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Home My WebLink About09-13-06 --.J 15056041169 REV-1500 EX(06-05) PA Department of Revenue Bureau of Individual Taxes PO Box 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number t2J CXo OVJl.o Date of Birth 162-36-7572 12142005 08181943 Decedenfs Last Name Suffix MILLER JR Decedent's First Name MERLE MI E (If Applicable) Enter Surviving Spouse's Infonnatlon Below Spouse's Last Name Suffix MILLER Spouse's First Name KATHRYN MI N Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW IX! 1. Original Return o 4. Limited Estate IX! 6. Decedent Died Testate (Attach Copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach Copy of Trust) D 10. Spousal Poverty Credit (date of death IX] 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONRDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D 3. Remainder Return (date of death prior to 12-13-82) IX] 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes 804 WAYNE AVENUE JQG 'j C) 11 ,'),-= - ::0 _u~ .;~ :x:- ::c: RONALD S. KEARNS Firm Name (If Applicable) SMITH ELLIOTT KEARNS & COMPANY, LLC First line of address Second line of address City or Post Office State ZIP Code <=> o DATE FILED CHAMBERS BURG PA 17201 Correspondenfs e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it Is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT RE OF PERSON RESPONSIBLE FOR FILING RETURN DATE . ~~aT/i/X - 3'-~ PA 17013 DATE ,,?-/ AVENUE, CHAMBERSBURG, PA 17201 PLEASE USE ORIG Y Side 1 L 15056041169 15056041169 ....J ..-J 15056042160 REV-1500 EX Decedent's Name: MERLE E MI LLER JR RECAPnuLATlON 1. Real estate (Schedule A) . . . . .. . . .. .. .. . . .. .. .. . . .. . .. . . . . . . . .. . . . . . .. 1. 2. Stocks and Bonds (Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 6. JoinUy Owned Property (Schedule F) 0 Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 Separate Billing Requested.. .,... 7. 8. Total Gross Assets (total Lines 1 - 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 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) .... .......... ........ ... ......... 11. 12. Net Value of Estate (Line 8 minus Line 11).............................. 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J). . . . . . . . . . . . . . . . . . . . . . .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . .. . .. . .. .. . . . .. . . . .. 14. TAX COMPUTATION - SEE INSTRUCTIONS FORAPPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .OL 770,028.34 15. 16. Amount of Line 14 taxable atlinealratex.Oi5, 352,215.43 16. 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. TAXDUE ........................................................ 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042160 Decedent's Social Security Number 162-36-7572 714,000.00 184,593.39 183,956.50 35,569.23 123,718.31 1,241,837.43 46,156.73 73,436.93 119,593.66 1,122,243.77 1,122,243.77 0.00 15,849.69 15,849.69 o 15056042160 ...J REV.1500 EX Page 3 Decedent's Complete Address: DECEDENl'S NAME Merle E. Miller, Jr. STREET ADDRESS 450 McClures Ga Road File Number 21-06-0236 CITY Carlisle STATE Pa ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 15,849.69 Total Credits (A + B + C) (2) 0.00 3. InterestlPenalty it applicable D. Interest E. Penalty TotallnterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIll In box on Page 2, Une 20 to request a refund. (4) 0.00 B. Enter the total of Line 5 + 5A This is the BALANCE DUE. (5) (5A) (5B) 15,849.69 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A Enter the interest on the tax due. 15,849.69 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Iil b. retain the right to designate who shall use the property transferred or its income;. . . . . . . . . . . . . . . . . . .. 0 ~ c. retain a reversionary interest; or ......................................................... 0 ~ d. receive the promise for lite of either payments, benefits or care? ................................ 0 ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 iii 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .. . .. 0 Iil 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . .. .. . .. .. .. . . .. . . . .. .. .. .. .. .. . . . . .. . . . . . . .. . .. .. . .. .. ... Ii] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE rr AS PART OF THE RETURN. 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 three (3) percent [72 P.S. ~9116(a)(1.1.)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116(a)( 1.1 )(ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disdosure 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 zero (0) percent{72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 All real property owned solely or as a tenanlln comnon must be reported at fair market value. Fair market value Is defined as the price at which property would be exchange between a wRUng buyer and a wiling seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real which Is ~ with lit of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 450 McClures Gap Road, Carlisle, Pa Deed Book 34-Q, Page 44/45 Parcel No. 29-07-0471-038 Undivided 1/2 Interest-Appraisal Attached 542 Boca Ciega Point Blvd, St. Petersburg, Fla. Map Ref 04-31-15; Parcel#04-31-15-09655-014-2108 Undivided 1/2 Interest-Appraisal Attached 2 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) VALUE AT DATE OF DEATH 524,000.00 190,000.00 714,000.00 REV-1503 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF RLE NUMBER Merle E. Miller, Jr. 21-06-0236 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 2352 Shs State Auto Financial Corp @$35.67 2 2823.032 Shs State Auto Financial Corp @$35.67 VALUE AT DATE OF DEATH 83,895.84 100,697.55 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) 184,593.39 REV-1504 EX+ (6-98) SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 Schedule C-1 or C-2 (including all supporting information) must be attached for each cIosely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See lnstruclions for the supporting information to be submitted for soIe-proprletorships. ITEM NUMBER 1. DESCRIPTION 160 Shs Miller Insurance Associates, Inc Undivided 1/2 Interest Sale Proceeds-Sale Agreement to Unrelated Party Attached VALUE AT DATE OF DEATH 183,956.50 TOTAL (Also enter on line 3. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 183,956.50 REV-1505 EX+ (6-98) C-1 SCHEDULE CLOSELY-HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA STOCKINFORMA~ON REPORT INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 1. Name of Corporation Miller Insurance Associates, Inc State of Incorporation Pa Address 19 Brookwood Avenue Date of Incorporation 2/28/1978 City Carlisle State P a Zip Code 17013 Total Number of Shareholders 2 2. Federal Employer 1.0. Number Business Reporting Year April 30 3. Type of Business Insurance Agency Product/Service Insurance 4. . stoCK ...>If!E i...i...... ~TAl~()f "P~\'ALlJ~ ,>>. ...~~QI=..~.....,..f. "i.)\(~9F'I11E ". ", ~~YotIng ", '$HAAEs~ING . ,~"MIEijeCe6Ekr' . , 'DECEOENT'S STOCK .' . Common Votinq 160 $5 . 00 1/2 of 160 $ 183, 956 . 50 Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ......................... .. ............. .. .. . . . .... . .. . . .IilYes DNo If yes, Position President-CEO Annual Salary $ 5 8 , 121 . 73 lime Devoted to Business 100% 6. Was the Corporation indebted to the decedent? ............................... . ....................... . ....DYes IilNo If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? . . . . . .. . .. .. DYes IilNo If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Old the decedent sell or transfer any 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 !XI No If yes, o Transfer o Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? . . ., . ..DYes IXINo If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? . . . . . . ....... .. ....... .. .......... .. . . .... . ............... .. ....... . .,. . ...... . . . .IXIYes DNo If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? . . . . . . . . . . . . . . . . . .. .. . DYes IXINo If yes, provide a breakdown of distributions received by the estate, Including dates and amounts received. 12. Old the corporation 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. I "... ......rtrHE..'FOi.[:OWlNGtNFt\'JRtMtfON.MUSTBE;$UBMI1.fED~!.i.6_Utt!; ;.::1 ;'. .' :;:!,~):~~:~;;~~:;:<~)~~~:~'.-r::j;'i,-' -; I :._.,' .....' .',.' .,:..', ,_ _..-.". " _ "'- "'.:_ .' _ .,.. " ".' c. :.". ..',., '.:.' "_' . '., .''',_,,,: ,";~: -..... __' .' ',-, "'-"~ .,- '.,;.. .'. .,,,'-.... .. ".. . i." "-, '..-" ., :.. -, . ".' --', " "-,.-.-.. ,..,.,....:.',- :,.'.... ", ,"'"". - .-.-.' ,,-.",.'- -:', ,....".,.., ;........----;-- ,.... ' .,. '--~...- --.- ',,' '...' . 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) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF Merle E. Miller, Jr. FILE NUMBER 21-06-0236 1. Name of Partnership Address Date Business Commenced Business Reporting Year City 2. Federal Employer 1.0. Number 3. Type of Business State Zip Code Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. PERcENT '. OF INcoME ~~CEOF .....cAPt'tALACCOUNT,. A. B. c. D. 6. Value of the decedent's Interest $ 7. Was the Partnership indebted to the decedent? ......................................... DVes 0 No If yes, provide amount of Indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? . . . . . . . . . . . . 0 Ves 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Old 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? DVes DNo Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. If yes, o Transfer DSale Percentage transferred/sold Consideration $ Date 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . . . . . . DVes 0 No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interestsold? .......................................... DYes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ...... ..... ... .. ..... .DVes DNo If yes, provide a breakdown of distributions received by the estate, Including dates and amounts received. 13. Was the decedentrelated to any of the partners? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DVes 0 No If yes, explain 14. Old the partnership have an interest In other corporations or partnerships? . . . . . . . . . . . . . . . . . . . . DVes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each Interest. I ;,'_\F~lJ.;~NG.~~~MU$T~ESUSllilh.tI:PWtt'lt1i1IS$Q"l:DlJL-iE '.k-.',. ,. ....~:s:'~;,~~;;v,;il 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+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 All property JoInt1y-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets ofthe same size) REV-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 2 3 DESCRIPTION 2004 Ford F150 Pick-up Truck-Appraisal Attached 2002 Pro-Sport Boat-Sale Proceeds Three Shares of Boca Ciega Point Associates General Partnership-Owns the Common Recreational Facilities for Boca Ciega Point Condominium Non-Marketable-Oral Valuation by Condominium Asso~ Refund on Boat-Progressive Insurance Co 4 VALUE AT DATE OF DEATH 21,350.00 10,800.00 3,355.98 63.25 TOTAL (Also enter on line 5. Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 35,569.23 REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 If an anet was made joint within one year of the decedent's date of death, It must be reported on Schedule G. SCHEDULE F JOINTLY-OWNED PROPERTY SURVMNG JOINTTENANT(S) NAME ADDRESS RELATlONSHIPTO DECEDENT A. B. c. JOINTLY-OWNED PROPERTY: lET1ER DATE DESCRPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INClUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR StlllLAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT DENTFYING NUMBER. ATTACH 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+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF RLE NUMBER Merle E. Miller, Jr. 21-06-0236 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 INClOOE THE NAME OF THE TRANSFEREE, THER RELATlONSHPTO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF ~ER. ATTAOf A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPI.ICAIlLE) VALUE 1. IRA-Raymond James Fin. A/C60674028 Beneficiary-Surviving Spouse 5~,476.94 100 55 ,476.94 2 IRA-Raymond James Fin. A/C60674212 Beneficiary-Surviving Spouse 54,910.97 100 54 ,910.97 3 Investors Life Annuity-Policy#IAOOO0240 Beneficiary-Surviving Spouse 1~,330.40 100 13 ,330.40 TOTAL (Also enter on line 7, Recapnulation) $ 123,718.31 (If more space is needed, insert additional sheets of the same size) REV.1511 EX+ (12.99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Merle E. Miller, Jr. FILE NUMBER 21-06-0236 ITEM NUMBER A. 1. 2 3 4 Debts of decedent must be reported on Schedule I. DESCRIPTION FUNDERAL EXPENSES: Hoffman-Roth Funeral Home-Funeral Cumberland Valley Memorial Gardens-Grave Marker cumberland Valley memorial Gardens-Open/Close Grave Betty Warner-Funeral Catering B. ADMINISTRATNE 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. Family Exemption: (If decedenfs address is not the same as claimanfs. attach explanation) Oaimant Kathryn N. Miller Street Address 450 McClures Gap Road City Carlisle State~ZIP 17013 Relationship ofOaimantto Decedent Surviving Spouse 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 8 9 10 11 12 Cu Law Journal-Advertise Letters Testamentary The Sentinel-Advertise letters Testamentary Register of Wills-Filing Pa Inheritance Return Hughes Pitts Associates-Fla Condo Appraisal B-H Agency Appraisal Services-Pa Property Appraisal Register of Wills-Filing Disclaimers TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) AMOUNT 7,897.70 1,509.00 1,045.00 1,800.00 20,000.00 3,500.00 628.00 9,000.00 75.00 137.03 15.00 325.00 200.00 25.00 46,156.73 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 Report debts IncumId by the decedent priorto death which remained unpaid IS of the date of death, Including unl"8lmbul'led medical expenses. VALUE AT DATE OF DEATH ITEM NUMBER 2 DESCRIPTION Advanced Marine Construction-Repair Boat Ramp- Fla Condo (1/2 of $11,300.00) Katherine P. Neier-Balance Due on Mortgage Note Pa Property (1/2 of $134,605.85) US Treasury-2005 Federal Income Tax Due Pa Dept of Revenue-2005 Pa Income Tax Due 5,650.00 1. 3 4 67,302.93 172.00 312.00 TOTAL (Also enter on line 10, Recapitulation) S (If more space is needed, Insert additional sheets of the same size) 73,436.93 REV.1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Merle E. Miller, Jr. NUMBER NAME AND ADDRESS OF PERSONlS) RECEMNG PROPERTY I TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] FILE NUMBER 21-06-0236 RELATIONSHIP TO DECEDENT Do Not list Trustee(s) 1 M Eugene Miller,Jr. Residual Trust UW Daughter Stephanie M. Coulson, Residual Bene 911 Sadler Court,Carlisle, Pa 17013 M Eugene Miller,Jr. Residual Trust UW Son Brian E. Miller, Residual Bene 681 Buchanan Blvd.,Red Bank, NJ 07701 M Eugene Miller,Jr. Residual Trust UW Daughter Leslie K. Thumma, Residual Bene 1512 Inverness Dr,Mechanicsburg,Pa17050 2 3 AMOUNT OR SHARE OF ESTATE 1/3 Residue 1/3 Residue 1/3 Residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18.ASAPPROPRIATE, ON REV-1500 COVER SHEET U NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLEANDGOVERNMENTALDISTRIBUTlONS TOTAL OF PART 11- ENTER TOTAl NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed. insert additional sheets of the same size) REV.1514 EX+ (12-03) SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on REV.1500 Cover Sheet) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF RLE NUMBER Merle E. Miller, Jr. 21-06-0236 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. iii Will 0 Intervivos Deed of Trust 0 Other ....yJ::~~sr~~,~~~Qg~ttQt{;,.;T,' . .'. i" ....'. .... !!6A~tiF~~ ,. "~Sf~At ....!;'_()f:~i '. DAtEQFasATH:LIFE:~~tEI$PAYABLE Kathr N. Miller 10-28-43 62 1. Value of fund from which life estate Is payable .............................................. $ 2. Actuarial factor per appropriate table. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interest table rate- 031/2% 06% 010% IXIVariableRate 5.43% % 3. Value of life estate (Line 1 multiplied by Line 2) . . . . . . .. . .. . . . . .. . . . .. . . . . . . .. . . . . . .. . .. . .. $ AN~.lJITYJ.'t,nEfU:$T CALCULAll()N. .. ,- .. ..".... - .:",",'. ,'- .'.... ',-' -""""" '.....;".,..-..:..,...,.'>- ;'-'./,--,.-.-,.,. .....-,::... ';"_:,.." " . . .......... . NEARESTAGEAT ,.DAlEOFBIRTH 'OATEOFDEATH 1. Value of fund from which annuity is payable ................................................ $ 2. Check appropriate block below and enter corresponding (number) .............................. Frequency of payout- OWeekly (52) OBi-weekly (26) o Monthly (12) o Quarterly (4) 0 Semi-annually (2) OAnnually (1) 0 Other ( ) 3. Amount of payout per period ............................................................ $ 4. Aggregate annual payment, Une 2 multiplied by Une 3 ....................................... 5. Annuity Factor (see instructions) Interest table rate - 0 3 112% 06% 010% OVariable Rate % 6. Adjustment Factor (see instructions) ................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity -If using 3 112%,6%, 10%, or if variable rate and periOd payout is at end of period, calculation is: Une 4 x Line 5 x Une 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ If using variable rate ~nd period p~yout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Une 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ iii 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 862,258.68 .59152 510,043.25 ~'_9fYEARS...' .... '.~~~MY.t~ ...... 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 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) Estate of Merle E. Miller, Jr. PA Inheritance Tax Return Schedule K M. Eugene Miller, Jr. Residual Trust UW Life Tenant: Kathryn N. Miller DOB 10/28/43 December Mid-term Rate 120% Age 62 Life estate 0.59152 Residuary estate 0.40848 Assets Funding Trust Schedule A - real estate Schedule B: 2,352 shares State Auto Financial Corp. 160 shares Miller Insurance Associates, Inc. Undivided 1/2 interest Less: Funeral expenses and administrative costs Debts 5.43% $ 714,000.00 83,895.84 183,956.50 (46,156.73) (73,436.93) $ 862,258.68 ~ Table S (5.4) Section 1 Single LIfe Factors BaHcI on LIfe TabIe.9OCM Interest at 5A Percent life life Estate Remainder e Annu Estate Remainder .96002 .03998 55 12.5823 .67944 .32056 .96717 .03283 56 12.3611 .66750 .33250 .96612 .03388 57 12.1353 .65531 .34469 .96477 .03523 58 11.9055 .64290 .35710 .96324 .03676 59 11.6725 .63032 .36968 5 17.8066 .96155 .03845 80 11.4365 .61757 .38243 6 17.7731 .95975 .04025 61 11.1973 0:i? .39535 . "7 17.7373 .95781 .04219 62 10.9540 .40848 8 17.6993 .95576 .04424 83 10.7067 .42184 .t. 17.6588 .95357 .04843 Sot 10.4558 .56481 .43539 10. 17.6155 .95123 .04877 65 10.2014 .55088 .44912 11 17.5696 .94876 .05124 66 9.9431 .53693 .46307 12 17.5213 .94615 .05385 87 9.6802 .52273 .47727 13 17.4713 .94345 .05655 88 9.4133 .50832 .49168 14 17.4205 .94071 .05929 69 9.1432 .49373 .50627 15 17.3696 .93796 .06204 70 8.8711 .47904 .52096 16 17.3187 .93521 .08479 71 8.5983 .46431 .53569 17 17.2678 .93245 .06755 72 8.3254 .44957 .55043 18 17.2159 .92966 .07034 73 8.0531 .43487 .56513 19 17.1628 .92678 .07322 74 7.7806 .42015 .57985 20 17.1071 .92378 .07622 75 7.5068 .40537 .59463 21 17.0491 .92065 .07935 78 7.2312 .39048 .60952 22 16.9889 .91740 .08260 77 6.9537 .37550 .62450 23 16.9258 .91399 .08601 78 6.6751 .36045 .63955 2A 16.8597 .91042 .08958 79 6.3968 .34543 .65457 25 16.7901 .90666 .09334 80 6.1213 .33055 .66945 28 16.7170 .90272 .09728 81 5.8504 .31592 .68408 27 18.6399 .89858 .10144 82 5.5852 .30160 .69840 28 18.5593 .89420 .10580 83 5.3259 .28760 .71240 29 18.4750 .88985 .11035 84 5.0707 .27382 .72618 30 18.3870 .88490 .11510 85 4.8181 .26018 .73982 31 16.2955 .87998 .12004 88 4.5704 .24680 .75320 32 18.2001 .87480 .12520 87 4.3306 .23385 .76615 33 18.1004 .86942 .13058 88 4.0990 .22135 .77865 34 15.9967 .86382 .13618 89 3.8755 .20928 .79072 35 15.8882 .85796 .14204 90 3.6604 .19766 .80234 38 15.7752 .85186 .14814 91 3.4570 .18668 .81332 37 15.6575 .84550 .15450 92 3.2689 .17652 .82348 38 15.5345 .83887 .16113 93 3.0957 .16717 .83283 39 15.4065 .83195 .16805 94 2.9346 .15847 .84153 40 15.2727 .82473 .17527 95 2.7820 .15023 .84977 41 15.1330 .81718 .18282 98 2.6386 .14249 .85751 42 14.9873 .80931 .19069 97 2.5061 .13533 .86467 43 14.8356 .80112 .19888 98 2.3818 .12862 .87138 44 14.6777 .79260 .20740 .. 2.2608 .12207 .87793 45 14.5144 .78378 .21622 100 2.1429 .11572 .88428 48 14.3453 .77464 .22536 101 2.0271 .10946 .89054 47 14.1710 .76524 .23476 102 1.9134 .10332 .89668 48 13.9913 .75553 .24447 103 1.8008 .09724 .90276 49 13.8061 .74553 .25447 104 1.6807 .09076 .90924 50 13.6150 .73521 .26479 105 1.5634 .08442 .91558 51 13.4184 .72459 .27541 108 1.4130 .07630 .92370 52 13.2167 .71370 .28630 107 1.2313 .06649 .93351 53 13.0100 .70254 .29746 108 .9506 .05133 .94867 54 12.7986 .69112 .30888 109 .4744 .02562 .97438 17 "",""'n-.c~, .l^^-~.l'&';'~-n..L"'''''-.Lr1JJ.LJ.Ljt..J, I\""Y"'V t..J1"""u.... .LII6UA"~. .L......""",... -.. -.... ".. -.... - -0- -- ---- TABLE 3 Rates Under Section 382 for November 2005 Adjusted federal long-term rate for the current month ............................. Long-term tax-exempt rate for ownership changes during the current month (the highes of the adjusted federal long-term rates for the current month and the prior two months. ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TABLE 4 Appropriate Percentages Under Section 42(b)(2) for November 2005 Appropriate percentage for the 70% present value low-income housing credit Appropriate percentage for the 30% present value low-income housing credit TABLE 5 Rate Under Section 7520 for November 2005 Applicable federal rate for determining the present value of an annuity, an interest for life or a term of years, or a remainder or reversionary interest .............. December 2005 (Rev. Rul. 2005-77,I.R.B. 2005-49) TABLE 1 Applcable Federal Rates (AFR) for December 2005 Annual Period for Compounding semiannual Quarterly Short-Term AFR 110% AFR 120% AFR 130% AFR ..................... a lit ......... 4.34% 4.78% 5.22% 5.66% 4.29% 4.72% 5.15% 5.58% 4.27% 4.69% 5.12% 5.54% ... ....... ..... .... ............. . ............ .... lit. ...... ... .... ......... .... .................. lit http://tax.cchgroup.comlprimesrclbinlhighwire.d11?U=wdvi27&MH=50&QBE=N&RR=Y... 8/25/2006 \....\....n-c.I\.C, .1~-~~.I,j.,-ru".v-.L~.LJ.LIU, 1I"'T....v.....,"'..,&... .Lu.v&..,... .L......,n....., A _w -- .... -- - -0- - . -- -- Mid-Term AFR ......... ................ ....... 4.52% 4.47% 4.45% 110% AFR ........................... ..... ~ 4.92% 4.89% 120% AFR ..... ... .............. ....... ... 5.4 5.36% 5.32% 130% AFR ............................... . .89% 5.81% 5.77% 150% AFR ..... ... ... ........ ... .......... 6.82% 6.71% 6.65% 175% AFR ..... ... .... ...... .... .......... 7.97% 7.82% 7.75% Long-Term AFR ................ ........ ... ..... 4.79% 4.73% 4.70% 110% AFR ............................ .... 5.27% 5.20% 5.17% 120% AFR ......... ......... .... .......... 5. 76% 5.68% 5.64% 130% AFR ............................... . 6.24% 6.15% 6.10% TABLE 2 Adjusted AFR for December 2005 Short-teDm adjusted AFR Mld-ter.m adjusted AFR Long-ter.m adjusted AFR ................... Annual 2.98% 3.51% 4.40% Period for Semiannual 2.96% 3.48% 4.35% Compounding Quarterly 2.95% 3.46% 4.33% .............. ....... ... ............. .... TABLE 3 Rates Under Section 382 for December 2005 Adjusted federal long-teDm rate for the current month ............................. Long-ter.m tax-exempt rate for ownership changes during the current month (the highes of the adjusted federal long-ter.m rates for the current month and the prior two mon ths . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TABLE 4 Appropriate Percentages Under Section 42(b)(2) for December 2005 Appropriate percentage for the 70% present value low-income housing credit Appropriate percentage for the 30% present value low-income housing credit http://tax.cchgroup.comlprimesrrlbinlhighwire.d11?U=wdvi27&MH=50&QBE=N&RR=Y... 8/25/2006 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L RENUUNDERPREPAYMENT OR INVASION OF TRUST PRINCIPAL RLE NUMBER 21- 06- 0236 REV-1644 EX+ (3-04) I. ESTATE OF MILLER MERLE E -~_.__. -- (Last Name) (First Name) (Middle Initial) This schedule Is appropriate only for estates of dececlents 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 uncler the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. u. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on B. Name(s) of Life Tenant(s) or Annuitant(s) (Date) Date of Birth Age on date of election Tenn 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 UnincludableAssets. . . . . . . . . . . . . . .. $ 4. Total from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ E. Total Value of trust assets (Line G-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) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) Date of Birth Age on date corpus consumed Tenn 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) REV-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 Merle E. Miller, Jr. 21-06-0236 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. n. 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 ID. 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 oouse at appropriate tax rate Check One 0 6%, 3%, 0 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 06%, 04.5% ........................ $ (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) COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01101/92 TO 12/31194) REV-1648 EX (11-99)(1) ESTATE OF FILE NUMBER Merle E. Miller, Jr. 21-06-0236 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PARTI...CALCUl.AnoNDF'GROSSESTATE 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. 6b. 5. PA Lottery Winnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. PARTU ...?il,.....s~'('j(J~I~~~I?.;JJ\~ct'I~I.~.~~e~HiI:'nttiV'ttd~II~~e.[~ Income: 1. TAXYEAR: 19 2. TAX YEAR: 19 3. TAXYEAR: 19 a. Spouse .. .. .. .. .. .. 1a. 2a. 3a. b. Decedent .......... 1b. 2b. 3b. c. Joint .............. 1c. 2c. 3c. d. Tax Exempt Income .. 1d. 2d. 3d. e. Other Income not listed above ........ 1e. 2e. 3e. f. Total .............. 1f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (if) +(21) + (3f) (+3) 4b. Average Joint Exemption Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " = If line 4(b) is Tester thsn $40,000 - STOP. The estate is not ell Ible to claim the credit. If not, continue to Part Ill. ';p4Rtm..~GALcgt.l1itHi'l)F.I~.AL-I,>QYERttG.pft~<>RRlEiJQ$ttt:.D'~.Re$IQENl"i~.fA"tE$ \._"-,,~,;;;~- 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less. . . . . . . . . . . . . . . . . . . . . . . 1. 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 oftotal credits on line 18 of the cover sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. For Nonresidents, enter the ratio of the decedenfs gross estate in PA to the value of the decedenfs gross estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . . . . 5. REV-1649 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF RLE NUMBER Merle E. Miller, Jr. 21-06-0236 Do not complete thlllchedule unless the estate Is making the eIecIIon to tax assets under SectIon 9113(A) of the Inherltlnce & Estate Tex Ad. If the election applie~ tQ IlIOl'8 than one trust or simUar jmnll1'ment a seplr!lte form must be fled for each trust. Thiselectlonappllestothe M. Eugene MJ.ll.er, Jr. ResJ.Qual. Trust UW Trust(marltal,residuaIA,B,By.pass,UnifledCredk,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 simHar 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. Ifless than the entire value of the trust or similar p-operty is included as a taxable transfer on Schedule 0, the personal represenlative shaH be considered to have made the election only as to a fraction of the trust or simHar 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 tolal 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 surviving spouse under a Section 9113(A) trust or similar arrangement. DesalpUon Value M Eugene Miller, Jr Residual Trust UW, N. Miller-Schedule K Life Interest FBO Kathryn N Miller Residual Interest FBO Three Children Beneficiaries-Stephanie M. Coulson -Brian E. Miller -Leslie K. Thumma FBO Kathryn 862,258.68 $510,043.25 $352,215.43 Part A Total $ 862,258.68 Part B: Enter the description and value of all interests included in Part A for which the Section 9113(A) election to tax is being made. DescriplJoo Value M Eugene Miller, Jr Residual Trust UW, FBO Kathryn N. Miller-Residual interest 352,215.43 Part B Total $ (If more space is needed, insert additional sheets of the same size) 352,215.43 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSQN(Sl RECEIVING PROPERTY Do Not list Trustee(1} OF ESTATE I TAXABLE DISTRIBUTIONS [mclude outright spousal distributions, and transfers under Sec.9116(a){1.2)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,A5 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 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF RLE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONCS) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pnclude outright spousal dislributlons, and transfers under Sec.9116(a)(1.2)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,ASAPPROPRIATE, ON REY.1500 COYER SHEET II NON.TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLEAND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART n - ENTER TOTAL NON- TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets ofthe same size) HI05.805 REV 1105 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ll.:- ~. f.... ~""~~~ Local Registrar Fee for this certificate, $6.00 p 12045352 DEe 1 7 2005 Date H'05.'.w_. '/Ill COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECOAOS CERTIFICATE OF DEATH (Coroner) IWEFILE-...eR SECURITY NUMIlEA DlROF Dl!RH _. Doy,-., .. December 14, 2005 E UNDER' _ DlROFlI/R1lt __ - I-Coy.. Aug.18.1943 .. OF DEIIIH Carlisle IIIR1M'\.ACE tcIIY ond _ "'......" Coul*yJ Bedford I PA ~D KIND OF IUA\IMNG 8POU8E CI-IlIwo__ Kathryn N8ietl': ..... I ~ I DEAD_.1lIy. . 11: 05 P. II. December 14, 2005 17.~1: f:"":':=::::'b~-_""_Do"'_""_oI",,",,_h"_"''''''''''-'_'''-- i==- j--- ..... \f\NICo\SE_1O ... ",,0 Cllhor...-._-......_bu1 ...__n"'~_"""FMTI. p CABG DUE1O(ORAS"CONlIE~ OF): DUE 10 (OR AS.. CONSEQUENCE OF): 1WltlPSV_ ~PIlIOAlO OF CAUSE OF oe.cnn Ml\NNEROFDEIlIH TIME OF INJ\JRY .... Coroner I I!; I -rnc c ..../lMJCMnrYaIQIIHY8ICIAN~ ball pranoiR:ing......and~to~oIdWh} _..._01....__.-_....._.___--....._---.......................... .IEDICAL." *.~~ CQIICIHeR Onlho_"'_ond'ar~.....,......_._-..lho-.......ond.......ond-tolho-..o(o)_ --_...... ......................................... .......................... ..................... ... .,.. REG .s_....o ~.~~ ~d ptll,O I 14. DS- STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND es ta te of M EUGENE MILLER JR (First, Middle, ust) a/k/a MERLE E MILLER JR (First, Middle, Last) SHORT CERTIFICATE I, GLENDA FARNER STRASBAUGH Register for the Probate of wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 16th day of March, Two Thousand and Six, Letters TESTAMENTARY in common form were granted by the Register of said County, on the , late of NORTH MIDDLETON TOWNSHIP in said county, deceased, to KA THRYN N MILLER and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 15th day of March Two Thousand and six. File No. PA File No. Date .of Death S.S. # 2006-00236 21- 06- 0236 12/14/2005 162-36-7572 .~, ~tU/U4 .4tA~ eglster Of Wills '~ ~ ~/\.. ~eputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL Ii WAYNEF.SHADE Attorney It Law S3 West Pomfiet Slreet Carlisle, Pennsylvania 17013 IN RE: ESTATE OF M. EUGENE MILLER, JR., Deceased, Late of the Township of North Middleton Cumberland County, Pennsylvania : IN TIIE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DMSION : NO. 21-06-236 DISCLAIMER AND RENUNCIATION OF BENEFICIAL INTERESTS PURSUANT TO 20 Pa.C.S. ~6201, et seq. I, KATHRYNN. MILLER, surviving spouse ofM. Eugene Miller, Jr., late of North Middleton Township, Cumberland County, Pennsylvania, Deceased, hereby state, as follows: 1. My husband died testate on I;)ecember 14,2005. His Last Will and Testament dated April 16, 1999, was duly probated with the Register of Wills of Cumberland County, Pennsylvania, on March 16,2006, and is recorded at 21-06-236. 2. Pursuant to 20 Pa.C.S. ~6201, et seq., I hereby disclaim and renounce all beneficial interest I am to receive in the following: (a) The interest of my husband in certain real estate premises, with improvements thereon erected, known and numbered as 450 McClures Gap Road, Carlisle~ Pennsylvania; (b) The interest of my husband in certain real estate premises, with improvements thereon erected, known and numbered as 542 Boca Ciega Point Boulevard North, S1. Petersburg, Florida; WAYNEF. SHADE Attorney at Law S3 West Pomftet StRct Carlisle, Pennsylvania 17013 (c) The interest of my husband in one hundred sixty (160) shares of the common stock of Miller Insurance Associates, Inc.; (d) My interest as beneficiary of CNA Life Insurance policy number AURE002803 in the face amount of$600,000 on the life of my husband; and (e) My interest as beneficiary of UnumProvident Group Life Insurance policy number 1072 in. the face amount of $50,000 on the life of my husband. 3. I have not accepted any interest in the property which I am disclaiming herein. 4. I have not received any consideration for making this Disclaimer and Renunciation. 5. I intend this Disclaimer and Renunciation to be an irrevocable and unqualified refusal by me to accept any beneficial interests to which I am entitled in the property disclaimed therein except as under the said Last Will and Testament of my husband. IN WITNESS \\'HEREOF, and intending to be legally bound hereby, and intending that this Disclaimer and Renunciation shall be filed of record in the Office of the Clerk of the Orphans' Court of the Court of Common Pleas of Cumberland County, Pennsylvania, I have hereunto set my hand this ~d day of March, 2006. ~n~ K . Miller J, WAYNEF.SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 COMMONWEALTH OF PENNSYL VANIA ) ) SS: COUNTY OF CUMBERLAND ) On this, the J.r;'&t day of March, 2006, before me, the undersigned officer, personally appeared KATHRYN N. MILLER, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that she executed the same for the purposes therein contained. IN WITNESS \\'HEREOF, I hereunto set my hand and official seal. No~fJ1dC Ct~""'i<iONV< ".AIM '.H OF PENNSYLVANIA NOTARIAL SEAL CONNIE J. TRITT, Notary Public Carlisle Boro., Cumberland County My Commi.~_ Expires October 5, 2(D .'( .. IN RE: ESTATE OF M. EUGENE MILLER, JR., Deceased, Late of the Township of North Middleton Cumberland County, Pennsylvania : IN TIm COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DMSION : NO. 21-06-236 DISCLAIMER AND RENUNCIATION OF BENEFICIAL INTERESTS PURSUANT TO 20 Pa.C.S. ~6201, et seq. I, STEPHANIE M. COULSON, a daughter ofM. Eugene Miller, Jr., late of North Middleton Township, Cumberland County, Pennsylvania, Deceased, hereby state, as follows: 1. My father died testate on December 14,2005. His Last Will and Testament dated April 16, 1999, was duly probated with the Register of Wills of Cumberland County, Pennsylvania, on March 16,2006, and is recorded at 21-06-236. 2. Pursuant to 20 Pa.C.S. ~6201, et seq., I hereby disclaim and renounce all beneficial interest I am to receive in UnumProvident Group Life Insurance policy number 1072 in the face amount of 550,000 on the life of my father. 3. I have not accepted any interest in the property which I am disclaiming herein. 4. I have not received any consideration for making this Disclaimer and Renunciation. 5. I intend this Disclaimer and Renunciation to be an irrevocable and unqualified WAYNEF. SHADE refusal by me to accept any beneficial interests to which I am entitled in the property Attorney at Law S3 West Pomfi'et Street Carlisle,I~~lvania disclaimed herein except as under the said Last Will and Testament of my father. .1(: ~, . WAYNEF.SHADE Attorney at Law S3 West Pomfiet Street Carlisle. Pennsylvallia 17013 IN WITNESS \\1IEREOF, and intending to be legally bound hereby, and intending that this Disclaimer and Renunciation shall be filed of record in the Office of the Clerk of the Orphans' Court of the Court of Common Pleas of Cumberland County, Pennsylvania, I bave bereunto set my hand this .-i?!l day of March, 2006. ~ -~~~ 'AU! ~ Step . eM. Co son COMMONWEALTII OF PENNSYLVANIA ) ) SS:. COUNTY OF CUMBERLAND ) On this, the J9""" day of March, 2006, before me, the undersigned officer, personally appeared STEPHANIE M. COULSON, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that she executed the same for the purposes therein contained. . IN WITNESS \\1IEREOF, I hereunto set my hand and official seal. N9:;:tt~ COMMOHWIIULTH OF PENNSYLVANIA NOTARIAL SEAL CONNIE J. TRITT, NcUry Public u..~ Boro., Cumberland County MJ Commission Expires October 5, 2008 / INRE: ESTATE OF M. EUGENE MILLER. JR., Deceased, Late of the Township of North Middleton Cumberland County, Pennsylvania : IN TIIE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DIVISION : NO. 21-06-236 DISCLAIMER AND RENUNCIATION OF BENEFICIAL INTERESTS PURSUANT TO 20 Pa.C.S. ~620 1, et seq. I, BRIAN E. MILLER, a son ofM. Eugene Miller, Jr., late of North Middleton Township, Cumberland County, Pennsylvania, Deceased, hereby state, as follows: 1. My father died testate on December 14,2005. His Last Will and Testament dated April 16, 1999, was duly probated with the Register of Wills of Cumberland County, Pennsylvania, on March 16,2006, and is recorded at 21-06-236. 2. Pursuant to 20 Pa.C.S. ~620 1, et seq., I hereby disclaim and renounce all beneficial interest I am to receive in UnumProvident Group Life Insurance policy number 1072 in the face amount ofS50,000 on the life of my father. 3. I have not accepted any interest in the property which I am disclaiming herein. 4. I have not received any consideration for making this Disclaimer and Renunciation. 5. I intend this Disclaimer and Renunciation to be an irrevocable and unqualified refusal by me to accept any beneficial interests to which I am entitled in the property WAYNEF.SHADE disclaimed therein except as under the said Last Will and Testament afmy father. AtIomey at Law S3 West Pomftet Street Carlisle, PennsylvllDia 17013 J' ," INRE: ESTATEOF M. EUGENE MILLER. JR., . Deceased, Late of the Township of North Middleton Cumberland County, Pennsylvania : IN mE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DIVISION : NO. 21-06-236 DISCLAIMER AND RENUNCIATION OF BENEFICIAL INTERESTS PURSUANT TO 20 Pa.C.S. ~6201, et seq. I, LESLIE K. TIlUMMA, a daughter ofM. Eugene Miller, Jr., late of North Middleton Township, Cumberland County, Pennsylvania, Deceased, hereby state, as follows: 1. My father died testate on December 14,2005. His Last Will and Testament dated April 16, 1999, was duly probated with the Register of Wills of Cumberland County, Pennsylvania, on March 16,2006, and is recorded at 21-06-236. 2. Pursuant to 20 Pa.C.S. ~6201, et seq., I hereby disclaim and renounce all beneficial interest I am to receive in UnumProvident Group Life Insurance policy number 1072 in the face amount of $50,000 on the life of my father. 3. I have not accepted any interest in the property which I am disclaiming herein. 4. I have not received any consideration for making this Disclaimer and Renunciation. 5. I intend this Disclaimer and Renunciation to be an irrevocable and unqualified WAYNE F. SHADE refusal by me to accept any beneficial interests to which I am entitled in the property Attorney at Law S3 West Pomfret Street ~isle, Pennsylvania 17013 disclaimed herein except as under the said Last Will and Testament of my father. ,.' ,t. .." . WAYNEF.SHADE Attorney at Law 53 West Pomfret Street Carlisle, PennsyIVlllia 17013 IN WIlNESS \\'HEREOF, and intending to be legally bound hereby, and intending that this Disclaimer and.Renunciation shall be filed of record in the Office of the Clerk of the Orphans' Court of the Court of Common Pleas of Cumberland County, Pennsylvania, I have hereunto set my hand this ~ day of March, 2006. COMMONWEAL TII OF PENNSYL VANIA ) ) SS: COUNTY OF CUMBERLAND ) On this, the ~ t:1. day of March, 2006, before me, the undersigned officer, personally appeared LESLIE K. TIIUMMA, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instnnnent and acknowledged that she executed the same for the purposes therein contained. IN WITNESS \\'HEREOF, I hereunto set my hand and official seal. S;JJt~ COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL CONNIE J. TRITT. Notary Public Carlisle 8010., Cumbertand County Commission Expires October 5, 2008 ,". \ " , , 1 .