i 11 'i (SEAL) n A. Koller, S ccessor Trustee !\ !: ~ : i! Ii !i II 1J j, I' q I i COMMONWEALTH OF PENNSYLVANIA II ~0QS.~iY\6V'~tc.V\.,l II COUNTY OF W~IJ I! lion this &Bi\c1 day of ^rit I . 2004, before me, a Notary Public, the l! undersigned officer, personally appeared Joseph E. Koller Jr., Successor Trustee, known to I! me (or satisfactorily proven) to be the persons whose name are subscribed and II acknowledged that they executed the same for the purposes therein contained. i! . II ,"'" "'-""1 LV-'. i \ I Notarial Seal " Tracy M. Shelton, Notary Public i, ;,,: Irwin Boro, Westmoreland County My Commission Expires Aug. 13, 2007 ',i i I Member, Pennsvlvania Association of Notaries 11 if II COMMONWEALTH OF PENNSYLVANIA II G..)Q$;tvv\b v-e.. kv\",d II COUNTY OF WE~ MORLAND i\ H II On this c:S2Yf\d day of..Apn I , 2004, before me, a Notary Public, the I! undersigned officer, personally appeared John A. Koller, Successor Trustee, known to me II (or satisfactorily proven) to be the persons whose name are subscribed and acknowledged :! that they executed the same for the purposes therein contained. !i II IN WITNESS WHEREOF, I have her unto set my hand and notarial seal. \ I COMMONWEALTH OF PENNSYLV"'..NIA i I NOiarial Seal II! Tracy M. Shelton, Notary Public I' Irwin Boro, Westmoreland County ! My Commission Expires Aug. 13, 2007 I ! Member, Pennsylvania Association of Notaries I!***********************************~*************************************** 'I ;\ !i !< U II H li II Ji !I Ji ss. e her/~to set my ha~nd n~~rial seal. VLtlL \A &Q-~~:~'-~- ota Public ***************************************** ****************************** 55. v---- Certificate of Residence n I, the undersigned, do hereby certify that the Grantee's precise residence is: c/o C ", Jd t."Je (I B c-..i\k"-"!lI' It.ie> ,....<t-;)<~- S Q. / 3c.,o c.' L€_"'~c1e",\ ,",-.:d ~ Rtl, I' J~tr:. I-It't.:'{ c..i I ,v.T. og05'1, 1/ iI iJ II ii I' q -1~. I.', !jl~'ll~ I ..... _, ':'>',._:~'J \1 c2,3rd day of l1-7t1r ~ \ Witness my hand this , 2004. ~--- ~ - ? 2 i,l ~~~~ !.. // \ // '''''''''''2// .~ ~,~~~~"~.\;-'~.~~: ~~:_; L'\..it\j ';- r~or.~G::~3 A \If=i\';LX:: 808 ALLEGHENY BU!U:;;.IG !i'''~~r'\f'''\lil,...",I'''\'1 !;""\I\ J~rl,"",~('\ . ,=," ---_.,--~ A, Settlement Statemerit u.s. Department of Housing and Urban Development OMS No. 2502.0265 REV. HUD-1 (3/86) S. TYPE OF LOAN 1. DFHA 2. DFmHA 3. IIlConv. Unins. 4. OVA 5. DConv. Ins. 6. FILE NUMBER /7. LOAN NUMBER 04C.419 HUNTER! 0027598366 8. MORTGAGE INSURANCE CASE NUMBER C.Nole: "11rfarm"~rurntstn!d1~al,,,,,,:,,,1 'W' ..~I~.' ..ofUl..........I.......I~. ,A,..u.mts-p;rkttu'"3mttTt~I",tl....I.y..,,1 a. U' ""I::... . I , TiIleE~press Selllemenl System iteMs marked "Ip_o_c.)" were paid oufslde the C1051rtg: they are ~hown here for Informallon purposes and .r. "at fncluded In the (ola(s. ~:.,;:~~~:~: I~:~~': :;.~~:rr~p=::.:::= ;::7:: ::':~;J~:;:du~~.'~~ t:lr:na~D;t~~~ ss,:~~~o;m:~!I)alUes upon Prinled 04/2312004 al 06:34 CAK O. NAME Of BORROWER: Samuel Hunter, IV and D. W. Bowman ADDRESS: E. NAME OF SELLER Catherine E. Koller Trust, dated November and Joseph E. Koller, Jr., Successor Trustee ADDRESS: F. NAME OF lENDER: Coldwell Banker Mortgage --AQORf:S::;: 3000 LEADEN HALL ROAD MT. LAUREL N.J. 08054 G. PROPERTY ADDRESS: 2526 Jefferson Drive, West Mifflin, PA 15122 -' BorouQh of West Mifflin H. SETlLEMENT AGENT: American General Services Corporation, Telephone: 412-263.5000 Fax: 412.263.5005 PLACE OF SETTLEMENT: Coldwell Banker Real Estate West Mifflin PA 15122 I. SETlLEMENT DATE: 04/23/2004 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER lOt. Conlract sales mice 64 750.00 401. Conlracl s,!les orice 64,750.00 102. Person"t Prooerty 402. Personal P'ooertv ~S.!llllem;nl charooslo borrower Wne 14001 4107.11 403. r-1Q!.. 404. ~..- 405. Adjushnents for items paid by seller in advance Adjustments for /lems paid by seller in advance 107. CoullN la~es 04/231041012/31104 120.39 407. Counlv la~es 04/231041012/31/04 120.39 108. School Taxes 04/23/041006/30/04 234.89 408. School Taxes 04/23/041006/30/04 234.89 109. 409. 110. 410, 111. 411. 112. 412. _ 120. GRO~S~!'>'IO\JNT DUE FROM BORROWER 69 212.39 420. GROSS AMOUNT DUE TO SELLER ~1.Q5.28_ 200. AMOUNTS ~ArD BY OR ON BEHALF OF BORROWER 500. REDUCTIONS IN AMOUNT DUE 10 SELLER 20~ or earnesl money 1 000.00 501. E~cess Deoosillsee inslruclionsl 202. Pri~~T1ounl of new loans 61 512.00 502. Setllemenl charoes 10 seller (fine 140m 8 430.50 203. Exislina loanlsllaken subiecllo 503. Existina loanls1laken subiecllo 204. 504. Pavoff of First MorIQaae Loan ~. 505. 206. 506. 207. 507. 208. 508. 209. 509. Adiustments for items unpaid bv seller Adjustments for items unpaid bv seller 210. Cilvnown laxes 01101/041004/23/04 83.71 510. Cilvno\Vnla~es 01/01/041004/23/04 83.71 213. 513. 214 514. ';'\1. I \,l:.\TJ:'n p. '1:'I1H,., '. lUT ,I \. 215. 515. .. ~. 216. 516. i'1J\c. .l/U:- 11/':'.JrVIY,HO/LlII VI' 217. 511. iW" S"-11../:.1\. 218- 518. _~19. 519. 220. TOTAL PAID BY/FOR BORROWER 62.595.71 520. TOTAL REDUCTION AMOUNT DUE SELLER 8514.21 300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLER 301. Gro"s amount due from borrower mne 1201 69 212.39 601. Gross amount due fo seUer fline 4201 65 105.28 302. Less amoonls oaid b~/lor borrower Cline 2201 62595.71 602. Less reduction amoonl due seller (Hne 520l 8,514.21 ~3. CASH FROM BORROWER 6616.68 603. CASH TO SELLER 56 591.07 SUBSTITUTE FORM 109!J SELLER STATEMENT: The In'ormatlon conMlned herein Is Important lOll( 1"lo'01<1Uon and Is being furnished to tho lnl~rnal RCVemJD Service. If you are rp.3uirCd to file iI (otur ~1~l!~:'~I~~~~r~~~~l,~,~~h,rlrO s~~:~~~r,:~~~:~~r;:;~:~r~~l~,~~~IS Ilem 1$ required to be repOrled and the IRS determines thai It has not been reported. Tlte Contract Sales PrIce ascribed 011 You onw IClf\\llHHt by t;\W ,.... J1rov1t.t~ thl! s~1Ul!menl #genf jFt!d. Tu 10 tlo: ) wIth your COHl~C:' I;upayer Id"ntlUc311on 'lumber. "you do no' provldo your COrlf!cl taxPilyer Ideu,mcatlon numhor, r(jll m(lY be: sllbj'.'!ct to civil or .;r1mll1al p@naltles Impos~d by law. Under penal\1es or perJury, I cor1I'y lhdt (ho number shown on Ihls sl;atoment Is InY correct (3xp"ycr h:fontlflcallon number. I1N'.~a~_.__'_._._ SEllER(S)SIGNATURE{S): SELLER(SI NEW MAILING ADDRESS: SELLERISI PHONE NUMBERS: IHI (WI ... _.-'.-"----- --"'-j.jD lJRi;;AN DEVELOPMENT ~g-ii",..A''''~~T'gTATltMENT REV HUD 1 (3/86) ", ------ File Number: 04C-41!HIIJNrEf<f TiUeExoress Settlement System Printed 0412312004 al 06'34 CAK SETTLEM PAJDFROM PAID FROM L. SETTLEMENT CHARGES ~?TAL SALES/BROKER'S COMMISSION based on price $64.ll!).00 l1il6.17B = 4 000.00 BORROWER'S SELLER'S Division or commissiOlllline 700\ as follows: FUNDS AT FUNDS AT 701. $ 2,000.00 10 Norlhwood Really SETTLEMENT SETTLEMENT 702. $ 2.000.00 10 Coldwell Banker Real Estate 703. Commission paid at 5etUement 3 000.00 704. $1 000.00 PaC Eamesl Monev retained as nart 01 commission bv Coldwell Banker Real Eslate 1 000.00 705. Real Estate Broker""" Fee to Coldwell Banker Real Estate 395.00 BOO. ITEMS PAYABLE IN CONNECTION WITH LOAN '801. Loan Orioination Fee 0.500 %Coldwell Banker Martnane LR 307.56 802. loan Discount % 803. Aooralsal Fee 804. Credit Reoort 10 FNMA cec Svstems LR 21.90 805. Lende(s Insoeclion Fee 806. MllItllaoe ADDlicalion Fee 10 Coldwelll3anker MarinaDe fP.O.C.) 250.00 Buver LR 200.00 807. Assumo/ion Fee 808. Flood Certification 10 stars LR 19.50 809. Documenl Preoaralion Fee 10 Coldwell Banker Morloaoe lR 85.00 810. BIt 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Inleresl From 0412312004 to 0510112004 @$ 10.8800 Iday 8 Davs LR 87.D4 902. Morta3Qe Insurance Premium lor 10 903. Hazard Insurance Premium for 10 Goodville Mutual Causallv tP.O.C.) 253.00 Buver 904. 905. 1000. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard Insurance 3 mOJn)$ 21.081mo 63.24 1002. Mort"""e Insurance mo. tiil-:' lmo 1003. Cily P,ooertv Taxes 11 mo. Ifil $ 22.34 /mo 245.74 1004. County Prooerty Taxes 4 mo.tiil$ 14.53 /mo 58.12 1005. School Taxes 11 mo. /Ii)$ 105.07 /mo 1155.77 1009. Aooreaale Analv~s Adiuslmenl \0 Coldwell Banker MorlnaDe -157.01 0.00 1100. TITLE CHARGES 1101. Setllemeni or dosina fee 10 Nat C. Cohen Es.nuire 100.00 1/02. Abstract or litle search 1103. Tille examinalion 1/04. Title insurance binder 1105. DEED PREPARATION 1106. Nolarv Fees 10 Nat C. Cohen Esouire 12.00 12.00 1/07. Allornev's fees to Nat C. Cohen ESDuire 410.00 (includes above ilems No: I 1108. Tille Insurance 10 CB Settlement Services Inc. 238.75 __ !includes above items No: \ 1109. Lender's Coveraae $ 61 512.00 . 1110. OWner's Cover:!nP. $ 64750.00 .238.75 1111. END 100 END 300 END 900 /8.lb CB Settlement Services Inc. 150.00 1112. ~l3. ClosinflServiceLeller to CB Settlement Services Inc. 35.00 ~90VER'NMENT RECORDING AND TRANSFER CHARGES 1201. Recordi'l!l.E!ms Deed $51.00 . Mortn:lfle $ 8tOD . Release $ 132.00 _J202. Cily/Counlv lax/stamM Deed $647.50 . MorloMe $ 647.50 1203. Slale Ta'llslamDs Deed $647.50 . Morlnaoe $ 647.50 r-llQ4. 1205. ABC Fea 10 Norlhwood Realtv Services 195.00 1300. ADDITIONAL SETTLEMENT CHARGES .J.;j0 I. SurveV:_ 10 Affidavit _fl.92. Pesllnspeclion to Safe-flard Consolidated Services lP.O.C.150.00 Buyer 1303. MUNICIPAL UEN LETTERS 10 AMERICAN GENERAL SERVICES EXHIBIT ACCOUNT 145.0( 1304. Horlle Warranty to Home Securitv of America 399.0{ 1305. Radon Remediation 10 Radon Detection & Control 785.Oi ~. Caroenler Ani Treatment 10 COQk Exterminatinn 212.01 1307. Repairs 10 Barberal:lectric 250.01 .-1308. Additional ~'ir Work 10 Jacko RMD. Inc. 1 6B5,1} 1400. TOTAL SETTLEMENT CHARGES (enler on lines 103, Seclion J and 502, Section KI 4107.11 8 430.5 HUD CERTIF'CAnON OF BUYER AND SELLER ccurate slalement of all receipts and dlsbursomenfs mild. on my .lccnunl 0 _ ::rh~ ~,iJ:~~~~~(~~lle;:.~gs;~~~~g;~I~~~~:';~~~~~r;~n~:~: ~t t::: ~U~~1~~f~I:;~~:e:~~e~:n~~"~f.~,J 'J (~1f~... -- - .- _ _,~.J J\A~~'''-~' -"',11/' --:1" Lj'-_=~ ~;Jtflt:rnfffuJrtUT. IV - 2.10ti07142 ) ,~~- C:J!tl1rrlrnrf:=-Ko"~r-Tm"S"t;.lf::ltm.Nuvl::'mbt'T--.-- ~~4-- ~ VMRltltJG; IT IS ^ CruME 10 KNOWlNGL Y MAKE FAl_Sf': S!~T_E~~~.~5_!.<?..~~l~.~.. ThB mo- eUlerno'll_Slatl!mont whlc.h I have pr~p:Hcd t.. i:\ (rUB and :;\ccunte ;U:COUi.\ of \hls 1,.!Osa, . '--..- ~_... -~ ....rt1 ~........ ,h,. ,...,..1., r,:..Jo'll' r11......n:nrilnar:cnrrf<lnl:a with this stalnmont. REV-1510 EX + (6-98) . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOWMAN D. WILLIAM FILE NUMBER 21 05 0455 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE Of TRANSFER. ATTACH A COPY OF THE DEED FOR REAl ESTATE VALUE OF ASSET INTEREST VALUE (IF APPliCABLE) 1. SEPIIRA 46,941.48 100. 46,941.48 0.0 TRC44751363 MML Investors Services, Ine 2. SEPIlRA 125,516.01 100. 125,516.01 0.0 BMA949264 MML Investors Services, Inc. For informational purposes only - decedent was under age 59 at time of death . TOTAL (Also enter on line 7 Recapitulation) $ 0.00 o o COMBINED ACCOUNT REPORT D. William Bowman Printed On: 04/19/2005 Page 1 D. William Bowman TRC44751363 - SEPJlRA MML-Fidelity VIP Contrafund-Transitions MML-Aim VIF Financial Srvs- Transitions MML-Aim VIF Technology-Transitions MML-Emerging Growth-Transitions MML-Opp Global Securities-Transitions MML-T Rowe Price Mid-Cap Growth-Transitions 10/31/2002 10/31/2002 10/31/2002 1 0/31/2002 10/31/2002 10/31/2002 743.357 $9,486.45 04/08/2005 381.788 $4,120.74 04/08/2005 442.716 $4,056.39 04/08/2005 842.442 $8,957.18 04/08/2005 801.780 $10,129.71 04/08/2005 813.323 $10,191.01 04/08/2005 $46,941.48 Totals For D. William Bowman $46,941.48 ASGW Securities products and services are offered through Registered Representatives of MML Investors Services, Inc., 214 Senate Ave, Suite 303 Camp Hill, PA 17011 Telephone:(717) 763-7365 This report has been prepared from information obtained from outside sources deemed reliable. However no guarantee is made as to the accuracy. reliability or completeness of the information. You should rely on the statements from the product sponsors as the official record of your account. COMBINED ACCOUNT REPORT Michele E Bowman Printed On: 04/19/2005 Page 1 D. William Bowman BMA949264 - SEP/IRA Putnam GI Natural Resources A Franklin Real Estate A F A Health Care A Templeton Growth Fund A L A Affiliated A NFS Prime Fund- MM Franklin Income A F A Technology A 06/14/2002 06/14/2002 07/08/2002 07/08/2002 08/12/2002 12/31/2002 03/03/2003 06/10/2003 994.836 771.411 593.057 656.116 1,170.072 8,169.480 8,603.572 444.845 $26,233.83 $19,262.13 $12,288.14 $15,169.40 $16,837.34 $8,169.48 $21,078.75 $6,476.94 $125,516.01 04/08/2005 04/08/2005 04/08/2005 04/08/2005 04/08/2005 04/08/2005 04/08/2005 04/08/2005 Totals For Michele E Bowman $125,516.01 ASGW Securities products and services are offered through Registered Representatives of MML Investors Services, Inc., 214 Senate Ave, Suite 303 Camp Hill, PA 17011 Telephone:(717) 763-7365 This report has been prepared from information obtained from outside sources deemed reliable. However no guarantee is made as to the accuracy, reliability or completeness of the information. You should rely on the statements from the product sponsors as the official record of your account. COMBINED ACCOUNT REPORT Michele E Bowman Printed On: 04/19/2005 Page 2 Report Total $172,457.49 ASGW Securities products and services are offered through Registered Representatives of MML Investors Services, Inc., 214 Senate Ave, Suite 303 Camp Hill, PA 17011 Telephone:(717) 763-7365 This report has been prepared from information obtained from outside sources deemed reliable. However no guarantee is made as to the accuracy, reliability or completeness of the information. You should rely on the statements from the product sponsors as the official record of your account. REV-1511 EX'" (12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOWMAN D WILLIAM SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule I. FILE NUMBER 21 0455 05 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hollinger Funeral Home 2,612.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (5) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(5} Commission Paid: 2. Attomey Fees Duncan & Hartman, P.C. 800.00 3. Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation) 3,500.00 Claimant Michele Bowman StreetAddress 603 S. SprinQ Garden Street City Carlisle State P A Zip 17013 Relationship of Claimant to Decedent spouse 4. Probate Fees Register of Wills 87.00 5. Accountanfs Fees 6. Tax Retum Preparer's Fees 7. Register of Wills, Filing fees, tax return 15.00 8. Reserve for additional fees 200.00 TOTAL (Also enter on line 9, Recapitulation) $ 7,214.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) '* SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOWMAN. D. WILLIAM FILE NUMBER 21 05 0455 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. Coldwell Banker Mortgage on 2526 Jefferson Drive, West Mifflin, PA 1/2 of $60,867.41 VALUE AT DATE OF DEATH 30,433.70 2. Holy Spirit Hospital 66.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 30 499.70 Mr~Al !.pan Number: 0027598366 Cl _./1 if Vl/./.J ...J ,ill.! I ...) III /;'l I fC::-.-~-=~.'-:",~;~) NOTE April 23. 2004 [Date] WEST MIFFLIN [City] Pennsylvania [State J 2526 JEFFERSON WEST MIFFLIN. PA 15122 [Properly Address] 1. BORROWER'S PROMISE TO PAY In return for a loan that I have received, I promise to pay U.S. $ 61.512.00 (this amount is called "Principal"), plus interest, to the order of the Lender. The Lender is Co 1 dwe 11 Banker Mortgage I will make all payments under this Note in the form of cash, check or money order. I understand that the Lender may transfer this Note. The Lender or anyone who takes this Note by transfer and who is entitled to receive payments under this Note is called the "Note Holder." 2. INTEREST Interest will be charged on unpaid principal until the full amount of Principal has been paid. I will pay interest at a yearly rate of 6.367 %. The interest rate required by this Section 2 is the rate I will pay both before and after any default described in Section 6(B) of this Note. 3. PAYMENTS (A) Time and Place of Payments I will pay principal and interest by making a payment every month. I will make my monthly payment on the Olst day of each month beginning on June 1st. 2004 . I will make these payments every month until I have paid all of the principal and interest and any other charges described below that I may owe under this Note. Each monthly payment will be applied as of its scheduled due date and will be applied to interest before Principal. If, on May 1st. 2034 , I still owe amounts under this Note, I will pay those amounts in full on that date, which is called the "Maturity Date. " I will make my monthly payments at 3000 Leadenha 11 Road Mount Laurel. NJ 08054 or at a different place if required by the Note Holder. (B) Amount of Monthly Payments My monthly payment will be in the amount of U.S. $ 383. 44 4. BORROWER'S RIGHT TO PREPAY I have the right to make payments of Principal at any time before they are due. A payment of Principal only is known as a "Prepayment." When I make a Prepayment, I will tell the Note Holder in writing that I am doing so. I may not designate a payment as a Prepayment if I have not made all the monthly payments due under the Note. I may make a full Prepayment or partial Prepayments without paying a Prepayment charge. The Note Holder will use my Prepayments to reduce the amount of Principal that I owe under this Note. However, the Note Holder may apply my Prepayment to the accrued and unpaid interest on the Prepayment amount, before applying my Prepayment to reduce the Principal amount of the Note. If I make a partial Prepayment, there will be no changes in the due date or in the amount of my monthly payment unless the Note Holder agrees in writing to those changes. MUlTISTATE FIXED RATE NOTE-Single Family-Fannie Mae/Freddie Mac UNIFORM INSTRUMENT .