HomeMy WebLinkAbout04-11-06 (2)
z
o
J=
<(
~
::l
CL.
~
o
(,)
><
~
217
REV-1500 EX (6-00)
COMMONWEAL TH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
-
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
21-05-0658
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
COUNTY CODE
NUMBER
YEAR
SOCIAL SECURITY NUMBER
~
z
w
c
w
(,)
w
c
FUNK, JANE M.
DATE OF DEATH (MM-DD-YEAR) /DATE OF BIRTH (MM-DD-YEAR)
7/13/2005 I 11/28/1918
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
207-07-6191
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 1. Original Return
04. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAl TAX INFORMATION SHOULD BE DIRECTED TO:
NAME
o 2. Supplemental Return
04a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
010. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
~ 8. Total Number of Safe Deposit Boxes
011. Election to tax under Sec. 9113(A) (Attach Sch 0)
o 3. Remainder Return (date of death prior to 12-13-82)
05. Federal Estate Tax Return Required
COMPLETE MAILING ADDRESS
17 South Second Street, Sixth Floor
Harrisburg, PA 17101
(1 )
(2)
OFFICIAL USE ONLY
~
~gll)
og:~
Woo
J:rx..J
oll.m
ll.
~
~
Z
W
C
Z
o
CL.
en
w
a:::
a:::
o
(,)
Brid~et M. Whitl~y, Esquire
FIRM NAME (If Applicable)
SKARLA ros & ZONARICH LLP
TELEPHONE NUMBER
o
o
~:~.:-..,
717 -233-1000
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) NONE
(4) NONE
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
(5)
35,433
6. Jointly Owned Property (Schedule F) (6) NONE
Dseparate Billing Requested
7. Inter-Vivos Transfer & Miscellaneous Non-Probate Property
(Schedule G or L) (7)
C)
(...fi
21,477
(8)
4,276
7,667
(11 )
(12)
(13)
(14)
z
o
t=
<(
...J
::l
~
ii:
<(
(,)
w
a:::
8. TOTAL GROSS ASSETS (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
56,910
11. TOTAL DEDUCTIONS (total Lines 9 & 10)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) :10)
11,943
44,967
1,000
43,967
12. NET VALUE OF ESTATE (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not
been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate ,or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
x .0 (15) 0
-
41,967 X .O~ (16) 1,731
x .12 (17) 0
2,000 x .15 (18) 300
(19) 2,098
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Pt.
STATE ZIP
PA 17055
(1 ) 2,098
2,250
Total Credits (A + B + C) (2) 2,250
217
Decedent's Com lete Address:
STREET ADDRESS
2608 Rose arden Boulevard
FUNK, JANE M.
-
207-07-6191
o
152
o
o
1.
Did decedent make a transfer and:
a. retain the use or income of the property transferred;
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
2.
b. retain the right to designate who shall use the property transferred or its income;
c. retain a reversionary interest; or . . . . . . . . . . . . .
d. receive the promise for life of either payments, benefits or care?
If death occurred after December 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . .
Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?
Yes
o
o
o
o
o
o
CITY
Mechanicsbur
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
No
o
o
o
o
o
o
o
TotallnterestlPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
A Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + SA This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
3.
4.
Did decedent own an Individual Retirement Account, annuity or other non-probate property which
contains a beneficiary designation? . . . . . . . . . . .
7E)
i 7 Db
PA 17055
ADDRESS
uire 17 South Second Street Sixth Floor Harrisbur PA 17101
F or 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. Section 9116 (a)(1.1 )(i)].
F or dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosu
the surviving spouse is the only beneficiary.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%,
~ ~~ '<<\
1 '" ~ \) ~
--. -..
~ ~~ ~~~\
~\\\~ \~.~ ~ ~<(-ii
, an adoptive parent,
~ction 9116 (a)(1.1 )(ii)].
II applicable even if
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 c
or a stepparent of the child is 0%[72 P.S. Section 9116(a)(1.2)].
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. Se
individual who has at least one parent in common with the decedent, whether by blood or adoption.
Jnder Section 9102, as an
;(1.2) [72 P.S. Section 9116(a)(1)].