\ " II. . LAST WILL AND TESTAMENT I, M. EUGENE MILLER, JR., of the Township of North Middleton, County of Cumberland, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at anytime heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my personal representative or representatives, hereinafter named, as soon as conveniently may be done after my decease. SECOND. Ifmy wife, KATIlRYN N. MILLER, should fail to survive me, I authorize my personal representative. or representatives hereinafter named to distribute, in accordance with his or her discretion, items of tangible personal property from my Estate in accordance with any of my wishes expressed in writing. Such tangible personal property shall be restricted to common personal possessions and shall not include cash, bank books, stock certificates, bonds or the like unless otherwise expressly stated in my said written wishes. In the event of any conflict between my said written wishes and this my Last Will and Testament, this shall control. In the event of any cash bequests in my said wishes expressed in writing, I hereby authorize my personal representative or representatives hereinafter named to distribute the bequests to any minor legatees by WAYNEF. SHADE AtIomey at Law '3 WCS1 Pomfret Street Carlisle, PamsyMaia 17013 . making distribution directly to any parent or legal guardian of the minor legatee. In the event of my failure to leave a list, I order and direct that all of my said tangible personal property, other than as specifically bequeathed herein, be liquidated and distributed as part of my residuary Estate. In the event of the failure of any of the legatees, designated in any of my said written wishes, to survive me, I order and direct that their bequests be . . dated and distributed as part of my residwuy Estate. In the event of the failure of any of the legatees to survive me, nothing herein shall be interpreted to prevent my personal representative or representatives here~r named from selling any oCthe items, which would have passed to those legatees, to my other legatees at fair market value. In the event of a dispute as to any asPeCts of the list, I order and direct that any such disputed tangible personal property be liquidated and distributed as part of my residuary Estate. THIRD. In the event that my wife should fail to survive me" I give, devise and bequeath the residue of my Estate, real, personal and mixed, whatsoever and wheresoever situate unto such of my issue who shall survive me, in equal shares, by representation and not per capita. FOURm. In the event that my wife should survive me, I give, devise and bequeath assets from my residwuy estate to my wife, valued as of the date allocated or distributed, selected by the Trustee, equal in value to an amount which, when added to the fmal estate tax value of all other property included in any gross estate which passes to my wife and which qualifies for the federal estate tax marital deduction, will entitle my Estate to the minimum federal estate tax marital deduction, allowable in determining the federal WAYNEF. SHADE Aaoracy at Law estate tax payable by reason of my death, necessary to reduce my taxable estate to an '3 West Pomfiel SIreet CIlrIisIc, PennsyMnia 17013 ., amount on which no federal estate tax is due and the federal unified credit available to my Estate is fully utilized; provided that the aforesaid devise and bequest to my wife shall be satisfied only from assets qualifying for the marital deduction. I give, devise and bequeath the remaining portion of my residuary estate, ereinafter referred to as the "Residuary Trost", to my wife, in trust, to be held, administered and distributed by the Trustee, as follows: A~ PAYMENT AND DISTRIBUTIO~ OF RESIDUARY TRUST Payment of Income and Principal to Wife (1) The Trostee shall pay to or apply for the benefit of my wife during her lifetime all of the net income of the Residwny Trost in monthly or in other convenient installments, but in no event less often than annually. If at anytime in the discretion of the Trustee my wife should be in need of additional funds for her proper maintenance and SUpport, and if the trust estate ofthe"Marital Trust, if any, is entirely exhausted, then the Trustee, in addition to the income payments hereinabove provided, shaU in the discretion of the Trustee pay to' or apply for the benefit of my wife such amounts from the principal of the Residuary Trost, up to the whole thereo~ as the Trustee from time to time may deem advisable. Division of Trust Estate' (2) On the death of my wife, the Trostee shall divide the trust estate of the Residuary Trost into as many equal shares as there are children of mine then living and WAYNEF.SHADE Aaonacy .. Law 53 Wesa Pom~ S1Iect Carlisle, PeaasyIvmia 17013 _'l_ ri children of mine then deceased but leaving issue then living. Each share shall constitute and be held, administered and distributed by the Trustee as a separate Trost (a) One equal share shall be set aside for the benefit of each of my children who may then be living and shall constitute the trust estate of such child's Trust. (b) One equal share shall be set aside for the benefit of the issue of each of my deceased children who leave issue then ~iving and shall constitute the tnJst estate of the Trust for such issue. Distribution of Trust Estate (3) The Trustee shall apply and distribute the net income and principal of each of the shares of the tnlst estate, as follows: WAYNE F. SHADE AIfDmey .. Law 53 West Pamfta StRd Carlisle. PenasyMoia 17013 (a) Until a beneficialy shall reach the age of twenty-two (22) years, the Trustee shall pay to or apply for the benefit of the beneficiary in monthly or other convenient installments so much of the net income from his or her share of the.tnJst estate, up to the whole thereof, as the Trustee in its discretion deems advisable for the beneficiary's proper care, support, maintenance and education. At the end of each year the Trustee shall accumulate and add to the principal of each beneficiary's share of the tnlst estate the balance, if any, of the said net income. A r WAYNEF.SHADE AaonIey. lAw 53 West Pomfiet Stnet Carlisle, PeaasyIvania 17013 (b) If at anytime in the discr~tion of the Trustee, a beneficiary shall be in need of funds for his or her proper care, support, maintenance and education, the Trustee shall in its discretion, in addition to the payments hereinabove provided, pay to or apply for the benefit of such beneficiary such amounts from the principal of his or her share of the trust estate, up to tbe whole thereof, as the Trustee may from time to time deem advisable. (c) When a beneficiary shall attain the age of twenty-two (22) years, the Trustee shall distribute to such beneficiary all of the balance ofhis or her share of the trust estate. (d) If any beneficiary for whom a share of the trust estate has been set aside should fail to survive to distribution of the full balance ofhis or her trust estate, then on the death of such beneficiary, all of the balance of such deceased beneficiary's share of the trust estate shall be added equally to the shares and partial shares set aside for the benefit of my other children and the issue of any deceased child of mine. As to distribution to the share of a previously deceased child, it shall be by representation and not per capita. ~ WAYNEF.SHADE AIIDnIeJ It Law 53 West Pamftet StIcct c.rtisle, PamsyIWIIia 17013 Maximum Duration of Trust (4) All of the Trusts established herein shall in any event tenninate on the expiration of twenty-one (21) years after the death of the last survivor of all my children in being at the time of my death. Defmitions (5) The following tenns, as used in this my Last Will and Testament, shall be defined, as follows: (a) The term "children" includes adopted children and any who may hereafter be born. (b) The term "issue" means lawful blood descendants in the first, second or any other degree of consanguinity of the ancestor designated, and includes legally adopted children. (c) All references to the "Trust" or the "trust estate" unless otherwise specifically provided herein, refer, in the event of separate Trusts herein, to each of the separate Trusts herein provided, respectively, and the trust estate of each Trust. (d) The term "education" includes both college and post- graduate study at any accredited institution of the beneficiarys choice for any period of time that in the judgment of the Trustee is advantageous to the beneficiary; the Trustee shall provide adequate amounts for all related living and travel expenses of the beneficiary within reasonable limits. Beneficiaries' Other Means of Support (6) The Trustee in exercising its discretionary authority with respect to the payment of income or principal of the trust estate to any beneficiary shall take into consideration any income or other resources available to such beneficiary from sources outside of this Trust that may be known to the Trostee. The TruStee may accept as fmal and conclusive the written statement of the beneficiary receiving payment as to other available income or resources. The determination of the Trustee with respect to the advisability of making payments out of income or principal to any beneficiary shall be conclusive on aU persons interested in the Trost. Benefits to Guardian and FamUy (7) The Trostee is hereby specifically authorized to distribute to any person nominAtM in this my Last Will and Testament and serving as Guardian of the person of any beneficiary of this Trost until the beneficiary shall reach the age of eighteen (18) years to utilize such funds from this Trost as are reasonably necessary to offset any econ~c burdens occasioned to the Guardian by virtue of acting in such capacity. By way of illustration and not of limitation, I expressly authorize expenditure of ~ds from this Trost to expan~ enlarge or remodel the existing home of the Guardian or to purchase a larger home, if reasonably required, in order to permit all oCthe beneficiaries of this WAYNEF.SHADE Aaaney. Law Trust while they are under the age of eighteen (18) years to reside with such Guardian in S3 West Pam&eI SUeet c.rtisIe, PenasyIymia 17013 comfort. The reasonableness of the need to enlarge the Guardian's present home or to purchase a larger one, as the case may be, shall depend in part on the number and ages of children for whom the Guardian of the person is required to care (including his or her own children) and the amount of the principal of this Trust. Funds from this Trust may so be utilized to pay any increases in living expenses occasioned by such Guardianship, including, but not limited to, increases in homeowners' fire and casualty insurance, proPCrty taxes incurred by remodeling or expansion of said Guardian's home or the purchase of a new home, utility bills and food bills. It is my intention that the foregoing powers may be exercised by the said Trustee without prior Court approval and without further responsibility to the beneficiaries, their parents or to any other person or persons taking care of the minor beneficiaries. Incapacity of Benefidary (8) If at anytime any beneficiary entitled to receive income or principal from the trust estate shall be a minor or an incapacitated person or a person whom the Trustee shall deem unable to handle funds properly or wisely if paid directly to the beneficiary, the Trustee in its discretion may make payments in anyone or more of the following ways: (a) Diredlyto the beneficiary; (b) To the natural guardian or legally appointed guardian of the person or estate of the beneficiary; or (c) By making expenditures directly for the care, support, WAYNEF. SHADE Aaomey III Law '3 Wcsa Pamfia StIect en.. PcnnsyMnia 17013 maintenance or education of the beneficiary. o The Trustee shall not be required to see to the application of any funds paid or applied in any of the aforementioned ways and the receipt of the payee shall be full acquittance to the Trustee. The decision of the Trustee as to which of the aforementioned thods should be used in making payments shall be conclusive and binding on all Undistributed Payments to Sueeeeding Beneficiary (9) Upon termination of~e right of any beneficiary to receive payments from net income or principal hereunder, all such payments accrued or undistributed by the Trustee at the date of such termination shall be distributed to the beneficiary next entitled to the successive interest by the tenns of this my Last Will and Testament. ConOieting Claims (10) Whenever there are conflicting claims as to the person entitled to any payment or distribution from the trUst estate, the Trustee may in its discretion withhold without payment of interest aU or any part of any disputed payment or distribution until the matter has been finally adjudicated by the appropriate court. Alienation and Attachment of Beneficiary's Interest (II) No beneficiary or remainderman of any Trost shall have any right or power, except as othenvise specified, to sell, transfer, assign, pledge, mortgage, alienate or hypothecate his or her interest in the principal or income of the tnJst estate in any manner whatsoever. To the fullest extent of the law, the interest of each and every beneficiary WAYNEF.SHADE AaorDI:yIlLaw and remainderman shall not be subject to the claims of any of his or her creditors or liable 53 Welt Pamf'rct Street Carlisle, Pcansyhuia 17013 n o attachment, execution, bankmptcy procx:edings or any other legal process. The Trustee shall pay, disburse and distribute principal and income of the trust estate only in the manner provided for in this my Last Will and Testament and not on any attempted transfer or assignment, whether oral or written, of any beneficiary or remainderman or by Distribution of Trust Assets by Executor (12) If on tennination of the administration of my probate estate there has been no distribution in trust to the Trustee and events have occurred which would require the Trustee under the terms of this my Last Will and Testament to make immediate distribution of my entire estate, my personal representative shall perform aU of the acts necessary to complete such distribution and for that purpose shall have aU the powers granted herein to the Trustee. B. GENERAL ADMINISTRATIVE POWERS OF TIIE TRUSTEE In order to carry out the purposes of any Trost established in this my Last Will and Testament, the Trustee, in addition to all other powers and discretions granted herein or by law, shall have the following powers and discretions, subject to any limitations specified elsewhere herein: Retain Assets (I) To continue to hold any and all property received by the Trustee or subsequently added to the trust estate or acquired pursuant to proper authority including WAYNEF. SHADE AtIomcy III Law 53 West Pomht Street CIrIisIc. PawtlVlllia 17013 shares of Trustee's own stock and stock in any corporation controlling, controlled by or .^ under common control with the Trustee if ~d as long as the Trustee, in exercising reasonable prudence, discretion and intelligence, shall consider that the retention is in the best interests of the Trust; provided, however, that unproductive property shall not be retained as an asset of the Trust for more than a reasonable time during the lifetime of my wife without the written consent of my wife. Investments (2) To invest and reinvest in every kind of property, .real, personal or mixed, and every kind of investment, specifically including, but not by way of1im.itation, corporate obligations of every kind, and stocks, preferred or common, which persons of prudence, discretion and intelligence acquire for their own accounts, including any common trust fund administered by the Trustee pursuant to the Uniform Common Trust Fund Act. Management of Securities (3) To exercise, respecting securities held in the trust estate, all the rights, powers and privileges of an owner, including, but not limited to, the powers to vote, give proxies and pay assessments and other sums deemed by the Trustee necessary for the protection of the trust estate; to participate in voting trusts, pooling agreements, foreclosures, reorvni7Ations, consolidations, mergers and liquidations, and in connection therewith, to deposit securities with and transfer title to any protective or other committee under such terms as the Trustee may deem advisable; to exercise or sell stock subscription or conversion rights; and to accept and retain as an investment any securities or other WAYNEF. SHADE Aaiamey at Law 53 West Pomfiet StIed c.rIisJe. Pennsylvania 17013 . j, property received through the exercise of ~y of the foregoing powers, regardless of any limitations elsewhere in this instrument relative to investments by the Trustee. Form of Ownership of Trost Property (4) To hold securities or other trust property in the name of the Trustee as Trustee under each Trust or in the Trustee's own name or in the name of a nominee or under such conditions where ownership will pass by delivery. Business Interests (5) To continue and operate, to sell or to liquidate, as the Trustee shall deem advisable at the risk of the trust estate, any business or partnership interests received by the trust estate; provided, however, that unproductive property shall not be retained as an asset of the Trust: for more than a reasonable time during the lifetime of my wife without the written consent of my wife. SeD and Exchange (6) To sell for cash or on deferred payments at public or private sale, to exchange and to convey any property of the trust estate. Division of Trust Estate (7) On any division of the trust estate into separate shares or trusts, to apportion and allocate the assets of the trust estate in cash or in kind, or partly in cash and partly in kind, or in undivided interests in the manner deemed advisable in the discretion of the Trustee; after any division of the trust estate, the Trustee may make joint investments with W A mE F. SHADE AnonIey at Law 53 Wcsa Pomht StteeI Cadisle. PetmsyIvIDia 17013 ~'" '. - funds from some or all of the several shares or Trusts, but the Trustee shall keep separate accounts for each share or Trost Abandonment of Trust Assets (8) To abandon any trust asset or interest therein in the discretion of the Trustee. Option (9) To grant an option involving disposition of a trust asset and to take an option for the acquisition of any asset by the trust 'estate. Lease (10) To lease any real or personal property of the trust estate for any purpose for terms within or extending beyond the duration of any Trost Property Management (11) To manage, control, improve and repair real and personal property belonging to the trust estate. Deve~pmeDtofProperty (12) To partition, divide, subdivide, assign, develop and improve any trust property; to make or obtain the vacation of plats and adjust boundaries or to adjust differences in valuation on exchange or partition by giving or receiving consideration; and to dedicate land or easements to public use with or without consideration. WAYNEF.SHADE Aaaney IlLaw 53 West Pam&a S1Rct CulisIc, PcnDsyIyania 17013 1'] Repair, Alter, ~emolish and Erect (13) To make ordinary and extraordinary repairs and alterations in buildings or other tmst property, to demolish any improvements, to raze party waIls or buildings and to erect new party walls or buildings as the Trustee shall deem advisable. Borrowing and Encumbering (14) To borrow money for any trust purpose from any person, firm. or corporation, including one acting as Trustee hereunder, on the terms and conditions deemed appropriate by the Tmstee and to obligate the trust estate for repayment; to encumber the trust estate or any of its property by mortgage, deed of trust, pledge or otherwise, using whatever procedures to consummate the transaction deemed advisable by the Trostee; and to replace, renew and extend any encumbrance and to pay loans or other obligations of the trust estate deemed advisable by the Trustee. Natural Resources (15) To enter into oil, gas, liquid or gaseous hydrocarbon, sulphur, metal and any and all other natural resource leases on terms deemed advisable by the Trustee, and to enter into any pooling, unitization, repressurization, community and other tyPes of agreements relating to the exploration, development, operation and conservation of properties containing minerals or other natural resources; to drill, mine and otherwise operate for the development of oil, gas and other minerals; to contract for the installation and operation of absorption and repressuring plans; and to install and maintain pipelines. WAYNEF.SHADE ADaraey _ Law S3 West Pomfict StIeel Carlisle" PaInsyIvuia 17013 _1&_ Insurance (16) To procure and carry at the expense of the trust estate insurance of the kinds, forms and amounts deemed advisable by the Trustee to protect the trust estate and the Trustee against any hazard. Enforcement of Hypothecations (17) To enforce any deed of trust, mortpge or pledge held by the trust estate and to purchase at any sale thereunder any property subject to any such hYPothecation. Extending Time of Payment of Obligations (18) To extend the time of payment of any note or other obligation held in the trust estate, including accrued or future interest, in the discretion of the Trostee. AdjusfinentofC3aim (19) To compromise, submit to arbitration, release with or without consideration, or otherwise adjust claims in favor of or a~in~t the trust estate. Litigation (20) To commence or defend at the expense of the trust estate any litigation affecting each Trust or any property of the trust estate deemed advisable by the Trustee. Administration Expenses (21) To pay all taxes, assessments, compensation of the trustee and all other expenses incurred in the collection, care, administration and protection of the trust estate. WAYNE f. SHADE AItiDnIey at Law S3 West JtcJmht SIrcct Culisle, PamsyIvania 11013 . Employment of Attorneys, Advisen and Other Agents (22) To employ any attorney, investment adviser, accountant, broker, tax specialist, appraiser or any other agent deemed necessary in the discretion of the Trustee; and to pay from the trust estate reasonable comPenSation for all services performed by Termination by Trustee of Small Trust (23) To terminate in the discretion of the Trustee any separate Trust held for an income beneficiary and remainderman if the fair market value of the separate Trust at anytime shall become less than $10,000 and, regardless of the age of the income beneficiary, to distribute the principal and any accrued or undistributed net income to the income beneficiary, or unto his or her guardian or other fiduciary. Distribution (24) On any partial or final distribution of the trust estate, to apportion and allocate the assets of the trust estate in cash or in kind, or partly in cash and partly in kind, or in undivided interests in the manner deemed advisable at the discretion of the Trustee and to sell any property deemed necessary by the Trustee to make the distribution. General (25) To do all the acts, to take all the proc.PPlfings and to exercise all the rights, powers and privileges which an absolute owner of the property would have, subject always to the discharge of its fiduciary obligations; the enumeration of certain powers WAYNE F. SHADE Attamey8lLaw herein shall not limit the general or implied powers of the Trustee; the Trustee shall have 53 West PclIIlht Snd Carlisle, PcIInsyIvaaia 17013 1C I additional powers that may now or hereafter be conferred on it by law or that may be necessary to enable the Trustee to administer each Trust in accordance with the provisions of this my Last Will and Testament, subject to any limitations specified herein. Powers Inconsistent with Marital Deduction (26) None of the powers or discretions granted in any provision in this Will to the Trustee shall be exercised in a manner inconsistent with the allowance of the federal estate tax marital deduction, to which.my Estate would otherwise be entitled, regardless of any provision herein to the contrary. C. OPERATIONAL PROVISIONS Determination of Income and Principal (1) Subject to the right of my wife to give controlling directions, the Trustee shall . ~ have power to allocate receipts, disbursements and losses to principal or to income, in accordance with generally accepted 8ccounting practices. However, the Trustee shall make no allocation of any receipt to principal or any disbursement to income if such allocation would result in my wife's receiving less income from the Marital Trust or legacy and residuary trust than that to which she otherwise would be entitled under Pennsylvania law if there were no provision in this instrument dealing with such allocations. Trustee's Fees (2) The Trustee shall receive reasonable fees for the ordinary and extraordinary WAYNE F. SHADE Aaamey . Law 53 West Potafta Stnlct c.rtisle. PamsyIYIIIia 17013 services rendered by it in accordance with its customary charges therefor. Waiver of Trustee's Bond (3) No bond for the faithful perfonnance of duties shall be required of any person Limit of Trustee's Liability (4) No individual Trustee appointed under this my Last Will and Testament shall at anytime be held liable for any action or default of himself or his agent or any other Co- Trostee, if any, or of any other person in connectio~ with the administration of the trust estate, unless caused by his own gross negligence or by a willful commission by him of an act in breach of trust. Choice of Law (5) The validity and administration of any Trost established herein and all questions relating to the construction or interpretation of any such Trost shall be governed by the laws of the Commonwealth of Pennsylvania in effect as of the date hereof. FJ.1t-lH. Ifmy wife should fail to qualify as Trostee herein or should decline or cease so to serve, I nominate, constitute and appoint ORRSTOWN BANK., with offices in Carlisle, Pennsylvania, its successors or assigns, as such Trustee. SIXTH. All estate, inheritance and succession taxes, together with any interest and penalties thereon, payable as a result of my death and imposed with respect to any property, whether or not disposed of by this Will, shall be paid out of the Residuary Trust set forth hereinabove. WAYNEF.SHADE Aaomey II Law 53 West Pclmfiet Sbeet Carlislc. PennsyMnia 17013 10 SEVENTH. If any beneficiary or r~maindennan under this my Last Will and Testament shall in any manner, directly or indirectly, contest or attack this my Last Will and Testament or any of its provisions, without being able to establish probable cause therefor, any share or interest in my Estate or in the estate of any Trost established herein and given to that contesting beneficiary or remainderman herein is hereby revoked and shall be distributed in the same manner provided herein as if that contesting beneficiary or remainderman had predeceased me without issue. EIGHTH. My wife and I are executing Wills at approximately the same time in which each ofus is the primary beneficiary of the Will of the other. Either Will may be revoked after the death of the first spouse to die. NINTH. For the purposes of this my Last Will and Testament, a person shall not be deemed to have survived me unless he or She shall have survived me by more than nine1y (90) days. Ifmy wife shall die simultaneously with me or there is no direct evidence to establish that my wife and I die other than simultaneously, I direct that I shall be deemed to have predeceased my wife, notwithstanding any provision of law to the contraly, and that the provisions of my Will shall be construed on such presumption. If any legatee, devisee or beneficiary of any Trost, other than my wife, shall die simultaneously with me or there is no direct evidence to establish that such person and I died other than simultaneously, I hereby declare that I shall be deemed to have survived such person. WAYNE F. SHADE Aaamcy. Law S3 West Pamht SUect c.lisIc, PamyIVlllia 17013 .n TENTH. My personal representati~e or representatives hereinafter named shall, . addition to the powers vested in them by law and by other provisions of this my Last Will and Testament have, without the necessity of prior Court approval, the power to carry on alone or jointly with others any business in which I may have an interest at my death for whatever period of time they may think proper, without personal liability for any operating losses. In the operation of said business, they shall have the power to do any and all things they deem necessary or appropriate, including the power to merge or incorporate the business, the power to borrow and to pledge assets contained in my Estate as security for such borrowing, and the power to close out, liquidate or sell the business at such time and upon such terms as to them shall seem best ELEVENTH. I order and direct that, upon my death, my body be cremated in lieu of burial and that disposition of my ashes be at the discretion of my personal representative. LASTLY. I nominate, constitute and appoint my wife, KATIlRYN N. MILLER, to be the Executrix of this my Last Will and Testament, but it: for any reason, she should fail to qualify as such Executrix or decline or cease so to serve, I nominate, constitute and appoint my children, STEPHANIE G. COULSON, BRIAN E. MILLER and LESLIE K. MILLER, to be the successive alternate personal representatives hereot: all to serve without bond. IN WITNESS WHEREOF, I, M. EUGENE MILLER, JR., have hereunto set my WAYNEF. SHADE Altomeylllaw hand and seal to this, my Last Will and Testament which consists oftwenty-tbree (23) S3 West Pamfta Street c.rt., PamsyIwnia 17013 typewritten pages to each of which I have ~ftixed my signature, this 16th day of April , A.D. One Thousand Nine Hundred Ninety-Nine (1999). ~ ~ .. fJ4fJ)Q~(SEAL) M. Engen . ler, Jr. .' <- The prece-dillg instrument, consisting of this and twenty-two (22) other typewritten pages, each identified by the signature of the Testator, was on the date thereof signed, sealed, published and declared by M. EUGENE :MILLER, JR., the Testator, therein named, as his Last W1l1 and Testament, in the presence of us, who, at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. (L/~ ~ ~.-..- ..::J:-/;Yll<-- Acknowledgment COMMONWEALTH OF PENNSYLVANIA ) ) SS: COUNTY OF CUMBERLAND ) WAYNEf. SHADE I, M. EUGENE MILLER, JR., the person whose name is signed to the foregoing AaonIcy.. Law instrmnent, having been duly qualified according to law, do hereby acknowledge that I '3 West Pomfiet SUect Carlisle. PamsyIvaia 17013o . '" 1 WAYNEF.SHADE Aaomey. Law 53 West Paalht Shet OIdisle, PamsyIvuia 17013 signed and executed the instrument as my Last Will and Testament and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affinned and acknowledged before me by M. EUGENE MILLER, JR., this 16th day of April . 1999. a-.. ~ ?u-a: Notary bUe Notarial Seal Connie J. Tritt, Notary Public Carlisle, Cumberland County . My Commission expires Oct. 5, 2000 Affidavit COMMONWEALrn OF PENNSYLVANIA ) ) SS: COUNTY OF CUMBERLAND ) We, Wayne F. Shade and Karen F. Byers . the witnesses whose names are signed hereto, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as his Last Will and Testament; that the Testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testator signed the Will as a witness; and, that to the best of our knowledge, the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. WAYNE F. SHADE AtIorDey II Law 53 West PamfieI SIrect c.rtisle. PeansylvaDia 17013 Sworn to or affmned and subscribed to before me by Wayne F. Shade Karen F. Byers . witnesses; this 16th day of April dA ~~ .~. . ~ ... '.. ' .3!'4( -\.<V' ~'1u;ir Notary 'c Notarial Seal . Connie J. Tritt. NoIaIy Public Carlisle. Cumbedaa4 County L. My Commission expires Oct. 5. 2000 ....'ar" JII.IfI: _MIOINIGIp.... 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BUG'" JULIo", Jl. .1l1$;.'~ililmnJ. 1lUoLII, hi. wife, of the ~0U9" of ceUa'., c:...,,~~~y, .....y1vaa1., puUo. of tbe HGOft4 pan, 1IK0lft oa';;.i~,~1BI~:r WIftlll8Ul'1l, dill. i'"'' ~'i::.i~i~i' .......1 ..,.:.~ '''.' '.'." :., i ...... . ..... "'" ... "'* ....., II.... ~1':t t' ~:.. _ "... .........,...., ......,..Mf........... .. t.~...". IIIltl~U.., tbel~ Mira and a.ai9ftll,' :'.Ji~'9:~!>,:~::.~. Ar.r. thAt certain tl'8Ct of l~:.,:':(."i'. \0getber' whb the 1lIp&'ovOMftt. tbe~ .roCt"'I~_~;Ul IIot'tb Middloton '1'cIwn.hlp. CUllberllml Caunt.y. PeRMyl"aIIW;:.~~.~tlclll.dy Ilouaded all4 desedMIS .. fon.... ~;~.!:<(:'.;':.\< 81C1N1fIIIC at . .tono at cor~~~;.;:~:iOJ:..rlY of the bein of lollben Pi.bbum &nd of 'f. P. ,~,.;"'..rly of CUrle. II. Bowan., thonce by the litter lana and"'\l~"::!X' fonerlyof L. ~ker. South ,,,.. 15' ".t'.:l1"'"rctsa to a poat, then. by 10neS _ or f"~rlJ' of JlIIvard ....., IIOJ-t.b 3.. ....t n.. perch.. to 8 poUt, tlleAc=e ~ the ..... North: ..l.. 45' ...t 1'7.5 pel'Ches 'to a.po1atl tho_ by UMI _, IIorth U. .-s' ....t 38.2 perches to a .tone; thenae by lalld 110II or Conerly of the ISt.te of GeortJo Briner, .ol'th 7.- 15' ".t a:sO;5tptl'~be. to a .toIIe, thenco by l;and [onerll' of Mid 'lehJ:lutia 1&01&'., South ,. U'. ...t In.. parcho. to a .t_, the ~.~ftt and place ot. .IBGlllllaIG. ~AIHIaIG !SO aere., strict. ~.lll'.' Las, .IKlItBVIlR, tlMl follow.b., tracts of 1.nd. . '. .' . ..r . 1. 'fl'&~ comrey~,'?Y. -A. L~..8i.~. to'..Ja_ a. Maynard and wite, by 4Hd ..t........,. ,1.,. .1~30. .~~ ricOcdoc& in tbe Office of tbe 1ec:00000r of .he!&. in, and' for CWlberland County, "nn.ylv&lUa, in I'Je4!4' ~ ~.D., VOl... 11, ....,. 136, 2. 'l'z'aGt __yed bY' ~~."k ~Drne)r '.t~ Mward If. Rotb and S. tinerv. Roth, by "...ck.tate4: 1IO.v..ber 10, lU'. ancI rac:orded ill the Office of tM..~~.rc1.1' of Od.cIe, afor..aid. ill Deed Book .'., Y0-1. 12, "~:.12", 3. t'ract convoy'" by Pl'1Ulk Pomctf to hnneylvanio Tur;npike ec.ai.aion, by tle84 ckto... October 2l, 1940, and rClOQ&'ded In the GfUes of the '_der of Deed., afonuid, j.n Deed Book "'., Vol. 12, ..... no, .nd 4. 'l'ract conveyecJ by rrAAk POl'ney a Golclio I. Wolf .nd Ruth M. Wolf, by deeel d.ted Septe-.r 27, Ufl, and recorded 1n the Oft1. of. tlte b~der of Deed., 8fore..ld, ill Deed look "I.", Vol. 12, '.90 451. :~,I'. <0' t)'';;'' ..I,.,' .", ~... . "0 . ",~ ." ;. . " ..: :,. . .......,:.. ...,....;._,....'...4;1',. ...1(....:..... .......,UoW........c...(IIIIt-..r17 e BBIIG the __ pretliu. ""1.ch Herbert II. Forney and John I. 'arnor, br deed dated Au,u.t 26, 1946, a04 r~rd8d 1.n the Office of tho Roc:ardor of llaccI., ,fonoiel, ill Deed IIook -1-, Vol. 13, "'0 JOO, ,rontad anti OOIlvoyocl to Merlo I. M1llw and Louil. G. Millu, Ilia wif.. '!be 01e1 lle1'1. I. IUller: elL.ct Apdl Z, ua., "I'evpon f.. .Up1e tLU. to t:he herei.n "80l'i.beII pr....... _teel 1n the .,U r-1_ G. IIUler, the GI'~OI' llere1n. ~ vitllia -v:I~ k,~~~.. g11114, .. uierefara, i..... froa. \!:tfi':2~~J~0:~75. I I I li ~";;.;~ii~?:2:' ;:." ::~"":~";". :..:.>~> ~. ~. .::"' ,..".:' ',. 1\:7:';;;- :.? ~""~~;?'.,:;.:}. ::J'~:~:~+r:;:x :'.~;.::".~.:..::>:';: ,', .... ..... .'. ,.'~ .." ;........,.. , ""0,.-. '; . . '. ," ~-. .' " .... '''':', .. " S H~ c: '" .;gn i =~~ ", .C.I~' .. " .. ~ ,... :,"1' . - " " ..... I ~... ' " ,"1". " 3: .... : ... co ... -r::I : : g;:n " .' Co: z'"' ,., ; "'",0 ,. ~O""g .... .. m '-ii! '. j: Mi : ;. " .. L; .~:~~!;.~/~~,~ ~~I~.:'~~':~;~~~~~{~~ii:~'~~:~:'::l~:;;: ~;:~~~~~~;,~~~~~"~:~~~~~~~,,::~~;!{~-:,,,;::~'r~;~:,j~'J~.-~'. ~:~:;.. ;;~~~i::~; ~;:.Ii~~.:}L~~~,,~'\.~::~~~:~r.:;~/,"~:.:: :~;.:'.:.~, '.;'::'.:.;:.. ': :,.~;:~~:,~:.:~. :.~~ ........._ ......_.....4IIII...m AnACHIlEHT 1 BOARD APPROVED CHECKLIST FOR ASSISTANTS THE IKWU) tM8 APPRCM!D lHI8 CHECIWST FOR USE BY ASSfSTANTSfI'RAINEES WHEN ASSISTIt.IG IN PI!RFORIIANCE Of AI""R"'''''' · FOR QUAUIYING EXPERIENCI!. A COP\' Of THE CHECKLIST IS TO tNCWIlED IN ALL APPRAISAL REPORTS COIIPlEIED BY ASSISTAN'I1iIII'RAWEE. THE CHECIUJST BE RETAINI!D .. YCMt WORk fILl! AND INCLIJGB) WR1f THE APPRABAL REPORTS ntAT ARE BY THE lOUD OFFICE. '.~ ~~ ~ .::a'~ ~~: .~.; ~ .~:~:~.'~":.::;./~.~.~'~::~~~.~. n.. ...............___.......... ~"~~. AIpOIt hae........ in ....foIowInQ: x .............. fanM and ~~::)',)~~tIlIanport. ......., ,_::10"',' A8eIRId ............ ................. .f ","~ ~. ',1:.- ~ --'!It ......11lIon "'lIIIP. Flood ~ U ...... ZaIIng IIAI. . :~~,"';~..... ....1r4ormMla.~ .. ',. ..,..~~: a.,..~~ t'" ',: . aan ~ ...............In ............~..'~ propwty. A.-....~.....,...... HIgIIMt.ad ~.~~~~~ PfCII*lY. x ~ lit................ "' .... w'..i (j.r'~' ~........ ..aIIId and"""" GIC c:omp8I'aNe 1Ind........ ::'" ;.; .:.: '.': .~. \~ '.,~ ..'~~.:'. ':. " AIMtId........... .....,1ilIIIIoco for u.e~:~r,~h dnI,..... and...... the ooM MNlUnla. A8IiIIId............. r-v - far ~:~~~.... vertIIecI and 8IIaIyDd tbe lWIfaI data. ':.l.": ;'--" ':l";~~: A.-.............. ....IIAl1l.41 far ~.~_;................ WI'IIed and........ . .....--.......... . : ". . .;.:.. ". AlIIMId lit..,.......... Tax Ann 'R)t.~ ReaordBr aI 0..- 0Ific&. CowIty STEB R10fIUlIy ..... CauaIJ All4 - t ..........~.:~ s.Mce. AIItItId .... .......111 rill ~.~.. ~ ........ .... 8IlII otIIer comparllbl8L MIIIaIlIIII ...... ....... ....... lit........ ...,.....~:~.~.~~.....dIIta In" ClDII1IIMIIIt.... . :.~ . ...: -.. : -, . ." .:. ..' MUdId...... 1111 ...tNI~CIf~~"'SlItljectpnlll8l1,y. "\.. ...... . .' . .:. AMtIIIdln............ aI~.~' .' :II x x x x x Ie .It 'C: It. IC 8IGNAlUREOFMlllTMTI1'RMIEE: ..,. tL.- 1 1_............................. .. ". Ii\ ..............cM::llldllbllllM. 8IlJMTURE :~:;),~~1;.~~::.~!:~.ih~-:.~::~~~:.:-t.:;~~.::.f::.;~.;~~~...:~>::~::.~~.~. ~::.~..: .:::-': ~.:~~;,,;,,::~.,,".',: .:..". .......,.......,... ....c..,.,....m APPRAISAL OF lEAL PIOPIRn LOCATED AT: 542 IIoce CIIII Polnlllvd. NarIh IlrICII a.ga PolnlEMt Bldg. 2100. Apt 21.. FOUItIen CancIo St. ....... FL 3S7OI FOR: EItIIII rt..... E. ....... Jr. 10 w.yne F.SIwdlI. "..,., II ...... W. PllInhl..... CIrIIII. PA 17D1~ AI OF: DeclIIlar 14. 2DD5 IY: Judith C. HMIIy Farm GAl -'WnTOTAI.'...1GlIwn IIJ all madt, lac. -l~ IUlllIARY OF IAUEIT FEATURES SubjICI AdlNs 542 BclCI CiegII Point IlhId. NaIlh l.IgII..... BclCI CiegII Point e.t 1IIdg. 2100, Apt 2101 Foun-n Condo car St. I'etIrIbuIg CcuIlr PIndM .. FL _CadI 33701 c... TIIl:l 251.01 !lip RIIna 04-3,.,5 ~ Frk:I S NtA IIIII<<~ IIlIP 1123IOI BanawICIIrt EalIIlI of Merle E. Miller, Jr. 1.1I* EalIIlI of Merle E. Miller, Jr. . (SqiM fell) 1,ll70 Frk:I pIr" fGal S LacIIan BclCI ClIga PI . 33Y_ CclnIan UpdldBd TalII RoamI 5 ...... 2 .... 2 .... Judilh C. ......., DlIII<< AppnjHd VIM o.c:.mbIr 14, 2lIll5 RIIII EIInIIII<< VIM s 380,000 fGnn SSO - 'MllOTAl..IppIIiIII....1Iy alllllllll, Inl:. -I-<<1O-A1.AMOOE ..-., ......... .... individual Condominium Unit ADDI'IIsaI ReDort FII' == lbI ....... III .. II " ..- .. __II1II .......... n -- M......... -- III" nwtlII VIIIII Ill.. ..... -. I faIrty AdINa ............ # ~ ClIv SlIII R 1In ca !37M ~ .am- Jr. llwMr III PuliIIc IlIcanl ..." ~ N. I'.llIdv PineII.- ~... o.-PoW~_.!ltllll-A..t21l11l ~PIn:II' 1-1 1 101 TIIlV.. 200II R.E.T_S !ll11l.M IPml:IIIInI ...... ::iMaPolnl- ....# 14 ....RlIna 04-31-15 CInIIlITract 251.l111 ~~ow. T... ,Val:Inl -~S /I HOAS:I2!Ii.OO r1__ MOIrmonl1 ~ ~ fie SlnIIII n \.IMIGId n Ok ldal:lIIIl T,. ...... TIRdan I' RIIma TIRdan !l(I Ok dal:lIII I.mdIrICIR .....- r. AdINa lAW 11.. allIIId lIIr.. cr ha. .. allnllllr..1n ........1IlIIIlIII "..1lIIctM .. III.........., IIIDaII dIII.-aIl' .... .............,1 IIllI ~II. "........ PA 17013 r~ VIs J'X! No .......1; I 0 dd . 181 till 1IIll.... c:anncllllr.. fer..... pII'Cl-.I DISIl:lIan. EIIpIIkI" ...... III.... Ill.. -.ctlar.. cr why" ~ _1IIll lIIiiiinMd. . .- .....;.. CoIh:lPllclI NlA o.lIICo1h:l II,,__"_III-~ ~VIS ["No DaSClll1:ll11 ~.~ 1IlJ1lnn:iII................ .. --. gill cr ~1IIlIlInCI. &)"" pill IIr IIlJ pq GIl..... lII..lIanuW? 1111. ......I11III d* __ dIII:IIII......".. .lid. N1A [] VB 181110 ~.~_..~. ';i~i~:~~--:~'" i..ac*I ~ ~ SlIIullII r AnI 1_"'" 121 SlIIIII lloo!IIolnII ,...11. 0. 751 25-751 \RIIr 2ft J ..... !5(] In IIIIIRcI 0. SulIlIIv lInMII IIlIIIId OOSllllll &lalI IIIIIIIIIIIIII'IIIII \RIIrS'" OOM" r 0.__ 80InIIdIs A- N PllI:E Nli 0ntUIIl S mnm """I 2-4. M lllw - ..- 575 11m M C4InMl:III ,yo PrIll. 33 Ok ~ ~ ~ ~ ~ 5~ E In .....~ lIIr...... 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FnddII MIl: Farm 465 MIrch ZOO5 ....1 a18 faIriI Mae Farm 1073 MIn:lI2005 ram 1073 - 'WInTOTAI.' ........ salIwn by IIlIlllldl, Inc. -l.aoo.N..AMOOE 08060236 Individual Condominium Unit ADoralsal Reoort ""08060236 0IIcIIbe.. cardIian III" -- _ -lIIlill1l1M1aft. . h..;It in a aarden rI-. The BSrI . The ,.... 0IIcIIbe.. t:CIIIIIIIlll'" _1IC:lIIIIn IlIcIIlIII. bo.l- __ -..t.or ft-'" c:ommunitv. laundtv .......... llInriI-. MIl ~ __.....IIIIId~ er."~' AaocIIIIan? 'VII 1)( NIl 1 Va dIsaIIa ..IIIIlII-. ...... 1s..lI.ctlllllilcllD...1II1I'I VII IX' NIl n..$ .. _ ldllc:rlllllrmlllld concIIonIl ~...... r.:-. ........1IIliIl:I1llt 1IId1VDl? ~ Va [1 NIl I No. dIIc:rIII... CGI1III1ft lIII..lIIIc:lllll_ "'1IlIIbIabIiIv. I U lid l2Si lid 1llIl..,... CIlIIdanlilin ...-1iudgII." _,... ~ Ill..... III" ...,.1II..1iudg11 (IdIquIey III...., -. *l. . lIlIy ..1IIIInII_1llIl......... ~...- .....1.... .....lIlAdIInIII1... .. III" 1IIliIl:Ir.:-.? Va~NII 1 Va. 1mII" cIIanIII... dac:riIIt. ClIIIIInd lD. 1II....111111v IIId dIIlan. III IUIIIIcIIIII din _ I IIIaII !Xl ~ . '11_ llIaII. low dacrIII ~... "" IpICiIIII' lIIIIIlII c:hn:lllllllcl1II",..lbaId lIII" ClIIIlbIiniIn cIaclI1MI.lIlA 1IIIlIngs, .. ~ lI-.lD..1pIIIiIIr7 !J Va ~ NIl 1 Va. dIIaIlI_IIIIIIIn..lIIIc:lllll_.......... NanII ~ ldlMm$ Z.1lO _IIIlIIIIIXI2 _I 3.1IIIlI1Ill ... 1lIIIIII__ "'11I___.$ 2.711 .....1ncUIIlI1n....__ IIIIlI[J_ J ,.......... I. I HIClIll:llr I I GII rx1 WIIIr rx1 Ii.- rx1 CII* ~ 0Iw IdIIaIIIl ~ Gmllnda MIaa. .....lv. Trull ,"~..' .o;, -:.-" ,,:/-,. .... .. "," _._'.." ", <.... ~ .......,. ;';.~ :'C'~<\:;'I > ~-.:, E.~~ ..:~"~'~=ii_ IIIIlI I5G 0.- eo-d I J ODIn .1IIc.. 1 Car .iX1 CInfnIIt IXIInlMU11It IIIIl WIilIClIl -...Ava ~ i AIIIiIlId r><IOlnd i 0Iw /dIIaIlI IlIIcn ___AWl 0Iw Dock i WIIlIdlMr PmIna s.e. ,... _...... ClIIIIID: 4 IlolnI 2 IJIdIoana 2 .. I UIIll SalIn ftlllII Gal UIIna Ana AIIM GIIdI ~........ _......IIdlIdIlII.....-Iv....., 1&1 Va NIl 1110......... .....rGl-lDal.-lIIIIIdIln......... AdIIIanII..... /IIIIdII....,_.... &1 ----- 1lIIaIIe.. CllIdIanIll..===:..... RDmn *.1. or exliImal nolMI. ~ "'1III1IIIIIIicII dIIII:IInl:IaII'..... ClIIlIIGnI...IlIIIcl.. II'.....1IIIIlIIV III" - r I Va r><I NIl n.. dacrIII ...""-> . ... be in an A 1IocxI_. '-r ... .. IllIIIIDmtlD.. Clll1IlnIc:Illn*.? ~ Va - NIl 1110. dacrIII I I2Q lid L lid 1llIl-a...1III er...._III.. -- ...........- Mr-= lid ~ lid IllIllMll_1IIIcr ..... .......11I.. ...... _1IIIcr1D..1llIclIlI dlllllltiI..... 0Ila ICIlRI/sI Mr-= ~lId I lid IllIllMll_* ..... .......11I.. __ ..... f1lr.. Vllrllllcr "" dill III" III" CGIIIInblIIIII. 0Ila mIllIIIl RIDarl.. .....11I.. -.:II.......... III" '* 11II..... IlIIY III" "'Cd .......... 1ImII......1IIIcr .....11I_ 31. IBl I SII.ECT ClIlPMMlE SAlE .1 COMPMMlE SAlE #2 I ClIlPNWllf SAlE #3 0. III PIb- SIWf..... IUI2I III 12111 3/111I1 IlII2O/I5 Pri:l1II PIb- SlWTAI1IfIr 11111!l. m IIIlU 111 IIII1ll IS387JillO DIll Slua/I 1- - Pub. ... IPu . - IPub._ EllIcIIII 0.11I 0Ila 51m1/11 IlII2lll lII2lll 1M IIIII2IIIIII .. allrlCI'lIIIer..... _III.. ...- 11II.... wllhIn PIlar _ rib FnIddIe Mac Form 485 MIn:lI2005 ...... 2 rl6 fIrne Mae Form 1073 MIrch 2005 fann 1073 - ...1OTAL.IppIIiIII....1lJ .lIl1111llt, Inc. - l.allll-ALA11OOE individual Condominium Unit . . I Reoort FIt, == lbn.. " I CIIIBI aIInd Iar l1li In .. 1n0dM1nIIII1 '1DlllIlI IDI 578500 ...... 111 ---...!W:.. ~"""'IIIGIIIII"In"_tnnl 1S.SIC IDI 448800 IallllE I ~ 1 :g # 2 Clll'AIWIl! SALE # 3 MmI_ 542lloc:1i ClIll8 PalnlBMI. .llloc:1i CIIga Palnl Bhd. S. 573lloc:1i CIIga Palnllllvd. N. 471 lloc:Ii CIIga Paint BMI. S. INti Sl--- ~ - t... ..............:: ~ ....08 ..............-. a - 1St PlIIMsbura. FL 33708 ~~nlloc:liCllgaPaint~ lloc:IiCllgaPalnl~ lloc:IiCllgaPaint~ lloc:IiCllga~~ .... 14 Sblr- IEiahtCando I_ID_ "":. ~ O.15~SE O.D2m1e1SW 0.15 miles SE S* PriI:II 1 Nl""i,:; ":"'':>'''''''',. $ 3111Mt .~.\ ,. .",:~~:>.c';; ,1$ ~ - 0'" /' :'~,,,. '.;';.: .' 1 388000 :=:SlJl... 1 .....II.~=K,.. ':'~' !.lt~~~t,.;",J""};': ~LS~1~~IU:<. .,,; VIIIIcIIiII_.1 .,,.,.' , ^"'... .............. Do"._ OR 1 ~ ...... R8c. OR 141142.7V5 VAUE AIlJUS1IotEN1S IlESCRPlIIII IlESCRPlIIII +/~'I"- IlESCRPlIIII +1-1 S _ DESCRP1lllH +"'1_ 6*1.. FiIRIng , .';X:,";'.:' Conv8nticIlIIII c..h ConvrionIIl ClIasllanI., ..a1S1l111in1 :.:),:.;.) '..\',., wlniiiil LDCIIlII PI ~- IIlIA 1Ia....... en.. a..III ...1IIc. FIllIIIs flIIar LDCIIlII - .~ ActIIIII... eo... MMllIIIII IlIlam CllUIIl GnlIILJIIim.. ........ RnImI llalInI...llIIIII l'tIIcIIaRIIlJIIIv -- .:- fIIcIR.... ~ NIt ..... S* PriI:II ~~ IndIc* va... S*I ',.' ...; ",".:." EIIn*I-lIIIIIIIt-.1 -a1~ .....o..t wIhln .....VllllIIr: ... ..,.,. """ mil. !IlOS PI 32lI,IlII PaoI,~ '11 1 1~1.1ll PolIl,nr-. '11 1 F- ....... Il'Wrl PolIl,~ '11 1 :18. PaoI,nr-. '11 lat ~w. ICRllIA... ICRltIA_ 33Y-- I,"y_ !......- A- T....'.....'... T.... t..... .... 4Til, ~.~ 1M1ft....1I. 1~1I. NONE NONE 'None None 10- 10- :iil!~-;';' ~,- ICIlS/A_ :wy.... ,- TGIIl 1.....1... II 2 I 2 1oi11ll1111. II. NONE None A__ +1 TGIIl .....1.... iii , I 7 1Mll1 .... ft. NONE None ~ !r.-...- 10- o A_ I A- le. A- I - ..... ..... ..... lMk Dodl .....,...: ~ 1'i?I-+ S NIt 4.7 1 QuIa 4.7 1 1 -6.1llX 1-1 + NIt ~IlIUlllll 6nIIs 1 , $ 3IIIl.llOO In-'. 151W n+ 1')('. 1 NIl 1.3 1 :U11llX QuIa 1.3 1 $ -.. 1 380 000 .;..... 7IIlIII X an.1la- Iar mnt......- 1 MV -. ".:. \. ~7lIm11 .. > ,,' '::~ : ".. . ..-;: . . IndIc* v-.IIV IncamI AIIII-" ---- 1M .1 1 'UII\ Mft . ~7lI mil .... =::;-.--,;-;: to 1IiI1plIIiIII1I.-. ~... .", [J...".... per pin n .......... .. .. ... a111lJl1l111111l;1 ClIIdIan ... .. ____ ~ - I~ 0 IUlIjIclID "laIawIIV npIis ar IIlIIJlIDIlI .. .. ... all ~ ~..., ... .. .. .. ........ .... _ ~ ar 0... ".. IlIIId .... ..... ClIIdIaIIII __ _ l1li.... ...... .. -= "Aa .... No .. II . ....... .............."..IIIIIllar........ _"...... ....-.......... !I.M.""""" ~.. ..... ....... .. ..... ....... ., (DIIt .... " .. .... ~ . ...... ." II. ... IRfIIlr l1li II III ..... " ...1IIjIoIt II S 380000 ." ~14 2Oll5 ..... II III _" -.......... _"....-..iL P1g131l16 FunlI.... Fonn 1073 Muc112Oll5 frIddII MIl: Fonn 465 MIlCII2Oll5 Farm 1073 - 'WInTOTAL.IIIpIliIII..... bJ IIIIlIlldI, Inc. -l-GAlMOOE individual Condominium Unit 060110236 FIII'06Ol10236 this report fOl11l Is designed to report an lIJIPraIsaI ofl unit In . condominium project or I condominium unit In I planned unit development (PUD). This report fOI11l Is not designed to report an appraisal of a manufactured horne or a unit In I cooperaIIve projact. this appraisal report Is subject to the folowillQ scope of work, In1IncIed use, Intended user, deflnltlon of marlatt value, staIIment of llsumplIons II1d ImIlIng condllons, and CIIlIfIcaIIons. MocIIIcatIona, adcIlIlIIS, or deletions to 1IIe Intended use, Intended lIIII', delInltion of marlatt value, or auumpllons and Imltlng conclIlIons are not pennItIed. The appraiser may upend the scope of wwII: to IncIudlI lilY IdcIIIonII I'IIII/llh or anaIyIls nlClIIIIY based lIII the compIelCIty of this IppIlIisal IIslgnmenl MocIfIcations or deIelIons to 1IIe cer1lflcallons are also not pennItted. However, adcIIIonaI certifications that do not ClIIIstIlule matelIII IIIeraIIonI III this appraisal report, auch II thole reqund by Iew or those reIIIlId to 1IIe appraiser'. continuing educallon or I1lIIllbeI8hIp In III appgIsaI arganIzaIIon, are pennItted. SCOPE Of WORK: The scope of wwk for 1II1s eppraiIaI Is dsflned by the compIuIty of this appraisal assignment and the repor1Ing requirements 01 1hI8 Ijlpl'IIisal report form, Including the following cIelinlllon of marlatt value, statement of ISIlIII1JlIonI and ImIlIng concIItIanI, and celtIfIcalIons. The Ippl'IIser must, at a ninlmum: (1) perfonn I complelI visual Inspection of the InteIIor II1d exterior areu of the subject unit, (2) InIpect and lIIIIyze the conclomInlum project, (3) inspect the nelghbarhood, (4) Inspect eacII of the compnble ... from at Ieut the atnet. (5) march, VItIIy, IIId IIIIIyze data from reIabIe pubic IIIcIIar pRvate 1OlIICII, and (6) report his or her 1IlIIysIa, apInIana, end cancIuIIonI in this appraI8aI report. INTENDED USE: The Intended use of this Ijlpl'IIisal report il for the Iender/clent to evaluate the property that Is the subject of 1hIs apprIIsaI for I lllCIltgIge finance n.action. INTENDED USER: The Intllnded lIIII' 0I1111s appraisal report Is the Iender/Clenl MARKET VALUE: The most probable price which I property should bring In I compelillve and open marIcat under d concIItlons requisite to I '* sale, the buyer and HIler, IlICh acting prucIen\Iy, knowledgeably and IllUming the price Is not aIfICted by undue 1IImlU. 1",** in 1hIs cIelinItlon II the ClIIIIUI11llIIlIon 01 I sale II of I epecIlIed date ancIthe puslng of lItIe from ....r to buyer under ClIIIdItione whereby: (1) buyer and HIler are typk:aIy motIvlDd; (2) IIath parties are ... inIarmed or wll IIMHcI, and IlICh acting in what ha or ehe coneIdere his or her own best InIIIIII; (3) I rusonabIe time Is IIowId for IlqIClIlA In the open mar1lat; (4) payment Is made In lIlrmI of cash In U. S. daIare or In lIlrmI of flnanclal lIIIWlgements comparebIe 1heretD; II1d (5) the price repreIIIltIthe IlCImIII ClIIIsIdenIIon for the JIl'lIIIIrtY sold undected by specIaJ or craaIIvII financing or Illes COIlCIIIIonI* grantlId by III~ IIIlICIaIad with 111. sail. * Acljustmen1I to the comparables must be made for IplICiaI or cnNIlIve financing or Illes COIICI88Iuns. No edjultmlntl are necenary for thole coslI which are normdy paid by ...... II I result oIlradil1on or lew in I marlatt _: 111111 costs are I'IIIIIy IdenIIfiabIe lince the IIIIer pays these costa In vIrtudy II ... tranIIcllonI. SpecIal or cruIIve flnanclng adjuatments CII'I be made to the comparable property by CCIft1IIIIIlIII. to flnancIng lIlrmI oIfIred by I 1hInI party instllullonal lender that is not IIrlIIdy invalvtd in the praperty or tanIIcIlon. Ally adjuIIment IhauId not be calcul8tlld lIII I mechenical doIar for dollar COIl of the fInIncIng or clIIIClIIlon bul1hI doIIr IIIICIlIllt of lIlY MIjuItmInt ahouId apprlIIdmate the 1lIII'kIt'. I1IIClIon to tha flnanclng or CICIIICIIIIonI bIIed on 1hI tppnIIIer'l ~ment. STATEMENT Of ASSUMPTIONS AND UMmN6 CONDITIONS: The lPPfllser'a CII1IIIclIlIlIn In 1his report II subject III the following IIIUIlIPlIons and ImItIng conditions: 1. The appraiser wiD not be responsible for rnalIers of I legal nature that lIffact either 1IIe property being lIIlPI'IIsed or the lIlIe to it, IIll:IpI for InformalIon that he or ehe became lware 0/ duIfng the resarch InvaIvtd in pIfformlng thla appraisal. The appraiser IIIUI11IIthat the lItIe Is good IIId rnarblabIe and wi. not I8IlCIer lIlY opinion. ebout 1IIe lItIe. 2. The lIIIIIRUer has provided . IileII:h in thla llPPfIIuJ report to show the appnlIldmate cImensIona of the Improvements. The skat1:h is included lIIIly to usiIt the reader in vtsualzlng the property and underatendlng the appraIser'. detelmlnatlon 0/ Itulz.. 3. The IIJPIlIiser hII lIXIl11ined 1hI available flood I11IPlI thllt are JMOVIded by the Federal Emargency Manegement Agency (or Cllhar dill 1ClUl'CII) and hII noted in tIW apprUII report whether any pclIIIon of the subject site Is located in an identified SpecIal flood Hazard Area. BICIIIII 1hI appllliser II not I surveyor, ha or she makes no guarentaes, axpnISI or Impled. regardng 1hIs detIrmInatIon. 4. The IIJPIlIIItr wtII not give tlIIIImony or appear In court because he or aha made en eppraJsaI of the property in queatlon, unless specific: arrangements to do 10 hive been made beforehand. or II otherwise requIrecI by law. 5. The appraiser hll noted in 1hiI appraisal report any Idverse condllon. (euch . IIIIdecI repalre, detarIorIlIon, the presence 01 haZIrdous wastes, lIDIIc substanc., etc.) obsllVld IIurIng 1IIe Inspecllon 01 the subject property or that he or ehe became aware of during 1IIe resllll1lh invalvtd in perfonnIng tIW lIJIPrIiIaI. Unl... otherwise ItIIed in 1hIs appraisal report. the lIJIPI'Iiser has no knowledge 0/ any hidden or ullappll'lnt physical delIclencltls or lIllverH concIIIons 0/ tha property (such II, buI not ImitecI to, IIlIIIIed repaiR, dIIlerfcnIIon, the presence 0/ hazardous wastes, lIDIIc subatlIIIcea. adveree environmental condlIona, ..) that WlIUId rnaIaI 1hI pruperty leu valuable, and has IllUmed that 111.. are no such concllllon. IIId IIIIkn no ~ Ill' w.1'IIIlIII, ....... or implied. The appraiser wi not be responsible for eny such conclIlIona that do exist or for eny enginllllllng or tuIIng lhal might be required to discover whather such concIIIIons exist. BlICIUII 1hI ipprIIaer II not en tllPIIt in the field of envlnlnlllllllll hazanIs, this appraisal report must not be consldered II en envIRIIll'I1IIlIII ISIIIII1lIllt of the PflIIIIlty. 6. The lIJIPI'IIser has based his or her appraisal report and valulllon conclusion for an appraisal that II aubject to salIsfectory CGqJIatIon, repaire, or alterations lIII 1IIe auumpllon lhal the compIeIIon, repairs, or aIIeralIons of the subject property wll be perfonned in I pnJfesIionll manner. FreddIe Mec Fonn 465 M1rd1200S Pege4ul8 FlIIIIIIe MIe Form 1073 Mercb 200S fann 1013 - 'WInTOrAl. '1plIIIIiIaIIIIlIwn by. II madI, 1nI:. -1.m.uM01E Individual Condominium Unit ll606O236 FIll' 06060236 APPRAISER'S CERTlRCA nON: Thl ApplaIslr cdlS and IlI111l1111at 1. I havI. at a minimum, deveIaped and reported this appraisal In lICCOIllance wIlh lIIe scopl 0/ WOIk requlremen1s stated in this appraisal report. 2. I perfonned a complete visuallnspecllon 0/ lIIe Interior and IlllIerlor areu 0/ lIIe subject property. I reportecIlIIe condition 0/ tile Improvements In facluaI, specIlIc terms. Ildenllfled and reported tile physical delldenclellllld coukI affect lIIe Uvablllty, IIOUIldness, or 8lI'uCluIII InIegrIly 0/ tile propeIty. 3. I pedormed this appraisal in accordance wIlh tile requirements of lIIe Uniform Standards of Professional Appraisal Practice 1IIat WIll adopted IIIlI promuIgaIed by lIIe AjlpIaIsaI Standards BoanI 0/ l1le AppraIsal foundation and lIIld were in place ld lIIe time 1hi8 appraisal report wu pqpared. 4. I developed my apinlon 0/ 1111 market value 0/ lIIe 181I property 1IIld is lIIe subject of 11118 report ba8ed on 1111 sales camparIson appnIICh to valul. I have adequaIII comparable market data to cIeveIop a retIabIe ..... comparison approach for lIIis appraisal aulgnment. I further certify 1IIat I consldered tile cost and Income approach. to value but cId not cltvelop 11111I1, unless 0lIIrMH indicated in this report. 