|
- ---� _ � . � • ' ,�� •- -;'�;�.i:l` . j
<br /> - -�-� ' . - ... __'-_.- '
<br /> _ � .
<br /> . ..-`'-''__.-,.�
<br /> ' .--.._ 1 :... _ .
<br /> .-:_ .. ` \�:�� " . . � --'---. .. . � .. , .� ..
<br /> .. -_,_ _ .— t.� _ ' � n , . � � •. - '.` -=?�3`--.=_a`'-•' -
<br /> w
<br /> ,. - — s. . :...� . _ . -. . . -.a.+�Y�..=-
<br /> . -- . .. •• ..__ _
<br /> �-���! � w1r.-..,i..... � . � , �.._:�...`'...... . . .. �_ __
<br /> _R_ --�:���_��-� T__ _ . ' . . ' ' . . .. . - - _ ar�.��
<br />. -,�. _. '1_-•�z_-1k�•.L:� .� . ."_�'"" ' . _ . . "_ _' . � ; ' �![s-.i� ,..
<br /> '__ . - 7.a . _ . _. . . _,. . . . - i .� .. _.�. _
<br />. .._� ._...G�Cz�Ss�.:.�11.�... �1 .,-..,,.a:u.aw.r....._..�...._�_�!._.�s�,...ax:y.-.. __-..._...... ._._._._ __�. _=14 _^�.1 3P:la°lt.iT
<br /> ._� _.. ..,:.s..... .
<br /> ���_ ...._
<br /> --•:°-a-.+i.3.�ir+.iii'iA1�-r1i•s"_.' '",T .___'....s - :. . . _ ,'„ • ... - ., _� .. �. ` . - _. .z_ . i--�`_T__._,_ ..-..
<br /> . _ �L'_AY� ..� .. .. . . � . . . . ... _- - . .
<br /> .. 1_"13'.i�._ • a
<br /> . .-('1 �._c_.� _ � . ' a. . . ' . . . _ . .. _ .. - 'aYt�cAa=� ._.
<br /> - '. �. ._ . �_
<br /> ' -- r_� . . .. . ' ' _ � ��
<br /> • �4TZ... .-���1F.�F�9e T,.-��,.��
<br /> .. . _ ..�. .....�.... �.a�lfa.����� '��w�.�a.rwi.�ia.- ...... .
<br /> _ .. ._ .�.
<br />. n�.�a - .. .. .."___"' _` w..�..��_..� . ... ... - `_'
<br /> �� �11y1 F-':-.
<br /> ' a"�'^' �.�D(�'r�wl� �,��,-.
<br /> �;.
<br /> • R,, i:
<br /> - — ,...��—.. -- �_.
<br /> ...,.. -- ....�... _�...........---�-- �.^'^�'_'�`�"'�"" ' ..
<br /> .... .�..�.�.....�. �`_'.'
<br /> ...........�.....� [.p:
<br /> F.
<br /> — ._ --- �
<br /> S. I.ist tho vatuo of xll sto�ks,Dal:la,uuct�,pcn9ion�conUinution�,or odicr sa9cts:M._,____�. �r:=;
<br /> �-
<br /> w_.__.,,,,_.��..�.. --
<br /> 6. [Do you mvn�I�onw or oUicr rcxl cstdo?, — """'
<br /> 7. Uid you havo Rny asscts ici the lest M'o Yeara not tieted wbovo?,,_.__ If ycs,did ynu dlspo.RO o��ny asaets for less —
<br /> thwn falr tturket v�lao?_,__ f�litd����t�t Uio nesct�wciu elthu�ivcn�way or en1A nt Icss Ui�n the Rllnucd mukct
<br /> valuo.) tlBtat wcro 1ho�ssct9,tho markct valuo at Uio tlmn af�lisposidon,tho amount n;�eivcA�nd tho dato yau cllaposrd of tho
<br /> R�t:i::19� — - --
<br /> Annual Househnld Ir,como S'_"""_""' -
<br /> pr.cu�l incomo fro�a�Ar.�ec�if Vn1ucA at I.es3 thrn SS,Q�O: S^^ --'--- `
<br /> Ach�a!Income fox�n Assetv if Vducd xt I►loiv thx��SS.OQO " S-- —
<br /> Anrzs d�lue Grteter Ih+►�S5,o00 X lntputecl Iloto af 2.5 9b " s
<br /> Por Mvstts Valued�t Mvre thRn SS,OtI(►. �
<br /> Add to Tot�i lacome tha Grc-ntct of Actual or lmputcd Incatttu --�-------^
<br /> Tnu!E� ��hr!1d II1Cl1IIltl� �
<br /> RgS�paPl'p'S STA'i'sMRNT: Uwo unckratanc!th�t tho dwvo infottnstioa i�beiny collcctal to detecm;�ro m�/our
<br /> .,_ W.:L..__..I.......I�n.d,...rr.uflf;natlne
<br /> cf1;3!:3t3i;for c=±�!�+y, Uwo aull�orize tho ownutnt�nayerco�cri�Y�ui i�m,��..�.P.•�••�••.••�•....T.�-�----.._------._ -- -
<br /> and my/c�ur niRn+►tum ie our cotuant to obuin�vch vtrific�dun. tl�e oeriify that l/we h�vo n+ve�te.�i�ii��sot.currcn�ly�efd
<br /> or proviouvly diy�oiod of u�d tfut Ilwu h�►vo no otlier aRaeW th�n thnsa lietcd on Ihie tom�(other th�n persanAl property). 1lwo
<br /> flinhe�certify tfi•a tho ecatemente n��do in thls AppliondonlCcrtificadon aro anio�nd completu to�ho beot of mylour knowledgo
<br /> wnd bellef�ncl a�o+�KOU'e 1h�t i�lee�stxtement�nro puni�hxblo unckr fcderd l�w.
