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HomeMy WebLinkAbout07-21-09 (2) UHIC,~ REV-1500 EX (D6-D5) PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 RESIDENT DECEDENT 2 1 0 8 1 1 8 0 Harrisbur , PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 3 1 4 2 0 1 6 2 7 1 0 2 7 2 0 0 8 0 2 1 0 1 9 2 0 Suffix Decedent's First Name MI Decedent's Last Name T S U T H E R L I N H A R R Y (If Applicable) Enter Surviving Spouse's Information Below Suffix Spouse's First Name Spouse's Last Name Spouse's Social Security Number MI FILL IN APPROPRIATE OVALS BELOW l Return t ^ 3. Remainder Return (date of death 0 1. Original Return ^ a 2. Supplemen prior to 12-13-82) te t d E ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required ^ a s 4. Limite death after 12-12-82) te t T ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes es a © 6. Decedent Died (Attach Copy of Will) Received d ^ (Attach Copy of Trust) f death t 1 D~ a r ^ nder Sec. 9113(A) 11 ~ a s ^ 9. Litigation Procee 95) 1 and 1 betweenl2 31-91 O) (Attach Sch BE DIRECTED T0: THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIA L n ml T U O O - CORRESPONDEN D ber ne Num elepho e T Name D C L I F F~ E S Q 7 1 7 2 6 9 '~ 8 . D A V I D H R A ~, - . Firm Name (If Applicable) t ~ REGISTER O •"-C7" US- E~ONk~F~ =- ~ R A D C L I F F L A W P C O F F I C E ~ r - c~ ~ ~ ~'` ~ - ~~ ~` I v ~~~'~ ~ First line of address , __, _, _ L Jt JTy'`° , ~ 1 0 1 1 M U M M A R O A D I '~~ ~ ~' --~ u Second line of address . w ~i -ram--~ ~ ~' ~r S U I T E 2 0 1 T~ I `~ ~ DATE FILED City or Post Office State ZIP Code __ ~ -- - - - _ - L E M O Y N E P A 1 7 0 4 3 Cerresp^nden±'s a-mail address: DHRRD lX.NETCOM.COf:~ Under penalti~e~ of ~e n oletee Declahation of p sparer other thanutherpersolnal aepresentative s based on aldl ntfor a6on of wh ch preparerf has any knowledge.belief, SIGNATjt1RE,Opi PERSON RESPQt31SIBLEf,~OR FILING RETURN Y / ADDRESS BETHLEHEM PA 18018 1814 MAIN STREET DATE . SI URE OF PREP RFb~OTHEFj.T}i~REPRESENTATIVE .? J' ~ ~ /1T,,.. C.sci~l/ i 1011 MUMMA RD #-2'01 1505607121 LEMOYNE PLEASE USE ORIGINAL FORM ONLY 1505607121 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Side 1 PA 17043 1505607121, 1505607221 REV-1500 EX Decedent's Social Security Number 3 1 4 2 0 1 6 2 7 Decedent's Name HARRY T SUTHERLIN RECAPITULATION 1. • 1. Real estate (Schedule A) 2 9 9 4 8 7.5 5 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. 4. Mortgages & Notes Receivable (Schedule D) 1 2 4 9 3. 6 4 5. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-PrSo paraterBieng Requested ....... 7. • (Schedule G) ^ 1 1 1 9 8 1. 1 9 .. $. 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses 8 Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, 8 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 13. ............ an election to tax has not been made (Schedule ...... 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 D D D 15. (a)(1.2) X ~0 16. Amount of Line 14 taxable 1 D 3 3 D 5 4 2 1s. at lineal rate X .045 17. Amount of Line 14 taxable D D D 17. at sibling rate X .12 18. Amount of Line 14 taxable D D D 18 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 7 7 7 4. 6 6 9 D 1. 1 1 8 6 7 5. 7 7 1 0 3 3 0 5. 4 2 1 0 3 3 0 5. 4 2 o. o D 4 6 4 8. 7 4 0. o D 0. D 0 4 6 4 8. 7 4 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME File Number 21 08 1180 HARRY_ T. SUTHERLIN _ _ - STREETADDRESS 1 LONGSDORF WAY _ _ - - _ -- -- _ _ _ _ - _ - - CITY CARLISLE Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments 4,000.00 C. Discount 210.52 3. InteresUPenalty if applicable D. Interest _- -__ _- STATE ZIP PA 17013 (1) 4,648.74 Total Credits (A + B + C) (2) 4,210.52 E. Penalty Total InteresUPenalty (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 Llne 2, enter the difference. This is the TAX DUE. (3) (4) 0.00 0.00 (5) 438.22 (5A) A. Enter the interest on the tax due. (5B) B. Enter the total of Line 5 + 5A. Thls is the BALANCE DUE. 438.22 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 X a. retain the use or income of the property transferred, ................................................. O b. retain the right to designate who shall use the property transferred or its income; ^ X ^ retain a reversionar interest; or ............................................................................................... c Y . ^ X 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? ..................................................................................... Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? 3 . ^ 0 . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which . ^ X 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 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 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-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER HARRY T. SUTHERLIN 21 08 1180 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT UAI E NUMBER DESCRIPTION OF DEATH 1, 20,000 PHILADELPHIA PA AUTH FOR INDL DEVELOPMENT 21,455.62 @ 5.125% DUE 10/1/2026 CUSIP 71781QBR8 WITH ACCRUED INTEREST OF $75.82 2. 20,000 PHILADELPHIA PA WATER & WASTEWATER REVENUE BOND 18,974.88 @4.8% DUE 11/1/2021 CUSIP 717893MS7 WITH ACCRUED INTEREST OF $469.48 3. 5,000 LEHIGH CO PA GENERAL PURPOSE AUTH HOSP REV BOND 4,884.56 @5.0% DUE 7/1/2031 CUSIP 524805U97 WITH ACCRUED INTEREST OF $81.51 4 000 FNMA REMIC TRUST 2001-79 2 1,985.52 . , CUSIP 31392BMK9 WITH ACCRUED INTEREST $.52 5. 465.61802 SH DUKE REALTY CORP @$10.65/SHARE 4,958.83 CUSIP 264411505 6. 482.95338 SH KIMCO REALTY CORP COM @ $17.62/SHARE 8,509.64 CUSIP 494468109 7. 100.835 SH CAPITAL INCOME BLDR FD @$38.51 3,883.16 CUSIP 140193103 8. 88.181 SH CAPITAL WORLD GRTH & INCOME @$23.14 2,040.51 CUSIP 140543109 g. 1550.351 SH LORD ABBETT AFFILIATED FD @$8.08 12,526.84 CUSIP 544001100 10. 1228.202 SH LORD ABBETT INVT TR BAL STRGY @$7.49 9,199.23 CUSIP 543916209 11. 529.448 SH LORD ABBETT MID CAP VALUE FD @$9.51 5,035.05 CUSIP 543919104 12. 879.549 SH PIONEER HIGH YIELD FD @$6.68 6,033.71 CUSIP 723698208 TOTAL (Also enter on line 2, Recapitulation) I $ 7.55 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHERITAtvCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER HARRY T. SUTHERLIN 21 08 1180 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ORRSTOWN BANK ACCT #106004669 722.89 2. EDWARD JONES ACCT 377-07308-1-4 MONEY MARKET 9,612.02 3. 2008 FEDERAL INCOME TAX REFUND 1,331.00 4. REFUND -HIGHMARK INS PREMIUM 176.97 5. REIMBURSEMENT -HIGHMARK 31.39 6. REFUND - DIAKON LUTHERAN 553.98 7. BETHLEHEM STEEL 13.13 8. EXXON MOBIL CORP 52.26 TOTAL (Also enter on line 5, Recapitulation) I $ 12,493.64 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8r ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER HARRY T. SUTHERLIN 21 08 1180 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 3,472.34 B. 2. 3. 4 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City State _ Year(s) Commission Paid: Attorney Fees RADCLIFF LAW OFFICE, P.C. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees FULKS, BARNARD & GAY, LLC LEGAL ADVERTISING -CUMBERLAND LAW JOURNAL LEGAL ADVERTISING -THE SENTINEL FILING FEES -INVENTORY & PA 1500 PNC BANK -INCOMING WIRE TRANSFER FEE PNC BANK -FEE FOR CASHIER'S CHECK ADDITIONAL SHORT CERTIFICATE REIMBURSEMENT PRIORITY MAIL ADDITIONAL PROBATE Zip 68.00 235.00 75.00 118.72 30.00 12.00 10.00 4.00 9.60 240.00 TOTAL (Also enter on line 9, Recapitulation) I $ ~ ~~„ ac Zip 3, 500.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, H~ LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER HARRY T. SUTHERLIN 21 08 1180 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. CONTINUING CARE RX 338.46 2. 2008 PA INCOME TAX PAID WITH FINAL RETURN 206.00 3. RADCLIFF LAW OFFICE, P.C. (INVOICE #18434 FOR AUG/SEPT) 200.00 4. HIGHMARK 27.70 5. METLIFE 106.15 6. ~NETZERO I 22.80 TOTAL (Also enter on line 10, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-^ 513 EX + (g_00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF HARRY NUMBER I. 1. 2. 3. 4. T. SUTHERLIN NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)I WILLIAM R. FERRY 1814 MAIN STREET BETHLEHEM, PA 18018 RICHARD L FERRY 3105 BIRCH WHITEHALL, PA 18052 GERARD K. SUTHERLIN 3150 RAMBLEWOOD DRIVE, APT 1B INDIANAPOLIS, IN 46268-4521 MARIETTA SUTHERLIN 8/11 REDDALL STREET MANLY #2095, NSW, AUSTALIA FILE NUMBER 21 08 1180 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal Lineal Lineal Lineal AMOUNT UR SHARE OF ESTATE 25, 826.36 25,826.35 25,826.36 25,826.35 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 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 SHEET $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, HARRY T. SUTHERLIN currently residing at 109 Ege Drive, Carlisle, Cumberland County, Commonwealth of Pennsylvania, being in good health and of sound and disposing memory do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all of my debts not barred by the statute of limitations, expenses