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HomeMy WebLinkAbout05-18-09 (2) 1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Numt~er Bureau of Individual Taxes INHERITANCE TAX RETURN Po sox 2aosol 2 1 0 9 0 2 4 2 Harrisbu , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Suffix Decedent's First Name MI P E F F E R J A C Q U E L Y N L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL Q IN APPROPRIATE OVALS BELOW 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 ~ death after 12-12-82) 5. Federal Estate Tax Return Required © 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received ~ ~ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death ~ between 12-31-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number J A C Q U E L I N E A K E L L Y 7 1 7 5 4 1 5 5 5 0 Firm Name (If Applica ble) ----------------___-_ -_ _ REGISTER 9F WILLS USE:ONLY J A N L B R O W N & A S S O C ~` ; ~~ , ~_~ - ~ -; - / First line of address _ ~ ? ` ` ~ ~ 8 4 5 S I R T H O M A S C 0 U R T % ~ ~;~ Second line of addres s ~ ` ~-' ' ~ - :'j `7 ~ - S U I T E 1 2 ~ ~ ' -~ 'DAVE FILED City or Post Office State ZIP Code ~- -- - - --- - - - - H A R R I S B U R G P A ~~ _; 1 7 1 0 9 Correspondent's a-mail address: J A C K I E J L B a V E R I Z O N• N E T Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Dedaretion of preparer other than the personal representative ~ based on all information of which preparer has any knowledge. SIGNAT RE OF PER ON RESPON'6!'B FOR FILING RETURN ~ -~~~ ~~ ADD SS J 2300 L WISBERRY RO D YORK HAVEN PA 17370 SIGNATURE OF PREPAR R THAN RF~PR~ESENTATIVE DATE ADDRESS 845 SIR THOMAS_COURT, SUITE 12 HARRISBURG PA 17109 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 ~' J 1505607221 REV-1500 EX Decedent's Name: JACQUELYN L• PEEPER Decedent's Social Security Number 1 7 4 2 0 8 3 2 6 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. ' 8 7 3 0 1. 5 9 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... . 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... . 6• 4 0 5 6, 8 2 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property ~ Separate Billing Requested ...... . 7. 2 3 9 5 1, 0 3 (Schedule G) 8 1 1 5 3 0 9, 4 4 8. Total Gross Assets (total Lines 1-7) ......................... .. . 9 1 8 2 7 2. 1 6 9. •.•••••. •. Funeral Expenses 8 Administrative Costs (Schedule H) .. . •. . 6 2 8, 9 7 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......... 10 . . 11 1 8 9 0 1, 1 3 11. Total Deductions (totalLines9810) ..••~••••••••~••••••••• • •• 12 9 6 4 0 8. 3 1 12. Net Value of Estate (Line 8 minus Line 11) ............... • • • • .... . .. 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which ' . an election to tax has not been made (Schedule J) ................ .. 13. 9 6 4 0 8. 3 1 14. Net Value Subject to Tax (Line 12 minus Line 13) ............ .... ..1a. TAX COMPUTATION -SEE INSTRUCTIONS FOR APP LICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 Q 0 0 15 0. 0 0 . 16. Amount of Line 14 taxable 9 6 4 0 8. 3 1 16 4 3 3 8. 3 7 at lineal rate X •~45 . 17. Amount of Line 14 taxable 0 . 0 0 17 0 . 0 0 at sibling rate X .12 18. Amount of Line 14 taxable 0 . 0 0 18 0 . 0 0 at collateral rate X .15 , 19. 19. Tax Due ................................................ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505607221 Side 2 4 3 3 8. 