<br /> Signa�uro of He�d of Houeehoid: - -_ — ��'--- �
<br /> Sigasnim af Spauno oa�CaTen�nta �� ._... Vate:_,...__ —..--.-- _.
<br /> OWN�k'9 STATAMBNT: Bxsed nn thu reprcrent�tioav heain��sd upon tho proof uN1 doc:umentatlon obtainad,tho
<br /> ha�erbold named in Sc.cdon 1 of thie AppliostiordC,e�dfin�don ie eliriblo undor the provleiona af Secdon A2 of 1he Internal
<br /> Rovenuo C.c►dc,�auiended�to livo in�unit in tha c�i xotapment, pasod on tha rep�Y+�e�etaUona Aer:.in and upon tft�pmofs and _
<br /> docununadon obtalned�the hnueehold cons6tutes A tlaw-incomo reatckne whoso�ntloi�te�!�onutl i��come for tiiv mezt twelvo
<br /> muodG+cbeA nnt oaceed S iQu�Ilt�inB incomo).
<br /> Slgnnwro of Owner'a o�[�oveloper'e ,
<br /> Authodzal Rcpre�ntativo:,_,�,..._,_._.�.�— � Datu:
<br />-- 011171745.1 ��'�
<br /> .__.._._ —�_.. _..__..._.,—. - - - - — - - - _ _
<br /> . _ , ...
<br /> _..,
<br /> -...��:M�r-._-._--- -
<br /> . ._ — *�„� f�.-_. � `,�` , �� _
<br /> —i: —1 . � . , . - . � . � . . . . +iff!"�,�+r j .i . . � ' . >�#��ti1�t _
<br />- ' � �. .. . ' . . ..�. ' ' �.` :i•i`�-�
<br /> Q1. ' , 1 . � . . .� �.. _ .rT�- I+ �'„2.`• v+y' y-� taL�n$ �.�_
<br /> ' - : � x �f� ii � ' . -. . . � -_iri7 �'L"'.���tr�.���r*.- -
<br /> r1Y
<br /> ikr?.;a 1r _ 1 i i � - . . ..... .w.�y-... '�' ..,.�.�„�nS�� .`.a . ya.� ,�1.. .FU-�'�
<br /> �7•f Yr ."s�h •.� �, ��. '�K, - . ' ..4. .,... � , '.T'.t. nP'� ... . . , R ��.� '_
<br /> . - . . . .. •� .. - . � . _ �' . . • -�-�4 '4i: r.y��._.
<br />,� '� � '; �T , " �._'..^ _�'7,ifi P -' 1 ._ . . . . �� _ ���.�'�t
<br /> M y ii -i�t T t- . � Y- _' i� -
<br /> ';�f�F r�F .l � y y�.4`7^C'� �{%` . ,r -��(S.�� �.� x' '.t: .. tJ'�- ;�ay 3 � ��,.Q . 'r.
<br /> + �{ ;(,� f r ��xY�
<br /> �Rh��r :�•'�`dr"�f�ITY�f�(yM� �� '1�°'°Y����� - .i .. . . - ' ' � —i:.:um�r�—c�� -i� .. ,
<br /> R�.�� 1;����]lIS��,."�i Y"". JiS. .. ._ . .. ' " . _ r . .a. _ _.__�}9�.R'+..�� ._� -._. ._ ___ ��-
<br />
|