-5N (0207).01 Form 32001/01 @ VMP MORTGAGE FORMS - (800)521-7291 Page 1 of 3 Initials: Prepared By; stacey Geller. Coldwell Banker Mortgage 3000 Leadenhall Road Mount Laurel. NJ 08054 Return To: Coldwell Banker Mortgage 2001 Bishops Gate Blvd. Mount Laurel. NJ 08054 Parcel Number: Loan #: 0027598366 [Space Above This Line For Recording Data] MORTGAGE DEFINITlONS Words used in multiple sections of this document are defined below and other words are defined in Sections 3, 11, 13, 18, 20 and 21. Certain rules regarding the usage of words used in this document are also provided in Section 16. (A) "Security Instrument" means this document, which is dated Apri 1 23. 2004 together with all Riders to this document. (B) "Borrower" is Samuel Hunter IV. AN UNMARRIED MAN Borrower is the mortgagor under this Security Instrument. (C) "Lender" is Co 1 dwe 11 Banker Mortgage Lender is a Corporat i on PENNSYLVANIA - Single Family - Fannie Mae/Freddie Mac UNIFORM INSTRUMENT _ -6fPAI (0008) @ Form 3039 1/01 Page 1 of 16 Initials: VMP MORTGAGE FORMS - (8001521-7291 Payment Interest Principal Balance of Number Date Days Payment Payment Payment Principal 5/1/2004 61,512.00 1 6/ 1/2004 31 383.43 326.37 57.06 61,454.94 2 7/ 1/2004 30 383.43 326.07 57.36 61,397.58 3 8/ 1/2004 31 383.43 325.77 57.67 61,339.91 4 9/ 1/2004 31 383.43 325.46 57.97 61,281.93 5 10/ 1/2004 30 383.43 325.15 58.28 61,223.65 6 11/ 1/2004 31 383.43 324.84 58.59 61,165.06 7 12/ 1/2004 30 383.43 324.53 58.90 61,106.16 8 1/ 1/2005 31 383.43 324.22 59.21 61,046.95 9 2/ 1/2005 31 383.43 323.90 59.53 60,987.42 10 3/ 1/2005 28 383.43 323.59 59.84 60,927.58 11 4/ 1/2005 31 383.43 323.27 60.16 60,867.41 12 5/ 1/2005 30 383.43 322.95 60.48 60,806.93 13 6/ 1/2005 31 383.43 322.63 60.80 60,746.13 14 7/ 1/2005 30 383.43 322.31 61.12 60,685.01 15 8/ 1/2005 31 383.43 321.98 61.45 60,623.56 16 9/ 1/2005 31 383.43 321.66 61.77 60,561.78 17 10/ 1/2005 30 383.43 321.33 62.10 60,499.68 18 11/ 1/2005 31 383.43 321.00 62.43 60,437.25 19 12/1/2005 30 383.43 320.67 62.76 60,374.49 20 1/ 1/2006 31 383.43 320.34 63.10 60,311.39 21 2/ 1/2006 31 383.43 320.00 63.43 60,247.96 22 3/ 1/2006 28 383.43 319.67 63.77 60,184.19 23 4/ 1/2006 31 383.43 319.33 64.11 60,120.09 24 5/ 1/2006 30 383.4 3 318.99 64.45 60,055.64 25 6/ 1/2006 31 383.43 318.65 64.79 59,990.85 26 7/ 1/2006 30 383.43 318.30 65.13 59,925.72 27 8/ 1/2006 31 383.43 317.96 65.48 59,860.24 28 9/ 1/2006 31 383.43 317.61 65.82 59,794.42 29 10/ 1/2006 30 383.43 317.26 66.17 59,728:25 30 11/ 1/2006 31 383.43 316.91 66.52 59,661.72 31 12/ 1/2006 30 383.43 316.56 66.88 59,594.84 32 1/1/2007 31 383.43 316.20 67.23 59,527.61 33 2/ 1/2007 31 383.43 315.84 67.59 59,460.02 34 3/ 1/2007 28 383.43 315.48 67.95 59,392.07 35 4/ 1/2007 31 383.4 3 315.12 68.31 59,323.76 36 5/ 1/2007 30 383.43 314.76 68.67 59,255.09 37 6/ 1/2007 31 383.43 314.40 69.04 59,186.06 38 7/ 1/2007 30 383.43 314.03 69.40 59,116.66 39 8/ 1/2007 31 383.4 3 313.66 69.77 59,046.89 40 9/ 1/2007 31 383.43 313 .29 70.14 58,976.75 R'V~'''' ex .''* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER HI n. WILLIAM 21 05 0455 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pnclude outright s~usal distributions, and transfers under Sec. 9116 (a) (1. )} 1. Samuel Hunter, IV step-son 4,166.30 2526 Jefferson Drive West Mifflin, PA 15122 2. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18. AS APPROPRIATE. ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. Michele Bowman 603 W. Spring Garden Street Carlisle, PA 17013 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) PA.100 2-98 1. 0 YES ~NO 2. 0 YES ~NO IS THIS ESTABLISHMENT SELLING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION IN PENNSYLVANIA? IF YES, COMPLETE SECTION 18. IS THIS ESTABUSHMENT SELLING CIGARETTES IN PENNSYLVANIA? IF'tES, COMPLETt: SECTIONS 18 AND 19. 3. UST EACH COUNTY IN PENNSYLVANlA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SAlES ACTIVITY(IES). COUNTY COUNTY COUNTY COUNTY COUNTY COUNTY ATt4.CH AOOmONAl. 8 1/2" x II" SHEErS IF NECESSARY. PART 1 SECTION 9 - ESTABLISHMENT EMPLOYMENT INFORMNION 1. a YES )t NO 2. 0 YES ,-NO 3. 0- YES ~ NO qoES THIS ESTABl.ISHMENT PAY REMUNERATION FOR SERVJC~S TO PERSONS YOU DO NOTCONSIDER EMPlOYEES? IF YES, EXPlAIN THE SERVICES PERFORMED PART 2 DOES THIS ESTABUSHMENTEMPLOY INDIVIDUAlS WHO WORK IN PENNSYLVANIA? IF YES,INDICATE: a. OATE WAGES FIRSt PAID ....................................................... b. DATE WAGES RESUMED WHEN FOLLOWING ABREAK IN EMPLOYMENT. . . : . . . . . . . . . ., . . . c. TOTAL NUMBER OF EMPLOYEES ................................................. d. NUMBER OF EMPLOYEES PRIMARIL YWORKING IN NEW CONSTRUCTION ................ e. NUMBER OF EMPlOYEES PRIMARIL YWORKING IN RENOVATIVE CONSTRUCTION. . . . . . . . . . r. ESTIMATED GROSS WAGES PER QUARTER ........................................$ .00 DOES THIS ESTABLISHMENTEMPLOY PARESIDENTS WHO WORK OUTSIDE OF PENNSYLVANIA? IF YES, INDICATE: a. DATE WAGES ARST PAID ....................................................... b. OATE WAGES RESUMED WHEN FOllOWING ABREAK IN EMPLOYMENT. . . . . . . . . . . . . . . . . . c. ESTIMATED GROSS WAGES PER QUARTER. ........................................$ .00 1. 0 YES ~NO IS THIS REGISTRATION ARESULTOF ATAXABLE DISTRIBUTION FROM A BENEFITTRUST, DEFERRED PAYMENT OR RETIREMENTPLAN FOR PA RESIDENTS? IFYES.INOICATE: a. DATE bENEFITS FIRST PAID ..................................................... b. ESTIMATED BENEFITS PAlD PER QUARTER ......... . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .$ .00 SECTION 10 - BULK SALE/TRANSFER INFORMArION N/A IF ASSETS WERE ACQUIRED IN BULK FROM MORE THAN ONE ENTERPRISE, PHOT OCOPV THIS SECnON AND PROVIDE THE FOLLOWING INFORMATION ABOUT EACH SElLERlTRANSFEROR. 1. 0 YES 0 NO DID THE ENTERPRISE ACQUIRE 51" OR MORE OF ANYCLASS OF THE PA ASSETS OF ANOTHER ENTERPRISE? SEE THE CLASS OF ASSETS LISTED BELOW. 2. 0 YES o NO DID THE ENTERPRISE ACQUIRE 51% OR MORe OF THE TOTALASSETS OF" ANOTHER ENTERPRISE? IF THE ANSWER TO EITHER QUESTION IS YES, PROVIDE THE FOLLOWING INFORMATION ABOUT THE SELLERlTRANSFEROR. 3. SELLERlTRANSFEROR NAME 4. FEDERALEIN 5. SElLERfTRANSFEROR STREETADDRESS STATE I ClTYrrOWN I ZIP CODE + 4 6. DATE ASSETS ACQUIRED 7. ASSETS ACQUIRED: o ACCOUNTS RECEIVABLE 0 FIXTUREl:) 0 MACHINERY o CONTRACTS 0 FURNITURE 0 NAME AND/OR GOODWILL o CUSTOMERS/CLIENTS 0 INVENTORY 0 REALESTATE o EQUIPMENT 0 LEASES 0, OTHER IMPORTAN'r. IF. IN ADDITION TO ACQUIRING ASSETS IN BULK, THE ENTERPRISE AlSO ACQUIRED ALL OR PARTOF APREDECESSOR'S BUSINESS, SEcnON 14 MUST BE COMPLETED. 6 6. CHECK THE APPROPRIATE BOX(ES) TO DESCRIBE THIS CORPORATION: CORPORATION: 0 STOCK 0 PROFESSIONAL BANK: 0 STATE ~ NO~TOCK 0 COOPERATIVE 0 FEDERAl D MANAGEMENT 0 STAtuTORY CLOSE LLC membership interests 6. S.cORPORATlON: 0 FEDERAl 0 PENNSYlVANIA s. 0 YES D{No IS THIS CORPORATJON'S STOCK PUBLICLY TRADED? MUTUAL THRIF"r. 0 STATE o FEDERAl INSUAANCE 0 PA COMPANY: 0 NON-PA (REV-1640 MUSTBE FILED TO ELECT PENNSYlVANIA $ STATUS.) SECTION 12 - REPORTING & PAYMENT METHODS 1. 0 YES ~ NO 2. 0 YES Ii NO 3. 0 YES ~ NO 4. 0 YES ~ NO S. 0 YES ~ NO 6. 0 YES ~ NO DOES THIS ENTERPRISE MEET THE DEPARTMENT OF REVENUE'S REQUIREMENTS FOR ElECTRONIC FUNDS TRANSFERS (EFT) FILING? THE REQUIREMENTOF PAYMENTVIAEFT APPlIES TO PAYMENTS OF $20,000 OR MORE. DOES THIS ENTERPRISE WANT TO PARTICIPATE IN THE DEPARTMENT OF REVENUE'S EFT PROGRAM EVEN THOUGH ITDOES NOT MEET THE $20.000 PAYMENTTliRESHOLD? IS THIS ENTERPRISE INTERESTED IN RECEIVING INFORMATION ABOUT THE DEPARTMENT OF REVENUE'S ELECTRONIC DATA INTERCHANGE (EDI) PROGRAM? DOES THIS ENTERPRISE MEETTliE DEPARTMENT OF LABOR & INDUSTRY'S REQUIREMENT FOR REPORTING WAGE INFORMATION ON MAGNETIC MEDIA? THE REQUIREMENT OF REPORTING VIA MAGNETIC MEDIAAPPLIES TO 250 OR MORE WAGE ENTRIES PER QUARTERLY REPORT. IS THIS ENTERPRISE INTERESTED IN RECEIVING INFORMATION ABOUT THE DEPARTMENT OF LABOR & INDUSTRY'S MAGNETIC MEDIA REPORTING METHODS? THIS INCLUDES A PERSONAL COMPUTER PROGRAM TO ASSIST IN PAYROlL PREPARATION. TAX WITHHOLDING AND UC REPORTING AND FILING PREPARATION. IS THIS ENTERPRISE INTERESTED IN RECEIVING INFORMATION ABOUT THE DEPARTMENT OF LABOR & INDUSTRY'S OPTION TO ELECT TO FINANCE UC COSTS UNDER THE REIMBURSEMENThlETHOD IN LIEU OF THE CONTRIBUT ORY METHOD? SECTION 13 - GOVERNMENT FORM OF ORGANIZ410N N/A 1. IS THE ENTERPRISE A: o GOVERNMENTBODY o GOVERNMENT OWNED ENTERPRISE o GOVERNMENT & PRIVATE SECTOR OWNED ENTERPRISE 2. IS THE GOVERNMENT: o DOMESTlClUSA 3. IF DOMESTIC. IS THE GOVERNMENT: D FOREIGN/NON USA o MULTI-NATlONAL o FEDERAL o STATE GOVERNOR'S JURISDICTION o STATE NON-GOVERNOR'S JURISDICTION LOCAl; 0 COUNTY o CI1'Y o TOWN o TOWNSHIP o BOROUGH o SCHOOLDISTRICT o OTHER 7 PA.100 2-98 DEPARTMENT USE ONLY N/A COMPlm tHIS SECTION IF THE REGISTERING ENTERPRISE IS WHOllY OR PARTlAll Y SUCCEEDING A PREI:>ECESSOR. FOR ASSISTANCE, CONTACT THE NEAREST lABOR AND INDUStRY REID ACCOUNl1NG SE~VICE OFFICE. IF THE ENTERPRISE HAS MORE THAN ONE PREDECESSOR, PHOTOCOPY THIS PAGE TO PROVIDE THE FOlLOWING INFORMATION ABOU'fEACH. 1. PREDECESSOR LEGAl. NAME 2. PREDECESSOR PAUC ACCOUNTNUMBER 3. PREDECESSOR TRADE NAME 4. PREDECESSOR FEDERAL EIN CliYffOWN ZIP CODE + 4 5. PREDECESSOR STREET ADDRESS 6. SPECIFY HOW THE aUSINESS OPERATION WAS ACQUIRED: o CONSOUDATlON 0 GIFT 0 MERGER o ACQUISITION OF EXISTING OPERATION 0 CHANGE IN LEGAL STRUCTURE o IRC SEC. 338 ELECTION 0 OTHER (SPEOFY) 7. D ACQUISITION DATE 8. PERCENTAGE OF THE PREDECESSOR'S TOTAl. BUSINESS OPERATION (PMND NOtH'A) ACQUIRED 'l(, 9. PERCENTAGE OF THE PREDECESSOR'S PA BUSINESS OPERATION ACQUIRED % IF LESS THAN 100%. PROVIDE THE NAME(5) AND ADDRESS(ES) OF THE EST ABLISHMENT(S) THAT CONDUCTED OPERATIONS IN PAOR EMPLOYED PARESIDENTS. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. ' NAME OF EST ABUSHMENT(S) ADDRESS(ES) 10WHATWAS THE PREDECESSOR'S BUSINESS ACTIVITY IN THE PAIlUSINESS OPERATION THATWAS ACQUIRED? 11. ASSETS ACQUIRED: 0 ACCOUNTS RECEIVABLE o CONTRACTS o CUSTOMER$lClIENTS o EQlJIPMENT o FIXTURES o FURNITURE o INVENTORY o LEASES o MACHINERY o NAMEAN~ORGOOD~L o RI:ALESTATE o OTHER) 12.0 YES [3 NO HAS THE PREDECESSOR CEASED PAYING WAGES IN PA1 IF YES, ENTER THE DATE PAWAGES CEASED. IF KNOWN. 13. a YES o NO HAS THE PREDECESSOR CEASED OPERATIONS IN PA1 IF YES, ~NTER THE DATE PA OPERATIONS CEASED, IF KNOWN. IF NO, DESCRIBE THE PREDECESSOR'S PRESENTPABUSINESS ACTlVIiY,lF KNOWN. b. 0 YES 14. ATTHE TIME OF TRANSFER FROM THE PREDECESSOR ENTERPRISE TO THE REGISTERING ENTERPRISE: a. DYES D, NO WERE AtN OF THE OWNERS, SHAREHOLDERS (5% OR GREATER), PARTNERS. OFFICERS OR DIRECTORS OF THE PREDECESSOR QB OF AtN AFFILIATE. SUesiDIARY OR PARENT CORPORATION OF THE PREDECESSOR ALSO OWNERS, SHAREHOLDERS (5% OR GREAtER). PARTNERS. OFFICERS OR DIRECTORS OF THE REGISTERING ENTERPRJSE QR OF At<< AFFIUATE. SUBSIDIARY OR PARENTCORPORATlON OF THE REGISTERING ENTERPRISE? WAS fHE PREDECESSOR, OR At<< AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE PREDECESSOR, AN OWNER. SHAREHOLDER (5% OR GREATER) OR PARTNER IN THE REGISTERING ENTERPRISE? WI'S THE REGISTERING ENTERPRISe. OR ANY AFFILIATE. SUBSIDIARY OR PARENT CORPORATION O~ THE REGISTERING ENTERPRISE. AN OWNER. SHAREHOLDER (5% OR GREATl:R) OR PARTNER IN THE PREDECESSOR? [3 NO c. 0 YES o NO IF THE ANSWER TO AtN OF THE QUESTIONS IN 141S YES, PROVIDE THE FOllOWING INFORMATION. ATTACH ADDITlONAl81/2 X 11 SHEETS IF NE;CeSSARY, . IDENTIFY THOSE PERSONS AND ENTITIES BYTHEIR FUll NAME; . DESCRIBE THEIR RElATIONSHIP TO THE PREDECESSOR AND ANYAFFIUATE. SUBSIDIARYAND PARENTCORPORATlON OF THE PREDECESSOR; AND . DESCRIBE THEIR RELATIONSHIP TO THE REGISTERING ENTERPRISE AND ANYAFFILlATE. SVBSIDIARYAND PARENTCORPORATION OF THE REGISTERING ENTERPRISE. ,. THE REGISTERING ENTERPRISE MAY APPLY FOR A TRANSFER IN 'MiOLE OR IN PART OF THE PREDECESSOR'S UNEMPLOYMENTCOMPENBATlON (UG) EXPERIENCE RECORD AND RESERVE ACCOUNTBAlANCE,IF THE REGISTERING ENTERPRISE IS CONTINUING ESSe:NTlALLYTHE SAME BUSINESS ACTIVITYAS THE PREDI:CESSOR AND BOTH PROVIDED PA COVERED EMPlOYMENT. COMPLETE SECTION 15 AND, IF APPlICABLE. SECTION 16. NOTE: AREGISTERING ENTERPRISE MAY APPlYTHE UC TAXABLE WAGES PAID BYAPREDECESSOR TOWARD THE REGISTERING ENTERPRISE'S UC TAXABLE WAGE BASE FOR THE CALENDAR YEAR OF ACQUISITION WITHOUTTRANSFERRlNG THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNTBALANCE. 8 PA.100 2.98 ENTERPRISE NAME Eastern states DEPARTMENT USE ONLY N/A A REGISTERING ENTERPRISE MAY APPLY THE UNEMPLOYMENT COMPENSATION (UC) TAXABlE WAGES PAID BY A PREDECESSOR TOWARD THE REGISTERING ENTERPRISE'S UC TAXABLE WAGE BASE FOIt THE CALENDAR YEAR OF ACQUISITION WITHOUT TRANSFERRING THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNTBALANCE. REFER TO THE INSTRUCTIONS TO DETERMINE IF ITlS ADVANTAGEOUS TO APPlYFOR APREDECESSOR'S UC EXPERIENCE RECORD AND RESERVE ACCOUNTBALANCE. IMPOATAN'r. THIS APPlICATION CANNOl BE CONSIDER EO UNLESS IT IS SIGNED aYAN AUTHORIZED SIGNATORY OF BOTH THE PREDECESSOR AND THE REGISTERING ENTERPRISE. THE TRANSFER IN WHOLE OR IN PARTOF THE EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE IS BINDING AND IRREVOCABLE ONCE IT HAS BEEN APPROVED BYTliE DEP ARTMENT OF LABOR AND INDUSTRY. APPUCATlON IS HEREBY MADE BY THE PREDECESSOR AND THE REGISTERING ENTERPRISE FOR ATRANSFER TO THE REGISTERING ENTERPRISE OF THE PENNSYLVANIA UNEMPlOYMENTCOMPENSATlON EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE OF THE PREDECESSOR WITH RESPECTTO THE TRANSFER. WE HEREBY CERTlFYTHA TlllE TRANSFER REFERENCED IN SECTION 14 HAS OCCURRED AS DESCRIBED THEREIN AND THATTHE REGISTERING ENTERPRISE IS CONTINUING ESSENTlAlLYTliE SAME BUSINESS ACTIVITY AS THE PREDECESSOR. COMPLm THIS SECTION mID: IF YOU WANT TO APPLYFOR THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNTBALANCE. 1. PREDECESSOR NAME DATE AUTHORIZED SIGNATURE TYPE OR PRINT NAME TITLE 2. REGISTERING ENTERPRISE NAME DATE ' AUTHORIZED SIGNATURE TYPE OR PRINT NAME TITLE N/A COMPlETE THIS SECTION IF THE REGISTERING ENTERPRISE ACQUIRED ONL VPARTOF THE PREDECESSO~'S PENNSYLVANIA(PA) BUSINESS OPERATION AND 1$ MAKING APPU- CATION FOR THE TRANSFER OF A PORTION OF THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNTBALANCE. COMPlETE REPLACEMENT UC.VSOR PART1Al TRANSFER (FORM UC-252). THE PREDECESSOR'S PAPAYRQLL RECORDS FOR THE TWO YEARS PRIOR TO THE QUARTER OF THE TRANSFER AND/OR ACQUISITION MUST REMAIN AVAILABlE TO THE REGfSTERING ENTERPRISE TO E.NABLE THE REGISTERING ENTERPRISE TO PROVIDE REQUIRED INFORMATION REGARDING SEPARATED AND/OR TRANSFERRED EMPLOYEES. UNEMPlOYMENT COMPENSATION (UC) TAXABLE WAGES ARE THOSE WAGES THATDO NOTEXCEEO THE UC TAXABLE WAGE BASE APPLICABLE TO AGIVEN CALENDAR YEAR. 1. NUMBER OF EMPLOYEES WHO WORKED IN THE PART OF THE PRE- DECESSOR'S PABUSINESS OPERATION THATWAS TRANSFERRED TO OR ACQUIRED BYTHE REGISTERING ENTERPRISE: 2. DATE WAGES FIRSTPAID BY PREDECESSOR OR PRE-PREDECESSOR(S) IN THE PARTOF THE PABUSINESS OPERATION TRANSFERRED (ACQUIRED) FOR WHICH CONTRIBUTIONS WERE PAID UNDER THE PROVISIONS OF THE PAUC LAW. DATE: 3. CHECKMARK THE CALENDAR QUARTERS IN THE YEAR OF TRANSFER AND IN THE PRECEDING FIVE CALENDAR YEARS IN WHICH PAUC CONTRIBUTIONS WERE PAID IN niE PART OF THE PABUSINESS OPERATION THAT WAS TRANSFERRED. ENTER A ZERO IN EACH QUARTER WHEN NO CONTRIBUTION WAS DUE AND PAYABLE IN THE PART TRANSFERRED. YEAR_ YEAR___ YEAR__ YEAR_ YEAFL-_ 4. CHECKMARK THE CALENDAR QUARTERS IN THE YEAR OF TRANSFER AND IN THE PRECEDING FIVE CALENDAR YEARS IN WHICH PAUC CONTRIBUTIONS WERE PAID IN THE PART OF THE PA BUSINESS OPERATION TliAT WM. I<<U TRANSFERRED. ENTER A ZERO IN EACH QUARTER WHEN NO CONTRIBUTION WAS DUE AND PAYABLE IN THE PART RETAINED. Sa. PREDECESSOR'S PAUC TAXABLE PAYROLL IN THE PART OF THE PA BUSINESS OPERATION TRANSFERRED FOR TliE PERIOD OF TliREE CALENDAR YEARS PRIOR TO THE YEAR OF TRANSFER (ACQUISITION). 5b. IF THE PART OF THE PABUSINESS OPERATION TRANSFERRED WAS NOT IN EXISTENCE FOR THREE CALENDAR YEARS PRIOR TO THE YEAR OF THE TRANSFER, ENTER THE PA TAXABLE PAYROLL FOR THE PERIOD OF ITS EXIS- TENCE TO DATE OF TAANSFER. OR 6. PREDECESSOR'S ENTIRE PAUC TAXABLE PAYROLL FOR SAME PERIOD INDICATED IN ITEMS Sa OR 5b. 7. PREDECESSOR'S ENTIRIO PAUC TAXABLE PAYROLL FOR THE PERIOD FROM THE BEGINNING OF THE QUARTER OF TRANSFER TO THE DATE OF TRANSFER 9 PA-100 2.98 ENTERPRISE NAME Eastern states DEPARTMENT USE ONLY PART 1 ESTABUSHMENT INFORMRJON N/A COMPLETE THIS SECTION FOR EACH AODITlONALESTASLlSHMENTCONOUCTING BUSINESS IN PA OR EMPlOYING PA RESIDENTS. PHOTOCOPYTHIS SECTION M NECESSARY. 1. ESTABLISHMENT NAME (doing business 8S) 2. DATE OF FIRST OPERATIONS 3. TELEPHONE NUMBER COUNTY ( STATE ) ZIP COOE + 4 4. STREET ADDRESS 5. SCHOOLOISTRICT 6. MUNICIPALITY PART 2 ESTABUSHMENT BUSINESS ACTIVITY INFORMATION REFER TO THE INSTRUCTIONS TO COMPLETE THIS SECTION. 1. ENTER THE PERCENTAGE THAT~CH PABUSINESS ACTIVITY REPRESENTS OF THE TOTAl RECEIPTS OR REVENUES AmlS ESTABLISHMENT. LIST ALL PRODUCTS OR SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY. ENTER THE PERCEN'rAGE THATTHE PRODUCtS OR SERVlCES REPRESENTOF THE TOTAl RECEIPTS OR REVENUES ATTHIS ESTABLISHMENT. PA BUSINESS ACTIVITY % PRODUCTS OR SERVICES % ADDmONAL % PRODUCTS OR SERVICES Construction Manufacturing Retail Trade Wholesale Trade Finance . Insurance Real Estate Transportation Warehousing Communications Agriculture, Forestry, Fishing , Mining, Quarrying OiVGas extraction Utility or Sanitary Servic~ Services (Personal or Buslnes~) Domestic TOTAl 100% 4.. 0 YES 2. ENTER THE PERCENTAGE THATTHIS ESTASlISHMENrS RECEIPTS OR REVENUES REPRESENTOF THE TOTAl. PARECEIPTS OR REVENUES OF THE ENTERPRISE. _% 3. ESTABLISHMENTS ENGAGED IN CONSTRUCTION MUSTENTER THE PERCENTAGE OF CONSTRUCTION ACTlVITYTHATlS NEW AND/OR RENOVATIVE. " NEW _" RENOVATIVE IS THIS ESTABLfSHMENTSOLEL YENGAGEO IN THE PERFORMANCE OF SUPPORTACTlVITIES FOR OTHER ESTABLISHMENTS OF THE SAME ENTERPRISE? IF YES, LIST Tl-IE NAME(S) OF THE SUPPORTED ESTABLISHMENT(S) AND CHECK THE APPROPRIATE BOX rO DESCRIBE THE SUPPoRT ACTIVr1'Y. o NO o ADMINISTRATION o RESEARCH/DEVELOPMENT o STORAGElWAREHOUSE o OTHER (SPECIFY) 10 DEPARTMENT USE ONLY PA-100 2.98 ENTERPRISE NAME Eastern states Claims Service ~ ESTABUSHMENT SAlES INFORMJflON LLC 1. 