3 7 0 1505607221 REV-1500 EX Page 3 File Number nnrnrlont'c rmm~iptp Address: 21 09 0242 DECEDENTS NAME JACQUELYN_L. PEEPER a/kJa JACQUELINE L. PE_FF_ER____ _ _ ___ _____ ___ _ _ _ __ __- STREET ADDRESS 204_FOUR SEASONS LANE_ ___- -- ---- - -_ - -- -- _ _ _ __ _. CITY ;STATE ZIP ENOLA ; PA ', 17025 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) (1) 4,338.37 2. Credits/Payments A, Spousal Poverty Credit B. Prior Payments C. Discount 216.92 Total Credits (A + B + C) (2) 216.92 3. Interest/Penalty if applicable D. Interest E. Perialty Total InteresUPenalty (D + E ) 4. If lane 2 is greater than Une 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) 4,121.45 (5A) (5BJ 4,121.45 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; .......................... .. ... ^ c. retain a reversionary interest; or ........................................................................................... ..... ^ d. receive the promise for life of either payments, benefits or care? ................................................. ...... 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 'in trust fol' 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 benefaary designation? ............................................................................................ .. IF THE ANSWER TO ANY OF THE ABOVE 4UESTIONS 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)J. 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 exemat 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 childtwenty-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)J. 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)J. 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 + (8-98) SCHEDULE E CASH, BANK DEPOSITS, 8c MISC. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER JACQUELYN L. PEEPER A/IVA JACQUELINE L. PEEPER 21 09 0242 Indude the proceeds of litigation and the date the prooseds 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 y . AmeriChoice Federal Credit Union 28,068.97 Certificate of Deposit #32267-63 2. AmeriChoice Federal Credit Union 28,054.08 Certificate of Deposit #32267-64 3. AmeriChoice Federal Credit Union 24,059.78 Certificate of Deposit #32267-65 4. AmeriChoice Federal Credit Union 1,825.03 Checking Account #32267-16 5. AmeriChoice Federal Credit Union 4,717.80 Money Market Account #32267-18 6. AmeriChoice Federal Credit Union 42.35 Savings Account #32267-01 7. Boscov's [HSBCJ credit card refund 15.00 8. Erie Insurance Group renter's insurance refund 9.00 g, Highmark FreedomBlue premium refund 148.40 10. IWinterdale Arms LLC security deposit refund I 361.18 TOTAL (Also enter on line 5, Recapitulation) ~ S g7 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN OF SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER JACQUELYN L. PEEPER A/K/A JACQUELINE L. PEEPER 21 09 0242 H an asset was made joint within one year of the decedents date of death, k must be reported on Schedule G. ADDRESS TIONSHIP TO DECEDENT SURVNING JOINT TENANT(S) NAME A. Sylvia A. Powley c IOINTLY-OWNED PROPERTY: 31 S. Humer Street Enola, PA 17025 daughter ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANGAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1 • A • 7/2007 AmeriChoice Federal Credit Union 8,113.63 50. 4,056.82 Sub-Savings, Funeral Account # 32267-02 TOTAL (Also enter on line 6, Recapitulation) I S 4,056.82 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN ESTATE OF JACQUELYN L. ITEM NUMBER 1• SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY L. FILE NUMBER 21 09 024 This schedule must be completed and filedrf the answer to any of questions 1 through 4 on fhe reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTInN nF oonoroTv I INCLUDE THE NAlAE OF THE TRANSFEREE, THEIR RHATIONSFgP TO DECEDENT AND THE DATE OF TRANSFER ATTACH A COPY OF THE PEED FOR REAL ESTATE AmenCholce Federal Credit Union 'IRA Certificate of Deposit Account #32267-80 Per contract agreement, default beneficiaries are: Melanie Haring, Richard L. Crone, and Sylvia Powley (natural children of decedent) DATE OF DEATH % OF DECD'S EXCLUSION VALUE OF ASSET INTEREST (IFAPPUCABLE) 23, 951.03 100. TOTAL (Also enter on line 7 Recapitulation) ~ S (If more space is needed, insert additional sheets of the