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Home My WebLink About03-12-08 -.J 15056051058 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 Nu mber 21 07 0704 174-05-0272 July 12, 2007 Date of Birth December 7,1912 Decedent's Last Name Suffix Horn Decedent's First Name Mildred MI E. (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW . 1 Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 4. Limited Estate 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes ::. 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Andrew C. Sheely, Esquire 717-697-7050 Firm Name (If Applicable) Andrew C. Sheely, Attorney at Law REGISTER OF WILLS USF.,..QNLY 127 South Market Street 1---'" :..0 -::;:1 :~:J First line of address Second line of address N PO. Box 95 m1 I City or Post Office Mechanicsburg State ZIP Code DA.EJ::tLED ----I ,-D PA 17055 Correspondent's e-mail address:.andrewc.sheely@verizon.net 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. !~ATURE OF PERS~ ,REnN~B~. ._._..._..! ..!IILlLI.NNGG R R..E_TURN " /J f'H<= ~L1 J~ --..-21~/I;~ooP AnnRFSS Laura A. Bistline, 27 Goodyear Road, Carlisle, PA 17013 &;PF r2A REPRESENTATI~~__ _ ________ . _ MC/?t: l~ ..~;; Andrew C. Sheely, Esquire, 7 S. Market Street, P.O. Box 95, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 .-J ~ -I 15056052059 REV-1500 EX Decedent's Name: Horn, Mi Idred E. RECAPITULATION 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. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 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 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers unclor ~ec. 9116 (a)(1.2) X .0. 16. Amount of Line 14 t~v'lble at lineal rate X .045 0.00 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . .. . . . . ... . .. . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT :::::\;:::,a L ~~ <:t::.~ =:2...1) 15056052059 Side 2 Decedent's Social Security Number 174-05-0272 4,446.02 4,446.02 1,471.83 13,923.56 15,395.39 0.00 0.00 0.00 0.00 15056052059 -I . REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Mildred E. Horn 0704 DECEDENT'S SOCIAL SECURITY NUMBER 174-05-0272 STREET ADDRESS 442 Walnut Bottom Road CITY Carlisle ~ STATEpA ~IP 17013 ------.-- -.------ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) 0.00 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. 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 00 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 00 c. retain a reversionary interest; or.......................................................................................................................... 0 [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 00 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 00 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT 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. 39116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even 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. 39116(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. 39116(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 PS. ~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. fWVLiOO Ix I (6.081 , .~(~?~ 'i4:~~. COMMONWU\LI H OF PENNSYLVANIA IMII.RITA.NCE TAX RI:TURN HESIDfNI mCTDENl ESTATE OF Mildred E. Horn SCHEDULE F JOINTlY-OWNED PROPERTY FILE NUMBER 21-07 -0704 SURVIVING JOINT TENANT(S) NAME If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. A Laura Bistline B C JOINTLY.OWNED PROPERTY: ADDRESS 27 Goodyear Road, Carlisle, PA 17015 A DESCRIPTION OF PROPERTY iNCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE 01/16/01 ADAMS COUNTY NATIONAL BANK, Checking Account #192570 _n 1_ DATE or DEATH VI>,[lJE OF ASSE.; Daughter RELATIONSHIP TO DECEDENT 8,89205 50% TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ['''ECEU!