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HomeMy WebLinkAbout04-02-08 Estate of _Gerald G. HUQhes. Jr. Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS ~ \ 0'6 oao~ No. also known as , Deceased Petitioner(s), who is/are 18 years of age or older, apply(ie$ for: (COMPLETE "A" OR "B" BELOW) Social Security No. rc1 A. Probate and Grant of Letters and aver that Petitioner is the executrix named in the Last Will of the Decedent, dated to\",c:~ 1, tDo~ and codicil(s) dated State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent ............................................................................................. n B. Grant of Letters of Administration (c.t.a., db.n.c.t.a: pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if an and heirs: c5 ("") N Name Relationship esidence ~ ~ (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or principal residence at 309 E. Main Street. Mechanicsburo, Pennsylvania 17055 (list street, nun1:>er and municipality) Decedent, then ...11L years of age, died March 26, 2008, at Geisinoer Medical Center, 100 North Academy Drive, Danville, (Hahonina Tounship) Mountour County, Pennsylvania 17822 (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PAl All personal property... ... ...... ...... ........ ...... ......... ...... .................. ...... ............... ...... .......... ..$ (If not domiciled in PAl Personal property in Pennsylvania (If not domiciled in PAl Personal property in County Value of real estate in Pennsylvania........................... ........................ ...... ............ .............................. ......... ...$ Total................................................... ............................................................ .._...................... .......$ -0- -0- -0 ~ Real Estate situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented witlthis Petition and the grant of letters in the a ro riate form to the undersi ned: Po. David Hu hes rinted name and residence 47 Timberview Drive Bloomsburg, Pennsylvania 17815 Fonn RW.' Page 1 of 2 (OauJhin County,- Rev. 9192 Oath of Personal Representative Cormnonwealth of Pennsylvania County of Cumberland The Petitioner( s) above-named swear( s) and affirm( s) that the stateme s in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner( s) and that, as personal [ presentative( s) of the Decedent, Petitioner( s) will well and truly administer the estate according to law. before me this ~ Sworn to and affirmed and subscribed tJO ~1:,~; ,~.:~) ~ ~ 0 ~J__"_~) ~Q3$ ill tH C"1 .--... -,. 08~ :r> ~:/ \-1 O :z: -,-- ' " 1 :>--0 ........................................................................~ii.....~..~...... DECREE OF REGISTER ~ ,,') C;;~ d \ 0'6 C:8\D~ No. tjpJJl_ Estate of Gerald G. Huohes. Jr. also known as day of 20 of! Deceased Social Security No: Date of Death: March 26. 2008 AND NOW, ,20_, in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Lettes.; Griestamentary 0 of Administration _ are hereby granted to DavicfiRuohes in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters..................x.. . Short Certificate( s). .(5)... . Renunciation................. . Affidavit ( )................. Extra Pages ( )............ -6edtctt....... PoA.......... JCP Fee.....~....~.~.. Inventory...................... . Other............................ . TOT AL................ Form RW-t Page 2 (')f 2 (Dauphin Count) - Rev. 9J92 $ :2.0 Register of Wills $ ?-D $ $ $ $ '2..0 $ j~ $ $ Attorney Signature: Attorney: Shaun E. O'Toole J.D. No: 44797 Address: 2813 North Second Street HarrisburQ, Pennsvlvania 17110 Telephone: (717) 213-6653 DATE FILED: $ l~ This is to certify that the information here given i: correctly copied from an original Certificate of Deatl duly filed with me as Local Registrar. The origina certificate will be forwarded to the State Vita Records Office for permanent filing. ._~ HIO) 0{l~ KI.:V {OJ/OIl LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for. this certificate. $6,00 P 14285310 Certification Number stral:g ~j S3~~ 'J> <:0 zen", CJ (')0 ~~~ ~.... ?I\ H1D5-143REV 1112006 TYPE 1 PRINT IN PERMANENT BlAC1< 11<I< COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) 1.Namod_IF...._.Iasl,_1 S. JqlILasl _)1 14. MariW SlaIus: Matritd, Neve, Manled, W_... Di>arcecI (Spocl)1 Married 7S_IC 49 v" lib Countyotllealh Montour Feb. 11, 1959 Danville PA tt.DtcedeltsU.ua1 most 01 ...Oonot.tal8r. KilddWort Kind 01 Boslr\eSS/1ndostry Correctional Officer State Corr. Institute lI.lloc-.r. lWi'1I-'" tS01el. CIty 1_. _. zip-I 309 E. Mlin Street Mechanicsbu PA 17055 12. Was Decedenl ever in 1tle U.S. Armed Forces? IXlYfi ONe ~~ 17.._ Pennsylvania 17b. County ClIrber 1 and He. 0 Yes, OecedenHNtd In 17dliiJ~~:"_n I'. FatMw', Name (IFni, miOJe, tasl suffix) 1? Mottler', Name (FIrSt. midde. maideo sumamel MAR 2 <<::::) c::::> CD >- -0 ::0 I N Dateb'slIed -rl -"') o Xl ,"--'., ;-'i1 C1 C)c> ... . -"il -n <-=S __ 0-'71 ,[) ..