~'<. ~\\\\~~
217
REV-1502 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
FUNK JANE M. 21-05-0658
All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell. both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
NOTE: 30 North Second Street, Steelton, PA - Sold 6/1/2005; under 20 Pa. C.S. Sectior
2514 (16.2), the net sale price is payable to the devisee, Carol J. Beane
VALUE AT DATE
OF DEATH
o
TOTAL _(Also enter on line 1, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$
o
-
-
217
REV-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY I
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FUNK JANE M.
FILE NUMBER
21-05-0658
ITEM
NUMBER
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.
DESCRIPTION
M& T Bank (per verification attached hereto as Schedule E)
VALUE AT DATE
OF DEATH
24,020
2
PA Department of Revenue - Final Pension Payments
982
3
Health Management Associates, Inc. - Refund of overpayment
173
4
AFL Ins. - Refund of unused premium
345
5
Penn Treaty Network America Insurance Co. - Refund of unearned premium
76
6
Guideposts - Subscription refund
95
7
The Church of God Home - Refund
8,835
8
Deposit posted to Decedent's checking account on 7/19/2005
907
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
35,433
-
. 217
REV-1510 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
FUNK, JANE M.
FILE NUMBER
21-05-0658
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. . Allianz Life Insurance Company of North America (per verification 21 ,4 77 100.00% 21,477
attached hereto as Schedule G); Beneficiary: Carol J. Beane,
Decedent's daughter
TOTAL (Also enter on line 7 Recapitulation) $ 21 477
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 SH EET is yes.
(If more space is needed, insert additional sheets of the same size)
217
REV-1511 EX + (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FUNK, JANE M.
I
FILE NUMBER
21-05-0658
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. James F. Stone Funeral Home, Inc. 286
2. Carol J. Beane - funeral luncheon expense 37
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees 3,500
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 103
5. Accountant's Fees
6. Tax Return Preparer's Fees 350
7.
TOTAL (Also enter on line 9 Recaoitulation) $ 4.276
-
(If more space is needed, insert additional sheets of the same size)
. REV-1512 EX+ (12-03) 217
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FUNK JANE M.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
FILE NUMBER
21-05-0658
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
DESCRIPTION
Carlisle Regional Medical Center - Balance due
Continuing Care RX - Balance due
Andorra Radiology Associcates, P.C. - Balance due
Philhaven - Balance due
West Shore EMS - Carlisle - Balance due
State Employes' Retirement System - Reimburse 8/14/05 - 8/30105
Church of God Home - check cleared after 000
Penn Treaty Network Premium - check cleared after 000
Phi/haven - check cleared after 000
Carlisle Regional Medical Center - check cleared after 000
Continuing Care RX - check cleared after 000
VALUE AT DATE
OF DEATH
182
21
9
37
72
770
6,053
90
45
308
80
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
7,667
I
. 217
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FUNK JANE M
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Connie Vance Sister-in-law 1,000.00 Specific Bequest
Miriam Green Sister-in-law 1,000 Specific Bequest
Alfretta Vance - Deceased
Freeda Murphy - Deceased
Bryan Beane Grandson Estate Residue
Carol J. Beane Daughter 21,477 & 14,850
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
St. John's Lutheran Church 1,000
TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0
21-05-0658
(If more space is needed, insert additional sheets of the same size)
-
II
ESTATE OF JANE M. FUNK
FILE NO. 21 - 05 - 0658
INHERITANCE TAX RETURN - SCHEDULE E
-
m M&fBank
499 Mitchell Street, Millsboro, DE 19966
August 3,2005
Skarlatos & Zonarich LLP
Attorneys At Law
Skarlatos & Zonarich Building
17 South Second Street, 6th Floor
Harrisburg, PA 17101-2039
RE: Estate of: Jane M. Funk
Date of Death: July 13, 2005
Social Security Number: 207-07-6191
Dear Mr. Chelap:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type...........................Checking Account
Account Number. . .. . .. . .. . .. . .. . .. . .. 34639446
Ownership (Names oj).............. Jane M. Funk
Opening Date...........................08/28/64 (account closed 07/26/05)
Balance on Date of Death........ .$24,020.14
Accrued Interest
$
0.00
Total. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ... .$24,020. 14
M""
The above named decedent did~have a safe deposit box.
For any additional information on these accounts please contact our Steelton
branch at 717-255-2260.
Sincerely, .
