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HomeMy WebLinkAbout04-07-10 (3)1 1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO Box 280601 INHERITANCE TAX RETURN 2 1 1 0 0 0 7 7 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 3 1 0 4 7 3 3 0 1 0 7 2 0 1 0 0 6 1 7 1 9 2 0 Decedent's Last Name Suffix Decedent's First Name MI R A F F E N S P E R G E R E L E A N O R L (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 a 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 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 ~ 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 5F10ULD BE DIKtG I tU I U: Name Daytime Telephone Number J A N L B R O W N 7 1 7 5 4 1 5 5 5 0 Firm Name (If Applicable) J A N L B R O W N & A S S O C First line of address 8 4 5 S I R T H O M A S C T S T E 1 2 Second line of address City or Post Office H A R R I S B U R G State P A ZIP Code __ REGISTE F WILLS US ~ LY ~ ~ ~ ~~, I~ ._._ ; .l-: ~ r Q -'~-~ `-' ; '" ~ ~k'~E FILED ;, ' ` _ 1 7 1 0 9 Correspondent's a-mail address: BRENDAJLB _VERIZON.NET yr .iC' t ; .,, -~'`r c`":.~ .:.,.... Under penalties of pery'ury, 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. SI N URE OF PERSON R SPONSIB FOR FILING RETURN DATE ~}-~i~.n~ ~ `~~~~[ ~ 4 / 6 / 2 010 110 FAIRVIEW DR HARRISBURG PA 17112 SIGNATURE OF P ER THAN REPRESENTATIVE DATE __ 4/6/2010 845 SI~`-~MAS CT STE 12 HARRISBURG PA 17109 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 J REV-1500 EX 1505607221 Decedent's Name: ELEANOR L • RAFFENSPERr;ER Decedent's Social Security Number 2 0 3 1 0 4 7 3 3 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. • 9 5 4 5 7 . 1 8 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Properly (Schedule F) ^ Separate Billing Requested ....... 6. 3 0 7 3 5. 0 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 6 1 6 8 7 3. 3 9 8. Total Gross Assets (total Lines 1-7) ........................... 8. 7 4 3 0 6 5. 5 9 9. Funeral Ex enses & Administrative Costs Schedule H P ( ) ................ 9. 1 9 0 8 6 . 3 8 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 9 g ( ) ............ 10. 1 0 1 8 . 4 0 11. Total Deductions (total Lines 9 & 10) ........................... 11. 2 0 1 0 4 • ? 8 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12• 7 2 2 9 6 0 . 8 1 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. 7 2 2 9 6 0 . 8 1 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. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 7 2 2 9 6 0. 8 1 16. 3 2 5 3 3. 2 4 17. Amount of Line 14 taxable 0 0 0 0 0 0 at sibling rate X .12 17, • 18. Amount of Line 14 taxable 0 0 0 0 0 0 at collateral rate X .15 . 1 g, . 3 2 5 3 3. 2 4 19. Tax Due ............ .......................... ... ....... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 1505607221 Side 2 0 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0077 DECEDENTS NAME ELEANOR L. RAFFENSPERGER STREET ADDRESS 770 Po lar Church Road East Pennsboro Township CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: ~• Tax Due (Page 2 Line 19) (1) 32,533.24 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 1,626.66 Total Credits (A + B + C) (2) 1,626.66 3. Interest/Penalty if applicable D. Interest E. Penalty 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. 6. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) 0.00 (5) 30,906.58 (5A) (56) 30,906.58 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ ^X d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... Q ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ Q 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-0ne 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)]. 0.00 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-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ELEANOR L. RAFFENSPERGER FILE NUMBER 21 10 0077 -- Indudethe proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T Bank Checking 61207446 8,197.42 2 M&T Bank Savings 15004222002682 1,000.12 3 M&T Bank CD 31003913944590 8,892.57 4 M&T Securities AZD-415941 20,102.82 Cash balance 5 PNC Bank Checking 5004894008 9,822.53 6 PNC Bank Money Market 5004414473 38,781.38 7 Residuary Trust UWO Carl Raffensperger 0.14 Ck 101 dtd 1 /14/10 payable to Estate of Eleanor L Raffensperger for 2009 interest 8 Carl T Raffensperger Trust 758.00 Ck 1011 dtd 1 /14/10 payable to Estate of Eleanor L Raffensperger for 12/09 interest 9 Residuary Trust UWO Carl Raffensperger 223.99 Ck 1038 dtd 1 /14/10 