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HomeMy WebLinkAbout01-08-10J 15056041046 { REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Dept.280ti01 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ I ~ ~ 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ 98 ~~.'8ga9 - 03 t aooq ~ l oh ~a3b Decedent's Last Name Suffix Decedents First Name MI ~ 0 8) 1J s o t~ M A B ,~ L 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 t• 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) tl• 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 T0: Name Daytime Telephone Number ~> ~EtN~IS ltc~ ~~cN~nT ~ i ~ a~~ t~~~-~ Firm Name (If Applicable) „~,,,~~ First line of address ~~ +~ YJ• OLD Second line of address City or Post Office CAR~15Z~. ~0 1R4~ 12DA State ZI/P Code L- 7f~ i~41 t. , LLS USE ~ ~LY ~ ~ ~ t k t ~~ r ~, a - _.~ .~ ~ ~ DATE FILED ' -n -~ < <:~ -, ~_: -r;;), C ~--~ F tr? t ~ ..-T"1 e..~ ~~; Correspondent's a-mail address: ~~°Ch,r`~ ~ G'ISMCQ,S~. /'?P~ 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 preparer has any knowledge. OF PERSON RESPO SIBLE FOR FILING RETURN ~~ DATE r~cas: ~ ~ ~~~cl a1t ~" > 4~ Yl u Q r'y ~ g . o~ 01 O ~a7 W, ~1L1 ~~r~ SIGNATURE OF PREPARER OTHER THAN DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056D41046 15056041D46 J J 15056042047 REV-1500 EX Decedent's Social Security Number y I ~ ICJ"'' ~~~~~-~~'or;q. Decedent's Name: __ :.,...~a,a.~f'`,x--~ --~•~-~_-~~=~~*~-+- RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. ,. .. ~ ~~ y~ 2. Stocks and Bonds (Schedule B) ..................................... .. 2 ,., ' ~ a' 1ve~.~~r 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ ;~u~~~ri., ~~sr.~rnr>c =.<a~ t5 C » 4. 9 9 ( ) ........................... Mort a es & Notes Receivable Schedule D 4. .. ~ ,~ ,~. d x' 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. r. ~ % 1 ~.,~'' s ,. ''` . _ ?- . Awufi 1 6. Jointly Owned Property (Schedule F) C Separate Billing Requested ....... 6. C ~~:n :., 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested........ 7. F C 8. Total Gross Assets (total Lines 1-7) .................................... 8. ~ ~ ~ °~~ ~; ~+, ~i- 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~ h d l S 0 ~ ~ 3 y ~ ~ ~ `~ d? 10. .. e I) ........... e u c Debts of Decedent, Mortgage Liabilities, & Liens ( ... . , . 11. Total Deductions (total Lines 9 ~ 10)......... , .. . ................... ... 1L 8 .. ~ ~ ~ ~ "' ~. . t ; ~ 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. .. ~ ~ ~ ., .,. » . e. ,~ .i- ~ ~ ~ a _.. , 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which h'^ an election to tax has not been made (Schedule J) ..................... ... 13. a 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ ,~o ~ l •_ ~ ~- T TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 •, ~ ~~ , 16. Amount of Line 14 taxable Q at lineal rate X .0 ~ ~ ~D d' I 1 ~ 16. ~ u ~ ~ I 17. Amount of Line 14 taxable ~ 17 ~` ~ _--, Q r . at sibling rate X .12 . 18. Amount of Line 14 taxable _,-- ~ ~ __-.~ ~ • at collateral rate X .15 18. ~ ~ ~ 19. TAX DUE ...................................................... ...19. p~ . .~".~ °~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 15056Q42047 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: 4 DECE ENT'S NkME ~~~-- STREETADDRES CITY -- -- - ~- _ I~ L L ~ STATE 'ZIP ~'>a I'701,5' Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments p C. Discount +t~ X . 0 5 ~? L 3= 3 8.O o 3. Interest/Penalty if applicable D. Interest E. Penalty O PiIA Number Total Credits (A + B + C) (2) 3 g, QO (3) d (4) Q - Total Interest/Penalty (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 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. (5) Co 8~0.0C7 (5A) Q (5B) ~D ~ (o . ~ d 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 : ...................................... ...... ^ 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? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 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-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MA~3 ~L A . l~o~~ti ~o~ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCNEDI~LE B COndnnONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER M fl~E L A .