HomeMy WebLinkAbout05-19-11 (2)15D561D143
C Fx(at-to>
REV-1 SOO OFFICIAL USE ONLY
PA Department of Revenue pennsylvania county coda veer File Number
Bureau of Individual Taxes °~'""^'~'"°"
PO 80X.280601 INHERITANCE TAX RETURN 21 11 0299
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
171 03 5052 02 21 2011 07 08 1917
Decedent's Last Name
SHAW
Suffix Decedent's First Name
ERNEST
(lf Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
T
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
X^ 1. Original Retum ~ 2. Supplemental Return ~ 3, Remainder Return (date of death
priorto t2-13-62)
q, Limited Estate ~ 4a. Furore Interest Compromise
(date of death after 72-i2~2) ~ 5. Federal Estate Tax Retum Required
6 oecadem Died restate
(Attach Copy of Will) ~ ~ ~Aeftcaed~epoPYiof~nest)a Living Trust
c g, Total Number of Safe Deposit Boxes
g. Litigation Proceeds Received ~ t p. e~iween?2~3a1 Y C~it{detge5gr death
91 I ~ t t Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT • THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL L BANGS 717 730 7310 P__'.
_,.,
First line of address
429 SOUTH 18TH STREET
Second line of address
City or Post Office State ZIP Code
CAMP HILL PA
n . - -~ -
REGISTER O~YVpyL,$~USE OyLY
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DATE FILED
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Correspondent's a-mail address:
Under penalties of perjury, I dectare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belle},
it is true, correct and complete. geclaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
Michael H. Shaw
OF
429 South
15D561D143
Hill. PA
Michael L. Bangs
Side 1
//
15D561D143 J ~~
J
REV-1500 EX
o.ceaern~,Name: Shaw, Ernest T.
Decedent's Social Security Number
171 03 5052
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 8 Notes Receivable (Schedule D) ........................................................ 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous f~ nq Probate Property
(Schedule G) ~_J Separate Billing Requested............ 7,
8. Total Gross Assets (total Lines 1-7) .................................................................... . 8.
9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10.
11. Total Deductions (total Lines 9 & 10) ................................................................... 11.
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14,
TAX COMPUTATION - 3EE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable 207 , 328.27 16.
at lineal rate X .045
17. Amount of Line 14 taxable
0
0 0
17
.
at sibling rate X .12 .
18. Amount of Line 14 taxable
0
00
18
.
at collateral rate X .15 .
19. Tax Due ................................................................................................................. . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1505610243
158,811.51
56,592.17
215,403.68
7,329.08
746.33
8,075.41
207,328.27
207,328.27
0.00
9,329.77
0.00
0.00
9,329.77
Side 2
L 1505610243 1505610243
Rev-tsoe Ex. la•sal
COMMON W EALTH OF PENNSYLVANIA
INNERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Shaw, Ernest T. 21-11-0299
Include the proceeds of litiCanon and the tlete the proceeds were received by the estate.