5. I IWlIIf'Ched, VIIIIIed, anaIyztd, and reported on any eutrIIlt IlIreement fclr .... for 1111 IUbjIct property, any o/ferIng for sale of tile subject property in 1111 tweIYe months pilar to the efteclIvI dati 0/ this applIiIaI. and tile pilar ..... of lIIe subject property fclr a mlnInIIm of 111111 yean pilar to tile lIfIIcllve cIaII 0/ thiI appraIIeI, unless aIhM'wI8I IndIcatIlCI in 1hI8 report. 6. I resean:hed. verIIIed, analyzed, and reported on tile prior ..... of lIIe comparable sa/es for a m1nin'Rlm of one year prior to the cIaII 0/ sale 0/ the comperable ilia, unless otherwise IndicaI8d In 111I8 report. 7. I seIec:ted lIlcIllled comperable sale8111ld an 1ocaIlonaIIy, physically, and functionaly tile most similar to tile subject property. 8. I have nOlIl8ed comparable sales that WIll tile raul of comblnlng a land ilia wIlh the contract purchase price 0/ a home that hll been buill or will be built on 1IIe land. 9. I have rIIIOI1ed edjustmenls to the camparalJle saleI1IIat rIIIect the ITIIIIcIIt's IIIC\Ion to lIIe cItIerenc. between lIIe subject property and the c:omperable saleI. 10. I verIIIed, from a cIainterutad IOlIrce, II infonnaIIon In this report 1IIld wu provldecI by parties who have a ftnanciallnterest In lIIe sale or ftnlliclng 0/ thl subject property. 11. I have knowledge and uper\ence In appraIslnfI thia type of property In thia market ana. 12. I am awan or, and have acceis to, the nlClI88IIY and appruprtate pubic and privati data 1OUl'CII, such II multiple IstIng HIYic., fix assessment 1'ICCIrds. pubic land ncords and othtr such clata IOUICI8 for 1IIe ana In which tile property is 1ac8ted. 13. I obtained 1IIe InlonnatIon, estImaIeI, and opinions fumlahed by other parties and exprassed in lhis appraisal report from rIIabIe sourc. 1IIal I beIeve III be tnle and c:onect. , 14. I have 1IkIn Into con8lderallon the facIln 1IIld have an Impact 011 value wIlh rwpec:t III the subject nllghborhood, subject property, and the prcJldmIty or 1he subject property III adVlIrIe WklIncIIIn the dIveIapmenl or my aplnlon 0/ IllII1lIt value. I have nOllId In thia appraisal report any adveIIe condItIonl (such II, but not ImIlIId to. needed 1'lIIJIIIra. dItIrIondIon. the prasancl at hazanIauI WIIlII, bdc IUbllanC., IlMlIII IIMI1IllfllIIltaI conclIlIone, elC.) -.ved dlI1ng 1he inspection at lIIe IUbjICI property CIl' 1IIat I bec:ne aware of dlI1ng the mean:h involved In I*fom*Io 1hI8 lIJlIlI1IsaI. I have COIlIIcIerecI1IIese adveIIe concltlons In my analysis 0/ lhI property value, and have "POrted 011 lhIlffect 0/ lilt conclllona on lhI value and IT1IIllIlabiIlly at lhI lIUbjIICt property. 15. I havl not knowingly wIlhheld any Ilgnillcant InlonnatIon from 111I8 appraisal report and, III the best of my knowledge, all IlalImInts and InfonnalIon In this appraisal report an trul and c:onect. 16. I stated in this lIPIHIi8aI report my own pnonaI, unbiased, and prafllllSlonal anaIysIa. opinions, and conclullonl, which an IUbject only III the aasumplions IIllIlmIlIng condItIon8 In this lIPIHIi8aI report. 17. I have no PIHInt or JII1IIIIIClIvt IntInI8t In the property 1IIat is the IUbject at this f'IIIOIt, and I have no prwent CIl' proapectIve pnonaIlnterast CIl' bias wIlIIlI8JIlICt to thl par1Iciplnls In lhI trInIacIIon. I cId not basa, aIlhIr partIaIy CIl' completely, my analysis and/or opinion at markIt value In lhlII apprlIiIaIlIPGI1 on the reel, color, 1IIIglon, IIlIll, .. I1IIIlmI staIII8. hanclcap, farnIIaI 8llIIul, or nallonll lIIIgIn at aIlher the prospecIIve ownlll CIl' occupanls of the subject property CIl' a1l11e plllllnt ownn or occupanls 01 the properll. In the vicinity at 1he subject pruperty or 011 any olher basis prohIbIlId by law. 18. My empkJyment and/or compansallon for performing lIIis appraIIaI or any future CIl' antIclpalId appraIuIs was not conditioned on any IlIIHment CIl' under8IancIng, wrIItlln or otbeIwln, 1IIat I wouIcl report (or prwlnt analysis supporting) a precIetlInnIned speclllc value, a pr'IIdetarmlned minimum value, a raftlll CIl' clIrectIon In value, a value 1IIat favors 1IIe cause at any pIMty, CIl'the lIIIlIInment of a speclllc mull or 0CCUITIIIClI of . specIlIc subllQl*lt evant (such II approval at a pending lIllIl1lIaIIe loan applIcalIon). 19. I persona/Iy prepand all concIuaIonl and opInIone about 1he 181I I8tIIe 1IIld wn set foIth in this lIPIHIi8aI report. If I reied on IIgnltlcant mI property appraIaaI I8Iis1IncI from any IndvIduaI CIl' IndIvIGlaIs In lie pelfonnance at this appraisal CIl' the preparelIon or this appraIaaI repoI1, I have named IUch lncIvIcUI(s) and d8cIosed 1IIe specIlIc taska performed In 1hI8 appraIaaI report. I certify that any IncIvlcluaI 10 named is quaIlIlId tD pIlform the taska. I have not aulhollzIlI anyone III maIcI a change to any 11Im In thll appraIIaI report; therelorl, any chanlll made to lhis appraIaaIls unaulhOl1zlll and I WUI taka no responslblllly for It. 20. I ldanlIIIlld the Iender/clent In this appraisal report who II 1he IndIvtcIuaI, organIzalIon, or lIlent for lhI Cll'lIIIdzIlIon lIIld onIered and wII receive thlllPJll'llsal report. FrecIdIe Mac Form 465 Ma1:h 2llO5 Pagesar6 Fannie MIl fon111073 March 200S faan 1073 -"WlnTOTAI.'1lIlIIIiaI1Gllwan by all madl,1nc. -1~ Individual Condominium Unit 0IlIl60236 FIoIIOllll60236 21. Thl IIndtr/cllnt may cllCloal Ill' dlatrlbutt this eppraisal report ID: the bomlwer; another lender at tile request or tile bonvwtr; Iht lIlOI1pgtt Ill' ill suc:cessors Illd ..signl: mortgagl Insullll1l; government sponsored entlrpllsu; other IIClOI1dIry nwkIt 1JII'lIeIpanta; cIeta colItclIon Ill' rtpCIl1Ing stnIcts; proItuIonaI IjlpIIiaII organizations: any eItpartment. agency. Ill' InatrumIntdy of Iht IMIlllcI SlatIa; Illd 111'/ lIlatt, Iht DIst11ct or Columbia. Ill' Cllhlr jurisdictions; without having ID obtain 1ht ~s Ill' IUPII'ViIarY appndur'1 (II appIIc:abIe) consent. Such consent must be oblalntd btflll'l this lIPPrtIaaI report may be cIscIostd Ill' cIatIibuttd III lilY Cllher party (including. but nallm11td III, thl pubic thraUgh advtrtIsing. public rellllonl. ntWI. ..... Ill' Cllher medal. 22. I am IWIrt that any dIcIosurt or dlatrtbution of this appraisal report by me or the Iender/cHent may be subject to certain laws and reguIIIIons. Further. I am aIao subject ID till provIaionI of tile UnIIonn Standardt of ProltIlIonal AppraIaaI Practlcl t11lt perlIIn III chclosurt Ill' dIaII1butIon by me. 23. The borrowtr. another lender at till request of till ballOW<<. tile I110ftgagIl or Its SUCClllore and IIIlgns, mortgage In8llrtl1l, government sponsored enterprI.... Illd oIhar lecondary markIt parUcIpanlS may rtIy on tills appralsaI report as part of ..y morlgIgt ftntnc. trensaction t11lt InVoIvts lilY one or mart of Ihese ....... 24. "1hIa IPPrfIaaI report was trenamIIltd .. 111 "eItclnlnIc record" contIInlng my "eItcIronIc slgnIIurt," .. lhoee terms Ire dIIIntd In IIppIcIbIe ftdnlllld/Dr stall laws (1llCludIng tucIo and v\cIeo rec:anIIngs). or I tacIImIIt 1rInlmleslon of IhIa epprUaI report containing . copy Ill' repreaantIdIon of my tIgnaUI, tht IPfll'IIuI report I11III1 be .. tlIlC1iv1, anforctabIe and VIId u " . PIPIl' YIrtIon of IhIa eppraiAI report were dtIIvtrtd cantaInIng my original hand wrttten Ilgnature. 25. Any Intentional Ill' nagIIgent rn\srtprIIIntdl(l) conl:IIntd In IhIa appreIsal report may mull In civil llalilty aneIIor criminal pendles IncIudng, but not ImIItd to. flnl or impItlOllment or both under Iht PfOVisIons of TIlle 18. UnItwd States Coda, StclIon 1001, II 1IlI., or similar stall IaWI. SUPERVISORY APPRAISER'S CERTlRCATION: Th. SuptMsory AppraIatr cerlIfI.. and agrees thai: 1. I cIrtctIy lupeMltd till appraIatr for tills appraisal assIgmMnt, hlVl read Iht appIIisal report. and agree with till ippl'Iiser'l anaIyIiI, opInlonl, statements, conc\uIIonl, Illd tile IPPI'IiHr'I cerlIlIcaIIon. 2. I accepI ful ruponslbluty fur till contInI8 of thll appraIaaI report including, but not ImIttd ID, tht appraIser'1 analylls, opIn1C1111, stlIlImentI, CClIlCIuIIon.. and thl lIPPrtIaar'l cerlIlIcaIIon. 3. TIlt 1PPI'Ii.... IdentIftad In tills appraIIII report Is Iilhtr . sub-cxlnlraclDr or an If11lIoYtt of tht suptrvlaory IjIprtiaer (or till appreIaaI h), Is lJIIIlled to perform IhIa appreIsaI. Illd Is ICCepIabIe ID perform tills appraisal under tht lIPPlIcabIt mbIlaw. 4. This appraIsaJ report compIes with Iht UnIform S1andanls of ProfesllonaJ Appr8IsaI PraclIct IhIt were adoptId and prumulgattd by Iht AppraIsal standardI BaIrd of TIlt AppraIsal foundation and IhIt were In placl It tht 1Imt 1II1s appraIaal report ... prtpIrtd. 5. "tills..... report wu transmllftd .. .. "tlaclRJnJc record" containing my "1ltclronIc aIgnalurt," u lhoee terms Ire dIIIned In appIIcabla federtI aneIIor stall IaWI (_1ucIng audIIl and wIdto recordnos). or . ftcIImIIt lrmIamIuIon of this appraisal report containing . copy or rapruantalIan of my aV1abn. 1111 appraIstI report ahaII be .. eIhIcIIv8, IIIlfon:ttblt and VIId u if I PIPIl' .ralon of IhIa appraisal report were dtlvered COlIlaInIng my ar\glnal hand WIIIttn lignllure. ~~~~_&- TeIep/lont Number m 58810118 EmaII~h&.lI---...ClIIII DiItt of S1gnlturt and Report JuIv 1I5 2OOl5 Eff1IclIya DiItt of AppraIsal ~ 14 2lllI5 SIata CtrUIIcIlIon # IlI'State 1..Icen.. # R118314 R . .d T..... AIIaIwIMr or~er QD# State FL ElcpIratIan DiItt of CIllIIlcalIon or Llcensl 11l3Ol2OO8 SUPERVISORY APPRAISER (ONLY IF REQUIRED) SIgnature ~~~ Name YMldv ~ PIIIlI Company Name tIuaI-. PIIIlI... . Company Addrts. 125O......111vcL sa. 1 lMao. Fl33770 ADDRESS OF PROPERlY APPRAISED 542 80clI c-. PaInt Blvd. Narlh .542 at. ~ Fl3370l APPRAISED VALUE OF SUBJECT PROPERlY S 380 0110 LENDERlCUENT Nama Company Nama EataIa of..... E. ...... Jr. ~Y AddrtIs cfo Wa_ F.SMdIl -. Law 53 W. Par PDmInII SIrMl c..tIeIlI PA 17013 EmlIII Address TtltphCllll Number 727 SIIIl10118 EmaII AddrIIIhwI~-.1.ClIIII DiItt of SIgnature Julv 5. :!008 StIle CIItIIIcatIon # or SIaIII LIe.... # RI'VWWl18 SI Celt AM Ar1Dir StIle Fl EllpIndIon DiItt of CIl1II\caIIon or Llel"" 11l3Ol2OO8 SUBJECT PROPERlY o DId not Insptct subject property i8l DId Inapact lIXlerior of subject property from atretl DiItt of Inaptct\on 7/112008 o DId Inaptct InttIlor and utartor of subject property Dalt of Inspection COMPARABLE SALES o DId not Inspect IlderIor of c:ompartbII..... from atrHt l8J DId Inapact IlderIor of c:ompartbII'" from atrIIt Data of InapeclIon 7/112008 FnlddIa MIl: Fcrm 465 M1rc112005 Plge8of& FII1IIie Mae Fcrm 1073 MIrch 2005 farm 1073 - ....1OTAl..1AIIIiIII1CIlIwt IIr ala 1IIllII.1nl:. -1-<<JO.AUMODE Subject PIlato 'a.. IF ~;:;... CaunlY PtnelIn SlIIIFL liD Code 33708 lubJ'" 'ront 542 Boca CiIIga Point Blvd. NoIIh. . 542 SIIII PrIce HlA GnIII UIlng Ala 1.400 TaIIIRlllllIII .. TaIIIllIdraamI 2 TallllIIInamI 2 I.Gl:IIIan Boca CiIIga PI VIIll w.wftonl/GOOd SIll GuIIlr CBSlAvg All 33 V... SubJect Rear lullJect street Farm PICPIIl.SR - ...mAl.' ..............1Irt IIa madl,1nc. -l-tlJO.AUMOOE Sublect Interior Photo P8ge IE ~::::... CaII1lr ~ MFL lID Code 33701 =1 Sultject 542 Boca a. Point Blvd. NoIlh. .542 SIlls PrIc:e NtA Grall liWlll- 1,400 TIIIlII~ .. TIIIlIIIIIchams 2 TIIIlIIIIIhlllIIIII 2 \.aCIIIan Boca Clega PI VIew w.tIIrfranlIGoa $II fIuIIIY C8S1AVlI . 33 V..,. ..,.. IIId New Oedt IuItJect InterIGr l<IIcIlIn hll)Ht Interior GueIl Bed.-n fGM PlCI'Il.Sl- 'WInTOTAL .1IIlIIIiIlI.....lJy III modi, i1c. -I-1OO-A1.AMOllE Subject Interior '11010 '.ge I:=-===-~Jr'~ l.IndIr :.. of MIllie E. ~. CculIv PinllIIII S. FL zm CadI 33708 .u...... Interior 542 IlclClI CIIIga Point Blvd. North, . 542 SIlls PricI NlA 6IuA I.hing AlIa 1,400 TlIlII Raams 4 TlIlIIlIIchcIR 2 TlIlII WnamI 2 LocIIIon IlclClI CIIIga pt VIIw W~ SIB lIuIIlr CBSIAvu AlII 33 V... ....,~ ........ laterlor EndclIed PardI lu...... Ceurtrard Ent" FcInn PQllX.SI- 'WInTOTAI.' .....1dlRI by ala IIDdI, inc. -l-8lJB.A1.AM01lE Comparable Photo 'age I;=' ~.::~... l.IndIr &tale of Merle E. MiIIllr Jr. COUntY Pinellas SIIIIFL Zil CadI 33708 Com,.rallle 1 361 Boca CiIll8 Point EIMI. S. Plal.lD WIjIcI 0.15..... SE *1'III:a 316.000 6IuII1MIg AlII 1.400 TllIIIlloamI 5 TllIIIlldlIGllII 2 TllIII__ 2 LaliaI Boca Ciega PI VIllI WIIfmlIGood SIll llIIIlr CBSIA\IlI Age 35 V... ea.,.ra.... z 573 Boca a.ga PoInIBMI. N. Plal.lD MjICl 0.02 ..... WI *1'III:a 315,000 6IuII1MIg AlII 1,400 TllIIIlbnI 5 TllIIIllIdIDaIII 2 TllIII__ 2 lDCIlIlII Boca CiIll8 PI VIllI WIIfmlIGood Sill llIIIIIIr CBSIAvg Age 33 V... C_paralll. a 471 Boca CiIll8 PaInlIllvd. S. PIIIl.lD SdIIIIct 0.15..... SE * I'III:a 3111,000 6IuII1MIg AlII 1,400 TllIIIlbnI 5 TllIIIlIIInamI 2 TllIII...... 2 l.DCIllon Boca CiIll8 PI VIllI WIIfmlIGood SIll llIIIIIIr CBSlAvg ,. 34 V_ fGrm fIOIkCR - "WnTOTN..' WIIIaIIlIIlwn by III macll.1nc. -l.alJO.Al.AllOOE Building Sketch IF :-=':~- l.II* :...of.... E. MiIw Jr. .... ~ Caunly PinelIa U' ... Ca* 8Ul1 .,. - os AREA CALCULATIONS ~ ___ _ IIotT_ _& no. 1"'.00 1"'.00 JPn.__ ____ aa.oo aa.oo __ Hl.00 _.00 _ ...00 ...00 TOTAL LIVABLE (RlUIldIId) SlIIIFL ~. ..- -- -- ; t -- -- - .:.~/,= '/ .. A ... rr. LMNG AREA BREAI<DOWN - - I'U:ft _ U.O. ,",.0 1..0. ".0 1097 2 C..... . ~ 1.. TCMI (rouncIecI) Falm SKTJlIdSld - "WinTOTAl'1pIlIlIiIII1lIftwn ~ IIIIIlIlII, Inc. -l.aJD.A1.AMOOE ZID CadI 33708 111.00 a.. 00 1897 Lacall. Map IF!iE~~- l.IndIr Eatalt of E. MIIIIr . Cowtv ~ SlIII FL zm CadI 33708 FGIm 1IAP.LllC - 'WnTOTAl.............1Iy ala II1lIdI, me. -l.a.ALAM01lE MULn-PURPOSE SUPPLEMENTAL ADDENDUM FOR FEDERAlLY RELATED TRANSACTIONS Hu;1II NI nl Assoc*. "' 08060238 FlIe No.: 08060238 IlIcIr-.a.c EalIIIa of ;;E.~...Ic,. ::::::.:.0.::...::,":- ... " . l.IndIr =MIIIlI7~ ZIp Cade 337011 ThllIUl-PurpoIa 5up!IIImInIII AddIncPn tar FIdIIIIIy RIIIIId TIIlIIIdIana _ dHIpd tD plQWIIllIlIIlIl'IIW'" . c:an- VIIIiIIlt way tD __..... CUIIIlIlIllPlllAl alIndIrdIlIIII............ ~1lI FedIrII DIpoIIt -....:e CaIpcnIIan (flllC). III 0IlIce ~ .. CGmpI1lIIIr aI CuIIIncy (OCCI. 1lle 0IIca of 1lIltt SUpInIIkllI lOTS). .. RIIlIUIaD TIUIt CaIpcnIIan (RTCI.IIIII III FedInI RIIIM. 1'UIlPOIE' fUfICTlDII OF APPIlAIIAL 1lle....... III till appnlNllI tD....... ..IIlIIllIlVllul aI..IllllllctJlllllllllY _ cIIIInId..... 1lle I\InCIIIII aI"llIPIIIAIlIlD UIiIt .. ~ l.IndIr In....... ....JIIllIIIIIY lor 1IndIIg......... ThllII......, nlllldhllllCtlan. 18I EmNT OF N'I'IlMIAL PROCEll ZI 1lle appraisal II"" an" inIamIIIIOII gIIInd br" ~tnlm puIlIIc __. .....1dInIIlId _1nIpIC1Ion III" IIIIIIIctJlllllllllYIIIII ~.IIIII........ 111-.............. ....1IlIIllIl-. 1lle GltGInII- aI"_ panIIIIIls ~ In" DalaSau1:e IICIIIIII of....atpld ........... _ aI~............ 1lle GltGInII_1I ............ 1lle _II1II dill.. cCIIIIIdnd....... WIlIn &:ldcIInO inIamIIIIOII_ PIQWIded. .. - dIIrIIId IllOIl r1Iable l1li.... UIIII. IlaII boIIewd III III........ _ nallncluc11d In....... narUlld _. bIIII b... VIIuI CClIlCUIan. 181 1lle RIpnIGIClIan Colt III1111d an MaNMlI n Swift n kaI CDIt IndlcIIl!!!I ~ br"IPIRWIllnaWIedlIIof..1DcII1IlIIllIl. ::8l PhpICII dIpIICleIn Is.... an""""'" 1IIdvI.... aI..1IIIIIIct PRIl*lr. FIIIllllIanIlIIId/fIr aIImII dIprIClalIan. · ...... III1J1Cl1c11t addnuIlIln III appnINI npIIIt or.....1lIdIndL In 1IIIm*lI" III VIIuI. .. ~ l1li nIIId an pnanaI IIMwIIcllII of...1DcII1IlIIllIl. 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ADVRS PAGE 15 National City Shareholder Services Operations **Attn: Dividend Investment February 3 t 2006 To Whom It May Concern: p. ,- 5/75. a.3:z... ..sjl-S Q ...3.5", t--7 =- / 8~ S93,. 3.7 Estate of M Eugene Miller C/O Kathryn N Miller 450 McClures Gap Road Carlisle, P A 17013-8951 We have received yow request to re-register the account referenced above. Please be advised that we require the items checked below to complete the process: (lk sure to return this fonn with the checked items) 9( The signature of the lllJIhorized ....,-.1I8Iivc for the aCCOllllt, Medallion Quarantee Slampod. lil!lli8J 11l1lleir C&D8dlli (surriviDl! teD..t. executor. t....tee. E!S:} on a letter of instrueUon or the enclosed StoCk power. Please provide the new account's name, address and tax 1.0. OJ social security number. This Stamp may be obtained at a participating fmanciel institution such as a bank branch, broke.rage fum, credit union, trust company, etc. Please contaCt the financial institution about the legal documentation you wilt need to take with you to their office to obtain the Medallion Guarantee Stamp. o All original stock certificates noted abe.ve. If you cannot locaw your certificatc(s), please contact our office immediately. Please mail any certificates via Federal Express. Registered Mail or Dffi.. etc. ~ The enclosed. W-9 fom comnleted an4~ to certify the tax I.D. or social SClC1JI'ity number for the new account. l' Failure to provide this will result in Federal Tax Withholding on any dividends paid or sale requests processed. o An Inheritance Tax Waiver from the S1ate of ~ AJllnheritmce rill< Waiver Stamp. n,is stamp reads, .We Certify 1hat Iba Decedent in ibis rnmsa<tion. Resided in · State which does not require an lnheritmce Tax Waiver." It is available at the same financial institution as the Medallion Guarantee Stamp. - OR- Affidavit of Domicile properly notarizc:d. This sen'CS to certify the residence of the decedent(s). An Inheritance Tax Waiver may be required if applicable for theit state of residence. ..If it II YOIU' IDteDtion to feU these .hares .poD completioJa of tile tnufer, plel" lDclud. · slped request to .eU the ab.res. *'" o Other. Please mail these items to the following: National City Bank Shareholder Services Operations P.O. Box 92301 Cleveland, OH 44101 National City Bank Shareholder Services Operations 4100 West 150m Street LOC 5352 Cleveland,OB 44135 Sincerely. Shareholder Services Operations Shareholder Communications 1-800-622-6757 1-216-257-8663 1-216-257-8508 (Fax) E-Mail: Shareholdet.InquirieS@NationalCity.com Wc:1J:iilc:; WWW.NllLioua1ChvSLuL;k.TnUlsrl;~ . .* If this request Is submitted and is de8dent tor any of the cbeeked items, the en.tlre package .nil be returned Dot transferred. .* WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, PeMsylvania 17013 AGREEMrnNTFORPURCHASEANDSALEOFSHARES THIS AGREEMENT is entered into in Carlisle, Pennsylvania, as of this, the 20th day of March, 2006, by and among the ESTATE OF M. EUGENE MILLER, JR. and KATHRYN N. MILLER of 450 McClures Gap Road, Carlisle, Pennsylvania 17013 (hereinafter referenced in the singular as "Seller") AND KIMBERLY A. SHOFF of 160 Lefever Road, Newville, Pennsylvania 17241 (hereinafter referenced as "Purchast:r"). WHEREAS, Seller is the owner of one hundred sixty (160) of the issued and outstanding capital shares of Miller Insurance Associates, Inc., a Pennsylvania corporation (hereinafter referenced as "Corporation"); and WHEREAS, Seller desires to sell to Purchaser, and Purchaser desires to purchase from Seller, all of said one hundred sixty (160) issued and outstanding capital shares of the Corpora~ion on the lenns and conditions contained herein. NOW, THEREFORE, in consideration of the mutual promises and conditions herein contained, the parties agree, as follows: 1. Purchase and Sale of Shares. Subject to the terms and conditions of this Agreement, Seller agrees to sell, transfer and assign to Purchaser, and Purchaser agrees to purchase, at the closing. as hereinafter defined, one hundred sixty (160) shares of common stock, par value of Five and No/lOO ($5.00) Dollars per share, of the Corporation, such share.s in the aggregate constituting all of the issued and outstanding capital stock of the Corporation which are not already owned by Purchaser. At the closing, Seller shall del iver to Purchaser a certificate or certificates evidencing the one hundred siX;ty (160) shares of the Corporation's stock in fonn r~ady for transfer and duly endorsed to Purchaser. At the closing, and from time to time thereafter, Seller shall execute and deliver such other documents and instruments, and take such other actions, as Purchaser may reasonahly request, in order more fully to vest in Purchaser and perfect her title to (a) all right, title and interest in and to said one hundred sixty (160) shares of the Corporation's stock; and (b) any and all other right, title, interest, claim or demand of any kind that Seller may have in, to or on any of the properties, assets or business of the Corporation. . WAYNEF. SHADE Attorney at Law 53 West Pomfiet Str=t Carlisle. Pennsylvania 17013 2. Purchase Price. The total price to be paid by Purchaser to Seller for the said one hundred sixty (160) shares of common stock of the Corporation being sold hereunder shall be Three Hundred Sixty-Seven Thousand Nine Hundred Thirteen and Noll 00 ($367,913.00) Dollars. 3. Payment of ))urchase Price. The purchase price described in Paragraph 2 hereof shall be paid by a bank cashier's or certified check at the closing on the closing date. 4. The Closing and the Closing Date. The closing date under this Agreement shall be within thirty (30) days from the date hereof, or on such other date as Purchaser and Seller may mutually agree from time to time. The closing shall be held at the offices of Wayne F. Shade, Esquire, 53 West Pomfret Street, Carlisle, Pennsylvania 17013, unless another place is mutually agreed upon. 5. Representations and Warranties by Seller. Seller represents and warrants to Purchaser, as follows: (a) Title to the Corporation's Stock. Seller has good, absolute and marketable title to the said one hundred sixty (160) shares of the Corporation's stock, free and clear of all liens, claims, encumbrances and restrictions of every kind. Seller has the complete and unrestricted right, power and authority to sell, transfer and assign the said one hundred sixty (160) shares of the Corporation's stock pursuant to this Agreement. The delivery of the said one hundred sixty (160) shares of the Corporation's stock to Purchaser as herein contemplated will vest in Purchaser good, absolute and marketable title to all of the Corporation's stock, free and clear of all liens, claims, encumbrances and restrictions of every kind other than any liens imposed against the stock by virtue of Purchaser's financing of this transaction. (b) Organization. The Corporation is a duly organized and validly existing Pennsylvania corporation in good standing, with all requisite corporate power and authoritY to carry on its business as presently conducted. The Corporation has no subsidiaries and has no direct or indirect equity interest in any other firm, corporation or business enterprise. . (c) Capitalization and Long-Term Indebtedness. (i) The Corporation is authorized by its Articles of Incorporation, as amended, to issue two hundred (200) shares of common stock, par value Five and No/tOO ($5.00) Dollars per share, all two hundred (200) shares of which are duly -2- WAYNEF.SHADE Attorney at Law 53 West Pomfret Street Carlisle. Pennsylvania 17013 and validly issued and outstanding, fully paid and nonassessable. The Corporation has no authority to issue any other capital stock or other security. (ii) Seller has delivered to Purchaser true copies of all instruments relating to the Corporation's long- and short-tenn indebtedness, and the Corporation is not in any default or violation of any provision of its outstanding long-tenn or short- tenn indebtedness. (iii) Other than a Buy-Sell Agreement of July 2, 1997, between the Corporation and Purchaser herein, there are no outstanding options, contracts, commitments, warranties, agreements or other rights of any character affecting or relating in any manner to the issuance of the Corporation's capital stock or other securities, or entitling anyone to acquire the Corporation's capital stock or other securities. (d) Financial Statements. Purchaser is aware of all of the assets and liabilities of the Corporation such as would appear upon a balance sheet of the Corporation prepared in accordance with generally accepted accounting principles. (e) Tax Returns and Audits. The Corporation has duly filed all federal, state and local tax returns required to be filed by it and has paid all federal, state and local taxes required to be paid with respect to the periods covered by such returns. The Corporation has not been delinquent in the payment of any tax, assessment or governrnentat' charge. The Corporation has not had any tax deficiencies proposed or assessed against it and has not executed any waiver of the statute of limitations on the assessment or collection of . any tax. The Corporation's federal tax returns have never been audited by the Internal Revenue Service. The Corporation's state tax returns have never been audited. In the event tha4 after the closing date, a deficiency is detennined in the amount of federal or state tax paya ble by the Corporation, which deficiency relates to periods prior to the closing date, Seller shall be responsible for the payment of eighty (80%) percent of said deficiency. . (f) Litigation. There are no legal actions, suits, arbitrations or other legal administrative or other governmental proceedings pending or threatened against the Corporation, its properties, assets or business; and neither Seller nor the Corporation is aware of any facts that, to the knowledge of either, might result in any such action, suit, arbitration or other proteeding. (g) ComplianCE' with the Law and Other Instruments. Seller has no knowledge of any violation of any laws, rules or regulations, including, but not limited to, violations of environmental, zoning, building or other laws, rules, regulations or -3- WAYNEF. SHADE Attorney at Law S3 West Pomfret S1R:Ct Carlisle. Pennsylvania 17013 ordinances which may affect the premises upon which the business of the Corporation is being operated. The business and operation of the Corporation have been and are being conducted in accordance with all applicable laws, rules and regulations of all authorities, except those that do not, either individually or in the aggregate, materially and adversely affect the Corporation or its properties, assets, businesses or prospects. Performance of this Agreement will not result in any breach of, constitute a default under or result in the imposition of any lien or encumbrance on any property of the Corporation under any arrangement, agreement or other instrument to which the Corporation or Seller is a party or by which either is bound or affected, and will not violate the Articles of Incorporation, as amended, or the By-Laws of the Corporation. The Corporation is not in violation of its Articles of Incorporation, as amended, its By-Laws or of any indebtedness, mortgage, contract, lease or other agreement or commitment. (h) Environmental Actions. There are no environmental liens against the premises upon which the business of the Corporation is being operated. There are no outstanding requests for information or notices that the premises upon which the business of the Corporation is be ing operated are or may be potentially involved in any investigation or clean-up of any threatened or actual release of any hazardous materials. (i) Title to PrOlterties and Assets. The Corporation has good, absolute and marketable title to all its properties and assets, including, without limitation, those reflected in the balance sheet and those used or located on property controlled by the Corporation in its business, except inventory sold in the ordinary course of business, subject to no mortgage, pledge, lien, charge, security interest, encumbrance or restriction except those that are disclosed on the balance sheet as securing specified liabilities. All the equipment of the Corporation is in good condition and repair, reasonable wear and tear excepted. The Corporation has not been threatened with any action or proceeding under any building or zoning ordinance, regulation or law. (j) Contracts. The Corporation is not a party to, or otherwise bound by, any written or oral contract not made in the ordinary course of business; employment or consultant contract not terminable at will without cost ot other liability; labor union contract; deed of trust, mortgage, conditional sales contract, security agreement, pledge agreement, trust receipt or any other agreement or arrangement whereby any of the assets or properties of the Corporation are subject to a lien, encumbrance, charge or other restriction; license agrel~ment, whether as licensee or licensor. To the best of Seller's knowledge and belief, the Corporation has in all respects performed all obligations required to be performed to date and is not in material default in any respect under any of the contracts, agreements, leases, documents or other commitments to which it is a party or otherwise bound or affected. All parties having contracts with the Corporation are in material compliance th{~rewith and are not in material default thereunder. -4- WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle. Pennsylvania 17013 (k) Compensation of Officers and Others. There has not been any change in any compensation, commission, bonus or other remuneration payable to any officer, director, agent, employee or consultant of the Corporation, except for increases in the ordinary course of business consistent with prior practice. (1) Records. TIle respective books of account and minute books of the Corporation are complete and correct, and reflect all those transactions involving its business which properly should have been set forth in such books. (m) Absence of Certain Changes or Events. There has not been any change in or any event or condition, financial or otherwise, affecting the properties, assets, liabilities, operations or prospects of the Corporation other than changes in the ordinary course of its business, none of which has, either when taken by itself or when taken in conjunction with all other such changes, been materially adverse. (n) No Brokers or Finders. Neither the Corporation nor Seller will be obligated in any way for any commission, fee or other remuneration to any finder, broker or the like employed by Purchaser in connection with this Agreement or its negotiation, execution or performance. (0) Accounts Receivable. All of the accounts receivable of the Corporation are valid and enforceable claims. Such accounts receivable are fully collectible. (p) Purchase Commitments and Outstanding Bids. No purchase commitments of the Corporation are in excess of normal, ordinary and usual requirements of its business or were made at any price in excess of the then current market price or contain terms and conditions more onerous than those usual and customary in the industry. (q) Insurance Policies. There are in full force all policies of fire, liability and other forms of insurance in amounts and against such losses and risks as are generally m~tained by comparable businesses. (r) Disclosure. No representation or warranty by Seller in this Agreement or in any writing furnished or to be furnished pursuant hereto contains or will contain any untrue statement of a material fact or omits or will omit to state any material fact required to make the statements herein or therein contained not misleading. 6. Actions of the Corporation Pending Closing. Where Purchaser is operating the business, Purchaser agrees that from the date hereof through the closing date: -5- WAYNE F. SHADE Attorney at Law S3 West Pomfret Street Carlisle, Pennsylvania 17013 (a) Operations. Purchaser will cause the Corporation to operate only in the ordinary course of business; and to not enter into any transaction or perfonn any act that would constitute a breach of the representations, warranties or agreements contained herein. (b) Access to Records. Purchaser will cause the Corporation to afford Seller access, during normal business hours, to all its business operations, properties, books, files and records, and \\ill cooperate in Seller's examination thereof. No such examination, however, shall constitute a waiver or relinquishment by Purchaser of her right to rely on Seller's covenants, representations and warranties as made herein or pursuant hereto. Until t he ~losing, Purchaser will hold in confidence all information so obtained, and any docwnent or instrument heretofore or hereafter obtained by Purchaser in connection herewith shall be held on an express trust for and on behalf of Seller and the Corporation. (c) Compliance. Purchaser will cause the Corporation and its officers and employees to comply with all applicable provisions of this Agreement. 7. Conditions Precedent to Obligations of Purchaser. Unless waived, in whole or in part, in writing by Purchaser, the obligations of Purchaser hereunder are subject to the fulfillment, prior to or at the closing, of each of the following conditions: (a) No Material Errors. The representations and warranties of Seller in Paragraph 5 hereof shall be deemed to have been made again on the closing date and to be true and correct at that time, subject to any changes contemplated by this Agreement. Seller shall have perfonned all of the obligations to be performed by Seller hereunder on or prior to the closing date. (b) Resignation of Officers. Seller shall have delivered to Purchaser her written resignation as an office::- of the Corporation. (c) Opinion of Seller's Counsel. Seller shall deliver to Purchaser the opinion, dated the closing date, of Wayne F. Shade, Esquire, in form and substance satisfactory to Purchaser to the effect 1 hat: (i) The Corporation is a duly and validly organized and existing corporation in good standing under the laws of the Commonwealth of Pennsylvania with full corporate power to carry on the business in which it is engaged, and is legally qualified to do business as a foreign corporation in good standing in each jurisdiction wherein the nature of its activities or of its properties owned or leased makes such qualification necessary. -6- WAYNE F. SHADE Attorney at Law S3 West Pomfiet Street Carlisle. Pennsylvania 17013 (ii) The performance of this Agreement and the consummation of the transactions con1emplated herein will not result in any breach or violation of any of the terms or proyisions of, or constitute a default under, the Corporation's Articles of Incorporation or By-Laws or any order, rule or regulation of any court or governmental agency or body having jurisdiction over the Corporation or any of its activities or properties or any statute, indenture, mortgage, deed of trust, lease, loan agreement, security agreement or other agreement or instrument known to said counsel, to which the Corporation is a party, by which it is bound or to which any of its property is subject. (iii) No provision of the Articles of Incorporation, as amended, By-Laws, as amended, min utes or share certificate of the Corporation, or of any contract to which the Corporation or Seller is a party or otherwise bound or affected, prevents Seller from delhering good, absolute and marketable title to the Corporation's stock to Purchaser as contemplated by this Agreement. (iv) Seller has complete and unrestricted power and right to transfer, sell, assign and deliver to Purchaser the Corporation's stock, and good, absolute and marketable title 10 the Corporation's stock, free and clear of all liens, encumbrances, charges, escrows, equities and other restrictions. (v) The Corporation is authorized by its Articles of Incorporation to issue two hundred (200) shares of common stock, par value Five and No/I 00 ($5.00) Dollars per shart:, of which there are two hundred (200) shares issued and outstanding, all of which are duly authorized, validly issued and outstanding, fully paid and nonasst:ssable, and to the knowledge of such counsel the issuance and sale of such shares did not violate the Securities Act of 1933, as amended (the "Securities Act"), or the rules and regulations of the Securities and Exchange Commission thereunder or any applicable state securities laws. The Corporation has no other authorized or outstanding series or class of capital stock or other securities. (vi) Such counsel has no knowledge of any litigation, proceeding or governmental investigation or labor dispute or labor trouble pending or threatened against or relating to the Corporation, its properties or business, except as set forth in said opinion. (d) Covenant Not to Compete. It is expressly agreed that, after the sale of the Shares ofa Shareholder, Seller will not, for the period of three (3) years from the date of closing on the sale of the Shares of Seller, engage in the following activities within the boundaries of Cumberland County, Pennsylvania: -7- WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle. Pennsylvania 17013 (i) Directly or indirectly as an owner, shareholder, partner. agent, employe~', joint venturer or independent contractor engaged in the insurance business in any capacity; (ii) Directly or indirectly consult with any of the customers of the Corporation ;18 of the date of sale of said Shares of the Shareholder, to solicit any such insurance business; (iii) Personally solicit or accept or through third parties or authorize the solicitation or acceptance of any insurance business from any previous clientele of the Corporation; and (iv) Disclose to any person or organization any information concerning the business of the Corporation or its affairs. This covenant 011 the part of Seller shall be construed as an agreement independent of any other provision of this Agreement; and the existence of any claim or cause of action of Seller against Purchaser, whether predicated on this Agreement or otherwise, shall not constitute a defense to the enforcement of this covenant by Purchaser or the Corporation. Seller and Purchaser agree that the value of said covenant shall be $1 and only that portion of the purchase price may be so allocated. Seller further expressly acknowledges that an action at law for any violation of this covenant shall be inadequate and that Purchaser and the Corporation shall be entitled to injunctive relief in equity for any violation hereof. If at anytime any court of competent jurisdiction should determine that the restrictions stated herein are unreasonable or otherwise unenforceable under circumstances then existing, the parties hereto agree that the maximum period, scope or geographical area determined to be reasonable under such circumstances by such court will be substituted for the stated period, scope or area. ( e) Other Matters. All corporate and other proceedings and action taken in connection with the transactions contemplated hereby and all certificates, opinions, agreements, instrument:; and documents mentioned herein Of incident to any such transaction shall be sati~factory in form and substance to Purchaser. 8. Nature and Survival of Representations and Warranties. All statements of fact contained in any memorandum, certificate, instrument or other document delivered by or on behalf of Seller for information or reliance pursuant to this Agreement shall be deemed representations and warranties by Seller under this Agreement. All . representations and warranties of the parties shall survive the closing. 9. Indemnifiea1 ion. Seller hereby agrees to indemnify and hold harmless Purchaser against and in respect to all damages, as hereinafter defined. Damages, as used -8- WAYNEF. SHADE Attorney at Law 53 West Pomfiet Street Carlisle. Pennsylvania 17013 herein, shall include any claim, action, demand, loss, cost, expense, liability, joint or several, penalty and other damage, including, without limitation, counsel fees and other costs and expenses reasonably incurred in investigating or in attempting to avoid same or oppose the imposition thereof or in enforcing this indemnity, resulting to Purchaser from any inaccurate representation made by or on behalf of Seller in or pursuant to this Agreement, breach of any of the warranties made by or on behalf of Seller in or pursuant to this Agreement, or breach or default in the performance by Seller of any of the obligations to be performed by it hereunder. Notwithstanding the scope of Seller's representations and warranties herein, or of any individual representation or warranty, or any disclosure to Purchaser herein or pursuant hereto, or the definition of damages contained in the preced:ing sentence, or Purchaser's knowledge of any fact or facts at or prior to the closing, danlages shall also include all debts, liabilities and obligations of any nature whatsoever, whether absolute, accrued, contingent or otherwise and whether due or . to become due, of the Corporation, whether known or unknown by Seller; all claims, actions, demands, losses, costs, expenses and liabilities resulting from any litigation involving the Corporation whether or not disclosed to Purchaser; and all losses, costs and expenses, including, without limitation, all fees and disbursements of counsel relating to damages. Seller shall rdmburse Purchaser on demand for any payment made by Purchaser at any time after the closing, based on the judgment of any court of competent jurisdiction or pursuant to a bona fide compromise or settlement of claims, demands or actions, in respect to any damages to which the foregoing indemnity relates. Purchaser agrees to give Seller prompt written notice of any litigation threatened or instituted against the Corporation that might constitute the basis of a claim for indemnity by Purchaser against Seller. 10. Records of the Corporation. For a period of seven (7) years following the closing date, the books of account and records of the Corporation pertaining to all periods prior to the closing date shall be available for inspection by Seller for use in connection with tax audits. 11. Expenses. Each of the parties shall bear all expenses incurred by it in connection with this Agreement and in the consummation of the transactions contemplated hereby and in preparation thereof. 12. Amendment and Waiver. This Agreement may be amended or modified at any time and in all resp~cts by an instrument in writing executed by Purchaser and Seller. 13. Assignmen1. Neither this Agreement nor any right created hereby shall be assignable by either Seller or its successors in interest, or Purchaser without the prior written consent of the other, except for an assignment incident to a merger, consolidation or reorganization of either party. Nothing in this Agreement, expressed or implied, is -9- WAYNEF. SHADE Attorney at Law 53 West Pomfret Street Carlisle. Pennsylwnia 17013 intended to confer on any person, other than the parties hereto and their successors, any rights or remedies under or by reason of this Agreement. 14. Notices. Any notice, communication, request, reply or advice (hereinafter severally and collectively called "notice") in this Agreement provided or permitted to be given, made or accepted by either party to the other must be in writing and may be given or be served by depositing the same in the United States mail, addressed to the party to be notified, postage prepaid and registered or certified with return receipt requested or by delivering the same in person to such party. Notice deposited in the mail in the manner hereinabove described shall be effective only if and when received by the parties to be notified. For purposes of notice, the addresses of the parties shall, until changed as hereinafter provided, bt:, as follows: (a) If to Seller: Kathryn N. Miller 450 McClures Gap Road Carlisle, Pennsylvania 17013 With a copy to: Wayne F. Shade, Esquire 53 West Pomfret Street Carlisle, Pennsylvania 17013 or at such other addresses as Purchaser may have advised Seller in writing. (b) If to Purchaser: Kimberly A. Shoff Miller Insurance Associates, Inc. 19 Brookwood Avenue Carlisle, Pennsylvania 17013 With a copy to: Wayne F. Shade, Esquire 53 West Pomfret Street Carlisle, Pennsylvania 17013 or at such other addresses as Seller may have advised Purchaser in writing. -10- WAYNEF.SHADE Attorney at Law 53 West Pomfm Stn:let Carlisle. Pennsylvania 17013 15. Headings. Headings contained in this Agreement are for reference purposes only and shall not affect in any way the meaning or interpretation of this Agreement. 16. Counterpal1 Execution. This Agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. 17. Parties in Interest. All the terms and provisions of this Agreement shall be binding on and inure to the benefit of and be enforceable by Purchaser and Seller, their heirs, executors, admini strators, successors and assigns. 18. Integrated Agreement. This Agreement constitutes the entire agreement between the parties hereto and there are no agreements, understandings, restrictions, warranties or representntions between the parties other than those set forth herein or herein provided for. 19. Choice of Law. It is the intention of the parties that the laws of Pennsylvania should govern the validity of this Agreement, the construction of its terms and the interpretation of the rights and duties of the parties. -11- WAYNEF. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 20. Entire Agreement. The foregoing constitutes the entire agreement and understanding of the parties on the subject hereof and supersedes all prior agreements and understandings relating to the subject matter hereof. IN WITNESS \\HEREOF, the parties have hereunto set their hands and seals the day and year aforesaid. .WIlNESS: ESTATE OF M. EUGENE MILLER, JR. . 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[ - =i:l ~!iClll H'--. - .2 ~ : Ii: ~ i i I ! t-aJ! k !.. u..!- ....~1; I i f;: It) SiC;; Ii ii'_ . :1= ~= r:- .~ iHa i1i51'ii :!'l!!iI !~~~ :,';''ili 't.'~ Jit>.::!'!! ;i:: ~I i~.i~ ~~ i'E!~r; I~D ii:8 HIGlll'i i~~ :i:.:~ ::ilili;S ji~ lEr!1!!: ~!'= ;fi~~ i":~4ti .. ,~;~ III )'.::"":"; =I ~ iij; C ~1t~ ~ >r~~ ... l'f!li&! e !Il!:!~: o :1J'!iiii~ , HI CD" ~~L. ' == ~~ - " .'Qry:c...i ~~1i CL ~"~~ , ~ ~ fI6S 170 York Rd. Carlisle, PA 17013 Carlisle (717) 249-2215 1 800 Harrisburg (717) 234-0662 - -745-4811 Fax (717) 249-1437 7-(0-0(0 o vJ /"0 M ,-{ TVV.. Y UJ r) c.:(:'r n ) ple,,-se be.- qJv; ~< J +1-...+ the.. ;;MdL{. F\SV 'XLI Su.perc~h L.j)(<-{(\JIW JfTP.Xl'-l5J.itJB>40'10(P~ o c.0 I') ecP b 1 k. 0. +\"11"1 Vl TV. WI f (fe 'I he. ~ .:::t Yl a"pl.rox I wl '\. +c: -l: .,-OI&-€- . IV) vq \ '-' e . 0.\ :f-.I, 3 50. ----r\\ \ :5 11 &i I u e \.S b <1 '}c J)e> Y) CA (' J tJ I Je.. ~e July ']1:)0(0 N1ttJf! o~~; C:IC\. \ t.Js<cR (q<-kts .c;Vldoo;,-ecO,) now I~ , f ("~s . Form 1120 u.s. Corporation Income Tax Return For calendar year 2005 or tax year beginning MAY 1, 2005 ,ending APRIL 30, 2006 EXTENSION GRANTED TO 01/15/07 2005 OMB No. 1545-0123 Department of the Trusury Intllmlll Rllv.,ue Service A Check If: Use Name 1 Conaolldated retum D IRS MILLER INSURANCE ASSOC IATES , INC. (atmch Form 851) label. 2 Per80nel holding co. D Other. Number, street, and room or suite no. If a P.O. box, see Instructions. (atmch Sch. PH) D I 19 3 Per80nel service corp. Wle, BROOKWOOD AVENUE, SUITE 102 (_ Instructions) print 4 Schedule M-3 requlred...---, or type. City or town, state, and ZIP code (atblchSch.M-3) I I CARLISLE. PA 17013 E Check If: (1)[ ] Initial return 2)[ ] Final return (3\r 1 Name chanDe l4\[ ] Address chanoe 1 a Gross ..-Ipts or sIIIes I 6 31 , 811 .1 b Less retumund allowances I Ie Bal ~ 1c 2 Cost of goods sold (Schedule A, line 8) ......................................................................................................... 2 3 Gross profit. Subtract line 2 from line 1c ......................................................................................................... 3 4 Dividends (Schedule C, line 19) .................................................................................................................. 4 5 Interest ...... ....................................................................................................... ...................................... 5 6 Gross rents ........................................................................... ............. ........ .......................... ........... ........ 