~df3JN~0 rJ All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+(197) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER M A~~ L ~ .263~~ ~o~ 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. ~''/} ~N a~C ~f~N ~ 100 Ob ~. ~3AN1~ UEQd~ ~7~ ', C tTIZ~N.~ ~8WIN1~ , ~~G~I, ~.~} ~ i i-i ~ oc~ ~ C h i c l~.tiric~ ~ G X66 ~r.Z Za ~ s ~ 6 ~ 3. o a ~ ~v'~N(~S ~, ~~~'l!0 3~I1,a ~ ..# .ADO.O o ~ ~N~RRjN~ P~~1~AR~L ~C ~oTt~~~~~ ~ ~~d, ao ~ t--J a vSk N~ ~ FU p„N lT u P..~ ~ 1, ~O CS • 0 4 TOTAL (Also enter on line 5, Recapitulation) I a ~ ~ s / ~]~ (~Q (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCNEDVLE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER M REEL A . r?I X31 ~ Sor„y Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. !~'~~RS ~u~~'D~AI. MohA ~ , MFe~Ar~~cS~~~e,.co~ }~{~ ~ 'S~~~l~ ~. , 0 0 ~. s' ~41n- r ~T~ ~ ~~tv S C1~u~. e~-1 ~ 5 ©a . o0 C SFR~ICE RNO ~~'~12.E'S~1 M ~~Z ~~ ~w~ ~) NINA, B. 1 2. 3 4. 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: Attorney Fees 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 p Probate Fees ~ ~ U~cY- Fj,e ti• ~ ~ (~ O u VVZ~ e(~`jR'r Y1v~~ ,1 ~ ~ ~ 1 ~ d Accountant's Fees ~ A~,.L~`fL~' ~ ~~ Co Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) I $ ~ ! Q ~ ~~ QG~ State Zip (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER /~l f}'S~L a • `~ZoB~ N ~o ru Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. d 0 (If mare space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCNEDIJLE J • COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER M ~t~ ~ ~. p- • ~~ 1~~011~ NUMBER I ~.I 3, '~ . II NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~a'~n wi 5 ~e e~o,,l~ Coa ~ w . o~d, `~bRlc gip. Cc~- r 1 ~ d le ~ ~ ~- ~ nv I ~- ~ ebr~ X11 ~ s a r~ ~ a ~ g ~ c.~ t -~ c7_ final q ~ ~ ~o~ s M ECb1 ~ w i G S ~3v~--`, p (~ 170 5 0 7Do~no~`d- U~'ci ea1n,~ ~` i ~ ~~NT ~av a ~ tZb C'>~RL1~Lg~ ~~ l7o~s' ~.~ y (~~hwel 1 RELATIONSHIP TO DECEDENT I AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE son dau~h-ler S©u cl av~o~.lrrl-~e r a 5 9a a~~b ~ 5 f~ ~~ ~a 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 N ~A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. ~ lp TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2009- 01089 PA No . 21- 09- 1089 Estate Of : MABEL A ROBINSON (First, Middle, Last) Late Of : CUMBERLAND COUNTY Deceased Social Security No : 198-22-8929 WHEREAS, on the 23rd day of November 2009 an instrument dated July 28th 2009 was admitted to probate as the last will of MABEL A ROB/NSON /First, Middle, Las1J late of M/DDLESEX TOWNSH/P, CUMBERLAND County, who died on the 31st day of October 2009 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: DENN/S M PECHART who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 23rd day of November 2009. ~ ~ eglste~ o / ~ /~ ~`, r ~ J. `~ Deputy j **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) ~E GAS~I"ZVILL ~~D 2~S~IA~IE~I' OF' ~Ka6eC~6inson I, Mabel Robinson, a resident of the Commonwealth of Pennsylvania and County of Cumberland; and being of sound mind, do hereby make, publish and declare this to be my Last Will and Testament, thereby, revoking and making null and void any and all other Last Wills and Testaments and/or Codicils to Last Wills and Testaments heretofore made by me. All references herein to this Will shall be construed as referring to this Last Will and Testament only. FAMILY CLAUSE At the time of executing this Last Will and Testament, I am unmarried. The names of my children are listed below. If I do not leave any property to any of my children, my failure to do so is intentional. Dennis Pechart Debra Allison Donald Wright Peggy Ashwell RESIDENCY CLAUSE Having in mind the possibility that I may temporarily reside outside of, or simply be absent from the Commonwealth of Pennsylvania. and County of Cumberland, at the time of my death, I elect and hereby declare that this Will and each and every disposition and provision contained herein shall be construed and regulated by and in accordance with the