0 YES o NO N/A 2. 0 YES o NO 3. LIST EACH COUNTY IN PENNSYLVANIA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SAlES ACTIVITY(IES). COUNTY IS THIS ESTABlISHMENT SEllING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION INPENNSYLVANIA? IFYES,COMPLETESECTION 18. ' IS THIS eSTABLISHMENT SaLING CIGARmES IN PENNSnVANIA? IF YES. COMPLETE SECTIONS 18 AND 19. COUNTY COUNTY COUNTY COUNTY COUNTY ATTACH ADDITIONAL e 112- x 11- SHEETS IF NECESSARY. PART 4a 1.0 YES o NO fSTABUSHMENT EMPLOYMENTINfORMATJON 2. 0 YES o NO 3. 0 YES o NO PART 4b OOES THIS ESTABUSHMENTEMPlOY INDIVl/)UAlS WHO WORK IN PENNSYLVANIA? IF YES,INDICATE: a. DATE WAGES FIRST PAlO ................................................... b. DATE WAGES RESUMED WHEN FOLLOWING ,A.9REAK IN EMPLOYMENT. . . . .'. . . . . . . . . c. TOTAl NUMBER OF EMPlOYEES ............................................. d. NUMBER OF EMPLOYEES PRlMARIL YWORKING IN NEW CONSTRUC110N ............ e. NUMBE:R OF EMPLOYEES PRIMARlLYWOro<lNG IN RENOVA'nVE CONSTRUCTION ..... f. ESTIMATED GROSS WAGES PER QUARTER ...................................$ DOES THIS ESTABlISHMENTEMPlOY PARESIDENTS WHO WORK OUTSIDE OF PeNNSYI,.V ANIA? IF YES, INDICATE: a. DATE WAGES FIRST PAID ................................................... b. DATE WAGES RESUMED WHEN FOLLOWING ABREAK IN EMPLOYMENT. . . . . . . . . . . . .. Co ESTIMATED GROSS WAGES PER QUARTER ...................................$ DOES tHIS ESTABLISHMENT PAYREMUNERA110N FOR SERVICES TO PERSONS YOU DO NOTCONSIDER EMPlOYEES? IF YES, EXPLAIN THE SERViCES PERFORMED .00 .00 1. 0 YES o NO IS THIS REGISTRATION A RESUlt OF A TAXABLE D1STRIBU1l0N FROM A BENEFIT TRUST, DEFERRED PAYMENT OR RETIREMENT PlAN FOR PARESIDENTS? IF YES. INDICATE: a. DATE BENEFITS FIRST PAID ............... .. .. . .. .. .. .. . .. . . .. . .. . . .. . .. . .. . b. ESllMATEO BENEFITS PAlO PER QUARTER. ., '" . . . . ., . .. . . . . .. .., . . . .. .. ... . .$ .00 SECTION 6A - ADDITIONAL OWNERS, MRTNERS, SHAREHOLDERS, OFFICERS, RESPONSIBLE PARTY INFORMATION PROVIDE THE FOllOWING FOR AU. INOIVlDUAlAND.()R ENTERPRISE OWNERS, PARTNERS. SHAREHOlDERS. OFFICERS AND RESPONSIBlE PARllES: IF STOCK IS PUBLICLY TRADED. PROVIDE THE FOllOWING FOR At(( SHAAEHOlDER WI1H AN EQUI'TYPOSITION OF 5% OR MORE. PHOTOCOPYlFADDITIONAL SPACE IS NEEDED. 1. NAME 2. SOCIAL SECURITYNUMBER 3. DATE OF BIRTH . 4. FEDERAL EIN SIGNATURE L NAME 8 4 54 a. PERCENTAGE OF OWNERSHIP 9. EFFECl1VE DATE OF OWNERSHIP 1 % 1-1 STATE ZIP COOE -t- 4 Cumberlan PA 17013 o EMPlOYER WITHHOlDING 0 MOTOR FUElTAXES 2. SOCIAl SECURITYNUMBER 3. OATE OF BIRTH . 4. FI:DERAL EIN 7. EFFECTIVE DATE a. PERCENTAGE OF 9. EFFECTIVE DATE OF OF TITLE OWNERSHIP OWNERSHIP 5. 0 OWNER 0 OFFICER 6. TITLE o PARTNER 0 SHAREHOLDER o RESPONSIBLE PARTY 10. HOME ADDRESS (streel) 11. PERSON RESPONSIB~E TO R!:MIT: CITYITOWN % COUNTY STATE ZIP CODE -I- 4 o SALES TAX o EMPLOVtR WITHHOLDING o MOTOR FumAXES SIGNATURE . OA TE OF BIRTH REQUIRED ONL YIF APPLYING FOR ACIGARmE WHOLESALE DEAlER'S UCENSE, A SMAlL GAMES OF CHANCE DISTRIBUTOR UCENSE OR A SMAllGAMES OF CHANCE MANUFACTURER CI:Rl1FICATE. .. II PA-100 2-98 ENTERPRISE NAME Eastern DEPARTMENT USE ONLY SALES USE AND HOTEL OCCUPANCY TAX, PUBUC TAANSPORTATlON ASSISTANCE TAX OR VEHICLE RENTAL we ' PART 1 ENTERPRISES APPLYING FOR ^ SIILES. USE ^NO HOTEL OCCUPANCY TAX LICENSE. PUBLIC TRANSfiORT^ TlON ASSISTAACE TAX LICENSE AND/OR VEHICLE RENT ^L TN<. COMPLETE PART 1. IF THE ENTERPRISE IS: . SELLING TAlW3LE PRODUCTS OR SERVICES TO CONSUMERS IN PENNSYLVANIA. ENTER DATE OF ftlRSTTAXABLE SAlE . PURCHASING TAXABLE PRODUCTS OR SERVICES FOR ITS OWN USE IN PENNSYlVANIA. AND INCURRING NO SAlES TAX, ENTER DATE OF FIRSTPURCHASE . SElLING NEW TIRES TO CONSUMERS IN PENNSYlVANIA, ENTER DATE OF FIRSTSALE . LEASING OR RENTIN<l MOTOR VEHICLES, ENTER DATE OF FIRSTLEIISE OR RENT AI. . RENTING FIVE OR MORE MOTOR VEHICLES. ENTER OA TE OF FIRST RENTAl. . CONDUCTING RETAIL SALES IN PENNSYlVANIA AND NOT MAINTAINING ^ PERMANENTlOCATlON IN PA. ENTER DATE OF FIRST TAXABLE SAlE (COMPlETE PART :2) . ACTIVELYPROMOTIHG SHOWS IN PENNSYLVANIA WHERE TAXABLE PRODUCTS WllL8E OFFEREO FOR RETAIL SAlE, ENTER . D^TE OF FIRST SHOW . (COMPlETE PART 3) SAlES TAX COLLECTED MUSTtlE SEGREGATED FROM OTHER FUNDS AND MUSTREMAIN IN THE COMMONWEALTH OF PENNSYL V ANIAUNTIL REMITTED TO THE OEP ARTMENT OF REVENUE. (COMPLETE PART 4) N/A PART 2 TRANSIENT VENDOR CERlFICATf IF THE ENTERPRISE PAAnCIPATES IN A1ff SHOWS OTHER THAN THOSE LISTED, PROVIDE THE NAME(S) OF THE SHOW(S) AND INFORMATION ABOUT THE SHOW(S) TO THE DEPARTMENT OF REVENUE AT LEAST 10 DAYS PRIOR TO THE SHOW. IF THE ENTERPRISE IS NOT ASSOCI"TED WITH APAlICENSED PROMOTER FOR EACH SHOW. A$500 SECURITY DEPOSITMUST BE SUBMITTED WITH THIS FORM. PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW: I 1. PROMOTER NUMBER 12. SHOW NAME 3. COUNTY I 4. SHOW ADDRESS (STREET, CITY, ST"TE, ZIP) 5. START DATE 1. PROMOTER NUMBER \2. SHOW NAME 4. SHOW ADDRESS (STREET, CITY, STATE, ZIP) 3. COUNTY 16. END DATE I 5. START DATE 6. END DA TE ATTACH ADDITIONAL 81/2 X 11 SHEETS IF NECESSARY. PART 3 PROMOlER UCENSE PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW: 1. SHOW NAME 5. SHOW ADDRESS (STREET. CITY. STATE. ZIP) 6. COUNTY 4. END DA TE 2. TYPEOFSHOW 1. SHOW NAME 2. TYPEOFSHOW 5. SHOW ADDRESS (STREET. CITY, STATE, ZIP) 6. COUNTY ATTACH ADDmoNAL 81/2 x 11 SHEETS IF NECESSARY. PART 4 LOCATION OF SALES TAX COLLECTED PROVIDE THE FOlLOWING INFORM"TlOti "BOUT THE PENNSYLVANIA FINANCIAL INSTITUTION OR OTHER LOCATION WHERE SALES TAX FUNDS WILL BE PLIICED PENDING REMISSION TO THE DEPARTMENT OF REVENUE. 1. NAME OF FINANCIAL INSTITUTION 2. ACCOUNTNAME 3. ACCOUNTNUMBER 4. TYPE OF ACCOUN! o SAVINGS o CHECKING o CD o ESCROW 5. FINANCIAL INSTITUTION STREET ADDRESS CITYrrOWN COUNTY STATE I ZIP CODE + 4 I , 6. OTHER lOCATION CITYrrOWN COUNTY STATE ZIP CODE + 4 12 PA-100 2-98 ENTERPRISE NAME Eastern states DEPARTMENT USE ONLY PART 1 UCENSE TYPE N/A CHECK THE APPROPRIATE BOX(ES) TO INDICATE LICENSE TYPE REQUESTED. A SEPARATE LICENSE MUSlBE OBiAINED FOR EACH ESiABlISHMENTTHATSELLS RETAIL, OVER.THE-COUNTER CIGARETTES. A SEPARATE DECAL MUST BE PURCHASED FOR EACH VENDING MACHINE LOCATION. ACHECK OR MONEYORDER MUSTlIE SUBMITTED WITH THIS APPliCATION. LICENSE TYPE NUMBER FEE AMOUNT REMrTTED o RETAILOVER-THE-COUNTER @ 25 EACH LOCA TlON S o VENDING MACHINE (ATTACHA LISTING OF LOCATIONS) @ 25 EACH DECAl $ IJ WHOLESALER @ $ 500 o CIGARETTE STAMPING AGENT AND WHOLESAlER @ $ 1.500 TOTAL AMOUNT REMItTED $ PART 2 MA~CHEcKSPAYABLETO PADE"IlTIdENT OF REVENUE CIGARETTE WHOLESALER LIST CIGARETTE STORAGE LOCATlON(S) (P.O. BOXES ARE NOT ACCEPTABLE). 1. STREETADDRESS rOUNTY I STATE IZIP CODE + 4 HAS ANY OWNER, PARTNER, OFFICER, DIRECTOR OR MAJOR STOCKHOLDER BEEN CONVICTED OF ANY VIOLATION OF THE PENNSYlVANIA CIGARETTE TAX ACT OR ANY MISDEMEANOR OR FELONY? IF YES, LIST ALL CONVICTIONS WITHIN THE PREVIOUS 10 YEAR PERIOD. ATTACH ADOITIONAL8112 X 11 SHEETS IF NECESSARY o NO CITY!fOWN 2. 0 YES 3. THE APPUCANT HAS CCMPUED WITH ARTICLE II-A OF THE CIGARETTE SAlES AND LICENSING ACT. UNDER PEt-W.TY OF PERJURY, OF ADHERENCE TO STATE PRESUMPTIVE MINIMUM PRICES OR APPROVAL TO SELLATA DiFFERENt PRICE, IN ACCORDANCE WITH THE ACT: o CIGARETTES WILLBE SOLD ATOR ABOVE THE PRESUMPTIVE MINIMUM PRICE. o CIGARETTES WILLBE SOLO ATAN APPROVED MINIMUM PRICE. PART 3 CIGARErrE STAMPING AGENT 1.0 YES o NO DOES THE ENTERPRISE PURCHASE OR SELL ANY CIGARETTES WHICH ARE NOTPA STAMPED? IF YES. LISi STATES: 13 PA-100 2-98 ENTERPRISE NAME Eastern states DEPARTMENT USE NL Y . ~ DISTRlBl1fOR AND/OR MANUaCTURER N/A TO BE COMPlETED BY ALLAPPlJCANTS (DISTRIBUTOR AND10R MANUFACTURER) APPUCANTS MUST SUBMIT A COpy OF THE CERTIFICATe OF INCORPORATION, ARTiClES OF INCORPORATION, CERTIFICATE OF AUTHORITY{NON-PA CORPORATIONS), BY- LAWS, CONSTITUTION OR FICTITIOUS NAME REGISTRATION. APPUCANTS FOR A MANUFACTURER CERTIFICATE MUST SUBMIT A COPY OF THE COMPANYlOGO{S). 1. CHECK APPROPRIATE BOX(ES) TO INDICATE TYPE OF LICENSE/CERTIFICATE REQUESTED UCENSElCERTFICATE TYPE FEE AMOUNT REMITTED o DISTRIBUTOR UCENSE $1,000 $ o MANUFACTURER REGISTRATION CERTIFICATE $ 2,000 $ o REPLACEMENTLICENSE 100 $ o REPLACEMENTCERTlFICATE 100 $ NUMBER OF BACKGROUND INVESTIGATIONS FOR OWNERSIOFFICERS, ETC. @ 10 $ TOTALAMOUNTREMITTED $ MAKECHECKSPAYA8lf TO' M DEi\RTMENT OF REVENUE IF THE DEPARTMENT DENIES AN APPLICATION, A$100 APPLICATION PROCESSING FEE SHALLBE RETAINED BYTHE DEPARTMENT. NO PART OF THE REGISTRATION OR LICENSE FEE SHALLBE SUBJECT TO PRORATION. NO INVESTIGATION FE! SHAUBE REFUNDED, 2. MANUFACTURERS AND DISTRIBUTORS UST ALL INDIVIDUALS RESPONSIBLE FOR TAKING ORDERS AND MAKING SALES OF SMALL GAMES OF CHANCE MERCHANDISE. IF AN INDIVlDUALRESIDES IN PENNSYLVANIA, INDICATE IF COMMISSION OR NONCOMMISSION. NAME TITLE o saLS FOR DISTRIBUTOR o COMMISSION o SELLS FOR MANUFACTURER o NONCOM MISSION HOME ADDRESS (STREET) CITYfTOWN STATE I ZIP COOE+ 4 I TELEPHONE NBR. ( ) NAME TITLE . o SELLS FOR DISTRIBUTOR o COMMISSION o saLS FOR MANUFACTURER o NONCOMMISSION HOME ADDRESS (STREET) , CITYfTOWN STATE I ZIP CODE + 4 I TELEPHONE NBR. ( ) ATTACH ADDmoNAL 8112 X 11 SHEETS IF NECE~SARY MANUFACTURERS ONLY MUST SUBMIT A CATALOG OF THE SMALLGAMES CHECKED BELOW. IF CATALOG IS UNAVAILABLE, PROVIDE NAME OF GAME(S) AND FORM NUMBER(S), NUMBER OF TICKETS PER DEAL. HIGHEST INDIVIDUAL PRIZE VALUE AND PERCENTAGE OF PAYOUT. 3. CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE TYPES OF SMALlGAMES DISTRIBUTED OR MANUF ACTURED. o DAILY DRAWINGS o PULl-TABS o PUNCHBOARDS o RAFFLES o DISPENSING MACHINES PART 2 DISTRIBUlOR L1STALLSMALl GAMES OF CHANCE MANUFACTURERS WITH WHOM THE DISTRIBUTOR DOES BUSINESS. MANUFACTURER'S LEGAL NAME MANUFACTURER'S CERTIFICATE NBR. MANUFACTURER'S CER T1FICATE NBR. ( ) ZIP CODE +4 STREETADDRESS MANUFACTURER'S LEGAL NAME STREETADDRESS ZIP COOE +4 ATTACH ADDITIONAL 8 112X 11 SHEETS IF NECESSARY 14 PART 3 SMAll GAMES OF CHANCE CElIFlCAnON N/A MUST BE COMPLETED BY ALL SMALL GAMES OF CHANCE APPLICANTS. I CERTIFY TIfAT TIfE FOLLOWING TAX $TATEMENTS ARE TRUE AND CORRECT . ALL PA STATE TAX REPORTS AND RETURNS HAVE BEEN FILED, AND . ALL PASTATE TAXES HAVE BEEN PND, OR · ArN PA STATE TAXES OWNED ARE SUBJEClTO TIMELY ADMINISTRATIVE OR JUDICIALAPPEAL; OR ANYDELlNQUENT PAT AXES ARE SUBJECTTO DULY APPROVED DEFERRED PAYMENT PLAN (COPY ENCLOSED). I CERTIFY TllAT NO OWNER, PARTNER, OFFICER. DIRECTOR, OR OlliER PERSON IN A SUPERVlSORYOR MANAGEMENT POSmoN OR EMPLOYEE ELIGIILE TO MAKE SAlES ON BEHALF OF TllIS BIISINESS: · HAS BEEN CONVICTED OF A FELONY IN A STATE OR FEDERAL COURTWITHIN THE PAST FIVE YEARS; OR · HAS BEEN CONVICTED WITHIN TEN YEARS OF THE DATE OF APPUCATION IN A STATE OR FEDERAL COURTOF A VIOlATION OF THE BINGO LAW OR OF THE LOCAL OPTION SMALL GAMES Ot: CHANCE ACT OR A GAMBLING-RELATED OFFENSE UNDER TITLE 18 OF THE PENNSYLV ANlA CONSOLIDATED STAtUTES OR OTHER COMPARABLE STATE OR FEDERAL LAW; OR · HAS NOTBEEN REJECTED IN ANYSTATE FOR A DISTRIBUTOR LICENSE OR MANUFACTURER REGISTRATION CERTIFICATE, OR EQUIVAlENTTHERETO. I DEClARETHATI HAVE EXAMINED THIS APPLlCATION,INCLUDlNG ALl,ACCOMPANYING STATEMENTS, AND TO 'rHE BEST OF MYKHOWLEDGE AND Bt!UEF rr IS TRUE, CORRECT AND COMPlETE. NOTARY SWORN AND SUBSCRIBED TO BEFORE ME THIS DAY OF 'AlItHORitAWN""::" , 19 SIGNATURE OF AN OWNER, PARTNER, OFFICER OR DIRECTOR SOCIALSECURITYNUMBER NOTARY PUBLIC PRINTNAME DATE MY COMMISSION EXPIRES TITlE ( ) TELEPHONE NUMBER NOTARY SEAL CORPORATE SEAL 15 PART 1 VEHICLE OPERATIONS A DECAL IS REOUIRED IF AN ENTERPRISE IS OPERATING AQUALIFIED MOTOR VEHICLE, SEE PAGE 25, P ART1- VEHICLE OPERATIONS. CHECK THE APPROPRIATE BOX(ES) TO DESCRIBE TH~ ENTERPRISE OPERA TtONS: o COMMON CARRIER 0 CONTRACTCARRIER 0 FOR HIRE CARRIER 0 PRIVATE CARRIER INDICATE THE FUaTYPES FOR PENNSYLVANIA BASED QUALIFIED MOTOR VEHICLES; o DIESEL 0 GMOUNE 0 ETHANOUGASOHOL MOTOR CARRIER ROAD 'AX/fFTA VEHICLE DECAL REQUESTS COMPlffi THE FOLLOWING FOR EACH QUALIFIED MOTOR VEHICLE YOU INTEND TO OPERATE IN PENNSYLVANIA DURING THE ENSUING CALENDAR YEAR. HOTE: DECALS ARE $5.00 p~ SET OF TWO. 1. IFTA DECALS (NUMBER OFVEHlClfS THATTRAvalNPAAND OUTOF STATE) 2. NON 1FT" DECALS (NUMBER OF VEHICLES THAT TRAVEL IN PA EXClUSIVELY) 3. TOTA!. DECALS REQUESTED (ADD LINES 1 ANO 2) 4. TOTALAMOUNT DUE (MUlTtPlYLlNE 3 BY $5) N/A REMITTANCE SUBMnTED: 5. AUTHORIZED ADJUSTMENT(ATTACH ORIGiNAl CREDITNOTICE) 6. CHECK OR MONEYORDER AMOUNT [) lPGAS o CNG.tNG MAkE CHECKS PAYABLE TO PA DE~RrMENT OF REVENUE CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE JURISDICTION(S) WHERE: COlUMN A - QUALIFIED MOTOR VEHICLES ARE OPERATED COlUMN B - BULK STORAGE OF DIESEL FUEL IS MAINTAINED ABCD ABCD o 0 0 0 AK -ALASKA 0 0 0 0 10 - IDAHO o 0 0 0 AL --'lAllAMA 0 0 0 [J IL - ILLINOIS o 0 0 0 AR - ARKANSAS 0 [J 0 0 IN - INDIANA o 0 0 0 AI. -ARIZONA a 0 0 0 KS - KANSAS o 0 0 0 CA - CALIFORNIA 0 0 0 [] KY - KENTUCKY o 0 [] [] CO - COlORADO [J [J [] [] LA - LOUISIANA o 0 0 0 CT - CONNECTICUT 0 0 0 0 MA - MASSACHUSETTS o 0 0 0 DC - Dl$T. OF COLUMBIA Cl [] 0 0 1.40 - MARYlAND o [] 0 0 DE - DELAWARE 0 0 0 [] ME- MAINE o [] 0 [] Fl - FLORIDA 0 0 0 0 MI - MICHIGAN [] 0 0 0 GA - GEORGIA 0 0 0 [] MN - MINNESOTA o 0 0 0 HI - HAWAII 0 0 0 0 MO- MISSOURI o 0 0 0 IA ~IOWA 0 0 0 [] MS - MISSISSIPPI ABC D [] [] [] 0 AS -ALBERTA [] 0 0 0 BC -BRITISH COLUMBIA [] 0 0 0 MB - MANITOBA ABC 0 o [J [J [J HB - NEW BRUNSWICK o 0 [J [] NF - NEWFOUNDlAND [] [] DONS - Nr:NA SCOTIA COlUIIN C - BULK STORAGE FOR GASOLINE IS MAINTAINED COlUIIN D - BULK STORAGE OF ANY OTHER MOTOR FUELIS MAINTAINED ABCD ABCD o 0 0 0 "'T - MONTANA 0 0 0 [] RI - RHODE ISLAND o 0 0 b He - NORTH CAROLINA 0 [J 0 0 SC - SOUTH CAROLINA o 0 0 0 NO - NORTH DAKOTA 0 [J 0 0 8D - SOUTH DAKOTA o 0 DONE - NEBRASKA 0 0 0 0 TN - TENNESSEE o 0 0 0 NH - NEW HAMPSHIRE 0 0 0 0 TJ( - TEXAS o 0 0 0 NJ - NEW JERSEY 0 0 0 [] UT - urN! [] 0 0 0 NM - NEW MEXICO 0 0 [J 0 VA - VIRGINIA o 0 0 0 NV - NEVADA 0 0 0 0 VT - VERMONT o 0 0 0 NY - NEW YORK 0 0 0 0 WA- WASHINGTON o 0 0 0 OH - OHIO 0 [] 0 0 WI - WISCONSIN o [J 0 0 OK - OKLAHOMA [J 0 0 0 'NIl - WE8TVIRGINIA [] 0 0 0 OR- OREGON 0 0 0 [] WY- WYOMING o 0 0 0 PA - PENNSYLVANIA ABC D D [] 0 0 NT - NW TERRITORY [] 0 0 0 ON- ONTARIO o '0 0 0 PE -PfUNCE EDWARD IS. ABC D o (] 0 0 PQ - QUEBEC o [] 0 [] SK - SASKATCHEWAN [] 0 [] CI YT. YtIl<ON TERRITORY PART 2 FUELS CHECK THE APPROPRIATE BOX(ES) IF THE ENTERPRISE W1LLSELL, USE OR TRANSPORT A~ FUaS IN PENNSYlVANIA. o LIQUID FUELS AND FUelS TAX - YEARLY PERMIT REQUIRED BYWHOlESALE DISTRIBlTTORS ~.8. ONE liCENSED TO HANDLE TAX FREE LIQUID FUELS OR FUELS IN PAl OR AN IMPORTER OR EXPORTER OF LIQUID FUELS OR FUas. ESTIMATED DATE OF FIRSTTAX.fREE LIQUID FUEUl PURCHASE OR SALE o A!. TERNATtVE FUelS TAX - YEARLY PERMIT REQUIRED BY At TERNATlVE FUELDEALER-USERS FOR THE REMISSION OF TAX ON ALTERNATIVE FUELS (HIGHWAYFUELS OTHER THAN LIQUID FUELS OR FUELS) PLACED INTO THE SUPPlYTANK OF A MOTOR VEHICLE FOR USE ON PA HIGHWAYS. ESTIMATED DATE OF FIRSTFUEUNG OF VEHICLES PROVIDE A LIST OF All PALOCATlONS WHERE L10UID FUaS OR FUELS WItlBE SOLD. STREETADDRESS CITYITOWN COUNTY STATE ZIP CODE + 4 STREETADDRESS CITYITOWN COUNTY STATE ZIP CODE + 4 ATTACH ADDITIONAl 8 112 x 11 SHEETS IF NECESSARY 16 PA-100 2-98 DEPARTMENT USE ONLY cztIIJt ACT55 OF 1997. KNOWN AS THE INSrmmoNS OF PURELY PUBliC CHARITY ACT, WAS SIGNED INTO LAW ON NOVEMBER 26, 1997. THIS LAW HAS CODIFIED THE REQUIREMENTS AN INSTITUTION MUST MEET IN ORDER TO aUAUFY FOR EXEMPTION. OUTLINING FIVE CRITERIATHAT MUST BE MET. EACH INSTITUTION MUST: (1) ADVANCE A CHARITABLE PURPOSE; (2) DONATE OR RENOER GRATUITOUSLY A SUBSTANTIALPORTION OF ITS SERVICES; (3) BENEFIT A SUBSTANTlALAND INDEFINITE CLASS OF PERSONS WHO ARE LEGmMATE SUBJECTS OF CHARITY; (4) RELIEVE THE GOVERNMENTOF SOME BURDEN; (5) OPERATE ENTIRELY FREE FROM PRNATE PROFITMOTlVE. N/A ORGANIZATIONS OF THE FOLLOWING TYPE DO NOT QUALIFY FOR EXEMPTION STATUS: . AN ASSOCIATION OF EMPLOYEES. THE MEMBERSHIPOF WHICH IS LIMITED TO THE EMPLOYEES OF A DeSIGNATED ENTERPRISE . ALABOR ORGANIZATION . AN AGRICULTURAL OR HORTlCUL TURALORGANIZATION . ABUSINESS LEAGUE. CHAMBER OF COMMERCE. REAL ESTATE BOARD. BOARD OF TRADE OR PROFESSIONAL SPORT LEAGUE . ACLUB ORGANIZED FOR PLEASURE OR RECREATION . A FRATERNALBENEFICIARY SOCIETY, ORDER OR ASSOCIATION. TO APPLY OR RENEW SALES TAX EXEMPTION STATUS A REV-72 APPLICATION MUST BE COMPLETED. THIS APPLICATION MAYBE OBTAINED BY COMPLETING THE BELOW FORM OR CALL (717) 783-5473. TTD# (717)712-2252 (HEARING IMPAIRED ONL Y). . IF THE ORGANIZATION CONDUCTS SALES ACTNlTIES AND IS NOTREGISTEREO FOR COLLECTION OF PASALES TAX, REFER TO SECTION 18 OF THIS BOOKLET. ~. _ _ __ _ _ _.n._ __ n __.. _h __ __. . _ __ _ .__u __. mu_ _u__ _._._ _u __._ _. _.._ _._.. __ _.._ ___um._n n _m_ _. _ ...u._ _. _ n _._.. .__ __. __ _. __.. .._n._ -- - __n. ___ n n....__.____. _ - __ u .m_ - h.. _'m _. m... -.- ----- ~ REQUEST FOR SAlfS TAX EXEMPT STATUS APPlICATION NAME I CITYITOWN UZIPCODE+4 MAILING ADDRESS RETURN COMPLETED FORM TO: PA DEPARTMENT OF REVENUE BUREAU OF BUSINESS TRUST FUND TAXES DEPT. 280909 HARRISBURG, PA 17128-0909 17 CtJf'-j Microfilm Number Filed with the Entity Number ?fC(ftJ;)70 Secretary of CERTIFICATE OF ORGANIZATION-DOMESTIC LIMITED LIABILITY C DSCB:15-8913 (Rev95) In compliance with the requirements of 15 Pa.C.S. ~8913 (relating to certificates of organization), the undersigned, desiring to organize a limited liability company, hereby states that: 1. The name of the limited liability company is Eastern States Claims Service, LLC. 2. The address of this limited liability company's registered office in this Commonwealth is: initial 603 South Sprinq Garden St.,Carlisle, PA Number and Street Ci ty State 17013 Zip Code Cumberland County 3. Management of the, limited liability company shall be vested in one or more managers. The number of managers and the manner in which they are selected shall be as prescribed in or by the operating agreement. 