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HomeMy WebLinkAbout02-05-09 (2)REV-1513 EY ,+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER R(~RFRT .I HnC;AN SR ?_ 1 nA 1 1 RR RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME ANU ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [nclude outright spousal distributions, and Vansfers under Sec. 9116 (a) (1.2)] 1. Robert J. Hogan, Jr. Lineal 1070 Roxbury Road Newburg, PA 17240 2. David G. Hogan Lineal 615 Pine Ridge Drive Lakeland, FL 33809 3. Kevin Douglas Hogan Lineal 2436 Columbus Road Wooster, Ohio 44691 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (It more space Is neetletl, Insert atltlltlonal sheets of the same size) 1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 2so6o1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 8 1 1 8 6 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 0 4 2 0 1 3 7 9 0 1 1 1 6 2 0 0 8 D 7 1 6 1 9 1 8 Decedent's Last Name Suffix Decedent's First Name MI H O G A N S R R O B E R T J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW a 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J E D W A R D B E C K J R 7 1 7 ~ 6 4 ];Q 1 0 CQ ~n ~-'~ -~- Firm Name (If Applicable) REGISTE ILLS US LY - K E L L E R K E L L E R & B E C K ~a~, _ , First line of address ~Cl~~ U1 _.:. , ~.j 1 0 3 5 W A Y N E A V E N U E ~~ ~'"' '-~ ` _- - ~ ~ _ ~ , Second line of address - ~ -- - ~'r} tV .. .:) City or Post Office State ZIP Code DATE FILED C H A M B E R S B UR G P A 1 7 2 0 1 Correspondent's a-mail address: ebeCk(a~kkfb.COm Under pena es o p rj , 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, co a co plete. Declaration of r other than the personal representative is based on all information of which preparer has any knowledge. SI NAT E R N RESPONSIBLE FILIN ETURN DAT RESS 1070 OXBUR OAD NEWBURG PA 17240 SIGNAT~IJ/R P PA THER HAN PRESEN TIVE J~ATE / / i n ~/~nl %% Q 1035 WAYNE AVENUE CHAMBERSBURG PA 17201 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 J 1505607221 REV-1500 EX Decedent's Social Security Num ber Decedent's Name: R O B E R T J- H O G A N, S R 0 4 2 0 1 3 7 9 0 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. 2 9 3 3 5 6 • 4 1 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ..... .. 7. 2 1 2 8 6. 4 6 8. Total Gross Assets (total Lines 1-7) ......................... .. 8. 3 1 4 6 4 2. 8 7 9. Funeral Expenses & Administrative Costs (Schedule H) .......... ...... 9• 1 8 4 7 9 • 5 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...... ...... 10. 2 5 3 • 6 2 11. Total Deductions (total Lines 9 & 10) ..................... ...... 11. 1 8 7 3 3 . 1 2 12. Net Value of Estate (Line 8 minus Line 11) ................... ...... 12. 2 9 5 9 0 9 • 7 5 13. Charitable and Governmental Bequests/Sec 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. ..... 2 9 5 9 0 9 . 7 5 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.0 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 2 9 5 9 0 9 7 5 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 98 19. Tax Due ............ .......................... ... ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505607221 0. 0 0 1 3 3 1 5. 9 4 o. 0 0 0. 0 0 1 3 3 1 5. 9 4 1505607221 J REV-1500 EX Page 3 DQcedent's Complete Address: File Number 21 08 1186 DECEDENT'S NAME ROBERT J.HOGAN,SR - __ STREET ADDRESS 1070 ROXBURY ROAD - -__ _ - __. ----- CITY STATE ZIP NEWBURG PA 17240 Tax Payments and Credits: ~ Tax Due (Page 2 Line 19) (1) 13,315.94 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 665.80 Total Credits (A + B + C) (2) 665.80 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E ) 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. 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) 0.00 (4) 0.00 (5) 12,650.14 (5A) (56) 12,650.14 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 : ...................................................................... ^ X^ b. retain the right to designate who shall use the property transferred or its income; ............................... ^ ^X c. retain a reversionary interest; or ................................................................................................ ^ X^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ 0 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... X^ ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ^ X^ 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. §9116 (a) (1.1) (ii)J. 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. §9116(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. §9116(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 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 ~X + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT J. HOGAN, 6R 21 08 1186 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Edward Jones Investment Account No. 486-08813-1-9 (See Valuation Report attached) 293,356.41 TOTAL (Also enter on line 5, Recapitulation) S 293,356.41 (If more space is needed, insert additional sheets of the same size) REV-1510 ~X + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ROBERT J. HOGAN, SR 21 08 1186 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION pFAPPLICABLE~ TAXABLE VALUE 1. Checking Account No. 3138443 at First National Bank, Orville 24,286.46 100. 3,000.00 21,286.46 Ohio payable on death to Kevin D. Hogan (See Estate Account Inquiry attached) TOTAL (Also enter on line 7 Recapitulation) I $ 21 286.46 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT J. HOGAN SR 21 08 1186 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Auble Funeral Home, Orville, Ohio -funeral bill 1,765.25 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: 2, Attorney Fees Keller, Keller & Beck 12,500.00 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation) 3, 500.00 claimant Robert J. Hogan, Jr. Street Address 1070 Roxbury Road City Newburg state PA Zip 17240 Relationship of Claimant to Decedent SOn 4• Probate Fees Cumberland County Register of Wills 387.00 5 Accountant's Fees 6. Tax Return Preparer's Fees 7. Cumberland Law Journal -advertising 75.00 8. Shippensburg News Chronical -advertising 88 25 9. Edward Jones -fee for opening estate checking account 164.00 TOTAL (Also enter on line 9, Recapitulation) I $ 18 479 50 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ROBERT J. HOGAN, SR 21 08 1186 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 1. Medco -prescription drugs 100.00 2. Clark & Daugherty Hospital -balance due at death 15.30 3. Clear Choice -telephone bill 35.16 4. Verizon -telephone bill 103.16 TOTAL (Also enter on line 10, Recapitulation) I $ 253 62 (If more space is needed, insert additional sheets of the same size) REV-1513 EX t (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER R(~RFRT.I HnC;AN SR ?_1 Ofi 11f1F RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [nclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Robert J. Hogan, Jr. Lineal 1070 Roxbury Road Newburg, PA 17240 2. David G. Hogan Lineal 615 Pine Ridge Drive Lakeland, FL 33809 3. Kevin Douglas Hogan Lineal 2436 Columbus Road Wooster, Ohio 44691 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. 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N ',tl O V W [71 '.Y 41 12/18/2008 THU 15:51 FAX 3306828810 First National Bank (~J002/012 ;f~~'S~ ~Q~IQIIQE ~Qit~C Estate Accouat Inquires Name Robert J Hogan, Sr SOCIaI Security # 042-01-3790 Date of Death 11/16/2008 Checking accounts: The decedent had: [ J no checking accounts [~/] the following checking accounts Account # DOD Balance DOD Accr Int Account Ownership 3138443 24,286.46 25.55 individual Saving accounts: The decedent had: (/] no savings accounts [ ]the following savings accounts Account # DOD Balance DOD Accr Int Account Ownership Certificates of Deposit: The decedent had: [fJ no CD accounts ( ]the following CD accounts Account # DOD Balance DOD Accr Int Account Ownership Individual Retirement Accounts: The decedent had: (~/] no IRA accounts [ ]the following IRA accounts Account # DOD Balance DOD Accr Int Account Ownership Safe Deposit Box: The decedent had: [~/J no Safe Deposit Box [ ]the following Safe Deposit Box Box # Bank Branch Account Ownership Employee Signature Q/Y1 Date ~a - ~ ~-~ 12/16/2008 THU 15:51 FAX 3306828810 Fizst National Bank Fir National Sack 1J01 Rest Mazkat St O Bos 57 Orrvil2e, OH 44667 (330)682-1010 - Rest Hi h Office OWNERSHIP OF ACCOUNT -PERSONAL PUAPOSE ® INDIVIDUAL ^ ^ JOINT - YvfTH SURVFVORSHIP land rwt ae tenarRS In commoN ^ JOINT- NO SURVIVORSHIP to tenants in commoril D TRUST-SEPARATE AGREEMENT: ^ REVOCABLE TRUST OR ® PAY-ON-DEA7fa DESIGNA710N AS DEFINED IN THIS AGREEMENT Name and Address of Benetidaries: »vix n. aocnx 2 436 COLAMBt75 RD _ -fOO3TER, OH 44691 R£PL~ACENIENT CARD OWNERSHIP OF ACCOUNT -BUSINESS PURPOSE ^ SOLE PROPRIETORSHIP ^ CORPORATION: ^ FOR PROFlT ^ NOT FOR PROFIT ^ PARTNEflSHIP BUSINESS: COUNTY & STATE OF ORGANIZATION: - AUTHORIZATION DATED: DATE OPENED 10/28/2008 gYMaryR INITIAL DEPOSIT ! 0.00 ^ CASH ^ CHECK `~ ~pT HOME TELEPHONE p (330) 317-6580 BUSINESS PHONE !' DRIVER'S LICENSE # 29760405 E-MAIL EMPLOYER RETIIO;D MOTHER'S MAIDEN NAME ~~ TVp REHSTER Name and address of someone who witl always know your location: SANDRA HOG?.N 330-q66-5837 BACKUP WITHHOLDING CERTIFlCAT)ONS TIN; 042-O1-3790 ® TAXPAYER I.D. NUMBER - The Taxpayer Identrfication Number shown above (TINT is my correct taxpayer identification number. ® BACKUP WITHHOLDING - I am not subject to backup withholding either because (have net been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Interns( Revenue Service has notified me that [ am no longer subject to backup withholding. ^ EXEMPT RECIPIENTS - I am an exempt recipient under the Interne( flevenue Service Regulations. SIGNATURE: I cartify,unda penakies of perjury the statemems rheaked in this section t rn a U.S arson f nc[uding a t).S_ resident alien). ~ ~ r ® ©t 992 Ba a SysUma, Inc.. St. Cloud MN Form MPSGLAZ-OH 4/19/2004 X003/012 ACCOUNT 03138443 NUMBER NAME & ROBERT J HOC,AN SR 1825 LYtat DR ORRVILLE OH .44667 RF.P1JiCFMEN'.I' CARD: Add POA, Chg. To Platinum Checking Mailinst address: CIO COIlera Zimmerman i ] 8 S Crown Hdl Rd, OtrviIle, OH 44667 ^ NEW ® EXISTWG TYPE OF ® CHECKING ^ SAVINGS ACCOUNT ^ MONEY MARKET ^ CERTIFICATE OF DEPOSIT ^ NOW ® PLATZNCRd Ctt£~NG This is your (check one): ® Permanent ^ Temporary account agreement. Number of signatures required for withdrawal 1 FACSIMI/LE SIGNATURE(S) ALLOWED? ^ YES ® NO SIGNATURE(S) -The under gne ag a to the terms stated on every page of Iles form and a n wbdga oeipt of a completed copy. The undersigned further a o ze the fi nciatinstitution to verify credit and empbyment hiato endlor have a oredit reporting agency prepare a credit report on the undersigned, as iniividuals_ The undersigned also scknowledge the receipt of a copy and agree to the terms of the fofbwing drsclosure(s): ^ Deposit Account ^ Funds Availability ® Truth in Savings ^ Dectronic Fund Transfers ^ Privacy ^ Substitute Checks (1). LX ~" ~~ 1 ROBERT J 80GAN SR IrD. # 042-O1-3790 p.0-B_ 07/16/1918 (21: 1 _- J 1.D. # D.o.6. (3): LX 1 I.D. # 0.0.B. (4): ~` I.D. # D.0.8. ® Authorized Signer Ondividual Accounts ,nly) [X KEVIN D HOGAN, POA I.D.# 220-58-7530 p,0.g, 02/06/2953 (page 1 a! Z! LAST WILL AND TESTAMENT I, Robert J. Hogan, Sr., of Newburg, ]~ennsylvania, declare this to be my Last Will and revoke any will previously made by me. I. The expenses of my last illness and funeral shall be paid by my estate- 1I. I direct that the residue of my estate be divided into three (3) equal shares and Y give to each of the following who survives me the number of shares set forth below' ~, C7 A _ To Kevin Douglas Hogan, cny son, one ( X ) share . ~ ~ ~ -~" ~ ~ :~ :i~ Zn ca i.' __: B . To David G . Ho an m son vne (1) share . ~~' ~ y r~*' N ~:'-; ' '; 9 y .t,..~-3 ~o m _cn~ ~, ,~ C . To Robert J . Hogan , Jr . , my svn, one (1) share . <~o --n ac _ - .: ~- ; c ',~~ ~o If any of the above named beneficiaries fails to aurcriv~ me, IF direct that that beneficiary's share shall descend to that benef Xcia~y`s surviving issue, per sCirpes. In the event that any of the above named beneficiaries fails to suXVive me without issue then surviving, Z direct that his or her share be added to the shares of the others in the same proport~,ons they now bear to each other. III. I further direct that any beneficiary under this Will who has not attained the age of twenty one (21.) years who shall inherit under this my Laet Will and Testament shall, have his or her share deposited into ara account established pursuant to the Pennsylvania Unl.form Transfers to Minors Act (or the similar law of the state in whiG21 Lhe beneficiary resides at the time of my deatb.)_ Said account shall have as custodian for the beneficiary, the parent of ;~ ~ ` Che beneficiary who is a descendant of mine. In the event the beneficiary has no Yxving parent who is a descendant of thine, then the beneficiary's aurvzving parent shall be the substitute custodian of tkie beneficiary's account. IV. All administrative costs, including inheritance taxes, estate takes and transfer taxes imposed upon my estate passing under my will or otheYwi9e shall be paid out of the principal. of my residuary estate. V. I appoint as ~cecutor of this mY Laet W~.ll Robert ,T. xogan, Jr. In the event an alternate or successor Executrix be required, Z appoint as such Judy Hogan. I direct that no trustee, executor, guardian ox other fiduciary named, nominated, or appointed in this Will shall be required to poet any bond or give any security of any type for any purposes whatever. zN WITNE55 WFFEREOF, I, Robert J_ iiogan, Sr., the above named Testator, have to this, my Last Will and Testament, set ttty hand and Beal. this 27th day of August, 2008. Ro ert J. og Sz. J SIG2JED, SEALED. PLFBLiSHED AND DECLARED by the above named Testator, as and for his will, in the presence of us, who aC his request, in his pxesenCe, and in the presence of each other, have hezeunto subscribed our names as witnesses in attestation thereof. (/ 313-B South Potomac Street `- Address Waynesboro, PA I7266 _ - ~, 343-B South Potomac Street ~~., a~Addresa Waynesboro, PA 17268 CONlNIONWEAI~TH OF PENNSYLVANYA: :ss COUNTY OF FRANKLIN - We, Robext J_ Hogan, Sr., Cindy L. Kolpaek, and parlene Sease, the Testator and the witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undezsigned authority that the Testator signed and executed the in.~trument as has Last Will and Testament and Chat he executed iL as his free and voluntary act for the puzposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witnesses and that to the best of their lcr~owledge the Testator was at the time eighteen years of age or older, of sound mind and under no constraint ar undue influence. -Witness ~ ' witness Subscribed, sworn to and acknowledged before me by the Testator and subscribed and sworl7 to before me by Cindy L. Kolpaek and Darlene Sease, witnesses, this 2yth day of August, 20os_ w a Notary c COM~+iONYVE4 TF1 OF ENN YLV NiA Notarial Seal iinde Ft, Eafde, Notary Public Waynesboro Born, Frankly- Ctwrtty Corrmt9slon ~pi-ea: Oct. 2. 2008