laws of said Commonwealth of Pennsylvania. It is my desire that this Will be probated in the Commonwealth of Pennsylvania, my place of domicile, and that the principal administration of my Estate be made in said Commonwealth of Pennsylvania and that none of the assets of my Estate which may be found in my place of domicile, be remitted to any other jurisdiction for administration or distribution. Page 1 of my Last Will and Testament ~ `~~'^~ ~ ~~-wi°'~`" (Signature) 608.5481 DOC DEBT CLAUSE I direct that the executor named pursuant to this Last Will and Testament review (as soon after my death as practical) all of my just debts and obligations, including funeral expenses and the expenses incident to my last illness; excepting those long term debts secured by real or personal property which may be assumed by the Heir of such property, unless such assumption is prohibited by law or upon agreement by the Heir. The executor shall pay these just debts only after the creditor provides sufficient evidence to support their claim. My executor shall pay out of my gross Estate, as if they were my debts, and without proration or appointment, all estate and inheritance taxes, by whatever name called; (including any interest due thereon) becoming payable because of my death in respect to all property comprising my gross Estate for death tax purposes, whether or not such property passes under this Last Will and Testament. I further direct that if any Heir or Heirs named in this Last Will and Testament should be indebted to me at the time of my death, and evidence of such indebtedness is provided or made available to the Executor of my Estate, then that share of my Estate which I give, devise, and bequeath to any and each such Heir shall be reduced in value by an amount equal to the proven indebtedness of such Heir or Heirs, unless I have specifically provided in this Last Will and Testament for the forbearance of such debt, or unless such Heir is the sole Principal Heir. SPECIAL DIRECTIVES CLAUSE Notwithstanding any other provision of this Last Will and Testament, including those express directives in the Debt Clause above and the Principal Distribution and Specific Bequest clauses below, I furthermore direct that: All assets, money (certificates of deposit, cash, checking, savings), and materials (mobile home, car, furniture, etc.) should be divided equally among the four children listed in this Will. Contact Citizen s Bank in Mechanicsburg, Pennsylvania for account information and All State Insurance in Mechanicsburg, Pennsylvania for insurance account. Page 2 of my Last Will and Testament `~7G~._.. ~e~~.~~--z (Signature) PRINCIPAL DISTRIBUTION CLAUSE I give, devise, and bequeath to the persons named below (my "Principal Heirs"), if he or she, whichever the case may be, shall survive me, all of the residue and remainder of my gross Estate after payment of all my just debts, expenses, taxes, administration and specific bequests, if any, in the percentages set forth below. 1. Name: Dennis Pechart Relation: Son Percentage: 25 % In case such Principal Heir does not survive me, I direct that the share of my Estate which would have been given to such Principal Heir shall be distributed to: Ryan Pechart. 2. Name: Donald Wright Relation: Son Percentage: 25 % In case such Principal Heir does not survive me, I direct that the share of my Estate which would have been given to such Principal Heir shall be distributed to: Keith Wright. 3. Name: Debra Allison Relation: Daughter Percentage: 25 % In case such Principal Heir does not survive me, I direct that the share of my Estate which would have been given to such Principal Heir shall be distributed to: Richart Dolbin (RJ)-grandson. 4. Name: Peggy Ashwell Relation: Daughter Percentage: 25 % In case such Principal Heir does not survive me, I direct that the share of my Estate which would have been given to such Principal Heir shall be distributed to: Katrina Walters. Page 3 of my Last Will and Testament ~a-Cwe Tr- ~ r.~~..-,~~ (Signature) SPECIFIC BEQUESTS I give, devise, and bequeath to the persons reamed below if he or she, whichever the case may be, shall survive me, the following items of property: 1. To my grandson, Richard Dolbin (Rn, I give: Don s antique tractor. 