HomeMy WebLinkAbout11-16-09-~ REV-1500 1505607120
FJC (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year Fife Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO 60X.280601
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 0 9 075(0
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
115145668 05162009 01081923
Decedent's Last Name Suffix Decedent's First Name MI
PERSAK LOUISE A
(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 IN APPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ qa. Future Interest Compromise
(date of death after 12-12-82) ^ 5. Federal Estate Tax Return Required
® g Decedent Died Testate ^
(Attach Copy of Will) ~ Decedent Maintained a Living Trust
(Attach Copy of Trust) ~
- 8. Total Number of Safe De
pOSit BOXeS
^ 9. Litigation Proceeds Received ^ 1 p, Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
^ 11, Election to tax under Sec. 9113 A
( )
(Attach Sch. O)
,C,ORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIONt SHOULD BE DIRECTED T0:
rename
Daytime Telephony Number
RICHARD E. CONNELL ESQ. 7172328731 ''"~
Firm Name (If Applicable) ~~ "t
BALL , MURREN & CONN
ELL REGISTERr~ILLS US NLY`-~ •
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First line of address •~ µ„ ~
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2303 MARKET STREET ~
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Second line of address ~~ ~
City or Post Office
CAMP HILL
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DATE FILED ""~
State ZIP Code -=
PA 17011
Correspondent'se-mail address: connell~bmc-law.net
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. DeGaration of prepares other than the personal representative Is based on all information of which prepares has any knowledge.
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lA.~.~ ~'` _ Warren J. Persak I t ~ I l~ o ~
ADDRESS
13 Dewber Court, Mechanicsburg, PA 17055
SIGNAT E OF PREP,eRER THER PR TA DATE
Richard E. Connell Esq. ~ ~ ~ / v
ADDRESS
2303 Market Street, Camp Hill, PA 17011
1505607120
Side 1
1505607120 J
J 1505607220
REV-1500 EX
Decedent's Social Security Number
Decedent's Nema: P E R S A K, L O U I S E A. 11514 5 6 6 8
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4.
5• Cash, Bank De osits & Miscellaneous Personal Pro e
P p rty (Schedule E) ................
5. 5 0 0 . 0 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6. 2 6 , 0 2 5 . 5 7
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ............. 7, 1 1 , 0 9 5 . 8 9
8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 3 7 , 6 21.4 6
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 12 , 2 5 6.17
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10.
11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 12 , 2 5 6.17
12• Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 2 5 , 3 6 5 . 2 9
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .....:........................................... 13. 4 0 0 . 0 0
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. 2 4 , 9 6 5 . 2 9
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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 2 4, 9 6 5. 2 9 16. 1, 12 3. 4 4
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. 1 , 12 3 . 4 4
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505607220 1505607220 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 09 - 0756
Persak, Louise A.
STREET ADDRESS
4833 East Trindle Road
Room 573
CITY
Mechanicsburg STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
p, Interest
E. Penalty
975.00
51.32
Total Credits (A + B + C)
(1) 1,123.44
(2) 1,026.32
Total InteresUPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
q. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3) 0.00
(4)
(5) 97.12
(5A)
(56> 9 7.12
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................. ^ x^
b. retain the right to designate who shall use the property transferred or its income :.................................... ^ x^
c. retain a reversionary interest; or .................................................................................................................. ^ ^x
d. receive the promise for life of either payments, benefits or care? .............................................................. ^ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ^ ^x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ ^x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... ^x ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE'IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(0) percent [72 P.S. §9116 (a) (1.1) (ii)]. 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)]. 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
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Persak, Louise A. 21 - 09 - 0756
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 Personal Effects 500.00
TOTAL (Also enter on Line 5, RecapitulationQ, ~ 500.00
SCHEDULE F
COMMNHERITANCETAXRETURNANIA JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Persak, Louise A. 21 - 09 - 0756
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
Warren John Persak 13 Dewberry Court Son
A Harrisburg, PA 17055
JOINTLY OWNED PROPERTY:
LETTER
ITEM ~ FOR JOINT
NUMBER TENANT DATE
MADE
JOINT Include name o~Ffina ciaTnatitutlon a pd bank account number
or similar identifying number. Attach deed for jointly-held real
estate. DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1 A Schwab: Account No. 70297937 46,841.36 50% 23,420.68
2 A 01/31/1998 Members 1st Federal Credit Union 3,779.28 50% 1,889.64
i 173565-05
3 A
II
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I
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t
I ~
i
i 01/31/1998
i
I
i Members 1st Federal Credit Union 1,430.49 50% (
I
i
I
I
I 715.25
TOTAL (Also enter on line 6, Recapitulation) 26,025.57
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Persak, Louise A.
FILE NUMBER
21 - 09 - 0756
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
InGude 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 EXCLUSIpN
(IF APPLICABLE)
TAXABLE VALUE
1 Members 1st Federal Credit Union 11,095.89 100% 11
095.89
IRA for Louise A. Persak
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I
I ,
TOTAL (Also enter on line 7, Recapitulation) ' 11,095.89
~, -
COAMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
St:FEDULE H
~F~1y~~Ew72A~L.D~~EE~N~SyES~&-
/~~LAr~1~F71 IW I IYG V~.h71 ~7
ESTATE OF Persak, Louise A. FILE NUMBER
21 - 09 - 0756
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Malpezzi Funeral Home 9,545.97
2 Burial Fee 1,075.00
3 Reception 465.20
B.
1
DMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
2.
3.
~itY State Zip
Year(s) Commission paid
Attorney's Fees Ball, Murren 8~ Connell
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
4.
5.
6.
7.
1
Street Address
City State Zip
Relationship of Claimant to Decedent
probate Fees
accountant's Fees For final lifetime returns
fax Return Preparer's Fees
~therAdministrative Costs
ax Program for Decedent's Final Returns
540.00
500.00
100.00
TOTAL (Also enter on line 9, Recapitulation) 12,256.17
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Sched~Ye H
w~,~,,F~,u,~n,~er~alNF~ert~ses &
/"1R~Y 1 ^1 Y~ aY~ ~lJ~~
ESTATE OF Persak, Louise A. FILE NUMBER
21 - 09 - 0756
2 Register of Wills Cumberland County -filing fees
Inheritance Tax Return $15
Inventory $15
30.00
Page 2 of Schedule H
REV-1 ti13 tJt+ (9.00)
a a
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA
INHERITAN
T BENEFICIARIES
CE
AX RETURN
RESIDENT DECEDENT
ESTATE OF
Persak, Louise A. FILE NUMBER
21 - 09 - 0756
NUMBER '; NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO
DECEDENT SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($$$)
RECEIVING PROPERTY Do Not ust Trustee(s)
I~ TAXABLE DISTRIBUTIONS [include outright spousal
j distributions, and transfers
under Sec. 9116 (a) (1.2)]
1 ;Warren J. Persak Son
I, 13 Dewberry Court
Mechanicsburg, PA 17055
2 'Janice L. Neske Daughter
1056 Chedworth Circle
Mahwah, NJ 07430
,!Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropriate, on Rev 1500 cover sheet
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS
NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 Saint Joseph Church 200.00
2 Saint Joseph Church 200.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 400.00
LAST WILL AND TESTAMENT
OF
LOUISE A. PERSAK
KNOW ALL MEN BY THESE PRESENTS, that I, LOUISE A. PERSAK,
presently residing at 4833 East Trindle Road, Mechanicsburg, Cumberland County,
Pennsylvania, do hereby make, declare, and publish this as my List Will and
Testament, hereby revoking all former Wills and Codicils heretofore made by me at
any time.
PAYMENT OF EXPENSES
I. Payment of Expenses. I direct that my Executor (Executrix), hereinafter
named, shall have the power; but not the duty, to pay all my just debts, expenses of
my .last illness, and funeral expenses from my estate as soon after my decease as
shall be found convenient.
GIFTS
II. Specific Bequests:
A. I give and bequeath to St. Joseph Home for the Blind, Jersey City, New
Jersey the sum of Two Hundred ($200) Dollars.
B. I give the sum of Two Hundred ($200) Dollars to St. Joseph Roman
Catholic Church, Mechanicsburg, Pennsylvania to have Masses- offered for the
repose of my soul.
C. I give and bequeath to my daughter, JANICE L. NESKE, all of my
jewelry.
D. I have not included monetary gifts for my sisters, MARIE FRANCE or
JANET O'MOORE, not however out of any lack of concern for them. I do wish to
express my deep affection for each and my gratitude for the support, love and
concern which they have displayed for me during our lives.
III. Personal and Household Effects: I bequeath my household aid personal
effects and other tangible personalty of like nature (not including cash or
securities), together with any existing insurance thereon to be divided equally
between my son, WARREN J. PERSAK and my daughter, JANICE L. NESKE. If
either my son, WARREN J. PERSAK, or daughter, JANICE L. NESKE predeceases
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me or dies within thirty-one (31) days after my death, leaving issue to survive him
or her, said child's share shall be allotted to his or her then living issue, per stirpes,
but in default of such issue, such share shall be added to the share of my other
child.
The costs of packing, shipping, disposing of, insuring or valuing said personal
property shall be paid by my Executor (Executrix) as ari administrative expense of
my estate.
I may leave a written memorandum referencing certain items of my personal
property and while the instructions therein are not legally binding, I express the
hope that the personal representative and my beneficiaries named hexein will honor
those requests.
IV. Residu Estate.
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 situated, specifically including that property held in trust over which I
have a limited power of appointment under Paragraph 7(B)(3) of the Will of my
father, John F. Burns, said trust being administered by Bankers Trust Company
and do hereby exercise the power of appointment and direct that the principal of my
share of the trust be paid over completely, absolutely, and free of tryst obligations
pursuant to this Residuary clause, in equal shares to my son, WARREN J.
PERSAK, and my daughter, JANICE L. NESKE, if the respective beneficiary
survives me by thirty-one (31) days, but if not, then as further provided in this
Paragraph IV.
A. If my son, WARREN J. PERSAK, has predeceased me or dies within
thirty-one days after my death, I give his share to my daughter-in-law, MICHELE,
but if she has predeceased him or dies within thirty-one (31) days of m~ death, said
share shall be distributed in equal shares to Warren and Michele's chilldren,
CHRISTOPHER, BRYAN and KATHLEEN, but if any of them have predeceased,
then to their issue, per stirpes and not per capita.
B. If my daughter, JANICE L. NESKE has predeceased me or dies within
thirty-one days after my death, 1 give her share to her daughter, JENNA.
FIDUCIARIES
V. Executor. I hereby nominate, constitute and appoint my son, WARREN
J. PERSAK, Executor of this my Last Will and Testament. In the event that he
~''~ ~. ~
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should predecease, or decline the appointment, I appoint my daughter, JANICE L.
NESKE, as Executrix.
VI. Compensation of Executrix Any individual Executor (Executrix) is
entitled to be paid for the fair and reasonable value of services rendered.
Regardless of whether or not such individual chooses to accept such compensation,
she (he) shall be reimbursed for all expenses incurred as a result of so serving.
VII. Bond. No Executor (Executrix or guardian appointed hereunder) shall
be required to give bond or enter security for the performance of his/her duties.
ADMINISTRATIVE PROVISIONS
VIII. Management Provisions. My Executor (Executrix) shall have, in
addition. to the powers and authority conferred upon them by law, the following
additional powers and authority:
A. Sell/Lease. To sell at public or private sale, exchange, lease, mortgage or
pledge any property, real or personal, at any time, and upon such terms and
conditions as he/she shall deem wise.
B. Retain/Invest. To retain and to invest in all forms of real and personal
property, including common trust funds, mutual funds and money market
deposit accounts regardless of any limitations imposed by law on investments
by executors, or any principle of law concerning investment diveirsification.
C. Title to Property. To cause any security or other property which may
constitute a portion to be issued, held or registered in his/her owtn name, or in
the name of a nominee, or in such form that title will pass by delivery.'
D. Capital changes. 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 benefilt of any such
reorganization, consolidation, readjustment or sale; to exercise any
conversion privilege or subscription right given to him/her as the owner of
any securities constituting a portion of my Estate; to accept and hold as a
portion of my Estate securities resulting from any reorganization,
consolidation, readjustment, sale, conversion or subscription.
E. Expense of Trust or Estate. To pay all costs, taxes, charges and
expenses in connection with the administration of my Estate.
-3-
F: Allocate. To determine what is "income" and what is "principal"
hereunder, and his/her 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 (Executrix) may
determine.
G. Borrow. To borrow money from any person, firm ~or corporation, for the
purpose of protecting and preserving or improving my Estate hereunder; to
execute promissory notes or other obligations for amounts so borrowed.
IX. Beneficiaries Under 21 or Disabled. If any beneficiary hereunder
becomes entitled to an outright clistribution .of income or principal and is (i) under
the age of 21 years or (ii) in the Executor's opinion, disabled by ill.hess or other
cause and unable to properly manage the funds: .
A. Payments: As much of such income or principal as the Executor may from
time to time think desirable for that beneficiary either shall be paid to
him/her or shall be applied for his or her benefit; and
B. Balance: The balance of such income and principal -- and the net
income from those funds -- shall be kept invested and managed as a separate
account for that beneficiary, with the funds paid to or for the beneficiary in
accordance with the provisions of the preceding paragraph. When the
beneficiary reaches the age of 21 or, in the Executor's opinion, becomes free of
disability, as the case may be, the balance shall be paid to the beneficiary. If
he/she dies before that time, the balance shall be paid to his personal
representative.
Any funds to be applied under this article. either shall be applied clirectly by the
Executor or shall be paid to a parent or guardian of the beneficiary or to any person
or organization taking care of the beneficiary. Funds applied for minors may also
include distribution to a custodian selected and appointed by my Executor under
the Uniform Gifts or Transfers to Minors Act of any state. The Executor shall have
no further responsibility for any funds so paid or applied.
X. Protective Provision: To the greatest extent permitted b~ law, before
actual payment to a beneficiary no interest in income or principal shall be (i)
assignable to a beneficiary or (u) available to anyone having a claim against a
beneficiary.
XI. Death Taxes: 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 the residue of my estate; that my Executor (Executrix) pays, or provides
for payment of all such taxes at such time, or times, and in such manner as my
Executor (Executrix) deems best.
XII. Tax. Options. I authorize my Executor (Executrix) to exercise any
options available in determining and paying death taxes in my estate.
IN WITNESS WHEREOF, I, LOUISE A. PERSAH, the Testatrix of this, my
Last Will and Testament, typewritten on six (6) sheets of paper which I have
identified at the bottom of each page by my signature, hereunto set my hand and
seal this ~ day of ~,,.~.~; , 2001.
LOUISE A. PERSAK
~~ a ~~-~
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The preceding instrument consisting of this and five (5) other typewritten
pages, each identified by the signature of the Testatrix, LOUISE A. PERSAK, was
on this day and date there of signed, published and declared by, LOUISE A.
PERSAK; the Testatrix therein named, as and for her Last Will, in the presence of
us who, at her request, in her presence, and in the presence of each other have
subscribed our names as witnesses.
i
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1~~,_~~
~~~.~ ~~
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND :
I, LOUISE A. PERSAK, Testatrix whose name is signed to the attached or
foregoing instrument, having been duly qualified according to lalvv, 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.
~~~.~
LOUISE A. P~RSAK
Sworn or affirm to and acknowledged before me, by LOUISE A. PERSAK,
the Testatrix, this o? day of F~ , 2001.
RICHARD E. CO L, ESQ.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, %~i..~,,.s ~Q. ~a~Ps~ ,and ~ar+~en :~ ! Er,~.k . ,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
Testatrix sign and execute the instrument as her Last Will; that she signed
willingly and that she executed it as her free and voluntary act for, the purposes
therein- expressed; that each of us in the hearing and sight of the Testatrix signed
the Will as witnesses; and that to the best of our knowledge Testatrix was at that
time eighteen or more years of age, of sound mind and under no constraint or
influence.
~~
Sworn and affirmed to and subscri ed to before me by jifoMab ~, ~y~rp~ and
uJ,~ rr~+ T t~i~se.k ,witnesses, this a - day of /_,~,,~r~ , 2001.
RICHARD E. CONNE ,ESQ.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS
On this, the~~ay of , 2001, before me Gloria Coppersmith, the
undersigned officer, personally appe d RICHARD E. CONNELL, ESQ., known to
me or satisfactorily proven to be a member of the bar of the highest court of
Pennsylvania and certified that he was personally present when the foregoing
acknowledgment and affidavit were signed by the testatrix and witnesses.
I have signed my name and affixed seal.
(SEAL) - -'
Not rv 'c .
td07ARIAL SEAL
GLORIA J. COPPERSMITH, Nc3t~ryl Pubic
C H311 l3aro, Ct~r~asia~d G~uasEy
MY Cammi~iorr irc~ Jttr~a 2t, ',2UA3