--) -'-;".J > :x U1 N D <6 ()3~ 2008 nOt"", -~: 10. Race: Amoflcan InOiaIl, ~ack, 'Ntllle, tit!: (~/}j Hhlte Roxy (Maiden Unknown) T"" Mechanicsburg Qtyf&<<> Gerald G. Hu hes Sr. 20it 1nklfmanI'$ Nltme (Type I P1lnI) 2{tJ. tnfonnant's Mailing AOi:eas (Street, dIy I town, stala, zip code) Shirley Hughes 120 S. 2nd St., Shamokin PA 17872 21a.1IoII1od d Ilispos>tion O~ 0 ~ 21b. 0... d l>spo$ilion 1_. day, )OMI 21c. PIaco ~ [);spo$diOO (Name ~ cometeoy, _" oIher placel 21d.loca"'" (Qty 110,,", $late,'P codel lKl - 0 Rel11cwalbomSlato -~.._.-O 0 \'\pril 5 20ll St Pauls Refonred Church Caretery East Caireron Twn., PA 17872 o OIhot-Sp<QIy: ..,-..E_/CofOlW1 v.. Ne ' I..... 22i" ~.... of Fun.a! Setva lICtOS8t la P'fIOIl adIlg as such) 22b.lictnse Numbtr 22c. Name an4.wuss of Fdty -~~ Kevin J. Shervinskie Leonard J. Lucas Funeral Hare Ltd. '" ~ ~ Approxlmateirllervat: Onset 10 Deattl Part N: EntfJf other ~mrdIinn!l. COI"Itt1llima1lLl!litb. but not r~ng in the lI'1d9rtying cause lJven In Part I 26. Was Case Relerred 10 Medical Examin8f I ComnfJf tor a Reason Other than Cfema\loo or Dooatioo? o v.. [jdNe ?-oo =-~=)~ .. E...J. <;~......" \;.I~ r J-'....'L'>C Due 10 (or as a CUlS8Ql.lenc8 ot): Alc..\..O\\l c; rr "'.~ it, Due 10 lor as a consequence ot): 5elJJenIiatJIistc:orlOilons,'any, aeadinQlohCilJSQiSledonh.. E* lie UNDERlYING CAUSE =-~~=...'1trtl'" b. Duetolorasa~of): :lOa. Was an hAopsy P- d. n_ Were Auklpsy Frdngli Available POOr 10 CompIeIioo ~ eau.. d Doelhl Dyes ONe ald, Tlm8 at kljurv 32g localion of'InfurY (Sleet, city 11oWn, slale) 31. Manner of Deal\ [gNalunll 0- D-D-Invootigalioo o Su_ 0 Could NoI be DoIermif>ed M. 32a. Dale oIlnpry (MontI, djty, year) Dyes IZ!I.IO m ~ l'> ~ 33a ConiIo< tci'ock "'" """} Co<tlIytng pOyaIcIan 1_ COIliI)Wlg """'................- _ "" poooouncad""'''' ~ '10m 231 r.lIlo....ot..,_, __ cM.....cau..)..............-.. _ _ _ _ _ u _ _ _ _ _ _ __ _ _ _ _ _ ___ _ _ _ _ _ n_ _ 0 ~.==:,':.:='::"~::~...~.:::.'t"=':':'man..... ........_ __ __ u__ __ _ _ _ __ _ ~ :--: ~~Iftd' or kwntiptIon, In.y opinion, dNth occwncIat.. ItMl, daII, and plKtl, and due to the cauM(1) IPd tnannet'.1 Itlled_ 0 34. Name anet Address of Person 'M1o ~ CalISe of Dttalh (Item 21) Type I Print fl\AA<. M.......... ,>0_ M~ ". .., A, _ol-:> IJ-., *",_ ..:\'c. Ab Il\l'tU 36. Dale Filed (Mof\lh, day, year) ILJ. 19 11-/ 1510 I -J.g- ;>.oog IlI""",",,"P."""No. 00<10845 28. Did Tobacw Use Contribute to Death? o Yeo Ll-bIf I8r N. 0 Unknown 29 " Female o N~_.","paol_ [J Pregnant allime 01 death o No! preg>aflt. buI pregoanl within 42 Clays "'''''''h o Not pr~fll. bul pregnan* 43 days 10 I yeil beIoredealh o Unknown'",og>enl""""lhepaol)09l 32c. Pia<>> of Injury: Home, Fatm, Streel, Fac1ory, arlCe Bulking, etc (Specify} 33d. Dale SIgned (MontI, daV yeal) M ~~ J... J,. b "2. 001? PENNSYLVANIA GENERAL DURABLE POWER OF ATTORNEY THE POWERS YOU GRANT BELOW ARE EFFECTIVE EVEN IF YOU BECOME DISABLED OR INCOMPETENT NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMJNA:rES YOUR AGENT'S AUTHORITY. YOUR AG):NT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR "~'GJNr'*UNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTOpy ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERI: IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I ~~ ~ UNDERSTAND ITS CONTENTS. ~lp ;g DATE: .3/ ( '0 't( ~U3g; ..:., 88~ ~ ;::l) ~ ~-f ::- -#. OF PRINCIPAL) UI ~ r:, c=:> f~}d c,'.) c, -~ PENNSYLVANIA GENERAL DURABLE POWER OF ATTORNEY THE POWERS YOU GRANT BELOW ARE EFFECTIVE EVEN IF YOU BECOME DISABLED OR INCOMPETENT NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE TO BE EFFECTIVE EVEN IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. 30 Cj ut1AI I\l ~ TO {l1..ec. (J 1tI< \. cS ~ I Ge~& t~ \-\.H.\J> " _0t' .> address] appoint J)tuJ\ D f2 4t rG:i H E-<; [insert your name and L/7 " \}\.l\~ v U l-t..