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HomeMy WebLinkAbout02-04-1015056041114 -' REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 _ Harrisburg, PA 17128-0601 RESIDENT DECEDENT , U ~ ~gG ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 12182008 08231911 Decedent's Last Name Suffix Decedent's First Name MI RICHWINE LUCY (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE 1MITH THE REGISTER OF WILLS © 1. Original Retum ~ 2. Supplemental Retum Q 3. Remainder Retum (date of death prior to 12-13-82) 0 4. Limited Estate ~ 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Retum Required death after 12-12-82) © 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death 0 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 ROBERT G. FREY 7172435838 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY FREY & TILEY First line of address 5 SOUTH HANOVER STREET Second line of address City or Post Office CARLISLE Correspondent's e-mail address: Under penalties o perjury, I declare tha SIGNA ~ -.- yvy .-.,+ ~ ~ ADDRESS 5 SOUTH HANOVER STREET State ZIP Code PA 17013 aver other than the ers FOR FILING R PRESENTATIVE L 15056041114 information of which ARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 w C7 `~ s:LL~, Q ca -*~ {`J'`a `~ f'+'i ~_ ` 1.% C7 CS7 ~? ~ r~Tl 1 ;: ~, ~ t' x .. _a: ~ iN :..~A _.~ . G- st o my knowledge and belie has any knowledge. DATE 2-`f-(o Z ~Z ~i ~ +r``r rt~t ~% 4-~` r`T* f 1'1 _~~ +:Y3 c;'t '~'" ' "~ ~~ 15056041114 J n~ 15056042115 REV-1500 EX Decedent's Social Security Number Decedent's Name: LUCY RICHWINE RECAPITULATION 1. Real estate (Schedule A) ........................................... 1. 118 O 0 0. 0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. NONE 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. NONE 4. Mortgages & Notes Receivable (Schedule D) ............................ 4. NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 2 5 0 0 . 0 0 6. Jointly Owned Property (Schedule F) Separate Billing Requested ........ 6. 4 4 0 . 0 0 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested ........ 7 NONE 8. Total Gross Assets (total Lines 1-7) .................................. 8. 12 O 9 4 0 . 0 O 9. Funeral Expenses & Administrative Costs (Schedule H) ................... . 9. 3 9 7 0 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. . 10. NONE 11. Total Deductions (total Lines 9 & 10) ................................ . 11. 3 9 7 0 . 0 0 12. Net Value of Estate (Line 8 minus Line 11) ............................ . 12. 116 9 7 0 . 0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... 1 g. O . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... 14. 116 9 7 O . 0 0 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 .0 0 15. O.0 0 16. Amount of Line 14 taxable at linealrateX.o 45 116970.00 16. 5264.00 17. Amount of Line 14 taxable at sibling rate X • 12 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X , 15 18. 0 . 0 0 19. TAX DUE ....................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 5264.00 L 1 5056042115 J REV-1500 EX Page 3 199-07-2018 Decedent's Complete Address: File Number 21-08-1289 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER LUCY RICHWINE 199-07-2018 STREET ADDRESS 19 EAST PINE STREET CITY MT. HOLLY SPRINGS STATE PA ZIP 17065 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 5264.00 Total Credits (A + B + C) (2) 0.00 Total InteresUPenalty (D + E) (3) 0.00 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. (4) 0.00 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. (5) 5264.00 (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 5264.00 Make Check Payable to: REGISTER OF WILLS, AGEAIT 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 : ...................................... . ~ a 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 "intrust 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? ...................................................... 