same size) 23 TAXABLE VALUE 23- 9 0 REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ATE OF SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS FILE NUMBER JACQUELYN L. PEEPER A/IVA JACQUELINE L. PEEPER 21 09 0242 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. B ADMINISTRATIVE COSTS: Personal Representative's Commissions AMOUNT 7,509.07 150.00 450.00 Name of Personal Representative (s) Ronald D. Peffer Street Address 2300 LewisberN Road Cary York Haven State PA z;p 17370 Year(s) Commission Paid: 2009 2 , Attorney Fees Jan L. Brown & Associates 3. Family Exemption: (If decedent's address is not the same as daimanfs, attach explanation) Claimant Street Address COY State Zip Relationship of Claimant to Decedent '+ • ~ Probate Fees Register of Wills, Dauphin County 5 • I Accountant's Fees 6 • I Tax Return Preparer's Fees 4,685.73 4,612.38 181.00 7 • The Sentinel, legal advertising 187.54 8. Cumberland Law Journal, legal advertising 75.00 9. PPL Electric Utilities Corporation 259.61 10 Comcast Cable, utilities 5.53 11. Verizon, final phone bill 26.40 12. Debbie Lupold, Treasurer, 2009 County personal taxes 4.90 13. Register of Wills, Family Settlement Agreement filing fee 20.00 14. Register of Wills, Inheritance Tax Return and Inventory filing fees 30.00 15. Register of Wills, additional probate fees 75.00 TOTAL (Also enter on line 9, Recapitulation) ~ _ (If more space is needed, insert additional sheets of the same size) DESCRIPTION FUNERAL EXPENSES: 1. Richardson Funeral Home, Inc. 2. Romberger Memorials, marker 3. United Methodist Women, funeral lunch 6 REV-1512 EX + (12.03) SCHEDULE / COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, ~ LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER JACQUELYN L. PEEPER A/K/A JACQUELINE L. PEEPER 21 09 0242 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VAOF DEATDHTE 1. American Home Medical Equipment CH, outstanding medical bills 2. ~Verizon, check cleared after death 3. Check cleared after death, Ck# 3404 4. Check cleared after death, Ck# 3406 5.Check cleared after death, Ck# 3409 6. Check cleared after death, Ck# 3411 7.Check cleared after death, Ck# 3412 8. Check cleared after death, Ck# 3413 228.75 44.81 23.00 25.00 57.25 100.00 130.16 20.00 TOTAL (Also enter on line 10, Recapitulation) I S (If more space ~s needed, insert additional sheets of the same size) REV-1513 EX ti (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT tSIA1tUF FILE NUMBER JACQU ELYN L. PEEPER A/K/A JACQUELINE L. PEEPER 21 09 0242 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 [ndude outright spousal distributions, and transfers under Sec. 9t 16 (a) (1.2)] 1. Richard L. Crone Lineal 21 663 77 42 N. 34th St. , . Harrisburg, PA 17109 2. Kevin J. Haring (son of daughter, Melanie Haring, DOD 3/7/09) Lineal 10 831 88 50 South York St., PO. Box 51 , . Etters, PA 17319 3. Nicholas L. Haring (son of Melanie Haring) Lineal 10 831.88 50 South York St., PO. Box 51 , Etters, PA 17319 4. Paul William Peffer, Jr. Lineal 13,680.10 405 High St., P.O. Box 121 Summerdale, PA 17093 5. Ronald D. Peffer Lineal 13,680.10 2300 Lewisberry Road York Haven, PA 17370 6. Sylvia Powley Lineal 25,720.58 31 S. Humer St. Enola, PA 17025 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-15()0 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1• B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1• TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 5 (li more space Is needed, insert additional sheets of the same size) REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: _ 4,338.37 Discount: 216.92 i _ __ _ _ --- --- - - - - - --- --- ---- - --- - - - _-- __ ___ __ . --- - --- - ----'- I TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: _________.