4. This certificate of organization may be amended in the manner prescribed at the time by statute, and all rights conferred upon members in this certificate of organization are granted subject to this reservation. 5. The name and address of the organizer are: D. William Bowman 603 South Spring Garden St.. Carlisle, PA 17013 6. The effective date of this filing shall be April 1, 2001. IN WITNESS WHEREOF, the undersigned has executed this certificate of organization as the organizer of the limit iability company this 22~ day of March, 2001. 1065 u.s. Return of Partnership Income OMB No. 1545-0099 Form Department of the Treasury For calendar year 2004, or tax year beginning , and ending . _ _ _ _ u u u _ _ _ _ _' 2(())O4 Internal Revenue Service ~ See seDarate- i-~;t~~~ti~-~;.- A Principal business activity Use the Name of partnership o Employer identification no. HEAVY EQUIPMENT API IRS EASTERN STATES CLAIMS SERVICE LLC 25-1884414 B Principal product or service label. Number, street, and room or suite no. If a P.O. box, see page 14 of the instructions. E Date business started APPRAISAL Other- 603 SOUTH SPRING GARDEN STREET 4/1/2001 C Business code number wise, City or town State ZIP code F Total assets (see page 14 print of the instructions) 541990 or type. CARLISLE PA 17013 $ 35571 G Check applicable boxes: (1) D Initial return (2) D Final return (3) 0 Name change (4) D Address change (5) D Amended return H Check accounting method: (1) 0 Cash (2) D Accrual (3) D Other (specify) ~ u u_ uu u __ - - u_ - - __ - u u I Number of Schedules K-1. Attach one for each person who was a partner at any time during the tax year ~ _ _ _ _ _ _ _ _ _ _ - _ - - - - - - - - - - - - --~ Caution: Include only trade or business income and expenses on lines 1 a through 22 below. See the instructions for more information. 1 a Gross receipts or sales 1a 265,075 b Less returns and allowances 1b 1c 265,075 2 Cost of goods sold (Schedule A, line 8) 2 395 Q) 3 Gross profit. Subtract line 2 from line 1 c 3 264,680 e 4 Ordinary income (loss) from other partnerships, estates, and trusts (attach schedule) 4 .E 5 Net farm profit (loss) (attach Schedule F (Form 1040)) 5 6 Net gain (loss) from Form 4797, Part II, line 17 6 7 Other income (loss) (attach statement) 7 8 Total income loss. Combine lines 3 throu h7 8 264,680 lil c: 9 Salaries and wages (other than to partners) (less employment credits) 9 .2 .~ 10 Guaranteed payments to partners 10 210,000 ~ .g 11 Repairs and maintenance 11 U) 12 Bad debts 12 c: 0 "13 13 Rent 13 ~ 14 Taxes and licenses 14 155 .1:; Q) 15 Interest 15 = '0 16 a Depreciation (if required, attach Form 4562) 16a 378 ~ Q) b Less depreciation reported on Schedule A and elsewhere on return 16b 378 g> Co 17 Depletion (Do not deduct oil and gas depletion.) Q) Q) .!!!- 18 Retirement plans, etc. ! 19 Employee benefit programs 0 13 20 Other deductions (attach statement) 20 18,687 :J "C d 21 Total deductions. Add the amounts shown in the far ri ht column for lines 9 throu h 20 21 229,220 22 Ordina business income loss. Subtract line 21 from line 8 . . . . . . . . . . . .. 22 35,460 Under penalties of pe~ury, 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 general partner or limited liability company member is based on all information of which preparer has any knowledge. May the IRS discuss this relurn with the preparer shown below (see instructions)? 00 Yes D No ~ Signature of general..partner or limited liability company member manager ~ Date Sign Here Preparer's .... 1,\ ...<'", Date signature ~ f\....._ A:..j~-, 3/16/2005 Firm's name (oryoufs GROUPS TAX AND PAYROLL SERVICE if self-employed), .... 524 SOUTH PITT STREET address, and ZIP code ~ CARLISLE State PA For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. (HTA) Paid Preparer's Use Only Check if Preparer's SSN or PTIN self-employed ~ D P00056645 EIN ~ 23-2933778 Phone no. 717-245-8581 ZIP code 17013 Form 1065 (2004) Form 1065 (2004) Cost of Goods Sold (see oaae 19 of the instructions) at beginning of year 1 s less cost of items withdrawn for personal use 2 bor 3 395 I section 263A costs (attach statement) 4 ts (attach statement) 5 d lines 1 through 5 6 395 at end of year 7 oods sold. Subtract line 7 from line 6. Enter here and on page 1, line 2 8 395 EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Page 2 Schedule A 1 Inventory 2 Purchase 3 Cost of la 4 Additiona 5 Other cos 6 Total. Ad 7 Inventory 8 Cost of 9 9 a Check all methods used for valuing closing inventory: (i)DCost as described in Regulations section 1.471-3 (ii)DLower of cost or market as described in Regulations section 1.471-4 (iii)DOther (specify method used and attach explanation) ~ __ __ _ _ __ _ _ __ __ __ __ _ - -- - -- - - -- - -- - -- - - - - -- - -- - -- -- -- - - -- --- b Check this box if there was a writedown of "subnormal" goods as described in Regulations section 1.471-2(c) . . . . . ~D c Check this box if the LIFO inventory method was adopted this tax year for any goods (if checked, attach Form 970) . . . ~D d Do the rules of section 263A (for property produced or acquired for resale) apply to the partnership? . . . .. 0 Yes 0 No e Was there any change in determining quantities, cost, or valuations between opening and closing inventory? 0 Yes 0 No If "Yes," attach explanation. ~ Other Information 1 What type of entity is filing this return? Check the applicable box: Yes No a DDomestic general partnership b DDomestic limited partnership c [RJDomestic limited liability company d DDomestic limited liability partnership e DForeign partnership f DOther ~ _________________________________________ 2 Are any partners in this partnership also partnerships? . . . . . . . . . . . . . . . . . . . . . . X 3 During the partnership's tax year, did the partnership own any interest in another partnership or in any foreign entity that was disregarded as an entity separate from its owner under Regulations sections 301.7701-2 and 301.7701-3? If yes, see instructions for required attachment . . . . . . . . . . . . . . . . . . . . X 4 Did the partnership file Form 8893, Election of Partnership Level Tax Treatment, or an election statement under section 6231 (a)(1 )(B)(ii) for partnership-level tax treatment, that is in effect for this tax year? See Form 8893 for more details. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X 5 Does this partnership meet all three of the following requirements? a The partnership's total receipts for the tax year were less than $250,000; b The partnership's total assets at the end of the tax year were less than $600,000; and c Schedules K-1 are filed with the return and furnished to the partners on or before the due date (including extensions) for the partnership return. If "Yes," the partnership is not required to complete Schedules L, M-1 , and M-2; Item F on page 1 of Form 1065; or Item N on Schedule K-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X 6 Does this partnership have any foreign partners? If "Yes," the partnership may have to file Forms 8804, 8805 and 8813. See page 20 of the instructions .......... .. . .............. X 7 Is this partnership a publicly traded partnership as defined in section 469(k)(2)? . . . . . . . . . . . . X 8 Has this partnership filed, or is it required to file, Form 8264, Application for Registration of a Tax Shelter? . . X 9 At any time during calendar year 2004, did the partnership have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? See page 20 of the instructions for exceptions and filing requirements for Form TO F 90-22.1. If "Yes," enter the name of the foreign country. ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ X 10 During the tax year, did the partnership receive a distribution from, or was it the grantor of, or transferor to, a foreign trust? If "Yes," the partnership may have to file Form 3520. See page 21 of the instructions . . . . . X 11 Was there a distribution of property or a transfer (e.g., by sale or death) of a partnership interest during the tax year? If "Yes," you may elect to adjust the basis of the partnership's assets under section 754 by attaching the statement described under Elections Made By the Partnership on page 9 of the instructions . . . . . X 12 Enter the number of Forms 8865, Return of U.S. Persons With Respect to Certain Foreign Partnerships, attached to this return . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ Designation of Tax Matters Partner (see page 21 of the instructions) Enter below the general partner designated as the tax matters partner (TMP) for the tax year of this return: Name of desi!1nated TMP Address of desi!1nated TMP ~ D. WILLIAM BOWMAN .... 603 SOUTH SPRING GARDEN STREET ~ CARLISLE Identifying .... number of TMP ~ 202-42-7375 PA 17013 Form 1065 (2004) Form 1065 (2004) i .9 - j EASTERN STATES CLAIMS SERVICE, LLC Partners' Distributive Share Items 1 Ordinary business income (loss) (page 1, line 22) . . . . . . . . . . . . . . . . . . 2 Net rental real estate income (loss) (attach Form 8825) 3 a Other gross rental income (loss). . . . . . . . . . . . . . . . 3a b Expenses from other rental activities (attach statement) . . . . .. 3b c Other net rental income (loss). Subtract line 3b from line 3a . . . . . 4 Guaranteed payments . . . . . . . . . . . . . . . . . . . . 5 Interest income . . . . . . . . 6 Dividends: a Ordinary dividends. . . . . . . . . . . . . . . . . . . . . . . . b Qualified dividends. . . . . . . . . . . . .. 6b 7 Royalties.................... . . . 8 Net short-term capital gain (loss) (attach Schedule D (Form 1065)). . . 9 a Net long-term capital gain (loss) (attach Schedule D (Form 1065)). . . b Collectibles (28%) gain (loss). . . . . . . . . . . . . . . .. 9b c Unrecaptured section 1250 gain (attach statement) . 9c 10 Net section 1231 gain (loss) (attach Form 4797). . . . . . . . . . 11 Other income loss attach statement ............ 12 Section 179 deduction (attach Form 4562) . . . . . . 13 a Contributions. . . . . . . . . . . . . . . . . . b Deductions related to portfolio income (attach statement) c Investment interest expense . . . . . . . . . . . . . . . . . . d Section 59(e)(2) expenditures: (1)Type ~ _______uu____uu______ e Other deductions attach statement 14 a Net earnings (loss) from self-employment . . . . . . . b Gross farming or fishing income . . . . . . . . . . . c Gross nonfarm income . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 a Low-income housing credit (section 42(j)(5)) . . . . . . . . . . . . . . . . . . . . b Low-income housing credit (other). . . . . . . . . . . . . . . . . . . . . . . . c Qualified rehabilitation expenditures (rental real estate) (attach Form 3468) . . . . . . . d Other rental real estate credits. . . . . . . . . . . . . . . . . . . . . . . . . . e Other rental credits. . . . . . . . . . . . . . f Other credits and credit reca ture attach statement 16 Name of country or U.S. possession ~ _ _ u_ __ _u u_ _ __ u u u u _ _ __ __ _ _ _ _ _ _ _ _ _ _ __ _ __ __ b Gross income from all sources . . . . . . . . c Gross income sourced at partner level . . . . . . . . . . . . . . . . . . . . . Foreign gross income sourced at partnership level d Passive ~_ _ _ _ _ _ _ _ _ _ _ _ e Listed categories (attach statement) ~. _ _ _ _ _ _ _ _ _ _ _. f General limitation ~ Deductions allocated and apportioned at partner level 9 Interest expense ~ __ _ __ u _ u u u _ u _ u u u h Other . . . . . . . . . . . .. ~ Deductions allocated and apportioned at partnership level to foreign source income i Passive ~_ _ _ _ _ _ _ _ _ _ _ _ j Listed categories (attach statement) ~. _ _ _ _ _ _ _ _ _ _ _. k General limitation ~ I Foreign taxes: (1) Paid ~ ,u _ u u u u u _ u __ u u u (2) Accrued . ~ m Reduction in taxes available for credit attach statement 17 a Post-1986 depreciation adjustment . . . . . . . . b Adjusted gain or loss . . . . . . . . . . . . c Depletion (other than oil and gas) . . . . . . . d Oil, gas, and geothermal properties-gross income e Oil, gas, and geothermal properties-deductions . f Other AMT items attach statement 18 a Tax-exempt interest income b Other tax-exempt income . . . . c Nondeductible expenses . . . . 19 a Distributions of cash and marketable securities b Distributions of other property 20 a Investment income. . . . . . . . . . . b Investment expenses. . . . . . . . . . c Other items and amounts attach statement Schedule K 25-1884414 ~ o ts ::J d ~ ..Q ~!i ~ e! en~::J ;t::"Cc. iCl)~ aallS a::: en 8 ts ! ... l- e en 'iIJ ~ .~~~ 'tVEJ!! E~- J!! .- i :a: .5 <( :E- e o ~ ~ ... CI) 5 (2) Amount Page 3 Total amount 35,460 210,000 86 ~ 10 11 12 13a 13b 13c 13d 2 13e 14a 14b 14c 15a 15b 15c 15d 15e 15f 264,680 650 245,460 378 1,221 36,248 86 Form 1065 (2004) EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Page 4 Analvsis of Net Income (Loss) 1 Net income (loss). Combine Schedule K, lines 1 through 11. From the result, subtract the sum of .1 244,8961 Schedule K, lines 12 throuah 13e, 161(1 ,and 161(2) . 1 2 Analysis by (i) Corporate (ii) Individual (iii) Individual (iv) Partnership (v) Exempt (vi) Nominee/Other partner type: (active) (passive) organization a General partners 244,547 349 b Limited oartners Note: Schedules L M-1 and M-2 are not re uired if Question 5 of Schedule B is answered "Yes." Balance Sheets er Books Beginning of tax year Assets (b) 1 Cash.......... 2 a Trade notes and accounts receivable . . . . . b Less allowance for bad debts . . . . . . . . 3 Inventories............... 4 U.S. government obligations . . . . . . . . 5 Tax-exempt securities . . . . . . . . . . . 6 Other current assets (attach statement) . . . . 7 Mortgage and real estate loans . . . . . . . 8 Other investments (attach statement) . . . . . 9 a Buildings and other depreciable assets . b Less accumulated depreciation 10 a Depletable assets . . . . . b Less accumulated depletion . 11 Land (net of any amortization) 12 a Intangible assets (amortizable only) b Less accumulated amortization . . . . . . . 13 Other assets (attach statement) . . 14 Total assets . . . . . . . . . Liabilities and Capital Accounts payable . . . . . . . Mortgages, notes, bonds payable in less than 1 year. Other current liabilities (attach statement) . . All nonrecourse loans . . . . . . . . . . Mortgages, notes, bonds payable in 1 year or more. Other liabilities (attach statement) Partners' capital accounts . . . . . . . . . Total liabilities and ca ital . . . . . . . . . Reconciliation of Income Loss 1 Net income (loss) per books . . . . . . 2 Income included on Schedule K, lines 1, 2, 3c, 5, 6a, 7, 8, 9a, 10, and 11, not recorded on books this year (itemize): . _ _ __ __ _ _ _ __ _ _ _ __ __ 3 Guaranteed payments (other than health insurance) . . . . . . . . . . . . . 4 Expenses recorded on books this year not included on Schedule K, lines 1 through 13e, 161(1), and 161(2) (itemize): a Depreciation $ __ _ _ __ __ _ _ _ _ __ _ __ _ _ _ ___ b Travel and entertainment $ . _ _ __ _ __ _ _ J,.7_~1. c 5 Add lines 1 throu h 4 . . . . . . . . 6,130 6,130 er Books With Income Loss er Return 33,675 6 Income recorded on books this year not included on Schedule K, lines 1 through 11 (itemize): Tax-exempt interest $ _ __ __ __ _ _ __ _ __ ____ Schedule L 15 16 17 18 19 20 21 22 Schedule M-1 210000 1,221 244,896 S h I 2 c edu e M- Analvsis of Partners' Capital Accounts 1 Balance at beginning of year 6,130 6 2 Capital contributed: a Cash b Property 7 3 Net income (loss) per books 33,675 4 Other increases (itemize): _ _ __ __ __ _ ____ 5 Add lines 1 throuClh 4 8 39,805 9 3,557 3,557 a b 7 ------------------------------------------- Deductions included on Schedule K, lines 1 through 13e, 161(1), and 161(2), not charged against book income this year (itemize): a Depreciation $ __ _ _ _ _ __ _ __ _ _ __ ___ b ------------------------------------------- c ------------------------------------------. 8 9 Add lines 6 and 7 . . . . . . . . . Income (loss) (Analysis of Net Income Loss , line 1 . Subtract line 8 from line 5 244,896 Distributions: a Cash b Property Other decreases (itemize): 36,248 ------------------------------------------. ------------------------------------------. 36,248 3,557 Form 1065 (2004) Add lines 6 and 7 Balance at end of year. Subtract line 8 from line 5 Schedule K-1 (Form 1065) 2(Q)04 Department of the Treasury Internal Revenue Service ,2004 ,20 Tax year beginning and ending Partner's Share of Income, Deductions, Credits, etc. ~ See back of form and separate instructions. D Final K-1 D Amended K-1 6511 OMB No. 1545-0099 Ordinary business income (loss) 15 Credits & credit recapture 35 105 2 Net rental real estate income (loss) 3 Other net rental income (loss) 4 Guaranteed payments 210 000 5 Interest income 85 6a Ordinary dividends A Partnership's employer identification number 25-1884414 B Partnership's name, address, city, state, and ZIP code EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE PA C IRS Center where partnership filed return Cincinnati, OH D 0 Check if this is a publicly traded partnership (PTP) E 0 Tax shelter registration number, if any F 0 Check if Form 8271 is attached 17013 G Partner's identifying number 202-42-7375 H Partner's name, address, city, state, and ZIP code Partner: 1 D. WILLIAM BOWMAN 03 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 o General partner or LLC member-manager J 0 Domestic partner D Limited partner or other LLC member D Foreign partner K What type of entity is this partner? Active Individual L Partner's share of profit, loss, and capital: Beginning Ending Profit Loss Ca ital M Partner's share of liabilities at year end: Nonrecourse. . . . . .. $ Qualified nonrecourse financing . $ Recourse. . . . . . .. $ N Partner's capital account analysis: Beginning capital account. . $ Capital contributed during the year. $ Current year increase (decrease) . $ Withdrawals & distributions. $ Ending capital account. $ 33,338 36,248 2,645 o o D GAAP D Section 704(b) book Tax basis Other (explain) For Privacy Act and Paperwork Reduction Act Notice, see Instructions for Form 1065. (HTA) 99.