2. Tv my grandson, Brandon McKillip, I give: Half of my gun collection, my air compressor, and my press drill. 3. To my son, Dennis Pechart, I give: Half of Don's guns in the gun collection and my power tools. 4. To my son, Donald Wright, I give: 331/3% of any items that he wishes to have. 5. To my sister, Mary Hess, I give: Any of my personal clothing. 6. To my daughter, Debra Allison, I give: 331/3% of any items that she wishes to have. 7. To my daughter, Peggy Ashwell, I give: 331/3% of any items she wishes to have. EXECUTOR APPOINTMENT CLAUSE (A) I nominate, constitute and appoint my son, Dennis Pechart, to be the Executor of my Estate. (B) If, for any reason, my first nominee Executor should fail to qualify or be unable or unwilling to accept or to continue as the Executor of my Estate, I nominate, constitute and appoint my son, Donald Wright, to be the Executor of my Estate. (C) If for any reason, all of the nominees designated above in Paragraphs (A) and (B) should fail to qualify or be unable or unwilling to accept or to continue as Executor of my Estate, I nominate, constitute and appoint my daughter, Debra Allison, to be the Executor of my Estate. Page 4 of my Last Will and Testament ~~'~~ ~ (Signature) EXECUTOR POWER OF APPOINTMENT CLAUSE (A) All directives in this Will that use by reference the word Executor mean and include any person named herein as my Executor (or personal representative, as may be defined under state law) and any person who may be acting in either capacity, at any time. Such person shall have broad and reasonable discretion under the directives of this my Last Will and Testament with respect to any property, real or personal, left by or held by me, or acquired by my Executor on behalf of my Estate. (B) I wish my Executer to have broad and reasonable discretion in the administration of my Estate, to have all of the powers permitted to be exercised by an Executor under state law, and to be able to do everything he or she deems advisable for the best interest of my Estate and the Heirs thereof, all without the necessity of court approval or supervision. I direct that my Executor perform all acts, take all such proceedings, and exercise all such rights and privileges, although not specifically mentioned in this Will, with relation to any such property, as if the absolute owner thereof; and in connection therewith, to make, execute and deliver any instruments, and to enter into any covenants or agreements binding my Estate or any portion thereof. (C) No such person named in, or appointed in connection with this Will in a fiduciary capacity shall be required to file any bond or other security for the faithful performance of his or her duties as such fiduciary in any jurisdiction; and if, despite this directive, a bond should be required, I request that it be accepted without sureties and in a nominal amount. NON-LIABILITY OF FIDUCIARIES Any fiduciary, including my Executor and any trustee, who in good faith endeavor to carry out the provisions of this Last Will and Testament, shall not be liable to me, my Estate, yr my heirs, for any damages or claims arising because of their actions or inactions based on this Last Will and Testament. My Estate shall indemnify and hold them harmless. Page 5 of my Last Will and Testament -~'1'I c~.Gi~ ~' ~.~~-- (Signature) SAVING CLAUSE If a court of competent jurisdiction shall at any time invalidate or find unenforceable any provision of this Will, such invalidation shall not be construed as invalidating the whole of this Will. All of the remaining provisions shall be undisturbed as to their legal force and effect. If a court finds that an invalidated or unenforceable provision would become valid if it is limited, then such provision shall be deemed to be written, deemed, construed and enforced as so limited. Page 6 of my Last Will and Testament ~ a..~,C_ (~„~,~..