All properly joimlycwnsd with the light o(survlvorship must be dlselosed on schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 Refund from Asbury Communities 1,990.58
2 Refund from PA Department of Revenue - 2009 taxes 1,210.94
3 Refund from PA Department of Revenue - 2009 income taxes 10.61
4 Wachovia Bank -Checking Account 17,402.36
5 Wells Fargo Cash -Resource Account 34,500.96
6 Wells Fargo Cash and Money Market 1,476.72
TOTAL (Also enter on Line 5, Recapitulation) I 56,592.17
(If more space is needed, additional pages oT the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule E (Rev. 6-98)
REV-1161 Ex+ (10-08)
COM~~r,(~F(~~ANIA
SCHEDULE H
FUNERAL EXPENSES 8
ADMINISTRATIVE COST:
ESTATE OF I FILE NUMBER
Shaw, Ernest T. 21-11-0299
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 3,293.52
B. I ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s) Commission paid
2, Aftornev's Fees Michael L. Bangs 3,500.00
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationshio of Claimant to Decedent
4. Probate Fees 315.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 220.06
See continuation schedule(s) attached
TOTAL (Also enter on Ilne 9, Recapitulation) 7,329.08
Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Shaw, Ernest T. 21-11-0298
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e~ Haas
1 Neill Funeral Home 3.293.52
H-A 3,293.52
Other Administrative Costs
2 Cumberland Law Journal -estate advertising 75.00
3 The Sentinel -estate advertisement 145.06
H-B7 220.06
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev1512 EX+ (12-09)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8t LIENS
COM MON W EALTM OF PENNSYLVAN IA
INIffRITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shaw, Emest T. 21-11-0299
Report dsMa Incurred 6y the tlacedeM prior to death that romalnsd unpaid at the data of deagr, Including unrelmhurrd medical s:penses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Bonnie Miller - 2011 per capita tax 9.80
2 Carey Associates -preparation of 2010 income tax returns 160.00
3 State Employees' Retirement System -Return of retirement overpayment 305.53
4 US Department of Treasury - 2010 income tax due 271.00
TOTAL (Also enter on Line 10, Recapitulation) I 746.33
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-7500 Schedule 1 (Rev. 12-08)
REV-1613 EXs (11-0B)
SCHEDULE J
0O"'~~°~~e~~~""'" BENEFICIARIES
ESTATE OF
FILE NUMBER
~nr~w, ~rnesz i. 21-11-0 299
NUMBER NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S) RECEIVING PROPERTY (Words) ($$$)
I TAXABLE DISTRIBUTIONS [inGude outright spousal
distributions, and transfers
under Sec. 8118 a 1.2
Michael H. Shaw Son 207,328.27
190 South Franklin Street
Harrisburg, PA 17109
Total 207,328.27
Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 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
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
Estate Valuation
Date o! Deaths 01/21/2011 ~ Ratate ofr Eraeat T. Shaw
Valw tioa Dates 01/21/2011 Accounts -9454 and -9941
Proce ssing Dats: 04/28/2011 Report Typo: Date of Death
liwbar o! eeauritiear 15
Pile iD: 3hax9454,Erneet005375
Shares security Mena and/or Security Div and Iat
I dentifier or Par Deeeriptioa Eigh/Aak Lox/Eid Adjust~eata Value Accruals
1) 019118401 300 ALLIED IA,`.SH BL8 P L C '
BPOE ADA QAD
E4nr work 'stock Exahaage
Os/SB/1011 0.81000 0.79000 H/L
01/21/1031 0.79000 0.76000 H/L
0.790000 137.00
2) 002068102 266 ATiT IEC (T)
C091
wax York Stock Estohaage