% 99.% 99.% 5,555 6b Qualified dividends 7 Royalties 8 Net short-term capital gain (loss) I I 9a Net long-term capital gain (loss) 9b Collectibles (28%) gain (loss) 9c Unrecaptured section 1250 gain 10 Net section 1231 gain (loss) 11 Other income (loss) 12 Section 179 deduction 13 Other deductions 14 A 16 Foreign transactions 17 Alternative minimum tax (AMT) items A 18 Tax-exempt income and nondeductible expenses 19 Distributions .__ _.~.Ei,?18 85 C 262 033 *See attached statement for additional information. >- c o g.J :J en Q:; b LL Schedule K-1 (Form 1065) 2004 Form 1065 Partner's Basis Statement Note to Partner: Keep for your records 2004 Partner's name D. WILLIAM BOWMAN Partnership's name EASTERN STATES CLAIMS SERVICE LLC Summary Partner: 1 Identifying Number 202-42-7375 Employer 10 Number 25-1884414 Beginning Share of Other Other Withdrawals, End of of Year Taxable Income Increases Decreases Distributions Year 4,726 35, 190 1 852 36 248 1 816 Basis Computation - Section 704(b) 1 Beginning Basis . . . . . 2 Contributions . . . . . . 3 Increase in share of liabilities 4 Other Adjustments . . . . 5 Share of taxable income . . 6 Share of tax-exempt income . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Add lines 1 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Decrease in share of liabilities (not to exceed 7) . . . . . . . . . . . . . . . . . . 9 Subtract line 8 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Distributions (not to exceed line 9) . Distributions in excess of basis . . . . . . . . 11 Subtract line 10 from line 9 . . . . . . . . . . . . 12 Share of nondeductible expenses (not to exceed line 11) 13 Subtract line 12 from line 11 . . . . . . . . . . . . . . . . . . 14 Share of deductions not subject to basis limitation (not to exceed line 13) . . . . . . 15 Subtract line 14 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . 16 Share of taxable losses and deductions subject to basis limitation (not to exceed line 15) 17 Endingbasis,subtractline16fromline15. . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 6 7 8 9 10 4,726 35,190 39,916 39,916 36,248 11 12 13 14 15 16 17 3,668 1,209 2,459 643 1,816 1,816 Alternate Basis Computation DCheck to use the alternate computation. 1 Capital account balance . . . . . . . . . . .. 1 2 Share of liabilities . . . . . . . . . 2 3 Accumulated tax/book timing differences . . . . . . 3 4 Carryover nondeductible expenses . . . . . . . . 4 5 Excess deductions not subject to basis limit 5 6 Carryover losses and deductions . . 6 7 Distributions in excess of basis . . . . . 7 8 Other differences . . . . . . . . . . . . . . . 8 9 Alternate basis. Combine lines 1 - 8 . . . . . . . . 9 Beginning Increase (decrease) Ending EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Share of Taxable Income 1 Ordinary income from trade or business activities . . . . . . 2 Net income from rental real estate activities 3 Net income from other rental activities . . . . . . . . . . . . . . . . . . . . . . . 5 Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Ordinary dividends . . . 7 Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Net short-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a Net long-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Net section 1231 gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total - Share of Taxable Income . . . . . . . . . . . . . . . . . . . . . . . . . . Share of Taxable. Losses and Deductions 1 Ordinary loss from trade or business activities . . . . . . . . . . . . . . . . . . . . 2 Net loss from rental real estate activities . . . . . . . . . . . . . . . . . . . . . . 3 Net loss from other rental activities . . . . . . . . . . . . . . . . . . . . . . . . 8 Net short-term capital Joss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a Net long-term capital Joss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Net section 1231 loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Other loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Section 179 expense deduction . . . . . . . . . . . . . . . . . . . . . . . . . . 13b Deductions related to portfolio income . 13c Interest expense on investment debts 13d Section 59(e)(2) expenditures . . . . 13e Other deductions . . . . . . . . . CF Carryforward of Taxable Losses and Deductions from prior year Total - Share of Taxable Losses and Deductions . . . . . . Loss CarryoverS Loss items carried over to next year . . . . . . . . . . . . . . . . . . . . . . . . . . Nondeductible expense items carried over to next year . . . . . . . . . . . . . . . . . . . 1 35,105 2 3 5 85 6 7 8 9a 10 11 35,190 1 2 3 8 9a 10 11 12 13b 13c 13d 13e CF D. WILLIAM BOWMAN 202-42-7375 6511 o Final K-1 o Amended K-1 OMB No. 1545-0099 Schedule K-1 (Form 1065) 2(())04 Department of the Treasury Internal Revenue Service ,2004 ,20 Ordinary business income (loss) 15 Credits & credit recapture 355 2 Net rental real estate income (loss) Tax year beginning and ending Partner's Share of Income, Deductions, Credits, etc. . See back ofform and separate instructions. A Partnership's employer identification number 25-1884414 B Partnership's name, address, city, state, and ZIP code 3 Other net rental income (loss) 4 Guaranteed payments 5 Interest income 6a Ordinary dividends 6b Qualified dividends 7 Royalties 8 Net short-term capital gain (loss) 9a Net long-term capital gain (loss) Collectibles (28%) gain (loss) 9c Unrecaptured section 1250 gain 10 Net section 1231 gain (loss) 11 Other income (loss) EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE PA c IRS Center where partnership filed return Cincinnati, OH D D Check if this is a publicly traded partnership (PTP) E D Tax shelter registration number, if any F D Check if Form 8271 is attached 17013 G Partner's identifying number 183-44-2392 H Partner's name, address, city, state, and ZIP code Partner: 2 MICHELLE E BOWMAN 603 SOUTH SPRING GARDEN STREET CARLISLE, PA 17013 J [Xl [K] D D Foreign partner General partner or LLC member-manager Limited partner or other LLC member Domestic partner 12 Section 179 deduction K What type of entity is this partner? Passive Individual 13 Other deductions L Partner's share of profit, loss, and capital: Beginning Ending Profit Loss Ca ital 1.% 1.% 1.% M Partner's share of liabilities at year end: Nonrecourse. . . . . .. $ Qualified nonrecourse financing . $ Recourse. ..... $ 14 Self-employment earnings (loss) . .._;3q~ 16 Foreign transactions 17 Alternative minimum tax (AMT) items 18 Tax-exempt income and nondeductible expenses 19 Distributions 7 20 Other information C 2 647 *See attached statement for additional information. N Partner's capital account analysis: Beginning capital account. $ Capital contributed during the year. $ Current year increase (decrease) . $ Withdrawals & distributions. $ Ending capital account. $ 912 575 >- c o ~ ::::l CJ) ~ ~ 337 D D D GAAP D Section 704(b) book Tax basis Other (explain) For Privacy Act and Paperwork Reduction Act Notice, see Instructions for Form 1065. (HTA) Schedule K-1 (Form 1065) 2004 Form 1065 Partner's Basis Statement Note to Partner: Keep for your records 2004 Partner's name MICHELLE E BOWMAN Partnership's name EASTERN STATES CLAIMS SERVICE LLC SUmmary Partner: 2 Identifying Number 183-44-2392 Employer ID Number 25-1884414 Beginning Share of Other Other Withdrawals, End of of Year Taxable Income Increases Decreases Distributions Year 566 356 19 903 Basis Computation - Section 704(b) 1 Beginning Basis . . . . . 1 2 Contributions . . . . . . 2 3 Increase in share of liabilities 3 4 Other Adjustments . . . . 4 5 Share of taxable income . . 5 6 Share of tax-exempt income . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Add lines 1 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7 8 Decrease in share of liabilities (not to exceed 7) . . . . . . . . . . . . . . . . . ., 8 9 Subtract line 8 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . ., 9 10 Distributions (not to exceed line 9) . 10 Distributions in excess of basis . . . . . . . . . . . . 11 Subtract line 10 from line 9 . . . . . . . . . . . . . . . . 11 12 Share of nondeductible expenses (not to exceed line 11) . . . . 12 13 Subtract line 12 from line 11 .............. .... 13 14 Share of deductions not subject to basis limitation (not to exceed line 13) . . . . . . 14 15 Subtract line 14 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . 15 16 Share of taxable losses and deductions subject to basis limitation (not to exceed line 15) 16 17 Endingbasis,subtractline16fromline15. . .. . . . . . . . . . . . . . . . .. 17 566 356 922 922 922 12 910 7 903 903 Alternate Basis Computation DCheck to use the alternate computation. 1 Capital account balance . . . . . . . . . . .. 1 2 Share of liabilities . . . . . . . . . 2 3 Accumulated tax/book timing differences . . . . . . 3 4 Carryover nondeductible expenses . . . . . . . . 4 5 Excess deductions not subject to basis limit 5 6 Carryover losses and deductions 6 7 Distributions in excess of basis . . . . . . 7 8 Other differences . . . . . . . . . . . . . . . 8 9 Alternate basis. Combine lines 1 - 8 . . . . . . . . 9 Beginning Increase (decrease) Ending EASTERN STATES CLAIMS SERVICE, LLC Share of Taxable Income 1 Ordinary income from trade or business activities . . . . . . 2 Net income from rental real estate activities 3 Net income from other rental activities 5 Interest . . . . . . . . . . . . . . 6 Ordinary dividends . . . 7 Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Net short-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a Net long-term capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Net section 1231 gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Other income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total - Share of Taxable Income . . . . . . . . . . . . . . . . . . . . . . . . . . 25-1884414 Share of Taxable Losses and Deductions 1 Ordinary loss from trade or business activities . . . . . . . . . . . . . . . . . . . 2 Net loss from rental real estate activities . . . . . . . . . . . . . . . 3 Net loss from other rental activities . . . . . . . . . . . . . . . . . . . . . . . . 8 Net short-term capital loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a Net long-term capital loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Net section 1231 loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Other loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Section 179 expense deduction . . . . . . . . . . . . . . . . . . . . . . . . . . 13b Deductions related to portfolio income 13c Interest expense on investment debts 13d Section 59(e)(2) expenditures . . . 13e Other deductions . . . . . . . . CF Carryforward of Taxable Losses and Deductions from prior year Total - Share of Taxable Losses and Deductions . . . . . . Loss Carrvovers Loss items carried over to next year . . . . . . . . . . . . . . . . . . . . . . . . . . Nondeductible expense items carried over to next year . . . . . . . . . . . . . . . . . . . 1 355 2 3 5 6 7 8 9a 10 11 356 1 2 3 8 9a 10 11 12 13b 13c 13d 13e CF MICHELLE E BOWMAN 183-44-2392 Form 1065 EASTERN STATES CLA Basis Summary 25-1884414 2004 Keen for vour records Grand Totals: 5292 35.546 1,871 36 248 2719 Paqe Totals: 5292 35 546 1,871 36 248 2719 Partner Partner (a) (b) (c) (d) (e) (f) Number Name Beginning Share of Other Other Withdrawals, End of of Year Taxable Income Increases Decreases Distributions Year 1 D. WILLIAM BOWMAN 4726 35 190 1 852 36 248 1.816 2 MICHELLE E BOWMAN 566 356 19 903 . Form 1065 EASTERN STATES CLA Capital Account Summary 25-1884414 2004 Keeo for your records Grand Totals: 6.130 33 675 36 248 3557 Pace Totals: 6130 33.675 36 248 3557 (a) (b) (c) (d) (e) Partner Partner Capital Account Capital Partner's Share of Withdrawals Capital Account Number Name at Beginning Contributed Schedule M-2 and at the of Year Durina Year lines 3 4 & 7 Distributions End of Year 1 D. WILLIAM BOWMAN 5555 33 338 36 248 2645 2 MICHELLE E BOWMAN 575 337 912 Form 4562 Depreciation and Amortization (Including Information on Listed Property) OMS No. 1545-0172 2(0)04 Department of the Treasury Internal Revenue Service . See se arate instructions. . Attach to our tax return. Name(s) shown on return Business or activity to which this form relates EASTERN STATES CLAIMS SERVICE LLC HEAVY EQUIPMENT APPRAISALS Election To Expense Certain Property Under Section 179 Note: If ou have an listed ro ert , com lete Part V before ou com lete Part I. 1 Maximum amount. See page 2 of the instructions for a higher limit for certain businesses . . . . . . . . . .. 1 2 Total cost of section 179 property placed in service (see page 3 of the instructions). . . . . . . . . . . . .. 2 3 Threshold cost of section 179 property before reduction in limitation . . . . . . . . . . . . 3 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 4 5 Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing se aratel ,see a e 3 of the instructions . . . . . . . . . . a Descri tion of ro ert Attachment Se uence No. 67 Identifying number 25-1884414 102,000 410 000 6 5 c Elected cost 7 Listed property. Enter the amount from line 29 . . . . . . . . . . . . . . . 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 9 Tentative deduction. Enter the smaller of line 5 or line 8 . . . . . . . . . . . 10 Carryover of disallowed deduction from line 13 of your 2003 Form 4562. . . . . . 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 (see instructions) 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 13 Car over of disallowed deduction to 2005. Add lines 9 and 10 less line 12 . . . . . . . Note: Do not use Part /I or Part III below for listed ro ert . Instead use Part V. S ecial De reciation Allowance and Other De reciation Do not include listed ro 14 Special depreciation allowance for qualified property (other than listed property) placed in service during the tax year (see page 3 of the instructions) . . . . . . . . . . . . . . . . . . . . . . . 15 Property subject to section 168(f)(1) election (see page 4 of the instructions) . . . . . . . . . . . . . . . . 16 Other de reciation includin ACRS see a e 4 of the instructions . . . MACRS De reciation Do not include listed ro ert. See a e 5 of the instructions. Section A 17 MACRS deductions for assets placed in service in tax years beginning before 2004 . . . . 18 If you are electing under section 168(i)(4) to group any assets placed in service during the tax year into one or more general asset accounts, check here . . . . . . . . . . . . . . Section B . Assets Placed in Service Durin 2004 Tax Year Us in the General De (b) Month and (c) Basis for (d) Recovery (e) year placed depreciation period Convention in service business/investment 7 8 9 10 11 12 14 15 . . . . . 16 (a) Classification of property (g) Depreciation deduction 19 a b c d MM MM MM MM 2004 Tax Year Us in the Alternative De Section C - Assets Placed in Service Durin 20 a Class life b 12- ear c 40- ear Summa see a e 8 of the instructions 21 Listed property. Enter amount from line 28 . . . . . . . . . . . . . 22 Total. Add amounts from line 12, lines 14 through 17,lines 19 and 20 in column (g), and line 21. Enter here and on the appropriate lines of your return. Partnerships and S corporations - see instr. 23 For assets shown above and placed in service during the current year, enter the portion of the basis attributable to section 263A costs . . . . . . . . . . . . . . . . . . . . For Paperwork Reduction Act Notice, see separate instructions. (HTA) 12 rs. 40 rs. MM 21 378 22 23 Form 4562 (2004) 2004) EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Pa e 2 Listed Property (Include automobiles, certain other vehicles, cellular telephones, certain computers, and property used for entertainment, recreation, or amusement.) Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a, 24b, columns (a) through (c) of Section A, all of Section B, and Section C if applicable. Section A - De reciation and Other Information Caution: See a e 9 of the instructions for limits for assen er automobiles. 24a Do you have evidence to support the business/investment use claimed? DVes DNo 24b If "Ves," is the evidence written? Dves DNa (a) (b) (e) Businessl (d) (e) Basis for (f) (g) (h) (I) Elected Type of property Date placed investment use Cost or depreciation Recovery Methodl Depreciation section 179 list vehicles first in service ercenta e other basis business/investment eriod deduction cost 25 Special depreciation allowance for qualified listed property placed in service during the tax ear and used more than 50% in a ualified business use see a e 8 of the instructions 25 26 Property used more than 50% in a aualified business use (see pace 8 of the instructions): See Attached Stmnt 27 Pro e used 50% or less in a ualified business use see a e 8 of the instructions: 378 S/L - S/L - S/L - 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 . . 28 29 Add amounts in column i, line 26. Enter here and on line 7, a e 1 . . . . . . . . Section B - Information on Use of Vehicles Complete this section for vehicles used by a sole proprietor, partner, or other "more than 5% owner," or related person. If you provided vehicles to your employees first answer the auestions in Section C to see if vou meet an exceotion to comoletina this section for those vehicles. 