}JT'S !i'rI !--HE (.1T 4,44602 4.446.02 .SEN'f BY: 8-15- 7 6:55 .... 7176977065;# 1/ 1 ~ ADAMS COUNlY NATIONAL HANK Q::g.;~ )~{{~o:l:t~? (~)trrr~d July 30, 2007 I.aura Bistline 27 Goodyear Rd Carlisle; PA 17015 Re: Estate of Mildred Horn Dear Ms. Bistline: The following information is being provided as per your request: Acct. Type Account No. Account Principal on D.n.D. Checking ]92570 $8,891.41 Accrued Interest to D.O.D. $.64 Ownership Date Opened Date Joint It. wi Laum Bistline 1-16-0) 1-16..()1 Inquiries concerning At""NB Corporation stock information should be directed t.o the Registrar and Transfer Conlpanyat 1-800-368..5948. If you need any additional infonnaliol1, please contact me at (717)339-5116. Sincerely, 'hbt/:J 0-, r\~ Lois ^ K ime Deposit Services PO Box 511.9. GFI"rVSIIlJkb, l'A 1 i'32~; I PlIONI! 71'1.3:H. ~ 1 61 I "1.~'Lu'Arl' I.HH~UJ1.ACNil (2262) I www"m:f1b.~""" R5V-1511 EX,+- (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mildred E. Horn FILE NUMBER 21-07-0704 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Hoffman-Roth Funeral Home 2. Carlisle Memorial Service, Inc. 582.83 170.00 B. ADMINISTRATIVE COSTS: 1 . Personal Representative's Commissions Name of Personal Representative(s) Laura A. Bistline Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 27 Goodyear Road City Carlisle . State PA Zip 17013 Year(s) Commission Paid: 2. Attorney Fees 375.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City . State _Zip Relationship of Claimant to Decedent 4. Probate Fees 79.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 8. Filing Fees Reserves for taxes, accountings, additional filings 15.00 25000 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,47183 Hoffman-Roth Funeral Home & Crematory. Inc. 1 i 9 North Hanover Srreet Carlisle. PA 17013 ( 717)243-4511 August 17. 2007 Laura A, Bristlme 17 Goodyear Road Carlisle. PA 17015 The funeral Service for Mildred E. Horn 15090-156 \Ve sincerely appreciate the contidence you have placed in us and "ill continue to assist you in every way \ve can. Please reel tree to contact us If you have any questions in regard to this statement. THE FOLLOWiNG IS AN ITElvllZED STATEMENT OF THE SERVICES, FACILITIES. )~UTOMOTrVE EQUlPi\tENT, .;\"\0 MERCHANDISE THAT VOL' SELECTED \'tHEN MAKING THE FUNERAL ARRANGBtENTS Ot'R SERVICE: TradlnOl1ai Funcral Service Package . . . . . . FUNERAL HOME SERVICE CHARGES 5415000 $4150.00 SELECTED MERCHANDISE: Sterling 1 S ga Stee~ Casket. . 52040.00 S1390.00 Conrinenmi lnlcm1cm Receptacle. . . . . . . . . . . . , . . . . THE COST OF OUR SERVICES, EQurP~IEl\'T, ,"~D MERCHANDISE THA r ),Ot' HAVE SELECTED . . . . . . . . . . . . . S7380.00 Cash Advances Opening Grave, . . . . . . . ~cwspap::r Obilwry ~olice- Semfnel . Certified COPlcs of Death Certificates. Flowers. . H",irdress~r. . . . . . . . . 5500(10 5161.75 560.00 513 I 08 530.00 TOT At CASH ADVANCES AND SPECIAL CHARGES . $982.83 Total Tota; Cost . ~ . . . ~ " . ~ ~ . . . .' .. . .. .. .. .. .. .. . .. . . 5836283 Histo~' OSl6(W07 VaHey Forge Ufe OS/16/1{HJ7 Di~NHll Received. s- 7202.52 5-777.43 TOTAl.HIOl'NT Dt'E $582.83 This statemlmt ia nat and payable In full wIthin 30 days of receipt. --_..._.._-~_...-----.._----...--------------._---.--------------- Please return this portion with your Remittance $ Amount Enclosed Service 10 # 15090-156 \lildred E. Horn ~ CARLISLE MEMORIAL SERVICE, INC. 41 SOUTH BEDFORD ST CARLISLE, P A 17013 Invoice DATE INVOICE # 8/23/2007 27-087 BILL TO LAURA BISTLINE 27 GOODYEAR ROAD CARLISLE PA 17015 !----------m-----------r------ - u_ ___ ___ _____ n______~ I TERMS i TELEPHONE 1-- Net 15---i 717 243 5480 LI ITEM: DESCRIPTION I LEITERING--~------I:I ~~~~:r~1'~:~g~~~f.