O:VvLunv () OA/lPr<l
Charlene Warrington, Records Management
1-888-502-4349
ESTATE OF JANE M. FUNK
FILE NO. 21- 05 - 0658
INHERITANCE TAX RETURN - SCHEDULE G
-
Allianz Life Insurance Company of North ~rr.,,:r:(~
PO Box 59060
Minneapolis, MN 55459-0060
800/950-1962
Allianz <ill)
August 10,2005
ESTATE OF JANE M FUNK
C/O SKARLATOS & ZONARICH
ATTN: GREGORY S CHELAP
17 WOUTH SECOND ST. 2ND FLOOR
HARRISBURG PA 17101-2039
,
Re:JaneM Funk,deceased
Annuity Policy Number: 5549621
Dear Executor:
This letter is in response to your request for the date of death value on July 13,
2005 for the above policy number. Jane M Funk was both the policy owner and
annuitant.
The policy was annuitized effective July 15, 1998 under the Benefit Deposited
with Interest (Interest Only) Option. Checks were sent to Jane M Funk on a
monthly basis representing interest earned on the annuitization value on deposit
is $27,108.15. As of July 15, 2005, we had issued seventy-two of the one
hundred twenty payments.
The cash surrender value that was available as of the date of death was
$21,477.47. The Post Tefra Cost Basis on this contract is $20,000.00.
Should you have any questions, please feel free to contact our office. Thank
you.
Sincerely,
~
Michele Hechanova
Claims Examiner
C: Anthony Garisto #17420
If you are an Illinois Resident: Part 919 of the Rules of the Illinois Department of Insurance
governing claims practices requires that our company advise you that you may express any
concerns with the Illinois Department of Insurance. It maintains a consumer division at 100 W
Randolph Street, Suite 9-301, Chicago, Illinois 60606 and at 320 West Washington Street,
Springfield, Illinois 62767.
ESTATE OF JANE M. FUNK
FILE NO. 21- 05 - 0658
INHERIT ANCE TAX RETURN
LAST WILL AND TESTAMENT
LAST WILL AND TESTAMENT
OF
JANE M. FUNK
I, JANE M. FUNK, of Steelton, Dauphin County, Pennsylvania,
declare this to be my Last Will and revoke any Will previously made
by me.
ITEM I: I direct that all my just debts and funeral
expenses, including the cost of a suitable gravemarker and
perpetual care for my burial plot, shall be paid from the assets of
my estate as soon as practicable after my decease.
ITEM II: I give my real estate at 30 North Second
Street, Steelton, Dauphin County, Pennsylvania, and the contents
thereof to my daughter, CAROL J. BEANE.
ITEM III: I bequeath the sum of $1,000.00 to St. John's
Lutheran Church of Steelton, Pennsylvania.
ITEM IV: I bequeath the sum of $1,000.00 to my sister-in-
law, ALFRETTA VANCE.
ITEM V: I bequeath the sum of $1,000.00 to my sister-in-
law, FREEDA MURPHY.
ITEM VI: I bequeath the sum of $1,000.00 to CONNIE VANCE.
Page One (1) of Seven (7) Pages
ITEM VII: I bequeath the sum of $1,000.00 to MIRIAM GREEN.
ITEM VIII: I give, devise and bequeath all the rest,
residue and remainder of my estate, real, personal and mixed,
wheresoever situated, to my grandson, BRYAN BEANE.
ITEM IX: No interest in income or principal shall be
assignable by or available to anyone having a claim against a
beneficiary before actual payment to the beneficiary.
ITEM X: All federal, state, and other death taxes
payable on the property forming my gross estate for tax purposes,
whether or not it passed under this Will, shall be paid out of the
principal of my residuary estate just as if they were my debts, and
none of those taxes shall be charged against any beneficiary.
ITEM XI: I authorize my Executor:
(a) to retain and to invests in all forms of
real and personal property, regardless of ( i) any limi tations
imposed by law on investments by executors or trustees, (ii) any
principle or law concerning delegation of investment responsibili ty
by executors or trustees, or (iii) any principle of law concerning
investment diversification;
(b) to compromise claims and to abandon any
property which, in my Executor's opinion, is of little or no value;
to borrow from, and to sell property to others, and to pledge
Page Two (2) of Seven (7) Pages
property as security for repayment of any funds borrowed;
(c) to sell at public or private sale, to
exchange or to lease for any period of time any real or personal
property, and to give options for sales or leases;
(d) to join in any merger, reorganization,
voting-trust plan or other concerted action of security holders,
and to delegate discretionary duties with respect thereto;
(e) to use administrative or other expenses of
my estate as income tax or estate tax deductions and to value my
estate for tax purposes by any optional method permitted by the law
in force when I die, without requiring adjustments between income
and principal for any resulting effect on income or estate taxes;
and
(f) to distribute in kind and to allocate
specific assets among the beneficiaries in such proportions as my
Executor may think best, so long as the total market value of any
beneficiary's share is not effected by such allocation.
