HomeMy WebLinkAbout12-21-09--~ REV-1500 1505607120
EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 8 0 12 2 8 '
PO 60X.280601
Harrisburg, PA 17128-0601 ~ RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
11242008 05151940
Decedent's Last Name Suffix Decedent's First Name MI
JUMPER DAVID C
(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 ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
0
® g Decedent Died Testate ^ 7 Decedent Maintained a Living Trust 8. Total Number of Safe De osit Boxes
(Attach Copy of Will) (Attach Copy of Trust) P
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113 A
between 12-31-91 and 1-1-95) ^ ( )
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
ame Daytime Telephone Number
JAMES J. MCCARTHY, JR., ESQ. 7172335974
Firm Name (If Applicable) P'`a
MCCARTHY WEISBERG CUMMINGS, P.C.
First line of address
2041 HERR STREET
Second line of address
City or Post Office
HARRISBURG
State ZIP C d
w..a.
REGISTER LS USEILY
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PA 17103-1624
Correspondent'se-mail address: jamesjmccarthyi@comcast.net
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' 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. Declaration of preparer other than the personal representative Is based on all information of which oreDarer has anv knnwlPrlnP
vi yr rcr~ rv rtcar}~rv I~LC rVR rILIIVb RCI VKIV DATE
1?~C 1 TRACEY S. BARRICK ~ Z ~~ ~-~" ~
ADDRESS
328 LAKE MEADE DRIVE, EAST BERLIN, PA 17316
SIGNATUR OF PREPARER OT ER THA REPRESENTATIVE DATE
G,,.-_...~, James J. McCarthy, Jr., Esq. ~ 2. ~ d _ ~
ADDRESS
2041 Herr Street, Harrisburg, 710 1624
Side 1
1505607120
1505607120
J
J 1505607220
REV-1500 EX
Decedent's Social
RECAPITULATION
1. Real Estate (Schedule A} ..........................................................._......................... 1.
2. Stocks and Bonds (Schedule B) .......................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) .............................__........................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ®Separate Billing Requested ............. 7.
8, Total Gross Assets (total Lines 1-7) ............................................................_...... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................... 10.
11. Total Deductions (total Lines 9 & 10} ................................................................. 11.
12. Net Value of Estate (Line 8 minus Line 11 } .......................................................... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .............................................. 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) .............................._................ 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X ,12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due ..............................__............................__............................__..............----- 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
7,759.28
0.00
7,759.28
6,182.00
8,741.04
14,923.04
-7,163.76
0.00
Side 2
1505607220 1505607220
J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 08 - 01228
JUMPER, DAVID C
STREET ADDRESS
121 WALNUT BOTTOM ROAD
___
CITY
SHIPPENSBURG
I, STATE -- ZIP
PA
17257
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
Total Credits (A + B + C)
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT.
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 theTAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(1) 0.00
(2) 0.00
(3) 0.00
(4)
(5) 0.00
(5A)
(5B) 0.00
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 :............................................................................. ~ ~ ~~
b. retain the right to designate who shall use the property transferred or its income :................................ ~~ l
-- -
c. retain a reversionary interest; or .............................._ ~
. ............................._.............................................. ._-~ i_X]
d. receive the promise for life of either payments, benefits or care? ........................................................... ~ _l ! x_
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ..............................._............................_.............................._..................... ~ x] ~~_ _'
i ,.__.~
i decedent own an "in trust for" or payable upon death bank account or security at his or her death....... ! ~ xJ
--
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
- --
contains a ene iciary designation~ ..........................................................._.............................__.................... ~~ U
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETUR
.. , H~~ r~ ~~`'~. ,. ~ ~,.,
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 statutedoes not exemota 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.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
---- - -- - -- ------- ---1-
ESTATE OF JUMPER, DAVID C
Include the proceeds of litigation and the date the proceeds were received by the estate411 property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 ORRSTOWN BANK -ACCOUNT NUMBER 570465 6,475.07
2 AUCTION OF PERSONAL ITEMS -DAN HERSHEY AUCTION SERVICE, LLC 1,264.08
3 ADAMS ELECTRIC -REFUND 8 32
4 CARLISLE REGIONAL MEDICAL CENTER -REIMBURSEMENT 11.81
TOTAL (Also enter on Line 5, Recapitulation)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.;
PERSONAL PROPERTY
-- - -- - _
TFILE NUMBER
21 -08-01228
7,759.28
COMMONWEALTH OF PENNSYLVANIA ' SCHEDULE G
INHERITANCE TAX RETURN I INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF JUMPER, DAVID C i FILE NUMBER
21 - 08 - 01228
_...._..._.._. _._.__._ -- __..____ _____...- __-____-. _ - _._. L._____....__-_ _
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF EXCLUSION
NUMBER Include the name of the transferee, their relationship to decedent ~ VALUE OF ASSET DECD'S TAXABLE VALUE
and the date of transfer. Attach a copy of the deed for real estate. INTEREST ' (IF APPLICABLE)
1 CASH -PAID TO FRIEND (NO RELATION) OF 2,500.00 100% 2,500.00 0.00
DECEDENT ON NOV. 5, 2008. i, ',
BRIDGETTE GETTLE
1642 RITNER HWY I,
SHIPPENSBURG, PA 17257 j
j
i
i
I~
i
~,
TOTAL (Also enter on line 7, Recapitulation)
0.00
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA ~~~
INHERITANCE TAX RETURN ~ ~
RESIDENT DECEDENT ~'~~+, • ~, , ~ ` `~^~!V 1 V
ESTATE OF JUMPER, DAVID C
Debts of decedent must be reported on Schedule I.