___._______ _______ Penalty: ESTATE OF JACQUELYN L. PEFFER A/K/A JACQUELINE L. PEFFER NO.: 21-09-0242 ATTACHMENT TO REV-1500 Decedent information on page 1 for Name (Last, First, Middle Initial) should be as follows: PEFFER, JACQUELYN L A/K/A PEFFER, JACQUELINE L Melanie Haring, who is one of the decedent's daughters, passed away on March 7, 2009. She did not survive the decedent by thirty (30) days as required pursuant to Article IV of the decedent's Last Will and Testament, which is attached hereto. Melanie Haring's share will be split between her two sons, Kevin J. Haring and Nicholas L. Haring, who are included on Schedule J. LAST WILL AND TESTAMENT OF JACQUELYN L. PEFFER a/k/a JACQUELINE L. PEFFER I, JACQUELYN L. PEFFER a/k/a JACQUELINE L. PEFFER, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from app c_7_ ~.~ person. This provision is not a waiver of any right which my Executor has to claim reim~rsemar~ _ ,_ ~ ,~, . ,-. for any such taxes which become payable as the result of any property over which I have t}ie~power __; :_,:-: ~~ of appointment. ~' ~.. ; ~~ ~ fV Article III I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exi st at my death, and if there is a conflict, the memorandum having the latest date shall govern. Article IV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath IN EQUAL SHARES to my children, SYLVIA POWLEY, of Cumberland County, Pennsylvania, RICHARD CRONE, of Dauphin County, Pennsylvania, RONALD D. PEFFER, of York County, Pennsylvania, MELANIE HARING, of Etters, Pennsylvania, and PAUL WILLIAM PEFFER, JR., of Cumberland County, Pennsylvania. If any of my beneficiaries predecease me or fail to survive me by thirty (30) days, I give, devise and bequeath1 his or her share to his or her issue who survive me, per stirpes, or if he or she has no issue, the share(s) are to be added equally to the other shares. Article V I nominate, constitute, and appoint my daughter, MELANIE HARING, as Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint my stepson, RONALD D. PEFFER as successor Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond and in addition to those powers granted by la~v, I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could have filed if living. My Executrix or successor Executor shall receive reasonable compensation for services rendered to my estate. Article VI In addition to the powers conferred by law, I authorize my Executrix and successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and -3- (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, JACQUELYN L. PEFFER a/Wa JACQUELINE L. PEFFER, hereby set my hand to this my Last Will and Testament, on - ~ ~ 2007. ' ~~~ti ~~ ~{,~~ ~ ~r~ ~~ ~' ~1~L~G'~uz.~'.~ ~- ~G,~7..~'c~ ~ACS,~'[JELYN L. PEFFER ' a/k/a JACQUELINE L. PEFFER In our presence, the above-named JACQUELYN L. PEFFER a/k/a JACQUELINE L. PEFFER signed this and declared this to be her Last Will and Testament and no~v at her request, in her presence, and in the presence of each other, we sign as witnesses. Name `~c~~~-- tC 1, n-~z- A rt r[racc 845 Sir Thomas Court, Suite 12. F{arrisbur~, PA 17109 845 Sir Thomas Court Suite 12 Harrisburg PA 17109 /,i -4- I, JACQUELYN L. PEFFER a/k/a JACQUELINE L. PEFFER, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by JACQUELYN L. PEFFER a/k/a JACQUELINE L. PEFFER, the Testatrix on ~- f ( 2007. ~. ~~~,~~ ota rPublic COfYIMONMEALTN Of PENNSYLVANIA NOTARIAL SEAL 1ACOUEIINE A. KELIY, NOTARY PUBLIC tOYJER PAXTON TWP., DAUPHIN COUNTI MY COb1MISSION EXPIRES DEC. 17, 2007 ._ AC LYN L. PEFFER a/Wa JACQUELINE L. PEFFER We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to la~v, depose and say that we were present and sa~v the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before(~me by ~~~~ t ct1 C ~.Lu- ~ and _1..,~:. 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