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Home My WebLink About05-04-09--~ REV-1500 1505607120 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes ounty a ear ~ e um PO 60X.280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 0 2 8 Social Security Number Date of Death Date of Birth 397665747 07162007 02251960 Decedent's Last Name Suffix Der~denYs First Name MI TIIHH3 LARRY G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Retum ^ 2. Supplemental Return ^ 3, Remainder Retum (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Retum Required (date of death aRer 12-12-82) ® g, Decedent Died Testate 7. Decedent Maintained a Living Trust (Attach Copy of Will) ^ (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 1 Q, 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) ame Daytime Telephone Number DALE F SHIIGHART; JR. ESQIIIRE 7172414311 Firm Name (if Applicable) First line of address 10 QPEST HIGH STREST Second line of address City or Post Offlce State ZIP Code CARLISLB PA 17013 REGISTEI~F WILLS U§1 ONLY _•_ - -,. - '~ - =j`~ i _, ~: .~ I - Dk~ILED "' Cv Correspondents e-mail address: itfirs t~rue~, ~Irnre~ct an d~com' e~ Dt~ia~ratlon of mined this return, incltxiinngg accomparrying schedules and statements, and to tha best of my knowledge and belief, pl p parer other than the personal re resentaUve is based on all information of which preparer ttas am knowledge. ' ~ r`~ Dale F Shughart, Jr. Esquire /~~~ zl~~ 10 West High Street, Carlisle, PA 17013 Side 1 1505607120 1505607120 J r~~ 11273 Bell Road, Wisconsin Rapids, WI 54494 REV-1500 EX oe~ede~rs Name: T U B B S, LARRY G. RECAPITULATION 1505607220 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) p Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested ............. 7, 8. Total Gross Assets (total Lines 1-7) ....................................................................... g. 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 12• Net Vatue of Estate (Line 8 minus Line 11) ............................................................. 12. 13. Charitable and Governmental BequestslSec 9113 Tr sts 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 (ax1.2) X .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 . 0 0 16. 1'7. Amount of Line 14 taxable at sibling rate X ,12 17. 18. Amount of Line 14 taxatiTe at collateral rate X .15 18. 19. Tax Due ..................................................................................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Decedent's Social Security Number 397665747 3,512.48 0.00 3,512.48 24,928.40 2,332.53 27,260.93 -23,748.45 -23,748.45 0.00 Side 2 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 09 - 0028 Tubbs, Larry G. STR ET AD RE ----- 106 "A" Street ITS' Carlisle TAE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Total Credits (A + B + C) InteresUPenalty if applicable (2) 0 , 0 0 p. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.0 0 4. If line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request arefund - 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.0 0 A. Enter the interest on the tax due. (5A) g. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0 " 0 Make Check Payable to: REG/STER OF WILLS, AGENT ~d~ett 9, .~c5~ i>a-r i :.} rs~ }k d~. j ~i3 `r _ ~SN,r•. :: } yrsY r.. , • i c., n _~.. , ,., .. r . ~.a~lG. tSC ,_ . ._ ..~ ~. .. ,. , , r - -i~F~y~7R'if.Sr J'~- r.IST~ _ .. lM S.i.,I~Y.,t .u, 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 :.................................... ^ 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? ....................................................................................................................... ^ 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 beneficiary designation? ............................................................ ........................ .................................. ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART O F THE RETURN. For dates o 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 exemot 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 decedents 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)]. 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. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Tubbs, Larry G. FILE NUMBER 21 - 09 - 0028 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 Household goods, furniture and furnishings 60.00 2 1993 Saturn stationwagon, value based upon actual private sale price. 500.00 3 State Farm, refund of auto insurance. 