__ _- - __
ITE M _ - ---
NUMBER (FUNERAL EXPENSES: DESCRIPTION
A. 1 FISHER FLORIST -FLOWERS FOR FUNERAL
2 FIRST WESLEYAN CHURCH
B. ADMINISTRATIVE COSTS:
1. Personal RenresPntativP's Cnmmi~sinnc
FILE NUMBER
~ 21 - 08 - 01228
- - - _ _ ,-
AMOUNT
~! 399.00
300.00
Social Security Number(s) / EIN Number of Personal Representative(s):
161-60-2469
Street Address 328 LAKE MEADE DRIVE
City EAST BERLIN State PA zip 17316
'~ Year(s) Commission paid
2. Attorney's Fees MCCARTHY WEISBERG CUMMINGS, P.C.
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 CUMBERLAND COUNTY REGISTER OF WILLS ~,
5. ' Accountant's Fees MCCARTHY SHEA, P.C. '
6. Tax Return Preparer's Fees ~I
7. Other Administrative Costs
1
TOTAL (Also enter on line 9, Recapitulation)
3,000.00
2,100.00
83.00
300.00
6,182.00
SCHEDULE
s DEBTS OF DECEDENT, MORTGAGE i
COMNOERITANCEOAXRETURNANIA LIABILITIES, & LIENS
RESIDENT DECEDENT
-- - --- -- --- -------- --- ----. -- L- -- -
------
FILE NUMBER
ESTATE OF JUMPER, DAVID C
21 -08-01228
Include unreimbursed medical expenses.
ITEM -- -
NUMBER DESCRIPTION AMOUNT
__
1 EMBARQ -LAST PHONE BILL 47.47
2 CARLISLE REGIONAL MEDICAL CENTER 11.81
3 KINETIC IMAGING 12.63
4 SHIPPENSBURG HEALTH CENTER -CABLE BILL 10.00
5 LEWIN & NADAR ASSOC, MD 1.63
6 PA DEPARTMENT OF PUBLIC WELFARE -CLASS 3 CLAIM 7,997.50
7 TRACEY BARRICK -MEDICAL SERVICES - REIMBURESED TRAVEL - 6 MONTHS @ 2 660.00
TRIPS PER MONTH; 50 MILES ONE WAY = 1,200 MILES @ .55 PER MILE
TOTAL (Also enter on Line 10, Recapitulation) 8,741.04
REV-1513 EX+ (9-00)
' ~ * ~ SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
----
ESTATE OF JUMPER, DAVID C i FILE NUMBER
21 - 08 - 01228
RELATIONSHIP TO ! SHARE OF ESTATE i AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY ~ co Not ust Trusteels)
__
~__ _ -
I. TAXABLE DISTRIBUTIONS[include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)] I ',
1 TRACEY WITHJACK BARRICK ,Daughter j ENTIRE ESTATE
328 LAKE MEADE DR
;EAST BERLIN, PA 17316
i
II.
i
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 SHEE 0.00
URRSTOV'VNBANK
. 'A Tradition of Excellence
P.O. Box 250
° ORRS Shippensburg, PA 17257
0
Return Service Requested
001064 0.6804 AV 0.324 TR00004
.~~
David C Jumper
$ Bridgette Gettle
1642 Ritner Hwy
Shippensburg PA 17257-9767
Date 11/20/08
Primary Account
Enclosures
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C H E C K I N G A C C O LI N T S
Account Title David C Jumper
~ Bridgette Gettle
Page 1
570465
50+ IntezQSt_ ChPCking C~.eck Saf_~keepz.rR
Account Number 570465 Statement Dates 10/21/08 thru 11/20/08
Previous Balance 16,454.23 Days In The Statement Period 31
2 Deposits/Credits 1,342.59 Average Ledger 6,998.40
8 Checks/Debits 11,565.70 Average Collected 6,998.26
Service Fee .00 Interest Earned .64
Interest Paid .64 Annual Percentage Yield Earned 0.11
Current Balance 6,231.76 2008 Interest Paid 4.36
0
N
o Deposits and Additions
o Date Description
11/18 De
osit Amount
~
V'~
p ~
104.59 i-~'
11/19 SOC SEC US TREASUR Y 303 1,238.00 ~-
o PPD
0
0
0
0 11/20 Interest Deposit .64
0
- - -
CHECIC SU~IARY - - -
° Date Check No Amount Date Check No
Amoun t
~^
o`
° 10/31 1439
11/20 1440 145.78tiY0/24 1443
' 37.98'
r~
10/23 1441 20.OOv~
0/27 1445* 150.00 r/"
N
o~
10/29 1442 8,617:631x1/06 1446
16.56
ri/18 1447 2,SOO.OOi..~
`'
* Denotes missing check numbers ~ 77.75 ~'
. ~ ~ DAN j3ERSHEY AUCTION SERVICES LLC
790 West High Street
Carlisle, PA 17013
~~~--~- -~.._...~717) 532-4647
~. Steve Ege 717-385-5438 dell Chris Bream 717-226-1920 Cell
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DGt U ~ Gt .~ U~ Wt Q ~ DATE ~7~, ~ ~`,
SELLEI3,S NAME l ~, 1 } ~ ~. ,_.., _., t -~ -~~~
~7 ~ ~ 1 ~YIP~ ~`~ I ~}Y1 Wc~ ~ ~1I ~~ ~Y~U ~~J PHONE -1 ~ ~' _ ,.T,. ~ ~
ADDI3,ESS ~ -~
"7 c
~ ~ AUCTIONEER % -'
-~ OTHER
STEILOCATION ~ ~ ~ ~~ ~ ~~ CLERK %
AUCTION DA
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DESCRIPTION OF MERCHANDISE
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~ ~.JL ~~l ~' ~~ ~ ~C..~ /ti~ (~ ~ ~ :~ C.! I G± r~ ~ f ~ ~ yt `I t~'~ ~..{,~ f ~ yi'~ ~ ! ~ t~.l ~~j ~ ' i'. ~ ~ ~ (~; ; ~ .
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~~~~ Spa~(w Rc ~ ~, vS ~' ~ ~ 5f a t-~ x~~- 5 ~ l~- ;^ , J ~ ; ,r~ r..{ i~-~;, ~. ~ .
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5 (cr ~' ~ c..~ U VIP 5 ~ ~ ~ ~' -~ ~+ ~ v~1t C
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I Commission the Auctioneers to sell the merchandise to the highest bider by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement.
AUCTION SI ATURE LLERS~SIGNATURE
.lr
Total Sales (Clerking Tickets Attached) $
l ~ `~ `~
Less Sale Expense:
t ~~
.; % Commission Auctioneer $ ~ ~' -
% Commission Clerks $
OTHER:
TOTAL SALE EXPENSE DEDUCTED $
~, o ~?
,,-. SELLERS NET $ ' c f, ~ ~"~~
,/ _ lY -f
f l ~ //
`~ AUCTION SIGNATURE
SELLERS SIGNATURE
caw~IONwEAITN of PENNSYLVANIA
DEPARTMENT OF Pueuc VYELFARE
sUREMJ Of FINANCIAL OPERATIONS
DMSION OF TNIRD PARTY LIASILRY
ESTATE RECOVERY PROOiWA
PO SOX M06
MARRIBSURG. PA 17106-400
June 18, 2009
TRACEY BARRICK
328 LAKE MEADE DR
EAST BERLIN PA 17316
Re: DAVID JUMPER
CIS #: 710205017
SSN: 219-34-2595
Date of Death: 11/29/2008
Dear Ms. Barrack:
Please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and all eligible assets in the subject
estate. Although the amount in the estate may be considerably loss than that
xhich is oxed to the Department, our al:im is against the estate, no ono
else. Your responsibilities, as the primary next of
kin/administrator/executor, is to advise the Department of any assets in the.
estate and to insure that the remaining money, after all funeral and
administrative coats are deducted, is sent to the Department.
The Department of Public Welfare maintains a claim in the amount of
7 997.50 against the above-mentioned estate. This claim is for restitution
of medical assistance granted on behalf of the decedent for which the Probate
Estate is now responsible to reimburse the Department according to Act 99, 62
P.S. 1412, effective August 15, 1999, as amended by Act ~.Q~.95, effective June
30, 1995. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely ,? X997_50, was incurred during
the last six months of the decedent's life; therefore, it is a Class 3 claim
pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered
as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise when payment may be
expected. If the estate aaaountinq is complete, ploaso provido a copy. Ig
the estate aontaina real estate lease
~ p provide copies of the doed, the .
latest tax assessment and a current appraisal, if available.
Sincerely,
. LQ,
~~~~ ~~~
Dianna L. Stoneroad
TPL Program Investigator
717-265-7688
717-772-6553 FAX
Enclosure
LAST WILL AND TESTAMENT
OF
DAVID C. JUMPER
I, DAVID C. JUMPER, of 40 Colonial Caurt, Cumberland County, Shippensburg,
Pe2~nsylvania, being of sound and disposing mind, memory and understanding, do hereb make -
publish and declare this as and for my Last Will and Testament,l:ereby revoking all other wills
and codicils heretofore made by me.
FIRST: I direct that all my just debts and funzral expenses, including any
grave marker, shall be paid from the assets of my estate as soon as practicable after my decease.
SECONT~: I give, 'devise and bequeath the residue of my estate, of every
nature and wherever situate, to my Daughter, Tracey S. Wit;~jack, providing she shall survive me
by thirty (30) days. -'
THIRD:
I direct that ali taxes that may be assessed in consequence of my
death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary
estate as a part of the expense of the administration of my estate.
FOURTH: I nominate, constitute and appoint my Daughter, ~'racey S.
W ithjack, Executrix of this my Last Will and Testament.
FIFTH: I direct my Executrix and her successors shall not be required to
give bond for the faithful performance of their duties in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will
and Testament, consisting of two 2) typewritten pages, each identified by my signature, this
f~- day of ~'?.¢,~. ~-
(SEAL)
~''~
Davi C. Jumper
..-
Signed, sealed, published and declared by the above-named Testator, David C. Jumper, as
and for his Last Will and Testament, in the presence of us, who, at his request, in his sight and
presence, and in the sight and presence of each other, have hereunto subscribed our names as
witnesses.
~~.~ ti
Wr ness
~~m~i ~~
Witness
Date: ~-
Date: 3 ' 13 ' L~4-
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND )
I, David C. Jumper, 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 and Testament; that I signed it willingly; and that I
signed it as my free and voluntary act for the purposes therein expressed.
Sworn or aff rmed to and acknowledged before me by David C. Jumper, the Testator, this
,~r'~ day of ~~,4-~' ~ ~ ~. ' ~t-~ ~ .
..
(SEAL)
..--
_ ~ Notary Pu c
AtourW Seri
tf~doJ..lut~pet. Nat'~rft P~~ic
CrMI~ 8o~or Q~bMlrb Oourny
~A!-CaRNMion E~p~+es.lulp?~ 2006
t~Aeeieer. Pbrrs~ria Aror~lonO~ Woals
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND 1
We, f ~ ~ ~ and ~- ,
the
witnesses whose names are signe to a attached or foregoing instrument, being d y qualified
according to law, do depose and say that we were present and saw Testator sign and execute the
instrument as his Last Will and Testament; that signed willingly and that he executed it as his
free and voluntary act for the purpose therein expressed; that each of us in the hearing and sight
of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator
was at that time 18 or more years of age, of sound mind and under no constraint or undue
influence.
Sworn or affirmed to and subscribed to before me by ..,~ 1,
and ~ ` ,witnesses, this / ~ ~t day of
2004. "
''~.~,•~,,,,.'~ `f~_ 1 ~ .. ,Witness
t~
(SEAL)
Witness
i
r
`. ~ ,' i
I ~~
No Pub '
(SEAL)
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