01/18/1011 18.58000 18.35000 R/L
01/21/2011 18.41000 18.05000 R/L
18.350000 7,541.10
3) 064058100 441 GAEL OP ERR YOAR IDILLON COED (HL)
0011
Eax York Stock Ezahaage
01/18/2011 31.94000 31.19000 H/L
01/11/1031 31.45000. 30.84000 R/L
31.355000 13,858.91
4) 35906A108 99 PEOETIER C090lOEICATI0E8 COAP (PTA)
COM
Eex York Stock Euhaaga
01/18/1011 9.46000 9.36000 R/L
01/11/1011 9.46000 9.19000 R/L
9.367500 917.38
5) 693517106 ll1 PPL COAP (PPL)
C09[
Eax Tork Stock lbschange
01/18/1011 15.10000 24.93000 E/L
01/11/1011 1s.llooD 1l.eaooo H/L
25.005000 3,550.71
6) 749121109 254 axEET C09MOEICATI0918 IETL 71iC (p)
COY
Eex York Stock Exchange
02/18/1011 6.96000 6.71000 R/L
01/12/1011 6.73000 6.51000 R/L
6.717500 1,708.79
Divs 0.08 Bx: 03/16 Aecs 01/18 Pays 02/ 15/11 10.71
7) 92343V10! 414 YERIZOR C0101DEICATIOE8 IEC (VZ)
0091
Eew York Stock Esohaage
02/18/2011 36.81000 36.17000 H/L
01/11/2011 36.31000 35.85000 H/L
36.311500 15,033.38
8) 91857x109 315 VODIIPOEH fSRODP PLC EEx (VOD)
8POE8 ADR liEx
Eex Tork Stock Exchange
01/18/2011 29.75000 19.46000 R/L
OZ/11/ton 19.27530 18.67060 R/L
19.188975 9,116.09
9) 949746101 189 xELLB PAA00 a CO IDM (NPC)
C011
Eex Yosk Stock Exchange
01/18/1011 33.07000 31.34000 9/L
01/21/1011 31.14000 31.13000 R/L
31.195000 6,084.86
Div: 0.05 Exs 01/02 Aecs 02/04 Pays 03/01/11 9.45
Page 1
Please nee the Llwl gaga !OS IIOTDATAET Si1PO1a1J1TIOE AEOV! TEE EETATB VALDATIOE REPORT. ~
xell• Pargo Advisors does not reader tax or legal advice. I! you have any queatioaa please eoasult with your.taz
and legal advisors. xella Pargo Advisors is the trade saw wed by three separate registered broker-dealsrss Nell^ Pargo
Advieora, LLC, Nalle Fargo Advisors Piaaacial Eetrork, LLC and walls 7srgo Inveetaonts, LLC, Itesnbass BIPC, aoa-basilc
alfiliataa of M~11^ Pargo a Caaspaay.
Data of Daathr 02/21/2011
valwtioa Dater 02/21/x011
Pmcsssiag Dater 04/28/2011
8haru Security
Ideatilier or Par Description High/Aik Low/Did
10) 27824L504 1000.777 EATOE' VAIICE Mm18 TR (EVP11I)
PA MOE IECH 8
_ Mutwl Mnd (as quoted by EABDAQ)
02/10/2011 8.84000 ltkt
11) 27826L280 1573.97 EATON VAMCE MONE TR (ETPAI)
PA 4011 TECH A
Mutwl Pwd (as quoted by EABDAQ)
02/18/2011 8.54000 Mkt
12) 013904305 72 ALGTEL-COGENT (ALO)
ePOlreonm Aax
Eew York Stock Exehaage
02/16/2011 5.09000
07/22/2011 4.98000 R/L
4.90000 4.74000 R/L
13) 8362B4VY7 7BD00 STATE EE I1iDIA EEE YORE E!
Financial Times Iataractiva Date
DTDr 09/17/2010 Matr 03/17/2011 0.4~
Estate of: Ernest T. Shaw
Accowtr -9454 and -9941
Report Typer Date of Death
Number of Securities: 15
Pile ID: 8har9454,Ernaet005375
Mean and/or Security Div and Int
Adjustments Value Accruals
8.840000 8,846.87
8.540000 13,4{1.70
4.927500 354.78
02/18/2011 100.00000 Mkt
02/22/2011 loo.ooeoo Mkt
Iner o9/17/solo toot/21/2011 loo.ooooo0
14) MOART 1476.72 CAGE AED MONEY MAREET
1S) CABR 34500.96 REBOOxCE ACCDONT -9941
CABR AND MONEY MARESP
Total Yaluel
Total Accraalr
Totalr ;194,953.29
7e,oeo.oo
134.33
1,476.72
34,500.98
;194,789.19
;164.10
Page 2
~ Pluu see the Liaal page for L~ORTANT IEPORMATioE ABOOT THE ESTATE VALOATION REPOxT.
Halle Pargo Advisors does sot reader tax or legal advice. If you bare say questions plats• consult with your tax
and legal advisors. Nalis Pargo Advisors ie the trade aama wad by three separate registered broker-dealerss wells Pargo
Advisors, LLC, wells Pargo Advisors Piaaacial E~twork. LLC and Hells Pargo investments, LLC, Members BIPC, non-bask
aLfiiiates of wells largo c Coapany.