6 7 Gross royalties ............ ........................................ ....... .... .... ..... ......................... ....................... .............. .... 7 6 Capital gain netincome (attach Schedule D (Form 1120)) ................................................................................. 8 9 Net gain or (loss) from Form 4797, Part 1I,Iine 17 (attach Form 4797) .................................................................. 9 10 Other income (attach schedule) ............................................................~.$.$....~.';J;')\';J;'.$.~$.~.';J;'...J............. 10 11 Total Income. Add lines 3 throuoh 10 ................................................................................................... ~ 11 12 Compensation of officers (Schedule E, line 4) ................................................................................................ 12 13 Salaries and wages (less employment credits) ................................................................................................ 13 14 Repairs and maintenance ........................................................................................................................... 14 15 Bad debts ... ..... ................... .... ........ ..... ................... .............. ......... ........................................ ........... ....... 15 16 Rents ........ ..................... ... ........... ................... ................ ....... . .............. .................................................. 16 17 Taxes and licenses ...........................................................................~.$.$....~.';J;'~.';J;'.~~.$~.';J;'....~............. 17 18 Interest ....................... .... ........... ...... ...... ............ ............ ................................ ......... ..................... ........... 18 19 Charitable contributions SEE STATEMENT 3 AND SEE STATEMENT 4 19 ................................................................................j........j.................................... 20a Depreciation (attach Form 4562) .................................................................. 20a 1 7 , 424 . b Less depreciation claimed on Schedule A and elsewhere on return ..................... 20b 20c 21 Depletion ................................................................................................................................................ 21 22 Advertising .... ................................ ........................................................................................... .............. 22 23 Pension, profit-sharing, etc., plans ............................................................................................................... 23 24 Employee benefit programs .................................................................... ...... .............. ............................. ... 24 25 Domestic production activities deduction (attach Form 8903) .............................................................................. 25 26 Other deductions (attach schedule) ......................................................s.~~...S.~~~~M~N~...~............. 26 27 Total deductions. Add lines 12 through 26 ............................................................................................. ~ 27 28 T8XlIble Income before net operating loss deduction and special deductions. Subtract line 27 from IInel11 I............................. .... ... 28 29 Less: a Net operating loss deduction ......................................................... I 29a .................... b 8Decial deductions (Schedule Cline 20\ .......................................... 29b 29c 3D Taxable Income. Subtract line 29c from line 28 (see instructions If Schedule C, line 12, was completed) .................. 3D ::~i~~)..in....?:.'...................3..~.~.~.~.~; f Credits: (1) Form 2439 (2) Fonn 4136 32f 320 33 Estimated tax penalty (see instructions). Check if Form 2220 Is attached ................................................... ~ 00 33 34 Tax due. If line 32g is smaller than the total of lines 31 and 33, enter amount owed ................................................ 34 ~ Overpayment. If line 32g is larger than the total of lines 31 and 33, enter amount overpaid ....................................... 35 36 Enter amount of line 35 vou want: Credited to 2006 estimated tax ~ Refunded ~ 36 Under penalties of pllfjury, I declare thet I have examined this return, Including acco~ylng schedules and statements, and to the best of my knowledge and belief, It Is true, correct, and complete. Declaretlon of pIepareI' (other than taxpey~ Is besed on a1llnfonnatlon of which preparer has any knowledge. I =~~s I ~Slgnatureofofficer I Data ~ntle . 00 Yes 0 No Preparer's .... I Data I Check If Preparer's SSN or PTIN Paid signature r self-employed 00 PO 0 0 5 7 6 2 6 Prepare,.s ~~u::'-we ~SMITH ELLIOTT KEARNS & COMPANY, LLC I EIN ~ 52 0783935 Ule Only self-employed), 19 BROOKWOOD AVE., SUITE 101 I Phoneno. I 717) 243-9104 8cIdress, and ZIP code CARLISLE, PA 17013 JWA For Privacy/Paperwork Reduction Act Notice, see Instructions. B Employer identification number 23-2055739 C Data Incorporated 02/28/1978 o Total assets (see Instructions) s 245,567. 631,811. 631,811. . E 8 .5 ! o :g ~ i c 69. 631,880. 76,588. 204,152. 18,768. 3,945. 48,402. 30,406. 5,251. 380. 17,424. 37,004. 34,227. 122.446. 598.993. 32,887. 32.887. 4,933. ~ J 'g C . M {2 4,233. 7 . 707. Sign Here 511601 12-12-05 Form 1120 (2005) Fonn1120(2OO5) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Pa e2 t: . ,.:.. <::'.:.:.. ..:.. ...:.:.t:. ..::~ Cost of Goods Sold see Instructions 1 Inventory at beginning of year ..... ......... .................................... ......... ............... ..... ... ..................... ....... ........ ..... 1 2 Purchases.. .................... ......... .............. ....... ............ ............ ..................................................... ..................... 2 3 Cost of labor ........................................... ..... .................................. ......................................... ................ ........ 3 4 Additional section 263A costs (attach schedule) .......................................................... ..... ....................................... 4 5 Other costs (attach schedule) ....... ................. ............ ...... ....... ...................... .................................................... 5 6 Total. Add lines 1 through 5 .............................................................................................................................. 6 7 Inventory at end of year ........................................... ........ ................................................................................. 7 8 Cost 01 goods sold. Subtract line 7 from line 6. Enter here and on page 1, line 2 ......................................................... 8 9 a Check all methods used for valuing Closing inventory: (I) D Cost (il) D Lower of cost or market (Iii) D Other (Specify method used and attach explanation.) ~ b Check if there was a writedown ofsubnormal goods .............................................................................................................................. ~ D c Check if the LIFO inventory method was adopted this tax year for any goods (If checked, attach Form 970) ...................................................... ~ D d :1~:~n~I~~~:~::oc~::~~e~ u:~:~~~:;or. ~~~.~~.~~.~~: .~~~~~. ~~.~~.~~~.~~.~~.~ ~~.~~~~~~ .~~................................................. W e If properly is produced or acquired for resale, do the rules of section 263A apply to the corporation? ............................................. DYes D No 1 Was there any change in determining quantities. cost, or valuations between opening and closing inventory? If "Yes . attach eXDlanation n Yes nNo ................................................................................................................................................ I:t:"-:lfl Dividends and Special Deductions (see Instructions) (a) Dividends (b) % (c) Special deductions received (a) x (b) 1 Dividends from less-than-200/0-owned domestic corporations (other than debt-financed stock) .......................................................................................... 70 2 Dividends from 200/0-or-more-owned domestic corporations (other than debt-financed stock) ............................................................................................................... 80 3 see Dividends on debt-financed stock of domestic and foIeIgn corpollltlons .................................... Instructions 4 Dividends on certain pnlf8mlc\ stock of Iess-than-20%-ownecI public utilities ................................. 42 5 Dividends on certain pnlf8mlc\ stock of 20%-or-more-awned public utilities ................................. 48 6 Dividends frum 1_-than-20%-awned fonlign corporations and certain FSCs ................................. 70 7 Dlvidands frum 20%-or-more-awned foIeIgn corporations and certain FSCs ................................. 80 8 Dividends from wholly owned foreign subsidiaries ................................................... 100 ................................................................................................ ~~~tm~t;~j@~;m;~;~~~m;l 9 T ota I. Add lines 1 through 8 :;:;:::::::::::::::::::::;:::::;:;:::::::::::::::::::::::::::::::::::::::::::::::::::::;::::::: ................................................................................. :.;.:.:.:.:.:.:.:.:.:.:.:.;.;.:.;.;.:.;.:.;.:.:.:.;.:.:.:.:.:.:.:.:.:.;.;.:.:.:.:.:.;.:.:.:.;.;. 10 Dividends from domestic corporations received by a small business Investment company operating under the Small Business Investment Act of 1958 ........................... 100 11 Dlvldands frum affiliated group members and certain FSCs ................................................... 100 12 Dividends frum controlled fol'8lgn corporations (attllch Fonn 8895) ............................. ......~.......... 85 13 :"IIIIIIIII[llllilllllilllllilli ;;:::::::;::::::::::::::::;;:;::::::::::::;::::::::::::::::::;:;:::::;::::::;:;:::;:;:::;::::::: Dividends frum foIeIgn corporations not Included on lines 3, 6, 7. 8, 11, or 12 ................................ . 14 Income frum controlled fonlign corpol8tions under subpart F lattllch Fonn(s) 5471) ........................ ~:~: ~:~:~:~:;:; :;{:~: ~: ~:~: ~:;:~:;: ~:~:; 15 Foreign dividend gross-up .................................................................................. . 16 10 -DISC and fonner DISC dividends not Included on lines 1.2, or3 ........................................... 17 Other dividends ........................-........................................................................ 18 Deduction for dividends paid on certain preferred stock of public utilities ........................ ;~;~~~~~~~~~~~~~~ltjl~~~~~~I~~~~~I~~~~~~~l~~~~~~~~U~~~I~~1 19 Total dividends. Add lines 1 through 17. Ente r here and on page 1, line 4 ............... ~ ~~~~~~~;~~~;f~@~@~j~l~~1~@~1~@~~~j~1~~~;m~~~~mm~~~~lmm~tmmm 20 Total sDeclal deductions. Add lines 9 10 11 12. and 18. Enter here and on "aDe 1 line 29b ................................................ ~ t_1~1~~ Compensation of Officers I:: Ins:u..=- for page 1, IIn. 12) recelDts nine 1. Dlus lines 4 throu"" 10 on ~ 11_ $500 000 or IT1OI1l. ate: Co ate Sc:hedule E onlY if total (a) (b) Social security \~) Percent of Percent of corporation (I) Amount of Name of officer number lme devoted stock owned to business (d\ Common e \ Prefe rred compensation 1KIMBERLY SHOFF 1 6 1-5 8-1 2 50 1 0 0 1 00 . 00% 7 6,5 8 8 . 2 Total compensation of office rs ........................................................................................................................................ 7 6,5 8 8 . 3 Compensation of officers claimed on Schedule A and elsewhere on retu m ................................................................................ 4 Subtract line 3 from line 2. Enter the result here and on DaDe 1 line 12 ................................................................................. 7 6,5 8 8 . ~~~~~-k JWA Form 1120 (2005) Form 1120 (2005\ MILLER INSURANCE ASSOC IATES, INC. Kr":':w,,,,,,<::,' ..:::....:.:.::ijDmtjl Tax ComDutation (see instructlons\ 1 Check If the corporation is a member of a controlled group ........................................................................... .. Important: Members of a controlled group, see Instructions. 2a If the box on line 1 is checked, enter the corporation's share of the $50,000, $25,000, and $9,925,000 taxable income brackets (in that order): (1) 1$ b Enter the corporation's share of: 5 At the end of the tax year, did any indIVidual, partnership, corporation, estate, or trust own, directly or indirectly, 50% or more ofthe corporation's voting stock? (For rules of attribution, see section 267(c).) .................................... If "Yes: attach a schedule showing name and identifying number. (Do not include any Information already entered In 4 above.) Enter percentage owned ~ During this tax year, did the corporation pay dividends (other than stock dividends and distributions in exchange for stock) In excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) ............... If "Yes," file Form 5452, Corporate Report of Nondivldend Distributions. If this is a consolidated return, answer here for the parent corporation and on Form 851, Affiliations Schedule, for each subsidiary. 6 23-2055739 Paoe3 o.....w.......... .:::::::::::::::;:::: '.:.;.;.;.;.;.:.:.:.' :.;.;.:.:.;.:.:.;.;. ~I~~~~~~~1~~~~~~~i .;.;.;.;.;.;.;.;.;.;. ;.;.;.;.;.:.;.;.;.;.; !':'lli:!lj[illlll[I' :~:~:~:~:I~:;j~:~: '.:.;.:.;.;.;.;.;.;.; .:::;:::;:::;:;:::::. :'.llli::II:IIIIII"1 ;.;.;.;.:.;.;.;.;.;. 7 8 9 ;.;.;.:.;.;.;.;.;.;.; ~~~~~;m~~~~~m;~~: 10 11 Yel No 7 At any time during the tax year, did one foreign person own, directly or indirectly, at least 25% of (a) the total voting power of all classes of stock of the corporation entitled to vote or (b) the total value of all classes of stock of the corporation? ...... ........ .............................. ............. ... If "Yes," enter: (a) Percentage owned .. and (b) Owner's country .. c The corporation may have to file Form 5472, Information Return of a 25% Foreign-Owned U.S. Corporation or a Foreign Corporation Engaged In a U.S. Trade or Business. Enter number of Forms 5472 attached .. Check this box If the corporation issued publicly offered debt instruments with original Issue discount .............. 0 If checked, the corporation may have to file Form 8281. Information Return for Publicly Offered Original Issue X Discount Instruments. ::g;gft:~:~ :tt~f::f 9 Enter the amount of tax-exempt interest received or ":=::;::=:=:=;=;=:=;=;:;=;:;:;:;:;:;:;:;: :::::::::::::::::::: :::::::::::::::;:::: accrued during the tax year .. $ :.:.:.:.:.:.:.:.:.:. 10 Enter the number of shareholders at the end of the tax :;~;~;:;~;:;:;:;:;:; year (if 100 or fewer) .. 2 '::::I::::::ii::[: .:.:.:.:.:.:.:.:.:.: 11 If the corporation has an NOL for the tax year and is X electing to forego the carryback period, check here ... .. 0 ':':':':':'.':':'.' :::;:::;:::::::::::: If the corporation Is filing a consolidated retum, the statement :<:::::::::::::::: required by Temporary Regulations section 1.1502-21T(b)(3) :::;:;:::;:::::::;::. must be attached or the election will not be valid. 11'2 :;~:':::~":~Y~:=::~n~'''''''~ X 13 Are the corporation's total receipts (line 1a plus lines 4 through ::~:::i:::~::::~ :::::::::::::::::::: 10 on page 1) for the tax year and its total assets at the end of the .::::::::::::::::~: :~::::::::::~::::: tax year less than $250,OOO? ............................................. If "Yes," the corporation Is not required to complete Schedules L, ::::::::::::::::::::' :::::::::::::::::::: M-'. and M-2 on page 4a Instead. enter the total amount of cash ::~;:::::::::::::::: :::::;:::::::;:::::: . . . ( :i[j:::::!:j:i:![!:!~ !i:i:~:!jl!:!!!:!: ~:~ri~~~)n~:~~ ~eri~~~~:;~~ey~~~r~$rty dlstnbutlons other ........... ........... .......... .:.;.;.:.:.;.:.:.;.: ,,;.:.:.;.;.;.;.:.:.; .;.;.;.:.;.:.;.;.:.:. '.:.:.:.:.:.:.;.:.:.: ........................................ ............................,........... .......... .......... :.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:,:.:.:.:. .,:.:.:.:,:.;.:.:.;.:,:,:.:.:,:,:.:,;.:.: ::::::::::::::::;:::::::::::::;:::::::::: .......... .....,.... ........... .......... X 1~8 4,933. 4,933. 4.933. 4.933. Yes No (2) I $ I (3) $ (1) Additional 5% tax (not more than $11,750) S (2) Additional 3% tax (not more than $100,000) S 3 Income tax. Check if a qualified personal service corporation S TMT 6 (see Instructions) ... ........ ..... ................. ............. .................. ............... ................................... ............ .. 0 3 4 Altemative minimum tax (attach Form 4626) ......................................................................................................... 4 5 Add lines 3 and 4 .......................................................... ............ .......... ............................................................. 5 6a Foreign tax credit (attach Form 1118) ............................. ..................................... 6a b Possessions tax credit (attach Form 5735) ............................................................ 6b c Credits from: 0 Form 8834 0 Form 8907, line 23 ........................ 6e d General business credit. Check box(es) and Indicate which forms are attached: :.:.:.:.:.:.:.:.:.:. o Form 3800 0 Form(s) (specify) .. 6d B Credit for prior year minimum tax (attach Form 8827) ............................................. 6e f Bond credits from: 0 Form 8860 0 Form 8912 .............................. 6f 7 Total credits. Add lines 6a through 6f .................................................................................................................. 8 Subtract line 7 from line 5 ....................... ...................... .................. ........... ....................................................... 9 Personal holding company tax (attach Schedule PH (Form 1120)) ........................................................................... 10 Other taxes. Check if from: 0 Form 4255 0 Form 8611 0 Form 8697 o Form 8866 0 Form 8902 0 Other (attach schedule) ........................ 11 Totaltax. Add lines 8 throuoh 10. Enter here and on Daoe 1 line 31 ........................................................................... l{r..~:.:...:.:::.:.:::.:.:.:.:...:.:.:;:K;rl Other Information (see Instructions) 1 Check accounting method: a 0 Cash b [X] Accrual c 0 Other (specify) .. 2 See the instructions and enter the: a Business activity code no. .. 5242 1 0 b Business lICtivlty .. INSURANCE C Productorservlce .. SERVICE 3 At the end of the tax year, did the corporation own, directly or Indirectly, 50% or more ofthe voting stock of a domestic corporation? (For rules of attribution, see section 267(c).) ...... If "Yes,' attach a schedule showing: (a) name and employer Identification number (EIN), (b) percentage owned, and (c) taxable Income or (loss) before NOL and special deductions of such corporation for the tax year ending with or within your tax year. 4 Is the corporation a subsidiary In an affiliated group or a parent-subsidlary controlled group? ................................. If "Yes: enter name and EIN of the parent corporation .. ~~~lt~~~~~~~~ I~~~~~~~~~~~n~ .:.:.:.:-:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.: ....... ... ........... .......... .......... X .:.:.:.:.:.:.:.:.:.:. :.:.:.:.:.:.:.:.:.:.: .:.:.:.:,:-;.:.:-:.:. .:.:.:.:.:':.:.:.:.:. ~~~~~~~~~~~~~~~~~~~~~ .:.:.:.:.:.;.:.:.:.:. ~:~:~:~:~:~:~:~:~:~:~ :.:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.;.:.:.;.'.:.:.:.:.:.:.:.:.:.:. .:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:. .:.:.:.:.:.:.:.:.:.:. ::::::::::::::::;::::::::::::::::::::;:::: :~~~t~~~~~~~~~ll~~ :~:~:~:~:~t:~:~:~: :!I!illll[lllllilll!:i!I:I::!I:l!:!::j[[: :ttttt ~;~:~:~:~:~:~:~:~:~:~ .':':':':':':':':':':':':':':':':':':':':' '.:.:.:.:.:.:.:,:.:.:.:.:.:.:.:.:.:.:.:.:. :ll~~I!!l!!i!lil!li 1:~!l!:~I!ljl!lll!1 ~~~~~i~~~ ~ ~~~~~~~~~~ ~~~~ ~~~~~~ ~ ~~; ~~~ ~~ ~ ~ ;jl{r;~m ::::::::::::::::::::: :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: ':::::::::::::::::::: .:~::::::::::::::::: :mmm~;~~~~m :.:.:.:':.:.:.:.:.:.: illlllflllll1111: 11111111[1111:::111 ... .... ... ,.......... ..:.:.:.:.:.:.:-:.:.:,:.:,:,:.:.;.;.:.;-:. .:.:.:.:-:.:.:.:.:.:.;.:.:.:.:-:.:-:-:-: ........., ...".....,. .......... ......... ........... ........ .................'.. ',.,..',......'..... t~;~~~~~m' m;mi~~~i~lm :;:;:;:;:;:;:;:;:;:; ;:;:;:;:;:;:;:;:;:;:; ~:~:~:~:~:tt ~:~:~:~:;:~:;:~:~:~:~ ......... .......... .................'" ..................... 1~1:II!lIJ'I: :1:!I:j:~jii~::!: .......... ...-.... x :.:.:.:.:.:.:-:.:.: ........... .':':':':':':.:':-:' .:.:.:.:.:.:-:.:.:.:. Note: If the corporation, at any time during the tax year, had assets or operated a business in a foreign country or U.S. possession, It may be required to attach Schedule N (Form 1120), Foreign Operations of U.S. Corporations, to this return. See Schedule N for details. ~~~~-k JWA Form 1120 (2005) Form 1120 (2005) MILLER INSURANCE ASSOC IATES , INC. 23-2055739 p_4 Notl: The cOJDoratlon Is not reauired to comDlete Schedules l M001 and M-2 if Question 13 on Schedule K Is answered 'Yes." I:;;::,' .....,.. :.:<.:.:.:.' :. : Blllncl Shlets Dlr BDOks Beginning of tax yeer End of tax yeer Assets fa) fbl c) fd) ~a ~::e '~~i~~ '~~~i ~~~'~~i~' ;~~~'bi~"'.'. .... ~'.'.'.'. ,~~:I\:::~!~r:~:~~i:IH1~~~:~~~:~;~;~;:j:~1::: ~:t?!:?:r~;;:!~:':::~~:;~'~':\'f:lW;~~:t~~!@~:~}~: 'rt:ttJ{:~:Jt:::::;i:~::~:~~::i~:~::~1 :f#?~\:j\{':\.H~:';::i;~~:.~;:~;;~:::~:1 b less allowance for bad debts .................. I I 45,973. I ' 41,218. 3 Inventories ..... ......... ............................ 4 U.S. government obligations ... .............. 5 Tax-exempt securities ........................... & Other CUmlllt asets (att sch.) S.TMT.... 7.... 7 loans to shareholders ........................... 8 Mortgage and real estate loans.................. 9 Other Investments (att sell.) ........................ 101 Buildings and other depreciable assets ...... 11: ~::~e:~~~~::: de~~~~~~~~.~...::::::::::::.:: I 174 , 92 3 ~ ~:.:.:.:~::~::::~:~:~::r::f::i I 19 7 , 16 4 ~ ..... ~:.~.:.::.:.:~.:~ 2 . 12b lleasnsd a(~ceUt mOfualantyedamdeoprtlelztaIOt.non.).... ................ ~"": ....:::.::.:.:::.::::: :::::.::::::::: ::;:::::::..::::.:~:.:::..:.::.:::::..::::: :::.:::::: ': .' . . . 13a Intangible assets (amO~I~ble ~~~)...::::..::::~ff::::::::~::I:~m::::fr::~:.t:~:::5::5'::1"':: .' .. .. .::.:::....:.::::::::::::::1. ........... i 7~' ,"6 ~5 . _:::~:::r~;::t:f~:_ blessaccumulatedamortization ............... I 37 976 136,581. I 48 427 130,208. . .. ..... ... ~: ~~:Ir :::e~~ (~~:.~~~.'~..~.'.'~.'.'.'.'~~~.'~~:~:::.:~:::." 'i::;::::f:l!:!l!:~::~l!I!:!::::~:~f:~r~~:~::t:::...:~:: : 263, 176 . .;:,;:~';:t:.::::;:::;.:;:':::::;::i/.:~;':J::::':' .:L:::::;,}:::'.... 245,567 . :~ ==~~:::=:~;: ,~~~~~1i~~:,;c~:c~t k~>;'"\i~~r :: ::,;;:=:,~'S~~~S .\~~* 1::-:::"1 I 4::-:::' :~ ~=i;;:'(:;~7c~~:~.1~1.~:.~.:~.. : ;}l;:::.t;:!:?!::::!!:::.;::~::j~i!:i:r:::~~::: ,. !;:~~!j!:ii:j:1 ,. 22 Capital stock: B Preferred stock ............... l:::.;.:.::::.... :. . . . .:: .":':'}::fU'!.:)j:i;:)::: :)i:::{:i1:::::.;:;;'::r:'::~::)};:'::::::::': .. .. b Common stock ............... 1,000. 1,000. 1 000. 1,000. ~ ~~~:~ui;:!., ;;;;;;;~.' ~;;;;;;; .'.:.: ............. ...... '. ......:1 : 'limn Reconciliation of Income (loss) Der Books With Income Der Retum (see Instructions) :4 ;?~g:~~~~y= 2 ~: ~~~: 7 ~S~T:M~T~:rd1:0:~OFtarnm 466. !:i:i.i:i:l:l:i:':i.l.i:':!:!:'.i..:i.r.!:i:':i:!:'.':i:~:l:i:l.i.'::.'.!:':;:!:,:i:!:,.!:i.t:!.':::':,.,:i.I:J:i:::t:!:i:f::::.i.!:.;:i:l.i...I.~.:.I.'::.I::.'.'..~.!:i:i..'.I:I.l:::i. r-' Il!:ij!:!!i!i:!i::~~~::::~:::~1~!:j~~j!::1i;!j:~~::~!1i!~I;iili::~i1i:::!j!:~~j::j:1~1::!!: . . ., . ." . .. (itemize): 1:::::::::1~::~:~~~:I~:r:!r:~~)1)~~::::~::t1:::':;iI:~~~::m::jrt~f' 4 6 6 . 5 deducl8d on IhIS mum c-) ..~ ill... .. 8 :bD:aoodC~Uh:~:tr1~~::t1II:eOons;O~"O'.'~"'~"':':~$:r~=): ~:.~:::i:::.i.::::.i:.:::.:::.:i:::::!:::::::::::'::.::':::.::::'::::.::::l,::::ir:::::.~::.!..::::.!:::::.i::::.~::::i:::::.':::.~::::.i::::.::::::::::::.:'::::'::::::;'::::::.[~::::::::::.':::.'::.:i::::::.!::::~:::::':.'::::::::.i:...::..~:..:::::.i:::::::.;::::.'::::'::.::L::.:'::::::i:::.::~.:~:.,,:.:~w::..:;:i:.::::tit,::::.',,::::i:::.~.,,:::::.~'::::::.::::::::l...:::.'::.:.,.:::.:::.1.::::::::~::.::.:;I::.,:.::.:;:~.:::::r,::.::::!:.::::i,.::::l'"::;:::..:...~:::.~::;:::':::.:::..'":i::.:::...:':::::.:.::::'::..:.!:.::::!:::.':::.:,,:~::~:::.:..::.::..:::::::..:::.::.:::.;::!::~!.'. ;;;~~o; OOOUIh~~41ar::8t91 07 " .\~7.i _, ~:m~:, C ~:::""t ... $ ,. ':"::.::::;::f~:::::;:.~~t.t8::);:~:;::;tf1:t:: '. STMT 9 205 . 6 , 912. 9 Add lines 7 and 8 ....................................... 8 Add lines 1 throuah 5 ................................. 33,353. 10 Income (Daae 1 line 28\ -line 6 less line 9 ...... M~ .. .::.:.:.::...... "::::"=-::::.::::;1 Analvsis of UnaDIl rODriated Retained Eamlnas Der Books (Line 26. Schedule L) 1 Balance at beginning of year ..................... 233, 191. 5 Distributions: a Cash ...................... ....... 2 Net Income (loss) per books ..................... 2 ~.' 508 . b Stock .............................. · Other IPC...... Cite_): .~i8I8 Other d.......' :ft'::::;rty ...... ........... ...... 7 Add lines 5 and 6 ....................................... 254 , 699. 8 Balance at end ofvear (line 4 less line 7\ ...... i;ilillill!lnllfj~I:!!~I;:ji;llf.I;I:If,II!II,:!~!j!lijl11!lil 150. 466. 32,887. 4 Add lines 1 2 and 3 ................................. 254,699. 511631 12-12-05 JWA Form 1120 (2005) Fonn 2220 Underpayment of Estimated Tax by Corporations ~ Seeleparatelnstructlonl. ~ Attach to the corporatlon'l tex return. OMB No. 1545-0142 Depertment of the T_ury Inlllm" Revenue Service 2005 MILLER INSURANCE ASSOCIATES INC. Employer identification number 23-2055739 Name Note: Generally, the corporation is not required to file Fonn 2220. (see Part II below for exceptions) because the IRS will figure any penalty owed and bill the corporation. However, the corporation may still use Fonn 2220 to figure the penalty. If so, enter the amount from page 2,IIne 34 on the estimated tax penalty line of the corporation's Income tax retum, but do not attach Fonn 2220. rf".:;:::.:::.:;....r ~r: Re uired Annual Pa ent 1 Total tax (see Instructions) .... ...................... .......................... ......................... ........ ............................................. ..... 4 933. 2a Personal holding company tax (Schedule PH (Fonn 1120), line 26) included on line 1 ............... 2a b Look-back interest included on line 1 under section 460(b)(2) for completed long-tenn contracts or of section 167(g) for depreciation under the Income forecast method ............. ........ 2b c Credit for Federal tax paid on fuels (see instructions) ..................................... .... ................ 2c d Total. Add lines 2a through 2c ................................................................................................................................. 3 Subtract line 2d from line 1. If the result is less than $500, do not complete or file this fonn. The corporation does not owe the penalty ............................ ....... ....... .......... ........................................... ........................................ 4 Enter the tax shown on the corporation's 2004 income tax return (see Instructions). Caution: If the tax Is zero or the tax year was for less than 12 months, skip this line and enter the amount from line 3 on line 5 ................................. 1IIIi"'I!I[I:\11':1 :;:::::;:::;:::::;::: :.;.:.:.:.:.:.:.:.:.: ::;:::::::::::::::::; ::::::::::::::::::::: 2d 3 4 933. 4 4,357. 5 Required Annual Payment. Enter the smaller of line 3 or line 4. If the corporation is required to Skip line 4, enter the amount from line 3 ............. .... ...................................................... .............. ............... ......... ............. ....... ... 5 :mf ..:':''''': r ~~: Reasons for Filing - Check the boxes below that apply. If any boxes are checked, the corporation must file Form 2220 even If it does not owe a penalty (see Instructions). 6 0 The corporation is using the adjusted seasonal installment method. 7 D The corporation is using the annualized Income installment method. D 4 357. 8 The como ration is a "lame como ration" fiaurina its first reaulred installment based on the nrior vear's tax. Mr':.:':':'::::::":{"'11 Flaurlna the Unde ent fal Ibl tel fdl 9 Installment due dates. Enter in columns ~a) through ~) the 15th dar of the 4th (Form 990-PF !lers: se 5th month ,6th, 9th, and 12th months of the 08/ 15 /2005 10/ 1 7 /2005 01 / 17 /2006 K>4 / 1 7 /2006 corporation's tax year .................................. ........ ...... 9 10 Required Installments. If the box on line 6 and/or line 7 above is checked, enter the amounts from Schedule A, line 38. If the box on line 8 (but not 6 or 7) Is checked, see instructions for the amounts to enter. If none ofthese boxes are checked, enter 25% of line 5 above in each column ... 10 1,089 . 1.090 . 1,089 . 1,089 . 11 Estimated tax paid or credited for each periOd (see Instructions). For column (a) only, enter the amount from line 11 on line 15 .........-................................... 11 963 . 1.090 . 1,090 . 1,090 . Complete JInes 12 through 18 of one column before - going to the next column. 12 Enter amount, If any, from line 18 ofthe preceding column 12 13 Add lines 11 and 12 ................................................... 13 :~~~~~~~~~~~~~~~~~~~~~~~~~1~~~~~~~i~~;j~~j~~j~tmmtmr~1~m~mr 1,090 . 1,090 . 1,090 . 14 Add amounts on lines 16 and 17 of the preceding column 14 ~@~~~~~~~~~~~~~~~~~~~j~~~~~~~~~~~~~~~~~~~~~~j~~~~~~~f~~~j~~i~~m~~m~~~m 126 . 126 . 125 . 15 Subtract line 14 from line 13. If zero or less, enter-G- ...... 15 963 . 964 . 964 . 965 . 16 If the amount on line 15 is zero, subtract line 13 from line ill~illll!il!i!lllllllll~ll;~!I!!IIII!lil;~!!~I::I!111:I!~i \jljjjl\li\l~jlljlil\i~i~~ij~~~11jijili~li\j::~ii!i~l:!:l\jil 14. Otherwise, enter-G- ............................................. 16 :::::::::::;:;:::::::::::::::::::::::;:::::::::::::::;:;:::::::::;:::::::;::::::: 17 Underpayment. If line 15 is less than or equal to line 10, subtract line 15 from line 10. Then go to line 12 of the next column. otherwise, go to line 18 ................................. 17 126 . 126 . 125 . 124 . 18 Overpayment. If line 10 is less than line 15, subtract line 10 :~::I~lj!!I:~:~:!::[!j.~I:::::~[:IIIIII~ll[ltlillll:::!:~j::~~::~[: from line 15. Then 00 to line 12 of the next column ......... 18 Go to Part IV on DaDe 2 to flaure the Denaltv. Do not ao to Part IV If there are no entries on line 17 - no Denallv Is owed. JWA For Paperwork Reduction Act Notice, see separate Instructions. Form 2220 (2005) 512801 01-16-06 MILLER INSURANCE ASSOCIATES, INC. Fonn 2220 (2005\ 01M1~.i:1 Figuring the Penalty 23-2055739 Paae 2 (a\ lb\ (c) ld\ 19 Enter the date of payment or the 15th day ofthe 3rd month after the close of the tax year, whichever Is earlier (see STATEMENT 11 Instructions). (Form 990-PF and Form 990-T filers: Use 5th month Instead of 3rd month.) ..................................... 19 20 Number of days from due date of Installment on line 9 to the date ahown on line 19 ................................................... 20 21 Number of days on line 20 after 4/1512005 and before 101112005 ... 21 22 UnclerpaylT*lt on line 17 x Number of days on line 21 x 6% ......... 22 S ~ t S 385 23 Number of days on line 20 after 9/3012005 and before 41112006 ...... 23 24 UndarpaylT*lt on line 17 x Number of days on line 23 x 7% ......... 24 S S i~ S 365 25 Number of days on line 20 after 313112006 and before 71112006 ...... 25 26 UnderpaylT*lt on line 17 x Number of days on line 25 X '% ......... 26 S S ~ S 365 27 Number of days on line 20 after 6/3012006 end before 101112006 ... 27 28 Underpayment on line 17 x Number of days on line 27 x '% ......... 28 S S g: S 365 29 Number of days on line 20 after 9/3012006 and before 11112007 ...... 29 30 UndarpaylT*lt on line 17 x Number of days on line 29 x '% ......... 30 S S S S 365 31 Number of days on line 20 after 1213112006 and before 2116/2007 ... 31 32 Underpayment on line 17 x Number of days on line 31 x '% ......... 32 S S S S 365 33 Add linea 22, 24, 26, 28, 30, and 32 .................................... 33 S 1. s 2. s 2. $ 2. 34 Penalty. Add columns (a) through (d), of line 33. Enter the total here and on Fonn 1120; line 33, Fonn 1120-A line 29. or the comoarable line for other income tax returns .............................................................................. 34 Is 7. · For underpayments paid after March 31,2006: For lines 26, 28, 30, and 32, use the penalty interest rate for each calendar quarter, which the IRS will detennlne during the first month In the preceding quarter. These rates are published quarterly In an IRS News Release and in a revenue ruling in the Internal Revenue Bulletin. To obtain this information on the internet, access the IRS webslte at www.lrs.gov. You can also call1-80Q-S29-4933 to get interest rate Infonnation. JWA Fonn 2220 (2005) 512802 01-16-06 4562 OMB No. 1545-0172 Form Depreciation and Amortization 2005 (RIIY. Jenuery 2006) (Including Infonnation on Listed Property) OTHER Oepertment of the T_ury Attachment InterMI Revenue SeIvlc:e ~ See separate instructions. ~ Attach to your tex return. Sequence No. 87 NemeCs) shoWn on retum Business or ecllvlty to whloh this form relates identifying number MILLER INSURANCE ASSOCIATES, INC . bTHER DEPRECIATION 123-2055739 t ;.:' .....~: :!~ Election To ExIIense Certain ProDertv Under Section 179 Nole: If yOU have any listed Drooertv, comDlete Part V before, au como/ete Part I. 1 Maximum amount. See the instructions for a higher limit for cerlain businesses 1 105,000 . ................................................ 2 Total cost of seelion 179 property placed in service (see Instructions) 2 6.2 34 . ............................................................... 3 Threshold cost of section 179 property before reduction in limitation .................................................................. 3 420.000 . 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter .(). 4 ......................................................... 5 DoIIIIr limitation for lex year. Subtr8ct line 4 from line 1. If zero or less, enter -0-. If married filing separately, _Instructions .............................. 5 105.000 . 8 (e) Description of property (b) Cost (busln_ use only) (e) EIectIld oosl - PC TRONIC FAX 1,259 . 1.259 . OFFICE FURNITURE 7 19 . 7 19 . PRINTER. 2 SCANNERS 2,054 . 2.054 . .:.:.:.:.:.:.:.:.:.;.:.:.:.:.;.;.:.;.;.;.:.;.:.;.;.;.;.;.;.;.;.;.:.;.;.:.:.:.;.:.:.:.;.;.;.;.:.: LAPTOP 2,202 . 2,202 . :~l~!:llj:llljll!llll:~l:~l!l!ll~:~:l!l:l:!:~:~:::::::~!:~:!:!!:~::::~:~:::l::::j:~~~!~!l~!li~jl 7 Usted property. Enter the amount from line 29 I 7 .:.:.:.:.;.;.;.:.;.:.:.:.:.:.;.:.;.:.:.;.:.:.;.:.:.;.;.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.: ......................................................... ::::=;:::::::::::::;:::;=;:;:;:;:;:;:;:;:::;:;:;:;:;:;:;:;:;:;:::;:;:;:;:::;:;:;:;:;:;:;:::::;:; 8 Total eleeled cost of section 179 properly. Add amounts in column (c), lines 6 and 7 .......................................... 8 6.2 34 . 9 Tentative deduction. Enter the smaller of line 5 or line 8 ..................................................................................... 9 6.2 34 . 10 Carryover of disallowed deduction from line 13 of your 2004 Form 4562 ............................................................ 10 11 Business income limitation. Enter the smaller of business Income (not less than zero) or line 5 ........................... 11 39.50 1 . 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 6.2 34 . 13 Carryover of disallowed deduction to 2006. Add lines 9 and 10, less line 12 ............ ~I 13 I ~rmJmmmmmmrmmmtmmmImmm~ttJm~fmm 14 14 15 18 17 MACRS deductions for assets placed in service in tax years beginning before 2005 .............. .. .......................... 17 3 2 2 7 · 18 If au are electing to group any aRts placed In selVlce durin the tax Ylllll' Into one or more general aset lICCOunts, check here .... ..... ~ D &trr~rr~~~~~lmr~rmr~ttrtttf~~tfftmrr:fm Section B - Assets Placed in Service During 2005 Tax Vear Using the General Depreciation System (b) Month end (e) Basis for depreciation (d) Reoovery (e) Classification of property year placed (buslnessllnvestment use (e) Convention (1) Method (g) Depreciation deduction In swvice only - _ Instructions) pwIod 1 9a 3-year oronertv - b 5.vear orooertv c 7-year :::::::::::::::::::::::::::::::::::::::::::::::::::::::::: d 1 D-vear orooertv IIII ~I~: ll~II~II.! .II'lll:: l.~':IIIII~I:1 ~lll.11II.'I~. ~'. e 1 5.vear f 2D-vear orooertv :::::::::::::::;:::::::::::::::::::::::::::::::::::::::::. :::::::::::::::::::::::::::::::::::::::;:::::::::::::::::. a 25'vear Drooertv ~~~~~~~~~~~~~j~~~~l~1~t~~~~~~~~~~~~~~~~~~~~~~~~~ 25 vrs. SIL h Residential rental I 27.5 vrs. MM SIL properly I 27.5 yrs. MM SIL i Nonresidential real property I 39 vrs. MM SIL I MM S/L 20a Class life b 12- ear c 40. ear ~~P.j~ .:.t Summary (see Instructions) 21 Usted 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 retum. Partnerships and S corporations. see instr. ..................... 23 For assets shown above and placed in service during the current year, enter the ion of the basis attributable to section 263A costs ................................................ 23 5~~bs LHA For Paperwork Reduction Act Notice, see separate instructions. Section C - Assets Placed in Service During 2005 Tax Vear Using the Alternative Depreciation System SIL SIL SIL l\!~i~f,l~lijlj:jli j ~jl~:~~~l:~~lj 1~!j1jj~~j~~j~!~i~~:~ :::::::::::::::::::::::::::::::::::;:::;::::::::=:::::~:. I 12 rs. 40 rs. MM 21 7 963. 22 17 424. .1~11111:~ljl~III~I~II~I~lijll'I~lllilI11111IlII111111iljlj~ll!:! Form 4582 (2005) (Rev. 1-2006) Form 4562 (2005) Rev. 1.2006 MILLER INSURANCE ASSOCIATES INC. 23-2055739 Page 2 Listed Property Onclude automobiles, certain other vehicles, cellular telephones, certain computers, and property used for entertainment, recreation, or amusement.) Note: For any vehicle for which you 818 using the standard mileage rate or deducting lease expense, complete only 248, 24b, columns (~ throuah (c) of Section A. all of Section B, and Section elf BDDlicable. Section A - Depreciation and Other Infonnation (Caution: See the instructions for limits for passenger automobiles.) 248 Do ou have evidence to su ort the buslnesS/lnvestment use claimed? 00 Yes D No 24b If "Yes" Is the evidence written? 00 Yes D No (a) (b) (~) (d) (e) (f) (g) (h) (i) Type of properly Date.. BUSIness! Cost or BlISls for depreciation Recovery Method! Depreciation EI~cted (list vehicles firsf) placed In Investment other basis (buslnessllnvestment periOd Convention deduction section 179 service use percentage use only) cost 25 Special allowance for certain aircraft, certain property with a long production period, and qualified NYL or GO Zone ro e laced in service durin the tax ear and used more than 50% in a uallfied business use .............................. 25 28 Property used mono than 50~ ~ · filled bum: uae: SEE STAT~NT: ~ : I I I rt used 50% or less in a ualified business use: % S~. % S~. % S~. 28 Add amounts In column (h), lines 25 through 27. Enter here and on line 21, page 1 .................................... 28 7 29 Add amounts in column (i),line 26. Enter here and on line 7, page 1 ................................................................................. Section B - Infonnation 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 questions in Section C to see if you meet an exception to completing this section for those vehicles. :1:!!:I~:ljlllllllll:I!lllllllllllllllllllllllllll:1 7.963.1 27 P ~j~~~~~~\~jfj~\~j\~jIj~r~~~~j~I~~1~~~IrI~ .:.:.:.:.;,:.:.:.:.:.:,:.:.:.;.:.:.:.:.:.:-:.:.:.:.:.;.:.:. :,;,:,:,>,;.;,.,;,;.;.:-;.:.:.:.:.:.:.;.;.;.:.:.:.;.:.:.:.: ..., .,..,. '................. ...........,.,..........................................'.' .....,..,..................... ............,'.....'....................................... ...... ..... .................. .............................. ............................. ............................. 9 6 3 . :11Ill!lllllllililllilll!lll~I!lllllil~111Iilll!I!li~!l~~~ 29 (a) (b) (c) (d) (e) (f) 30 Total buslnesslinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 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 use Yes No Yes No Yes No Yes No Yes No Yes No 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 B for vehicles used by employees who are not more than 5% owners or related ns. 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 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 conceming qualified automobile demonstration use? ..................................................................... Note: ffyour answer to 37,38,39,40, or41 is "Yes,' do not complete Section B for the coveredvehicJes. !!"::;':':':'::;"::II:!! Amortization (a) Description of costs Yes No m~~~~l;~;~*~~~~; @~~~~l~t~~~; 42 Amortization of costs that LOAN COSTS (e) Amortizable lUTlOunt (d) Code section (f) AmortIzation for this Y"- 9 250. 77. 43 Amortization of costs that began before your 2005 tax year .............................................................................. 44 Total. Add amounts In column (f). See the instructions for where to report ......................................................... 516252101-05-06 43 8 594. 44 8 671. Form 4662 (2005) (Rev. 1-2006) MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER INCOME STATEMENT 1 DESCRIPTION AMOUNT SERVICE CHARGES 69. 69. TOTAL TO FORM 1120, LINE 10 FORM 1120 TAXES AND LICENSES STATEMENT 2 DESCRIPTION AMOUNT PAYROLL TAXES PENNSYLVANIA TAXES - BASED ON INCOME PENNSYLVANIA TAXES - OTHER 25,682. 3,859. 865. TOTAL TO FORM 1120, LINE 17 30,406. CURRENT YEAR CONTRIBUTIONS STATEMENT 3 DESCRIPTION AMOUNT TOTAL CURRENT YEAR CONTRIBUTIONS 380. 380. VARIOUS STATEMENT(S) 1, 2, 3 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 CONTRIBUTIONS STATEMENT 4 QUALIFIED CONTRIBUTIONS SUBJECT TO 100% LIMIT CONTRIBUTION SUBJECT TO LIMITATION: CARRYOVER OF PRIOR YEARS UNUSED CONTRIBUTIONS FOR TAX YEAR 2000 FOR TAX YEAR 2001 FOR TAX YEAR 2002 FOR TAX YEAR 2003 FOR TAX YEAR 2004 TOTAL CARRYOVER CURRENT YEAR CONTRIBUTIONS TOTAL CONTRIBUTIONS AVAILABLE TAXABLE INCOME LIMITATION AS ADJUSTED EXCESS CONTRIBUTIONS ALLOWABLE CONTRIBUTIONS DEDUCTION TOTAL CONTRIBUTION DEDUCTION 380 380 3,327 o 380 380 STATEMENT(S) 4 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER DEDUCTIONS STATEMENT 5 DESCRIPTION AMOUNT AMORTIZATION COMMISSIONS AUTO EXPENSE DUES & SUBSCRIPTIONS EDUCATION EXPENSE INSURANCE POSTAGE TELEPHONE UTILITIES OFFICE EXPENSE TRAVEL & LODGING CAIR EXPENSES PROFESSIONAL FEES MISCELLANEOUS LICENSES CONSULTING FEES LEASE EXPENSE MEALS NOT SUBJECT TO 50% MEALS AND ENTERTAINMENT 8,671. 35,290. 5,322. 4,253. 1,415. 13,461. 6,857. 10,120. 8,666. 8,503. 2,057. 2,979. 7,266. 1,256. 1,374. TOTAL TO FORM 1120, LINE 26 1,776. 1,290. 1,890. 122,446. STATEMENT(S) 5 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 TAX COMPUTATION STATEMENT 6 1. TAXABLE INCOME . . . . . . . . . . . 2. LESSER OF LINE 1 OR FIRST BRACKET AMOUNT 3. LINE 1 LESS LINE 2 . . . . . . . . . . . 4. LESSER OF LINE 3 OR SECOND BRACKET AMOUNT 5. LINE 3 LESS LINE 4 . . . . . . . . . 6. INCOME SUBJECT TO 34% TAX RATE . . . 7. INCOME SUBJECT TO 35% TAX RATE . . . 8. 15 PERCENT OF LINE 2 . . . . . . . . . . . . 9. 25 PERCENT OF LINE 4 . . . . . . . . . . 10. 34 PERCENT OF LINE 6 . . . . . . 11. 35 PERCENT OF LINE 7 . . . . . . . . 12. ADDITIONAL 5% SURTAX. . . . . . . . . . . 13. ADDITIONAL 3% SURTAX . . . . . . . . . . . . 14. TOTAL INCOME TAX . . . . . . . . . . 32,887 32,887 o o o o o 4,933 o o o o o 4,933 STATEMENT(S) 6 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE L OTHER CURRENT ASSETS STATEMENT 7 DESCRIPTION BEGINNING OF TAX YEAR END OF TAX YEAR NOTES RECEIVABLE - OFFICERS FEDERAL PREPAID TAXES STATE PREPAID TAXES 2,393. 957. 1,885. TOTAL TO SCHEDULE L, LINE 6 5,235. 150. o. o. 150. SCHEDULE L OTHER CURRENT LIABILITIES STATEMENT 8 BEGINNING OF END OF TAX DESCRIPTION TAX YEAR YEAR PAYROLL TAXES PAYABLE 961. 2,161. ACCRUED INTEREST 227. 93. DEFERRED TAX LIABILITY 7,748. 7,282. CHECKS WRITTEN IN EXCESS OF CASH 7,593. o. FEDERAL ACCRUED TAXES 707. STATE ACCRUED TAXES 782. TOTAL TO SCHEDULE L, LINE 18 16,529. 11,025. SCHEDULE M-l OTHER EXPENSES RECORDED ON BOOKS NOT DEDUCTED IN THIS RETURN STATEMENT 9 DESCRIPTION AMOUNT TOTAL TO SCHEDULE M-l, LINE 5 205. 205. LIFE INSURANCE PREMIUMS STATEMENT(S) 7, 8, 9 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE M-1 OTHER INCOME RECORDED ON BOOKS NOT INCLUDED IN TaIS RETURN STATEMENT 10 DESCRIPTION AMOUNT DEFERRED TAX ADJUSTMENT 466. 466. TOTAL TO SCHEDULE M-1, LINE 7 FORM 2220 COMPUTATION OF UNDERPAYMENT PENALTY STATEMENT 11 Q T EVENT REMAINING PERIOD OF DAYS INT AMOUNT OF R AMOUNT TYPE * UNDERPAYMENT UNDERPAYMENT RATE PENALTY -- A Q 126. 08/15/2005 09/30/2005 46 6.00\ 1. R 126. 09/30/2005 10/17/2005 17 7.0n O. <1,090.>P <964.> 10/17/2005 0 7.0n o. B Q 126. 10/15/2005 01/17/2006 94 7.0n 2. <1,090.>P <964.> 01/17/2006 0 7.00\ O. C Q 125. 01/15/2006 04/11/2006 86 7.00\ 2. <1,090.>P <965.> 04/11/2006 0 7.00\ O. D Q 124. 04/15/2006 06/30/2006 76 7.00\ 2. R 124. 06/30/2006 07/15/2006 15 8.00\ O. TOTAL TO FORM 2220, LINE 34 7. EVENT TYPE: Q = AMOUNT UNDERPAID AT START OF QUARTER P = PAYMENT W = WITHHOLDING R = INTEREST RATE CHANGE L = SWITCH TO OR FROM A LEAP YEAR STATEMENT(S) 10, 11 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 4562 TOTALS LISTED PROPERTY INFORMATION-MORE THAN 50% STATEMENT 12 (A) (B) (C) (D) DESCRIPTION DATE BUS. % COST (E) (F) (G) (H) (I) 179 BASIS LIFE MTH/CV DEDUCTION ELECTED (K) TOTAL MILES (L) BUSINESS MILES (M) (N) (0) COMMUTING PERSONAL WAS VEH. MILES MILES AVAIL.? Y N (P) > 5% OWNER? Y N (Q) ANOTHER VEH. AVAILABLE? Y N 2005 CHEVY 04/27/05 IMPALA 100.00 22,500. 19,540. 5 200DB-HY YRS 4,700. 2003 GMAC 08/16/99 YUKON - LIKE 100.00 29,995. 29,995. 5 200DB-HY YRS 1,775. 2003 CAMRY 01/25/01 - LIKE PROPERTY 100.00 13,852. 13,852. 5 200DB-HY YRS 532. 2003 CAMRY 05/30/02 - SEE ALSO ASSET 31 100.00 14,300. 10,010. 5 200DB-MQ YRS 956. TOTALS TO FORM 4562, PART V, LINE 26 7,963. STATEMENT(S) 12 Form 1120 u.s. Corporation Income Tax Return For calendar year 2004 or tax year beginning MAY 1, 2004 ,ending APRIL 30, 2005 2004 OMB No. 1545-0123 DlII*tmInt of the T_ury Int.erMI ~ue ServIce B Employer identification number A Check if: Use Name 1 =1=8~m 00 :::el. MILLER INSURANCE ASSOC IATES, INC. 2 Person8I holding 00. Other- Number, street, and room or suite no. " a P.O. box, see page 9 of Instructions. 3=naIs:,.,~oorp.O wise, 19 BROOKWOOD AVENUE, SUITE 102 (_ tnetruetlons) print 4 Schedule M-3 required Dr type City or town, state, and ZIP code (8tlachSdl.M-3) h . CARLISLE. PA 17013 E Check If: (1)[ ] Initial retum (2)[] Final retum (3)[] Name chanae (4)[] Address chanoe 1 . Gross ~pts or lI8Ies I 5 9 8 , 9 3 3 .1 bL_ retums end slIowences I I c Bal ~ 1 c 2 Cost of goods sold (Schedule A, line 8) .... ............................................... ...................................................... 