HomeMy WebLinkAbout09-11-06
(EV.l')~O EX (6-DO)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERIT ANCEl AX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
W
I-
lIl::$en
olt:lIl:
wQ.o
:coo
olt:..J
Q.lXI
Q.
~
FILE NUMBER
11_ - JL ~
COUNTY CODE YEAR
NUMBER
l D q r
~
Z
W
C
W
(.)
W
C
DECEDC~N~E ~~FIRST, AND MIDJ '~h F
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
\~-\3-:lDCS 03-:>"'3 \9~1
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
114-;;[ -~\~4
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ 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 (date of death after 12-12-82)
o 7. Decedent Maintained a living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
I-
Z
W
o
z
o
Q.
en
w
It:
It:
o
o
COMPLETE MAILING ADDRESS
I (pal{. New\J-j \\e.
Curl 15)e fA
\
\ 0<1 , O~~ I
None..
f'JclJe
f\J 0 fl €..
"d0530
N 0 t'\ -e.
N Ofle..
FIRM NAME (If Applicable)
R6~d
)lO\S
TELEPHONE NUMBER
l'1-3\<f-3G,<a9
r,.'
z
o
5
~
~
0:
<C
(.)
w
a::
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 Deposits & 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)
o .O"FFICfAL us~o~tr
fS?~ 'Q C~ (. :--.)
r-. : \
:p,"
l~
co
o
1'.)
,. ')
(8)
3 91d~ O~
1~c}3lf.S~
,aC({.e'3. ~\
(11 )
(12)
(13)
\ \ 390 to. <00
I 5"1 Orc, . 8 I
N d II e...
\Slota.Z\
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
a---;
~
Q.
:E
o
(.)
~
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x .0 _ (15)
x .0 <.l5 (16)
lOin. 8 \
--.J :=; 7 0 (0. ~ \
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
x .12 (17)
18. Amount of Line 14 taxable at collateral rate
x .15 (18)
19. Tax Due
(19)
lota\ 81
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
~
Decedent's Complete Address:
STREET ADDRESS
J' fA}
CITY
I 70)3
If
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
Total Credits ( A + B + C )
(2)
3.
Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( 0 + E )
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
(3)
(4)
(5)
(5A)
4.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
70fr;~jl
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
70ft; 1 ?J
)i
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;.......................................................................................... D ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ D gj
c. retain a reversionary interest; or.......................................................................................................................... D ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D ~
3. Did decedent own an "in trust fo~' or payable upon death bank account or security at his or her death? .............. D ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D []-'
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare 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 pre parer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE F PERSON RES NSIBLE FOR FILING RETURN
ADDRESS
/(;,O'l llIewJ/Jk /8arl
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
Cur/vie J fll)
/
J 7(fJ3
DATE
ADDRESS
;&{
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. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even
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 paren'
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. 99116(1.2) [72 P.S. 99116(a)(1)].
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. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as al
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6-98)
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OFJ h C d
d nF Ohra
FILE NUMBER
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.
DESCRIPTION
VALUE AT DATE
OF DEATH
:J {O fWd
J-fJ/O .~ ~
-----
TOTAL (Also enter on lir c;7J ().. f 0
(If more space is needed, insert addlfional sheels of the same puv' ~l '/1 ~
ITEM
NUMBER
1.
~ :l FC\-pr V\eW st C"r \, J) e \ fA \ 70\S
\-'1ou.).e en, J J d4,- h eJ >> " r<"d e <. w -,1""-
murk t v~ l\A e. of ~l.r-Ol 00 () - how e" {' r
O-HE'-d.e'\1- 0 v.>e-J I 09, ()K-a. lo ~ ~
. -h., ~c. (:)f"\ f rUfer~ )
0;:~~J · w'iTh ..fbred ()j\A reo
G. "" f I""') p1e", he c> h. r
Lo-\ ~ ~S'7 (l,lO:I:)
d.
-r- r-eCAJ loA r e. l- ~ \c.. e.
o \..lbo, .) , r A
(09
$'1 oOf. o~ ~ .