Date of Death: 03/41/2011
Valuation Date: 04/71/4011
Processing Date: 0!/28/2011
Portfolio Endaotea
IMPORTAxT IxPOREATIOx AHODT TAE ESTATE VALDATIOE REPORT
Estate oft 8raast T. Shaw
Aecoaat: -945! and -9911
Report Type; Date of Death
Aumbar of Securities: 15
File ID; 8haw9l5l,Ernest005375
Tha inlormatioa is this Estate Valuation Report (ralaraaeed below as the Aapost) is based on the Estate Valuation
xorksbaat provided to ue Dy the Financial Advisor requesting the Rapore. xe have oot uud client etateaats, internal
aacouatiaq data, or say other resources to lndepandaatly verify the identity or quantity o! securities held, the date of
death, or the alternate valuation date, if applicsble.
The Report uy iaolude assets that you currently hold awy lrom our lira, which may or may not be identified as being held
awy. Information oa asaeta held awy from xeils Pargo Advisors ws provided by you sad may not be covered by SIPC.
xells Pargo Advisors makes no zepreeentation with respxt to accuracy of information on outside holdings.
Ia moat cases, w use Estate Val, ^ valuation sad pricing program, to provide information oa the value o! seduritiea on
eh. ragnested data. Estate val sofewra is provided by Eatata valuatioaa a Pricing systems, Inc., (svP), a third-party
vendor unrelated to wells Pargo Advisors. Tha priaiaq sad wlnatioas generated by SVP era 8erived lrom sources it
believes to be reliable, but the accuracy aa8 completeness o! thin information is not guaranteed.
Depending on hor the Report will be used, the pricing generated by EVP For soma securities may warrant addieioaal
consideration. Oeers may want to supplement or adjust Che values provided for certain types o! securities. Por examples
- erokarad Certificates o! Deposit, sad eartais bonds, may possess a death put feature. EVP provida^ a value which does
not aoaount !or the pouibility that a auecessor owsr may bs able to put the security back to the iuuer at par, upon the
death o! the original over.
- Treasury Inllatioa Protection securities (TIPS) era often not ideatiliad as such is the Report, eo the inflation factor
may not be retlectad in the value sad accrued interest show.
- Variable race auatioa securities may be reported by SVP at par, without rellectiaq accrued interest or market
conditions. Other typos of variable rste securities may not reflect aearned interest.
- Accrued dividends are not reflected for smtaal funds with daily dividend accruals.
The databases wad by EVP do not aacompses all markets or types of investments. Por a:ample, Eatata Val does not provide
valuation data on iavestmeats such as annuities, equity options, limited partaerahips, or managed futures funds, among
others. If the Piaaacial Advisor is able to obtain pricing or valuation data from other sources with respect to such
iavestmeats, w may include that data is the AapOrt !or informational sad eoaveaieaee purposes. xe will identify such
investments is the Report. xa do nos audit or independently verily the data provided to us, sad make ao represeatatioaa
as to the accuracy or completeness o! information provided to w by others.
Thin Report does not is nay way supersede the ialormatioa contained in olieat statements sad trifle coafirmatioas, which
era the official record o! account positions and activity.
xe make ao representations chat the iaforsiatioa eoataiaad is this Report is suitable for any particular purpose. It is
the responsibility o! the client, together with his or her tar sad legal advisors, to determine the appropriate
information to include on nay tax return, inventory, or other accounting.
Page 3
• Please see the Baal page for IIBOATAxT IxPORYATIOE AEOOT THE ESTATE VALIIATIOE REPORT. +
Nell^ Pargo Advisors doaa not reader [ax os legal adviw. I! you haw aay,quaationa please consult with your tax
sad legal advisors. xelle Pargo Advisors is the trade name used by three separates registered broker-dealers: x~lls Fargo
Advisors, LLC, Malls Pargo Advisors Financial EsEwork, ISaC tad xells Pargo Invea'meats, LLC, xembers BIPC, non-bank
alfiliates o! Mall^ Pargo a Company.