30 Total business/investment miles driven during (a) (b) (c) (d) (e) (f) the year (do not include commuting miles - Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 See page 2 of the instructions) 31 Total commuting miles driven during the year 32 Total other personal (noncommuting) miles driven 33 Total miles driven during the year. Add lines 30 through 32 34 Was the vehicle available for personal Ves No Ves No Yes No Yes No Ves No Ves No use during off-duty hours? 35 Was the vehicle used primarily by a more than 5% owner or related person? 36 Is another vehicle available for oersonal use? Section C - Questions for Employers Who Provide Vehicles for Use by Their Employees Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who are not more than 5% owners or related ersons see a e 10 of the instructions. Ves No 37 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your employees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your employees? See page 10 of the instructions for vehicles used by corporate officers, directors, or 1% or more owners . 39 Do you treat all use of vehicles by employees as personal use? . . . . . . . . . . . . . . . . . . . . . . . . 40 Do you provide more than five vehicles to your employees, obtain information from your employees about the use of the vehicles, and retain the information received? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you meet the requirements concerning qualified automobile demonstration use? (See page 10 of the instructions.) Note: If our answer to 37 38 39 40 or 41 is "Ves "do not com lete Section B for the covered vehicles. Amortization (a) 41 (b) Date (e) Amortizable (d) Code (e) (f) Amortization for Description of costs amortization 42 43 73 44 73 Form 4562 (2004) 43 Amortization of costs that began before your 2004 tax year . . . . . . . . . . . . . . . . . . . . 44 Total. Add amounts in column . See a e 12 of the instructions for where to re ort . . . . . . . . . . EASTERN STATES CLAIMS SERVICE, LLC 25-1884414 Line 20 (Form 1065) - Other Deductions 1 Travel, Meals and Entertainment a Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a b Total meals and entertainment 1b 2,442 c 50% of line b . . . . . . . . . . . . . . . . . . . . . . . . . . . 1c 1,221 d Subtract line c from line b . . . . . . . . . . . . . . . . . . . . . . . . . . . 1d 2 From Form 4562 - Amortization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 ~q~~~!~i~~________________________________________________________________________________________. 3 4 ~~~~_~Q~_~~9~9!~~qQ~_____________________________________________________________________________. 4 5 !Q~~!~~P~__________________________________________________________________________________________. 5 6 !:q~t~9~___________________________________________________________________________________________. 6 7 !:r9J~~~19~~1!~~~_______________________________________________________________________________.___. 7 8 ~~QP~~~___________________________________________________________________________________________. 8 9 J_~I~p_~qQ~_________________________________________________________________________________________. 9 10 Total other deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2,848 1,221 73 1,430 300 2,011 1,103 250 3,285 6,166 18,687 Line 13a, Sch K (Form 1065) - Contributions A Code A - Cash contributions (50%) Total contributions. . . . . . . . . . . . . . . . . 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In '<t t"'l CXl "- "- t"'l c:: .Q iii N t o B" E ~ ~ .Q c:: ro ~ co 00 Q) c:: :0 :;.Q '- co '0 iii ~ m ~ 1? 'u ..- >-Q)O~ Q) '- en c:: .Q 2 c:: Q) dG)c...2 0'0 >.NCI)_O'O~ 1:: Q) Q) Q) ~ Q)c::'O'Otc:: c.'- :::I '- 0 c:: 02uCOg-Cll a. Q) .S ~ '- m '0 g:;.EN'B 2COQ)'O"-c:: ~ ~ .~ .~ ~ :; - = Cll Co .- Q) g-cou 02'0 oroc::c::C::.=2 >< .- 0 0 0 0 N Q) ~ t5 t5 t5 .S N g ~ -g -g ~ .9 ~ ~t-o-o-o~ g~~~~tN Clle..-..-..-O~ mc.c::c::c::~.q 'u ~ ,g .Q .Q 00 E 11>_01:51:500", ~:3~~JL~.f I 10100031501 RCT-101 PAGE 1 OF 6 STEP A Tax Year Beg. Tax Year End. xx XX STEP C Corp Tax Account 10 Federal EIN Corporation Name Address Line 1 Address Line 2 City State Zip xx XX XX XX XX XX XX XX STEP D A. Tax Liability from Tax Report CS/FF LOANS CNI TOTAL I I DEPARTMENT USE ONLY PA CORPORATE TAX REPORT 2004 STEP 8 01012004 12312004 XX XX XX N Y N First Report Koz/EIP Credit File Period Change Regulated Inv. Co. 52-53 Week Filer Address Change 4710494 251884414 EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN CARLISLE PA 17013 -, XX XX XX N N N B. Estimated Payments & Credits on Deposit C. Restricted Credits Calculation: A minus B minus C STEP E: Payment Make check for this amount payable to "P A Dept of Revenue" STEP F: RefundlTransfer Method Select one of the following options: Made Payment Via EFT A N Total transfer of credit 8 N Combination Transfer/Refund Enter transfer amount to right ~ C N Total refund of credit STEP G: Corporate Officer (Sign affirmation below) TRANS AMT NAME PHONE E-MAIL D. WILLIAM BOWMAN 7172419514 FORM I hereby affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete report. If prepared by a person other than the taxpayer, his declaration is based on all information of which he has any knowledae. Corporate Officer Signature/Date USE WHOLE DOLLARS ONLY N 1015 I 10100032502 I NAME EASTERN STATES CLAIMS SERVICE, ACCOUNT ID 4710494 TAX YEAR END 12312004 RCT-101 PAGE 2 OF 6 PA CORPORATE TAX REPORT 2004 SECTION A: CS/FF OLDEST PERIOD FIRST TAX PERIOD ENDING BOOK INCOME TAX PERIOD BEGINNING YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 CUR YR 04012001 01012002 01012003 11959 -10093 721 12312001 12312002 12312003 01012004 12312004 -788 2. TOTAL BOOK INCOME (sum of income for all tax periods up to, but not over 5 years total) 3. DIVISOR (In years and in part years rounded to three decimal places) See Instructions 4. Divide Line (2) by Line (3) 5. AVERAGE BOOK INCOME -Enter Line (4) or if Line (4) is less than zero enter "0" 6. Divide Line (5) by 0.095 7. Shareholders' equity at the END of the current period 8. Shareholders' equity at the BEGINNING of the current period 9. If Line (7) is more than twice as great or less than half as much as Line (8), add Lines (7) and (8) and divide by 2. Otherwise enter Line (7). 10. NET WORTH- Enter Line (9) or if Line (9) is less than zero enter "0" 11. Multiply Line (10) by 0.75 12. Add Lines (6) and (11) 13. Divide Line (12) by 2 14. $125,000 valuation deduction 15. CAPITAL STOCK VALUE- Line (13) less Line (14) but not less than "0". If 100% Taxable, enter Line (15) on Line (17). 16. Proportion of taxable assets or apportionment proportion (From Schedule A-1, Line 5) 17. TAXABLE VALUE- Multiply Line (15) by Line (16). If Jess than zero, enter "0" 18. CAPITAL STOCK/FOREIGN FRANCHISE TAX- Multiply Line (17) by 0.00699 L Investment in LLC Holding Company Family Farm XX XX XX N N N WHOLE DOLLARS ONLY 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1799 3.753 479 479 5042 3557 6130 3557 3557 2668 7710 3855 -125000 ~ NAME EASTERN STATES CLAIMS SERVICE, ACCOUNT ID 4710494 TAX YEAR END 12312004 I I 10100033503 RCT-101 PAGE 3 OF 6 PA CORPORATE TAX REPORT 2004 SECTION B: Bonus Depreciation 1. Current Year Fed. Depree. of 168k Prop. 2. Current Year Adj. for Disp. of 168k Prop. 3. Other Adjustments (Must Attach Schedule C-3 if claiming bonus depreciation) Business Trust XX N 1 Solicitation Only XX N 2 Single Entity LLC XX Y 3 Multi-Member LLC XX N PA-S XX N Taxable Built-In Gains XX N SECTION C: CORPORATE NET INCOME TAX 1. Income or Loss from federal return on a separate company basis 1 2. DEDUCTIONS: A. Corporate Dividends Received (From Schedule C-2, Line 6) B. Interest on U.S. Securities (GROSS INT less EXPENSES) C. Curr Yr. Addtl. PA Depree. plus Adjust. for Sale (Attached Schedule C-3) D. Other (Attached Schedule). See Instructions TOTAL DEDUCTIONS. Sum of (A) through (D) 2A 28 2C 2D 2 3. ADDITIONS: A. Taxes imposed on or measured by net income (Attached Schedule) B. Tax Preference Items (Attached copy of Federal Form 4626) C. Employment Incentive Payment Credit Adjustment (Attached Schedule W) D. Current Year Bonus Depreciation (Attached Schedule C-3) E. Other (Attached Schedule) See Instructions TOTAL ADDITIONS - Sum of (A) through (E) 3A 38 3C 3D 3E 3 4. Income or Loss with Pennsylvania Adjustments (Line 1 - Line 2 + Line 3) 5. Total Nonbusiness Income (or Loss) 6. Income (or Loss) to be Apportioned (Line 4. Line 5) 7. Apportionment Proportion (from Schedule C-1 Line 5) 8. Income (or Loss) Apportioned to PA (Line 6 x Line 7) 9. Nonbusiness Income (or Loss) allocated to PA 10. Taxable Income (or Loss) after Apportionment (Une 8 + Line 9) 11. Total Net Operating Loss Deduction (from RCT-103) can not exceed $2,000,000 12. PA Taxable Income (or Loss) (Une 10 - Line 11) 13. Corporate Net Income Tax (Line 12 x .0999) 4 5 6 7 8 9 10 11 12 13 L --.J USE WHOLE DOLLARS ONLY I 10100034504 NAME EASTERN STATES CLAIMS SERVICE, ACCOUNT ID 4710494 TAX YEAR END 12312004 RCT-101 PAGE 4 OF 6 PA CORPORATE TAX REPORT 2004 SECTION 0: LOANS TAX 1. Did this corporation have a fiscal officer resident in PA and paying interest on indebtedness of the corporation? 2. Did this corporation have indebtedness outstanding to individual residents and/or partnerships resident in Pennsylvania? 3. Did this corporation have indebtedness outstanding held by a trustee, agent or guardian for a resident individual taxable in its own right or by an executor or administrator of an estate wherein the decedent was a resident of Pennsylvania? List outstanding indebtedness. Attach separate schedule if additional space required. Interest Amount Interest Rate Taxable Value TAX INOEBT X X LOANS TAX XX SCHEDULE A-1: Apportionment Schedule For Capital Stock/Foreign Franchise Tax (Include Form RCT-102, RCT-105, or RCT-106) Three Factor Single Factor Property-PA 1A 1C Numerator 4A Property-Total 18 Denominator 48 Payroll-PA 2A 2C Payroll-Total 28 Sales-PA 3A 3C Apportionment 5 Sales-Total 38 Proportion SCHEDULE C-1: Apportionment Schedule For Corporate Net Income Tax (Include Form RCT-106) Three Factor Single Factor Property-PA 1A 1C Numerator 4A Property-Total 18 Denominator 48 payroll-PA 2A 2C Payroll-Total 28 Sales-PA 3A 3C Apportionment 5 Sales-Total 38 Proportion L USE WHOLE DOLLARS ONLY I XX XX XX N N N ~ NAME EASTERN STATES CLAIMS SERVICE~ ACCOUNT ID 4710494 TAX YEAR END 12312004 I I 10100035505 RCT-101 PAGE 5 OF 6 PA CORPORA TE TAX REPORT 2004 SECTION E: CORPORATE STATUS CHANGES Out of Existence X X N Out of Existence Date X X (Final Report) "'Date of Distribution of X X OR No Assets X X Assets to distribute PA Corporations: Report date business activity ceased and date assets were distributed. Foreign (Non-PA) Corporations: Report date business activity in PA ceased and date PA assets were distributed. "Schedule of Disposition of Assets MUST be completed and filed with the PA Corporate Tax Report. Has the corporation sold or transferred in bulk 51 % or more of any of the following classes of assets: X X N any stock of goods, wares, merchandise of any kind, fixtures, machinery, equipment, buildings or real estate. If so, please provide the name and address of the purchaser. (Attach separate sChedule if additional space required.) Purchaser Name X X Address Line 1 X X Address Line 2 X X City X X State X X Zip XX SECTION F: GENERAL INFORMATION QUESTIONNAIRE Brief Description of corporate activity in PA HE A V Y E QUI P MEN TAP P R A I S A L S Brief Description of corporate activity outside of PA List other states in which taxpayer has activity State of Incorporation Incorporation Date XX XX 04012001 If incorporated outside of PA, does the corporation solicit sales in Pennsylvania? If yes, does the corporation use: Employee X X Exclusive Sales Representative X X Independent Sales Representative X X XX N 1. Has federal government changed taxable income as originally reported for any prior period for which reports of change have not been filed in PA? XX N If yes: First Period End Date: Last Period End Date: XX XX L 2. Does any corporation hold all or a majority of the stock of this corporation? 3. Does this corporation own all or a majority of stock in other corporations? If yes, complete SChedule X. N N ~ I 10100036506 NAME EASTERN STATES CLAIMS SERVICE, ACCOUNT ID 4710494 TAX YEAR END 12312004 RCT-101 PAGE 6 OF 6 PA CORPORATE TAX REPORT 2004 SCHEDULE OF REAL PROPERTY IN PA (Attach separate schedule if additional space required.) Own/Rent Street Address City County CORPORATE OFFICERS Last Name First Name MI President XX Vice President XX Secretary XX Treasurer XX TAX PREPARER'S NAME AND ADDRESS Mail to Practitioner XX Y Federal EIN XX 232933778 Firm Name XX GROUPS TAX AND PAYROLL SERVICE Address Line 1 XX 524 SOUTH PITT STREET Address Line 2 XX City XX CARLISLE State XX PA Zip XX 17013 Tax Preparer's Signature/Date ~} ~ 03/16/05 NAME PHONE E-MAIL SUZETTE CASE 7172458581 GROUPTAX@EARTHLINK.NET L I KOZlKOEZ N N N N SSN ~ EASTERN'STATES CLAIMS SERVICE, LLC 25-1884414 EASTERN STATES CLAIMS SERIVCE, LLC 2002 RCT -101 EIN: 25-1884414 ACCOUNT 10: 4710-494 BOOK INCOME ADJUSTMENTS FOR CAPITAL STOCK TAX BOOK INCOME PER LINE 1 OF SCHEDULE M-1 OF FORM 106~ $35,460.00 lESS: DISTRIBUTIONS TO MATERIAllY PARTICIPATING MEMBER PER LINE 22 OF SCHEDULE K-1 OF FORM 1065 FOR D. WilLIAM BOWMAN. MR. BOWMAN WORKS MORE THAN 2000 HOURS PER YEAR IN FULL-TIME EMPLOYMENT FOR THE TAXPAYER. -$36.248.00 BOOK INCOME FOR CAPITAL STOCK TAX -$788.00 ~ 0405918129 PA-20S/PA-65 (09-04) 2004 Pennsylvania PA 5 Corporation/Partnership Information Return ENTER ONE lETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted label Filing Status: N PA-65 y PA-20S 251884414 C EASTERN STATES CLAIMS SERVICE, LLC 603 SOUTH SPRING GARDEN STREET CARLISLE PA 17013 Part I. Total PA Taxable Business Income (Loss) from Operations Everywhere 1a PA Taxable Business Income (Loss) from its Operations Everywhere 1 b Share of Income (Loss) from All Other Entities 1c Total Income (Loss). Add Line 1a and Line 1b 1d Previously Disallowed CNI Deductions - PA S only 1e Total Adjusted Business Income (Loss). Subtract Line 1d from Line 1c Part II. Apportioned PA Taxable Business Income (Loss) 2 Net Operating Income (Loss) from Line 7 PA Schedule H 2 Net Income (Loss) from Other Entities 2 Previously Disallowed PA Source CNI Deductions - PA S corporations only 2 Compute Adjusted/Apportioned Net Operating Income (Loss) - Total each column Part III. Allocated Other PA PIT Income (Loss) 3 Interest Income from PA Schedule A 4 Dividend Income from PA Schedule B 5 Net Gain (Loss) from PA Schedule D 6 Rent/Royalty Net Income (Loss) from PA Schedule E 7 Estates or Trusts Income from PA Schedule J 8 Gambling and Lottery Winnings from PA Schedule T 9 Total Other PA PIT Income (Loss) - Add Lines 3 through 8 EC Page 1 of 3 FC L 0405918129 ITJmITJ L Fiscal Year N Extension Requested N Final Return N Do you want to receive a 2005 y PA-20S/PA-65? EIN/Name/Address N Change Amended Information N Return 1a 1b 1c 1d 1e 2a 2e 2b 2f 2c 29 2d 2h 3 4 5a 5b 6a 6b 7a 7b 8a 8b 9 33589 33589 33589 33589 33589 86 86 0405918129 ~ -.J 0406018127 PA-20S/PA-65 - 2004 (09-04) 251884414 c EASTERN STATES CLAIMS SERVICE, L Part IV. Total PA S Corporation or Partnership Income (Loss) 10 Total Income (Loss) per Underlying Pennsylvania Books and Records 11 Total Reportable Income (Loss) (Add Line 1e and Line 9) or (Add Lines 2h and 9) 12 Total Nontaxable/Nonreportable Income (Loss) - Subtract Line 11 from Line 10 Part V. Pass - Through Credits - see instructions for each credit 13a Resident Shareholders Tax Credit - PA S corporations only 13b PA Employment Incentive Payments Credit 13c PA Jobs Creation Tax Credit 13d PA Research and Development Tax CreditlPA Film Production Tax Credit 14a PA 2004 Tax Withholding Payments from Nonresident Shareholders and Partners 14b Final Payment of Nonresident Withholding Tax 14c Total PA Income Tax Withheld - Add Lines 14a and 14b Part VI. Distributions - see instructions Partnerships Only 15 Distributions of Cash, Marketable Securities, and Property 16 Guaranteed Payments for Capital 17 Guaranteed Payments for Services PA S Corporations Only 18 Distributions from PA Accumulated Adjustment Account (AAA) 19 Distributions of Cash, Marketable Securities, and Property L 10 11 12 33675 33675 13a 13b 13c 13d 14a 14b 14c 15 16 17 36248 210000 18 19 Part VII. Shareholders and Partners Summary Enter the total number of owners of the PA S corporation or partnership, and the number for each type of owner. The entity must provide a PA Schedule RK-1 to each resident individual owner and a PA Schedule NRK-1 to each non-PA resident individual. The entity must provide each owner that is not an individual with both a PA Schedule RK-1 and a PA Schedule NRK-1. Read the instructions. 2 Total shareholders or partners Type of Shareholder or Partner Individuals Partnerships Estates Trusts PA S corporations All other corporations Page 2 of 3 L 0406018127 PA Resident Non PA Resident 2 0406018127 -.J --1 0407118124 L PA-20S/PA-65 - 2004 (09-04) 251884414 c EASTERN STATES CLAIMS SERVICE, L Part VIII. PA S Corporations Only - Accumulated Adjustment Account 1 Balance at the beginning of the taxable year 2 Total reportable income from Part IV, Line 11 3 Other additions - Submit an itemized statement. 4 Loss from Part IV, Line 11 5 Other reductions. Submit an itemized statement. 6 Add Lines 1 through 5 7 Distributions other than dividend distributions 8 Balance at taxable year end - Subtract Line 7 from Line 6. 