~'o -
J~,G,Cf
REV-I503 Ell. (1-97)
'*
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AEV-1504 EX. 11-97.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
FILE NUMBER
-=
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 information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV~1506 EX+ i9-_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Partnership
Address
Date Business Commenced
Business Reporting Year
State
Zip Code
City
2. Federal Employer 1.0. Number
3. Type of Business
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
c.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
Date
DYes 0 No
11. Was the decedenfs partnership interest sold? ....................................... 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedenfs death? ................... 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 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 partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership 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. Any other information relating to the valuation of the decedent's partnership interest.
REV-1507 EX+ (1-97)
, '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-l508EX: (1.97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
Cal}~d
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF J h'
- 0 n
F
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
3.
hOUJe h~ld
J\1 oJ;
b '^- \ C1 f) Ce.
- S\.A bG\ r'-\ ~r("eJ~"'"
~Cnr
.- ~ ("",,\.1 h '),'\y
VALUE AT DATE
OF DEATH
(I lO 011 09-
I <5'0
-
',"^OOI
~ ~8 I 'i.J-
DESCRIPTION
;;)~
a LA.-tb ~\:) b -~ \-<.
J u \,,, clee ,c I QW'1
y.
B4f'\K
(Y1~T
70()~. ~S
TOTAL (Also enter on line 5, Recapitulation) $ ~ 0 5"30" I ~
(If more space is needed, insert additional sheets of the same size)
"''''''''''''-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
FILE NUMBER
If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
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 identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE V ALU:
ATTACH A COPY OF THE DEED FOR REAl ESTATE_
NUMBER VALUE OF ASSET INTEREST !IF APPliCABLE)
1.
TOTAL (Also enter on line 7, Recapitulation) $
(If more space IS needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
I '*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Johl7
FILE NUMBER
ITEM
NUMBER
A.
F
CoJ1 ~J
Debts of decedent must be reported on Schedule I.
1.
DESCRIPTION
FUNERAL EXPENSES: R ~ L1-_
01\ G( r) [ U r'\~ r~ I r 1 QY'Y)e.-
C 'e l' '1 ,f -c e I f1 ov"e r.) I cl.t e.-~ uAi; I ~ V\~ Q,p ;...{ rnchT
tAl CA l - V'I'\ c. -r + d-t.- f' +- s 1-0 (' e...
~-aJ.. \ r e.. +ceo> ~ ~e", b, bu rJ 6.-\ C I ~ ~
;J.
B. ADMINISTRATIVE COSTS:
1.
2.
Personal Representative's Commissions
Name of Personal RepresentatiVe(S)_'<a r-L~ ~..{? ,-+S
Social Security Number(s)/EIN Number of Personal Representative(sLl '1 Co - <t-l? - 4- \ ~ .\
Street Address --1 ~ 0 y. tJ e w J\ \ \ e rC 0 cu1
City C (A .,.....-} \J \ ~ State ----eti Zip -.J 70 \ S
~ OC(Q
Attorney Fees U D ...-T ...h,.... ( -
-'- <, r '" f'\J'TL r-
Year(s) Commission Paid:
~
~ft Ih s t lte\ta.~ L~
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
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Ac1 Ve v-- -\"1;e fY'l e &'\ ~
Se n\-u,e... \ N e,Wj f'^ fer
f ~~ t rut-v!) Qo.JJ ~c.LJ
u. S __ fOJi-vt \ Sel~lt~
CA f'1~ \ \ .p r'ilI r~ \ fY1 c:-J
0.. "- J.. ..)~ ;"- f I
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
..).<:)
~'SS\,.
~y S ." bO
~ 3d' I . :)'1
s<+s, I~
:) s 4> I 00
S-3l)r
C[ ~ y {)()
Lf 0, 61
l:2"O~
REV-1512 EX' (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COh r~c/
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERIT ANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JohYl F
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
1.
AMOUNT
J.
3.
L\.
