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EXHIBIT B1
<br />
<br />Form 8283 IRev. 10-95) Pa? 2
<br />
<br />Name(s) shown on your ~ncorne tax return I IdealJfy~ m.~ber
<br /> Wilfred D. & Katherine A. Cagne J 476-18-9714
<br />,Section B--Appraisal Summary--List in this section only items (or groups of similar items) l'or which you claimed a
<br /> deduction of more than $5,000 per irenl Or grouP, Exception. Report contributions of certain publicly
<br /> traded securities only in Section A.
<br /> If you dona[ed art, you may have to attach the complete appraisal. See the Note in Part I below.
<br />li~':T'~l! Information on Donated Property--To be completed by the taxpayer and/or appraiser.
<br />
<br /> 4 Check type of property:
<br /> [] Art' (contribution of $20,000 or more) [] Real Estate [] Gems/Jewelry [] Stamp Collections
<br /> [] Art' (contribution of less than $20,000) [] Coin Collections [] Books [] Other
<br />'A~t includes paintings, sculptures, watercolors, pdnts, drawings, ceramics, antique furniture, decorative arts. textiles, carpets, silver, rare
<br />manuscripts, historical memorabilia, and other similar objects.
<br />Note: If,your total art contribution deduction was 520,000 or mote, you must a,'"tach a complete cop.y of the s~gned appraisal. See instructions.
<br />
<br />Description of donated property (if you need
<br />more space, attach a separate statement)
<br />
<br />(d) Date acquired
<br />by donor (mo.. yr.)
<br />
<br />(e) How acquired
<br />by donor
<br />
<br />(b) If tangible property was donated, give a brief summary of the overall (c) Appraised fair
<br />physical condition at the time of the gift market value
<br />
<br /> Donor's cost or
<br />(f) adjusted basis
<br />
<br />(~) For bargain sales, enter I See ins~uctions
<br />
<br /> amount received I (h) Amount claimed as a (i) Average tradino pace
<br /> deduction of securitie~
<br />
<br />~ Taxpayer (Donor) Statement--List each item include(~ in Part I above that is separately identified in th'~.
<br /> a, ppraisal as havinq a value of $500 or less. See instructions.
<br />
<br />Ideclare that the following i~.em(s) included in Part I above has to the best or' my knowledge and belie~ an appraised value of not nors than $500
<br />,~er it. em). Enter ider,~fyin9 letter from Part I and describe the specific item..'See instructions. ~
<br />
<br />Signature of taxpayer (donor) ~.
<br />~ :,~1~all~ Declaration of
<br /> Appraiser
<br />
<br />Date
<br />
<br />I declare that I am not the donor, the donee, a party to the transaction in which the donor acquired the property, employed by, or related to any
<br />of the foregoing persons, or married to any person who is related to any of the foregoing persons. And, if regularly used by the donor, donee, or
<br />party to the transaction. I performed the majodty of my appraisals dudng my tax year for other persons.
<br />Also, I declare that I hold myself out to the public as an appraiser or perform appraisals on a regular basis; and that because of my qualifications
<br />as described in the appraisal, I am qualified to make appraisals of the type of property being valued. I certify that the apprai~l fees were not based
<br />on a percentage of the appraised property value. Furthermore, I understand that a false or fraudulent overstatement of the property value as
<br />described in the qualified appraisal or this appraisal summary may subject me to the penalty under section 6701(a) (aiding and abetting the
<br />understatement of tax liability). I affirm that I have not been barred from presenting evidence or testimony by the Director of Practice.
<br />
<br /> Title
<br />Business address (inclu~ roQm,"~ suite r~J . I IdentJf~ng number
<br />
<br />Cgy or town. s~ate, an,d/~lP code
<br />
<br />~"~1~FB Donee Acknow)ed~lment--To be completed by the chad__table organization.
<br />This charitable organization acknowledges that it is a qualified organization under section 170(c) and that it received the donated
<br />property as described in Sec[ion B, Part 1, above on
<br /> (Date)
<br />
<br />Furthermore, this organization affirms that in [he event it sells, exchanges, or otherwise disposes of the property described in Section
<br />B, Part I (or any portion thereof) within 2 years after the date of receipt, it will file Form 8282, Donee Information Return, with the
<br />IRS and give the donor a copy of that form. This acknowledgment does not represent agreement with the claimed fair market value.
<br />
<br />Name of c~an[able organization (donee) Employer identification n~ber
<br />Address (number, street, and room or suite no.) CAy or town, state, and ZIP code
<br />Authorized signature Title Date
<br />
<br />
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