payable to Estate of Eleanor L Raffensperger for 12/09 interest 10 HARP LTC refund; Check 0028579495 dtd 1 /11 /10 107.50 11 HARP cancellation refund; Check 0028666420 dtd 2/3/10 21.05 12 Capital Blue Cross refund 342.67 13 Comcast subscriber refund; Check 0003832573 dtd 2/3/10 34.11 14 Golden Living Center refund 875.88 15 MetLife nursing home benefit; Check 000635202 dtd 1/4/10 3,906.00 16 United States Treasury; 2009 1040 overpayment refund 1,502.00 TOTAL (Also enter on line 5, Recapitulation) a 95,457.18 (If more space is needed, insert additional sheets of the same size) Continuation of REV-15001nheritance Tax Return Resident Decedent ELEANOR L. RAFFENSPERGER Decedent's Name Page 1 21 10 0077 File Number Schedule E -Cash, Bank Deposits, & Misc. Personal Property ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 17 PA Department of Revenue; 2009 PA-40 overpayment refund 889.00 SUBTOTAL SCHEDULE E 889.00 GRAND TOTAL SCHEDULE E ~ 95,457.18 REV-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF ELEANOR L. RAFFENSPERGER FILE NUMBER 21 10 0077 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 A. Todd W Lehman I s Jon V Lehman I C Louise L Hesse 667 W 161 St Apt 3H son New York NY 10032 735 State St son Lancaster PA 17603 110 Fairview Dr daughter Harrisburg PA 17112 JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND 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 DECEDENT'S INTERESI 1. A. 2006 M&T Bank Money Market 15004219140271; 18,312.28 50. 9,156.14 originally established in M&T Securities 428050 2 B 2006 M&T Bank Money Market 15004219140289; 33,438.27 50. 16,719.14 originally established in M&T Securities 428076 3 C 2006 M&T Bank Money Market 15004219140263 9,719.48 50. 4,859.74 originally established in M&T Securities 426344 TOTAL (Also enter on line 6, Recapitulation) I S 30,735.02 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ELEANOR L. RAFFENSPERGER 21 10 0077 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE 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 EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. Gift on 12/26/09 from Eleanor L Raffensperger to 13,000.00 100. 3,000.00 10,000.00 Todd W Lehman, son 2 Gift on 12/26/09 from Eleanor L Raffensperger to 13,000.00 100. 3,000.00 10,000.00 Jon V Lehman, son 3 Gift on 12/26/09 from Eleanor L Raffensperger to 13,000.00 100. 3,000.00 10,000.00 Louise L Hesse, daughter 4 M&T Securities IRA AZR-062771; Todd W Lehman, 57,405.85 100. 57,405.85 Jon V Lehman and Louise L Hesse, children, beneficiaries 5 Transamerica Nonqualified Annuity 02CBT090956; 126,012.36 100. 126,012.36 Todd W Lehman, John V Lehman and Louise L Hesse, children, beneficiaries 6 Residuary Trust UWO Carl T Raffensperger 403,455.18 100. 403,455.18 DOD value $409,529.18 less exp of $6,074 = $403,455.18 Note: Schedule O election was not made in the Estate of Carl T Raffensperger (File 21-06-0682). Dececent, spouse of Cart T Raffensperger, was primary beneficiary of this Trust. The remaindermen beneficiaries are: 75% - Fred C Raffensperger & Amy R Meade, Carl's children 25% - Todd W Lehman, Jon V Lehman & Louise L Hesse, Eleanor's children TOTAL (Also enter on line 7 Recapitulation) I ~ 616,873.39 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ELEANOR L. RAFFENSPERGER 21 10 0077 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hoover Funeral Homes & Crematory Inc 3,281.00 2 Memorial program 25.31 3 Isaac's; memorial luncheon 500.00 4 Memorial/marker inscription 200.00 B. 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Louise L Hesse Street Address 110 Fairview Drive city Harrisburg State PA Year(s) Commission Paid: 2010 Attorney l=ees Jan L Brown & Associates Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Zip 17112 5,962.00 6,792.00 4. 5. 6. 7. 8 9 10 11 Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills Acxountant's l=ees Parks & Company; final 1040 and 1041 prep Tax Return Preparers Fees Denk & Associates PC; 2009 income tax prep Cumberland Law Journal; legal advertising The Patriot-News; legal advertising Parking fee Postage Cleanup/disposal fee 339.50 500.00 395.00 75.00 300.41 4.00 12.16 700.00 TOTAL (Also enter on line 9, Recapitulation) S 19.086.38 (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 ESTATE OF ELEANOR L. RAFFENSPERGER SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 10 0077 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Amber Long Weyant; caregiver 250.00 2 