S.
rI 0 rei Lt', 1t :c'" ~ - rn u,..- -Tj '" J e....
'{' f't- L - V\ +, \':. >t, Y
f edeJ~ \
:r r1 C. \.i~e
'14~
\ b'1.p8' d \ to
'-t
4-03....,
9~' 0
s' c
~~
"3 i-}I
Qp f'*. o-f \/ A l:L~r.s - (Y'lC'cL c \ l'"l e. V'^, ",,"r
\ ( ec...J ~ v e.
L<<- t.e.- - OveJ
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$ 16 9,9 3 y., S(
I
REV-1513 EX+ (9-00)
, .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF J 0 h 1'1
NUMBER
I
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
r3r~ ~ )C c... R..'1 d ~"1f'\
{'O 13{)Sl. S-~3 Y:lY N \-Sd- ~+
rl b,.d<.sv.I\.O) w A q KS~ 3
f r\ LV. ~) ~ ~c;." J1- J~
P..Ol 136~ S-cJ3 4~<f N 1
r1 0 l'l1e) ",,, c./ l..j 11 '11 J i..sJ 3
6rl~~ ~~J~~A \
1'. Dc 86" 5~ 3 y~ 'I N ))+- jl'.
r1 () Yl1ej l:1 '" 0 I W '11 9 t J <.0 .3
r3 e " I: r- \ 7 O. ~ '1 d fYL~ '"
8"S-1 W ;1l,vV Grc)~ e<f~c1
~"-)I)}e\ fA }l6\3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
F Urrt r4-r!
1.
J.
.3.
y.
II
FILE NUMBER
RELATIONSHIP TO DECEDENT
Do Not list Trustee(s)
AMOUNT OR SHARE
OF ESTATE
~Jr'6-t+- -jrTA" cJf4() ~~,.
a 000 .
00
, t' e.- -<1 J"'-Go "J. '" j ~ j...
~o(y{). Ot)
J flA,u;L)~
s- S-6 0 > C D
olCc.~v ht--c r
r- S-(i) 0 ~
00
1.
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ~ 5' 00 0 ~ 0 {')
(If more space is needed, insert additional sheets of the same size)
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
RE~-1514 EX+ 112-03.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on REV-1500 Cover Sheet
ESTATE OF
FILE NUMBER
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table .................................................
Interest table rate - 031/2% 06% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Check appropriate block below and enter corresponding (number) .............. . . . . . . . . . . . .
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( )
3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................
5. Annuity Factor (see instructions)
Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions) ..................................................
7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 ..................................................$
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
REV-lb.44 EX+ (3-84)
_~.; 'J ~~~ ..
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE ilL"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL
FILE NUMBER
I. Estate of
II.
(last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions
of Sedion 714 of the Inheritance and Estate Tax Ad of 1961 or to report the invasion of trust principal.
Remainder Prepayment:
A. Election to prepay filed with the Register of Wills on
(attach copy of election)
B. Name(s) of life T enant(s) Date of Birth
or Annuitant(s)
(Date)
Age on date
of election
Term of years income
or annuity is payable
C. Assets: Complete Schedule l- 1
1. Real Estate
2. Stocks and Bonds
3_ Closely Held Stock/Partnership
4. Mortgages and Notes
5. Cash/Misc. Personal Property
6. Total from Schedule l- 1
D. Credits: Complete Schedule l-2
1. Unpaid liabilities
2. Unpaid Bequests
3. Value of Unincludable Assets
4. Total from Schedule l-2
$
$
$
$
$
$
$
$
$
III.
E. Total value of trust assets (line C-6 minus line 0-4)
-~.
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (line E x line F)
(Also enter on line 7, Recapitulation)
Invasion of Corpus:
A. Invasion of corpus
$
$
$
(Month, Day, Year)
B. Name(s) of life T enant(s)
or Annuitant(s)
Date of Birth
Age on date
corpus consumed
Term of years income
or annuity is payable
C. Corpus consumed
D. Remainder factor (see Table I or Table II in Instruction Booklet)
E. Taxable value of corpus consumed (line C x line D)
(Also enter on line 7, Recapitulation)
$
$
$
!I.EV-I645 EX... (7-85) INHERITANCE TAX
*'
SCHEDULE L-l
COMMONWEALTH Of PENNSYlVANIA REMAINDER PREP A YMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FilE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Value
A. Real Estate (please describe)
Total value of real estate S
(include on Section II, line C.1 on Schedule l)
B. Stocks and Bonds (please list)
Total value of stocks and bonds S
(include on Section II, line C-2 on Schedule l)
C. Closely Held Stock/Partnership (attach Schedule C.1 and/or C-2)
(please list)
Total value of Closely Held/Partnership S
(include on Section II, line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes S
(include on Section II, Line C..4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property S
(include on Section II, line C.5 on Schedule L)
III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) S
(If more space is needed, attach additional 8Y2 x 11 sheets.)
REV -16.46 EX + (3-8.4}
.
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION
-CREDITS-
FILE NUMBER
I. Estate of
(last Name)
(First Name)
II. Item No.
Description
A. Unpaid liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities S
(include on Section II, line 0- 1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include on Section II, Line 0-2 on Schedule L)
C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets S
(include on Section II, Line 0-3 on Schedule L)
III.
TOTAL (Also enter on Section II, Line 0-.4 on Schedule L)
(If more space is needed, attach additional 8Y2 x 11 sheets.)
(Middle Initial)
Amount
S
RE.V-1647 EX+ (9-00)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev-1500 Cover Sheet
ESTATE OF
FILE NUMBER
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
0 Unlimited right of withdrawal 0 Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) ..... .$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One o 6%, o 3%, o 00/0 . . . . . . . . . . . . . . . . . . . . . .$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One o 6%, o 4.5% .......................... .$
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ..... .$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) ..... .$
7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .$
(If more space is needed, insert additional sheets of the same size)
RE~.1648 EX 1,.92) ..
COMMONWEALTH OF PENNSYLANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
PART I - CALCULATION OF GROSS ESTATE
[FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
(AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91)
1. Taxable Assets total from line 8 (cover sheet) .................................................................... 1.
2. Insurance Proceeds on Life of Decedent ............................................................................. 2.
3. Retirement Benefits......................................................................................................... 3.
4. Joint Assets with Spouse................................................................................................. 4.
5. P A Lottery Winnings...................................................................................................... 5.
6b.
6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a.
6c.
6d.
6. SUBTOTAL (Lines 6a, b, c, d) ......................................................................................... 6.
7 . Total Gross Assets (Add lines 1 thru 6)............... .................. ............. ............................... 7.
8. Total Actual Liabilities...................... ....... .................. ................... .................................. 8.
9. Net Value of Estate (Subtract line 8 from line 7) ................................................................ 9.
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Returns for decedent and spouse. )
Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse...................... 10. 2a. 30.
b. Decedent................... 1 b. 2b. 3b.
c. Joint .......................... 1 c. 2c. 3c.
d. Tax Exempt Income..... 1 d. 2d. 3d.
e. Other Income not
listed above........... 1 e. 2e. 3e.
f. Total.......................... If. 2f. 3f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(If)
+ (2f)
+ (3f)
=
(+ 31
4b. Average Joint Exemption Income ................... ............. ..... ........... ...... ........ ........ ... ............ =
If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part III.
PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1 . Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1.
4.
2. Multiply by credit percentage (see instructions) .................................................................. 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................................
For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate..................................................................................................
Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spouse I
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet.
5.
~
..
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
RfY.1649 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin souse under a Section 9113 A trust or similar arran ement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made.
DESCRIPTION VALUE
Part B Total $
(If more space is needed, insert additional sheets of the same size)
499 Mitchell Road
Mi1l.aboro, 0e1aware 19966
1-888~502-4349
(302) 934-2955 fax
PI M&I'Bank
Fax
1b: Mukta Sharma-Carlisle Pila: Office From: Charlene Warrington
Fax: (717) 766-1793 Pages: 1
Phone: (717) 766-0507 Dat.e: 8/'28/2006
Re= John F. Conrad.. Date of Death
12/13/05
o Urgent Cl li'or Review o Please Comment ,0 Please Reply D Please Recycle
. Comments~
Please find belOW' the da.te of death balances you bad requested for the above named
decedent.
1. ACCOWlt 1Ype.... ........ ............... Checking Account
Account Number................. ......23518014-
Ownership (Namss oJ).............. John F. Conrad
Opening Dat&... ....... ......,.. ... ... .12/28/88 (aeeount c1o$ed 07/06/06)
Balance on Daf2 of Death........ ..$6~417 .19
ACD'UBd Intemst
$ 0.00
Total...... .... ..... ......h. ....... .,. ....$6,417.19
2. Account Type........ ................... Savings Account
Account Number.. ...... ............... 15004210919906
~hip (NQ1'flI!.$ ofJ.......... .... John F. Conrad
Opening Date...........................02j07/0S (account closecl12/22/05)
Bala.nce on Date of Death....... ...$585.04
Aocnted In:terest
'$' 0.02
1btaJ..... ...... ......................... ....$585.06
~7J~
~(
--\, I
.J \
@
~- ,
"',
APPLE CHEVROLET. ACURA' SUBARUlAUTO BUDGET CENTER . YORK, PA 17404
GL" CONTROL REFER
7241 0005663F'
7241 @ 0005663F'
AMOUNT DISC/MEMO DESC
11700.00
.01
* TE 02/10/06 091919
02/10/06 lO:~i6
NOTE:
PURCHASE VEHICLE
**APPLE CHEVROLET- ACURA- SUBARU**
ALL INVOICES MUSr HAVE A VALlI- P.O. tt FOR PAYMENT
DEED IN LIEU OF FORECLOSURE
82 FAIRVIEW STREET, CARLISLE,
CUMBERLAND COUNTY,
PENNSYLVANIA, 17013
TffiS INDENTURE is made this J ~ of February, 2006, byK:arla Roberts
Administrator of the Estate of John F. Conrad, residing at 1604 Newville Road, Carlisle,
PA 17013, (hereinafter referred to as "Grantor") and the Morequity Inc., its successors
and assigns, with offices located at 5010 Carriage Drive, Evansville, IN 47115,
(Hereinafter referred to as "Grantee").
KARLA ROBERTS, became the Grantor by virtue of an appointment as
Administrator of the Estate of John F. Conrad who passed away on December 13, 2005.
Letters Testamentary were granted by the Cumberland County Register of Wills at file
number 2005-01098.
WITNESSETH, that the Grantor for and in consideration of the sum of One
Dollar ($1.00) lawful money of the United States of America, unto them will and truly
paid by the Grantee at and before the sealing and delivery of these presents and other
good and valuable consideration, the receipt and sufficiency thereof is hereby
acknowledged, has granted, bargained, sold, aliened, enfeoffed, released and confirmed,
and by these presents does grant, bargain, sell, alien, enfeoff, release and confirm unto
the Grantee, its successors and assigns:
ALL THAT CERTAIN lot or piece of ground with the improvements thereon
erected, situate in the South Middleton Township, Cumberland County, Commonwealth
of Pennsylvania, bounded and described as follows:
FRONTING on Poor House Road for a distance of fifty (50) feet and extending
in depth at an even width a distance of three hundred (300) feet, being known as Lot No.
66, Block "H", of that certain Plan of Lots known as "Fairfield"~ which plan is recorded
in the Office of the Recorder of Deeds in and for Cumberland County at Carlisle"
Pennsylvania" in Plan Book 2, Page 80.
THE ABOVE-DESCRIBED premises have thereon erected a one-story from
dwelling house known as and numbered 82 Fairview Street.
BEING the same premises that John F. Conrad and June C. Conrad his wife, by
Deed dated February 24, 1989 to John F. Conrad, recorded on March 8, 1989 at Deed
Book 33V at Page 433.
BEING FURTHER DESIGNATED as Parcel number 40-23-0592-044 with the
Cumberland County Assessment Office.
TOGETHER WITH give right of easement if any.
SUBJECT to oil and gas rights of record and rights of way and easement of
record.
Tms Deed is given in lieu offoreclosure ofa certain Mortgage, dated July 3,
2004, secl,lfing a certain Promissory Note in the Principal amount ofS 107,000.00, given
by John F. Conrad, as mortgagor, and held by Wilmington Finance, A Division of AIG,
as mortgagee, and recorded on August 10, 2004 in the office of the Recorder of Deeds in
and for Cumberland County, Pennsylvania, in Mortgage Book 1876 Page 3967. It is the
intention of the Grantor, the Administrator for the Estate of John F. Conrad, to transfer
absolute title to the above-described premises to the Grantee free of any equity of
redemption by the Grantor or the Beneficiaries of the Estate of John F. Conrad. It is
further the intention of the Grantor and the Grantee that the lien created by the above
described Mortgage will not merge into the fee title acquired by the Grantee pursuant to
this Deed. No such merger will occur until such time as the Grantee executes a written
instrument specifically effecting such merger and duly records the same, or Grantee
records satisfaction of such Mortgage.
IN WITNESS WHEREOF, the Grantor has caused this Deed to be duly
executed the day and year first above written.
WITNESSES;
&~!:\ Hi3 to(\ 'lc\ S
J:. ,';)1\ tl,)h.\.~,,'\.~ ~
l(a~ t !fu kih-
K aria Roberts
Administrator of Estate of John F. Conrad
Grantee Morequity Inc.
I hereby certify that the correct address
of the Grantee is:
SO 10 Carriage drive
Evansville, IN 47115
By:
For Grantee
CO~ONNVEALTHOFPENNSYLV~A
: SS
L . J
COUNTY OF t.\~ L.{ru.-J
On this I~ day of, F~~V'M';""'J ' 2006, before me, a Notary
Public, the undersigned officer, personally appeared harIa Roberts, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within instrument
and acknowledged that they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~ /} H~
NO Y PUBLIC
(NOTARIAL SEAL)
My Commission Expires:
COMMONWEAlfH Of PENNSYlVANIA
l~l~~PldcI
---
AFFIDAVIT OF TITLE
AND ESTOPPEL
THIS AFFIDAVIT, made the ~
day of M~
2006, by KARLA ROBERTS EXECUTRIX OF THE ESTATE OF JOHN F. CONRAD,
DECEASED, hereinafter referred to as the Grantor,
WITNESSETH:
That the Grantor is the owner of certain real property
situate 82 Fairview Street, South Middleton Township, County of
Cumberland and Commonwealth of Pennsylvania, which is subject to and
more particularly described in a mortgage executed and given by John
F. Conrad to Wilmington Finance dated July 30, 2004 recorded August
10, 2004 in Book 1876 page 3967 in the original sum of $107,000.00,
and upon which there is an approximate unpaid balance of principal,
interest, and advances, (if any), as of the date hereof, of
$109,082.69, which the Grantor acknowledges she is obligated to pay.
The Grantor, unable to meet the obligations of said
mortgage according to the terms thereof, has made, executed and
offered to deliver a deed, of even date herewith, conveying the
described property to MOREQUITY INC., its successors or assigns,
either as mortgagee, or holder of said bond and mortgage by virtue of
his succession in said office, or as nominee of the mortgagee or
holder of said bond and mortgage.