of my last illness, fimeral expenses, costs of administration and claims allotted in the administration of my estate shall be paid by my Executor hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I bequeath my automobiles, household and personal effects and other tangible personal property of like nature (not including cash or securities), together with any existing insurance thereon, as are set forth in separate memoranda, which I shall place with my Will, to the persons therein designated. Any tangible personal property and other personal effects not otherwise specifically listed in such separate memoranda shall be distributed as provided in paragraph THIRD below. THIRD: To the extent that such memoranda fail to dispose of all personal property or if no memorandum is inexistence at my death, then I give all such personal property not disposed of by separate memorandum in four equal shares to my children GERARD K. SUTHERLIN and MARIETTA SUTHERLIN and my step sons WILLIAM R. FERRY and RICHARD L. FERRY, to be divided among them as they agree or, if they are unable to agree, then by making alternate selections of items in turn, with the oldest going first, until each has selected an equal dollar amount. Any of the above items not so disposed of shall be sold by my personal representative and the proceeds added to my residuary estate. FOURTH: If at the time of my death, I have any equity remaining in Cumberland Crossings or any traceable proceeds, I give and bequeath that into two equal shares as follows: A) One share shall be divided equally between GERARD K. SUTHERLIN, MARIETTA SUTHERLIN, WILLIAM R. FERRY and RICHARD L. FERRY; and B) One share shall be divided equally between my spouse's children RICHARD GROSS, RANDOLPH GROSS and NANCY WALSH. FIFTH: I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situate, in equal shares unto my children and my late wife's children, namely, GERARD K. SUTHERLIN, MARIETTA SUTHERLIN, WILLIAM R. FERRY and RICHARD L. FERRY, to be theirs absolutely. If any of them should fail to survive me, then to their respective issue, per stirpes. SIXTH: I hereby nominate, constitute, and appoint GERARD K. SUTHERLIN and WILLIAM R. FERRY, Executors of this, my Last Will and Testament. If GERARD K. SUTHERLIN fails to qualify or ceases to act as Executor, I nominate and appoint MARIETTA SUTHERLIN as an Executor without necessity for posting security regardless of state of residence, as Executor of this, my Last Will and Testament. If WILLIAM R. FERRY fails to qualify or ceases to act as an Executor, I nominate and appoint RICHARD L. FERRY as an executor of this my Last Will and Testament without necessity for posting security regardless of state of residence. All references to the Executor herein shall be applicable to said substitute Executor. SEVENTH: If any income or principal shall be payable under my Last Will and Testament or by operation of law to a beneficiary who has not yet attained the age of twenty-one (21), my Executors shall appoint a custodian and a substitute custodian for said beneficiary in accordance with the Pennsylvania Uniform Transfers to Minor Act. Nothing herein shall prevent my Executors-from serving as custodian. EIGHTH: To the greatest extent permitted by law, no interest in income or principal shall be assignable by, or available to anyone having a claim against, a beneficiary before actual payment to the beneficiary. However, a beneficiary may assign any part or all of his or her interest to his or her descendants. NINTH: My Executor shall have, in addition to the powers and authority conferred upon him by law, the following additional powers and authority: 1. To sell at public or private sale, exchange, transfer, partition, give options upon, lease, mortgage, pledge or otherwise dispose of any property, real or personal, at any time constituting a portion of my estate, and upon such terms and conditions as the Executor shall deem wise. 2. To invest any money at any time in such bonds, stocks, notes, real estate, mortgages, life insurance, annuities or other securities, or such property, real or personal, as the Executor shall deem wise, without being limited by any statutes or rule of law regarding investments by the Executor. 3. To retain, without incurring any liability, as investments, any property owned by me at the time of my death, as long as my Executor may deem it wise, and even though such property is not the kind of property an Executor would purchase as an investment; and even though to retain such property might violate sound diversification principles. 