The URL can be used to link to this page

Home My WebLink About03-06-09 c 0 .~, ca E ai . ~ a~ ~ ~ c as 'Q 0 .~ a 0 ~_ Y CB E 0 L Q~ U w W O ~ ~ N _ 0 o ~= o ~ ~ ~ Y U ~ O - m ~ C o E 1 ; ~ ~ N ~ Z ~ ( N ~ ~ N o~~ N ~N Q~ ~ ~ m # ~.V ~.-. y D OI~~ 1 N ~~ N a~p ~ -y ~ ~a.0 ~¢U¢ ~ ~ R W m W 0 } N ~ O ~ y NN~ O c ~ ~ Q N Y a~i Z C c of O ~ ~ N L LL~c~~r~a W 0 W y J J_ m ~ ~ M ` ~ ~ r 7d ~ ~ d Q ~ N n ^ ~ 1..~ O ~_ L ~ ~ Z p N C ~ ~ •~ a d O O V N ~~C~U~U H et = Q (~ Z M ~ ~ ~o °ac ~~ a~ ~Q 00 z ~, a N CQ M Cp Y ~ O ~.. Q ~ `SO ~ c'~~`~O U "_; ; '~~y a~ E 0 y~ ssaadx~ 15056051058 REV-1500 EX (06-05) pFFICUIL USE ONLY PA Department of Revenue Bureau of Individual Taxes Counly Cade Year File Number Po sox 280601 INHERITANCE TAX RETURN Hanisblxg, PA 1712&0601 RESIDENT DECEDENT ~ ~ C~~ Q~ ~ C~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 208-24-2287 03/15/2008 02/01/1934 Decedent's Last Name Suffix Decedent's First Name MI Staub Jr Nolan C (H Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Staub Diane ~ Spouse's Social Security Number 172-32-0511 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW • 1. Original Return 2. Supplemental Retum 3. Remainder Retum (date of death 4. Limited Estate prior to 12-13-82) 4a. Future Interest Compromise (date of 5. Federal Estate Tax Retum Required death after 12-12-82) • 6. Decedent Died Testate (Attach Copy of Will) 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (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 CONFIDENTUL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number John R. Kenny (602) 708-0030 Firrn Name (If Applicable) ^~ o " ~~ REGISTER ~1LLS USE OglLyr First line of address ~-C7 A =, ~ ~ ~ 4533 E. Lafayette Blvd 7:> ~Tl ~ ~ __~, ~ Second line of address I ~-, ,-- .~ City or Post Office ~._-_ _--~ N State ZIP Code DAx~I ED W Phoenix AZ 85018 ~ Correspondent's e-mail address: jkenny@gfnet.COm Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of know) it is true, correct and comp aration other than the my edge and belief, ~r p1epar~r~ personal representative is based on all information of which preparar has any knowledge SIGNATURE OF PER_ a c uciu 7•• •T-•I•-••••••••tr, ~~ ~ ~~~V RCI VRIY --- ------------- - ADDRESS 4533 E. Lafayette Blvd., Phoenix, 85018 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE 03/03/09 DATE ADDRESS ----------- ------ ------------ PLEASE USE ORIGINAL FORM ONLY ~~ -.~-~ ~ (.,'' 7 k::..! 'r.,-1 -... _J F i ~ _~-, 1 505605 1 058 Side 1 L 15056051058 J 15056052059 REV-1500 EX Decedent's Name: Nolan C Staub 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 8 Miscellaneous Personal Property (Schedule E) .... .... 5. 6. Jointly Owned Property (Schedule F) Separate Billing Requested ... .... 6. 7. Inter-Vivos Transfers 8 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/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. 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 00 286.42 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 18 19. TAX DUE ................................................ ..... ... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 Decedent's Social Security Number 208-24-2287 5,314.94 5,314.94 5,028.52 5,028.52 286.42 286.42 0.00 0.00 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: Fila Number DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Nolan C Staub _ 208-24-2287 STREET ADDRESS - - 5538 Moreland Court CITY --_ ---- -- - ~ STATE ~' ZIP ------ Mechanicsburg PA ; 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (3) (4) (5) (5A) (5B) (1) Total Credits (A + 9 + C) (2) Total Interest/Penalty (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. Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 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; .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or ............................................................... d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurced after December 12, 1982, did decedent transfer propeAy within one year of death without receiving adequate consideration? .................................................. 3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benef~iary designation? ....................................................................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requiremerrts 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 iwenty-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 benefiaaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)J. 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 EX+ (trgg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY w rwr ~ ur FILE NUMBER Nolan C. Staub, Jr ~tna_n~~n mciuae me proceeas of uhgauon and the date the proceeds were received by the estate. All property jointly-oMmed with richt of survivershin mu•f M rdewrnedl ..., c,.~~..~., e ~~~ ~~~~~~ ~Naw ~~ iwct,au, mserr aaamonar sneers a the same size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Nolan C. Staub, Jr ITEM NUMBER A. FUNERAL EXPENSES: t' Malpezzi Funeral Home SCHEpt~LE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS FILE NUMBER 2108-0320 l>abts of decedent must be reported on Schedule L 5,028.52 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(suEIN Number of Personal Representative(s) Street Address Crty .State Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as Gaimant's, attach explanation) Claimant SVeet Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip .Zip TOTAL (Also enter on line 9, Recapftulation) I s (If more space is needed, insert adddional streets of the same size) 5, 028.52 REV-1513 EX+ (li-OS) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF FILE NUMBER Nolan C. Staub, Jr 21r7R-ns~n NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY REDO NotSL st Trustee(s~NT AMOOF ESTATE ARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] 1. Diane C. Staub 5538 Moreland Court., Mechanicsburg, PA 17055 Spouse 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ 0.00 If more space is needed, insert additional sheets of the same size. - - - 01/09/1999 15:15 7177664906 LC~A WILLI PAGE 01 =~~ -~OVeI'el~l. Ba.~li STATEMENT O F ACCOUNTS "' ~bemertt Patiod OZI2SIOb1 TO 03r241E1s 1-877-SOV-HANK (1$77-788-2285) Mlw~+v.aoveroignb811k-com 80'VEREIQN FREE IN7'ER>I;ST CH~CKINO NOLAN C STAUB Account # 1689706995 Balabtces ~M-ntns 8alanoe 5328.42 current Batanos y188.14 OepoeitdCredite ~ 11,175.65 Average DaYy Balance 5851.49 Wlthdrswrets/Debita~ ~. - 11,037.83 ' lntabtist Paid fhle Period' S 0.07 Amt-al Percentage Yield Horned 0.1096 Eamed thi9 Period i 0.07 Palo last Year 5084 Paid YeanTo-Date S 0.20 ~~~ 'The Interest earned aftd the interest paid may differ 4epending on when inlerssl is credited td your ac00unt Checks Posted Check ~ Date Paid AnwuM R.ttence a Check if Date Paid Attlount Rehrenw 8 258,2 QSH7 518.80 818700710 2866• 03/44 SW.85 638061570 2684" 03113 :..__ i1o2-0t}"----- d3Q7987S0 _ .. 2867 (}x112 .. .,.yR~33:'!3 83662'4200 _. 