These authorities shall extend to all real and
personal property at any time held by my Executor and shall
continue in full force until the actual distribution of all such
property.
Page Three (3) of Seven (7) Pages
All powers, authorities, and discretion granted
by this Will shall be in addition to those granted by law and shall
be exercisable without leave of court.
ITEM XII:
I appoint my daughter, CAROL J. BEANE, and my
attorney, John R. Zonarich, Esquire, co-Executors under this Will.
I direct that any fiduciary acting hereunder shall not be required
to enter bond or other security in any Court or jurisdiction in
which said fiduciary may be called upon to act.
ITEM XIII: I appoint my daughter, CAROL J. BEANE,
Guardian of the estate over any property that may pass to any minor
children with respect to which property I am authorized to appoint
a guardian and have not otherwise specifically done so.
Such guardian shall have the same management
powers as those granted my Executor, may payor apply principal as
well as income for the minor's welfare, comfort, support or
education, without court approval, and if she, in her sole
discretion, determines that it is impractical to administer any
fund, she may deposit such fund in one or more savings accounts in
the minor's name, payable to him or her at majority. The guardian
shall have no further responsibility for any funds so paid, applied
or deposited.
Page Four (4) of Seven (7) Pages
, ...
IN WITNESS WHEREOF, I have hereunto set my hand and seal
and caused this my Last Will and Testament, consisting of seven (7)
typewritten pages, including this attestation clause and the
following Acknowledgment and Affidavit, to be executed, declared
,./ -fh 'D L~
and published this /;::; day of r-'ece---Ve~ , 1993, at
~e.e /101/ , Pennsylvania.
J~. ""^ ' ~ f1-
,. /-1'
JANWM. FUNK
Page Five (5) of Seven (7) Pages
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA)
SS:
COUNTY OF
I, JANE M. FUNK the Testatrix, whose name lS signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my Last Will; that I signed it willingly and that
I signed it as my free and voluntary act for the purposes therein
expressed.
Ii
r\ \\1\, ~f~
~-' CI,.../\.A-.t_
JANE M. lFUNK
Sworn or affirmed to and acknowledged before me by JANE M.
FUNK, the Testatrix this
1.3 -10 day of
.
Df/2c'e~~ bev
1993.
Notciry Publi
(SEAL)
My Commission
~
Page Six (6) of Seven (7) Pages
NOTARIAL SEAL
DANiEL K. BAYER, Notary Public
I. Steelton Borough, Dauphin County
~y Commission Expires May 18,1994
j.
.
\
;
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA)
SS:
COUNTY OF
)
~b~ J. ki\~-t;-t
, and
We,
, the witnesses, whose names are signed to
the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw
JANE M. FUNK sign and execute the instrument as his free and
voluntary act for the purposes therein expressed; that each of us
in the hearing and sight of the Testatrix signed the Will as
witnesses; and that to the best of our knowledge, the Testatrix was
at the time twenty-one (21) or more years of age, of sound mind and
under~ c~nst:..~,; .? or undue
C~L- C::. ~ ~:C-
(/~ N~
Q j.---
influence.
Residing at ~tcr a;;~,.J4.. p~
/j "r:1? ~
TI~'Z~a.-. V~'J
Residing at if )ffJnJL; OD-h!JA.
Yn~j ~4.
Residing at {:'~8' tAJjSl- 51\\ ~fT
,h./1.flt;( /)ih.l/l( A4
and acknowledged before me by
, and
, the witnesses, this _______ day of
, 1993.
_ I Swofn ~r affirmed to
"'V1) L" n \/~ -f .eft ~-z:-e---
Notary
(SEAL)
My Commission
Page Seven (7) of Seven (7) Pages
NOTARIAL SEAl
DANIEL K. BAYER. Notary Public
Steelton Borough, Dauphin County
My Commission Expires May 18,1994