\..U D'c- -- \;yo (insert the name and address of the person pointed] as my Agent (attorney-in-fact) to act for me in any lawful way with respect to the following initialed subjects: TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS. TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING. TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER WITHHELD. Note: If you initial Item A or Item B, which follow, a notarized signature will be required on behalf of the Principal. INITIAL (A) Real property transactions. To lease, sell, mortgage, purchase, exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any interest in real property whatsoever, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, tear down, alter, rebuild, improve manage, insure, move, rent, lease, sell, convey, subject to liens, mortgages, and security deeds, and in any way or manner deal with all or any part of any interest in real property whatsoever, including specifically, but without limitation, real property lying and being situated in the Commonwealth of Pennsylvania, under such terms and conditions, and under such covenants, as my Agent shall deem proper and may for all deferred payments accept purchase money notes payable to me and secured by mortgages or deeds to secure debt, and may from time to time collect and cancel any of said notes, mortgages, security interests, or deeds to secure debt. (B) Tangible personal property transactions. To lease, sell, mortgage, purchase, exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any personal property whatsoever, tangible or intangible, or interest thereto, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, improve, manage, insure, rent, lease, sell, convey, subject to liens or mortgages, or to take any other security interests in said property which are recognized under the Uniform Commercial Code as adopted at that time under the laws of the Commonwealth of Pennsylvania or any applicable state, or otherwise hypothecate (pledge), and in any way or manner deal with all or any part of any real or personal property whatsoever, tangible or intangible, or any interest therein, that I own at the time of execution or may thereafter acquire, under such terms and conditions, and under such covenants, as my Agent shall deem proper. (C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign, redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other securities in any business, association, corporation, partnership, or other legal entity, whether private or public, now or her~after belonging to me. (D) Commodity and option transactions. To buy, sell, exchange, assign, convey, settle and exercise commodities futures contracts and call and put options on stocks and stock indices traded on a regulated options exchange and collect and receipt for all proceeds of any such transactions; establish or continue option accounts for the principal with any securities or futures broker; and, in general, exercise all powers with respect to commodities and options which the principal could if present and under no disability. (E) Banking and other financial institution transactions. To make, receive, sign, endorse, execute, acknowledge, deliver and possess checks, drafts, bills of exchange, letters of credit, notes, stock certificates, withdrawal receipts and deposit instruments relating to accounts or deposits in, or certificates of deposit of banks, savings and loans, credit unions, or other institutions or associations. To pay all sums of money, at any time or times, that may hereafter be owing by me upon any account, bill of exchange, check, draft, purchase, contract, note, or trade acceptance made, executed, endorsed, accepted, and delivered by me or for me in my name, by my Agent. To borrow from time to time such sums of money as my Agent may deem proper and execute promissory notes, security deeds or agreements, financing statements, or other security instruments in such form as the lender may request and renew said notes and security instruments from time to time in whole or in part. To have free access at any time or times to any safe deposit box or vault to which I might have access. (F) Business operating transactions. To conduct, engage in, and otherwise transact the affairs of any and all lawful business ventures of whatever nature or kind that I may now or hereafter be involved in. To organize or continue and conduct any business which term includes, without limitation, any farming, manufacturing, service, mining, retailing or other type of business operation in any form, whether as a proprietorship, joint venture, partnership, corporation, trust or other legal entity; operate, buy, sell, expand, contract, terminate or liquidate any business; direct, control, supervise, manage or participate in the operation of any business and engage, compensate and discharge business managers, employees, agents, attorneys, accountants and consultants; and, in general, exercise all powers with respect to business interests and operations which the principal could if present and under no disability. (G) Insurance and annuity transactions. To exercise or perform