~~:l:D~~=~,<;,_:_ . -I_ -~ CHURCH OF GOD ! ___~~~~~T_______I 170.00 I ,- ~ ~l~~ 0 Q~&.f3 I I I I i . I FNKYOU FORAU-OWJ,G US TO sERVE YOU! -- -- - - -'I Total L _n - -$::0: l___________ -----~--..-------------------_______________________ _ _____________ _____ __ _ ___ _ _u__ _____ J RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Receipt Date: Rece~pt Time: Recelpt No.: 7/25/2007 12:23:23 1049300 HORN MILDRED E Estate File No. : Paid By Remarks: 2007-00704 LAURA A BISTLINE DM ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 211 Total Received... . . . . . . 45.00 15.00 4.00 10.00 5.00 ---------------- $79.00 $79.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN " RE\I-1512 EX+ (12-03) *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT F~TATF OF Mildred E. Horn FII F NIIMRFR 21-07-0704 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH United Church of Christ Thornwald Home - final bill 38.80 2. Mobilex 3805 3. Pennsylvania Department of Welfare - Class 3 claim 13,84671 TOTAL (Also enter on line 10, Recapitulation) $ 13,923.56 (If more space is needed, insert additional sheets of the same size) ,SENT BY: Laura Bistline 27 Goodyear Road Carlisle, Pa. 17015 Date Description 928.17 928.17 Bala:nl.~ Forward 09/12/07 09/12107 09112/07 Adjustment Adju!ltment Adjustment 10-14-27 ; 9:27AM ; ~ 7176977065;# 3/ 5 Statement United Chun:h of Cbriat Homes Thornwald Home 442 Walnut Bottom Road Carlisle, Pa. 17013 Statement Date: 09/01107 Due date: Mfl.S/07 Re: Mildred E. Hom # 648 Days Rate Charges Total -120.20 -297.39 -471.78 807.97 S10.58 38.80 SENT BY: 10-14-27 9:28AM 4 7176977065;# 4/ 5 PAGE: 1 925 ~ NURSING HOME: DATESOfSERVlCE: 07/09/07 ~ 07jO'fi/07 at 0 b i I e x m The Highl.oos 920 RldgeDroolt Road Sparks, MllYI8nd 21152 FORWARDING SERVICE REQUESTED ~*~***.**...........&...*..*..-.*... 001655 1 MB 0.360 MTT,nRF.D HORN' LAURA BISTLINE 27 GOODYEAR ROAD CARLISLE PA 17015-9440 In .111... 1II'III1.tt.I,M.t. II 1,.1.111111. JllIl.II...lllu.1 U", ." <lJ o .., .... MobJlex USA P.O. Box 17452 Baltimore, MD 21297-1452 AMOUNT OF PAYMENT: C. ) For CRIfft C.'" P8)IINflU s.. ~ s.. Pleost detach here. and mt:loise this portion witll 'OUt' prompt paymcmt. 71I.ank-gau! Th~_ ~tlar9~~,bille<i"di~y ~'~ -p,oli~~-l becaUe~Q ~o~y, doductib~' is" due"Or 'voo'r'CI~m WaS"denied by'yOOr insurance company. It is the patient's responsibility 10 provide current Insurance informliltion (see reverse side), ".~" FR'.)::!:::~RE " Ck ~'IJ /-,,-, I\SU.-,t.'.;c" A~. IS'!.lP.; ~ ?/,f r,"*' N,' ENT I..i"" c.. r:>)D~ L....,; ) (N ...' 'r "J.;;' 'f,V"'t',,~ ,'\ ')~~f)~'rTS "./1"'fy',f N-'-S _/i...ANCt 07/09/07, 71,Q10 CHEST ~ VU:'W 5b,OC 07/09/07 ALLOWANCE WRITE DOWN 3S.S:d 09/12/07 PENNSYLVANIA CARE PAID 12.54 09/12/07' ALLOWANCE WRITE DOWN 3.80 3.1 07/0 9 / 0,7 !' .Q0.Q92 SET UP FEE X RAY 23.0C 07/09/07 ALLOWANCE WRITE DOWN 7.81- 09/12/07 I PaNNSYLVANJ.A CARE PAID 9.83 09!l2/07 ALLOWANCE WRITE DOWN 2.90 2.4 0'7/09/07 ROO70 TRANSPORT X RAY 1 PT SEEN 215.0C 07/09/07, ~LLOWANCE WRITE DOWN 61.17 09/12/07: PENNSYLVANIA CARE PAID 123.06 30.7 " . ~ ~ '":.. " :~" . . " "...,' " , 27.0( O'l/O~/()7', "11.Q,:H> ,CHEST! VIEW READING ,07/0flJ/07 ' '" ~ ~ ALLOWANCE WRITE DOWN 17.81 f 09/12/07 PENNSYLVANIA CAAE PAID 6.'14 :09/12/07 ALLOWANCE WRITE DOWN .77 1.6 PATIENT Ri!:SPoNSIBILITY: CURRENT 30- I I I I I l 29- 29- OVER 120 BALANCE DUE 38.05 .00 .00 .00 ,,aD 3B.05 ) - CALL BETWeEN THE HOURS OF 8:00 A.M. AND 4:30 P.M. EST TELEPHONE 10800-118-1015 THIS BILL IS FOR PORTABLE XRAY SERVICES MIlA .. COMMONWEALTH Of PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 6466 HARRISBURG. PA 17105-8466 August 7, 2007 ANDREW C SHEELY ESQUIRE 127 SOUTH MARKET STREET I'IECHANICSBURG PA 17055 Re: MILDRED HORN CIS #: 110193334 SSN: 174-05-0272 Date of Death: 07/12/2007 Dear