22.00 4 EXEL, final pay (162.49 + 319.96 + 169.40 + 162.49) 814.34 5 Sovereign Bank, checking account #1691032859 458.11 6 Fidelity 401 K dividend checks (149.17 + 149.39 + 149.47) 448.03 7 U. S. Treasury, 2007 Federal Income Tax refund 1,210.00 TOTAL (Also enter on Line 5, Recapitulation) ~ 3,512.48 COMMONWEJILTHOFPENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENrDECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Tubbs, Larry G. FILE NUMBER 21 - 09 - 0028 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM NUMBED, DESCRIPTION OF PROPERTY Include the name of the transferee, their relationship to decedent and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Qualified Pepsico 401K Plan which is not subject to 21,396.37 100% 21,396.37 0.00 inheritance tax under PA Regulations because decedent was 47 years of age and was therefore subject to a 10% premature withdrawal penalty. Pepsico 401(K) Plan for hourly employees #W016423-21Aug07. Statement attached: Beneficiary: Estate of Larry G. Tubbs 2 Qualified EXEL 401(K) Plan which is not subject to 77.48 100% 77.48 0.00 inheritance tax under PA Regulations because decedent was 47 years of age and was therefore subject to a 10% premature withdrawal penalty. EXEL 401(K) Plan Fidelity Investments Account ENV #OP030668. Statement attached: Beneficiary: Rachael Cooper, daughter 1 TOTAL (Also enter on line 7, Recapitulation) , 0.00 COMMONWEALTH OF PENNSYLVANIA INHER{TANCE TAX RETURN RESIDENT DECEDENT S(:IiEDULE H /FryUN~E~R~A-~LpEXP~NSES ~ /~W11/91gh71 IW 11YG FILE NUMBER --- ESTATE OF Tubbs, Larry G. 21 - 09 - 0028 Debts of decedent must be reported on Schedule I. -~ ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Taylor Mortuary, Inc., funeral expenses 10,191.54 ____ 2 ~ Haertel Monuments, headstone B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Judy Andres Social Security Number(s) / EIN Number of Personal Representative(s): 388-70-8838 Street Address 11273 Bell Road city Wisconsin Rapids state WI zip 54494 Year(s) Commission paid 2010 2. Attorney's Fees Dale F. Shughart, Jr. (est 5,000) Charles Rector 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 Register of Wills. probate fees (paid 50, owe 10)) 5. j Accountant's Fees 6. ~ Tax Return Preparer's Fees Hamilton C. Davis, Esquire (estimate) 7. Other Administrative Costs 1 The Sentinel, advertise Letters 1,640.00 1,000.00 9, 707.05 60.00 500.00 150.64 TOTAL (Also enter on line 9, Recapitulation) 24,92$.40 ScFtedWe H Fuier~l Expenses & COMMONWEALTH OF PENNSYLVANIA ~ w INHERITANCE TAX RETURN 1 NYCaeuVG RESIDENT DECEDENT ESTATE OF Tubbs, Larry G. 21 ~09 , 0028 2 Cumberland Law Journal, advertise Letters 75000 3 Judy Andres, reimburse airfare to and from Pennsylvania to probate Will. 802.17 4 Postmaster, certified mail 6.00 5 Register of Wills, filing Inheritance Tax Return and Inventory 30.00 6 Judy Andres, reimburse out of pocket expenses, travel, postage, long 250.00 distance, etc. 7 Register of Wills, Short Certificates 16.00 8 Reserve for filing account 500.00 Page 2 of Schedule H SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABiLIT1ES & LIENS INHERRANCE TAX RETURN ~ RESIDENT DECEDENT FILE NUMBER ESTATE OF Tubbs, Larry G. 21 - os - oo2s Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Cumberland-Goodwill Fire & Rescue, ambulance 1,584.13 2 ~ APEX Asset Management (Carlisle Emergency Physicians) ~ 183.00 3 ~ ARS, Inc., bills (debited from checking account after death) ~ 525.40 4 ~ W. Probel, preparing 2007 income tax returns. ~ 40.00 TOTAL (Also enter on Line 10, Recapitulation) ~ 2,332.53 REV-1513 EX+ (8-00) _ ~ SCHEDULE J I:OMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF I FILE NUMBER Tubbs, Larry G. I 1 21 - 09 - 0028 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS (inGude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Rachael Cooper Daughter one hundred percent 205 North Locust Point Road Mechanicsburg, PA 17050 Enter dollar amounts for distributions shown above on lines 1 5 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 II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI 0.00 Sovereign Bank ESTATE OF Larry G. Tubbs SOCIAL SECURITY #: 397-66-5747 DATE OF DEATH: 3uly 16, 2007 Account #: 1691032859 Type: Checking Open date: 11/13/2004 In the name of: Larry G Tubbs Date of Death Balance: $458.11 Int.