any act, power, duty, right, or obligation, in regard to any contract of life, accident, health, disability, liability, or other type of insurance or any combination of insurance; and to procure new or additional contracts of insurance for me and to designate the beneficiary of same; provided, however, that my Agent cannot designate himself or herself as beneficiary of any such insurance contracts. (H) Estate, trust, and other beneficiary transactions. To accept, receipt for, exercise, release, reject, renounce, assign, disclaim, demand, sue for, claim and recover any legacy, bequest, devise, gift or other property interest or payment due or payable to or for the principal; assert any interest in and exercise any power over any trust, estate or property subject to fiduciary control; establish a revocable trust solely for the benefit of the principal that terminates at the death of the principal and is then distributable to the legal representative of the estate of the principal; and, in general, exercise all powers with respect to estates and trusts which the principal could exercise if present and under no disability; provided, however, that the Agent may not make or change a will and may not revoke or amend a trust revocable or amendable by the principal or require the trustee of any trust for the benefit of the principal to pay income or principal to the Agent unless specific authority to that end is given. (I) Claims and litigation. To commence, prosecute, discontinue, or defend all actions or other legal proceedings touching my property, real or personal, or any part thereof, or touching any matter in which I or my property, real or personal, may be in any way concerned. To defend, settle, adjust, make allowances, compound, submit to arbitration, and compromise all accounts, reckonings, claims, and demands whatsoever that now are, or hereafter shall be, pending between me and any person, firm, corporation, or other legal entity, in such manner and in all respects as my Agent shall deem proper. (J) Personal and family maintenance. To hire accountants, attorneys at law, consultants, clerks, physicians, nurses, agents, servants, workmen, and others and to remove them, and to appoint others in their place, and to pay and allow the persons so employed such salaries, wages, or other remunerations, as my Agent shall deem proper. (K) Benefits from Social Security, Medicare, Medicaid, or other governmental programs, or military service. To prepare, sign and file any claim or application for Social Security, unemployment or military service benefits; sue for, settle or abandon any claims to any benefit or assistance under any federal, state, local or foreign statute or regulation; control, deposit to any account, collect, receipt for, and take title to and hold all benefits under any Social Security, unemployment, military service or other state, federal, local or foreign statute or regulation; and, in general, exercise all powers with respect to Social Security, unemployment, military service, and governmental benefits, including but not limited to Medicare and Medicaid, which the principal could exercise if present and under no disability. (L) Retirement plan transactions. To contribute to, withdraw from and deposit funds in any type of retirement plan (which term includes, without limitation, any tax qualified or nonqualified pension, profit sharing, stock bonus, employee savings and other retirement plan, individual retirement account, deferred compensation plan and any other type of employee benefit plan); select and change payment options for the principal under any retirement plan; make rollover contributions from any retirement plan to other retirement plans or individual retirement accounts; exercise all investment powers available under any type of self-directed retirement plan; and, in general, exercise all powers with respect to retirement plans and retirement plan account balances which the principal could if present and under no disability. (M) Tax matters. To prepare, to make elections, to execute and to file all tax, social security, unemployment insurance, and informational returns required by the laws of the United States, or of any state or subdivision thereof, or of any foreign government; to prepare, to execute, and to file all other papers and instruments which the Agent shall think to be desirable or necessary for safeguarding of me against excess or illegal taxation or against penalties imposed for claimed violation of any law or other governmental regulation; and to pay, to compromise, or to contest or to apply for refunds in connection with any taxes or assessments for which I am or may be liable. G. W (N) ALL OF THE POWERS LISTED ABOVE. YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N). SPECIAL INSTRUCTIONS: ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT. -X.. I +& f 'C ~.. + of 'vIA, -fOvJ4 or ( ~ ~. t\~c1 J) A1j l e,O, \<-L ~.