4. To cause any security or other property which may constitute a portion of my estate to be issued, held or registered in the Executor's own name, or in the name of a nominee, or in such form that title will pass by delivery. 5. To consent to the reorganization, consolidation, readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of my estate, and to take any action with reference to such securities which, in the opinion of the Executor is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right --, given to my Executor as owner of any securities constituting a portion of my estate resulting from any reorganization, consolidation, readjustment, sale, conversion or subscription. 6. To pay all costs, taxes, charges and expenses in connection with the administration of my estate, including such compensations to Executor which shall be in accordance with established fees throughout the period of administration of my estate. 7. To determine what is "income" and what is "principal" hereunder, and my Executor's decision thereon shall be final; and to purchase securities at a premium or discount, and to apply or charge said premium or discount against income or principal as the Executor may determine. 8. The Executor may make payments to or on behalf of any person who is the beneficiary hereunder but in no event, however, shall payments be made to any creditor or other such person because of anticipation of payment by the beneficiary, and any such claim made by way of anticipation by the beneficiary shall be of no validity or legal effect. 9. To borrow money from any person, firm or corporation, including any corporation acting as an Executor hereunder, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. 10. To employ legal counsel, accountants, brokers, investment advisors, custodians, managers and other agents and employees and to pay reasonable compensation out of my estate or any funds held hereunder to which said compensation is attributable. 11. To carry on any business owned or controlled by me at my death for whatever period of time my Executor shall think proper, and my Executor shall have the power to do any and all things my Executor deems necessary or appropriate, including the power to close out, liquidate or sell the business at such time and upon such terms as my Executor shall deem best. 12. To do all other acts in my Executor's judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. TENTH: I direct that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executor pay, or provide for payment of all such taxes at such time, or times, and in such manner as my Executor deems best. IN WITNESS WHEREOF, I, HARRY T. SUTHERLIN, the Testator to this, my Last Will and Testament, typewritten on five sheets of paper which I have identified at the bottom of each page by my signature, hereunto set my hand and seal the ~ ~ day of 2003. ,~ G ~. HARRY . SUTHERLIN The preceding instrument consisting of this and four other typewritten pages, each identified by the signature of the Testator, HARRY T. SUTHERLIN, this day and date thereof signed, published and declared by HARRY T. SUTHERLIN, the Testator therein named, as and for his Last Will, 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. /~"LC~ lCc-~ g ~ ( COMMONWEA/LTH OF PENNSYLVANIA = SS COUNTY OF ( CIO ~ ~ C- A!U~ - I, HARRY T. SUTHERLIN, Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my-Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ,{ i!~ HARRY . SUTHERLIN ~~ ~ `Sworn or rrmed to and acknowledged before me by HARRY T. SUTHERLIN, Testator, the -~-~-~~'-day of , 2003. (SEAL) ~~ Notary Public NOTARIAL SEAL Public Roberta L. Rod ~ Co °~ of ~u~dand Wormleysburg Bo g 'Tres Jan. 20, 2005 My Commission Exp COMMONWEALTH OF PENNSYLVANIA COUNTY OF L.-UYnI~E~C ~ ^~~ We ~RJ/~ l~ ,~tgDur ~F and /-'t~Cf~,~~ ~ ~'4'~ ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his Last Will; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us ine Testator was at thatttime eighteen or more yearsJof ageWOf sound and that to the best of our knowledge th mind and under no constraint or undue influence. ~~ CL F~ and Sworn or affirmed to an subscribed to before me by ~'y~ witnesses, this r ~5~, day of of 2003. ll'I I L~~EL 3 yF ~~ ~ Notaryy Public ~ (SEAL) NOTARIAL SEAL Public Roberta L. Radcliff, Notaoryf Curr~dand 6 Wormleysburg Borough, Cour+tY 2005 MY Commission Exp+res Jan. 20,