(I'TD) from 1/1/2007 to 6/26/2007 Accrued interest to date of death: $0.00 other Info: Account closed on 01/12/09. $0.00 Page 1 of 1 ~ Sovereign Bank MA1 MB3 02-10 Court Ordered Processing/Decedent P.O.Box 841005 Boston, MA 02284 January 20, 2009 Dale F. Shughart, Jr. Attorney at Law 10 West High Street Carlisle, PA 17013 RE: Estate of Larry G. Tubbs Date of Death: 07/16/07 SS# 397-66-5747 Dear Mr. Shughart, Jr.: Per your request, enclosed please find account information as of the date of death for the above-named decedent. For your information, accrued interest in not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. Ve truly yours, I ~ ~e Nicole Job COP Specialist III Decedent Department (617) 533-1364 Exel January 30, 2009 Dale Shugart, Jr Attorney At Law 10 West High Street Carlisle, PA 17013 Dear Mr Shugart: I received your letter regarding Mr. Tubbs 401k account at Exel. Mr. Tubbs unfortunately did not have a beneficiary on file. Because he did not have a beneficiary named, our plan provides for the following protocol for transferring the deceased's account. That is as follows: N If no beneficiary is noted on file for the 401(k) account, the spouse is considered the automatic beneficiary; N If there is no spouse, then the account goes to the surviving children, in equal parts; N If there are no surviving children, the account goes to the surviving parents, in equal parts; N If there are no surviving parents, the account goes to the deceased's estate. According to the death certificate provided Mr. Tubbs was not married so his child(ren) would be the benefiiciaries and would receive equal parts. We will need birth certificates for any and ail of his children in order to proceed with distributing his account. You mentioned Mr. Tubbs daughter is a minor. We will also need paperwork showing her current guardian. As of the date of Mr, Tubbs death he did not have a balance in the 401k. The balance that is currently showing, $77.78 as of January 29, 2009, is the result of a profit sharing contribution made on behalf of Mr. Tubbs by the company. It is our policy that employees who pass away within a year that profit sharing is awarded are eligible for the contribution. The original contribution was made on May 9, 2008. If you have any questions, please do not hesitate to contact me at 614-865-8312 or Jenny.Furlow@Exel.com. Regards, ~~J~Z~/ nny Fur ow Benefits Coordinator-Retirement and Health & Welfare Exel, Inc. www.exel.com PEPSICO 407K PLAN FOR HRLY EMP 84513 MG THE ESTATE O LARRY G. TUBBS Ci0 JUDY ANDRES 11273 BELL ROAD WISCONSIN RAPID, WI 54494 :'SFJ~'A~Yii ' S~4•Ti4ivs V11, 1y r•aXy-Y4STq~>yq,~ Y .::-.- ta~' ~b~f~a Y £ .~~'~ ~ ~ ~ ~f..7.rF~ ~~ y v_ w'w. r'?c~{~`~)~~ v.K ~ 9t~~ x~.t't• ,ty+~+r/ ar::~+, e ~ _\ ~1C'~C~ftj/'~ITi(~St~~f1~S1n3#I~y tl w~~ ^1 \ .=fib ~., ...' ~ ... `fir~1 ~' \~ \ d ~. NVy. Y .: \ o~'G~F Nur~~elr ",, flcrot~nt EqurxtfiYei; ~"Date o~~fte 23$f~9b2~ ~ ',$,45}3 \. s :Feb 1~,~d0~. 'Pay to the Orcfer of, THE ~.STATS= ~O LAf~RY G. TUBBS ~ r. Ci0 JUDY ANDR~S;- ~fty=, <: 11273 $Ei L . ~.pA WISCONSIN-RQ~I~;,, WT :-54:494 Payment type: Death Benefit -non-spousal bene~ic ary Check Number: Check Date: 00238199523 February 17, 2009 Description Gross Curretrt Taxable $21,396.37 -- ----• $21,396.37 ~~f,. ~7 0528500016101 Lifetimes ,. PepsiCo 401(k} Plan for Hourly Employees MG4K 84513 THE ESTATE OF LARRY G. TUBBS Ci0 JUDY ANDRES 13273 BELL ROAD WISCQNSIN RAPIDS, WI 54494 February 17, 2009 uisxr~nuuon ~nxormatlon Ntease verity your transaction for accuracy, and report any discrepancies within 30 days. Discuss the taxability of this distribution with your tax advisor. Web: http:!/netbenefits.fideliiy.com {~ Phone:l-800-632-2014 Hours: Weekda 8:30 a.m. - Midni ht ET Important Information on Reviewing This Distribution Statement The following is a summary of a death benefit distribution processed from your account. Please keep this report until you receive a tax~form in January of next year. Remember to keep your address up-to-date, Distribution Summary Below is your total account balance after your withdrawal. Please verify the information for accuracy. Beginnsng Balance $21,396.37 Less withdrawal -21,396.37 Ending Balance $0.00 Tax Information Please verity the information for accuracy. Total Total Distribution $21,396.37 Total Taxable Amount $21,396.37 Ordinary Income Amount $21,396.37 Check Information Please verify the actual information agrees with this. THE ESTATE O LARRY G. TUBBS Chedc Date: 02/17/2009 Gross Amount $21,396.37 C!O JUDY ANDRES Check Number: 238199523 Net Amount $21,396.37 11273 BELL ROAD WISCONSIN RAPID, WI 54494 Confidential information Page 1 of 2 Fund Information The funds below were affected by your withdrawal. Please ver'rfy the information tar accuracy. Gash Withdrawn Pepsico Common Stck ` $37.0600 ~ 577.344 ~ $21,396.37 .