Edward E LaMarque MD 76.17 3 Golden Living Center 78,83 4 Jan L Brown & Associates; invoice dated 1/6/10 100.00 5 PharMerica 140.32 6 Verizon 15.58 7 West Shore EMS -BLS; dos 12/23/09 177.50 8 United States Treasury; federal withholding tax 150.00 9 PA Department of Revenue; state withholding tax 30.00 TOTAL (Also enter on line 10, Recapitulation) I ~ 1,018.40 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ELEANO R L. RAFFENSPERGER 21 10 0077 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE j TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Todd W Lehman, son Lineal 667 W 161 St Apt 3H, New York, NY 10032 Sch F & G 1 /3 residue 2 Jon V Lehman, son Lineal 735 State St, Lancaster, PA 17603 Sch F & G 1 /3 residue 3 Louise L Hesse, daughter Lineal 110 Fairview Dr, Harrisburg, PA 17112 Sch F & G 1 /3 residue 4 Fred C Raffensperger, son of Carl & stepson of Eleanor Lineal 17 Peverell St Apt 3, Dorchester, MA 02125 Sch G 5 Amy R Mead, son of Carl & stepson of Eleanor Lineal 467 Atlantic St, East Northport, NY 11731 Sch G ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET jj. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF ELEANOR L. RAFFENSPERGER I, ELEANOR L. RAFFENSPERGER, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. Article I 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~ a _. L7 i _' ~,J ~,~ ._ ~ ~_ / (~_ j _ ~ T.,, ' ,/ J _ ( ,• ' ~ ~/ 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 children, LOUISE L. HESSE, of Dauphin County, Pennsylvania, TODD W. LEHMAN, of New York City, New York, and JON V. LEHMAN, of Lancaster County, Pennsylvania. If any of my beneficiaries predecease me or fail to survive me by thirty (30) 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 Except as otherwise provided in this Will, I have intentionally failed to provide for any other persons or relatives, whether claiming to be an heir and/or relative of mine or not. Insofar as I have failed to provide in this Will for any of my relatives, and/or issue now living or later born or adopted, such failure is intentional and not occasioned by accident or mistake. Article VI If any person or entity other than me singularly or in conjunction with any other person or entity directly or indirectly contests in any court the validity of this Will, including any amendments or codicils thereto, then the right of that person or entity to take any interest in my estate shall cease, and that person or entity shall be deemed to have predeceased me. Article VII I nominate, constitute, and appoint my daughter, LOUISE L. HESSE as Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint my son, TODD W. LEHMAN as successor Executor of my Last. Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of TODD W. LEHMAN, I nominate, constitute and appoint my son, JON V. LEHMAN, successor Executor of my Last Will and Testament. I direct that my Executrix or successor 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 Executrix or successor Executors shall receive reasonable compensation for services rendered to my estate. Article VIII In addition to the powers conferred by law, I authorize my Executrix and successor 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, -3- (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 their 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 o~f fees in effect while their services are performed. IN WITNESS WHEREOF, I, ELEANOR L. RAFFENSPERGER, hereby set my hand to this my Last Will and Testament, on ~ 2006. -~ r. ELEANOR L. RAFF SPE GE In our presence, the above-named ELEANOR L. RAFFENSPERGER 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 /c:~,~ ,~ S~. Address 845 Sir Thomas Court, Suite 12, Harrisburg, PA 17109 845 Sir Thomas Court, Suite 12, Harrisburg, PA 17109 -$- I, ELEANOR L. RAFFENSPERGER, 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 ELEANOR . RAFFENSPERGER, the Testatrix on `x 3 2006. ,~ ota Public coMMONwEA~n+ OF PENrsnrANU- NOTARIAL SEAL JACQtIELfNE A. KELIX NOTARY PUBL~ LOYYER PAXTON TYVP., DAUPHIN COUNIY MY COMMISSION EXPIRES DEC.17, 2007 . d etc« Q ~.' Z -:c v~ ELEANOR L. RAF SP R 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~1' and i.v ~t, ~C-:` ~ sc~~C , witnesses, on ~ -a .~ , 2006. of Public COMMONMIEALTH OF PENNSYIYANUI NOTARIAL SEAL. 1ACQUEUNE A. KElll~ NOTARY PUBLlC IDWER PAXTON TWP., DAUPHIN COUNTY MY COMMISSION EXPIRES DEC. 11, 1007 -6- Witness L~2.C~ ~ • L"~ Sly fitness ~~ 7 `~ a l a . c~ ~,~flP~