1 2 3 4 5 6 7 8 Part IX. Nonresident Withholding Payments PA S Corporations and PA Partnerships Use this part to list all the withholding payments that the PA S corporation or partnership made on behalf of shareholders or partners that were not residents of Pennsylvania during the taxable year. A PA Tax Due on PA Taxable Income to Nonresidents. Enter on Line 14c NOTE. The amount on Line A must equal the total from all PA Schedules NRK-1 and the Total PA Income Tax Withheld, Line 14c. B Nonresident Withholding Payments during the Entity's Taxable Year: Date Amount Date Amount Total Nonresident Withholding Payments. Enter in Part V, on Line 14a C Reconciliation Payment. Subtract B from A, and enter in Part V, on Line 14b Pay any balance due with: · The PA-20S/PA-65 Information Return, or · The PA-40NRC, Nonresident Consolidated Tax Return, if all the nonresident owners elect to participate in a group return. Signature and Verification 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 general partner or limited liability company member) is based on all information of which preparer has any knowledge Signature of general partner, limited liability company member, or S-Corp officer Date Daytime Telephone Number Paid Preparer's Use Preparer's Signature (717) 241-9514 Firm's name (or yours if self-employed), address, and ZIP code /;\)V-- ~24 SOUTH PITT STREET CARLISLE PA 17013 Date 031605 Check if D self-employed Daytime Telephone Number 717-245-8581 I P00056645 232933778 I L 0407118124 FILE ALL 3 PAGES Page 3 of 3 0407118124 --1 ~ 0407910017 PA SCHEDULE M Reconciliation of Federal Taxable Ordinary Income to PA Taxable Business/Farm Income (09-04) PA-20S/PA.66 Schedule M Name as shown on PA-20S/PA-65 Information Return 2004 EIN OFFICIAL USE ONLY PA Sales Tax License Number EASTERN STATES CLAIMS SERVICE LLC 25-1884414 PA Schedule M, Part A Classifying Federal Ordinary Income (Loss) for PA Personal Income Tax Purposes Classify without adjustment for PA PIT rules, the federal income (loss) from the Schedule K of Federal Form 1120S or from Federal Form 1065. The entity must classify the amounts federal sources in ordinary income to the reportable PA PIT classes. Federal Form Classified for Pennsylvania Personal Income Tax purposes Form 1120S, Schedule Kline (a) (b) (c) (d) (e) (f) description Federal PA Business Interest Dividend Gain (loss) Rent & Royalty Form 1065, Schedule Kline Income Income Income Income From Sales Income (loss) description (Joss) (Joss) PA Schedule A PA Schedule B PA Schedule D PA ScheduleE Ordinary income (loss) from trade or business activities 35460 35460 Interest income 86 86 Ordinary dividends Royalty income Net short-term capital gain (loss) Net long-term capital gain (loss) Other portfolio income (loss) PA S corporations ONLY Net section 1231 gain (loss) from Form 4797 for Form 1120S PA S corporations ONLY Other income (loss) from Form 1120S Partnership ONLY Net section 1231 gain (loss) from Form 4797 for Form 1065 Partnerships ONLY Other income (loss) Partnerships ONLY I Guaranteed payments to partners from Form 1065. 210000 PA Income (loss) by classification. Total the amounts in each column. 245546 35460 86 Please enter losses in parentheses ( ). Columns (c) and (d) can never result in a loss. L 0407910017 SIDE 1 0407910017 ~ .-J 0408020014 PA SCHEDULE M Reconciliation of Federal Taxable Income to PA Taxable Income (09-04) PA-20S/PA-65 Schedule M Name as shown on PA-20S/PA-65 Information Return 2004 OFFICIAL USE ONLY EIN EASTERN STATES CLAIMS SERVICE LLC 25-1884414 PA Schedule M, Part B. Determining PA Reportable Business, Profession, or Farm Income or Loss b ) Enter the initial of the column. 1. 35460 tE B b. ~ ~ f. h. 2. Section 1. Federal Classified Income (Loss). Income class from Part A, Column: Section 2. Itemize income adjustments that increase PA reportable income (reduce the loss). a. Deferred income relating to advance payments for goods and services .. . . . . . . . . . . . . . . b. Difference in gain (loss) for each business sale of property where PA basis is lower than federal basis c. Gain from business like-kind exchanges, other than transactions qualifying as PA allowable like-kind exchanges -IRC Section 1031 ......................... . . . . . . . . . . . d. Gain (loss) on involuntary conversions - IRe section 1033 . . . . . . . . . . . . . . . . . . . . . . . . . . e. Income from cancellation of debt that PA treats differently from federal rules ......................................... f. Increases in income in the year of change resulting from spread in the year of change associated with IRC Section 481(a) adjustment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. Income from obligations of other states and organizations that is not exempt for PA purposes h. Other taxable income for PA ur oses that the enti does not re ort for federal ur oses submit statement 2. Total Lines a throu h h Section 3. Itemize income adjustments that decrease the PA reportable income (increase the loss). a. Decrease in gain for each business sale of property where PA basis is higher than federal basis .. . ,..... . ............. . a. b. Income from obligations of the U.S. Government and other organizations that is not taxable for PA purposes . . ............ . b. c. Decreases for previously reported income in prior year resulting from spread associated with IRC section 481 (a) ........... . c. d. Other PA nontaxable income that the entitv reoorted for federal ourooses (submit statement) ........................... . d. 3. Total Lines (a) throuah (d) 3. Section 4. Adiusted PA ReDortable Income. Total Lines 1 Dlus 2 minus 3. 4. 35460 Section 5. Itemize those expenses that PA law does not allow that the entity deducted on Its federal form. These adjustments increase PA reportable income (reduce the loss). a. Taxes paid on income from the worksheet in the PA PIT Guide (please submit worksheet) ......... . . .. .. . ..... . ....... . a. b. Differences in depreciation taken for PA and federal purposes ............... . ..,.. . ........ . ... . ... . .... . ....... . b. c. Key man life insurance premiums (owners as beneficiaries) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . -.. ...... . .......... . c. d. Differences in PA treatment of guaranteed payments for capital . . . . . . . ..... . . . . . . . . . . . . ...... . .................. . d. e. Differences in depreciation for bonus depreciation, PA law does not allow bonus depreciation. . . . . . . . ......... . .......... . e. f. Expense adjustments to qualify for the PA credits claimed in Part VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f. a. Other eXDenses that the entitv took on its federal return that PA does not allow (submit statement) .. .. . . ................ . a. 5. Total Lines (a) throuah (a) 5. Section 6. Itemize those expenses that PA law allows that the entity could not deduct on its federal form. These adjustments decrease PA reportable income (increase the loss) a. 50 percent of business meals and entertainment that the entity could not deduct and club dues ... . .. . ........ . ...... . .. . a. 1221 b. Sales tax on depreciable assets ... . ... . ........ . . . . . . . ........... . .... . .. . ........ . ... . . . .. . b. c. Qualified charitable contributions that the entity made .. . .. . ... . ...... . . . . . . . . . . . . ........ . . . ...... . ... . .... . c. 650 d. Differences in depreciation taken for federal and PA purposes. . .............. . ...... . . . .. . . . .... . . . .. . ... . .... . d. e. IRe section 179 expenses (the maximum for PA purposes is $25,000) . . . ... . . . .... . ... . . . ... . ... . ........ . ....... . e. f. Differences in depreciation for bonus depreciation ...... . ........ . .... . ........ . ............. . ................. . f. g. Expenses for employees, including PA S corporation shareholder-employees . . . . . . . . . . . .... . .... . .. . ..... . ......... . a. h. Life insurance premiums (PA S corporation or partnership as beneficiary) .. . .... . ........... . ....... . .............. . h. i. Expense adjustments to qualify for federal credits. . . . . . . . .................... . . . . . . . . . . . . . . . . . . . . . . . . .. . ....... . i. i. Other expenses that PA allows that the entitv did not deduct on its federal return (submit statement) ....... . .. . ... . ... . i. 6. Total Lines (a) throuah (j) 6. 1871 Section 7. PA Taxable Income (Loss) from the operation of a Business, Profession, or Farm. Total Lines 4 LOSS plus 5 minus 6. If a (loss), fill in the oval. D 7. 33589 L 0408020014 SIDE 2 0408020014 .-J --1 0406518126 L PA Schedule RK-1 (09-04) 2004 Resident Schedule of PA S Shareholder/Partner Pass-Through Income, Loss, and Credits 202427375 BOWMAN c 603 SOUTH SPRING GARDEN STREET Owners Amended N CARLISLE PA 17013 Stock Ownership % EASTERN STATES CLAIMS SERVICE LLC CARLISLE PA 17013 251884414 c Fiscal Filer N Shareholders and partners enter the amounts from lines 1 through 11 and Line 14 on their PA income tax or information returns. Read the instructions for PA.40, PA.41, or PA20S/PA.65. PA Taxable Business Income (Loss) from Operations = 2 Interest Income :. 3 Dividend Income 4 Net Gain (Loss) from the Sale, Exchange, or Disposition of Property 5 Net Income (Loss) from Rents, Royalties, Patents, and Copyrights 6 Income from Estates or Trusts 7 Gambling and Lottery Winnings 8 PA Resident Credit. PA S Shareholders only - 9 PA Employment Incentive Payments Credit .. c.. 10 PA Jobs Creation Tax Credit 11 PA Research and Development Tax CreditlPA Film Production Tax Credit Shareholders and partners need the amounts from parts IV through VII, other than line 14, to maintain their PA basis in the entity. Partners include line 14 in net classified income on their PA tax returns. 2!: 12 Distributions of Cash, Marketable Securities, and Property - not including guaranteed payments :. 13 Guaranteed Payments for Capital 14 Guaranteed Payments > 15 Distributions from PA AAA :. 16 Distributions of Cash, Marketable Securities, and Property :. .. 17 Nontaxable PA S corporation income (loss) Do not report this income or loss on your PA-40 Tax Return A. ~ 18 Member's Share of IRC section 179 allowed according to PA rules :. 19 Member's Share of Straight-Line Depreciation L 0406518126 D. WILLIAM 1 (Individual=1, S Corp=2, All Other Corp=3, EstatelTrust=4, Partnership=5, LLC=6, Exempt Org.=7) Partner's % of: Profit sharing 09900 09900 Loss sharing 09900 Capital 09900 Ownership N PA S Corp. Y Partnership 1 2 3 4 5 6 7 33253 85 8 9 10 11 12 13 14 36248 210000 15 16 17 18 19 0406518126 --1 .-J 0406518126 L PA Schedule RK-1 (09-04) 2004 Resident Schedule of PA S Shareholder/Partner Pass-Through Income, Loss, and Credits 183442392 BOWMAN MICHELLE E c 603 SOUTH SPRING GARDEN STREET Owners 1 (Individual=1, S Corp=2, All Other Corp=3, Estaterrrust=4, Partnership=5, LLC=6, Exempt Org.=7) Amended N CARLISLE PA 17013 251884414 c Partner's % of: Profit sharing 00100 00100 Loss sharing 00100 Capital 00100 Ownership N PA S corp. Y Partnership CARLISLE PA 17013 Stock Ownership % EASTERN STATES CLAIMS SERVICE LLC Fiscal Filer N Shareholders and partners enter the amounts from Lines 1 through 11 and Line 14 on their PA income tax or information returns. Read the instructions for PA-40, PA.41, or PA20SJPA.65. 1 PA Taxable Business Income (Loss) from Operations 1 336 = 2 Interest Income 2 1 to 3 Dividend Income 3 ... 4 Net Gain (Loss) from the Sale, Exchange, or Disposition of Property 4 5 Net Income (Loss) from Rents, Royalties, Patents, and Copyrights 5 6 Income from Estates or Trusts 6 7 Gambling and Lottery Winnings 7 8 PA Resident Credit - PA S Shareholders only 8 - 9 PA Employment Incentive Payments Credit 9 to 10 ... 10 PA Jobs Creation Tax Credit 11 PA Research and Development Tax CreditlPA Film Production Tax Credit 11 Shareholders and partners need the amounts from parts IV through VII, other than Line 14, to maintain their PA basis in the entity. Partners include Line 14 in net classified income on their PA tax returns. ~ 12 Distributions of Cash, Marketable Securities, and Property. not including guaranteed payments 12 to 13 Guaranteed Payments for Capital 13 ... 14 14 Guaranteed Payments > 15 Distributions from PA AAA 15 to 16 Distributions of Cash, Marketable Securities, and Property 16 ... :;: to 17 Nontaxable PA S corporation income (loss) Do not report this income or loss on your PA-40 Tax Return 17 ... :;: 18 Member's Share of IRC section 179 allowed according to PA rules 18 to 19 Member's Share of Straight-Line Depreciation 19 ... L 0406518126 0406518126 .-J i~..'.".~.'.'..'.. st L/l/l p, . l~ 1" & M~~~~~,,!: "- ~ .,- ~ ,,- :;,- ---- " :;,- " Instructions for Recipient Box 1. Shows interest paid to you during the calendar year by the payer. This does not include interest shown in box 3. If you receive a Form 1 099-INT for interest paid on a tax- exempt obligation, see the instructions for your income tax return. Box 2. Shows interest or principal forfeited because of early withdrawal of time savings. You may deduct this amount to figure your adjusted gross income on your income tax return. See the instructions for Form 1040 to see where to take the deduction. Box 3. Shows interest on U.S. Savings Bonds, Treasury bills, Treasury bonds, and Treasury notes. This mayor may not be all taxable. See Pub. 550, Investment Income and Expenses. This interest is exempt from state and local income taxes. This interest is not included in box 1. Box 4. Shows backup withholding. Generally, a payer must backup withhold at a 28% rate if you did not furnish your taxpayer identification number (TIN) or you did not furnish the correct TIN to the payer. See Form W-9, Request for Taxpayer Identification Number and Certification, for informa- tion on bac~up withholding. Include this amount on your income tax return as tax withheld 6662-2766 Box 5. Any amount shown is your share of investment expenses of a single-class REMIC. If you file Form 1040, you may deduct these expenses on the "Other expenses" line of Schedule A (Form 1040) subject to the 2% limit. This amount is included in box 1. Box 6. Shows foreign tax paid. You may be able to claim this tax as a deduction or a credit on your Form 1040. See your Form 1040 instructions. Nominees. If this form includes amounts belonging to another person(s), you are considered a nominee recipient. Complete a Form 1 099-INT for each of the other owners showing the income allocable to each. File Copy A of the form with the IRS. Furnish Copy B to each owner. List yourself as the "payer" and the other owner(s) as the "recipient." File Form(s) 1 099-INT with Form 1096, Annual Summary and Transmittal of U.S. Information Returns, with the Internal Revenue Service Center for your area. On Form 1096 list yourself as the "filer." A husband or wife is not required to file a nominee return to show amounts owned by the other. IMPORTANT - TAX DOCUMENT ENCLOSED o CORRECTED (if checked) PAYER'S name, street address, cny, state, and ZIP code and telephone no. Payer's RTN (optional) OMB No. 1545-0112 MEMBERS 1ST FEDERAL CREDIT UNION 5000 LOUISE DRIVE P.O. BOX 40 ~@O4 MECHANICSBURG PA 17055 Interest Income 800-283-2328 Form 1099-INT PAYER'S Federal identnication nuooer I RECIPIENTS identification number 1 Interest income not included in box 3 Copy B 23-1360906 251-88-4414 $ 86.42 For Recipient RECIPIENT'S name Street address (including apt. no.) City. state, and ZIP code 2 Early withdrawal penalty 3 Interest on U.S. Savings This is important fax EASTERN STATES CLAIM SVCS LLC Bonds and Treas. obligations Information and is being furnished to the PO BOX 864 $ 0.00 $ 0.00 Internal Revenue CARLISLE PA 17013 4 Federal income tax withheld 5 Investment expenses Service. If you are $ 0.00 $ 0.00 required fa file a return, a negligence penalty or 6 Foreign tax paid 7 Foreign country or U.S. other sanction may be possession imposed on you if this income is taxable and Account number (optional) the IRS determines fhat it has not been 0000204697251884414 $ 0.00 reported. Form 1099-INT (keep for your records) Department of the Treasury - Infernal Revenue Service Personal Tax info.2001 j income mileage iPER.MILE. septa I jan 1 $19,921.08 7616[ $ 5,000.00 I feb I $29,123.57 7730i i march [ $22,562.76 10205 i I i april : $26.754.98 . 9332. : $7,000.00 ! may : $21,345.78 7823, I june $21,929.92 ; 9440' I i I july i $17,867.56 9464: ! j august : $25,678.90 8649 [ 10,000.001 sept. ! $22,987.67 ! 83081 I I oct I $26,729.54 i 9629: i I I I i nov i $15,607.89 I 85141 I I i dec I $14,564.98 : 7127j i .I TOTAL 1('-.1 $265,074.63 i 1038371 22,000.001 I i I I ! I I 1 ! . I , i ! donation ! amount i ! i car I S .:! 500.,JO I , i I I I I i I i fire com. $ 100.00 I ! ! ch ruch $2,250.00 I i i i clothing $350.00 I ! i I ! I elect. i water 'oil i trash ! pest con. I i $122.65, I $90.10: $175.00! ! I i $37.431 i $175.00' i i I $90.101 I I $175.00: $123.00' i : ! I $175.00: i I $37.43 ! I $175.00: ! i ! $98.50! $150.00! $124.50' i I , $150.00: ! $37.43! I , ! $100.00 [ $737.00: I I , I $200.00: i $141.501 I $98.50 I $200.001 $123.79! I $37.43! $1,675.00' : I ! I : . j , I i taxes I i i i fed i : state [ 4-Apr; $12,211.001 ; 1,500.00; $12,500.001 i 1,500.00! 9.15.04 $12,500.001 1,500.00i .1.15.05 12,500.00i : 1,500.00 , I i i ! I i I I taxes ! enclosed-house. property, personal , .- ....- ! Interest , i - . see attached , . ! : Michele , $6,518.56 I I I I : I i I .. Business Exp. J Supplies v postageJfed-ex f 51 . ()' , book magazmes, , ' I sub-contractors cell phone local phone ;../ . I v' long dist. /d . onatlons J Membership J sponsorship ~ J Advertisment' j License / dinin Air Line Ticket Car Rental I .j Hotels . ).-" NEW EQUIPMENT / legal feesIT AX ./ ins. E &0 2004 expo $3,284.78 I.~ $1,103.49 $150.15 $395.00 Eastern States Claims Service, LLC business expo 201an~ int. I ~ -- &J) 1 Yji~/~~ . ~( <9 · I :PY\.0 .1 (Nl' ~ f?{)~V $155.00,pa. and delaware $2,442;00 ! , $0.001 I $O.OOi $1,546.33 I $O.OO! I $O.OOJinc. tax ret. i I .~/:~"') i I $2,011.00: E&O COVERAGE $2,939.32, I $1,458.00! I $1,768.42 I I $150.001 I $375.001 Little leag.lsoftball Teams I $1,054.741 I $150.00Itara I $20,987.23' total I (~ ~ ( /1 I ' ~ . -::::L!7/ - ~ ~'" /, need tk./ci JO:dC'-~I~"- I r.:: ~_1 ,-7 7 ~ /) j~' ,L., ~'f-;>U):x:...t.