~, C,,-.. (Signature) IN WITNESS WHEREOF, I, the undersigned Testator, declare that I sign and execute this instrument on the date written below as my Last Will and Testament and further declare that I sign it willingly, that I execute it as my free and voluntary act for the purposes expressed in this document and that I am eighteen years of age or older, of sound mind and under no constraint or undue influence. -tea ~ ,~~ ~ Oc~~, b, ~' (Signature of Mabel Robinson) Date: ~ ~ ~ °Z ~' a ~1' Page 7 of my Last Will and Testament ~--~~ ~.~ J ~ ~~.~~•~-... (Signature) ATTESTATION CLAUSE This Last Will and Testament, which has been separately signed by Mabel Robinson, the Testator, was signed, executed and declared by the above named Testator as his or her Last Will and Testament in the presence of each of us. We, in the presence of the Testator and each other, under penalty of perjury, hereby subscribe our names as witnesses to the declaration and execution of the Last Will and Testament by the Testator, and we declare that, to the best of our knowledge, said Testator is eighteen years of age or older, of sound mind and under no constraint or undue influence. Cigna f witness) (Print Name) Date: 2. (Signature of witness) Date: (~~~ ~ . ~~ Y0~'~ ~~ (Address) (city, state, ZIP) (Print Name) (Address) (City, State, ZIP) Page 8 of my Last Will and Testament ~'~~ ~-~ !1" "~ (Signature) STATEMENT OF INTERMENT, CREMATION and WISHES I, Mabel Robinson, the undersigned, having previously executed a Last Will and Testament on the date hereof, hereby state that, in addition to the directives and bequests set forth in said Last Will and Testament, it is my desire that my remains be interred in a burial plot. My further wishes and directives are as follows: I should be buried in the Rolling Green Cemetery, Lemoyne, Pennsylvania, beside my husband, Donald Robinson. The vault is already paid for and prepazed. My funeral arrangements are also already paid for. Myers Funeral Home in Mechanicsburg, Pennsylvania should be contacted to make all necessary arrangements. Dated: ~-~ - =~ ~ 9 `_~~ LX• ~~ ~~ low ~~r--'--~ Signature of Mabel Robmson WITNESS ATTESTATION CLAUSE This Statement of Interment, Cremation and Wishes, which has been sepazately signed by Mabel Robinson was signed, executed and declared in the presence of each of us. We, in the presence Mabel Robinson and each other, under penalty of perjury, hereby subscribe our names as witnesses to the declaration and execution of the Statement of Interment, Cremation and Wishes by Mabel Robinson and we declaze that, to the best of our knowledge, Mabei Robinson is eighteen years of age or older, of sound mind under n onstraint or undue influence. 1. ~~V ~cl~A~T (Si of witness) (Print Nar<ie) ~~7 (.~ .O ~ ~o~e k ~ (Address) / (City, State, ZIl') 2. (Signature of witness) Date: (Print Name) (Address) (City, State, ZIP) SELF-PROVING AFFIDAVIT Commonwealth of Pennsylvania County of Cumberland I, Mabel Robinson, the undersigned Testator, being first duly sworn, do declare to the undersigned authority that I signed and executed the attached or annexed instrument as my Last Will and Testament and that I signed it willingly, that I executed it as my free and voluntary act for the purposes expressed in that document and that at the time I signed the document I was eighteen years of age or older, of sound mind and under no constraint or undue influence. Date: 7 ' 2~ - ~'° 5 ''?' i-~,~-~.L. /~ ~~4~.. _,.~,-~. (Signature of Mabel Robinson) We, the undersigned witnesses, being first duly sworn, do each declare to the undersigned authority the following: (1) the Testator declazed to each of us that the attached or annexed instrument is his or her Last Will and Testament; (2) the Testator executed the will in our presence; (3) each of us, in the presence of the Testator, signed the will as witness; and (4) to the best of our knowledge the Testator is eighteen yeazs of age or older, o d min d under no constraint or undue influence. (Signs witness) (Print Name) 2. (Signature of witness) (Print Name) Acknowledgement of Notary Public: Subscribed, sworn and acknowledged to me on this by Mabel Robinson, as Testator, and as witnesses. day of , 20_, and Witness my hand and seal. Signature of Notary Public: