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Home My WebLink About04-13-11 1505610140 REV-1500 EX (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN _ Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 2 1? ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 9 2 3 0 0 3 9 3 0 2 1 1 2 0 1 ], 0 6 1 4 1 9 1 2 Decedent's Last Name Suffix Decedent's First Name MI D I T M E R T H E L M A C (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 WITH THE REGISTER OF WILLS 0 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ prior to 12-13-82) 5. Federal Estate Tax Return Required 0 D 6 d Di death after 12-12-82) . ece ent ed 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 SHOULD BE DIRECTED TO: Name Daytime Telephone Number ,- , C H R I S T A M A P L I N 7 1 7 ~.~ 1 5_ _~:.5 5 0 -,..., - _____ ---- -- REGISTEF~P 1~'pS USE-0NLY ~- I _:~ First line of address ~-~ , =, f _:. J A N L B R O W N ~ A S S O C~ f,~~,~~' =- ~~ _ _.~ ~ - ~ _ Second tine of address -; _1--~- '; - ' - ~ { i -'.' - ~ ~, 8 4 5 S I R T H O M A S C T S T E 1 2 ~- ~ `~ City or Post Office State ZIP Code ~ ______ _ _ DATE FILED ~ H A R R I S B U R G P A 1 7 1 0 9 Correspondent's a-mail address: CHRISTAJLBna VERIZON.NET under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tru correct d complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG TUR ERS PONSI E FOR FILI G RETURN DA E J ~ . b .~ ~, nRFCc '175 FLORENCE DRIVE HARRISBURG PA ],7112 SI TU E P PARF~R TH R T AW REPRESENTATIVE A ESS I ,{j 845 SIR THOMAS CT STE 12 HARRISBURG PA L71,n9 PLEASE USE ORIGINAL FORM ONLY L 1505610140 Side 1 1505610140 J r ~~~~ J 1,505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: T H E L M A C• D I T M E R 1 9 2 3 0 0 3 9 3 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1 2. Stocks and Bonds Schedule B 2. 6 1 3 1 0. 4 7 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. « 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 3 6 4 5 « 4 4 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 1 0 3 7 0 « 4 9 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~ S t Billi 4 ? 0 0 0 0 epara e ng Requested ....... 7. . 0 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 2 2 3 2 6 , 4 0 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 2 4 7 9 . 2 2 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ... .......... 10. 2 5 • 0 0 11. Total Deductions (total Lines 9 and 10) ..................... ... . ...... 11. 1 2 5 0 4 . 2 2 12. Net Value of Estate (Line 8 minus Line 11) .................. .......... 12. 1, 0 9 8 2 2 . 1 8 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. 1 0 9 8 2 2. 1 8 TAX CALCULATION -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 1 0 9 8 2 2. 1 8 1s. 4 9 4 2. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 1 g, 0. 0 0 19. TAX DUE ............................................. ......... 19. 4 9 4 2. 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME THELMA C. DITMER STREET ADDRESS 4905 EAST TRINDLE ROAD File Number 21 11 0217 -_ -__ T--STATE _ ...ZIP --- - ---- - - - ------ MECHANICSBURG PA 17050 Tax Payments and Credits: ~~ Tax Due (Page 2, Line 19) (1) 4,942.00 2. Credits/Payments A. Prior Payments 4,694.90 B. Discount 247.10 Total Credits (A + B) (2) 4, 942.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) 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. (5) 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 : ...................................................................... ^ 0 b. retain the right to designate who shall use the property transferred or its income; ............................... ^ X^ c. retain a reversionary interest; or ..................................................................... ........................... ^ 0 d. receive the promise for life of either payments, benefits or care? ......... ^ .............................................. ^ X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... Q ^ 3. Did decedent own an "intrust for" orpayable-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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 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 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 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 12 percent [72 P.S. §9116(a)(1.3)). Asibling is defined, unde Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER THELMA C. DITMER 21 11 0217 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Franklin Tax Free TR PA T/F INCM C (FRPTX); 3522.307 shs @ $9.730/sh 34,272.05 Mutual Fund 2. Franklin Tax Free TR HI YLD T/F C (FHYIX); 2828.287 shs @ $9.560/sh 27,038.42 Mutual Fund TOTAL (Also enter on line 2, Recapitulation) I $ 61, 310 47 (If more space is needed, insert additional sheets of the same size) ESTATE OF THELMA C. DITMER SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 11 0217 Include the 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. PNC Investment Money Market Fund #47054188 1 051.83 2. Country Meadows refund 2,341.37 3. Highmark health insurance premium refund 252.24 TOTAL (Also enter on line 5, Recapitulation) $ 3.645.44 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY t~ i A i t ur: FILE NUMBER: THELMA C. DITMER 21 11 0217 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. JOHN H. DITMER 175 FLORENCE DRIVE SON HARRISBURG, PA 17112 13. C JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET A. I12/1994IPNC CHECKING ACCOUNT # 5080393264 ~ 20,740.98 TOTAL (Also enter on Line 6, Recapitulation) If more space is needed, use additional sheets of paper of the same size. OF DATE OF DEATH DECEDENT'S VALUE OF INTEREST DECEDENT'S INTEREST 50. 10, 370.49 $ 10, 370.49 REV-1510 EX+ (08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT to i A ~ t ur FILE NUMBER THELMA C. DITMER 21 11 0217 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Gift to son, John H. Ditmer 50,000.00 100.00 3,000.00 47,000.00 on or after March 16, 2010 TOTAL (Also enter on Line 7, Recapitulation) ~ $ 47, 000 00 If more space Is needed, use addltlonal sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHFRITAN(F TnY RGTI IRnI SCHEDULE H FUNERAL EXPENSES AND ESTATE OF FILE NUMBER THELMA C. DITMER 21 11 0217 Decedent's debts must be reported on Schedule 1l. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: 1. Hoover Funeral Home & Crematory, Inc.; funeral expenses 2. Blue Ridge Memorial Gardens; cemetery costs 3. Skyline Restaurant; funeral luncheon B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address 5,350.00 1,675.00 129.20 City State ZIP Year(s) Commission Paid: 2, Attorney Fees: Jan L. Brown & Associates 4,500.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: Register of Wills, Cumberland County 190.50 5 Acx;ountant Fees: 6. Tax Return Preparer Fees: Parks & Company; fiduciary returns 300.00 7. Cumberland Law Journal; legal advertising 75.00 8. The Sentinel; legal advertising 187.54 9. Register of Wills, Cumberland County; Inventory and Inheritance Tax Return filing fees 30.00 10. PNC; estate checks 41.98 TOTAL (Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. AMOUNT 12.479.22 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER THELMA C. DITMER 21 11 0217 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Genesis Rehabilitation Services; outstanding medical bill 25.00 TOTAL (Also enter on Line 10, Recapitulation) I $ 25 00 If more space is needed, insert additional sheets of the same size. REV-1513 EX~ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES t51 A I t Uh: THELMA C. DITMER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).j 1. JOHN H. DITMER 175 FLORENCE DRIVE HARRISBURG, PA 17112 FILE NUMBER: 21 11 0217 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal AMOUNT OR SHARE OF ESTATE 109,822.18 100% residue, plus Schedules F & G ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ $ If more space is needed, use additional sheets of paper of the same size. REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: __-_ - _ _4,94_2.00 Discount: 247.10 Interest Table Year ,Days Delinquent ~ Balance Due ~~ Interest ~, this time period this year '~ this period 1---------------------- --~ ----- ------------ Before 1981 1982 -------------- ---~ _ -- - -- -- - -- -__ ---- - 1983 ~ ~ 4 ----- ---_ _ ------ ,_ _ _ --- - -_ _ ~ - --_ - _-- - a 1984 ~ - - - _ - - - - 1985 -_ - _ -- - ___- -- - - I - - ___ - -- -- __ -_--~------ --- - --- ----- - - ~ - _ - l 1986 ~ _ - - _ ! ---- -- ----- -- --- - --- _' - - , 1987 ~~ ___ - --- - ----I- - _ --- --- --- --- - - __ _ -- ~ - - - __ --- _. ! 1988 through 1991 _ - --a- __ - - ----- ~_1992_---- ~ ------~------ 1993 through 1994 _ '~ 1996 through 1-998 1999 - -- - - - _ _ r -------- ------- - - ~ - -- --- - - -; - --- --- - - - __ ---- -a (_..2000.