~t-/on5 Hl/:'S, U/'-, ----- ( ;J. j"ti'?1 ...-l.\.J. f v _' L___ /JJ/ --..- . J /1":-" ., Ii? '/ A~'_J .5, f/r.)(rH!..1.'iC~ /1{!./ :; J.' j'-l ....._, J I Personal Tax info.20d( v tolls .;) 1.301_:.0 I I U- i I I I I , I I donations .. 5C~J ::'0 i t! --+ J ~~(, I 1'- I -' / REV-1503 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF BOWMAN D. WILLIAM FILE NUMBER 21 05 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0455 ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 2,290.42 Metropolitan Life 58 shares @ 39.49 TOTAL (Also enter on line 2, Recapitulation) $ 2 290.42 ilf mnro ~n~"'Q iQ nt:).orf~rt inc:ort ~tltiiti"n~1 c::hootc: nf thQ Q~mA ~i7c.\ REV-1504 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF BOWMAN D. WILLIAM FILE NUMBER 21 05 0455 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting infonnation to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 10,116.98 Eastern States Claims Service, LLC TOTAL (Also enter on line 3, Recapitulation) $ 10116.98 REV-1505 EX + (6-98) *' SCHEDULE C-1 CLOSEL Y.HELD CORPORATE STOCK INFORMATION REPORT COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOWMAN D. WILLIAM FILE NUMBER 21 05 0455 1. Name of Corporation Eastern States Claims Service, LLC Address 603 S. SprinQ Garden Street City Carlisle State P A 2. Federal Employer I.D. Number 25-1884414 3. Type of Business appraisal service State of Incorporation P A Date of Incorporation 4/5/2001 Zip Code 17013 Total Number of Shareholders 2 Business Reporting Year December 31 Product/Service service 4. I STOCK TYPE TOTAL NUMBER OF PAR VALUE NUMBER OF SHARES VALUE OF THE I Voting/Non-Voting SHARES OUTSTANDING OWNED BY THE DECEDENT DECEDENrS STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX) Yes 0 No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....................................... 0 Yes IXI No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... 0 Yes 1XI No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 1XI No If yes, 0 Transfer 0 Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholde(s agreernentin effect at the time of the decedent's death? . . . . . . . . . . . . 1XI Yes 0 No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? .................................................0 Yes IX! No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedenfs death? ....................... IX! Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . . . . . . . . . ., 0 Yes IX! No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C--2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed. insert additional sheets of the same size) OPERATING AGREEMENT OF EASTERN STATES CLAIMS SERVICE, LLC This Operating Agreement of Eastern States Claims Service, LLC (the "Agreement") is made and entered into by and among D. WILLIAM BOWMAN, and MICHELE E. BOWMAN, individually and not as tenants by the entirety, as the members (the "Members"), and EASTERN STATES CLAIMS SERVICE, LLC, a Pennsylvania limited liability company (the "Company") . NOW THEREFORE, in consideration of the mutual covenants and agreements hereinafter set forth, the parties hereto, intending to be legally bound, hereby agree as follows: 1. Purpose. The obj ect and purpose of, and the nature of the business to be conducted and promoted by, the Company is engaging in any lawful act or activity for which limited liability companies may be formed under the pennsylvania Limited Liability Act, 15 Pa.C.S. ~ 8901, et seq., as amended from time to time (the "Act") and engaging in any and all lawful acti vi ties necessary or incidental to the foregoing. 2. Members. membership interest), interest) . The Members are and MICHELE E. D. WILLIAM BOWMAN (1% BOWMAN (99% membership 3. Term. The term of existence of the Company shall continue indefinitely. 4. Manaqement. (a) The business and affairs of the Company shall be managed by one Manager unless otherwise provided by a written resolution executed by Members owning more than 50% of the membership interests. The Manager shall be D. WILLIAM BOWMAN. Except as otherwise provided herein, only the Manager and agents of the Company authorized by the Manager shall have the authority to bind the Company. The Manager, on behalf of the Company, shall have the power to do any and all acts necessary or convenient to, or for the furtherance of, the business and affairs of the Company. (b) The Manager may appoint by written resolution officers and agents of the Company to which the Manager may delegate by written resolution whatever duties, responsibilities and authority the Manager may desire. Any officer or agent may be removed by the Manager at any time by written resolution. 5. Title to Company Property. All real and personal property shall be acquired in the name of the Company and title to any property so acquired shall vest in the Company itself rather than in the Members or Manager. Bank accounts shall require only the signature of the Manager. The Manager may designate other signatories to bank accounts as he shall deem appropriate. 6. Compensation of Manaqer. The Manager shall be reimbursed for all expenses incurred in managing the Company and may be paid compensation for Manager services rendered to the Company in an amount to be determined from time to time by the Company and the Manager. Members owning at least 50% of the membership interests shall determine for the Company any such compensation. The Manager's compensation shall be in the nature of a fee paid to the board of directors of a corporation and/or the compensation paid to officers of a corporation and shall not be considered a management fee. Members who are employed by the Company may be paid salaries (guaranteed payments for Federal income tax purposes) as determined by the Manager. 7. Distributions. Distributions shall be made to the Members (in cash or in kind) at the times and in the aggregate amounts determined by the Manager and as permitted by law. 8. Elections. The Manager may make any tax elections for the Company allowed under the Internal Revenue Code of 1986, as amended, or the tax laws of any state or other jurisdiction having taxing jurisdiction over the Company. 9. Transferability of Membership Interest. The interest of any Member in the Company is transferable either voluntarily or by operation of law. A Member may sell, assign, transfer, exchange, mortgage, pledge, grant, hypothecate, encumber or otherwise transfer (whether absolutely or as security) all or a portion of his or her interest in the Company. Upon the transfer of the interest in the Company, the transferee shall be admitted as a member at the time of the transfer and shall obtain all of the rights appurtenant to being a member of the Company. The transferee shall take the membership interest subject to the terms and conditions of this Agreement and shall not be required to execute this Agreement in order for it to be effective. 10. Admission of Additional Members. Additional members of the Company may be admitted to the Company at the direction of Members owning more than 50% of the membership interests. In the event that any additional members are added, this Agreement shall be construed to apply to all of the members, and the additional members shall not be required to ratify or approve this Agreement or execute a new operating agreement. Unless otherwise stated herein or required by the Act (or any other valid law or regulation to which the Company is subject), if additional members have been added to the Company and this Agreement has not been terminated or modified, the decisions of the members owning more than 50% of the membership interests in the Company shall constitute the decisions of the Members for purposes of the interpretation of this Agreement. 11. Liability of the Members. The Members shall not have 2 any liability for the debts, obligations or liabilities of the Company or for the acts or omissions of any other Member, Manager, director, officer, agent or employee of the Company except to the extent provided in the Act. The failure of the Members or Manager to observe any formalities or requirements relating to the exercise of the powers of the Members or Manager, or the management of the business and affairs of the Company under this Agreement or the Act, shall not, by itself, be grounds for imposing personal liability on the Members for liabilities of the Company. 12. Indemnification. The Company shall indemnify the Members, the Manager and those authorized agents of the Company identified in writing by the Manager as entitled to be indemnified under this section for all costs, losses, liabilities and damages paid or accrued by the Members, the Manager or any such agents in connection with the business of the Company, to the fullest extent provided or allowed by the laws of the Commonweal th of Pennsylvania. In addition, the Company may advance costs of defense of any proceeding to a Member, a Manager or any such agent upon receipt by the Company of an undertaking by or on behalf of such person to repay such amount if it shall ultimately be determined that such person is not entitled to be indemnified by the Company. 13. Dissolution. The Company shall dissolve, and its affairs shall be wound up, upon the first to occur of the following: (a) the written direction of the Members, or (b) the entry of a decree of judicial dissolution under Section 8972 of the Act. The death, retirement, insanity, resignation, expulsion or bankruptcy of a Member or Manager, or the occurrence of any other event that terminates the continued membership of a Member, shall not cause the Company to dissolve. Upon dissolution, the Company shall cease carrying on any and all business other than the winding up of the Company business, but the Company is not terminated and shall continue until the winding up of the affairs of the Company is completed and a certificate of dissolution has been filed pursuant to the Act. Upon the winding up of the Company, the Company's property shall be distributed (i) first to creditors, including any Members if the Members are creditors, to the extent permitted by law, in satisfaction of the Company's liabilities; and (ii) then to the Members. Such distributions shall be in cash or property or partly in both, as determined by the Members. 14. Conflicts of Interest. Nothing in this Agreement shall be construed to limit the right of the Members to enter into any transaction that may be considered to be competitive with, or a business opportunity that may be beneficial to, the Company. The Members do not violate a duty or obligation to the Company merely because the conduct of a Member furthers the interests of such Member. The Members may lend money to and transact other business with the Company, including being paid compensation as Manager. The rights and obligations of the Members upon lending money to or transacting business with the Company are the same as those of a person who is not a Member, subject to other applicable law. No 3 transaction with the because a Member has transaction. Company shall a c:iirect or be void or voidable indirect interest solely in the 15. Governinq Law. be construed under, the without reference to the jurisdiction. This Agreement shall be governed by, and laws of the Commonwealth of Pennsylvania, conflict of law rules of that or any other 16. Entire Aqreement. This Agreement represents the entire agreement between the Members and the Company. 17. Amendment. This Agreement may be amended or modified from time to time only by a written instrument executed by Members owning more than 50% of the membership interests. 18. Riqhts of Creditors and Third Parties. This Agreement is entered into by the Members solely to govern the operation of the Company. This Agreement is expressly not intended for the benefit of any creditor of the Company or any other person except the Manager. Except and only to the extent provided by applicable statute, no creditor or third party (other than a Manager) shall have any rights under this Agreement or any agreement between the Company and the Members, with respect to the subject matter hereof. IN WITNESS WHEREOF, the undersigned, intending to be legally bound hereby, have executed this Operating Agreement to be effective as of April 1, 2001. MEMBERS: ~~WMAN , \1u4fL t < A/v~~-y~ MICHELE E. BOWMAN EASrT BY~/ D. WILLIAM BOWMAN, MANAGER 4 ~C.'lX-- 1>,,, Dr" ;JC. - () I PA.100 (1) 2-98 COMMONWEALTH OF PENNSYLVANIA PA ENTERPRISE RIGISTRATION FORM RECEIVED DATE MAIL COMPLETED APPLICATION TO: '* DEPARTMENT OF REVENUE BUREAU OF BUSINESS TRUST FUND TAXES DE PT. 280101 HARRISBURG, PA 1112I.oto1 TELEPHONE (1111712-2341 DEPARTMENT USE ONLY TYPE OR PRINT LEGIBLY, USE BLACk INK DEPARTMENT OF REVENUE & DEPARTMENT OF LABOR AND INDUSTRY SECTION 1 - REASON FOR THIS REGISTRNION REFER TO THE INSTRUCTIONS (PAGE 18) AND CHECK THE APPLICABLE BOX(ES) TO INDICATE THE REASON(S) FOR THIS REGISTRA TlON. 1. rj{ NEW REGISTRATION 5. 0 ACQUISitiON OF All OR PARTOF AN EXISTING ENTERPRISE WAS THERE APRIOR OWNER? 0 YES 0 NO 2. 0 ADDING TAX(ES} & SERVlCE(S} 6. 0 APPlICATION FOR PAUC EXPERIENCE RECORD AND 3. 0 REACTIVATING TAX(ES) & SERVICE(S) RESERVE ACCOUNT BAlANCE OF PREDECESSOR 4. 0 ADDING ESTAallSHMENT(S} 7. 0 INFORMATION UPDATE 1. DATE OF FIRST OPERATIONS 4/1/01 4. ENTERPRISE LEGAl NAME Eastern states Claims 6. ENTERPRISE TRADE NAME (~dllferent than legal name) 2. DAte OF FIRST OPERATIONS IN PA 4/1/01 Service LLC 8. ENTERPRISE STREETADDRESS (do nol use PO Bo.) 603 S. S rin Garden st 9. ENTERPRISE MAlUNG ADDRESS Of different lhan street address} CITYITOWN a lisle CITYITOWN ZIP CODE + 4 17013 ZIP COOE + 4 10. LOCATION OF ENTERPRISI: RECORDS (street address) 603 S. S rin Garden st. 11. ESTABLISHMENT NAME (doing business a~) STATE ZIP COOE + 4 SECTION 3 - TAXES AND SERVICES AlL REGISTRANTS MUSTCHECK THE APPlICABLE BOX(ES) TO INDICATE THE TAX(ES) AND SERVICE(S) REQUESTED FOR THIS REGISTRATION AND COMPlETE THE CORRESPONDING SECTIONS INDICATED ON PAGES 2 AND 3. IF REACTIVATING ANY PREVIOUS ACCOUNT(S), lISTTHE ACCOUNT NUMBER(S) IN THE SPACE PROVIDED. PREVIOUS PREVIOUS ACCOUNT NM. ACCOUNT NBR. 0 CIGARffiE DEALER'S LICENSE CJ PUBLIC TRANSPORTATION ~ ASSISTANCE TAX UCENSE CORPORATION TAXES CJ SALES TAX EXEMPT STATUS 0 EMPLOYER WITHHOLDING TAX CJ SALES, USE. HOTEL OCCUPANCY 0 FUELS TAX PERMIT TAX LICENSE CJ SMAlL GAMES OF CHANCE lICJCERT. 0 LIQUID FUELS TAX PERMIT CJ TRANSIENT VENDOR CERTIFICATE 0 LOCAl SAlES, USE, HOTEL OCCUPANCY TAX 0 UNEMPLOYMENTCOMPENSATION 0 MOTOR CARRIERS ROAD TAX/lFTA 0 USE TAX 0 PROMOTER LICENSE 0 VEHICLE RENTAL TAX . PARTNER OR CORPORATE OFFICER) DAYTIME TELEPHONE NUMBER (717)243-7437 4 PA.100 2-98 ENTERPRISE NAME Eastern states . CHECK THE APPROPRIATE BOXES. IN ADDmON TO SECTIONS 1 THROUGH 10, COMPLETE THE SEC110N(S) INDICA TED. 1. 0 SOLE PROPRIETORSHlptINOIVIDUAl) II CORPORATION (Sfc. 11) 0 ASSOCIATION' 0 BUSINESS TRUST o PARTNERSHIP: 0 GENERAl CCf,fPANY: It LIMITED LIABILITY PAD ESTATE o lIMITEO STATE WHERE CHARTERED o liMITED UABILIlY 0 RESTRICTED PROFESSIONAL 0 OTHER, EXPLAIN o JOINT VENTURE STATE WHERE CHARTERED o GOVERNMENT (Sfc. 13) o TRUST 2. ~ PROFIT 3. 0 YES o NON-PROFIT tJ NO IS THE ENTERPRISE ORGANIZE!) FOR PROFITOR NON.PROFIT7 IS THE ENTERPRISE EXEMPTfROM TAXATION UNDER INTERNAlREVeNUE CODe SECTION S01(C){3)? IF YES, PROVIDE A COPY OF THE ENTERPRISE'S EXEMPTION AI1THORIZATION LETTER FROM THE INTERNAlREVENUE SERVICE. SECTION 6 - OWNERS, FARTNERS, SHAREHOLDERS, OFFICERS, RESPONSIBLE ~RTY INFORMATION PROVIDE THE FOUOWlNG FOR ALL INDIVIDUAL ANDIOR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS AND RESPONSIBLE PAR'TlES. IF STOCK IS PUBlICI.. Y TRADED, PROVIDE THE FOUOWING FOR ANY SHAREHOlDER WITH ~ EOUITYPOSI'T10N OF 5% OR MORE. AOOlnONAL SPACE IS AVAILABLE IN SECTION 8A. 1. NAM E D. William Bowman 5. :rg OWNER 0 OFFICER 6. TITLE o PARTNER ~ SHAREHOLDER o RESPONSIBLE PARTY 10, HOME ADDRESS (street) 603 S. Spring 11. PERSON RESPON TO IT: 3. DATE OF BIRTH. 4. FEDERAL EIN : '10 5/54 8. PERCENTAGE OF 9. EFFECTIVE DATE OF OWNERSHIP OWNERSHIP 9 9 % ,4 - 1 - 0 1 COUNTY STATE ZIP CODE + 4 Carlisle Cumberla d PA 17013 o EMPlOYER WITHHOLDING 0 MOTOR FUELTAXES SIGNATURE . DATE OF BIRTH REQUIRED ONLY IF APPLYING FOR ACIGARETTE WHOLESAlE DEALER'S liCENSE, A SMAlL GAMES OF CHANCE DISTRIBUTOR UCENSE OR A SMAlLGAMES OF CHANCE MANUFACTURER CERTIFICATE. SECTION 7 - ESTABLISHMENT BUSINESS ACTIVITY INFORMJlnON REFER TO THE INSTRucnONS TO COMPLETE THIS secnOH. COMPLETE SECTlON 17 FOR MULTIPLE ESTABLISHMENTS. 1. ENTER THE PERCENTAGE THAT EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAl RECEIPTS OR REVENUES ATTHIS EST ABUSHMENT. UST ALL PRODUCTS OR SERVICES ASSOCIATEO WITH EACH BUSINESS ACTIVITY. ENTER THE PERCENTAGE THAT THE PRODUCTS OR SERVICES REPRESENT OF THE TOTAl RECEIPTS OR REVENUES ATTHIS ESTABLISHMENT. PA BUSINESS ACTMTY % PRODUCTS OR SERVICES % ADDITIONAL % PRODUCTS OR SERVICES Construction Manufacturing Retail Trade Wholesale Trade Finance Insurance Real Estate Transportation Warehousing Communications Agriculture, Forestry, Fishing Mining, Quarrying. Oil/Gas Extraction Utility or Sanitary Service ServIces (Personal or Business) 100 Consultina Domestic TOTAl 100% 2. ENTE~ 1)i'OERCENT~GE THATTHIS ESTABLI$HMENl'S RECEIPTS OR REVENUES REPRESENTOF THE TOTAl PARECEIPTS OR REVENUES OF THE ENTERPRISE. 3. ESTABliSHMENTS ENGAGED IN CONSTRUCTION MUST ENTER THE PERCENTAGE OF CONSTRUCTION ACTIVITYTHATIS NEW AND/OR RENOVATIVE. N / A % NEW % RENOVATIVE 4, 0 YES XI NO IS THIS ESTA91.ISHMENT SOLElY ENGAGED IN THE PERFORMANCE OF SUPPORTACTIVITlES FOR OTHER ESTABLISHMENTS OF THE SAME ENTERPRISE? IF YE&, USTTHE NAMEfS) OF THE SUPPORTED ~H.~~ISHMENT(SJ AND CHeCK THe ^PPROPR'^TE sox TO ceseR/Of; THE SUPPORT ACTIVITY. o ADMINISTRATION o RESEARCH/DEVROPMENT o STORAG8WAREHOUSE o OTHER (SPECIFY) 5