~. .o .. o Source Information =o The sources below were affected by your withdrawal. Please verify the information for accuracy. ^ ~ o Beginning Vested Amount . o Source Balance 02/17/2009 Percent Withdrawn ~~ M ~~ Pre-Tax Flop $15,303.56 100.00 $15,303.56 ~ o Quaker Company Match $6,092.81 100.00 $6,092.81 ~ o ~r o ~^ ~ =a ~-~ ,. ~. N ~~~ ~~~ ~ ~ ~ s O _ r ~~ ~~ O ~-~ P =~ O• ~~ ~~ ~~ V O ~~ Page 2 of 2 Contidential Information LAST WILL AND TESTAMENT OF LARRY G. TUBBS I, Larry G. Tubbs, of North Middleton Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and revoke all Wills and Codicils previously made by me. ITEM T: I direct that all my legally enforceable debts and funeral expenses, including all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate. ITEM II: I bequeath any automobiles or motor vehicles I may own at my death, my personal effects, such household goods f:f.any as may be my .individual property and not the property of my wife or owned jointly by me with her, and other tangible personal property of like nature (not including cash or securities), together with any existing insurance thereon, to my wife, Tammy M. Tubbs, providing she survives me by thirty (30) days. Should my said wife predecease me or die on or before the thirtieth day following my death, I bequeath such tangible personal property and insurance thereon to such of my children as are living on the thirty-first day after my death, to be divided among them by my personal representative(s) with due regard for their personal preferences in as nearly equal shares as practical. I direct that any of the foregoing articles not selected by such children shall be sold at public yr private sale by my personal representative(s), and I further direct that the net proceeds thereof shall be administered and distributed as a part of the residue of my estate. ~ ~ ' L ITEM II: I devise and bequeath the residue of my estate of every nature and wherever situate, including any property over which I shall have any power of appointment, in equal shares to my wife, Tammy M. Tubbs, and to my daughter, Rachel S. Cooper. Should either my said wife or my said daughter predecease me, I devise and bequeath her share of my estate to the other. ITEM III: I appoint my wife, Tammy M. Tubbs, guardian of any property which passes, either under this Will or otherwise, to a minor and with respect to which I am authorized to appoint a guardian and have not otherwise specifically done so, provided that this appointment of a guardian shall not supersede the right of an fiduciary in its discretion to distribute a share where possible to the minor or to another for the minor's benefit. Such guardian(s) shall have the power to use principal, as well as income, from time to time for the minor's support, health and medical care, and education (including college education, both undergraduate and graduate), or to make payment for these purposes, without further responsibility, to the minor or to any person taking care of the minor. Should my said wife predecease me or fail to qualify or cease to act as guardian, I appoint my sister, Judy Andres, of Wisconsin Rapids, Wisconsin, guardian of the property. ITEM IV: All Federal, State and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether passing under this Will or otherwise, including any interest or penalty imposed in connection with such taxes, shall be considered a part of the expense of the administration of my estate and shall be paid out of the principal of my residuary estate without apportionment or right of reimbursement. ITEM V: I appoint my wife, Tammy M. Tubbs, Executrix of ~rhis my last Will. Should my said wife fail to qualify or cease G- to act as Executrix, I appoint my sister, Judy Andres, Executrix of this my last Will. ITEM VI: I direct that all fiduciaries acting under this Will, whether or not named herein, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal, this l0~ day of ~~tnti~ V 19 7 . r G- [ SEAL ] The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the Testator, was on the date thereof, signed, published and declared by Larry G. Tubbs, the Testator therein named, as and for his last 6~Ti11, in the presence of us, who, at his request, in his presence and in the presence of each other, have subscribed our names as witnesses hereto. ~ ' ~,<~' _ -- - COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND We, Larry G. Tubbs, William A. Addams and Mary M. Price, the Testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his last Will and that he has signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or 'due influence. ~' Li - Testator fitness y ~~ , ~~c.E,. Witness Subscribed, sworn to and acknowledged before me by Larry G. Tubbs, the Testator, and subscribed and sworn to before me by William A. Addams and Mary M. Price, the witnesses, this 10th day of September, 1997. L ~. Notary Public NOTARIAL SEAL MICHAEL A. RUNDLE, NOTARY PUBLIC BORO OF CARLISLE, CUMBERlANO COUNTY ' "' ''^"'""`~~~N FY.f~tRES OECEt~ABEfl 20. 1998