2 3 Gross profit. Subtract line 2 from line 1c ......................................................................................................... 3 4 Dividends (Schedule C,line 19) .................................................................................................................. 4 5 Interest . ....... ...................... ...... ........ .. ..... . ......... ......... ........ ....................................................... .............. 5 6 Gross rents ................................................ ........ ................................... .................................................. 6 7 Gross royalties .......................................................................................................................................... 7 8 Capital gain net Income (attach Schedule D (Form 1120)) ............ ..................................................................... 8 9 Net gain or (loss) from Form 4797, Part 1I,Iine 17 (attach Form 4797) .................................................................. 9 10 Other income (attach schedule) ............................................................~.~.~....~.';J;'A';J;'.~..M~~.';J;'....1............. 10 11 Total Income. Add lines 3 throuah 10 ................................................................................................... ~ 11 12 Compensation of officers (Schedule E,line 4) ................................................................................................ 12 13 Salaries and wages (less employment credits) .... ................................................. ................. .......................... 13 14 Repairs and maintenance ............................ .......................... ...... ................................... ....... ..................... 14 15 Bad debts ....... ...... ................. .... .., ............... ..................... .............. .............. ........................................... 15 16 Rents .. ....... .. . ..... ............................... ...... .. ................ .................................................................... .......... 16 17 Taxes and licenses ...........................................................................~.~.~....~.';J;'A';J;'.~M.~N';J;'....~............. 17 18 Interest ......... ........................................... .................. ...... .. ...... .................... ...... ......................... ........... . 18 19 Charitable contributions SEE STATEMENT 3 AND SEE STATEMENT 4 19 20 Depreciation (attach FO~ '4562)' ..:::::: :::::::::: :::::::::::: :::::::::::: ::::::::::: :::::: ::::::: ::.. i" 20" i................. ji; '4'6'4' . :::~t~~~~~~f~~: 21 Less depreciation claimed on Schedule A and elsewhere on retum ..................... 21a 21b 22 Depletion . ........ .... . . ........ ...................... ....... ..................... .. ............ .............. . ...... .. .............................. .... 22 23 Advertising ....... ...................................... ................................................................................................ 23 24 Pension, profit-sharing, etc., plans ..... ...... .................................. .................................................................. 24 25 Employee benefit programs .............. ...... ............................................... ...................... .................. ............. 25 26 Other deductions (attach schedule) ............ ................... ...... .................S.~~...S.';r~';r~.M~N';r...~............. 26 27 Total deductions. Add lines 12 through 26 ............................................................................................. ~ 27 28 TlIXSble Inoome befonl net openatlng loss deduction end special deductions. Subtract line 27 from line 11 .................................... 28 29 less: a Net operating loss deduction ......................................................... I 29a 1 ;.;.;.;.;.;.;.;.;.;.' b SDecial deductions (Schedule C line 2m .......................................... 29b 29c 30 Taxable Income. Subtract line 29c from line 28 ..................... ....................................................... .............. 30 :b~~;;=? .::......m.m~~~~E_ 31 C on Form 4466 ........................... 32c \ d Bal ~ 32d 5,320. ;;;;;;;;;;;;;;;;;;;;; e Tax deposited with Form 7004 ..................................................................... 32e .;.;.:.:.:.:.:.:.:.:. 1 Credit for tax paid on undistributed capital gains (attach Form 2439) .................. 321 :;:;:::::::::;:::::;. . Credit for Federal tax on fuels (attach Form 4136). See instructions ..................... 32g 32h 33 Estimated tax penalty (see page 17 of instructions). Check If Form 2220 is attached .................................... ~ 0 33 34 Tax due. If line 32h Is smaller than the total of lines 31 and 33. enter amount owed ................................................ 34 35 Overpayment. If line 32h is larger than the total of lines 31 and 33. enter amount overpaid ....................................... 35 36 Enter amount of line 35 vou want: Credited to 2005 estimated tax ~ 96 3. Refunded ~ 36 Under pen.lties of perjury, I declare that I have examined this retum, Including eccompenylng schedules end statements, end to the best of my knowledge end belief, It Ia true, ~~:;. conect, and c:omplete. OeclSnltion of pnlpIInIl' (other than taxpsyj Is besed on a1llnformatlon of which Prepsnil' h8s eny knowledge. I t!:.,~~s I ~stgn.tunlofolllcer Date ~T111e . Jl~J Yes D No . Preparer's ... I O.te I Check If Preparer's SSN or PTlN Paid slgnatunl F' self-employed [Xl PO 0 0 5 7 6 2 6 Prep.rer's Firm'sname SMITH ELLIOTT KEARNS & COMPANY LLC I EtN 5210783935 Use Only ~l:'~I~ed), ~'19 BROOKWOOD AVE., SUITE 101 ' I Phone no. (717) 243-9104 eddnlSS, end ,-: ~P~e CARLISLE, PA 17013 23-2055739 C Date Inc:orporated 02/28/1978 D Total -'s 1_ page 8 oflnstr.) s 263,176. 598,933. 598,933. j l/J c: o :g 1 Q 37. 598,970. 187,038. 80,576. 14,280. 343. 36,896. 22,042. 5,455. 100. 31,464. 33,297. 35,727. 122,707. 569,925. 29,045. 29,045. 4,357. f . ! 'a c: CD ! 5,320. o. 963. ~~~:~ JWA For Privacy/Paperwork Reduction Act Notice, see Instructions. Form 1120 (2004) Form 1120l2OO4) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Pa e2 ~%' .:;.:...:.:..,.:< ':" ....:t :~~ ost of Goods Sold see a e 17 of instructions 1 Inventory at beginning of year ........................................................................................................................... 1 2 Purchases.......................................... ................ .............. ................. ............................................................. 2 3 Cost of labor .... .............................................. ............. ....................... ..................................... ..... ........ ........... 3 4 Additional section 263A costs (attach schedule) ...................................................................................................... 4 5 Other costs (attach schedule) .......................... ............ .......... .................................... ........ .... ....................... .... 5 6 Total. Add lines 1 through 5 .............................................................................................................................. 6 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 9 8 Check all methods used for valuing closing inventory: (i) D Cost as described In Regulations section 1.471-3 (Ii) D Lower of cost or market as described In Regulations section 1.471-4 (iii) D Other (Specify method used and attach explanation.) ~ b Check If there was a wrltedown of subnormal goods as described in Regulations section 1.471-2(c) ............................................................... ~ D c Check If the LIFO inventory method was adopted this tax year for any goods (If checked, attach Form 970) ...................................................... ~ D d :1~:~n~I~~::~:~oc~::~:e~d u:~:~~;:;or. ~~i.~ .~~ ~~.~~: .~~~~~. ~~.~~.~~~~~ .~~.~~~.~~~~~~.~~................................................ W e If property Is produced or acquired for resale, do the rules of section 263A apply to the corporation? ............................................. DYes D No f Was there any change In determining quantities, cost, or valuations between opening and closing inventory? If 'Yes: attach explanation ......... .......................... ...................................................... .... ................................................... DYes n No 1:~t.~:ii;;:I.<;::;;;;:;t.:.:::~;a;;:~~~::::.::1 Dividends and Special Deductions (see page 18 of (a) Dividends (c) Special deductions .....~.:w. Instructions) received (b) % (a) x (b) 1 Dividends from less-than-20%-owned domestic corporations that are subject to the 70% deduction (other than debt-financed stock) ...................................................... 70 2 Dividends from 20%-or-more-owned domestic corporations that are subject to the 80% deduction (other than debt-financed stock) ...................................................... 80 see Instructions 3 Dividends on debt-financed stock of domestic and foreign corporations (section 246A) .... . . ............. . . 4 5 8 7 8 9 10 Dividends on certBln pref8rTed stock of 20%-or-more-owned public utilities .. . . . . . .. . . . . .. . . . . . . .. . . . .. . .. . . Dividends from less-than-20%-owned foreign corporations and certBln FSCs that _ subject to the 70% deduction.. ................... ................... ............... ....................... Dividends from 2O%-or-more-owned foreign corporations and certBln FSCs that _ subject to the 80% deduction .... ...... .................. ............................................... ~~~:~~=~~~rei~~~~~~~~~~~ .~~~j.~ .t~.~~............................. ................... Total. Add lines 1 through 8 ................................................................................. Dividends from domestic corporations received by a small business investment company operating under the Small Business Investment Act of 1958 ........................... Dividends from a1lIlisted Cp members end certain FSCs that 11 _ subject to the 100% eduction ........................... ........... ........... ............................. 12 ~~~=Iro:-&j~~~~~.~.~~~.~.~..................................................... 13 14 15 18 17 18 19 Im~mmmm~~ffmtt~I~Ij~j~[~~j~fI~~~I~~f~~lt~~m: ~{~~~~;~~m~~t~~~~1i~~W~j@; Dividends on certain prl!lferred stock ofless-than-20%-owned public utilities ................................. 42 48 70 80 100 100 100 85 Other dividends from foreign corporations not Included on lines 3, 6, 7, 8, 1 1, or 12 .... .. .. .... .... ....... . Income from controlled forl!llgn corporations under subpart F (atbIch Form(s) 5471) ......... .. ..... . .. .. ... Foreign dividend gross-up (section 78) .................................................................. Ie -DISC and former DISC dividends not Included on lines 1, 2, or 3 (section 246(d)) ............ ............ Other dividends ............................ .............................................. ...................... Deduction for dividends paid on certain preferred stock of public utilities ........................ Total dividends. Add lines 1 through 17. Enter here and on page 1, line 4 ............... ~ 20 TotallDeclal deductions. Add lines 9 10 11 12 and 18. Enter here and on DaOe 1 line 29b ................................................ ~ li~j~_:jI.jl::1 Compensation of Officers =~n~c:::;'= ~~:. WtoC:I=~~ ~~:~=~ 4 throutlh 10 on __11_$500 000 or more. (b) Social security (c) Percent of Percent of corporation (f) Amount of (a) Name of officer number time devoted stock owned . to business (d) Common I (e) Preferred compensation 162-36-7572 100 80.00% 123,925. 161-58-1250 100 20.00% 63,113. 1M EUGENE MILLER KIMBERLY SHOFF 2 Total compensation of officers .......................... ....................... ................... ............ ....................................................... 3 Compensation of officers claimed on Schedule A and elsewhere on retum .............................................................................. 4 Subtract line 3 from line 2. Enter the result here and on nane 1 line 12 ................................................................................. 1~~:J-~ JWA 187,038. 187,038. Form 1120 (2004) 23-2055739 Pa e3 INC. ................................. ~ D :t;rfit~~ .:;:::::::::::::::::: :.:.:.:.:.:.:.:.:.:. ::::;:::::::;::::::: ::::::::::;:::::::::: .:.:.:.;.:.:.:.:.:.:. :.:.:.:.:.:.:.:.:.:.: :.:.:.:.:.:.:.:.:.:. :.:.:.:.:.:.:.:.:.:.: :~~~~m~~~~~~~i~~~;~ .:.:.:.:.:.:.:.:.:.:. .:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.:.:. :.:.:.:.:.:.:.:.:.:.: :.:.:.:.:.:.:.:.:.:. :~m~~~;~;~~t~~~; .:IIIIIIIIIIIII.I!::1 28 ~I$ I ~ (1) Additional 5% tax (not more than $11,750) (2) Additional 3% tax (not more than $100.000) 3 Income tax. Check if a qualified personal service corporation under section 448(d)(2) STMT 6 (see page 21) .................................................................................................................................... ~ D 3 4 Alternative minimum tax (attach Form 4626) ........................................................................... ............... ............... 4 5 Add lines 3 and 4 ............................................................................................................................................. 5 6a Foreign tax credit (attach Form 1118) .................................................................. 6a b Possessions tax credit (attach Form 5735) ............................................................ 6b c Check: D Nonconventional source fuel credit D QEV credit (attach Form 8834) 6c d General business credit. Check box(es) and Indicate which forms are attached: .:.:.:.:.:.:.:.:.:.:. D Form 3800 D Form(s) (specify) ~ &d e Credit for prior year minimum tax (attach Form 8827) ............................................. 6e f Qualified zone academy bond credit (attach Form 8860) .......................................... 6f 7 Total credits. Add lines 6a through Sf .................................................................................................................. 8 Subtract line 7 from line 5 ..................................................................................................................... ............ 9 Personal holding company tax (attach Schedule PH (Form 1120)) ........................................................................... 10 Other taxes. Check if from: D Form 4255 D Form 8611 D Form 8697 D Form 8866 D Other (attach schedule) ............................................. 11 Total tal. Add lines 8 throu h 10. Enter here and on a e 1 line 31 ........................................................................... tr '::':':':':::':':::';':':':"':':':::Kt: Other Infonnatlon see a e 23 of instructions 1 Check accounting method: a D Cash b 00 Accrual ..!~~. ...~~... 7 At any time during the tax year, did one foreign person c D Other (specify) ~ ::::~tmrr: ::t:rt:I own, directly or Indirectly, at least 25% of (a) the total ::::::::::::::::::::: :::::~::::::::~::: voting power of all classes of stock of the corporation 2 See page 25 of the instructions and enter the: mmrmmt: I:n:::t::: entitled to vote or (b) the total value of all classes of stock a Business activity code no. ~ 5 2 4 21 0 ~;f;ttt~: ~ffft:~i ofthe corporation? ............................................................ b Business 8ClIvlty ~ INSURANCE :~:::?:::;?? :::::~:::;i:;:;;~: If "Yes,' enter: (a) Percentage owned ~ 3 ' =~-::.:: :~:~~c~rp.raUon"", dl_.r II, ~: ~~.:::~: :~;:to flO F... 5412. Into_., Indirectly,50% or more of the voting stock of a domestic :.:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.:.: Return of a 25% Foreign-Owned U.S. Corporation or a corporation? (For rules of attribution, see section 267(c).) ...... X Foreign Corporation Engaged In a U.S. Trade or Business. If "Yes.' attach a schedule showing: (a) name and :~:::::::::~::::~:~; ;~:~~~~::~!::: Enter number of Forms 5472 attached ~ ::~~r~~~~~~:: ~~O~::)(~~J~~~~:~~::c~fned. ~::I:::::::::::::: ::::~~I:::::::: 8 Check this box if the corporation issued publicly offered D deductions of such corporation for the tax year ending with or t::rr;tHtittr~i debtinstruments with original issue discount ............ ~ within your tax year. ':;:;;;:::::;:;;;;::: ;;:;;:;;:;:;;;:;;;:; If checked. the corporation may have to file Form 8281. l~~ml~1~~[~~1 ~r~t~~~u~~ 4 Is the corporation a subsidiary In an affiliated group or a :;:;:;:;:;:;:::;:::;. ;:;:;:;:;:;:::;:;::: Information Return for Publicly Offered Original Issue parent-subsldlary controlled group? ................................. ........... ..~... Discount Instruments. If "Yes,' enter name and EIN of the parent corporation ~ rrr:rr r::t:::mt 9 Enter the amount of tax-exempt interest received or .:::::::::::::::::::.:::::::::::::::::::: :;::::::::::::::::::: :::::::::::::::::::: d d . th tax ~ $ :::::::::::;::::::::: :::::=::;::::::::::: accrue unng e year 5 ;:~;rr:t~J5=;:: II :: ~:r~i:=::'::::~:'::r:r of attribution. see section 267(c).) .................................... X electing to forego the carryback period. check here '" ~ D If -Ves.- attach a schedule showing name and identifying ::~::::::::~::::::: :::::::::::::::f.::: If the corporation Is filing a consolidated return. the statement number. (Do not include any Information already entered :IIII~IIIIIIIIIII:IIIIIII ~~~~~~u~r ~:~::c~~ ~~~~a~~~~:~~i~nn~t1;eO~;~~~(b)(3)(I) In 4 above.) Enter percentage owned ~ :ift'fl tm~m 12 Enter the available NOl carryover from prior tax years 6 ~~~n::~ :u::~s ~~J~~s~~~~~~:~nP::C~:~nf~~ ~~:~) ;:I::I:~:~I;I:~III; 1~lillll:IIII:I:II~ ~~:.~o~ re:uce it by any deduction on line in excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) ............... .......... ...:~... 13 Are the corporation's total receipts (line 1a plus lines 4 through If "Yes,' file Form 5452. Corporate Report of ~:rff:~~~:; ~IfII~:~ 10 on page 1) for the tax year and Its total assets at the end of the NondMdend Distributions. XlIi ;:;tlff; tax year less than $250.oo0? .............. ............................... If this is a consolidated return, answer here for the parent tlfJ~ @~t{~~;:~ If "Yes,' the corporation is not required to complete Schedules l, ~::os~:::~:. on Form 851. Affiliations Schedule, for ..III..I:.II~I: 11~11..1111.11.1. ~:~ri~:~~~~ !~~~~~::~::~r.~~tvt~:~~~~I~~~ (fO~~~~ Note: If the corporation. at any time during the tax year, had assets or operated a business In a foreign country or U.S. possession. It may be required to attach Schedule N (Form 1120), Foreign Operations of U.S. Corporations. to this return. See Schedule N for details. 1~~~-1.. JWA b 4 357. 4 357. .;.;.:.:.:.;.:.;.:.;. ::;:::;:;:;::=;:;:;:; 4 357. 4 357. X .......... ........... ........... .......... .......... "......... ........... .......... .......... ........... ........... .......... .......... ........... ........... .......... ......".. ........... ........... .......... .......... ........... .. ,. ....... .. .... .... . ......... .... ....... . . . . . . . . . .. .......... . ..... .... .... ... .... ........... .......... .......... ........... ........... .......... .......... ........... .....,.................................... ........... .......... .......... ........... . ... ....... .......... .......... ........... . . . . . . . . . .. .......... .......... ........... ....'......................,.............. ........... .......... .:.:.:.:.;.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.: ........... .......... .......... ........... ........... .......... ...................'.'.....'.'............ .:.:.;,:,:.:.:,:,;.:,:.:.:.:.:.:.:.:.:.;.: '.:.:,:.:.:,:,:.:,:.:,:.:.:.:.:.:.:.:.:.:. .. .... .... .. ......... .."..,... .......... .. ... ..... .... ....... .... ....... ...... ..-. ............',......'.................... ....".... ........... ,.......... .......... ..,....... ........... .......... .......... .................... ..................... ....................,..................... .......... .. ..... .... .......................................... ........... .......... ."....... ........... .......................................... ........... .......... .................... ..................... ......................................... .......... ........... ........... .......... .......... ........... .......................................... ..."..... .......... .......................................... ....."... ........... .......... .......... .:.:.;.;.:.;.;.;.;.::.:-:.:.;.:.:.:.:.:.: .::::::::::::::::;:::;:::::::::::::::::::; .......... ........... :;~;~~;~~~~~t~1~i ~~~~~;~~~~~r~;;~~~ .................... ..................... .......... .......... ...... .... .. ......... .......... .......... .......... ........... .......................................... .......... .......... .......... ........... .......... ...... .... .......... ........... '.:.:.:.:.:.:.:.:.:. .:.;.:.:.:.;.:.:.:.;. ........" ........... ..:.:.:.:.:.:.:.;.:. .:.:.:.:.:.:.;.:.:.;. .......... ........... ~::::::~::::~::::. ::::::::::::::;:::::: gIl~l. ~~~;~l~~r:m~;@ .:.:.:.:.:.:.;.:.:.: :.:.:.:.:.:.:.:.:.:.: :::::;:::::::::::I::::::;:;:::::;:::::: ;.:.:.:.:.;.:.:.:-:. .:.:.:.:.:.:.;.;.:.;. .:::::::::::::~::::. :~::::;:::;::::::::; .:.:.:.:.:.:-:.:.;.: :.;.:.:.:.:.:.:.:.;.: :llllillllllllll: 11!:IIIIIIIIIIIII!111 Illlilllllllllllil: li!!llllil!I!III!!111 ................... ..................... ................... ..................... ~@~~t~~@~~~: ~~t~~~t~l; .;.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.;. :.:.:.:.:.:.:.:.:.:.:.;.:.:.;.:.;.;.;.:.: ......................................... ......... .......... :::::::;::::::::::::::::::::::;::;:;::;:; ......... .......... ......................................... n..n.... ........... ~1~1~@~~~~; ~~m~~~tlt II .::::::::::::;:::;:; :~::::::::::~:::::: x .:.;.;.:.:.:.;.;.:.:.;.;.:.;.;.:.:.:.;.:.; .;::::::::::::::::;:.:::;::::::::::;:::::; ...... .... ........... .......... .......... .......... ........... .................... ..................... .................... ..................... ........... .......... .......... ........... ;.:.:.:.:.;.;.:.:.:.:,;.:.:.:.:.:.;.;.;.:. .......... ........... .......... .......... .......... ........... .......... .......... .......... ........... ........... .......... .......... ........... .......................................... .......................................... :.:.:.:.:.:.:.:.:.;..,;.:.:.;.;.;.:.;.:.:. .......... ........... ........... .. ........ Form 1120 (2004) Form 1120(2004) MILLER INSURANCE ASSOCIATES, INC. 23-2055739 p_4 Nota: The comoration is not reouired to comDlete Schedules L M-1 and M-21f Ouestion 13 on Schedule K Is answered "Yes." II!:' .::.;...:.:.:.:.:....:.;.:...:.:\tiH Balance Sheets Def Books BegInning of tax year End of tax year ~ ~ ~ M M ~. ~::e '~~i~~ '~~d' ~~~'~~i~' ~~~~~'bi~"'. ~'.~'. ~ ~'. ~ I::::ft:;::::':,~:;t~f{;: :"4'~ :~':'~::~::i:::~!~ !:tt~:~::::t:~,~{.t:~:::\:~~~~~:~illii.~~l~f~! ~:r~tr~@~tI:~:~J::t~~!~~:;:::'::~':9:~~"::: 1:::,::;::::::i::::::::::;:::;::,:,;:::::f:;t~:~:~:1ttf::0~~~~::~:;> b Less allowance for bad debts .................. 42.406. I 45.973. : ~~:::,;;;;;j~b~b;;. lIir~1 ; ~~f~'~;0r7m ,~1f,1I 3.110. ; 5.235. 10. Buildings and other depreciable assets ...... 2 0 9 . 5 6 3 . f~~:mrt:]tllt:t~Itt:~~~~:~1IJ~:~:~f:I. 2 5 0 . 311 . ':i:~:~:Il:t~~'::?t}II:rf?:::::~:::::tt~::~f~?:~: bLessaccumulateddepreclation ............... ( 156.40001 53.163. ( 174.923.1 75.388. 11. Depletable assets . . . . . . . . . ... . . . . . . . . . . .. . . .. . . . . . ';::{:';:::;.:: ~ .::;:::{:!\r{t::I~::~I::~:l:~IlI:::~1 ...... .......... .. . :{:(:;):If}tmI~~ b Less accumulated depletion ..................... ( \ ( ~:. ~::~~~: ~~:::s ~~~:~=:~~ ~~.~).. ........... ........ !~ttJ:~~~J:f}:::;:i':~:ci.:::: :~:.~:.~;:i~ .. .. :: .:;.;);\::::::,i::A~;:;:}::/?i:nt~:m~:m:j ]:HI:~IIflaI~~~~~:j:~;i~~::g:~:~':':" : : .: .:; :.:::::':' ?,::"( bLessaccumulatedamortization ............... ( 26.97101 153.266. 37.976.. 136.581. ~: ~:Ir :::e~:s (~~: .~~~.'~. . :.... ............::: :....:: ...... :......::. ::':'.' ...:.:..:~:IIIIII~lllllllllil!lli~II!IIII~I:i!I!!lil:~:llil!::IIII::i:I:!:. 2 7 7 , 5 2 0 . :::::::::I:III:I!il!illllllll!~III;~~:1111!;:!I:!lil!1Ill[IIIIIIIIIllli!:liI11:1ill: 2 6 3 , 1 7 6 . j~ ~~g2~~'~ ::JlJl=I!II~~~~ 20 . ". .... ... ..... ..... ... . 183 358 ......J~~:~t::::::::.. .:::::::::::,.... ... . 135 681 : =~f~;~<<7.:K:~\:?;~:!:~:0:i:'DZy!;\~"l~~~^] .. ....;,Ti;&~ ~ ~~~::~u~~~:l~., ;;;~;i;;., ;;;~~;;; ,:;:,:lIiIi:,::;,:.t;::::... : ':.,::~ : 'J.iI~~1 Reconciliation of Income 'Loss) Der Books With Income Der Return (see oaoe 24 of Instructions\ ; ;E;~~~;;~: 3~:~:j: 7 ~:.;:~::~o~':trn<< .. (ttemize ) ::::::I:!::~I::f::~j!:;:~~:.::;:~i':::~:!.:;i:!:!I~I!ilIli:i::li~lljl:.I:j'I~!il.I.lliilli SEE STATEMENT 9 3.365. 8 5 ~~;f:=~~rn<< . c ~r:.~ment ... $ 2 ,208. .:.:.~.:.:.w...:....::.:.:.:.:....Jiiijiji!iiii:iiiii!i:ii!iiii!iillllillililllllll. STMT 10 205 . 2 . 413. 9 Add lines 7 and 8 ....................................... & Add lines 1 throuoh 5 ................................. 41.985 . 10 Income (Daoe 1 line 28). line 6 less line 9 ...... IW...."....::.':........;:.. .... ::::..::,::l Analvsls of UnaDDronriated Retained Earnlnas Der Books 'Line 25 Schedule U 1 Balance at beginning of year ..................... 201 . 347. 5 Distributions: . Cash .............................. 2 Net income (loss) per books ..................... . ." ~. ~.... ~..~ ~....~ b Stock .............................. 3 ""'or Incrusl$ ('.mla): ~ & ""'''..em.... :..::rty uu.u................. ~~~O~~~:'~:;.940. . 12.940. 12.940. 29,045. 4 ArlrI lines 1 2 and 3 ................................. 7 Add lines 5 and 6 ....................................... 233 . 191. 8 Balance at end ntvear lIine 4 less line 7\ ......... 233.191. Form 1120 (2004) 411631 12.22.04 JWA Fonn 4562 OMB No. 1545-0172 Depertment of the T_ury Inl8mlll RlIvenue Selvlce N8II'I8(s) Shown on retum Depreciation and Amortization (Including Infonnation on Listed Property) OTHER ~ See separate Instructions. ~ Attach to your tax return. Busln_ or activity to which this fonn relates 2004 Attachment Sequence No. 67 Identifying number THER DEPRECIATION 3-2055739 ~~ .:"';';';';::)~I~ Election To ense Certain Pro e Under Section 179 Note: If ou have an listed ro e ,com lete Part V before ou com lete Part I. 1 Maximum amount. See Instructions for a higher limit for certain businesses ...................................................... 1 102 , 000 ._ 2 Total cost of section 179 property placed in service (see instructions) ............................................................... 2 40 750. 3 Threshold cost of section 179 property before reduction in limitation .................................................................. 3 410 000. 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter.(). ......................................................... 4 5 Dol.... limitation for tax year. Subtrect line 4 from line 1. hero or 1-. enter-D-. If manied filing sepllflltely, _Instructions ................. ............. 5 102 000. ;URN I TURE (. Description of property (b) Cost (bUsln-; ~~; . (q E~ =; 6 3 .11.III.ljl.I.:I.I:I!II~~I:~j:.~I!l~:.....~lllllllll~l~11.11.lll.I~..I.I;I~I:.I.I.II...II.II.l.11 FILING CABINETS 2 7 7 2 7 7 .;.:.;.;.;.:.:.;.:.:.:.:.:.:.;.:.:.:.;.;.:.:.:.:.;.:.:.:.:.:.;.;.;.;.;.;.:.:-:.;.:.;.:.:.:.:.;.: . . rrrrrrr~IItIItt:::rt:~r:t~r::rn: COMPUTERS 10 110. 10 110. ij:!i~:~::::i!j:::j::~~i:~iI:ij!:::::::::!i!::::::::~::::~:::I:::::i::~:~:::::Ii: 7 Usted property. Enter the amount from line 29 ................................ ..................... . ... 7 2 9 6 0 . ~1::llllll:lllll:lll:I!III!IIIIIII::llllll:.llll~!111111!:II:lll!:lil:III:I:I:II'I~II:'II!.:II! 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 .......................................... 8 21 210. 9 Tentative deduction. Enter the smaller of line 5 or line 8.................................................................................... 9 21 210. 10 Carryover of disallowed deduction from line 13 of your 2003 Form 4562 ............................................................ 10 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 13 Carryover of disallowed deduction to 2005. Add lines 9 and 10, less line 12 ............ ~ 13 Note: Do not use Part 1/ or Part III below for listed property. Instead, use Part V. C:.:.:.:.:::::;...:f....:: S iel De reclation Allowance and Other De reciation 0 not Include listed 14 SpecllII deprecletlon 1II1owance for qullllfted property (other then listed property) pfllCed In service during the tax year <see Instructions) ................... 14 15 16 17 18 17 5 289. ", .............. ..................,.. ....,. ,........... ................................................................................'...........'..,..'..,..'.....'........ 1:1~:IIII!IIIIIIIIIII~llllilllll:lllll:llllllll:111111Illil:III:IIII!:llllil!!lllilllllllii!!:ll!!I!:I!:llll:1:1~i: Section B - Assets Placed in Service Durlna 2004 Tax Vear Usina the General DeDreclatlon Svstem (b) Month end (e) Basis lor depreclstion (d) Recovery (. elasslftcatlon of property year plllCed (businessllnv.tment use (e) Convention (1) Method (g) Deprecletion deduction In service only . _Instructions) period 19a 3-year property ::::::::::::::::::::::::::;:;:::::::::::::::::::;:;:::::;: ~~~~~~~~~~~~~~~~~m~tr~~t~ft~}~t~~~~ b 5.vear orooertv i! ::::!:: ::!j:::[j::~ !:j:~ ~!:! ::~: ij: ~~!::::!~: ~:!: ~i :j::; c 7 -vear property ............... .............. ........................................................" ::;:::::::::::::::;:::;:::::::::;::::;::;:;:;:;:::;:::;::: d 1 Q.vear orooertv !!~::!i!:i:!:!!l:::::::!::~:::::~j:!i!~::!::::i!:!~li!:i:! 15-year DrODerty ............................. e :~:~:;:~:~:~:~t:~:?~:~:}~:~:;:t;:;:~:~:~:~:~:~ :::::::::::::::::::::::::::::::::::::::::::::::::::::::::: f 2Q.vear ............... .............. .......................................................... ~~~~~~;~~~~~~n~~I~11~~~~~U1tm~mm~; a 25-year Droperty ::::::~:::::::::::::::::::::::::::::::::::::::::::::::::: 25 vrs. SIL h Residential rental I 27.5 yrs. MM SIL property I 27.5 yrs. MM SIL i Nonresidential real I 39 vrs. MM SIL property I MM SIL 20a Class life b 12- ear c 40. ear j:' ..:.;.:.:.:.~: ';r" Summary (See instructions.) 21 Usted 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 rtion of the basis attributable to section 263A costs ................................................ 23 1~~;.k LHA For Paperwork Reduction Act Notice, see separate instructions. Section C - Assets Placed In Service During 2004 Tax Vear Using the Alternative Depreciation System :::::::::::::::::::::::::::~:~:?~:::::~:::?::::::::: SIL i:~:i~~j::!:!t~lij:!!j:i:lj!!j!jl!!!!:l!!j!l:!!!!!:i!~ 12 rs. SIL I 40 rs. MM SIL 21 4 965. 22 31 464. .. . .. ... .. .. ~~~~~1~~~~~1j~~jj~~~~1j~~~~ili~1~~~~~~1~~l~~~~~~~~~~~~~1~11~1~~~~1~1~I~~~~~~ f~~~~~~~~~~~~~~~~~~~~~~r~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~;~~~~~~~~~~;~~~~~~~~;~;;~~~~m~~ Form 4562 (2004) Form 4562 (2004) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Page 2 LIsted Property Onclude 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 248, 24b, columns (a) throuah (c) of Section A, sll of Section B, and Section C If MDlicable. Section A - Depreciation and other Infonnetlon (Caution: See Instructions for limits for passenger sutomobiles.) Me Do ou have evidence to su ort the buslnesslinvestment use claimed? 00 Yes D No 24b If "Ves " is the evidence written? 00 Yes D No (a) (b) (~) (eI) (e) (f) (g) (h) (i) Type of property Date. Buslnessl Cost or Bals fordept'llClation Recovery Methodl Depreciation EI~cted (list vehicles first) placed In investment other basis (buslnessllnvastmant periOd Convention deduction section 179 service use percentage use only) cost 25 Special depreciation allowance for qualified listed property placed in service during the tax 'l.il,I.I.i.I.I.I,I.I.!.,I.I.I.I.l.i.!,I.I.l,I.I.I.f.1.1.l.i.l.t.i.I.I.;.l,i.l.f.l.i.:r.i.I,I.I.II.II,I.I:.ll,I ear and used more than 50% in a uallfied business use ........................................................................ 25 26 Pro rt used more than 50% In a uallfied business use: % SEE STAT NT: 11 % 4 965. 2 960. % 27 Pro used 50% or less in a uallfied business use: % S/L . ~~:l~:::~~::::~:::t~::::t:::'~:~~:t,t:t: ~:~:~:~:~:~:~:~:~:~:~:~:~:;:~:~:;:;:;:~:;:;:~:;:;:;:;:~:~: % S/L . ::::::::::::::::::::::::::::::,:::::::::::::::::::::::::,: % SIL . 1!!~1!!1!!1!!!~!!!:!!~~~!!1!!1!!1!!1!!:!!!!!1!!:~!! 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 .................................... 28 4 965. ~~~~~mmmm~~~lt~]it~~tf~ 29 Add amounts in column (i), line 26. Enter here and on line 7, page 1 ................................................................................. Section B - Infonnation 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 questions In Section C to see If you meet an exception to completing this section for those vehicles. (8) (b) (c) (eI) (e) (f) 30 Total businesslinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not Include commuting miles) .................. 31 Total commuting miles driven during the year ... 32 Total other personal (noncommuting) miles driven........................................................... .... 33 Total miles driven during the year. SEE PA /RT V STA TEMENT Add lines 30 through 32.................................... 34 Was the vehicle available for personal use Yes No Yes No Yes No Yes No Yes No Yes No 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 B for vehicles used by employees who are not lTlQf'e than 5% owners or related rsons. 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 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 ofthe vehicles, and retain the information received? ......................................................................................................... 41 Do you meet the requirements conceming qualified automobile demonstration use? ..................................................................... Note: "your answer to 37, 38, 39, 40, or 41 is 'Yes, · do not complete Section 8 for the covef8d vehicles. ]titf::;: "m Amortization (8) Description of costs Yes No t~~j~~~mmt;m ~m;1;~~m~m~l 42 Amortization of costs that (c) Amortizabla amount (d) Coda section (e) ~on period or peIC8IIlage (f) Amortization for this year 43 Amortization of costs that began before your 2004 tax year .............................................................................. 43 44 Total. Add amounts in column (0. See instructions for where to report ............................................................... 44 416252/11-15-04 Form 4562 (2004) Fonn 4562 Depreciation and Amortization (Including Infonnation on Listed Property) OTHER ~ See sepal'llte instructions. ~ Attach to your tax return. Business or lICIIvlty to which this fonn relates Department of the T~ury IntlmallW\.wlue Service Name(s) 8hown on mum OMB No. 1545.0172 2004 AtlIIchment Sequence No. 67 ldentlfylng number MILLER INSURANCE ASSOCIATES. INC. OTHER DEPRECIATION 23-2055739 Illil::1:J Election To Expense Certain Properly Under Section 179 Note: If you have any listed propertY, complete Part V before yOU com lete Part I. 1 Maximum amount. See Instructions for a higher limit for certain businesses ...................................................... 1 102 . 000 . 2 Total cost of section 179 property placed In service (see Instructions) ............................................................... 2 3 Threshold cost of section 179 property before reduction In limitation .................................................................. 3 4 Reduction in limitation. Subtract line 3 from line 2.lf zero or less, enter.(). ......................................................... 4 5 Dollerllmitatlon for tax yar. Subtrac:t line 4 from line 1. If z.-o or less, enter ..()...Ifmenled tiling separately, _Instructions .... .......................... 5 6 (8) Description of property (b) Cost (business use only) (e) Elected cost 7 Usted property. Enter the amount from line 29 .................._...................................... I 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 2003 Form 4562 ............................................................ 11 Business income limitation. Enter the smaller of business Income (not less than zero) or line 5 ................ ..... ...... 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 13 Carryover of disallowed deduction to 2005. Add lines 9 and 10, less line 12 ............ ~ I 13 410,000. ~~~:j!:~~!!~:i~:~:~~~~jij!:~~I~:!~j~~~:~!!:~:::~~~~~~!i:i~i:~~:~~~~~:~~~:~ 1111:.ll!IIII!'IIII!I~IIIIIIIII!lllllillllillllllllllllIIIIIII:IIIIIIII'IIIIII!II!IIIIIIIII! :1;:i.::.:.II:.!~:I:I.::.:!:!II!I:~I::i!il:!'.!I;I:II:.11:1!:I~II[lli~~:.::.:.::.:.:::~.:!I!.. ~~~~;~~~~~~~~~~~I~~~~~~~~~~~~~~~~~~~~~~~~;~~~~~~~;~~~i~~~~~t~~~~~t~~m~~~i~~;~~~~~~t~~ 8 9 10 11 12 :.:.:.:.:.:.:.:.:.:.:.:.;.:.;.:.:.:.;.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:. :~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:;:~:;:~:~:;:~:~:~:~:~:~:~:~:~:;:~:~:~:~:;:~:~:~:~:~:~:;{{:; ro 14 Special depreciation a1IOWl11lce for qualltled property (other than listed property) placed In service during the tax year (_ Instructions) .................. 14 15 Property subject to section 168(f)(1) election (see instructions) ........................................................................... 15 16 Otherde reciation Includin ACRS see Instructions ....................................................................................... 16 MACRS De iation 0 not include listed ro rt. See Instructions. Section A 17 MACRS deductions for assets placed in service In tax years beginning before 2004 .......................................... 17 18 If:;~n%e :~:~n~~~de~~:i::~8=~~t~r=ec~~::~~~.~I.~~~~.I.~.~~:I~~.~~~.~.~.~~~.~~.............. ~ D 1IIIIIIIlllil~I:III:III~:llilllll:IIII!~llllllll~I:111:1!111111111111111I1~1;1:~I~ill:IIIII;I:IIII!lljl:..1 Section B - Assets Placed In Service Durina 2004 Tex Year Using the General Depreciation Svstem (b) Month and (e) BasIs for depreciation (eI) Recovery (8) CI_ltlcatlon of property y..- placed (buslnessllnvestment use (e) Convention (1) Method (g) Deprecietlon deduction In service only - _ Instructions) period 19a 3,year b 5-year orooertv c 7.year oroperty d 10-Year orooertv e 15-year property f 20-Year a 25-year h Residential rental property i Nonresidential real property ............................. .......................................................... ............................. :~:~:~:~:~:~:~:~:~:;:~:~:~:~:~:~:~:~:~:~:fr~:~:~:~:~ ............................. ............................. ............................. ............................. ............................. ............................. . - 25 Yrs. 27.5 yrs. 27.5 Yrs. 39 vrs. MM MM MM MM I I I I Section C - Assets Placed in Service During 2004 Tax Year Using the Alternative Depreciation System ............................ :;:;:;:;:;:::;:::;:::::::;:::::::::::::;:;:::;::::::::::: ............................. SIL )~~t~~~~~l~~~l~~~~~~~~~~~~~*~~ :;:;:;~:;:;:;:::;:::::;:::;:::;:;:;:;:;:::;:::::~;:;~: 12 SIL I 40 rs. MM SIL 20a Class life b 12. ear c 40- ear f,.ai:t:~. Summary (See Instructions.) 21 Usted 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 retum. Partnerships and S corporations. see Instr. ..................... 23 For assets shown above and placed in service during the current year, enter the Ion of the basis attributable to section 263A costs ................................................ 23 1~~~ LHA For Paperwork Reduction Act Notice, see sepal'llte instructions. SIL SIL SIL SIL SIL 21 22 Jll1111Iijllll!lljIIJ11!llll~tlllljIIIIIIIIJ!llljI11Ijlllj!I~lli~I:1 Form 4562 (2004) Fam4~2~~ MILLER INSURANCE ASSOCIATES INC. 23-2055739 P~e2 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 8t8 using the standard mileage rate or deducting lease expense, complete only 248, 24b, columns (a) throuah (c) of Section A, all of Section B. and Section C If BDDUcable. Section A - Deprecietlon end Other Informetlon CCeution: See Instructions for limits for passenger automobiles.) 24e Do ou have evidence to su ort the businesslinvestment use claimed? D Yes No 24b If .Yes · Is the evidence written? D Yes D No (e) (b) (~) (d) (e) (f) (g) (h) (i) Type of property Date. BUSiness! Cost or Basis for deprtlClaUon Recovery Method! Depreciation EI~cted (list vehicles first) place~ In Investment other basis (buslnessllnvastmant period Convention deduction section 179 service use percentage use only) cost 25 S=::::::~: t:~w:;~el~o: q~:~: I:::SC:; .~~~.i~.:~.I~.~~.~.~~.~~~.~~........................ 25 :1111111\llllillll~IIII\IIII\111111111:1:\lj::;\I\II::.:'\ 28 Property used more t. han SOO6 In . )"aJlflad buol.ass uae, I ,,~=I I I 27 Pro rt used 50% or less In a ualified business use: % S~' % WL. % WL. 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, page 1 ................................................................................. 29 Section B - Informetion 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 questions in Section C to see If you meet an exception to completing this section for those vehicles. .:.;.:.;.:.;.:.:.:.:.:.;.;.;.:.:.;.:.:.:.;.;.:........".:. ::l:\:~t:::\t:~!j!:!:!i:j:::l:~::t::t!:::t:: .:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.;.:.:.:.:.;.:.:.:.:.:.:.:.:. :.:.;.:.;.:.:.:.:.:.:.:.:.:.:.:.;.;.:.;.:.:.;.:.:.:.:.:.:.: ............................. :.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.;.:.:.:.:.:.:.;.;.:.;.: :lililllllillllllllllll:1IlllI1IllilllllllllllllllllllIll! (8) (b) (c) (d) (e) (f) 30 Total buslnesslinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 31 Total commuting miles driven during the year ... 32 Total other personal (noncornmutlng) miles driven.... ........................................................... 33 Total miles driven during the year. Add lines 30 through 32.................................... 34 Was the vehicle available for personal use Yes No Yes No Yes No Yes No Yes No Yes No during off-duty hours? .................................... 35 Was the vehicle used primarily by a more than 5% owner or related person? .................. 38 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 B for vehicles used by employees who ere not more than 5% owners or related rsons. 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 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? ..................................................................... Note: If your answer to 37, 38, 39, 40, or 41 Is .Ves, . do not complete Section B for the covered vehicles. ~ ..;"':':':;:'\In Amortization (a) DescrtpUon of costs Yes No ............ ............. :::::::::::::::::;:::::::::::::::;;::::::::;;:;:: ::::::::::::::::::::;::::::::::;:;::::::::;;::;:: ............ ............ 43 Amortization of costs that began before your 2004 tax year .............................................................................. 43 44 Total. Add amounts in column (1). See instructions for where to report ............................................................... 44 416252/11-15-04 (c) ArnoItiz8bIe amount (d) Code section (e) 1fncr1lzaton period or peICII1lage (f) AmortlzaUon for this year 42 Amortization of costs that 11 005. 11 005. Form 4582 (2004) Election Not to Claim the Additional First Year Depreciation Allowable Under IRC Sec. 168(k) Miller Insurance Associates, Inc. 19 Brookwood Avenue, Suite 102 Carlisle, PA 17013 Employer Identification Number: 23-2055739 For the Year Ending April 30, 2005 Miller Insurance Associates, Inc., hereby elects, pursuant to IRC Sec. 168(k)(2)(D)(iii), not to claim the additional 30% and 50% depreciation allowable under IRC Sec. 168(k) for the following qualifying property placed in service during the tax year ending April 30, 2005. All property in the 3 year class. All property in the 5 year class. All property in the 7 year class. All property in the 10 year class. All property in the 15 year class. All property in the 20 year class. All property in the 25 year class. Computer software as defined by IRC Sec. 167(f)(I)(B). Qualified leasehold improvement property. See attached Form 4562. MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER INCOME STATEMENT 1 DESCRIPTION AMOUNT SERVICE CHARGES 37. 37. TOTAL TO FORM 1120, LINE 10 FORM 1120 TAXES AND LICENSES STATEMENT 2 DESCRIPTION AMOUNT PAYROLL TAXES PENNSYLVANIA TAXES - BASED ON INCOME PENNSYLVANIA TAXES - OTHER 18,694. 2,248. 1,100. 22,042. TOTAL TO FORM 1120, LINE 17 CURRENT YEAR CONTRIBUTIONS STATEMENT 3 DESCRIPTION AMOUNT VARIOUS TOTAL CURRENT YEAR CONTRIBUTIONS 100. 100. STATEMENT(S) 1, 2, 3 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 CONTRIBUTIONS STATEMENT 4 CARRYOVER OF PRIOR YEARS UNUSED CONTRIBUTIONS FOR TAX YEAR 1999 FOR TAX YEAR 2000 FOR TAX YEAR 2001 FOR TAX YEAR 2002 FOR TAX YEAR 2003 TOTAL CARRYOVER TOTAL CURRENT YEAR CONTRIBUTIONS 100 TOTAL CONTRIBUTIONS 10% OF TAXABLE INCOME AS ADJUSTED 100 2,915 EXCESS CONTRIBUTIONS o 100 ALLOWABLE CONTRIBUTIONS DEDUCTION STATEMENT(S) 4 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER DEDUCTIONS STATEMENT 5 DESCRIPTION AMOUNT AMORTIZATION COMMISSIONS AUTO EXPENSE DUES & SUBSCRIPTIONS EDUCATION EXPENSE INSURANCE POSTAGE TELEPHONE UTILITIES OFFICE EXPENSE TRAVEL & LODGING CAIR EXPENSES PROFESSIONAL FEES MISCELLANEOUS LICENSES CONSULTING FEES LEASE EXPENSE MEALS AND ENTERTAINMENT 11,005. 45,743. 2,913. 2,364. 1,652. 9,414. 4,864. 8,591. 3,057. 3,387. 3,361. 3,078. 8,116. 4,238. 85. 6,649. 1,982. 2,208. TOTAL TO FORM 1120, LINE 26 122,707. STATEMENT(S) 5 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 TAX COMPUTATION STATEMENT 6 1. TAXABLE INCOME . . . . . . . . . . . 2. LESSER OF LINE 1 OR FIRST BRACKET AMOUNT 3. LINE 1 LESS LINE 2 . . . . . . . . . . . 4. LESSER OF LINE 3 OR SECOND BRACKET AMOUNT 5. LINE 3 LESS LINE 4 . . . . . . . . . . . . . 6. INCOME SUBJECT TO 34% TAX RATE . . . . . 7. INCOME SUBJECT TO 35% TAX RATE . . . . . 8. 15 PERCENT OF LINE 2 . . . . . . . . . . . . 9. 25 PERCENT OF LINE 4 . . . . . . . . . . 10. 34 PERCENT OF LINE 6 . . . . . . . . . . . . 11. 35 PERCENT OF LINE 7 . . . . . . . . 12. ADDITIONAL 5% SURTAX. . . . . . . . . 13. ADDITIONAL 3% SURTAX . . . . . . . . . . 14. TOTAL INCOME TAX . . . . . . . . . . . . 29,045 29,045 o o o o o 4,357 o o o o o 4,357 STATEMENT(S) 6 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE L OTHER CURRENT ASSETS 7 STATEMENT DESCRIPTION BEGINNING OF TAX YEAR NOTES RECEIVABLE - OFFICERS FEDERAL PREPAID TAXES STATE PREPAID TAXES 1,993. 85. 1,032. 3,110. TOTAL TO SCHEDULE L, LINE 6 END OF TAX YEAR 2,393. 957. 1,885. 5,235. STATEMENT 8 SCHEDULE L OTHER CURRENT LIABILITIES DESCRIPTION BEGINNING OF TAX YEAR PAYROLL TAXES PAYABLE ACCRUED INTEREST DEFERRED TAX LIABILITY CHECKS WRITTEN IN EXCESS OF CASH 18,654. 514. 4,383. TOTAL TO SCHEDULE L, LINE 18 23,551. END OF TAX YEAR 961. 227. 7,748. 7,593. 16,529. SCHEDULE M-l TAXABLE INCOME NOT RECORDED ON BOOKS STATEMENT 9 DESCRIPTION DEFERRED TAX ADJUSTMENT TOTAL TO SCHEDULE M-l, LINE 4 AMOUNT 3,365. 3,365. SCHEDULE M-l OTHER EXPENSES RECORDED ON BOOKS NOT DEDUCTED IN THIS RETURN STATEMENT 10 DESCRIPTION LIFE INSURANCE PREMIUMS TOTAL TO SCHEDULE M-l, LINE 5 AMOUNT 205. 