~~. r )-etA-~ \ 4l^,-Lr~ ~ol~ ~MA;~ +('~ ~S ( C\li\) -s-~ --rt: l <-e ~ '1 C- -\ too N-t l U\ft; \ -suetA t-\uC \c s: ) THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WilL CONTINUE UNTIL IT IS REVOKED. THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER OF ATTORNEY AND SHALL CONTINUE TO BE EFFECTIVE EVEN IF I BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. (YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY TO ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS FORM, BUT YOUR AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU WANT TO GIVE YOUR AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION-MAKING POWERS TO OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD BE STRICKEN.) Authority to Delegate. My Agent shall have the right by written instrument to delegate any or all of the foregoing powers involving discretionary decision- making to any person or persons whom my Agent may select, but such delegation may be amended or revoked by any agent (including any successor) named by me who is acting under this power of attorney at the time of reference. (YOUR AGENT Will BE ENTITLED TO REIMBURSEMENT FOR ALL REASONABLE EXPENSES INCURRED IN ACTING UNDER THIS POWER OF ATTORNEY. STRIKE OUT THE NEXT SENTENCE IF YOU DO NOT WANT YOUR AGENT TO ALSO BE ENTITLED TO REASONABLE COMPENSATION ACKNOWLEDGMENT EXECUTED BY AGENT I, [name of agent], have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. PREPARATION STATEMENT This document was prepared by the following individual: Signature Typed or Printed Name Date FOR SERVICES AS AGENT.) Right to Compensation. My Agent shall be entitled to reasonable compensation for services rendered as agent under this power of attorney. (IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND ADDRESS(ES) OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.) Successor Agent. If any Agent named by me shall die, become incompetent, resign or refuse to accept the office of Agent, I name the following (each to act alone and successively, in the order named) as successor(s) to such Agent: Choice of Law. THIS POWER OF A TIORNEY WILL BE GOVERNED BY THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT WAS EXECUTED IN THE COMMONWEALTH OF PENNSYLVANIA AND IS INTENDED TO BE VALID IN ALL JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS. I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my Agent. I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party learns of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. Signed this I day of MtJl-i't ~J' ,20~ ~f?' [Your nature] STATEMENT OF WITNESS On the date written above, the principal declared to me in my presence that this instrument is his general durable power of attorney and that he or she had willingly signed or directed another to sign for him or her, and that he or she executed it as his or her free and voluntary act for the purposes therein expressed. ~~ .L\.~ a.. o..~ ~ Witness #1] ~ ~o<(:) "5 . ca~"" ~ 1] ~'ou."f\~ \>1\ \(ol-\~ 2] [Signature of Witness #1] [Printed or typed name of [Address of Witness #1, Line [Address of Witness #1, Line ~S#2]12l~7Jl ibztj 1] ~t6mon "~--\7D4? 2] [Signature of Witness #2] [Printed or typed name of [Address of Witness #2, Line [Address of Witness #2, Line A Note About Selecting Witnesses: The agent (attorney-in-fact) may not also serve as a witness. Each witness must be present at the time that principal signs the Power of Attorney in front of the notary. Each witness must be a mentally competent adult. Witnesses should ideally reside close by, so that they will be easily accessible in the event the are one da needed to affirm this document's validi . CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC COMMONWtALTH OF PENNSYLVANIA COUNTY OF 9~tVoN ~~ This document was acknowledged before me on -1JJ" 2.CH 1 rH [Date] by (iE.P.1f L ;) fi- - H u a- f-f E:-S I ~ [name of principal]. ..- ~ . ~., .,........', ",fl=' -...... t..j ..J.... .... ~. ': ""'7!!=m~ [Notary Seal, if any]: COMMONWEALTH OF PENNSYLVANIA Notarial Seal Michael W. szo\\OSe, Notary Public City Of L.ebanon, Lebanon County , ::. Myeommission Expires Aug. 23,2006 J;. . . . . \\ I ,'~ ~',' Member o"",,<,,"'o~k ~c.e"",,,I'on Of Notanes ". "'. '...... , " ""_l Notary Public for the Commonwealth of Pennsylvania My commission expires: 08'/2Z5/08 .....--- ~,