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+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE ESTATE OF FILE NUMBER Lucy Richwine 21-08-1289 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 exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. If more space is needed, insert additional sheets of the same size. 217 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Lucy Richwine 21-08-1289 Include the proceeds of litigation and the date the proceeds were received by the estate. (It more space is needed, insert additional sheets of the same size) z~~ REV_'so9 Ex, `s~sa' SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucv Richwine 21-Og_12gg If an asset was made joint within one year of the decedent's date of death, it must he reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Ross S. Richwine, Jr. 210 North Baltimore Avenue Son Mt. Holly Springs, PA 17065 B. Kathryn Rynard 101 Mooreland Avenue Daughter Mt. Holly Springs, PA 17065 C. JOINTLY-OWNED PROPER TY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTIMION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED fOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 7/5/00 Contents of Joint Safe Deposit Box. Note: All contents were 1,500 0.00% 0 property of Ross S. Richwine, Jr. and/or his 2 sons, Douglas p and Bradley Richwine p 2. A - B 10/15/07 PNC Bank Account no. 5004923577 1,319 33.33% 440 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on line 6 Recapitulation)I $ 440 (If more space is needed, insert additional sheets of the same size) REV-1511. EX + (10-06) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucy Richwine 21-08-1289 Debts of decedent must be reported on Schedule I. A. 1 FUNERAL EXPENSES: B. 1 tAINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2. 3. 4. 5. 6. 7. Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant SVeet Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Settlement charges from HUD-1 Settlement Sheet 1,500 Zip 2,470 TOTAL (Also enter on line 9, Recapitulation) ~ S (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-06) ESTATE OF Luc Richwine pennsyivania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES FILE NUMBER 21-08-1289 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] 1. Douglas Richwine, 19 East Pine Street, Mt. Holly Springs, PA Grandson 25% 2. John Richwine, 932 Emily Drive, Mechanicsburg, PA Grandson 25% 3. Deborah Stone, 1155 Pine Road, Mt. Holly Springs, PA Granddaughter 25% 4. Scott Rynard, 429 Pine Road, Mt. Holly Springs, PA Grandson 25% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ O If more space is needed, insert additional sheets of the same size. LAST WILL AND TESTAMENT OF LUCY S. RICHWINE I, LUCY S. RICHWINE, now domiciled in Cumberland County, Pennsylvania, declare this N to be my Last Will and Testament. I revoke all other wills and codicils that I ma'~~,,l~ve pre~uslyz:; i ~' ~J O ;~ : ;~ -r- t'ti i < ~ .~~ -r c~ made ~ r t_;• . .~.7 ~ O _I~~ l_J _J ~..._. ~ ~ r' ~, Article I -~' ~, ~"' ~; N My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be ,. charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. C~Op~ Article III I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. Article IV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath IN EQUAL SHARES to my daughter, KATHRYN RYNARD, of Cumberland County, Pennsylvania, and to my son, ROSS S. RICHWINE, of Cumberland County, Pennsylvania. If any of my beneficiaries predecease me or fail to survive me by thirty (34) days, I give, devise and bequeath his or her share to his or her natural issue, not to include stepchildren, who survive me, per stirpes, or if he or she has no natural issue, the share(s) are to be added equally to the other shares. Article V I nominate, constitute, and appoint KATHRYN RYNARD and )E~OSS S. RICHWINE as Co-Executors of my Last Will and Testament. I direct that my Co-Executors be permitted to serve without bond and in addition to those powers granted by law, I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could have filed if living. My Co-Executors shall receive reasonable compensation for services rendered to my estate. ~Oo G°~~l Article VI In addition to the powers conferred bylaw, Iauthorize my Co-Executors, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all