The Grantor acknowledges, agrees and confirms that the
aforesaid deed as of the date thereof is an absolute conveyance of
the title to said real property, and of the rights and interest of
Grantor therein and thereto, together with all buildings thereon and
appurtenances thereunto belonging and appertaining, with release of
all dower and similar rights or those in lieu thereof, and is not nor
intended to be a mortgage, trust conveyance, or security of any kind,
and also conveys, transfers, assigns and surrenders the rights of
Grantor to possession of and to said premises, and assigns, transfers
and sets over to the Grantee any and all rentals due or which may
become due;
Grantor acknowledges that the right to possession of said
premises is a consideration for conveyance, and in the event
possession is not immediately given to the Grantee by the Grantor or
any other person or persons in occupancy and claiming under Grantor,
the Grantor authorizes and empowers any attorney of any Court of
Record to appear for her, and enter an amicable action of ejectment
and confess judgment of ejectment therein for the premises described
in said mortgage and deed, and does authorize the immediate issuing
and execution of a writ of possession with appropriate clauses for
costs without asking leave of court;
The offer of said deed is the free and voluntary act of the
Grantor made in good faith on the part of the Grantor and Grantee,
without fraud, misrepresentation, duress, or any undue influence
whatsoever, or any misunderstanding on the part of the Grantor or
Grantee; the Grantor believes that the mortgage indebtedness
represents the fair value of said property, and said deed is not
offered as a preference against any other creditors of the Grantor,
and at this time Grantor is solvent and has no other creditors whose
rights would be prejudiced by such conveyance, and is not obligated
upon any note, bond or other mortgage, whereby any other lien has
been created or exists against the premises described in said deed;
The deed is executed and offered with the express
understanding that it does not operate, even though placed of record,
to effect such a merger of interest as to extinguish the mortgage
lien, and its receipt by the Grantee does not constitute legal
delivery and shall be of no binding force or effect whatsoever until
such time as Grantee consents to acceptance of said deed, such
consent to be evidenced by the acceptance and approval of title by
the Grantee. Said deed of conveyance shall not restrict the right of
the mortgagee or holder of the loan, the Grantee, or any of them, to
institute foreclosure proceedings naming the Grantor as a party or
owner, if Grantee deems it necessary or desirable, but the conveyance
of said deed, when accepted, shall be and is hereby intended and
understood to be an absolute conveyance and unconditional sale, with
the full extinguishment and complete release of all Grantor's rights,
title and interest of every character in and to said property,
providing all conditions herein have been fulfilled.
In consideration of Grantee's acceptance of the conveyance
Grantor represents, certifies, and affirms that
No alterations, additions or repairs have been made
to the premises within the past six months immediately
preceding the date of this affidavit for which any
contractor, workman or supplier, or any other person,
has a right to file a mechanic's lien for work done
or materials furnished;
No sidewalks have been laid, or any curbing, street
paving, sewer, water pipe or any other municipal work has
been done for which a municipal claim or lien has or
can be filed against the property;
All taxes, water and sewer charges, assessed or levied
against the premises during ownership of Grantor, have
been fully paid;
There are no fixtures, materials or equipment placed
in or on said premises which have not been paid for
in full;
Grantor is of full age and not under legal
disability; Grantor is not involved in divorce
proceedings in any jurisdiction;
No additions have been made to the house, carport or
other structures on said premises; outside lines of
the buildings have not been changed, and no other
buildings or fences have been erected;
There are no judgments or Federal liens entered against
Grantor which have not been satisfied of record, and
Grantor has not been adjudicated bankrupt and no
bankruptcy proceedings are now pending;
Grantor has not changed his, her name and had been known only
by the name and names under which title to the property is held
and as appear on this Affidavit, within the past ten years;
Grantor owns no other FHA/VA insured property;
There are no unpaid bills or notes owing for storm
windows, storm doors, equipment or other personal
property in or on said premises.
The subject property is vacant.
THIS AFFIDAVIT is and has been made for the protection and benefit of
the Grantee in said deed, his successors and assigns, and all other
persons and parties dealing with or who may acquire any interest in
the property described in said deed, and to induce any title
insurance company insuring the title, or any lawyer certifying the
title, of the Grantee or any other person or persons to said premises
under or through the deed from the Grantor, and shall bind the
respective heirs, executors, administrators, and assigns of the
undersigned.
WITNESS:
Lirff ;RTS&~