Form PA-41RK-1 2011 PA-41 Schedule RK-1 -Resident Schedule of Shareholder/Partner/Beneficiary Pass Through Income, Loss and Credits (PA-41 RK-1)

Manager 1 Off 1 PA Taxable Business Income (Loss) from Operations If a loss fill in the oval 1104510050 1104510050 14 Distributions from PA Accumulated Adjustments Account If liquidating fill in the oval Off 15 Distributions of Cash Marketable Securities and Property 15 16 Nontaxable income (loss) or nondeductible expenses required to If a loss fill in the oval 16 Off 18 19 Partner s Share of Nonrecourse Liabilities at year end 19 20 Partner s Share of Recourse Liabilities at year end 2 Interest Income 2 3 Dividend Income 3 4 Net Gain (Loss) from the Sale Exchange or Disposition of Property If a loss fill in the oval 4 5 Net Income (Loss) from Rents Royalties Patents and Copyrights If a loss fill in the oval 5 Off 6 Income of/from Estates or Trusts 6 7 Gambling and Lottery Winnings (Loss) If a loss fill in the oval 7 Off 8 ResidentCredit Submit statement 8 9 Total Other Credits Submit statement 9 10 Distributions of Cash Marketable Securities and Property not including guaranteed payments 10 11 Guaranteed Payments for Capital or Other Services 11 12 All Other Guaranteed Payments for Services Rendered 12 13 Guaranteed Payments to the Retired Partner 13 14 All Other Corp Begin Beneficiary s year end distribution: % Off calculate owner s basis Submit statement 17 Owner sShare of IRC Section 179 allowed according to PArules 17 18 Owner sShare of Straight Line Depreciation City or Post Office State ZIP Code Enter whole dollars only Entity: (Fill in one oval only) Estate/Trust Exempt FEIN PA Account # PA S Corp Off Final Off First Line of Address Amended Schedule Individual Last Name Suffix First Name M I Limited Partner Off LLC Fiscal Year Loss sharing: % Name of Entity Issuing RK 1 Name of Owner Receiving RK 1 (if other than an individual) NOTE: Amounts from this schedule must be reported on the appropriate PA Tax Return OffOff or LLC Member or Other LLC Member Owner: Ownership of capital: % PA S Corp PA SCHEDULE RK 1 1104510050 Part I General Information Part VII Part VIPart VPart IVPart IIIPart II Partner s percentage of: Partner: General Partner Off Partnership Off Partnership OffOff Phone Number Profit sharing: % Estate/Trust Resident Schedule of Shareholder/Partner/Beneficiary Pass Through Income Loss and Credits PA 41 RK 1 (06 11) (FI) 2011 Second Line of Address Shareholder s stock ownership: % Off Short Year OffOff Spouse s SSN If jointly held FEIN