thein'services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. ' C~Op~( IN WITNESS WHEREOF, I, LUCY S. RICHWINE, hereby set my hand to this my Last Will and Testament, on /l ~ ~ d '~ 2004. LUCY~RI HC I~ In our presence, the above-named LUCY S. RICHWINE signed this and declared this to be her Last Will and Testament and now at her request, in her presence, and in the presence of each other, we sign as witnesses. ' Name Address 845 Sir Thomas Court, Suite 12, Harrisburg, PA 1.7109 ~ ~Q,~ ' 845 Sir Thomas Court, Suite 12, Harrisburg, PA 17109 C~Op~ I, LUCY S. RICHWINE, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by LUCY S. RICHWINE, the Testatrix on / l ' ~ 2004. of ublic LUCY . RICHWINE coMMOnr~uN of rExNSrLnaul NOTARIAL S IACQUEtINE A. KELLK NOTARY PUBLlC 1O91ER PAXTON TWP., DAUPHIN COUNIY MI COMMISSION EXPIRES DEG 17 2007 We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before.me~ _ by ~ and ~~~i ~ e o witnesses, on - , 2004. otary ublic Witness /~ ~a.~ L( . fitness COMMONI'MEALTH OF PENNSILYANu NOTARIAL SEAL lACOUELINE A. KELLI( NOTARY PUBLIC LDYIER PAXTON TWP., DAUPHIN CDUNIY MY COMMISSION EXPIRES DEG 17 2007 C~Op~( ___ _ _ __ ~~~. 6. 2Li10 10:14AP~ PNC 6,4NK 412-105-1147 Vo.4~44 P, 2;2 ~Pi~~ ~>~~~~~~ January 6, 2010 Judy Yaw PNC Bank Mourn Holly Branch RE: Lucy 5 Richwine. SSN: 199-07-zo 18 DOD: 12-18-2008 Dear Ms. Yaw: In response to your request far Date of Death (bOb} balances for the customer noted above, our records show the following: Checlciug Account . Account # 5004923577 Established: 10-15-2007 LUCY S RICHWIl~TE KATHRYN I RY'~TARD ROSS RICHWII~TE DOD balance: $1,319.OU+ 0.07 aocrued interest safe Aeposit Son The decedent maintained safe deposit box 892 ROSS RICHWIlVE LUCY S RICHWINE Located at: Mount Holly Branch 2 West Pine St Mount Dolly Springs, PA 17065 (717)48b-3416 Please note that this office provides date of death balances for deposit aocaunts (IRt~s, CDs, Checking ax-d Savings}, 1~Ve do not proee~ ~'Y ignaudsl transsetiona or provide ststtementa. If you need assistance with any ofthese items, please call 1=88$-PIVC-INK (Z-888-762-2265} ar stop by your local PNC Bank branch office. . Sincerely, . National Financial Services Center PNC Bank, N.A. Membea~ FDIC Page 1 of 2 REV-485 EX+ (g-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENt OF REVENUE INHERITANCE TAX DIVISION DEPT, 280601 HARRISBURG, PA 17128-0601 SAFE DEPOSIT BOX INVENTORY Please Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE ~ r f FILE NUMBER Drs-~Z~f9 SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER ~~'1-07 -Zo~~ • DECEDENT'S N9q~~"E ( T, FIRST, MIDDLE) DATE OF DEATH ADDRESS OF DECEDENT STREET) (CIT1~ (~~E) (Z, / ~ ~S NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DE OSIT OX (NAME) 2e b is ~ ~-. ~'~ ~, (STREET NAME) S 5~~~ ~,.,~.~~r Sfi. (CITY) (STATE) C..r Il's~~ {'A (ZIP CODE) ~y~ NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING . a. (NAME) ~~ ~ ~ ~~ (RELATIONSHIP) ,.~ ~`t! ~ I.tr~x (STREET NAME) /bl ~hooc~c..r. ~ Q-d+~.. (CITY) TATE) 111 t. Nd~~ S r,' s ~~ (ZIP CODE} . 17v4~ b. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. (NAME) n p ~ ~ i\OSS 1~tC~t,~l~h ~ (RELATIONSHIP) ' Sy/1 ~XQGt. C~ (STREET NAME) ~ tit ~ r 21 r• 1V ~ ~; (CITY) (STATE) ' t - ~~ ~~ (ZIP CODE) / d j'„ + 0 .a e. • t fi . . ~ S • NAME AND ADDRESS OF FINANCIAL INSTTTUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) ~ ~ t ~ ~ \ (STREET NAME) ' ' ^^ 1 ~~ ~ T (CITY) (STATE (ZIP CODE) 1 NAME OF PERSON MAKING LAST EN ; t Lv S• ~~c~~'1 DATE D T OF ST ENTRY ~ o OF B DATE OF CONT ACT RENT BOX NUMB~ ~ TITLE UNDER WHICH BOX IS REQUESTED ,,, ( Q ~ c+ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO SOX ' a. (NAME) ~ lJ C ~ /~ . \ b. (NAME)\`~-~~ ~ I - n (STREET ADDRESS) S1" 1 c( ~. ~+ r`t (STREET ADDRESS) 21 o IV , i3,"Q t ~ r~ e ~c ~ ~ e . (CITY) ~ (STATE) (ZIP CODE) -^^)(, ~~~ S rc~ ~A 7p (CITY) (STATE) ~. ~, j S <ira s ~ (ZIP CODE) 170 G. RY EE T KiN HE INVENTO F EMPLO O TIT LE NAM E AND `~- {.. ~ r~ ~ / A n L 1 ~. ~ 7 V ~ ~7 • ~~`Q G~JI 1 G (~ WAS A WILL IN THE BOX7 ^ YES C~NO ' tf yes, a. Date of wiN: b. Name and address of personal representative, if named in the will (NAME) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. Name and address of attorney, if any - (NAME} (STREET NAME) (CITY) (STATE) (ZIP CODE) SAFE ®C~®~7! i ~o/\ !6V V GIV~~R I Page of lNSTRUCTlONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Ob{igations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8-}-AFl-other-contents. ITEM NO. ITEM DESCRIPTION SD ct ~' r• ! ~ ~ I.Jl~.