205. STATEMENT(S) 7, 8, 9, 10 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 4562, PART V LISTED PROPERTY INFORMATION-MORE THAN 50% STATEMENT 11 (A) (B) (C) (D) (E) (F) (G) (H) (I) 179 DESCRIPTION DATE BUS. % COST BASIS LIFE MTH/CV DEDUCTION ELECTED (J) (K) (L) (M) (N) (0) (P) (Q) AUTO TOTAL BUSINESS COMMUTING PERSONAL WAS VEH. > 5% ANOTHER VEH. NO MILES MILES MILES MILES AVAIL.? OWNER? AVAILABLE? Y N Y N Y N 2005 CHEVY 04/27/05 IMPALA 100.00 2003 GMAC 08/16/99 YUKON - LIKE 100.00 2003 CAMRY 01/25/01 - LIKE PROPERTY 100.00 2003 CAMRY 05/30/02 - SEE ALSO ASSET 31 100.00 22,500. 19,540. 5.00 200DB-MQ 2,960. 29,995. 29,995. 5.00 200DB-HY 1,775. 13,852. 13,852. 5.00 200DB-HY 1,596. 14,300. 10,010. 5.00 200DB-MQ 1,594. TOTAL TO FORM 4562, PART V, LINE 26 4,965. 2,960. STATEMENT(S) 11 Form 1120 u.s. Corporation Income Tax Return For calendar year 2003 or tax year beginning MAY 1, 2003 ,ending APRIL 30, 2004 OMB No. 1545-0123 Oep8rtment of the T_ury lntemlll fWvenue Selvlce 2003 A Check If a: 1 ConllOlldllt8d rwtum 0 (atlIIch Fonn851) 2 Person.. holding co. 0 (atlIIch Sc:h. PH) 3 PenIOlI8I ..vice corp.o (as defined In Regs. He.1.441-3(c:)) Name MILLER INSURANCE ASSOCIATES, INC. Number, street, and room or suite no. (If a P.O. box, see page 7 of Instructions.) 19 BROOKWOOD AVENUE, SUITE 102 City or town, state, and ZIP code CARLISLE. PA 17013 E Check aoolicable boxes: (1)[ ] Initial return (2)[ ] Final return (3)[ Name chanoe (4)[] Address chanoe $ 1 . GIllSS --'pili or lIlIIes I 5 9 7 , 5 3 2 .\ bLess rwtums snd sllowsnoes I I c Sal ~ 1 c 2 Cost of goods sold (Schedule A,line 8) ......................................................... ................................... ............. 2 3 Gross profit. Subtract line 2 from line 1c ......................................................................................................... 3 4 Dividends (Schedule C,line 19) .................................................................................................................. 4 5 Interest ................. .............. ..... ........................... .... ............................... .... ..... ..... ..................... .............. 5 8 Gross rents .................................. ................... ... .......... ..... ............ ......... ................ ...... ... ...... ..... .......... ... 8 7 Gross royalties ............. ....... ............................................ ......... .......... ................. ............................ .......... 7 8 Capital gain net income (attach Schedule D (Form 1120)) ................................................................................. 8 9 Net gain or (loss) from Form 4797, Part 1I,line 18 (attach Form 4797) .................................................................. 9 10 Other Income (attach schedule) ............................................................S.~.~....S.';J;'~';J;'.~~~~.';J;'...J............. 10 11 Total Income. Add lines 3 throuah 10 ................................................................................................... ~ 11 12 Compensation of officers (Schedule E,line 4) ................................................................................................ 12 13 Salaries and wages (less employment credits) ................................................................................................ 13 14 Repairs and maintenance ..................... .......... ...... ............................ ....... ......... .................... ...................... 14 15 Bad debts ................................................................................................................................................ 15 16 Rents ...................... ....... ........... ................ .............................................. .................... .... ... ... .... .............. 18 17 Taxes and licenses ...........................................................................S.~.~....S.';J;'~.';J;'.~~.~N';J;'....~............. 17 18 Interest ................................................................................................................................................... 18 19 Charitable contributions 1 9 20 Depreciation (attach Fo~ 4562)"'::::: ::::::::::: ::::::::::::: :::: :::: ::::: ::::::: ::::::::: ::::::::.. i" 20" i.................. 1"4';' s'o's' . ::::::::::::::::::::: 21 Less depreciation claimed on Schedule A and elsewhere on return ..................... 21a 21b 22 Depletion ................................................................... ............................................................................. 22 23 Advertising ............. ................. ... ..................................... ........ .... .......... ............... .......... ............... ......... 23 24 Pension, profit-sharing, etc., plans ............................................................................................................... 24 25 Employee benefit programs ............................ ............................................................................................ 25 28 Other deductions (attach schedule) ......................................................~~~...~~~~~M~N~...~............. 26 27 Total deductions. Add lines 12 through 26 ............................................................................................. ~ 27 28 Taxable Income before net operstlng loss cIecIuctlon and spec:lsJ deduc:tlons. Subtract line 27 from line 11 .................................... 28 29 Less: a Net operating loss (NOL) deduction ................................................ I 29a I fHtt:::: b Soeclal deductions (Schedule Cline 20) .......................................... 29b 29c 30 Taxable Income. Subtract line 29c from line 28 .......................................................................................... 30 : ~~T;~)u .3b..uuuu4;o7ii:--'; 31 b ~~~~~ :;I.e:t~nts ...... 82b 1 , 322 . ;:;:;:;:;:;:;:;:;:;:;:;:;:::;:::~;:::::;:::::::::;:;:;:;:::;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:::;:;:;:;:;:;:::::;:::::::;:::::::;:;:: C on Fo""4466 ........................... 82c I( ) d Sal ~ 82d 5,400. ........... e Tax deposited with Form 7004 ..................................................................... 82e ~~~~~i~:::~:~i::;i:: f Credit for tax paid on undistributed capital gains (attach Form 2439) .................. 82f tt:tm:t II Credit for Federal tax on fuels (attach Form 4136). See Instructions ..................... 3211 32h 83 Estimated tax penalty (see page 14 of instructions). Check If Form 2220 is attached .................................... ~ D 33 34 To due. If line 32h is smaller than the total of lines 31 and 33, enter amount owed ................................................ 34 35 Overpayment. If line 32h is larger than the total of lines 31 and 33, enter amount overpaid ....................................... 35 86 Enter amount of line 35 vou want: Credited to 2004 estimated tax ~ 85. Refunded ~ 36 Under pensJtles of perjury, I declare that I hllVe ISXIIIlllned this rwtum. Including IlCC:Ompsnylng schedules and ststemenlll, and to the best of my knowledge and belief, It Is true, comICt, end complete. Declaration of PNP8'W (other than tsxpBYj Is based on sJllnformetlon of which preparer has any knowledge. IE~~s I ~ Signatunt of officer Dste ~ Title "[xlves D No Pntpllllll's ... I Date I Check If Pntp8ntl"s SSN or PTlN Paid slgnatunt F self-employed [Xl PO 0 0 57626 Prepare...s Ann'sname SMITH ELLIOTT KEARNS & COMPANY, LLC I EIN 52 0783935 UseOnly l:.T-::'~I~ed), "'19 BROOKWOOD AVE., SUITE 101 I Phone no. (717)243-9104 ~~~eand rCARLISLE, PA 17013 Use IRS label. Other- wise, print Dr type. B Employer Identification number 23-2055739 COste Incorporated 02/28/1978 D Tots! -'s (s.. page 8 of InstNc:tlons) 277,520. 597,532. 597,532. " E 8 .E 87. 597,619. 204,017. 64,054. 12,792. 47. 34,774. 28,841. 5,603. II) C o :g t Q 14,805. 35,060. 36,033. 126,160. 562,186. 35,433. 35,433. 5,315. ! ~ D.. 'a c II ! 5,400. O. 85. Sign Here 311601 12-08-03 JWA ~ See Instructions for Paperwork Reduction Act Notice. Form 1120 (2003) Fonn1120(2OO3) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Pa e2 m' ..~.:...:.:::.,<., :.: ....:.:~~:: .:~~ Cost of oods Sold see a e 14 of Instructions 1 Inventory at beginning of year ..................... ..... ....................................................................................... ....... ... 1 2 Purchases....................................... ...... ...... ......................... ........... ........ ........ .... ~....... ................. .................. 2 3 Cost of labor .......... ........ ........................... ......... ............... ....... .................................. ..................................... 3 4 Additional section 263A costs (attach schedule) ...................................................................................................... 4 5 Other costs (attach schedule) ............... ............................... ................................................................... ...... .... 5 6 Total. Add lines 1 through 5 .............................................................................................................................. 6 7 Inventory at end of year .................................................................... ................................................................ 7 8 Cost 01 goods sold. Subtract line 7 from line 6. Enter here and on line 2, page 1 ............................................................ 8 9a Check all methods used for valuing closing Inventory: (I) 0 Cost as described In Regulations section 1.471-3 (II) 0 Lower of cost or market as described in Regulations section 1.471-4 (Iii) 0 Other (Specify method used and attach explanation.) ~ b Check if there was a writedown of subnormal goodS as described In Regulations section 1.471-2(c) ............................................................... ~ 0 c Check If the LIFO Inventory method was adopted this tax year for any goods (if checked, attach Form 970) ...................................................... ~ D d :1~:;n~I~~~~~:~oc~::e~d u:~:~~;:dor. ~~i.~ .~~~ ~~.~~: .~~~~.r.~.~.~~~~~.~~.~~~.~~~~~~ .~~..................... .................. .......... W e If property Is produced or acquired for resale, do the rules of section 263A apply to the corporation? ............................................. 0 Yes 0 No I Was there any change In determining quantities, cost, or valuations between opening and closing inventory? If "Yes." attach eXDlanation ................................................................................................................................................. 0 Yes 0 No l:t_i.i~:bJ Dividends and Special Deductions (I) Dividends (b) % (c) Special deductions received (a) x (b) 1 Dividends from less-than-20%-owned domestic corporations that are subject to the 70% deduction (other than debt-financed stock) ...................................................... 70 2 Dividends from 20%-or-more-owned domestic corporations that are subject to the 80% deduction (other than debt-financed stock) ....................................................... 80 3 see Dividends on debt-financed stock of do~tic and fot'eIgn corpollltlons (section 246Al ..................... Instructions 4 Dividends on certain p~ stock of less-thlln-20%-owned public utilities ................................. 42 6 Dividends on certain p~ stock of 20%-or-more-owned public utilities ....... .......................... 48 6 Dividends from 1llS8-than-20%-owned fonlign corporations and certain FSCs 70 that 11I1I subject to thll70% deduction ................ ....... ....................................... ................ 7 Dividends from 20%-or-monl-owned foreign corporations and cartaln FSCs 80 that _subject to the SO% deduction ........................ ........................................ ........... 8 ~~c:~~~.:t~~nli~~.~~~~.~~~~ .~~~j~.~.~.~. ............................. .................. 100 . . . . :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: 9 T ota I. Add lines 1 through 8 ................................................................................. ~~~mmm~mmmmmmmm:~mmmmmmm~~~mmmmmmmn~@~~~~ ~t~~;~~;;~~~~~~t~~t~~~t~~~~t 10 Dividends from domestic corporations received by a small business Investment company operating under the Small Business Investment Act of 1958 ........................... 100 11 Dividends from certain FSCs thllt _ subject to the 100'K deduction (section 2e(c)(1)) ..................... 100 12 Dividends from afIIllated group members subject to the 100% deduction (see. 243(el(3)) ..................... 100 13 Oth.- dividends from fonlign corporations not Included on lines 3, 6, 7, 8, or 11 ........................... ili.i.II.:ili.lll.li:l:il.:I~II.i.:lli.: ~[~~j~~~~~~~~~j~~I~~II~~\j~~~~~~~~~~~~~~~~~~~j~~~~~~~~~~~1~~@~~~~~~~~~j~~~~~~~~~j~1~~~1 14 Income from conbolled fonlign corporations under subpart F (IIttach Fonn(s) 5471) ........................ .. 15 Foreign dividend gross-up (section 78) .................................................................. . 16 Ie -DISC and former DISC dividends not Included on lines 1, 2, or 3 (section 246(d)) ........................ 17 Other dividends ................................................................................................ :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.;.:.:.:.:.:.:.;.:.:.:...:.:.:.:.;.:. 18 Deduction for dividends paid on certain preferred stock of public utilities ........................ .~i~~~i~~~~~~~~~~~~;~~~~~;~~~~~~~~~~~~~ttf~~~t~~~;~~~~~;~;;~~;~;~;~lf:;;~;~~~;~: 19 Total dividends. Add lines 1 through 17. Enter here and on line 4, page 1 ............... ~ ~l~;~~m~tl;tltf ~~~~Ul~;~;~ml@~~~j~~~ili~~~~~1~~I1~1~~~I~~l~1~@~1~~~;~~ 20 TotalsDeclal deductions. Add lines 9 10 11.12 and 18. Enter here and on line 29b . DaDe 1 ................................................ ~ 1~:~:~I.~ii::I~~1 Compensation of OffIcers !r-1nstructIons far line 12, page 1, on page 10 of Instructions) ate: ComDlata Schedule E onTv-1f tol8l r-*Dts fi'lnll111 Dlus lines 4 throuoh 10 on _ 11 11I1I $500 000 or more. (a) Name of officer (b) Social security W) Percent of Percent of corporation (I) Amount of number 'me devoted stock owned compensation to business fd' Common , fe' Preferred 1 M EUGENE MILLER 162-36-7572 100 80 . 00% 1 37,442 . KIMBERLY SHOFF 16 1-5 8-1250 100 20 . 00% 66,575 . 2 Total compensation of officers ........................................................................................................................................ 204,0 17 . 3 Compensation of officers claimed on Schedule A and elsewhere on retum .............................................................................. 4 Subtract line 3 from line 2. Enter the result here and on line 12 DaDe 1 ................................................................................. 204,01 7 . ~~~:lk JWA Form 1120 (2003) 23-2055739 Paoe3 Fonn 112012003\ MILLER INSURANCE ASSOC IATES . INC. n~""':':':"":::::':':'''''''::'''':'>:f''?'@ Tax ComDutation (see Daae 17 of Instructlons\ 1 Check If the corporation is a member of a controlled group (see sections 1561 and 1563) Important: Members of a controlled group, see instructions on page 17. 28 If the box on line 1 is checked, enter the corporation's share of the $50,000, $25,000, and $9,925,000 taxable income brackets (In that order): (1) 1$ b Enter the corporation's share of: ................................. ~ D tiitiiiri:i: ~jjrml~~~jJ~: ;.:.;.;.;.;.;.;.;.;.' I .:.:.;.:.;.;.;.:.;.: ~I~~I~t~~~~~ .;.;.;.;.;.;.;.;.;.;. (2) I $ I (3) I $ (1) Additional 5% tax (not more than $11,750) S (2) Additional 3% tax (not more than $100,000) S 3 Income tax. Check If a qualified personal service corporation under section 448(d)(2) STMT 4 (see page 17) .................................................................................................................................... ~ D 3 4 Alternative minimum tax (attach Fonn 4626) ......................................................................................................... 4 5 Add lines 3 and 4 ............................................................................................................................................. 5 8a Foreign tax credit (attach Fonn 1118) ................................................ ........... ....... 8a b Possessions tax credit (attach Fonn 5735) ............................................................ 6b c Check: D Nonconventional source fuel credit D Qf.V credit (attach Fonn 8834) 8c d General business credit. Check box(es) and Indicate which fonns are attached. ::::::::::::':::':::: D Fonn 3800 D Fonn(s) (specify) ~ 6d e Credit for prior year minimum tax (attach Fonn 8827) ............................................. 8e f Qualified zone academy bond credit (attach Fonn 8860) .......................................... 6f 7 Totll credits. Add lines 6a through 51 .................................................................................................................. 8 Subtract line 7 from line 5 ................................................................................................................................. 9 Personal holding company tax (attach Schedule PH (Fonn 1120)) ........................................................................... 10 Other taxes. Check If from: D Fonn4255 D Fonn8611 D Fonn8697 D Fonn 8866 D Other (attach schedule) ............................................. 10 11 Totlltlll. Add lines 8 throuoh 10. Enter here and on line 31. oaoe 1 .... ....................... ................................................ 11 [1" .::.:.:. :':::':':::':' :'i':" ":':":j '.' ;i::H Other Infonnation (see oaae 19 of instructions \ 1 Check method of accounting: I D Cash b CXJ Accrual Yel No 7 At any time during the tax year, did one foreign person c D Other (specify) ~ .:.:.:.......:.:... own, directly or Indirectly. at least 25% of (I) the total 2 See page 21 of the Instructions and enter the: :l:~:::~:::~:::: :::~:!:l:::~:~::: ~~~~U~W:~t:fo~I~~~a:::~O~ls~~~~ ~/:I~ ~~is~:~:~tock I Business activity code no. ~ 524210 t:mw mMff~ of the corporation? ............................................................ b Busl"..lIClivlly ~ INSURANCE ::r:flUpt:r:mr If"Yes," enter: (a) Percentage owned ~ 3 · =.~-:;;.: ~~~:~;C~'P'- .wn, dhocl>J or II. ~: ~'PO;::: :~~;:;. ftO Fonn 5472. Info_en Indirectly, 50% or more ofthe voting stock of a domestic .:.:.:.:.:.:.:.:.:.: Return of a 25% Foreign-Owned U.S. Corporation or a corporation? (For rules of attribution, see section 267(c).) ...... X Foreign Corporation Engaged in a U.S. Trade or Business. If "Yes,' attach a schedule showing: (a) name and t:i:f:~:~~:i:~: ~~mfmtt Enter number of Forms 5472 attached ~ :~!~:}~~r:Tn~~:: ~~O:::)(~~~J~~&:~~::c~fned. ::::::::::::!:~j!:::: :~!:!:!!!j!~i:!:!~i: 8 Check this box if the corporation issued publicly offered D . ==.=~:::::::n:::=;:::~O' II ~:':~:~*~:::=~:7~a:'~ parent-subsidiary controlled group? ................................. X Discount Instruments. If "Yes,' enter name and EIN of the parent corporation ~ :l:!j!::jl:!:!:!:!i! ::~:~~:~:~:::I:: 9 Enter the amount of tax-exempt interest received or :fflt~ :~:ftff~ accrued during the tax year ~ $ 1111 :: ;::I:li::7~E.::~d:~~: ::,::t '"x''' .......... electing to forego the carryback period, check here ... ~ D '~!j!:!:l:!j1:i:!; ~i:1!~1i:!:l:l1!:! If the corporation is filing a consolidated return, the statement :'.:::'::::::::::::: ::::::::::::::::,:,. required by Temporary Regulatlon~ sectl.on 1.1502-~1T(b)(3)(1) ftf~:~~:~ ~ij:~l~tl or (il) must b~ attached or the election WIll not be valid. ::::::::::::::,:::::' :::::::::::::::::::: 12 Enter the available NOL carryover from prior tax years ;1::::I~I:~I:lt :11:lli1!IIII ~~:.~o~ re:uce it by any deduction on line X 13 Are the corporation's total receipts (line 1a plus lines 4 through :;1:::l;:m~:: :t'::::::::;:3;: 10 on page 1) for the tax year and Its total assets at the end of the rtttt :!:frfr! tax year less than $250,ooO? ............................................. '.:.:.:.:.:.:.:.:.:. :;:::::/:::::::: If "Yes,' the corporation Is not required to complete Schedules L, .................. :.:.:.:.:.:.:.:.:.:. M-1, and M-2 on page 4. Instead, enter the total amount of cash :ftMt Witt distributions and the book value of property distributions (other l~tr!:r! than cash) made during the tax year. ~ $ '.;.;.;.;.;.;.;.;.;.: ;.:.;.;.:.:.:.:.;.:. I .:.:.:.:.:.:.:.:.:.: :11~IIr:tllll:1 7 8 9 5 At the end of the tax year, did any Individual, partnership, corporation, estate, or trust own, directly or indirectly, 50% or more of the corporation's voting stock? (For rules of attribution, see section 267(c).) .................................... If "Yes,' attach a schedule showing name and Identifying number. (Do not include any Information already entered in 4 above.) Enter percentage owned ~ 8 During this tax year, did the corporation pay dividends (other than stock dividends and distributions In exchange for stock) In excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) ............... If "Yes," file Form 5452, Corporate Report of Nondlvidend Distributions. If this is a consolidated return, answer here for the parent corporation and on Form 851, Affiliations Schedule, for each subsidiary. 5,315. 5.315. 5,315. 5,315. Yes No .:.:.:.:.:.:.:.:.:.:. ;.;.;.;.:.:.:.:.;.;.; ..............'......;:;:::::;:::::::::;:; ;.;.;.:.:.;.:.:.:.;.::=;:;:;::::=:::::=;:; ;.;.;.;.;.;.;.:.:.;.:::::::::::::::;:::::: X :::::::::::::::;::::; ~~m~~~~~mt~~;: mmm~tm~m :::::;:::;:;:;:;:::;: ~~m~r~~~~~t~~ ;.:.:.:.:.:.:.:.:.:.; ':';';';';';':';';'; IIt1~~II @~~~1~~~1I~f .:.:.:.:.:.:.:.:.:.: .~~~~iliIl~ lt~lJilit ~Ilf~ttl'. II x II Note: If the corporation, at any time during the tax year, had assets or operated a business in a foreign country or U.S. possession, it may be required to attach Schedule N (Form 1120), Foreign Operations of U.s. Corporations, to this return. See Schedule N for details. ~~~:-1a JWA Form 1120 (2003) Form 1120 (2003) MILLER INSURANCE ASSOC IATES, INC. 23-2055739 p_4 Note: The corooration Is not reaulred to comDlete Schedules L M-1 and M-21f Question 13 on Schedule K Is answered "Yes." 11~t... ..,. ': ':~:~:~J Balance Sheets DBr Books BegInning of tax yeer End of tax year ~ets ~ ~ W ~ 1 Cash................ ...................... ............. ~r:tltl~tmI~~:f;'~6;;;~~:;2I?~l',:'~:~:!4~:~~~~~i~7:;ri:7}i.@.:,:,~; ':':':':.':":.:'::':,::,::':.::.':'::":":.",.":'::'::."":",,,,',,:.,::,::".:"":.",":'.':.':':.':.':"""':"::":':::":"""':":~':'~~:':':":'::'::':":;'::~':'::":"'",,::,":;':.':: '":,:,:,:,,,,:,'~:,':':""":";;':':'::~':';;"":.",:,...:":":,~."",:,,,,:.,:,,.:.,:,,:,:, ~:.;':":.': mt:r:ml;II#IM:~::~\lI::::~t::r;:ITt: 2 5 , 5 75 · 21 Trade notes and accounts receivable .... ..... ,:,:,::,:,:,:,:,:;:,:,:,:, . . ,:,:,:,:,:, 4 2 , 4 0 6 . :;:::!:::::::;:::::::::::::!:::~:::;:ik~1~tfiii1iI:ii~:iji1i::i: bLessallowanceforbaddebts .................. I ' 62,477. 1 42,406. : ~.~~~~:~~~i ~bl~~ti~~~. ...................................... ,ii:;:::!!lr 5 Tax-exempt securities ........................... .. : ===.:,,~I.~~~:~ i:':..:.;:..:,::=::!:.i:.:::. 1 7 , 178 . 3, 110 . 8 Mortgage and real estate loans.................. :':.:':' 9 Other Inv.trnents (all sch.) ... .. .. .. .. .. .. . .. .. .. .. :;:,:j~~~~: 1 Da Buildings and other depreciable assets ...... :'::;:r, 2 0 9 , 5 6 3 . ~ml~mlW)?~?~:t:t:W1:t:r::t~~WFMl 2 0 9 . 5 6 3 . l:m:trtf::::':t;:::~:::~::f1::t:l)J:ndtt1 b Less accumulated depreciation ............... l 141 , 952 01 67, 611. l 156 , 400 01 .......... ... 5"3; f6"3..~.. 11 1 Depletable assets :.::..':t.t.'..~~~..t'.':.';.'?...':::r:..:;:: .:: ::::? ":'~:,.':: :::'::.::':' :'.:: :':;::::':.r::::::::: ::.'i.:.::.-:".'::: .:::::.;;. . .' '. ..:: ..:'. ::,' .::':." '., :.:::~:"::':~:;:~:?~::'::::: ::: .. . . . .. .. .. .. .. .. ..... . .. .. .... .. . .. . .. :.':" ":. ':. : :.::".;::.:...:..,: :::: '.;.:.::::,.,:,: b Less accumulated depletion ..................... l l ~:a ~~~~~~~ :::::s ~~~::~~ ~~~)..................... :~:::::::':::';:f:I~:~::"::'~;.~::~:~,:::~~::~1~~~~~::.. '. __ : ...... :;:::-:';:{~'6:~ ~'j~;~::i~: .. ::..... " bLessaccumulatedamortlzation ............... 19,25601 257,753. I 26,97101 153,266. ~: ~:; :::e: (~~:.~~~..~..........................:........:::::::::. :~:::::!!~:I~II:!I!III!II!!;:I!:I:!;~ii!:!:!!il!!:I:l:i~l;:!.I!l!!!I!lliillli~li:l; 450 , 313 . .!I!I!~I!li~il!lii~l~jiliill'il~IIII!lli~llll'I)lllil!111111~ 277 , 520 . j~ ~~~~?~~~;~ ~ :::_[~ 374 261 :"':'.. :.": .:}("...:.:...,..: ...... 183,358. ~ ;h:i;:'(:~d:c~r:~.I~~.~=.~~.:~.. ::. .................. ,. ..:::.:.:;:;::t:::'i:,:.::.:::~:::i:~::..~;:.:i>;:::!:::;;!;":::::'::';':'.: 22 Capital stock: . Preferred stock ... .........__ ," . : " : .". .. .' ... '::;:::;:::: b Common stock ............... 1,000. 1,000. 1,000. 1,000. E ~~r~~~u~ _ 171.042.(. 201.347. ~~ ~;~~~:~;:=of~~kslitEt~~inM~n~\~: ~~~ ~ ~ :~~~:I~:O:~;:~::::s :....:: ::..::::..:: ....:::.. 3 ~ : ~ ~;: 7 ::~::d r:Ot~i~ ;~:o~~~~::tar not ..........:..:..::.::::::....;:':,:,:.:!;I::!!:I~~:!~~!~111i!i:!!!;:~!~1~11[lill~!:ll.: 3 Excess of capital losses over capital gains Tax-exempt Interest $ ':.:.:.: .' . :.:...,-::.::. :,::}: ':'/'::::i:: ~.:; 4 ~~::z~~led to tax not recorded on books ~ls yew :!:I::I!:I:.I~"'!lill:lllllli:!III~!I!il!!I!llijii1:::~iil~;;ji:~;:ii;;i;iii;!i!;il;:i;!;:;;:: STMT 8 286. ::"::. .:..... ::: ".: 2':8:'~ ~. 5 ~:~y~~~~rn:50.. 8 f~~:;?~:r~:~:) 356._ STMT 7 205. 855. 9 Add lines 7 and 8 ....................................... 642. 6 Add lines 1 throuah 5 ................................. 36 , 075 . 10 Income (line 28 nane 1\ -line 6 Jess line 9 ...... 35 , 433 . If' .:-.:....:.:.:.:w '. ,..:.~...:N Analvsis of UnaDr~roDriated Retained Earninas ner Books tLine 26. Schedule U 1 Balance at beginning of year ..................... 1 71, 042. 5 Distributions: a Cash .............................. : :::=~~:~~~ muuuuuu ~,~~O.~:,~ :. =~.m ~W~;~~:;~~:~r::'~~~,i!~~:!!~~::~:~j:::!!;:::~1~~:i:~!t~~~!;:j~!i~:!l~: 6 Other decreases (itemIZe) 7 Add lines 5 and 6 ....................................... 201,347. 8 Balance at end ofvear (line 4 less line 7\ ......... 311631 12-08-03 JWA 201,347. Form 1120 (2003) 4 Add lines 1 2 and 3 ................................. 4562 OMB No. 1545-0172 Fonn Depreciation and Amortization 2 0 03 (Including Imonnation on Usted Property) OTHER OepertmIlnt of the T_ury AtIlIchment Inlllrnal RlIvenue Service ~ See separate Instructions. ~ Attach to your tax return. Sequence No. 87 N8I'I'l8(s) shOWn on Illtum Business or 8CtIvlty to which this fonn l1IIales Identifying number MILLER INSURANCE ASSOC IATES, INC . OTHER DEPREC IATION 23-2 05 5 7 39 ~i:) Election To ElDense Certain Tlnglble Property Under Section 179 Note: Ifvou have any listed prooertv, complete Part V before YOU complete Part I. ,',', . 1 Maximum amount. See Instructions for a higher limit for certain businesses ...................................................... 1 1 0 0, 0 0 0 . 2 T etal cost of section 179 property placed in service (see Instructions) ............................................................... 2 3 Threshold cost of section 179 property before reduction In limitation .................................................................. 3 40 0,0 0 0 . 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter .(). 4 .......................................................'0. 5 Dollar limitation for talt year. Sublnlc;t line 4 from line 1. If ZeIO or I_, enter -D-. If rnIII'Tled ftllng lI8plII8teIy 0 _ Instructions .............................. 5 ... ................ ........................... ................................................ ................................................ 8 Ie) Desc:rlption of property (b) Cost (busl~ use only) (c) Elected cost ................................................ ................................................................................................ ;.:.:.;.;.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.;.:.;.;.:.:.:. .;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.;.:.:.:.:.:.:.:.: I .. 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 .......................................... 8 9 Tentative deduction. Enter the smaller of line 5 or line 8.... ...... ........ .................................................................. 9 10 Carryover of disallowed deduction from line 13 of your 2002 Form 4562 ............................................................ 10 11 Business Income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 Carryover of disallowed deduction to 2004. Add lines 9 and 10, less line 12 ~I ................................................................................................ 13 ............ 13 r~~~~t~~~~~~t~~t~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~;~~~~~~~~~~~~ 14 Special depreciation allOW1ll1Ce for quallfted property (other than listed property) placed In selVlce during the tax year (_Instructions) .................. 14 15 18 17 18 17 8 778. ::i~i:i:i:ii!:i~i:!:il:!l:i!:i~!il:!:i!li!:iil:iii~i!liiii:iiili!l:!ji~l!liili~i!I::!!:li!li:i:ilili~I::I::::::: ;.:.:.:.:.;.:.:.:.:.:.:.:.:.;.:.;.;.;.:.:.:.:.:.;.:.:.;.:.;.;.:.;.:.;.:.;.:.:.;.:.:.:.;.;.:.;.:.:.;.;.:.:.;.:.:.:.;.;. .................................................................................................................... Section B - Assets Placed in Service Durina 2003 Tax Year Usina the General Denreclation SYstem (b) Month and (c) Basis for depreclallon (d) Recovery Ie) CI_lllcallon of property y.. placed (buslnessllnvestment use (e) Convention (1) Method (g) Depreclallon deduction In service only - _Instructions) period 19a 3-vear prooertv . b 5-vear prooertv c 7 -year prooertv d 10-year prooertv lm~mmm~m~~~~t~~~rtM~~~~~~tl . 15.year prooertv . f 2O-year prooertv a 25-vear prooertv 25 vrs. SIL h Residential rental / 27.5 vrs. MM SIL property / 27.5 vrs. MM SIL i Nonresidential real / 39 vrs. MM SIL property / MM SIL 20a Class life b 12 ear c 40- ear if ..:.:.:.:.:;: .:~: .:: Summary (See instructions.) 21 Ustecl 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 ion of the basis attributable to section 263A costs ................................................ 23 ~;t~f-k LHA For Paperwork Reduction Act Notice, see separete Instructions. Section C - Assets Placed In Service During 2003 Tax Yea, Using the Alternative Depreciation System SIL SIL SIL i:ll!ll:l!:I!:I!!1!:I:!III!11111::111!lll!111!1111111i ::;:::;:;::;:;::;;;:;::::;::;;:::::;::::::::::;;:::::;;::. I 12 rs. 40 rs. MM 21 6 027. 22 14 805. 1jllllll!j:lli:ill:lillll:::!:illl::IIIII:1111111111111lillll::I!I!:ll~I::: Form 4582 (2003) Fonn4562(2003 MILLER INSURANCE ASSOCIATES INC. 23-2055739 Page 2 Usted 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 248, 24b, columns (a) throuah fc) of Section A all of Section B. and Section C if BDolicab/e. SectIon A - Deprecletlon and Other Information (Caution: See instructions for limits for passenger automobIles.) 24e Do ou have evidence to su ort the buslnessJinvestment use claimed? 00 Yes 0 No 24b If 'Ves · Is the evidence written? 00 Yes 0 No (e) (b) (c) (d) (e) (f) (g) (h) (i) Type of property Date Buslnessl Cost or e.ls fordeprecllltlon Recovery Methodl Depreciation Elected (list vehicles first) place~ In Investment other basis (buslnessllnvestment period Convention deduction section 179 servlC8 use percentage use only) cost 25 Special depreciation allowance for qualified listed property placed in service during the tax :t.i:.:II.II.II.II.II.lt.i.II.lf.II.II.II.II.ll.l.l.i!r.if.!t.ll.ll.lr.il.r.ir.il.II.1 ear and used more than 50% in a uallfied business use ........................................................................ 25 28 Pr used more than 50% in a uallfied business use: % SEE STAT ENT: 9 % 6 027. % 27 Pro used 50% or less in a uallfied business use: .;.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.;.:.:.:. % S/L........................................................... : ::- 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 .................................... 28 0 2 7 . :::rtt~~rr::J::I::::t:t~r:::: 29 Add amounts in column (i). line 26. Enter here and on line 7, page 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 your employees. first answer the questions in Section C to see If you meet an exception to completing this section for those vehicles. (a) (b) (c) (d) (e) (f) 30 Total buslnessJinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 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 use Yes No Yes No Yes No Yes No Yes No Yes No during off-duty hours? .................................... 36 Was the vehicle used primarily by a more than 5% owner or related person? .................. 38 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 B for vehicles used by employees who are not more than 5% owners or related rsons. 37 Do you maintain a written policy statement that prOhibits all personai use of vehicles. Including commuting, by your Yes No employees? ....... ............. ............................... ............. .............................................................. ................. .................................. X 38 Do you maintain a written policy statement that prohibits personal use of vehicles. except commuting, by your employees? See instructions for vehicles used by corporate offICers. directors. or 1 % or more owners .......................................... X 39 Do you treat all use of vehicles by employees as personal use? ................................................................................................... X 40 Do you provide more than five vehicles to your employees, obtain Infonnation from your employees about the use of the vehicles, and retain the infonnatlon received? ......................................................................................................... X 41 Do you meet the requirements concerning qualified automobile demonstration use? ..................................................................... X Note: If your answer to 37, 38, 39, 40, or 41 is 'Yes, . do not complete Section B for the covered vehicles. ~1.::;.:.:.:.:;;),.::~ Amortization (8) Description of costs :::::;:::::::::::~::~: ::~::::::::::::::::::::: ::~;::::::::::::::::::: :;:;:::;:::::;::::::::::: 42 Amortization of costs that (c) Amortizable amount (d) Code section (e) ~ period or pen:enlage (f) Amortization for this year 43 Amortization of costs that began before your 2003 tax year .............................................................................. 43 44 Total. Add amounts in column (f). See Instructions for where to report ............................................................... 44 316252110-21-03 Form 4562 (2003) 4562 OMS No. 1545-0172 Fonn Depreciation and Amortization 2003 (Including Infonnatlon on Usted Property) OTHER o.p.vnent of the Trwsury Atblchment Intermll RIVen.. Service ~ See seperete instructions. ~ Attech to your tax return. Sequence No. 67 Nen'llI(.) 8hoWn on return Business or ectIvlty tv whk:h thl.lImn relates Identifying number MILLER INSURANCE ASSOCIATES, INC . OTHER DEPRECIATION 23-2055739 I,,: Election To ElDeMe Certain Tanalble ProDerly Under Section 179 Note: If YOU have any listed property, complete Part V before you complete Part I. :.' ',", 1 Maximum amount. See Instructions for a higher limit for certain businesses 1 100,000 . ...................................................... 2 Total cost of section 179 property placed In service (see Instructions) 2 ............................................................... 3 Threshold cost of section 179 property before reduction in limitation .................................................................. 3 400,000 . 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 ftllng separately, _Instructions .............................. 5 .............. ................... ,.. ..... ,'. .. ................................................................................................ 6 (e) Description of property (b) Cost (business use only) (e) Elected cost ~~~j~j~~~~~~~j~~~~~j~~~~~j~j~j~j~j~~~~~j~j~~~j~~~~~j~j~~~j~~~j~~~~~i~j~~~j~~[~jI~[~~j~jI~1 ................................................................................................ :::::::;:::;:;:::::::;:::::::;:;:;:::::::::::;:::::::::::::::::::::::::::::::::::::::;:::::::::: :.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.;.:.:.;.:.:.:.:.;.:.:.;.:.:.:.;.:.;.:.:.;.;.:. ................................................................................................ .............. ............................ ...... :;:::;:;:::;:;:::;;::;:::::::;:::::::::::::::::::::::::::::::::::::::::::;:::::::::::::::::::;:: ~~~~t~~~~~~~~~~~~~r~~~~I~~~~~~~~~f~t~~j~~~r~~~I~~I~II\~II :;:;:::;:;:;:;:::;:::::;:::::::::::::;::::::::::::::::::::::::::;:::::::;::;:::;:;:::::::::::;:: :.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.;.:.:.;.:.;.;.;.;.;.:-:.:.:.:.:.:.:.:.:.:.;.;.;.:. ................................................ ;.:.:.;.;.;.;.;.:.:.:.:.;.;.:.:.;.;.:.;.:.;.;.:.;.;.;.;.:.:.;.:.:.:.;.;.;.;.:.;.:.:.:.:.:.;.:.;. I ;~:~:~:~:;:~;~:~:~:~:~:;;~:~:~:~:~:~:~:~:~:~t:~:~:~:~:~:~:~:~:~:~:~:~;~:~:~:~;~:~:~:~;;:~;~:~ 7 Usted property. Enter the amount from line 29 ......................................................... 7 ~~~~t~~t~~~~~~~~~~~~;~~~;~;~~~~~~~~;~~~;~~;~~~~~~~~;I~~~~~~~~I~~~~~~~~~~~~~~~~~~~~~ 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 .......................................... 8 9 Tentative deduction. Enter the smeller of line 5 or line 8......... ........ .... .... ........ ...... ............................................. 9 10 Carryover of disallowed deduction from line 13 of your 2002 Form 4562 ............................................................ 10 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 ................................................. lines 9 10, less line 12 ~I ............................................. .. 13 Carryover of disallowed deduction to 2004. Add and 13 ................................................................................................ ;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.;.:.;.:. ............ ................................................................................................ ................................................ 14 Specl8I depreciation 8IIOWlI/lce for qu8llfted property (other than listed property) plllCed In service during the tax year (see Instructions) .................. 14 15 Property subject to section 168(f)(1) election (see instructions) ........................................................................... 15 16 Other de reciation Includln ACRS see instructions ....................................................................................... 16 ............................. ',.., .: '" MACRS De reciation 0 not Include listed ro . See Instructions. Section A 17 MACRS deductions for assets placed In service in tax years beginning before 2003 .......................................... 17 :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:. 18 If you are electing under section 168(i)(4) to group any assets placed in service during the tax :~:lt::::::t:::::::t:t:I:II:ltt:::It:::::::t:::ttIIlt:t ......D .;.:.;.:.;.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.;.:.:.:.;.:.;.:.:.;.:.:.:.;.;.:.:.:.; ear into one or more eneral asset accounts check here .................................................................. ....... :;:;:::::;:;:::::;:::::;:;::;;:::::::::;:;:;:::::::::;;;::::::;:::;:::;;;:;:;:;::;;;::::;:::::;:::::::;:;::::::::::::: D I io S Section B - Assets Pieced In Service Durina 2003 Tex Veer Usina the Generel eoreclet n ivstem (b) Month end Ie) Baals for depreciation (e!) Recovery (a) Claslftcatlon of property yeer plllCed (buslneaallnvlllltment use period (e) Convention (l) Method (g) Depreciation deduction In service only. _Instructions) 19a 3'vear prooertv ::::::;::::;::::::;::~:;:;:;::::;:::;:;;;;:;;:;:::::~:::; :;:;;::::::;:::;;::::::;:;:;:::;:;:;:::::;:::;:::;:;;::::: .......................................................... b 5-vear - c 7 -year prooertv d 1Q-year ~ ............................. ............................. ............................. ~ ............................. 15-vear .......................................................... e ~ .:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.: :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.;.:.:.:. ............................. .......................................................... ............................. 2Q-vear prooertv ............................. f ............................. .......................................................... .......................................................... .......................................................... .;.:.:.;.:.:.;.:.:.:.;.:.:.;.;.:.:.:.:.;.:.;.;.;.:.:.;.:.: 25'vear prooertv ......................................................... ............................. 25 Vr5. S/L a ............................. ......................................................... :::::::;:::::::::::::::::::::::::::::::::~:;::::::::::::. I 27.5 Vr5. MM SIL h Residential rental property 27.5 Vr5. MM S/L I I Nonresidential real I 39 Vr5. MM S/L property I MM SIL 20e Class life b 12. ear c 40. ear :r .::':':':':'::":r.:. Summery (See 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 Ion of the basis attributable to section 263A costs ................................................ 23 ~6.~f.k LHA For Paperwork Reduction Act Notice, see separate Instructions. Section C - Assets Placed In Service During 2003 Tax Vear Using the Alternative Depreciation System :~~tt:~tt@~~~~t@~~t@ltf SIL r~!I~::~:~~:~:::I:::~~::::jI~!:I:t:t 12 r5. SIL I 40 r5. MM SIL 21 22 1!lIJII::I~iilllllllllli!II~~!illllll!iil:~::I:I::il[:11:1!:I:li:!~I: Form 4562 (2003) Fonn4562(2003 MILLER INSURANCE ASSOCIATES INC. 23-2055739 Page 2 ~. ........:.:.:...:~:. ...;); Listed Property Onclucle 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 /ease expense, complete only 24a, 24b, columns (a) throuah (cJ of Section A all of Section B. and Section C " BDD/lcable. SectIon A - Deprecletion and Other Informetion (Caution: See instructions for limits for passenger automobiles.) 24e Do ou have evidence to su ort the buslness/investment use claimed? D Yes D No 24b If "Yes" Is the evidence written? D Yes D No (e) (b) (c) (d) (e) (f) (g) (11) (i) Type of property Date . Buslnessl Cost or Bals for depnlCiatlon Recovery Methodl Depreciation Elected (list vehicles flrsf) placed In Investment other basis (buslnessllnvestment period Convention deduction section 179 service use percentage usa only) cost ............. ........ .... .............................. ............................. .............................. 25 Special depreciation allowance for qualified listed property placed in service during the tax ;~;~~~t~~;~;~~~;;~~~~~~~~~;~~~~~~~~~~;~;~i~;m~~~~~r ear and used more than 50% In a uallfled business use ........................................................................ 25 :I:t;IImt;IIII~;ImIm 28 Property..... more "*' 50% In a jual1llad buslnass usa: I " ~ :1 I I used 50% or less In a uallfled business use: % SIL. % M- % SIL. 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, page 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 your employees, first answer the questions In Section C to see If you meet an exception to completing this section for those vehicles. 27 Pro ....... -..... ... ........... ... .................. ................. ................. .... ..........................'............................,', :t~;tl~~1~~l;~~;;t~~~~~m~tt~ - (e) (b) (c) (d) (e) (f) 30 Total buslnesslinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 31 Total commuting miles driven during the year ... 32 Total other personal (noncommutlng) miles driven. .............................................................. 33 Total miles driven during the year. Add lines 30 through 32.................................... 34 Was the vehicle available for personal use Yes No Yes No Yes No Yes No Yes No Yes No during off-cluty 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 B for vehicles used by employees who ere not more than 5% owners or related rsons. 37 Do you maintain a written polley 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 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 concemlng qualified automobile demonstration use? ..................................................................... Note: If your answer to 37,38,39,40, or41 ;s .Ves,. do not complete Section B for the covered vehicles. :~ ::':':':':;;":;vn Amortization (e) Desc:rIptlon of costs Yes No ~~~~i1l~r ~;mj~~~m~m~li; 42 Amortization of costs that (e) AmortIzllble amount (d) Code section (e) ArnoIilrion period or peItIIl1lIge (f) Amortization for this year 7 715. 7 715. Form 4562 (2003) 43 Amortization of costs that began before your 2003 tax year .............................................................................. 43 44 Total. Add amounts In column (t). See instructions for where to report ............................................................... 44 316252110-21-03 Election Not to Claim the Additional First Year Depreciation Allowable Under IRC Sec. 168(k) Miller Insurance Associates, Inc. 19 Brookwood Avenue, Suite 102 Carlisle, PA 17013 Employer Identification Number: 23-2055739 For the Year Ending April 30, 2004 Miller Insurance Associates, Inc., hereby elects, pursuant to IRC Sec. 168(k)(2)(C)(iii), not to claim the additional 30% and 50% depreciation allowable under IRC Sec. 168(k) for the following qualifying property placed in service during the tax year ending April 30, 2004. All property in the 3 year class. All property in the 5 year class. All property in the 7 year class. All property in the 10 year class. All property in the 15 year class. All property in the 20 year class. All property in the 25 year class. Computer software as defined by IRC Sec. 167(f)(1)(B). Qualified leasehold improvement property. See attached Form 4562. MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER INCOME STATEMENT 1 DESCRIPTION AMOUNT SERVICE CHARGES 87. TOTAL TO FORM 1120, LINE 10 87. FORM 1120 TAXES AND LICENSES STATEMENT 2 DESCRIPTION AMOUNT PAYROLL TAXES PENNSYLVANIA TAXES - BASED ON INCOME PENNSYLVANIA TAXES - OTHER 23,242. 3,874. 1,725. TOTAL TO FORM 1120, LINE 17 28,841. FORM 1120 OTHER DEDUCTIONS STATEMENT 3 DESCRIPTION AMOUNT AMORTIZATION COMMISSIONS AUTO EXPENSE DUES & SUBSCRIPTIONS EDUCATION EXPENSE INSURANCE POSTAGE TELEPHONE UTILITIES OFFICE EXPENSE TRAVEL & LODGING CAIR EXPENSES PROFESSIONAL FEES MISCELLANEOUS LICENSES CONSULTING FEES LEASE EXPENSE MEALS AND ENTERTAINMENT 7,715. 43,494. 4,258. 2,952. 486. 12,504. 3,567. 9,170. 2,948. 6,957. <190.> 3,446. 6,226. 5,453. 107. 14,254. 2,162. 651. TOTAL TO FORM 1120, LINE 26 126,160. STATEMENT(S) 1, 2, 3 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 TAX COMPUTATION STATENgNT 4 1. TAXABLE INCOME . . . . . . . . . . . 2. LESSER OF LINE 1 OR FIRST BRACKET AMOUNT . . 3. LINE 1 LESS LINE 2 . . . . . . . . . . . 4. LESSER OF LINE 3 OR SECOND BRACKET AMOUNT 5. LINE 3 LESS LINE 4 . . . . . . . . . . . . . 6. INCOME SUBJECT TO 34% TAX RATE . . . . . . . 7. INCOME SUBJECT TO 35% TAX RATE . . . . . . . 8. 15 PERCENT OF LINE 2 . . . . . . 9. 25 PERCENT OF LINE 4 . . . . . . . . 10. 34 PERCENT OF LINE 6 . . . . . . . . . . 11. 35 PERCENT OF LINE 7 . . . . . . . . . . 12. ADDITIONAL 5% SURTAX. . . . . . . . . . . 13. ADDITIONAL 3% SURTAX . . . . . . . . . . 14. TOTAL INCOME TAX . . . . . . . . . . 35,433 35,433 o o o o o 5,315 o o o o o 5,315 STATEMENT(S) 4 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE L OTHER CURRENT ASSETS r .) STATEMENT DESCRIPTION BEGINNING OF TAX YEAR PREPAID EXPENSES NOTES RECEIVABLE - OFFICERS FEDERAL PREPAID TAXES STATE PREPAID TAXES 307. 13,193. 3,678. TOTAL TO SCHEDULE L, LINE 6 17,178. END OF TAX YEAR o. 1,993. 85. 1,032. 3,110. SCHEDULE L OTHER CURRENT LIABILITIES 6 STATEMENT DESCRIPTION BEGINNING OF TAX YEAR PAYROLL TAXES PAYABLE ACCRUED CORP. TAXES ACCRUED INTEREST PREMIUMS PAYABLE DEFERRED TAX LIABILITY 3,194. 4,811. 1,160. 11,780. 4,669. TOTAL TO SCHEDULE L, LINE 18 25,614. END OF TAX YEAR 18,654. o. 514. o. 4,383. 23,551. 7 SCHEDULE M-l OTHER EXPENSES RECORDED ON BOOKS NOT DEDUCTED IN THIS RETURN STATEMENT DESCRIPTION LIFE INSURANCE PREMIUMS TOTAL TO SCHEDULE M-l, LINE 5 AMOUNT 205. 205. STATEMENT{S) 5, 6, 7 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE M-1 OTHER INCOME RECORDED ON BOOKS NOT INCLUDED IN THIS RETURN STATEMENT 8 DESCRIPTION DEFERRED TAX ADJUSTMENT TOTAL TO SCHEDULE M-1, LINE 7 AMOUNT 286. 286. FORM 4562, PART V LISTED PROPERTY INFORMATION-MORE THAN 50% STATEMENT 9 (A) (B) (C) DESCRIPTION DATE BUS. % (E) BASIS (F) (G) (H) (I) 179 LIFE MTH/CV DEDUCTION ELECTED (D) COST (J) AUTO NO (L) BUSINESS MILES (0) WAS VEH. AVAIL.? Y N (P) > 5% OWNER? Y N (K) TOTAL MILES (M) (N) COMMUTING PERSONAL MILES MILES 2003 GMAC YUKON - LIKE 08/16/99 100.00 29,995. 29,995. 5.00 200DB-HY 2003 CAMRY 01/25/01 - LIKE PROPERTY 100.00 13,852. 13,852. 5.00 200DB-HY 12,046 12,046 2003 CAMRY 05/30/02 - SEE ALSO ASSET 31 100.00 14,300. 10,010. 5.00 200DB-MQ 22,587 22,587 TOTAL TO FORM 4562, PART V, LINE 26 (Q) ANOTHER VEH. AVAILABLE? Y N 1,775. 1,596. 2,656. 6,027. STATEMENT(S) 8, 9 Form 1120 u.s. Corporation Income Tax Return For calendar year 2002 or tax year beginning MAY 1, 2002 ,ending APRIL 30, 2003 OMS No. 1545-0123 Oepa/trnent of the T_ry Internet Rev...ue Service 2002 f I '1:J c: II M ~ Name MILLER INSURANCE ASSOCIATES, INC. Number, street, and room or suite no. (If a P.O. box, see page 7 of instructions.) 19 BROOKWOOD AVENUE, SUITE 102 city or town, state, and ZIP code CARLISLE. PA 17013 E Check applicable boxes: (1)[ ] Initial return (2)[ ] Final return (3)[] Name chanoe 14\r 1 Address channe $ 1 . Gross ~pts or SIIles I 5 5 3 , 0 7 0 .1 b Less mumnnd 1II1ClW11nces I I c Bal ~ 1 c 2 Cost of goods sold (Schedule A,line 8) ......................................................................................................... 2 3 Gross profit. Subtract line 2 from line 1c ......................................................................................................... 3 4 Dividends (Schedule C,line 19) .................................................................................................................. 4 5 Interest ........................................................................................... ........ ............................ ........ ............ 5 6 Gross rents ...................................... ............................ ........................................................................... 6 7 Gross royalties ......................................................................................................... ..... ............................ 7 8 Capital gain net income (attach Schedule D (Form 1120)) ................................................................................. 8 9 Net gain or (loss) from Form 4797, Part 1I,line 18 (attach Form 4797) .................................................................. 9 10 other Income (attach schedule) ........ ...... ............................................. .............................. ............................ 10 11 Total Income. Add lines 3 throuoh 10 ................................................................................................... ~ 11 12 Compensation of officers (Schedule E,line 4) ................................................................................................ 12 13 Salaries and wages (less employment credits) ................................................................................................ 13 14 Repairs and maintenance ... ....... ....... ................................... .............. ........... ..... ....................... ..... ...... ... .... 14 15 Bad debts .............. ............................... ..................................................... ....................... ..... ........ .......... 15 16 Rents .................... .... .................................. ................. ........................................... ...... ....... ...... ... .......... 16 17 Taxes and licenses ...........................................................................~.~.~....~.~~~.~~.~~.~...J............. 17 18 Interest ............. ................... .. .......... .................... ....................... ............ . . ................................. ............. 18 19 Charitable contributions SEE STATEMENT 2 AND SEE STATEMENT 3 19 ................................................................................ j........ j.................................... 20 Depreciation (attach Form 4562) .................................................................. 20 47 , 503 . 21 less depreciation claimed on Schedule A and elsewhere on return ..................... 21a 21b 22 Depletion ............................................................................... ................... .............................................. 22 23 Advertising ....................................................... .................. .................................................................... 23 24 Pension, profit-sharing, etc., plans ............................................................................................................... 24 25 Employee benefit programs .......................... ...... ..................... ............................. ...................................... 25 26 Other deductions (attach schedule) ......................................................s.~~....s.';f~';f~~~~';f...4............. 26 27 Tot.1 deductions. Add lines 12 through 26 ............................................................................................. ~ 27 28 TlIX8bIe Income before net operating loss deductlon end speellll deductlons. Subtnlct line 27 from IIne,11 I...................... ............. 28 29 LBIS: I Net operating loss (NOL) deduction ................................................ I 29a ~m~~~l~~~~1m; b Soecial deductions (Schedule Cline 20\ .......................................... 29b 29c 30 T.xable Income. Subtract line 29c from line 28 .......................................................................................... 30 :~ ;=.~i~c~~.~~;;?.. ....~.. '32~" ... ... ....... ... ....... ... ........ .... !:II!I:!j!!!:j!I!~!!I!l:I:;!I!I!i:~!I!I!I!:\i!l:l!I!~!II:j:I:~!I!!I:I!I]II!!I!I!;I!!I!I:~II!:j!I!~!II:j:l:lj1!11!1:lllli!j:I:;IIII:I!;!:I:1 :~:::::;::~:::~: b ~~~I::tedd ~..e:~ments ...... 32b 9 , 440 · :t::::':::::::::~:::t::::r:::~:::t:~:::::::::::::::,::::~::tt:tr:t::::t::::::::::::::::::::::::::::::::::::::::::,:::::,:,:::: '.:.:.:.:.:.:.:.:.:.: C on Form 4468 n :.~.I......~................ 32c l d Bal ~ 32d 9,440. e Tax deposited with Form 7004 .......................................................... ........... 32e t~~ttlt f Credit for tax paid on undistributed capital gains (attach Form 2439) .................. 82f :::::::::::::::::::. D Credit for Federal tax on fuels (attach Form 4136). See instructions ..................... 32g 32h 33 Estimated tax penalty (see page 14 of instructions). Check if Form 2220 is attached .................................... ~ D 33 34 T.x due. If line 32h is smaller than the total of lines 31 and 33, enter amount owed ................................................ 34 35 Overp.yment. If line 32h is larger than the total of lines 31 and 33. enter amount overpaid ....................................... 35 36 Enter amount of line 35 vou want: Credited to 2003 estimated tax ~ 4 . 078 . Refunded ~ 36 Under penllllties of peljury, I decl818 that I hllVe examined this mum, Including lICCOmpenylng sc;hedules end statements. end to the best of my knowledge lInd belief, It Is true. COfT8Ct, and complete. Decleratlon of PreplIIllI" (other than taxpayj Is besecI on IlIIllnfonnetlon of which PreplIIllI" has any knowledge. I ~~~s I ~Slgnetul8ofomcer Dalll ~Tltle.[X:ry~~ D No Pnlparer's ... I oalll I Check if Pnlparer's SSN or PTIN Paid slgnetul8 P' self-employed [Xl PO 0057626 Preparer'1 Flnn'sname SMITH ELLIOTT KEARNS & COMPANY, LLC I ElN 52 0783935 Use Only (or yours If ~ s..f-employed), 19 BROOKWOOD AVE., SUITE 101 I Phone no. (717)243-9104 edd_. end ZIP code CARLISLE, PA 17013 n~~ JWA ~ See Instructions for Paperwork Reduction Act Notice. Use IRS I.bel. Other- wise, print or type. B Employer Id...tlfic:atlon number A Check if a: , ConsoIId8Nd rwtum D (attech Form 851) 2 Personal holding co. D (attech Sell. PH) 3 Personllll HIVlce corp. (- dellned In Regs. D see. 1.441-3(c)) 23-2055739 C Dallllncorporated 02/28/1978 D Total essets (see rage 8 of Instructions 450,313. 553,070. 553,070. . E 8 .E 553,070. 133,580. 70,362. 11,738. 338. 31,336. 23,114. 18,184. 475. III S J 47,503. 27,527. 26,442. 126,723. 517,322. 35,748. 35,748. 5,362. 9,440. o. 4,078. Sign Here Form 1120 (2002) Fonnll20C2OO2) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Pa e2 tr ..<: ...<.....;.;.; '.;.;.;~;.' .::j ost of Goods Sold See a e 14 of instructions. 1 Inventory at beginning of year ................... ......... .............................. ............................... ............................. ..... 1 2 Purchases............................................................... ....... ......... ............................ ........................................... 2 3 Cost of labor ... .............. ................. ................... .......... .... ... ............. ..................... ......................... ..... ............. 3 4 Additional section 263A costs (attach schedule) ...................................................................................................... 4 5 Other costs (attach schedule) ........................... .......................................... ..... ..... ............................................ 5 6 Total. Add lines 1 through 5 ............................ ........ ..... ............................ ........ .............. .............. ..................... 6 7 Inventory at end of year .. ......... ..... ........ ..... ....... ...... .......... ...... ................................ ................ .......................... 7 8 Cost of goods sold. Subtract line 7 from line 6. Enter here and on line 2, page 1 ............................................................ 8 9 a Check all methods used for valuing closing Inventory: (i) D Cost as described in Regulations section 1.471-3 (i1) D lower of cost or market as described in Regulations section 1.471-4 (III) D other (Specify method used and attach explanation.) ~ b Check if there was a wrltedown of subnormal goods as described In Regulations section 1.471-2(c) ............................................................... ~ D c Check if the LIFO inventory method was adopted this tax year for any goods (If checked, attach Form 970) ...................................................... ~ D d :1~:;n~I~~::~:~oc~::~:e~d u:~:~~;:;or.~I.~.~~~ ~~.~~:.~~~~~. ~~.~~.~~~.~~.~~.~ ~~.~~~~~~ .~~.......................... ........ ..... ...... .... W e If property is produced or acquired for resale, do the rules of section 263A apply to the corporation? ............................................. DYes D No f Was there any change in determining quantities, cost, or valuations between opening and closing Inventory? If "Yes' attach exolanation .................................................................................................................................-.............. n Yes nNO l:f:"'tl:~1 Dividends and Special Deductions (a) Dividends (b) % (c) Special deductions received (a) x (b) 1 Dividends from less-than-20%-owned domestic corporations that are subject to the 70% deduction (other than debt-financed stock) ...................................................... 70 2 Dividends from 20%-or-more-owned domestic corporations that are subject to the 80% deduction (other than debt-financed stock) ...................................................... 80 3 - Dividends on debt-financed stock of do~tlc and foreign corporations (section 246A) ..................... Instructions 4 Dividends on certain prefemld stock of less-than-20%-owned public utilities ................................. 42 5 Dividends on certIIln prefemld stock of 20%-or-mont-owned public utilities .......... ........... .... . .... .. . 48 6 Dlvl~ds from less-than-20%-owned foreign corporations and certain FSCs 70 thlIt _ subject to the 70% deduction ...... ........... ................................ .............. ..... .......... 7 Dividends from 20%-or-mont-owned foreign corporations and certain FSCs 80 thlIt _subject to the 80% deduction ....................... ......................................... ........... 8 ~~~-=.~~~~~:u>)reI~ ~~~~~~~~~ .~~~j.~.~ ~~................................. ............... 100 9 Total. Add lines 1 through 8 mtm~mmtm~~~mmm~t~~~~~~~mu~~~~u~~u~~~~m~~t~~~U~~~I ~:~;:t~:}~:~:~:;:;:~t:~:~:~{:; ................................................................................. ::;::::;::::::::::;:::::::::;:::::::::::::; 10 Dividends from domestic corporations received bya small business investment company operating under the Small Business Investment Act of 1958 ........................... 100 11 Dividends from certain FSCs that me subject to the 100% deduction (section 245(c)(111 ..................... 100 12 DIvI~ds from affiliated group members subject to the 100% deduction (see. 243(sl(3)) ..................... 100 13 Other dividends from foreign corporations not Included on lines 3, 8, 7, e, or 11 ........................... . 14 Income from controlled foreign corporations under subpart F (attach Fonn(s) 5471) ........................ 15 Foreign dividend gross-up (section 78) .................................................................. 16 10 -DISC snd former DISC dividends not Included on lines 1, 2, or 3 (section 246(d)) ........................ 17 other dividends ............................................-................................................... 18 Deduction for dividends paid on certain preferred stock of public utilities ........................ lI~~~~t~~~~~I~~~~~~~I~~~~~~~~~~~~~~~@~m~~~~~~~~~~~~~~;~~~~~~~~~~~~~~~~~~~~~~~~~~: 19 Total dividends. Add lines 1 through 17. Enter here and on line 4, page 1 ............... ~ ~;~~~;~~~~~~~~~~~~~~~~~~~~~~~~~@~U~~@~~~~~II~rn~i~~i~~~~~~~~ 20 TotalsDeelal deductions. Add lines 9 10 11 12 and 18. Enter here and on line 29b. Dane 1 ................................................ ~ 11~1~i~_[11::1 Compensation of Officers = InstJuctIons for line 12, pagel, on page 10 of InstruGtlon8) ote: ComolateSchedule E onrv-lftotall8OlliDts iiine la-Dlus lines 4 throuah 10 on page 1) _$500 000 Dr more. (I) Name of officer (b) Social security W) Percent of Percent of corporation (I) Amount of number 'me devoted stock owned compensation to business fd) Common fe) Preferred 1 M EUGENE MILLER 162-36-7572 100 90 . 00% 84.386 . KIMBERLY SHUFF 16 1-58-1250 100 10 . 00% 49.194 . 2 Total compensation of officers ....................................................................................................................................... 1 33,580 . 3 Compensation of officers claimed on Schedule A and elsewhere on retum .............................................................................. 4 Subtract line 3 from line 2. Enter the result here and on line 12, Daoe 1 .................................................................................. 1 33.580 . ~~~~~k JWA Form 1120 (2002) 23-2055739 Form 112012002\ MILLER INSURANCE ASSOC IATES, INC. (j!g"':::':' .,;..,. <::"':':':1jdlJ Tax Comnutatlon ISee Daoe 17 of Instructions\ 1 Check If the corporation is a member of a controlled group (see sections 1561 and 1563) Important: Members of a controlled group, see instructions on page 17. 2a If the box on line lis checked, enter the corporation's share ofthe $50,000, $25,000, and $9,925,000 taxable Income brackets (in that order): (1) 1$ b Enter the corporation's share of: ~I$ I ~ $ (1) Additional 5% tax (not more than $11,750) I S (2) Additional 3% tax (not more than $100,000) I s 3 Income tax. Check if a qualified personal service corporation under section 448(d)(2) S TMT 5 (see page 17) .................................................................................................................................... .. D 3 4 Altemative minimum tax (attach Form 4626) ......................................................................................................... 4 5 Add lines 3 and 4 ............................................................................................................................................. 5 8a Foreign tax credit (attach Form 1118) ...... ............................................................ 6a b Possessions tax credit (attach Form 5735) ............................................................ 6b c Check: D Nonconventlonal source fuel credit D QEV credit (attach Form 8834) 81: d General business credit. Check box(es) and Indicate which forms are attached. ,:r:tf:::::: D Form 3800 D Form(s) (specify) .. 6d e Credit for prior year minimum tax (attach Form 8827) ............................................. 6e f Qualified zone academy bond credit (attach Form 8860) .......................................... 8f 7 Total credits. Add lines 6a through 51 .................................................................................................................. 8 Subtract line 7 from line 5 ........................................................................................................... ...................... 9 Personal holding company tax (attach Schedule PH (Form 1120)) ........................................................................... 10 Other taxes. Check If from: D Form 4255 D Form 8611 D Form 8697 D Form 8866 D Other (attach schedule) ............................................. 11 Total tax. Add lines 8 throuDh 10. Enter here and on line 31. DaDe 1 ....................... .................................................... lff..~:.:.. :.:~.:<< :.'.: ">:':j!KIJ Other Information (See Daoe 19 of Instructions) 1 Check method of accounting: a D Cash b [Xl Accrual Yes No 7 c D Other (specify) .. i:::i:::::::::::i:i:. 2 a ~:I~::: :~~~h:~~:t:~:n;2~e~ti~he: :lllllllilllllllllt : ::;0=: : ~~;~~CE Ill!II:IIII:!lllll:: 3 ~~ti:~~~ ~~:::~::~f~:et:~t~:g~~:~o;. :~~~~::~ or !:jl\I.:I:lll'II[:'I. corporation? (For rules of attribution, see section 267(c).) ...... If "Yes," attach a schedule showing: (a) name and employer identification number (EIN), (b) percentage owned, and (c) taxable Income or (loss) before NOL and special deductions of such corporation for the tax year ending with or within your tax year. 4 Is the corporation a subsidiary in an affiliated group or a parent-subsidlary controlled group? .................. ............... If "Yes: enter name and EIN of the parent corporation .. 5 At the end Of the tax year, did any IndIVidual, partnership, corporation, estate, or trust own, directly or indirect~, 50% or more of the corporation's voting stock? (For rules of attribution, see section 267(c).) .................................... If "Yes," attach a schedule showing name and identifying number. (Do not include any Information already entered In 4 above.) Enter percentage owned .. 6 During this tax year, did the corporation pay dividends (other than stock dividends and distributions In exchange for stock) In excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) ............... If "Yes," file Form 5452, Corporate Report of Nondlvldend Distributions. If this is a consolidated return, answer here for the parent corporation and on Form 851, Affiliations Schedule, for each subsidiary. ................................. .. D ::;ij~~11~:~:~j~t :;:llll;llllliiilllli .:.:.:.:.:.:.:.:.:.: I ':=:=;=:=:::=:=::::: .:.;.:.:.;.:.;.:.;.:. ::llllilllllilllllll: .:::::::::::::::~:: I 7 8 9 ~j~~~i11~jW:@: 10 11 At any time during the tax year, did one foreign person own, dlrect~ or indirectly, at least 25% of (a) the total voting power of all classes of stock of the corporation entitled to vote or (b) the total value of all classes of stock of the corporation? ........................... .... ............ ................. If "Yes," enter: (a) Percentage owned .. and (b) Owner's country" c The corporation may have to file Form 5472, Information Return of a 25% Foreign-Owned U.S. Corporation or a Foreign Corporation Engaged in a U.S. Trade or Business. Enter number of Forms 5472 attached .. Check this box If the corporation Issued public~ offered debt instruments with original Issue discount .............. D If checked, the corporation may have to file Form 8281, Information Return for Public~ Offered Original Issue X Discount Instruments. t:~:::::::I::~ .:.:.:.:.:.:.:.:.:.: 9 Enter the amount of tax-exempt interest received or .:.;.;.:.:.;.;.:.:.: :.;.:.:.:.:.;.:.:.:. ........ fffJf :::::::::::::::::::: accrued during the tax year .... $ II ::~:~E=~:':::~:~:.::r:r X electing to forego the carryback period, check here ... .. D 11:~111111~llllll: Illllllllllliill ~:u~r~~~~~=~I~~i~~~gS:c~0::~~~~~~2~~~X3m) ~~(~r)":~~t ':':';':':':':':'.' .:.:.:.:.:.:.:.:.;.: be attached orthe election will not be valid. I:: 12:.;~~~:.~~=~~:ortaxyea~ X 13 Are the corporation's total receipts (line la plus lines 4 through ~. ~E:.sE~~€i:u:;:'Z=:'::~.;:' :::r:lt:I ....<............. M-l, and M-2 on page 4. Instead, enter the total amount of cash :IIf::t:: distributions and the book value of property distributions (other ttlll: ::tittt than cash) made during the tax year." $ X 118 Pane 3 5,362. 5.362. 5,362. 5,362. Yes No :ll;llll~~l~ll:ll: :ll\ll;;;llllll:;l:~; ':~::::::::::::::::: :~:~:~:~:~:~:~:~:1:~: X .:.:.:.:.;.;.:.:.:.:. :.:.:.:.;.:.;.:.:.;.; ::::::::::::::::::::: :.:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.:.:. ::::::::::::::::::::: :;:;:;:;:;:;:::;:;:;: II II .;::::::;:::::::;:::':::::::::::::::::::;: ......................................... II .:.:.:.:.~.:.:.:.:.. .:.:.:.:.:.:.:.:.:.:. .;.:.:.:.:.:.:.:.:.: :.:.:.:.:.:.:.:.:.:.: ::lI:I\[::l[\:~:l::[l:l:l[l:\:;:!::: .......................................... :ttr~~~~;~~. m;~tttt II ;::::::::::::::::::. :::::::::::::::~::::: x :::::::::~:::::::::. ::~:::~::;::~::::: :.:.:-:.:.:.:.:.:.: :.:.:.:.;.:.;.;.:.:.: ::::::::::::::::;::;:;:::;:;:;:;:::::::; It:t::~![~:; tl!j:1I:l:~:: Note: If the corporation, at any time during the tax year, had assets or operated a business in a foreign country or U.S. possession, it may be required to attach Schedule N (Form 1120), Foreign Operations of U.S. Corporations, to this return. See Schedule N for details. ~~~~k JWA Form 1120 (2002) Form 1120 (2002) MILLER INSURANCE ASSOC IATES, INC. 23-2055739 p_4 Note: The co oration Is not reaulred to comDlete Schedules L M-1 and M-21f Question 13 on Schedule K Is answered "Yes." [f 'P".'X': .:.\ .~tl Balance Sheetuer Boob Beglnnlngoftax y.... End oftax~ Assets (a' (b' (e' (d) ~a ~::e '~~t~~ '~~d' ~~~~~t~' ~~~b~" .................. f:ttt~~gI~j@Wfi:j]~~:f~:~:~~~i11~~~::'f~MmJJM:lt:t~j~~~~:j~i;~~~:::~:~:}~; l~m:Itt~:mU~tmtj:jgj~~~j::~~~;:1~~~:~:: i~:WIW .::. .::..~;.~::~:::~;::~::;;;;;~;: b Less allowance for bad debts .................. ( 39,175. 62,477. ~ ~~~~>;;;.u;u ..!.!.I.r.:J.!.~.i.~.!.!.!.l.I.~.i.!.I.'.l.I.!.[.!.l.!.1.!.l.'.I.,.I.I.r.i.,.!.;.!.i.i.;.~.r.!.;.i.:.r.'.b.j.i.:.,.!. 3 · 687 · 1 1 7 .178 · : =~:=;:~e:~e I~~~~.::: :::::: ::: ::: ::: ~:::;rjj~1:::.~:}~~~:j:i[mtUutf:rnHi#mI llli!!ii!; 10a Buildings and other depreciable assets ...... 18 3 . 7 30 . :f@mm:mttH~~:~~r~:f:l{@;:;@~:r:i::t: 2 0 9 , 5 6 3 . ::::::::::r~:::jtf:::::r::j::t;:::::i::: .' . . bLess accumulated depreciation .... .......... I 156,10101 ........ .........:fr~.62"9 ~ , 141. 952 ~ ......:..:.. ..... ...~..? ' 6 ~ 1. 11: ~:::::~~~~a~:~ d~~~ti~~'::::::::::::::::::::: I '.: .. .: ::\:..:.:~:?::j:!~::!;;;.:!~:j:\::\::::::l: ,::.;::::r::::::j:r::::':;ff:.:::~.::;.:'t... :" .. ..... 12 Land (net of any amortization) ...... ........ :"':T~:t:.;.:t:;:.;:;::{::.: ... .... .. I:~~:::::~::::::j~ifi::::~~:t~:~:t~:~:~:~:~:~:~:~:::~::i:::~:~i:::::::::::: .. ............... ............. .. .. . 13a Intangible assets (amortizable only) ......... 50 , 000 . _t;:::::r::?tr::~~: 2 77 , 009 . :~~:t:m:::jtr::::::::M1NtMMMf:::t::ttm bLessaccumulatedamortization ............... I 5,83301 44,167. I 19,256 257,753. :: E:=~atl~:~~~~~q~~ _ 135.772._~~~ 450.313. 16 Accounts payable ................................. 22,396. 17 Mortgllges, notes, bonds payllble In less then 1 y.... 18 Oth..CUlT8llt liabilities (all soh.) S.'l'.MT....1.... 25 . 614 . 19 Loans from shareholders ........................ 20 Morlgllges, notes, bonds payable In 1 y.... or more 3 7 4 , 2 6 1 . : :~:=:1:::::.... 1.000.1~: '(:Yi~ 1.00:~~ :: ===::~H:.:. _ ';Uj.HjjJ :: =ta=:a:~~ ~na~prOPriated ... ...... 1:iiiili::II[I~;j::::~~:::f:::I::j:ti~Il~I1;::~:::ItI' ~1403 ~8 :'~8 047 ~9 ~. ;!:.~:::.:::::!.:::::.i::::_.;:;::::i:::::';.::::::::~'.:::::::.'..::::!.I:::!::.:::::.'!::,.::::..:::.!,::.i..:=.:::::::.:::::8::::(::::\::::.:::.:.:::I::::..:.".,:::.w:::::.i:::::.:,:::i::::i:::I::::..!::::'W.i:o::.:::::.::.:.:::::.W::.i:.::~j:.~:.:::r!:::;:,:.::D:::.~:.,:.:.:::::.r:::.'~.:::::::.w:::.,;:.I::,.i:::.;i..i:.::W.i.:.w:...i::::r::..:::.';:.-.l:::.:,::.:.:.i:::::~:.:.::::..i:.,.,:.i~:.::::::.~:.::~,::.I,.::.i:.:::~!::.,_:i:.:~:::.;i::...:::.::..;::;.:.:.;..:.:.:::;..::.*::..:~:::..:;::::'::.!,.::.::.:::.::.:.::::.i::::::." 415701 · 034123. . :,:;;:~~~iL~~_I~:'~~=~~~~ru~\4:000' ; ;EI;~~;:;,:= 6 ~ : ~: i: 7 ~:~~Z{::::i:~t' OM ,.~.\.I.!.I.r.I.!.r.i.r.!.I.I.l.l.!.r.l.',I.I.l.!.!.r.!.I.f.I.I.r.;I~.r.l.i.i.r.r.I.'.",' (~emize): JIII;I:IIIIIII!I'rlltI11:'llli!;~II!II!IIIIII!11;1 ., 6. H.H...ym..W 6 :bDgs:coDT~nrM~butIo:T;n:'9;:.h.o.I.'~"'="':':~$:' ~~3): " 29 565 2~ .: ::::::..:::.i::::::::'.~::.~::.~::::.~:;:::.:.::;.::'..:.,:r:.,.:..'.~~::~:::::i::::.;t::.,.i:::t.,:::t.~::r:,.;::.:.:::.:':.~,::l::,:.':::;.~::::::r.,::,!:,~:':.'::.~.:::::.i:.;:.::.;:::.!::::;:::::::!.,:.:f.:::'.i:::::::.':.,,:!.,.,.,,::I:::;::::!:::..'::.~.r.;,:::.~::.'..:.i:::,.::...f::::'~::3~:..~:~:..:..~::..;::::.l::.:!:::'~::"~:":":'9~~,~:.,!::,.::::[.:.l:..:'.:::..l::....'..::. ,~.::::*~:::..:.::::;~..:::::::.:.~.':::12':..::,:::.l:.::::;::.:::i::,:~,,::.'.:::.::..t';:::'6~":::::::':.:.:t:..::i::.:;::~r:'[:::'~:":'::'?'8;":':':''':':[::'::.'li:::.tj::::.:::::.,'.,.::!.::~i.:..:.:.:::.i::.~.':::. ~~~rn:=~~~''':01.r!II., - m'<-:>'?:::; STMT 8 5 , 461 . 7 , 062. 9 Add lines 7 and 8 ....................................... 39 , 268 . 6 Add lines 1 throuah 5 ................... ............. 75,016. 10 Income IlIne 28. oalle 1\ -line 6 less line 9 ...... 35, 748. JH ':.'(. ..:.,>:.:.:....r:<<~:.:iI:?lN:::::1 Analvsis of UnaDIl rODriated Retained Eaminas OAr Books -'Line 25- Schedule U 1 Balance at beginning of year ..................... 108, 849. 5 Distributions: a Cash .............................. 2 Net Income (loss) per books ..................... 62 , 193 . b Stock .............................. 3 OIhe, ~c...... (itemize), ~ : Other doc~.... :",::rty .. ............. ......... Add lines 5 and 6 ....................................... 4 Add lines 1 2 and 3 ................... ............. 1 71 , 042. 8 Balance atend ofvear lIine 4 lAss line 7\ ......... 1 71 , 042 . 211631 12-20-02 JWA Form 1120 (2002) 4562 OMS No. 1545-0172 Form Depreciation and Amortization 2002 (Including Infonnation on Listed Property) OTHER Depertment of the T_ry AttlIchment Intemlll Rw...ue S8rv1ce ~ See seperetelnstructions. ~ Attach to your tax retum. Seq_ No. 87 N8me(s) shoWn on retum Business or ectlvlty to which this form relates identifying number MILLER INSURANCE ASSOCIATES, INC . OTHER DEPRECIATION 23-2055739 t~~::.:::::~tli:!2 Election To Expenle Certain Tangible Property Under Section 179 Note: If YOU have any listed Dropertv, complete Part V before YOU comDlete Part I. 1 Maximum amount. See Instructions for a higher limit for certain businesses 1 24,000 . ...................................................... 2 Total cost of section 179 property placed in service (see Instructions) 2 70,597 . ............................................................... 3 Threshold cost of section 179 property before reduction in limitation .................................................................. 3 $200,000 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter .()- 4 ......................................................... 5 OoIlar limitation for tax vear. Subtract line 4 from line 1. If zero or less ...tar -0-. If manIecI fllln _Instructions .............................. 5 24,000 . 6 (II) Description of property (b) Cost (business use only) (e) Electacl cost .. 2003 GMAC YUKON - SEE ASSET 31FOR FEDERAL 56,297 . 24,000 . ................................................ ................................................ ~~~~~~~~~~l~~I~~~~t~~I~~~~~1~~~~~~~~~~~~I~~~~~~~~~~~~~t~~I~~I~~~lJ~~ljj~~ I ................................................ 7 Listed property. Enter amount from line 29.................................................................. 7 ~~J~~~~t~tm~;~~~i~~t~ttf~~~I~;~;~~~;~;~~~;;;~;~1m~mrtmt 8 Total elected cost of section 179 property. Add amounts In column (c), lines 6 and 7 .......................................... 8 24,000 . 9 Tentative deduction. Enter the smaller of line 5 or line 8.................................................................................... 9 24,000 . 10 Carryover of disallowed deduction from line 13 of your 2001 Form 4562 ............................................................ 10 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 24,000 . 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 24.000 . 13 Carryover of disallowed deduction to 2003. Add lines 9 and 10, less line 12 ............ ~I 13 I~~mmmtmmml~~~~1~1~~~;~~~~~~;;~ltm;tl~tmmm~ 14 SpecIal depreciation allowance tor qualified property (other than listed property) placed In service during the tax year (_ Instructions) .................. 14 15 16 9 689. 17 18 17 588. .................................. .... ....... .... :.:.;.:.;.:.:.:.:.:.:.:.:.:.;.:.:.:.:.;.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.;.:.:.: ........................................................... ....................................................................................................................'.' :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:. ............................................................ .[~~t~;~~;ttm~;~;~~~~tttttt~~~1~t1~~Jt~~~1t~~t\tttttt~~ Section B - Assets Placed In Service Durlna 2002 Tex Vear Uslna the Oenerel DeDreclatlon SYstem (b) Month and (e) BasIs tor depreclatlon (d) Recovery (II) Claslficatlon of property year placed (busln-'lnvestmant use (e) Conv...tion ~ Method (g) DepAlCiatlon deduction In service only - _Instructions) period ............................. ........................,.... 3-vear ..... ...... ...... ............ 19a .......................................................... :.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.;.:.:. ............................. ............................. .........................................................' ............................. 2 2,6 0 8 5 ~O ODE 1, 1 3 1 5-vear ;.:.;.;.;.;.:.:.:.;.;.:.;.;.:.:.:.:.:.:.:.:.:.:.;.:.;.:.:. YRS MQ b .......................................................... .......................................................... . . . .......................................................... ............................. ........................................................'. 7.vear property ............................. c :::::::::::::::::::::~:::~~:::::::~:::::~::::~:::::: ::::::~:;:::;:::::::::::;:::::::::::::::::::::::::::::::' d 10-year property 11.1:111.1',:IIII:II:I:!llll!:I:11111111111111111111 e 15-year property :.:.:.:.:.:.;.;.:.;.:.:.:.;.:.:.;.:.:.:.:.:.;.:.:.:.:.:.;. 20.year property .......................................................... ............................. f ............................. a 25-vear ll:lllllilll:ill~:il~ll::I::ll::l~illllll~lillllllllllIi! 25 Yrs. SIL h Residential rental I 27.5 yrs. MM SIL property I 27.5 vrs. MM SIL I Nonresidential real I 39 vrs. MM S/L property I MM SIL 20e Class life b 12 ear c 40- ear r :::':':':<':;":r.:. Summery (See Instructions.) 21 Usted property. Enter amount from line 28 ...................................................................................................... 22 Totel. 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 retum. Partnerships and S corporations - see instr. ..................... 23 For assets shown above and placed in service during the current year, enter the rtlon of the basis attributable to section 263A costs ................................................ 23 ~6..~;.k LHA For Peperwork Reduction Act Notice, see seperete instructions. Section C - Assets Pieced in Service During 2002 Tu. Veer Using the A1temetive Deprecletion System ::~~:tf~:~~~~~*f~:::~1~:~::j~:j~f:~::~:~ SIL :::::::::r~:~::t:::~:~:t!:::f~:f~:~:f::: 12 rs. SIL I 40 rs. MM SIL 21 12 095. 22 47 503. 1.I.illl:ifl::I:II:I.lll:I:III:11ijlll::II~:11111111111~11111~11111:llillllil:llllllli:I:111 Form 4582 (2002) 2 MILLER INSURANCE ASSOCIATES INC. 23-2055739 P~e2 Usted Property OncJude 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 mlleBge rate or deducting /ease expense, complete only 24a, 24b, columns (a) throuoh (cJ of Sect/on A. all of Section B. and Section C If BDDllcable. Section A - Deprecietion and Other Information (Caution: See Instructions for iimlts for passenger 8Utomoblles.) 24a Do ou have evidence to su ort the business/1nveslment use claimed? [X] Yes D No 24b If "Ves . Is the evidence written? [X] Yes D No (a) (b) (e) (d) (e) (f) (g) (h) (i) Type of property Date. Business! Cost or Besls for depreciation Recovery Methodl Depreciation EI~cted (list vehicles first) placed in Investment other basis (buslnesslinvestrnent period Convention deduction section 179 service use percentage use only) 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 ........................................................................ 25 26 Property U_ m<n thM 50~ I~ "{allfled buBin: usa, SEE STATT~' I : I I I used 50% or less in a ualified business use: 4 2 9 0 . !111111111111111111111111111111111:~lili~1[~1il[[11il~11~:i 7 .805.1 27 P % SIL . :i~~i~~~i~i~~i;~~~~iff}t;~~f~r::tt ::::;:::~::::::::;:::;:~::::::::::::::::~::::::::::::::; : :~~ ~ :11~li~j~~I:1111111::~[II~llllllil~~lllil~il:~i:I!1111:~:. 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, p~e 1 .................................... 28 095 · ::~::t::::~t:~:i:~:~t~:~\:~~~:r~:~:::~:~:t: 29 Add amounts In column (i),line 26. Enter here and on line 7, page 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 your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles. (a) (b) (c) (d) (e) (f) 30 Total business/investment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 31 Total commuting miles driven during the year ... 32 Total other personal (noncommutlng) miles driven....................................... ........................ 33 Total miles driven during the year. SEE PA RT V STA TEMENT Add lines 30 through 32.................................... 34 Was the vehicle available for personal use Yes No Yes No Yes No Yes No Yes No Yes No 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 B for vehicles used by employees who are not more than 5% owners or related ns. 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 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? ..................................................................... Note: If your answer to 37,38,39,40, or41 Is "Yes," do not complete Section B fortha covered vehicles. ~: ..;." '.: \ . J:~ Amortization (a) Description of costs Yes No m~;~~~u~~~~~~n~~ ~~t~~~~~~~;~~~;~;M 43 Amortization of costs that began before your 2002 tax year .............................................................................. 43 44 Total. Add amounts in column (f). See instructions for where to report ............................................................... 44 216252/10-25-02 Form 4562 (2002) (e) Amortizable amount (d) Code sec:tlon (e) ~on plIIlod or peICIlIl1Ige (f) Amortization for this year 42 Amortization of costs that Fonn 4562 Depreciation and Amortization (Including Infonnation on Usted Property) OTHER ~ See sependelnstructions. ~ Attach to your tax return. Busln_ or ec;tivity to which this form relates ~tofthe T_ury In......" Rllvenue Service Nmle(s) shown on retum MILLER INSURANCE INC. THER DEPRECIATION :: .::;.:.:.:..: 'r': Election To eRle Certain Tan Ible Pro e Under Section 179 Note: If ou have an listed ro e I com Iete Part V before 1 Maximum amount. See instructions for a higher limit for certain businesses ...................................................... 1 2 Total cost of section 179 property placed In service (see 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.()- ......................................................... 4 5 001111I' lIm1tst1on for tu ear. Subtr8ct line 4 from line 1. If zero or less enter -0.. If rnsnled IIl1n _Instructions .............................. 5 6 (II) Description of property (b) Cost (business use only) (e:) Elected cost 7 Usted property. Enter 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 2001 Form 4562 ............................................................ 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 13 Carryover of disallowed deduction to 2003. Add lines 9 and 10, less line 12 ............ ~ 13 Note: Do not use Part II or Part III below for listed property. Instead, use Part V. r:.:':':':::::;"'l"'::: Sial De reciatlon Allowance and Other D reclatlon 0 not include listed ro 14 Specllll depreciation allowance forquallfted property (other then listed property) pl~ In selVlce during the tu year(_lnstructions) ........... ....... 15 Property subject to section 168(f)(1) election (see Instructions) ........................................................................... 16 Otherd lation ncludln ACRS see Instructions ....................................................................................... MACRS D reciation 0 not include listed . See instructions. Section A 17 MACRS deductions for assets placed in service in tax years beginning before 2002 ........................... ............... 18 If you are electing under section 168~)(4) to group any assets placed In service during the tax ear into one or more enera! asset accounts check here .................................................................... D OMS No. 1545-0172 2002 Atblchment Sequence No. 67 identifying number $200,000 . 8 9 10 11 12 14 15 16 17 '11:llliilli::llllillllllllllillilllll:lllil:liI1111111111111111111:I:illl.:':llli~::I::lll::I:l[[:i:iiili!1:~I: Section B - Assets Placed in Service Durina 2002 Tax Vear Uslna the Oeneral DeDreciation Svs1 em (b) Month and (e) Basis for depreciation (d) Recovery (II) Classlllcetlon of property year pl~ (buslnessllnvestrnent use (e) Convention (f) Method (g) Depreciation deductlon In selVlce only - _ Instructions) period 198 3-vear Droperty b 5-vear property c 7-year d 10'vear propertv e 15-year Droperty f 20-vear a 25-year property 25 vrs. SIL Residential I 27.5 vrs. MM S1L h rental property 27.5 vrs. MM S/l I i Nonresidential real I 39 vrs. MM SIL property MM SIL I ~"-- ..11':ji:!'I':I~:....llll![I:II:l::I..lll:IIII[III:I:I~ Section C - Assets Placed in Service During 2002 Tax Vear Using the Alternetive Depreciation System S1L SIL SIL 20a Class life b 12 ear c 40- ear ::- .::::':':':'~:'\ '. Summery (See Instructions.) 21 Usted 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 rtion of the basis attributable to section 263A costs ................................................ 23 1~2g.k LHA For Peperwork Reduction Act Notice, see separate instructions. 12 rs. 40 rs. MM I 21 22 ~\'llllllllilllllll..lllllllllllll..II..III!II!:I!llljl!11IIIll!IIIIIIIIII:111111'1111 Form 4562 (2002) ~~4~ OO~ MILLER INSURANCE ASSOCIATES INC. 23-2055739 P~e2 r . :':':':<. '. 'L Usted Property Onclude automobiles, certain other vehicles, cellular telephones, certain computers, and property used for entertainment, recreation, or amusement.) Note: For any vehicle for which you 818 using the standard mileage rate or deducting lease expense, complete only 248, 24b, columns (8) throuoh (c) of Section A all of Section B. and Section C If BDDlicsble. SectIon A - Deprecietion end Other Informetion (Ceution: See Instructions for limits for passenger automobIles.) 24e Do ou have evidence to su ort the buslnessllnvestment use claimed? D Yes D No 24b If "Yes" Is the evidence written? D Yes D No (e) (b) (e) (d) (e) (f) (9) (h) (i) Type of property Date Buslnessl Cost or 88111 for depIeclllion Recovery Methodl Depreciation EI~ted (list vehicles first) plaC8~ In Investment other basis (busInessllnvwtment period Convention deduction section 179 servICe use percentage use only) cost .:.:.;.;.;.:,..:.,.;.;.;.:.;.:.:.:.;.:.;.:.:.;.:.:.:.:.:.:. 25 S=::=:: t~:w:~el~o: q~:~: I::=:.~I~~~.I.~.:~.I~~.~~.~~~.~~~.~~......................... 25 Illllillllillilllllllllllll:illlllil:lll:illl:::::I::\:,::: 28 Praporly"- more_ 50% In OJ busln... uaa: I : : ~ :1 I I used 50% or less in a uallfled business use: % M. % S/L' % S~. 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, page 1 ................................................................................. 29 Section B - Informetion 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 questions In Section C to see If you meet an exception to completing this section for those vehicles. 27 P !..I.:[I[II:I::[:.III:II[l~I[I:I,!I:;IIIII:;::[:\:.;::.;' 11111:11111111111!1111:1[llill!I[I:.::I:::I.1111 (a) (b) (e) (d) (e) (f) 30 Total buslnesslinvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not Include commuting miles) .................. 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 use Yes No Yes No Yes No Yes No Yes No Yes No during off-duty hours? .................................... 35 Was the vehicle used primarily by a more than 5% owner or related person? .................. 38 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 B for vehicles used by employees who ere not more than 5% owners or related rsons. 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 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 Info~atlon 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? ..................................................................... Note: ffyoursnswerto 37,38,39,40, or41 is .Yes," do not complete Section B for the coveredvehic/es. :; .::.-.:.:.:.:::..:~;.-:..-} Amortization (8) Description of costs Yes No m~~@~~~m~~ 1ml~~trt (c) ArnortIuble lIfTlCIunt (d) Code section (e) ArnortiD1Ion period or pertlII1lage (f) Amortlzllion for this Yell/' 179 180 10 089. 43 Amortization of costs that began before your 2002 tax year .............................................................................. 43 44 Total. Add amounts in column (1). See instructions for where to report ............................................................... 44 216252110-25-02 3 333. 13 422. Form 4582 (2002) FORM 8824 NO. 1 Form 8824 Like-Kind Exchanges (and section 1043 confllct-of-Interest sales) ~ Attach to your tal return. OMS No. 1545-1190 2002 Att-=h.,.,rs.;;uence No. 109 Identifying number o.p.rtment of the T_ury Intemal Rlwenue Selvlce Name(s) shown on tax retum MILLER INSURANCE ASSOCIATES, INC. 23-2055739 f_~J.J@ Infonnation on the Like-Kind Exchange Note: If the property described on line 1 or line 2 is real or personal property located outside the United States, indicate the country. 1 Description of like-kind property given up ~ BUICK 2 Description of Iike-kind property received ~ Date Iike-kind property given up was originally acquired (month, day, year) ............................................................................. 3 08/16/99 Date you actually transferred your property to other party (month, day, year) ....... .................................................................... 4 04/30/03 Date like-kind property you received was Identified (month, day, year) (see instructions) ........................... ................................. 5 Date you actually received the like-kind property from other party (month, day, year) ................................................................ 6 c [Xl No Related party's identifying no. Address (no., street, and apt., room, or suite no.) City or town, state, and ZIP code Relationship to you 9 During this tax year (and before the date that is 2 years after the last transfer of property that was part of the exchange), did the related party sell or dispose ofthe IIke-klnd property received from you in the exchange? ......................................................... D Yes D No 10 During this tax year (and before the date that is 2 years after the last transfer of property that was part of the exchange), did you sell or dispose of the like-kind property you received? ...................................................................................................... D Yes D No If both lines 9 and 10 are "No. and this Is the year of the exchange, go to Part III. If both lines 9 and 10 are "No" and this is not the year of the exchange, stop here. If either line 9 or line 10 is "Yes,. complete Part III and report on this year's tax retum the deferred gain or (loss) from line 24 unless one of the exceptions on line 11 applies. See Related party exchanges in the instf1Jctions. 11 If one of the exceptions below applies to the disposition, check the applicable box: a D The disposition was after the death of either of the related parties. b D The disposition was an Involuntary conversion, and the threat of conversion occurred after the exchange. c D You can establish to the satisfaction ofthe IRS that neither the exchange northe disposition had tax avoidance as its principal purpose.lfthis box Is checked, attach an e lanation see Instructions . ~ .:.:":':'::":~l .J Realized Gain or Loss Reco nlzed Gain, and Basis of Like-Kind Property Received Caution: If you transferred and received (I) more than one group of like-kind properties or (b) cash or other (not Nice-kind) property, see Reporting of munl-allet euhangel in the instructions. Note: Complete Nnes 12 through 14 only if you gave up property that was not IIIce-kind. Otherwise, go to line 15. 12 Fair market value (FMV) of other property given up ............................................................... I 12 I 13 Adjusted basis of other property given up ........................................................................... I 13 I 14 Gain or (loss) recognized on other property given up. Subtract line 13 from line 12. Report the gain or (loss) In the same manner as if the exchange had been a sale ................................................................................................... 15 Cash received, FMV of other property received, plus net liabilities assumed by other party, reduced (but not below zero) by any exchange expenses you incurred (see instructions) .................................................................. 16 FMV of like-kind property you received ........................................................................................................................ 17 Add lines 15 and 16 ................. ........ ........ ............ ........... ....... ....... ............. ............................................................. 18 Adjusted basis of like-kind property you gave up, net amounts paid to other party. plus any exchange expenses not used on line 15 (see Instructions) ................................................................................................ 19 Relllzed gain or (1011). Subtract line 18 from line 17 ...................................................................................................... 20 Enter the smaller of line 15 or line 19, but not less than zero ............................................................................................. 21 Ordinary income under recapture rules. Enter here and on Form 4797, line 16 (see instructions) ............................................. 22 Subtract line 21 from line 20. If zero or less, enter -0-. If more than zero, enter here and on Schedule 0 or Form 4797, unless the Installment method applies (see instructions) .............................................................................. 23 Recognized gain. Add lines 21 and 22 ........................................................................................................................ 24 Deferred gain or (loss). Subtract line 23 from line 19.11 a related party exchange, see instructions .................................... ...... 25 Blsls of IIke-klnd aroaertv received. Subtract line 15 from the sum of lines 18 and 23 ......................................................... :::I::::::j::::!:: ~~tmm~~mm~ 14 15 16 17 o. 56.297. 56,297. 18 19 20 21 73.507. <17,210.> 22 23 24 25 o. <17,210.> 73.507. ~~k LHA For Paperwork Reduction Act Notice, see separate Instructions. Form 8824 (2002) FORM 8824 NO. 2 Form 8824 Like-Kind Exchanges (and section 1043 confllct-of-Interest sales) ~ Attach to your tu return. OMB No. 1545-1190 2002 Au.ctlment uence No. 109 Identifying number Depertment of the T_ry In"'" AllVenue Service Name(s) shown on tax return MILLER INSURANCE ASSOCIATES INC. 23-2055739 ~:lliUltt Infonnatlon on the Like-Kind Exchange Note: If the property described on line 1 or line 2 is 1eaI or personal property located outside the United States, indicate the countf)'. 1 Description of Iike-klnd property given up ~ CAMRY 2 Description of like-kind property received ~ 200 3 CAMRY 3 Date like-kind property given up was originally acquired (month, day, year) ........................................................................... 4 Date you actually transferred your property to other party (month, day, year) .......................... ....................... .............. ..... ....... 5 Date like-kind property you received was identified (month, day, year) (see Instructions) ............................................................ 6 Date you actually received the like-kind property from other party (month, day, year) ............................................................... 7 Was the exchange made with a related party (see Instructions)? If "Yes; complete Part II. If "No; go to Part III. a D Yes In this tax ear b 0 Yes in a rior tax ear c [Xl No rail;t::lt:: Related Party Exchange Infonnatlon 6 Name of related party 3 4 5 6 1/25/01 5 30/02 Related party's Identifying no. Address (no., street, and apt., room, or suite no.) city or town, state, and ZIP code Relationship to you 9 During this tax year (and before the date that is 2 years after the last transfer of property that was part of the exchange), did the related party sell or dispose ofthe like-kind property received from you in the exchange? .........................................................0 Yes D No 10 During this tax year (and before the date that Is 2 years after the last transfer of property that was part of the exchange), did you sell or dispose ofthe Ilke-klnd property you received? ...................................................................................................... Dyes D No If both lines 9 and 10 are "No" and this Is the year of the exchange, go to Part III. If both lines 9 and 10 are "No" and this is not the year of the exchange, stop here. If either line 9 or line 1 0 is 'Yes, " complete Part 111 and report on this year's tax retum the deferred gain or (loss) from line 24 unless one of the exceptions on line 11 applies. See Related party exchanges in the inst/Uctions. 11 If one of the exceptions below applies to the disposition, check the applicable box: a D The disposition was after the death of either of the related parties. b D The disposition was an involuntary conversion, and the threat of conversion occurred after the exchange. c D You can establish to the satisfaction of the IRS that neither the exchange nor the disposition had tax avoidance as its principal purpose. If this box Is checked, attach an e Ianation see instructions . :~ ,,:......:;.:::.::: Realized Gain or (Loss, Reco nized Gain and Basis of Like-Kind Pro Received Caution: If you transferred Ind received (I) more than one group of like-kind properties or (b) cash or other (not like-kind) property, see Reporting of multl-Isset exchanges in the Instructions. Note: Complete lines 12 through 14 only if you gave up property that was not like-kind. Otherwise, go to line 15. 12 Fair market value (FMV) of other property given up .................................. ............................. 12 13 Adjusted basis of other property given up ........................................................................... 13 14 Gain or (loss) recognized on other property given up. Subtract line 13 from line 12. Report the gain or (loss) In the same manner as if the exchange had been a sale ................................................................................................... 14 15 Cash received, FMV of other property received, plus net liabilities assumed by other party, reduced (but not below zero) by any exchange expenses you incurred (see instructions) .................................................................. 16 FMV of Iike-klnd property you received ... ....................... .............. ................................................................................ 17 Add lines 15 and 16 ................................................................................................................................................ 18 Adjusted basis of like-kind property you gave up, net amounts paid to other party, plus any exchange expenses not used on line 15 (see Instructions) ................................................................................................ 19 Relllzed glln Dr (loss). Subtract line 18 from line 17 ...................... .................... .................................... ........................ 20 Enter the smaller of line 15 or line 19, but not less than zero ............. ................................................................................ 21 Ordinary Income under recapture rules. Enter here and on Form 4797. line 16 (see instructions) ............................. ................ 22 Subtract line 21 from line 20. If zero or less, enter -0-. If more than zero, enter here and on Schedule 0 or Form 4797, unless the installment method applies (see instructions) .............................................................................. 23 Recognized gain. Add lines 21 and 22 ........................................................................................................................ 24 Deferred gain or (loss). Subtract line 23 from line 19.1f a related party exchange, see instructions ............... ...... ..................... 25 Blsls of IIke-klnd ro e received. Subtract line 15 from the sum of lines 18 and 23 .................................... ..................... ~~ lHA For Plperwork Reduction Act Notice, lee separate Instructions. :t%If .;.;.;.;.:-:.:.:-:.: :.;.;.:.:.:-:.;.;.;.; ;.;.;.;.;.:.;.;.;.;. ~:~::~:::::::~::. 15 16 17 o. 14 300. 14 300. 18 19 20 21 19 619. <5 319.> 22 23 24 25 o. <5 319.> 19 619. Form 8824 (2002) MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 TAXES AND LICENSES STATEMENT 1 DESCRIPTION AMOUNT PAYROLL TAXES OTHER TAXES 17,342. 882. TOTAL TO FORM 1120, LINE 17 4,890. 23,114. PENNSYLVANIA TAXES - BASED ON INCOME CURRENT YEAR CONTRIBUTIONS STATEMENT 2 DESCRIPTION AMOUNT CHARITABLE CONTRIBUTIONS 425. TOTAL CURRENT YEAR CONTRIBUTIONS 425. STATEMENT(S) 1, 2 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 CONTRIBUTIONS STATEMENT 3 CARRYOVER OF PRIOR YEARS UNUSED CONTRIBUTIONS FOR TAX YEAR 1997 FOR TAX YEAR 1998 FOR TAX YEAR 1999 FOR TAX YEAR 2000 FOR TAX YEAR 2001 50 TOTAL CARRYOVER TOTAL CURRENT YEAR CONTRIBUTIONS 50 425 TOTAL CONTRIBUTIONS 10% OF TAXABLE INCOME AS ADJUSTED 475 3,622 EXCESS CONTRIBUTIONS o ALLOWABLE CONTRIBUTIONS DEDUCTION 475 STATEMENT(S) 3 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER DEDUCTIONS STATEMENT 4 DESCRIPTION AMOUNT TOTAL TO FORM 1120, LINE 26 13,422. 47,628. 2,733. 3,220. 554. 10,840. 4,017. 8,206. 3,052. 4,118. 75. 2,787. 8,189. 661. 1,529. 14,090. 1,602. 126,723. AMORTIZATION COMMISSIONS AUTO EXPENSE DUES & SUBSCRIPTIONS EDUCATION EXPENSE INSURANCE POSTAGE TELEPHONE UTILITIES OFFICE EXPENSE TRAVEL & LODGING CAIR EXPENSES PROFESSIONAL FEES MISCELLANEOUS LICENSES CONSULTING FEES MEALS AND ENTERTAINMENT STATEMENT(S) 4 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 TAX COMPUTATION STATEMENT 5 1. TAXABLE INCOME . . . . . . . . . . . 2. LESSER OF LINE 1 OR FIRST BRACKET AMOUNT 3. LINE 1 LESS LINE 2 . . . . . . . . . . . 4. LESSER OF LINE 3 OR SECOND BRACKET AMOUNT 5. LINE 3 LESS LINE 4 . . . . . . . . . . . 6. INCOME SUBJECT TO 34% TAX RATE . . . 7. INCOME SUBJECT TO 35% TAX RATE . . . . . 8. 15 PERCENT OF LINE 2 . . . . . . . . 9. 25 PERCENT OF LINE 4 . . . . . . . . 10. 34 PERCENT OF LINE 6 . . . . . . . . . . . . 11. 35 PERCENT OF LINE 7 . . . . . . . . . . . . 12. ADDITIONAL 5% SURTAX. . . . . . . . . . . . . 13. ADDITIONAL 3% SURTAX . . . . . . . . . . 14. TOTAL INCOME TAX . . . . . . . . . . 35,748 35,748 o o o o o 5,362 o o o o o 5,362 STATEMENT(S) 5 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE L OTHER CURRENT ASSETS STATEMENT 6 DESCRIPTION BEGINNING OF TAX YEAR END OF TAX YEAR PREPAID EXPENSES DEFERRED TAX ASSET NOTES RECEIVABLE - OFFICERS FEDERAL PREPAID TAXES 307. 587. 2,793. 307. o. 13,193. 3,678. TOTAL TO SCHEDULE L, LINE 6 3,687. 17,178. SCHEDULE L OTHER CURRENT LIABILITIES STATEMENT 7 BEGINNING OF END OF TAX DESCRIPTION TAX YEAR YEAR PAYROLL TAXES PAYABLE 5,579. 3,194. ACCRUED CORP. TAXES 8,005. 4,811. ACCRUED INTEREST 383. 1,160. PREMIUMS PAYABLE 2,717. 11,780. ACCRUED SALARIES 5,024. o. DEFERRED TAX LIABILITY O. 4,669. TOTAL TO SCHEDULE L, LINE 18 21,708. 25,614. SCHEDULE M-l OTHER EXPENSES RECORDED ON BOOKS NOT DEDUCTED IN THIS RETURN STATEMENT 8 DESCRIPTION AMOUNT LIFE INSURANCE PREMIUMS DEFERRED TAX ADJUSTMENT 205. 5,256. TOTAL TO SCHEDULE M-l, LINE 5 5,461! STATEMENT(S) 6, 7, 8 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE M-1 OTHER DEDUCTIONS IN THIS RETURN NOT CHARGED AGAINST BOOK INCOME STATEMENT 9 DESCRIPTION AMOUNT ACCRUED SALARY TO OFFICER, PRIOR YEAR TOTAL TO SCHEDULE M-1, LINE 8 3,256. 3,256. FORM 4562, PART V LISTED PROPERTY INFORMATION-MORE THAN 50% STATEMENT 10 (A) (B) (C) (D) (E) (F) (G) (H) (I) 179 DESCRIPTION DATE BUS. % COST BASIS LIFE MTH/CV DEDUCTION ELECTED (J) (K) (L) (M) (N) (0) (P) (Q) AUTO TOTAL BUSINESS COMMUTING PERSONAL WAS VEH. > 5% ANOTHER VEH. NO MILES MILES MILES MILES AVAIL.? OWNER? AVAILABLE? Y N Y N Y N BUICK 08/16/99 100.00 29,995. 29,995. 5.00 200DB-HY 1,775. CAMRY 01/25/01 100.00 13,852. 13,852. 5.00 200DB~HY 1,330. 2003 GMAC 08/16/99 YUKON - LIKE 100.00 29,995. 29,995. 5.00 200DB-HY 2003 CAMRY 01/25/01 - LIKE PROPERTY 100.00 13,852. 13,852. 5.00 200DB-HY 1,330. 2003 CAMRY 05/30/02 - SEE ALSO ASSET 31 100.00 14,300. 10,010. 5.00 200DB-MQ 3,370. TOTAL TO FORM 4562, PART V, LINE 26 7,805. STATEMENT(S) 9, 10 Form 1120 u.s. Corporation Income Tax Return For calendar year 2001 or tax year beginning MAY 1, 2001 ,ending APRIL 30, 2002 OMB No. 1545-0123 o.p.rtrnent of the T_ury In.... Revenue ServIce 2001 A Check if a: 1 Consolidated rwtum D (attBch Fonn 851) 2 P8I8OI18I holding co. D (attBch Sc:h. PH) 3 Per8on8I..vlce corp. (M deftned In T~ D Regs.lMIC. 1.441-4T) Name MILLER INSURANCE ASSOCIATES. INC. I Employer ldentlftcatlon number 23-2055739 C Date Incorporated 02/28/1978 D Total essets (_ pege 8 of Instructlons) i i " c: II ! Number, street, and room or suite no. (If a P.O. box, see page 7 of Instructions.) 19 BROOKWOOD AVENUE, SUITE 102 City or town, state, and ZIP code CARLISLE. PA 17013 E Check applicable boxes: mr 1 Initial retum l2\f 1 Final retum l3\r 1 Name chanae l4\f 1 Address channe $ 1 a Gross rwcelpts or AI.. I 5 0 5 , 5 8 0 .1 b L_ retumund 1II10W81lce8 1 I c lal ~ 1 C 2 Cost of goods sold (Schedule A, line 8) .... ..................................................................................................... 2 3 Gross profit. Subtract line 2 from line 1c ......................................................................................................... 3 4 Dividends (Schedule C,llne 19) .................................................................................................................. 4 5 Interest .............................................................................................................................. ..................... 5 6 Gross rents ......................... .................................................................. .................................................. 6 7 Gross royalties ............................ ................................................................................................ .............. 7 8 Capital gain net Income (attach Schedule D (Form 1120)) ................................................................................. 8 9 Net gain or (loss) from Form 4797, Part 1I,Iine 18 (attach Form 4797) .................................................................. 9 10 Other Income (attach schedule) ............................................................~.~.~....~.';I;'~';I;'.~~~~.';I;'...J............. 10 11 Total Income. Add lines 3 throuah 10 ................................................................................................... ~ 11 12 Compensation of officers (Schedule E,lIne 4) ................................................................................................ 12 13 Salaries and wages (less employment credits) ........................................................................... ..................... 13 14 Repairs and maintenance ...... .......... ............................. ........................................... ...... ............................. 14 15 Bad debts ........ ......... ............... .................................................................. .............................................. 15 16 Rents ............................................... .............................. ......................................................................... 16 17 Taxes and licenses ................ .................... ......... ...... ........................~.~.~....~.';I;'~';I;'.~~~~.';I;'.. ..~............. 17 18 Interest ...................................................... ............................................................................................. 18 19 Charitable contributions ~.~.~....~.';I;'~';I;'.~~.~~.';I;'....~.........~.P........~.~.~...i~.';I;'~';I;'.~~~N';I;'....~t............ ...~.~. 20 Depreciation (attach Form 4562) .................................................................. 20 11 , 725 . ::::::::::::::::::::: 21 Less depreciation claimed on Schedule A and elsewhere on return ..................... 21a 21b 22 Depletion .......................... .................................. ........................... ......................................................... 22 23 Advertising ... .................................... ...................................................................................................... 23 24 Pension, profit-sharing, etc., plans ................................................................................... ............................ 24 25 Employee benefit programs ........ ...... .............................. ............................................................................ 25 26 Other deductions (attach schedule) ......................................................S.~~....S.'r.l\'r~~~N'r. ..~............. 26 27 Total deductions. Add lines 12 through 26 ............................................................................................. ~ 27 28 Tauble Income before net ol*8ling Ion deduction end specie! deductions. Subtract line 27 from line 11 ..................... ............... 28 29 Less: a Net operating loss (NOL) deduction ................................................ I 29a I Jj:tiII:! b SOAclal dAducllon!: ISchAdulA C.linA 20\ ............................... ......... 29b 29c 30 Tauble Income. Subtract line 290 from line 28 .......................................................................................... 30 :b~~~~).:.......i:.960~~i c onFonn4466 ........................... 32c d Bal ~ 32d 2 960. .......... e Tax deposited with Form 7004 ..................................................................... 32e :@f~~tj::: f Credit for tax paid on undistributed capital gains (attach Form 2439) .................. 32f m@t a Credit for Federal tax on fuels (attach Form 4136) ............................................. 320 32h 33 Estimated tax penalty. Check If Form 2220 is attached ........................................................................... ~ D 33 34 Tax due. If line 32h is smaller than the total of lines 31 and 33, enter amount owed ................................................ 34 35 Overpayment. If line 32h Is larger than the total of lines 31 and 33. enter amount overpaid ....................................... 35 36 Enter amount of line 35 vou want: Credned to 2002 estimated tax ~ Refunded ~ 36 Under pen.ties of peljUIY. I dec:I.w that I have examined this I1Ilum, Including ec;compenylng sc:hedulee end lItatIIrnents, end to the best of my knowtedge end belief, It Is true, Sign correct, end complete. Declarstlon of p~ (other than taxpayerj Is based on e!llnformatlon of which p~ h8s lI/lY knowledge. I ~ tl1!l~'!lscuss this I I ~~~p~~ Here ~Slgnatureofolficer Date ~Title H[Xj Yes D No Preperer's .... I Date I Check If Preparer's SSN or PTIN Paid signature ... self-employed [X] PO 0 0 57626 Preparer's Ann'sneme SMITH ELLIOTT KEARNS & COMPANY LLC T E1N 52 0783935 Use Only !:::;'-~':.~ ~19 BROOKWOOD AVE., SUITE 101 ' I Phoneno. ( 717) 243-9104 ~~=eend "'CARLISLE, PA 17013 Use IRS label. Other- wise. print or type. 135,772. 505,580. 505,580. . E J 75. 303. 505,958. 127,817. 62,999. 9,396. 204. 31,776. 23,256. 10,949. 50. '" S g 1 c 11,725. 35,194. 24,899. 110,018. 448,283. 57,675. 57,675. 9,419. 2,960. 6,459. 111601 01-02-02 JWA ~ See Instructions for Paperwork Reduction Act Notice. Form 1120 (2001) Form 1120l2O(1) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Pa e2 Jr' '::" ":::':"::'::"':""':':':~1r.'\ Cost of oOOs Sold See a e 14 of Instructions. 1 Invento'Y at beginning of year ........................... ...................... ............................ .............................................. 1 2 Purchases....... ............................................................................................................................ ................... 2 3 Cost of labor .................................................. ..................... ................................................................. ........... 3 4 Additional section 263A costs (attach schedule) .......... ............................................................................................ 4 5 Other costs (attach schedule) ................... ........ ............................ ............... .............................. ....... ................ 5 6 Total. Add lines 1 through 5 .............................................................................................................................. 6 7 Invento'Y at end of year .................. ............ ..... ...... ............. ............... ..... ................................... ....................... 7 8 Cost of goods sold. Subtract line 7 from line 6. Enter here and on line 2, page 1 ............................................................ 8 9 a Check all methods used for valuing closing Invento'Y: (I) D Cost as described In RegUlations section 1.471-3 (II) D lower of cost or market as described in Regulations section 1.471-4 (iii) D Other (Specify method used and attach explanation.) ~ b Check If there was a wrltedown of subnormal goods as described In Regulations section 1.471-2(c) ............................................................... ~ D c Check If the LIFO invento'Y method was adopted this tax year for any goods (if checked, attach Form 970) ...................................................... ~ D d ~~:~n~I~~~:~::oc~:::e~d u:::~~~;o~ ~~~~.~ ~~.~~: .~~~~.~ ~~.~.~~~~ .~~.~ ~~.~~~.t.~~. ~.~...................... .......................... ~I e If property is produced or acquired for resale, do the rules of section 263A apply to the corporation? ............................................. DYes D No f Was there any change In determining quantities, cost, or valuations between opening and closing Invento'Y? If 'Yes: attach explanation ................................................................................................................................................. D Yes D No f=@1IBm'1Ifl Dividends and Special Deductions (a) DMdends (b) % (c) Special deductions received (a) x (b) 1 Dividends from less-than-20%-owned domestic corporations that are subject to the 70% deduction (other than debt-financed stock) ...................................................... 70 2 Dividends from 20%-or-more-owned domestic corporations that are subject to the 80% deduction (other than debt-financed stock) ...................................................... 80 3 - Dividends on debt-financed stock of domestic end foreign corporations (section 246A) ..................... Instructions 4 Dividends on certain pref8nwd stock of less-then-20%-owned public utilities ........................... 42 -- 5 Dividends on certain prefemld stock of 20%-or-more-owned public utilities .............................. 48 6 Dividends from Iess-than-20%-owned foreign corporations and certain FSCs that are subject to the 70% deduction .................................................................................. 70 7 Dividends from 20%-or-more-owned foreign corporations and certain FSCs that are subject to the 80% deduction ................................................................................... 80 8 ~~~~:~~:r.:t:1'=relg~. ~~~.i~.I~~.~.~~!~.~.~~... ............ .......................... ..... .... 100 9 T ota I. Add lines 1 through 8 .................................................................................... IJI~rml~m~~mm~immmmmmm~m~mmmmmmmIj~~j j~~~~Im~lil;1~~~;~[~;f~1~ 10 Dividends from domestic corporations received bya small business investment company operating under the Small Business Investment Act of 1958 ............................ 100 11 Dividends from certain FSCs thatlllll subjecllo the 100% deduction (section 245(c)(1)) .................. 100 12 Dividends from afllllaled group members subJecllo the 100% deduction (sec. 243(8)(3)) .................. 100 13 Other dividends from foreign corporations not Included on lines 3, 8, 7, 8, or 11 ............................ ~I 1~1 I :!~111111:!!11111111!1:1 !II'!II:!~ Ii . 14 Income from controlled foreign corporations under subpart F (attach Fonn(s) 5471) ........................ 15 Foreign dividend gross-up (section 78) .................................................................... . 16 IC -DISC and Ionner DISC dividends not Included on lines " 2, or 3 (section 246(c:l)) ........................ 17 Other dividends ................................................................................................. 18 Deduction for dividends paid on certain prefe rred stock of public utilities ........................ ;~~~~~~~fi~~~~~~~~~1~1~~;~j~~~;~;~~~mIU@~@~~~@j1~~~~~~~~~~~~~~~~~~~~~~~~j~~~~~j~~~~ 19 Total dividends. Add lines 1 through 17. Enter here and on line 4, page 1 ............... ~ ~~~11~~~~~1~~~~~~~~~1~~~~~j~~~~~1~1~~I~~ ~~1~ln~~~~~~~~~~~~~I~1~~@~~!~~;~~~~;f:f:~~~;~f:~;~~~;~;~;~;~m~;~~~;~ 20 Total sDecll1 deductions. Add lines 9 10 11 12 and 18. Enter here and on line 29b DaDe 1 ................................................. ~ 1:::~::_j~lj~1 Compensation of Officers I:: Instrucllons for line 12, page 1.) Form 11201l11l1 S500 000 or more. l8: Collllllete Schedule E onw If Iotall8CelDls Oln. 1 a Dlus lines .. lhn:lUllh 10 on ~ 1 (a) Name of office r (b) Social secu rIty \C) Percent of Percent of corporation (f) Amount of number ime devoted stock owned compensation to business (d) Common (e) Preferred 1 M EUGENE MILLER 162-36-7572 100 90 . 00% 83,382 . KIM SHUFF 16 1-58-1250 100 10 . 00% 44,4 35 . 2 Total compensation of office rs ............................................................................................................................................ 127, 81 7 . 3 Compensation of officers claimed on Schedule A and elsewhere on retu m .............................................................................. 4 Subtract line 3 from line 2. Enter the result here and on line 12. Dace 1 .................................................................................. 12 7, 81 7 . ~~~~ JWA Form 1120 (2001) Fonn11201200n MILLER INSURANCE ASSOCIATES, INC. ~.: :...:....:::.:.::>:'..~:....:.:.:~r:a:rJ Tax ComDutatlon (See Daae 16 of InstructlonsJ 1 Check If the corporation Is a member of a controlled group (see sections 1561 and 1563) Important: Members of a controlled group, see instructions on page 16. 2a If the box on line 11s checked, enter the corporation's share of the $50,000, $25,000, and $9,925,000 taxable Income brackets (in that order): (1) Is b Enter the corporation's share of: 5 At the end of the tax year, did any Individual, partnership, corporation, estate, or trust own, directly or indirectly, 50% or more of the corporation's voting stock? (For rules of attribution, see section 267(c).) .................................... If "Yes,' attach a schedule showing name and identifying number. (Do not include any Infonnation already entered In 4 above.) Enter percentage owned ~ 6 During this tax year, did the corporation pay dividends (other than stock dividends and distributions in exchange for stock) In excess of the corporation's current and accumulated earnings and profits? (See sections 301 and 316.) ............... If "Yes,' file Form 5452. Corporate Report of Nondlvldend Distributions. ................................. ~ LJ :1iFII :.:.:.:.;.:.;.:.;.:. .;.;.:.:.;.;.;.:.;.: 23-2055739 Paae3 :::::;:::::::;:;:::. ;.;.;.;.;.;.;.;.;.;. .;.:.;.;.:.:.;.;.;.;. :::::::::::::::::::: .;.;.;.;.;.;.;.:.;.; :1:11:1:":'111111' :':':':':';':';':';', 7 8 9 10 11 If this is a consolidated return, answer here for the parent corporation and on Form 851. Affiliations Schedule, for each subsidiary. At any time during the tax year, did one foreign person own, directly or indirectly, at least 25% of (a) the total voting power of all classes of stock of the corporation entitled to vote or (b) the total value of all classes of stock of the corporation? ...... ........ ... .............. _.... .......... ....... ....... If "Yes,' enter: (a) Percentage owned ~ and (b) Owner's country ~ c The corporation may have to file Form 5472, Infonnation Return of a 25% Foreign-Owned U.S. Corporation or a Foreign Corporation Engaged In a U.S. Trade or Business. Enter number of Fonns 5472 attached ~ X 8 Check this box if the corporation Issued publicly offered debt instruments with original Issue discount ............ ~ D If checked, the corporation may have to file Form 8281, Infonnation Return for Publicly Offered Original Issue Discount Instruments. Enter the amount of tax-exempt interest received or accrued during the tax year ~ $ X 10 Enter the number of shareholders at the end of the tax _::':::::~::::::~: :::m~::~:~::: year (if 75 or fewer) ~ 2 :II::I~IIIIIIII: 111111111111111 n th~ corporation has an NOL for the tax year and Is :~11111:111111~11~ 11:llfi~111111 ;f~::~:::;:: =:I~~~~::S:::~d~~~~~~~e ~~t:efl 'f:~~::~~~::~Ij :::::IIj~~:::~ required by Regulations section 1.1502-21 (b)(3)(I) or (ii) must :t~ttl:' ::Jktt be attached orthe election will not be valid. X 12 Enter the available NOL carryover from prior tax years ::::::::::::t:::: (Do not reduce It by any deduction on line ttItt ................... 29a.) ~ $ II :.;.:.:.:.:.;.:.:.;.',:.:.;.:.;.:.:.:.:.: 119 9,419. 9,419. 9,419. 9,419. Yes No (2) I $ I (3) S (1) Additional 5% tax (not more than $11.750) S (2) Additional 3% tax (not more than $100,000) S 3 Income tax. Check if a qualified personal service corporation under section 448(d)(2) STMT 6 (see page 17) .................................................................................................................................... ~ D 3 4 Alternative minimum tax (attach Fonn 4626) ......................................................................................................... 4 5 Add lines 3 and 4 .... ................ ......... ...... ....... .................... .................... .................. ............. ......... .......... ......... 5 61 Foreign tax credit (attach Fonn 1118) .................................................................. 6a b Possessions tax credit (attach Fonn 5735) ............................................................ 8b c Check: D Nonconventional source fuel credit D QEV credit (attach Fonn 8834) Be d General business credit. Check box(es) and indicate which fonns are attached. :ffff::: D Fonn 3800 D Fonn(s) (specify) ~ 6d e Credit for prior year minimum tax (attach Fonn 8827) ............................................. 6e I Qualified zone academy bond credit (attach Fonn 8860) .......................................... 61 7 Totll credits. Add lines 6a through 6f .................................................................................................................. 8 Subtract line 7 from line 5 ................................................................................................................................. 9 Personal holding company tax (attach Schedule PH (Fonn 1120)) ........................................................................... 10 other taxes. Check if from: D Fonn 4255 D Fonn 8611 D Fonn 8697 D Fonn 8866 D other (attach schedule) ............................................. 11 Totlltax. Add lines 8 throuah 10. Enter here and on line 31 nane 1 ........................................................................... [J...::.:...:.:::.:.:~:...:.:.:...:.:.:11Kt11 Other Infonnation (See oaae 19 ofinstructions.\ 1 Check method of accounting: a D Cash b 00 Accrual Yes No c D other (specify) ~ ::III:~I 2 See page 21 of the Instructions and enter the: :::t::t:::~~:: : :~~~=::~:d~~~~~~O 1:1111111111:11::\:\7 c Product or service ~ SERVICE 3 At the end of the tax year, did the corporation own, directly or indirectly,50% or more of the voting stock of a domestic :::::::::::::::::::: corporation? (For rules of attribution, see section 267(c).) ...... X If "Yes,' attach a schedule showing: (a) name and employer identification number (EIN), (b) percentage owned, and (c) taxable Income or (loss) before NOL and special deductions of such corporation for the tax year ending with or within your tax year. 4 Is the corporation a subSidiary in an affiliated group or a parent-subsldiary controlled group? ................................. If "Yes,' enter name and EIN of the parent corporation ~ .....................:.:.;.;.:.:.;.:.:.:.: ,.:.:.;.;.:.;.:.;.;.;.;.;.;.;.:.;.:.:.;.;. ,:,:.:,:.:,:,:.:,:.:,:;:::;:;:;:;:;:::::;: .......... ;.;.;.:.;.;.;.;.;.;.; .......... .;.:.;.:.:.:.:.:.:-:. :~:~:~:;:~:~:~:~:~:; ~:~:~:~:~:;:~:~:~:~:~ .:::::;:::::::;::::: :::::::::::::;:::;:;: II .......... ........... X II II :iilllllil!ll!il!: ~'!I\ll:::j:::::::: ;1 ::;:::::::::::::::; ::::::::::::::::::::: ......... .......... II :::::::=::;:::::::::;:::::::::::::::::::: .;.;.;.:.'.;.:.;.:.;.;.;.;.;.;.:.;.;.;.;. Note: If the corporation, at any time during the tax year, had assets or operated a business In a foreign country or U.S. possession, It may be required to attach Schedule N (Form 1120). Foreign Operations of U.S. Corporations, to this return. See Schedule N for details. J~~:-k JWA Fonn 1120 (2001) Form 1120 (2001\ MILLER INSURANCE ASSOC IATES . INC. :.:* ..:.... ,. ..., 'i::;t;m~:i:;::~;i Balance Sheets Def Books Assets 1 Cash...... ........... ..................... ...... ....... 21 Trade notes and accounts receivable ......... b Less allowance for bad debts .................. 3 Inventories ....... .......... ............ ...... ....... 4 U.S. government obligations .................. 5 Tax-exempt securities ........................... 6 OtherCUnwlt..ts(Att Sell.) S.'r.M'r....I... 7 Loans to shareholders ........................... 8 Mortgage and real estate loans .................. 9 Oth..lnvestment!l (Att Sell.) ........................ 10a Buildings and other depreciable assets ... ... b Less accumulated depreciation ............... 111 Depletable assets ................................. b Less accumulated depletion ..................... 12 Land (net of any amortization) ...... ........... 13a Intangible assets (amortizable only) ......... b Less accumulated amortization ............... 14 Other assets (Att. Sch.) ........................ 15 Total assets ....................................... 16 17 18 19 Loans from shareholders ........................ : :.: ;.: -:~.. .: :t,. ::::f:: "~'::.;: ::':":: .~:::-:. :'::::',:';:::':'" :::'. .:.:;:. :::;':.::.::.: ..:; :.r:~:':\:.: : =~~:S::~,,7~i:~iG',;~;~;it ~'.:,:64 ~ ,,(;~~"d0?&EW' k$~~""= b Common stock ............... 1.000. ................. ..... 1'. 000 ~ 1,000.' . '. .......f.~..o'6..6'. ~ ~~;:~u~~; .' ~;;;;;;;.I ;;;;;;;; 23-2055739 P8ge 4 Beginning of tax Y8lll' End of tax Y8lll' _ (bl (C) (d) ::::::;:;:: \;.: .:~.. ;:i:: :;. : .~ :.~;:;~;:;~~:6~;~1~:; .~r:~:~~~~~~:~~~~:~,::~:::~:::~:i::~?:::::::?I~~~:':~~~:::f~: 1I~~I~~II::~~f~:I~~:1l~~I~::~:~:1~~:~~:~::~:: _i:1;:.;~:;~l~~:;~1;~:::;~: ( \ 26.505. I 39.175. ';'.::::: ::~.~:;~~ .:.:.:.:-:- ::~:~::~~ I~~~~~ .\fllll If:!: 181.977.~1 183.730.k'L1X'X'}F~1\ I 143.375~ 38.602. f 156,101~ 27.629. .:.,.,~.,.::::~..::..,.:'.i:f;tn~f:t!:t~?ft~t .:..;'.:::.:::::::.:: :.::~::~..:.:~;:.::::::~~}:{~~:::t:::~~:~:ttll: I , f \ I /'m"';~:'i~E~ "";~~n~i~~~ .il1Il.~III:IIIII:II!II~i!I!llllllllf;:I~lllr~II~I:I!r:ll!lllllllilllllll~: 12 7 . 7 1 8 . :..::::;:;:~:~i:111ill!ll:li:ill!jl!!!illil~IIIJjlf~111Illll!l: 13 5 . 7 7 2 . 3,687. Note: The corporation Is not required to complete Schedules M-1 and M-2 if the total assets on line 15, column (d) of Schedule L are less than 25000. :~~~r"::":":':w':' ",;,:''':':::r:..~t'~J: Reconciliation of Income 1 Net income (loss) per books ..................... 2 Federal Income tax per books ..................... 3 Excess of capital losses over capital gains 4 Income subject to tax not IlICOItled on books this Y8lll' (Itemize): IS Expenses recorded on books this year not deducted on this return (Itemize): a Depreciation ...... $ b ~=~s ...... $ c ~:~t $ ~::: 1 2 3 4 Add lines 1 2 and 3 ................................. ~~~~k JWA r Return 7 Income recorded on books this year not Included on this return (Itemize): Tax-exempt interest $ 8 Deductions on this return not charged against book income this year (Itemize): 1 Depreciation ...... $ b ~~=ns ......... $ STMT 10 7 108 849. 8 108 849. Form 1120 (2001) 4562 OMB No. 1545-0172 Fonn Depreciation and Amortization 2001 (Rev. March 2002) (Including Infonnation on Listed Property) OTHER eep.rtrIMnt of the T~ury Attllchment Intemlll Revenue Selvloe ~ See separate Instructions. ~ Attach to your tex return. Sequence No. 87 Neme(s) shown on return Buslness or activity to which this form l'lIlates identifying number MILLER INSURANCE ASSOCIATES, INC . bTHER DEPRECIATION ~3-2055739 tRnU Election To ElDense Certain Tanalble Property Under Section 179 Note: If YOU have any listed Dropertv. complete Part V before YOU comDlete Part I. 1 Maximum amount. See Instructions for a higher limit for certain businesses ...................................................... 1 24.000 . 2 Total cost of section 179 property placed in service (see Instructions) 2 1. 753 . ............................................................... 3 Threshold cost of section 179 property before reduction In limitation .................................................................. 3 $200,000 4 Reduction In limitation. Subtract line 3 from line 2. If zero or less, enter .(). 4 0 . ......................................................... 5 DoliIII' llnitatlon for tax Villi/'. SubtrBc:t line 4 from line 1. If zero or 1_ enter -D-. If merried fllIn _Instructions ............................... 5 24,000 . 8 Ie) Descrlptlon of p1Vperty (b) Cost (busln_ use only) (e:) EIectlId oost - PHONE SYSTEM 1,75 3 . 1.753 . 7 Usted property . Enter amount from line 29........... ......... ............ .... ............... ............ ... I 7 - 8 Total elected cost of section 179 property. Add amounts In column (c), lines 6 and 7 .......................................... 8 1.753 . 9 Tentative deduction. Enter the smaller of line 5 or line 8................ ................................................... ................. 9 1.75 3 . 10 Carryover of disallowed deduction from line 13 of your 2000 Form 4562 ............................................................ 10 11 Business Income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 24.000 . 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12 1,75 3 . 13 Carryover of disallowed deduction to 2002. Add lines 9 and 10, less line 12 ~I 13 ~:~:~:~:~:~;~:~:~:~:~:~t:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:}~:~:}~:~: ............ .:.;.;.;.;.;.:.:.:.;.;.:.;.;.;.;.:.;.;.;.;.;.:.;.;.;.;.;.:.:.:.:.;.:.:.:.;.:.;.:.:.:.:.:.;.:.:.: r 14 Speclel depnlciatlon 1II10W81\ce for certain p1Vperty (other thlll'lllsted Property)8IX1ulred lifter September 10, 2001 (_ Inswctlons) . . . . . .. . .. . .. . . .. . .. . 15 Property subject to section 168(f)(1) election (see instructions) ........................................................................... 18 Other d reclatlon Includin ACRS see instructions ....................................................................................... ;:.....:.:.:::.:...:~:..... MACRS De reelation 0 not include listed . See instructions. Section A 17 MACRS deductions for assets placed in service in tax years beginning before 2001 .......................................... 18 If you are electing under section 168(1)(4) to group any assets placed in service during the tax ear Into one or more eneral asset accounts check here .................................................................. ~ D 14 15 18 17 2 589. ::111:1111::11111111111:11111111111111111111111111111111111111111111111111111:\II:I:II[~I~:I[I::[:III:~:.:::I: Section B - Assets Placed in Service Durina 2001 Tax Vear Uslna the General DeDreclation SYstem (b) Month lII'Id (c:) Bals for deprec:latlon (eI) Rec:overy (8) CllISslflc:lltlon of property YIllI/' placed (busfnessllnvestment use (e) Convention (1) Method (g) Deprec:latlon deduction In servtce only - _ Ins1ructlons) period 19a 3-vear Dronenv - b 5-vear c 7 -year DroDertv .:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.;.:.:.:.:.:. 10-vear oropertv ............................. d ~~~~~t)~~~~~~~j~~~~~~~~1~~~~j~~~~~~~t~~~~~1~1~~~~~~~ e 15-vear orooertv ~j~~~~~~~~;~;~~~~~;~~~~~m~;~j~;~U@~;~@~;~It f 2Q-vear oropertv ~:~:~:~:~{:r~:j:~:~:~:~:~:~:~:~:}j:j:~:~:~:~:~:~:~: a 25-vear Dronenv :I:I:::::::::::::::::!::I:I!::II:!I:I: 25 yrs. SIL h Residential rental property I 27.5 Yrs. MM SIL I 27.5 yrs. MM SIL i Nonresidential real property I 39 vrs. MM SIL I MM SIL 20a Class life b 12- ear c 40- ear r .::::'>:':'::":r,':: Summary (See instructions.) 21 Usted 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 retum. Partnerships and S corporations - see Instr. ..................... 23 For assets shown above and placed in service during the current year, enter the ion of the basis attributable to section 263A costs ................................................ 23 116251 03-21-02 LHA For Paperwork Reduction Act Notice, see separate instructions. Section C - Assets Placed In Service During 2001 Tax Vear Using the Alternative Depreciation System ~:~tfftlttffl:::f:im:: SIL [:i:I[~I[:i:~::1:1::::::::[:[:1]It 12 rs. SIL I 40 rs. MM SIL 21 7 383. 22 11 725. ::::::::.:::::::::::::::::.:::::.:::::::.:::::::.:::.:.:.:-:.:.:.:::::':::::::::::::::::::'.. 11:llllllllillllliillllll:I~'IIIIIIIII:IIIIII;II::11111:11111111:111::::::::: Form 4582 (2001) (Rev. 3-2002) Form 4562 (2001)(Rev.3-2002) MILLER INSURANCE ASSOCIATES INC. 23-2055739 Page 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 248, 24b, columns (a) throuah (cJ of Section A all of Section B. and Section C if SDDllcable. Section A - Oeprecletion and Other Informetlon (Caution: See instructions for limits for passenger automobiles.) 24a Do ou have evidence to su ort the buslness/lnvestment use claimed? [X] Yes D No 24b If "Yes " is the evidence written? (a) (b) Date (c) (d) (e) (f) (g) (h) Type o~ property plac~ In Business! Cost or Basis for dept'llClatlon Recovery Method! Depreciation (list vehICles first) servrce Investment other basis (buslnessllnvestment periOd Convention deduction use only) 29 13 Yes D No (i) Elected section 179 cost 25 Special depreciation ailowance for listed property acquired after September 10,2001, and used more than 50% In a uaiified business use .............................................................................. 28 Pro used more than 50% In a uallfled business use: BUICK 81699100.00 % 29 995. CAMRY 12501100.00 % 13 852. % used 50% or less In a ualified business use: ..................'....................................... .............................. ..................,...,.................................... % S/L . }}}}}}i:iIj}}iiij!:j!i:II: % S/L - mtttt:ijjttttt}}}:j % S/L . jjtfj:jjjjj:jtjjtjjtjijmtttt 28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 .................................... 28 7 383. ftrtjilftttjtttt 29 Add amounts in column (i), line 26. Enter here and on line 7, page 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 your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles. :.:.:.:.:.;.:.:.:.:.:.;.:.;.:.:.:.:.;.:.;.;.:.:.:.;.;.:.:. ........................................................" I~~~~~~~t~~~t~t~~~1Itt~~t~1t~ ~;~~~r~~~~~~~;~~~~tt~~~~~~;~~1;~~~~~~t~~tm 950. 433. 27 Pro (a) (b) (c) (d) (e) (f) 30 Total business/lnvestment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle year (do not include commuting miles) .................. 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 use Yes No Yes No Yes No Yes No Yes No Yes No 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 B for vehicles used by employees who ere not more than 5% owners or related rsons. 37 Do you maintain a written polley 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 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? ..................................................................... Note: If your answer to 37, 38, 39, 40, or 41 is .Yes, . do not complete Section B for the covered vehicles. r....:.:.:::::....\..:..I:j: Amortization (a) Description of costs Yes No 1~~i;;~~~~f@;;1; i~;;;;;~f:r.~;~;~~~~;~ 42 Amortization of costs that (c) AmortIzable 8ITlOunt (d) Code section (e) Amor1Iza1lon period GI' peI'CllIltaOe (f) Amortiutlon for this year "6252 03-20-02 43 3 333. 44 3 333. Form 4562 (2001) (Rev. 3-2002) 43 Amortization of costs that began before your 2001 tax year 44 Totel. Add amounts In column (t). See Instructions for where to report ............................................................... MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER INCOME STATEMENT 1 DESCRIPTION AMOUNT TOTAL TO FORM 1120, LINE 10 303. 303. MISCELLANEOUS INCOME FORM 1120 TAXES AND LICENSES STATEMENT 2 DESCRIPTION AMOUNT PAYROLL TAXES OTHER TAXES STATE CNI TAX 16,275. 579. TOTAL TO FORM 1120, LINE 17 6,402. 23,256. CURRENT YEAR CONTRIBUTIONS STATEMENT 3 DESCRIPTION AMOUNT CHARITABLE CONTRIBUTIONS TOTAL 50. TOTAL CURRENT YEAR CONTRIBUTIONS 50. STATEMENT(S) 1, 2, 3 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 CONTRIBUTIONS STATEMENT 4 CARRYOVER OF PRIOR YEARS UNUSED CONTRIBUTIONS FOR TAX YEAR 1996 FOR TAX YEAR 1997 FOR TAX YEAR 1998 FOR TAX YEAR 1999 FOR TAX YEAR 2000 TOTAL CARRYOVER TOTAL CURRENT YEAR CONTRIBUTIONS 50 TOTAL CONTRIBUTIONS 10% OF TAXABLE INCOME AS ADJUSTED 50 5,773 EXCESS CONTRIBUTIONS o ALLOWABLE CONTRIBUTIONS DEDUCTION 50 STATEMENT(S) 4 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 FORM 1120 OTHER DEDUCTIONS STATEMENT 5 DESCRIPTION AMOUNT AMORTIZATION COMMISSIONS AUTO EXPENSE DUES & SUBSCRIPTIONS EDUCATION EXPENSE INSURANCE SUPPLIES POSTAGE TELEPHONE UTILITIES OFFICE EXPENSE TRAVEL & LODGING CAIR EXPENSES PROFESSIONAL FEES MISCELLANEOUS LICENSES CONSULTING FEES MEALS AND ENTERTAINMENT TOTAL TO FORM 1120, LINE 26 3,333. 50,571. 1,634. 3,147. 460. 8,476. 3,300. 4,585. 2,139. 6,440. <136.> 2,272. 7,205. 404. 254. 14,777. 1,157. 110,018. STATEMENT(S) 5 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 TAX COMPUTATION STATEMENT 6 1. TAXABLE INCOME . . . . . . . . . . . . . 2. LESSER OF LINE 1 OR FIRST BRACKET AMOUNT 3. LINE 1 LESS LINE 2 . . . . . . . . . . . 4. LESSER OF LINE 3 OR SECOND BRACKET AMOUNT 5. LINE 3 LESS LINE 4 . . . . . . . . . . . . . 6. INCOME SUBJECT TO 34% TAX RATE . . . 7. INCOME SUBJECT TO 35% TAX RATE . . . . . . . 8. 15 PERCENT OF LINE 2 . . . . . . 9. 25 PERCENT OF LINE 4 . . . . . . . . . . 10. 34 PERCENT OF LINE 6 . . . . . . . . . . 11. 35 PERCENT OF LINE 7 . . . . . . . . . . 12. ADDITIONAL 5% SURTAX. . . . . . . . . . . . . 13. ADDITIONAL 3% SURTAX . . . . . . . . 14. TOTAL INCOME TAX . . . . . . 57,675 50,000 7,675 7,675 o o o 7,500 1,919 o o o o 9,419 STATEMENT(S) 6 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE L OTHER CURRENT ASSETS STATEMENT 7 DESCRIPTION BEGINNING OF TAX YEAR PREPAID EXPENSES DEFERRED TAX ASSET NOTES RECEIVABLE - OFFICERS 3,501. 1,646. TOTAL TO SCHEDULE L, LINE 6 5,147. END OF TAX YEAR 307. 587. 2,793. 3,687. SCHEDULE L OTHER CURRENT LIABILITIES STATEMENT 8 DESCRIPTION BEGINNING OF TAX YEAR PAYROLL TAXES PAYABLE ACCRUED CORP. TAXES ACCRUED INTEREST PREMIUMS PAYABLE ACCRUED SALARIES 19,489. 509. 2,516. 3,474. 25,988. TOTAL TO SCHEDULE L, LINE 18 END OF TAX YEAR 5,579. 8,005. 383. 2,717. 5,024. 21,708. SCHEDULE M-1 OTHER EXPENSES RECORDED ON BOOKS NOT DEDUCTED IN THIS RETURN STATEMENT 9 DESCRIPTION LIFE INSURANCE PREMIUMS ACCRUED SALARY - OFFICERS, YEAR END DEFERRED TAX ADJUSTMENT TOTAL TO SCHEDULE M-1, LINE 5 AMOUNT 205. 3,256. 1,058. 4,519. STATEMENT(S) 7, 8, 9 MILLER INSURANCE ASSOCIATES, INC. 23-2055739 SCHEDULE M-1 OTHER DEDUCTIONS IN THIS RETURN NOT CHARGED AGAINST BOOK INCOME STATEMENT 10 DESCRIPTION AMOUNT ACCRUED SALARY TO OFFICER, PRIOR YEAR ACCRUED INTEREST - OFFICER, PRIOR YEAR TOTAL TO SCHEDULE M-1, LINE 8 5,330. 272. 5,602. STATEMENT(S) 10