Attorney Sheely: Please be advised that the Department of Public Welfare maintains a claim in the amount of $13,846.71 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for \-Ihich the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Ace 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $13,846.71, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3) - The balance of the claim, namely $.00, is to be entered as a priority Class 6 claim against the estate. ---- Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. . . Sincerely, ~) . . L~ GtLd{.. A{ }4//ldL Terri M. Smith Claims Investigation Agent 717-772-6961 717-772-6553 FAX Enclosure .. F~E~.15i3 EX+ (~-nO) ~~ COfl'1t;!ONWEMTH OF PENNSYLVANiA !MIERITANCE TAX RETURN RESiDENT DECEDENT SCHEDULE J BENEFICIARIES FILE NUMBER 21-07 -0704 ESTATE OF MILDRED E. HORN - RELATIONSHIP TO DECEDENT AMOUNT OF< SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Laura Bistline, 27 Goodyear Road, Carlisle, PA 17015 daughter RRR, 50%, Beatrice L. Laughman, 350 Grahams Woods Road, Carlisle, PA 17015 daughter F~RR, 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET " 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 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) GU!JY 1l.L&51 Jlill &ttb Qr~5tattUtt1 OF MILDRED E. HORN I, MILDRED E. HORN, of North Middleton Township, Cumberland County, Pennsylvania, make, publish and declare this to be my Last will and Testament, hereby revoking any and all former Wills by me at any time heretofore made. 1. I direct the payment of my just debts and funeral expenses as soon after my death as will be convenient to my Executrix hereinafter named. 2. I give to my daughter, LAURA A. BISTLINE, any and all bank accounts which I may own at the time of my death, including, but not limited to, checking accounts, savings accounts and any money market account. 3. All the rest, residue and remainder I divide in equal shares between my daughters, BEATRICE L. LAUGHMAN and LAURA A. BISTLINE. 4. I nominate, constitute and appoint my daughter, LAURA A. BISTLINE, to be the Executrix of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this : /"/1 /-,;/I\.( ! l day of -Apr.iJl, 1984. I I ). ./ J. / i,.c, l . I (-('it. ,: r(/ L. Mildred E. Horn /f-t'-ilK~ (SEAL) - I - Signed, sealed, published and declared by MILDRED E. HORN, the above named Testatrix, as and for her Last will and Testament, in the presence of us, who, at her request, in her sight and presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. \ i I ~ I I I' I \ , 'ei () :'_,~_I'J ;',t uu.U( '.), \tt:llUS~j , I U COMMONWEALTH OF PENNSYLVANIA 55...: COUNTY OF CUMBERLAND I, MILDRED E. HORN, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Willi that I signed it willinglYi and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MILDRED E. HORN, the Testatrix, this 10th day of May 1984. . "~) J I ',>'{ / i i; .~ .I 'u I~L- '1/)-1 , ;' ".(. f... ,l L- -CL. / ,I f L/ ' L,..--- Mildred E. Horn, Testatrix / I , " I . /. j' /'" C)/j/ i ' (,I II " / ,,~ [" . -'.,. .,' -. ..(. /, tary Public Shirley W Ahlers, NOTARY PUBLIC My Commission Expires July 14, 198:> Ceflillt, PA Cumberland Count)' "A,.~ - 2 - " . COMMONWEALTH OF PENNSYLVANIA SS.: COUNTY OF CUMBERLAND We, JAMES D. FLOWER and JAMES D. FLOWER, JR. , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that MILDRED E. HORN signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by JAMES D. FLOWER and JAMES D.FLOWER, JR. witnesses, this 10th day of May , 1984. , \ /; I (~\tr.-' l \') I CC U{L / i Witness \ \ ,lLC ( C':') ':+ . If. l' "'\ L-"" '" . I ('-.. ~_.' .... \_ . -""r-~\ Witness /iu;l;; 1//;~. No y Public Shirley W, lers. NOTARY PUBLIC My CommissilJO Expires July 14. 1911~ Carlisle. fA Cumberland County - 3 -