- __ -- - -- - _ _-- --_ ~__ _ - ------ ----- 2001 _~ _ - -- - -- - _. - - -- --- ---_ -------- --~ - _ - -------- ----- ------------- --- _ ___ _- ---- - -- -I r 2002 -- --------------------- - ------- - - 2003 _ -- -- - --- __ _ ----- -a 2004 ~- _-----__ -- -- - _ i. -_ _ - ___ 2005 ~_ - _ - ~ _ - - _- - - i - -- - - ~2_006 ~ 2007 -- - 2008- - -------------- ---_~ - --- ---- - ----- 2009 ---_ - ______ - - ---- - -- - -- - - - -- - -- - ----- ---- - - ---- ! 2010 --- - - ~ -- --- -- - ----- -I _ --- - _ _ __---------- -I -- --- - ---- - -- - - ~ - -- _ _ _-______ i _ _ -_ J --_ _ -- ---- ~- - ------- -- I~ ~------ TOTALS ------~---- ---------- -- Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: _ Penalty: REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No. 2011- 00217 PA No. 21- 11- 0217 Estate Of : THELMA C /7/TMER /Firs!, Middle, Lastl Late Of : HA MPDEN TOWNSHIP CUMBERLAND COUNTY Deceased Social Security No : 192-30-0393 WHEREAS, on the 17th day of February 2011 an instrument dated January 8th 2004 was admitted to probate as the last wi 11 of THEL MA C Dl TMER /First, Middle, Lastl 1a to of HAMPDEN TOWNSHIP, CUMBERLAND County, who died on the 11th day of February 2011 and WHEREAS, a true copy of the wi 11 as probated i s annexed hereto . THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: JOHN H DI TMER who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to 1 aw, all of wl~1i ch fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARL /SL E, PENNS YL VA NlA . IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 17th day of February 20 ~ 1. Register of Wills '~"- Deputy * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAST WILL AND TESTAMENT OF THELMA C. DITMER I, THELMA C. DITMER, 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 leave 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 an Y 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~ c_ ~ --. . y ~_- - ~1 . -~~ , ' 7 -- '- --- --. - -i 7 =- -~ J '_.. L!, ~~ ~ 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. All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath to my son, JOHN H. DITMER, of Dauphin County, Pennsylvania. In the event that JOHN H. DITMER predeceases me or fails to survive me by thirty (30) days, I give, devise, and bequeath the remainder of my estate, of whatsoever nature and wheresoever situate to my daughter-in-law, SHIRLEY M. DITMER, of Dauphin Count , Y Pennsylvania. If SHIRLEY M. DITMER predeceases me or fails to survive me by thirty (30) days, I give, devise and bequeath her share to her issue who survive me, per stirpes, or if she has no issue, the share(s) are to be added equally to the other shares. I nominate, constitute, and appoint my son, JOHN H. DITMER as Executor of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executor, I nominate, constitute and appoint SHIRLEY M. DITMER as successor Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of SHIRLEY M. DITMER, I nominate, constitute and appoint my granddaughter, LINDA L. DITMER, ofDauphin County, Pennsylvania as successor Executrix of my Last Will and Testament. I direct that my Executor or successor Executrixes 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 Executor or successor Executrixes shall receive reasonable compensation for services rendered to my estate. Article VI In addition to the powers conferred by law, I authorize my Executor and successor Executrixes, 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, -3- (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 of fees in effect while their services are performed. IN WITNESS WHEREOF, I, THELMA C. DITMER, hereby set my hand to this my Last Will and Testament, on _ ~ ' 2004, at Hamsburg, Pennsylvania. 7/. ~ _ . THELMA C. DITMER In our presence, the above-named THELMA C. DITMER 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 -4- I, THELMA C. DITMER, 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 THELMA C. DITMER, the Testatrix on _ / - ~ 2004. ,--~ i <~~ ~] -tip ` _~ ~~ -~------ ~ Not Public ~,, !AN 1. BROWN OTAI~ PUBLIC I~r Is~sloN a~l~~ Mn~ ~u ~a `,, .~~ ~ ~ ' ~ _ THELMA C. DITMER 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 subs ribed to before me by ~ ~ an . ~~ ? witn ses, on ~ --~ , 2004. n S~ ~~"ota~-y Public ~ ~ ~ ~~ ~ -~'~~ tness ~'- UCH ~~ ~~)c l ~ ~~ fitness N RIAl. 1AN L BROWN, NOTARY PUBLiC _ 5 MY C~OMMISS ON DIXPi~ S MARCH 29u ZO 4