~.,,,t' •e nr~ ~' t S l y!'e s ~- / vart: ~, t z z ro l ~ ~3~ f~ ~e n ~ tke s C z ~e I s t~ ti~~ r~ 3 7 's~ ~ w er 5 i 1 ~e r • e~vll~ s ,'„ ~ lc.c d ,, re, s ~. ~o (( ~-,~ r : ~ s is a~ 3 5 w ~ ~ c~ ~ 1rr b vhd' ~t ~ o 's r e+~~.cc~ H~. e(t~S $ t...; bv- 3 i J v D.tlt..c- ii a e r~' g ~ S~ s S ~e ~+w,~ Sir, ~ ~ ~~ N ~S. ?~ C~...h ~...~-~1~- ~ a~ l~ ~ 2 ~ ~, c " ~ c ~ t 'sg 5'~ e.1' c~oll~.cs 1 ~~ ~ .. 2 "L~ - ~ tom{ ~n r,~5 u ! ~1 r r 7 ~ 5 << ~ k ~. S 2'.S S 'S~ vt' n S . h~~ '~i I'~~ C ,~ ~ lam. ,. ~ i s ~~oo ~ h c ~- ~d ~. " ~n ,~ ~~ t O. s ~ o ~.0 3'S ~G I~~ Sr. t ' ri ~. ' ~~ ~ o ~ 1, ~I: W ' I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNATURE ~- ~ ' SIGNATURE PRINT NAME ~b~st G. Fn PRINT NAME AND CHECK APPROPRIATE BOX BELOW: PRINT TITLE ~1 ld~~ ~T ~~i"~`~ DATE ~ '~/2, ~j~ CHECK APPROPRIATE BOX: ~Executor(trix) ~ Administrator(trix) I 1 ~ state Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'!z' x t1" sheet(s) if necessary or use dup{icates of this page of form. Z r . fl.~ _~ sec ~ss 5 ~c~~~rV._ __ DISCLAIMER I, KATHRYN RYNARD, the person designated as a legatee as set forth in paragraph Article IV, in the Last Will and Testament of Lucy S. Richwine, absolutely disclaim and renounce any right, title, and interest in the real estate comprising a portion of the residue to which I am entitled pursuant to Article I V, without condition or reservation of any kind. I have not in any way acted to accept the property or any of its benefits. This Disclaimer is irrevocable and unequivocal, and constitutes a complete and unqualified refusal to accept any right, title and interest in the property. ,`„~NTENDING TO BE LEGALLY BOUND, witness my hand and seal this ~_day of , Witness: r--a r (SEAL) ATHR Y D Acknowledgment of Receipt We, Kathryn Rynard, and Ross S. Richwine, Co-Executors of the Last Will and Testament of Lucy S. Richwine, do he~by acknowledge receipt of the foregoing Disclaimer by Kathryn Richwine, this S day of ~~.1 , „~°.~ 1 ROSS S. RICHWINE Commonwealth of Pennsylvania }ss. County of Cumberland On this, the S ~ day of K ZO o `T, before me, the undersigned officer, personally appeare KATHRYN RYNARD, and ROSS S. RICHWINE, Co-Executors of the Estate of Lucy S. Richwine known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. • SE ) ~~~ ~x wo~r n. ter, Nosrvrr ~,~tx ~aaiyn of taelwa Lund tower M My to~don cexpbes ~e 4. X010 DISCLAIMER I, ROSS S. RICHWINE, JR., the person designated as a legatee as set forth in paragraph Article IV, in the Last Will and Testament of Lucy S. Richwine, absolutely disclaim and renounce any right, title, and interest in the real estate comprising a portion of the residue to which I am entitled pursuant to Article IV, without condition or reservation of any kind. I have not in any way acted to accept the property or any of its benefits. This Disclaimer is irrevocable and unequivocal, and constitutes a complete and unqualified refusal to accept any right, title and interest in the property. ~..~TENDING TD BE LEGALLY BOUND, witness my hand and seal this 5 ~ day of ~^ , Witn s: __.~ i L) ROSS S. RICHWINE, JR Acknowledgment of Receipt We, Kathryn Rynard, and Ross S. Richwine, Co-Executors of the Last Will and Testament of Lucy S. Richwine, do hereby acknowledge receipt of the foregoing Disclaimer by Kathryn Richwine, this ~~ day of ~a ~ ,~~L~ Commonwealth of Pennsylvania }ss. County of Cumberland On this; the ~ day of ?baY before me, the undersigned officer, personally appeared K THRYN RYNARD, and ROSS S. RICHWINE, Co-Executors of the Estate of Lucy S. Richwine known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ,~. ~ ~ ~r ~. ~ NO'i~1iR- M~ Ilwough a/ C,afYe ds~ewOnd Cer~M My Cow~ission fires 3oine 4. 2010 ROSS S. RICHWINE