4 CMak(a) Pasted a::84ti.66 An asterisk (') Indicabae a skip in esquential check numbers winch maybe caused by one of the folfovNng: ~ A deck not yet received • A t~tedc that was aonveRed to an elecfdonic b~aneaciion, which w4N bs listed in the 'Elet~lortic Checks Posbad" sectlOn bekwv. H no checks were alectronkxlfy converted, tlUb bection wip not appear. Electronic Checks Posted Check ft Date Pak! AmOtmb Payes Cheek d Dabs Paid Aneorx>< PayN 2669 Q3H 3 . SS.89 CAPITAL ON 7 Chsak(e) Posted Efet#rvnically~ 66.09 PNeee nob: The rnoronont you peld hoe oonvated tlbne checks kMO an ebcuor~c ttansadlon. Becticne we did not n>GSIw the orlylnel cfiectc or • copy of 1M check. we cannot OrovtOa Zf~e deck with this sta~en+erN. L! the chadt number ~ mm, tt means U» mercharA dki not pavkls the er-eck number fn the Droner tamot Ptaeq Iefer to the'Aaoount AdivRy seGlbn bakwv b kocate the check number In tl~e tranaacilon Oescriptlon. Account Actfvky Date Description 02-25 Bedinninp Baloutae 02-,27 -CH1eC+iFtfa PUR 378644 "~~i ~~~KCI-t~ANki :.: Addltlons 6ttAtractiana t s r 162-o6. ~3Z76r43 Beleuk:e 5328.42 ILO/7/IfA~• 01/09/1999 15:15 7177664906 LC~A WILLI PAGE 02 1-877-SOV-HANK (1.8T7.78&?~86) www.savsneip~k.oom ~~ TO 03/24/ON si•ONEREIOM FRi:E INTlJ!!~T CHECKMIG Account /lativtty (Corn, lot ACCtix 1681703915) Dsts D~sariptfop wdOitfonr 8ubbsttlors~ esi.r+c. 03-03 US TrtEASURY 903 11.038.00 SOC $EC 030308 11,313.43 A Sg,A :. ,, } ~ : N ~~, ~.,: z2o ~ .~ .. 1 03"12 ci~cK 2~~ ~~~'' _ , . ,4so. Ci~t1CK PYAA7 080312 ia•~ 51,209.79 2989 0314 _ ~'~ 2 , 0317 POS PAYMENT 881115 :~ ~ t ~. 1;114.9K VZWRLSSI b2WRLSSiVRD 1337.27 s777.e7 FOLSOM CA .'~~ s~ .rte ~.,~ ~. .. ~:. •~;;:'. °x$114 . i.: •+•' ~ :,.~, ~ 'y 'yr ~ ~: - ~~. s0~. +~ ~ ' .. '.i'1 ..,- 27.67 17 ATM W/D 310505 ,,,, MON81/ ACC SD3N21 STET 2.00 1485.87 CAMP HILL PA 03>7~ ~: 2582 03-24 INTEREST CREDIT ;:':i~.'~:'- :.; '19.90 =188.07• ~ Ba1a~ 10.07 1188.14 .1 nape 4 of S l68190S91S 7177664906 LC~A WILLI PAGE 03 ~~~' Michael J. Malpezzi, Owner • Jsremy J. Sharfzer, Punarxrl Dirselor HOME 8 Market Plarn Way • Mechanicsbwg, PA,170SS • Phone; (717) 697.4696 April 2l, 2008 $onnie Staub 5538 Moreland Count Mechanicsburg, PA 17055 The Funeral Service fnr Nolan Cttristiart Staub We sincerely appreciate the confidence you have placed in us and ~wili continue to assist you in every way we can. Please feat free to comact us if you have any questions in regard to this stittemettt. THE FALLOWING IS AN 11FMIZED STA'IENtENf OF TH,E SERVICES, FAC1L1'1'ff.3. AU'I'OM077VE EQC11PIvIENT, AND MERCHAriDISE THAT XOU SlrtECCED WHEN MAKING THE FUNERAL ARRANGP~N'I'S. 1. PROFF88IOI~iAL SERVICES 53263.00 Servioeb, Facilities end Cremuioa 9'[JNERAL HOMY SERVICY CHAItGYS ~~.~ 3ELECTI~.D iVIERCHANDISE: - . 5365.00 pltcrrrativo Cremetian Contain 5300.00 ALTERNATE S4S.00 Register, Folders, Adis. sssa.oo Merblo ICeepeak~ urr-a THE COST OF OUH SYICVICES, EQUIPMENT. AND MSRC.HI-PTDISE THAT YOII HAVE SELECTED S~t.4~2S.00 AT -fig 1IlvlE FUNERAL, ARRANC~EMEtJTS WERE MADE, WE ADYANC'ED CERTAIN PAYIviEN'19 TO OTHERS AS AN ACCOMMODATION. THE FOLLOWIIIG 1S AN ACCOUNI~1Ci FOR THOhE CHARC#E3. CASH ADVANCES Certified DatA Ce~tifitsltes 172.00 Newsom Notices - Patric 5256.52 ~~,~~ O SI00.00 ~.. Orgpnist .. _.... .. , .. ... ..__ ._ .. S7S.00 TOTAL CASH ADVANCES AND 5PECiAL CHARG3-S S3U-3.52 SUB-'DOTAL 53028.52 II1137AL PAYMENT / DLSCOIJNI' / CRF.DI'I'S TOTAL AMODNT DUE 53029.52 V ~ ~ / 01/09/1999 15:15 Will of Nolan C. Staub Part 1. Personal Information ' I, Nolan C. Staub, a resident of the State of Pennsylvania, Cumberland County, declare that this is my will. My Social Security number is 208-242287. Part 2. Revocation of Previous Wfils I revoke ail wills and codicils that I have previously made. Pert 3. Marital Statas I am married to:Diane C. Staub. Part 4..Chddren I havethe following children now living: Bonnie L. Staub and Christine Gloucher. Part S. Grandch~dren I have the following grandchild now Living: Angela Black. Part 6. Failure to Leave Property ff I do not Leave property. in this will to one or more of my cLuldren or my grandchild named above, my failure to do so is intentional. Part 7. Disposition of Property All beneficiaries must survive me for 45 days to receive property under this will. As used in this will, the phrase "survive me" means to be alive or in existence as an or ganization on the-45th day after my death. All personal and real property that I leave in this will shall pass subject to a~ enctimbrances or liens placed on the property as security for the repayment of a loan or debt. If I Leave property to be shared by two or more beneficiaries, it shall be shared equally by them unless this will provides otherwise. If I leave property to be shared by two or more beneficiaries, and any of them does not survive me, I leave his~ot her share to the others equally unless this will provides otherwise for that share: "Entire estate" means all property I own at my death that is subject to this wi11. I leave my entire estate to my wife Diane C. Staub, Lf my wife Diane C. Staub does not Pale i d 4 IniW1s: ~ ~` .• S Dates ~ ~ ~ C ~~ W~l of Nolan C. Staab survive me, I leave my entire estate to Bonnie L. Staub, Frank D. Kenny, Sharon L. Kenny and John R Kenny in equal shares. Part 8. Ezecutor I name John R Kenny to serve as my executor. If Tohn R Kenny is unwilling or unable to serve as executor, I name Frank D. Ken~r to serve instead. No executor shall be required to post bond. Part 9. Ezecutor"a Powers _ , I direct my executor to take all actions legally permissible to have the probate of my will done as simply and as free of court supervision as possible under the laws of the state having jurisdiction over this will, including filing a petition in the appropriate court for the independent administration of my estate. I great to my executor the following powers, to be exercised as he or she deems to be in the best interests of my estate: 1) To retain property without liability for loss or depreciation. Z) To dispose of property by public or private sale, or exchange, or otherwise, and receive and administer the proceeds as a part of my estate. 3) To vote stock, to exercise any option or privilege to convert bonds, notes, stocks or other secwhies belonging to my estate into other bonds, notes, stocks or other securities, and to exercise all other rights and privileges of a person owning similar property. 4) To lease any real property in my estate. 5) To abandon, adjust, arbitrate, compromise, sue on or defend and otherwise deal with and settle claims in fav6r of or against my estate. t7 To continue or participate in any business which is a pan of my estate, and to incorporate, dissolve or otherwise change the form of organization of the business. The powers, authority and discretion I grant to my executor are intended to be in addition to the powers, authority and discretion vested in him or her by operation of law by virtue of his or her office, and maybe exercised as often as is deemed necessary or advisable, without application to or approval by any court. Pale s of 4 ~~,,,~~' ~ -~ D~ ~~~ ~~a ~ Will of Nolan C. Staub Part 10. Payment of Debts Except for liens and encumbrances placed on property as security for the repayment of a loan or debt, I want all debts and expenses owed by my estate to be paid in the manner provided for by the Laws ofPennsylvania. Part 11. Payment of Taws I want all estate aad inheritance taxes assessed against property in my estate or against my beneficiaries to be paid in the manner provided for by the laws of Pennsylvania. Part 12. No Contest Provision If any beneficiary under this will corrtests this will or any of its provisions, any share or interest in my estate given to the contesting beneficiary under this will is revoked and shall be disposed of as if that contesting beneficiary had not survived me. Part 13. Severability ff any provision of this will is held im~alid, that shall not affect other provisions that can be given effect without the invalid provision. Signature I, Nolaa C. Staub; the testator, sign jmy name to this instrument, this _ 1 ~ ~~ ~y of _ ~4~C~~ ZbC3~-~ . at ll.~~~lt~ f~1~ ~ . I declare that I sign and execute this instrument as my last will, that I sign it willingly, and that I execute it as my free and voluntary act. I declare that I am of the age of majority or otherwise legally empowered to make a will, and under no constraint or undue influence. Signature: `-"~~ _ ~ - ~ Witnesses We, the witnesses, sign our names to this instnunerrt, and declare that the testator willingly signed and executed this instrument as the testator's last will. In the presence of the testator, and in the presence of each other, we sign this will as witnesses to the testator's signing. //// //// //// //// //// Pale 3 d4 Initlsls; y.~ ~ S Date: / ~ a z.~'. Will of Nolan C. Staab To the best of our laiowledge, the testator is of the age of majority or otherwise legally empowered to make a will, is mentally competent and under no constraint or undue influence. We declare under penalty of perjury that the foregoing is true and correct, this ( ~s -~ day of ~fQv~-~~ _ 2~~ , at ~~ ~ ~ ~ ~~~~~ ~ ~i~ Witness #1: ~ l ~'~lZ,/'7--- ~--~~~Lr1~ Residing at: ~~ Witness #2: Residing at: ~ /L/. ~%l~th / f f?ldl~l~~i,~ Ifl !/t'c ~l Z ~35'LS ~, ~~~ Page 4 ot4 Wtlals; - ~ ~ ~ ~a~ ~~~ ~" cam' / Affidavit ACKNOWLEDGMENT Commonwealth of Pennsylvania County of: ~1~~„~/~]~ I' (~~ 14 ~~ ~ v the testator whose name is signed to the attached or foregoing instument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Vvill; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Testator: '~-~-~~..~__.____ c~~- Officer: ~ , 1 ~ rT ~~l 1, _,_.. ~,s~ i`-t'k.•r~ T~ ~L..13-~ S. i~I.'7in:~ Pi.s~:v y i F ~-p'.L~i]iL`Q1~li~ 'bCa'O, CL~I1~Ei~a'fKl i~CU.'i~/ Mg~nber. P~ Associatior- Of Notaries Aff~davIt -Page 1 of 2 Affidavit AFFIDAVIT Commonwealth of Pennsylvania County of: C~~ ~-vlCtt We, i' ,Cl t~CL.~ ~ ~Yl c.-~ and _ ~l'~ Vt 9 ~/~1 ~ .the witnesses whose~names aze ~Signec~ to the attached or foregoing instrument, having been duly qualified according to law, do depose, and say that we were present and saw the testator sign and execute the instrument as his/her Last Will; that the testator signed willingly and executed it as his{her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testator signed the will as a witness; and that to the best of our knowledge the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. jS/Jw~,orn to or affirmed and subscribed to b~, ,ore me by ,~ 1 lLl~ C~- ~ ~ ~t~JL and ~'1a'~_- ~-t~.i/ with esses, this 1 c~ day of { C~~ , ~ _.~ Witness: '~~ ~11G~~~'. ~`~~ Witness: Off cer. ~ Flotarial Sc~ T. Burgess, Nofary Public _ _ Medianicsb~9 Bono. Cumberland County - - _ (,~y Cortxrrssion Expires Jae 26, 2006 - . - - - Member. RervisYNartia Assoaation Of WolatSs Affidavit -Page 2 of 2