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1/UVL rax server
Rdmv~oe I!} 3324479
Waohovia Bank
Balance ConBraution 3ervias
P O Baal 40028
Raanoloe, VA 24022
March 31, 2011
BANGS LAW OFFICE?
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SUBJECT': Veti~tiaa / Caef m~a dA~cowet and Balaeae Iafa~tion prided for:
CLrtoerer, P.RNE3T T SHAW ISSN ]~C-7~~52)
Date of Death: Pebrl,ar~ 21, 2011
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~x I~fi ~~~/~y
I, ERNEST T. SHAW, of Dauphin County, Pennsylvania, declare this to be my last will
and revoke any will previously made by me.
ITEM I. I direct that all my just debts and funeral expenses; including my gravemarker
and all expenses of my last illness, and any and all taxes and assessments imposed by any
governmental body as a result of my death, whether on property passing under this will or
otherwise, shall be paid from my residuary estate as soon as practicable after my decease as a
part of the expense of the administration of my estate.
ITEM II. I give and bequeath all of my household goods, automobiles, jewelry, and all
other articles of household and personal use, equipment and ornament, together with all
insurance thereon and relating thereto, to my wife, JANE N. SHAW j~rovided she survives my
death by thirty (30) days. Should my wife predecease me or be deceased on the thirty-first day
after my death, I give and bequeath all such items and insurance thereon to my son MICHAEL
H. SHAW provided he survives my death by thirty (30) days.
ITEM III. I give, devise, and bequeath all the rest, residue, and remainder of my
possessions and estate of every nature and wherever situate to my w~'e JANE N. SHAW
provided she survives my death by thirty (30) days. Should my wife predecease me or be
deceased on the thirty-first day after my death, I give, devise, and bequeath all the rest, residue,
and remainder of my possessions and estate of every nature and wherever situate to my son
MICHAEL H. SHAW provided he survives my death by thirty (30) rays.
ITEM IV. All of the interests of the beneficiaries hereunder shall not be subject to
anticipation or to voluntary or involuntary alienation nor shall they be subject to any execution or
attachment.
ITEM V. I appoint my son MICHAEL H. SHAW executor of this my last will.
ITEM VI. In addition to the other powers and authorities granted to my personal
representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby
give to my personal representatives the following powers and authorities effective without court
approval and until actual distribution of all property: to compromise any claim or controversy;
to make distribution in cash or in kind, or partly in cash and partly ii1 kind, and in such manner as
my personal representatives may determine and at valuations finally to be fixed by them; to
invest in all forms of property, including any stock or other securities in any corporate fiduciary
or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my
personal representatives deem proper, without regard to any principle of risk or diversification;
to retain any or all assets of my estate, real or personal, without regard to any principle of risk or
diversification; to sell at public or private sale, to exchange, or to lease for any period of time,
any real or personal property and to give options for sales, exchanges, or leases, for such prices
and upon such terms or conditions as my personal representatives deem proper; and to allocate
receipts and expenses to principal or income or partly to each as my personal representatives
deem proper in their sole discretion.
ITEM VII. I direct that my personal representatives and fiduciaries shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
2
IN WITNESS WHEREOF, I have hereunto set my hand this a~~~ day of
~~ uv~..~ , 2007.
~~~~~
ERNEST T. SHAW
J
The preceding instrument, consisting of this and THREE other typewritten pages, each
identified by the signature of the testator was on the date thereof signed, published, and declared
by ERNEST T. SHAW, the testator therein named, as and for his Dist will, in the presence of us,
who at his request, in his presence, and in the presence of each other, have subscribed our names
as witnesses hereto.
~.',~~--
4
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
The undersigned, being the testator whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law, does hereby acknowledge that I signed and executed the
foregoing instrument as my last will, that I signed it willingly; and that I signed it as my free and
voluntary act for the purposes therein expressed.
ERN~SHA W
Sa•arn or z~rmed to d acknowledged
befor. m y the s r a ed above
NotarV~ ser
6YendyK straub, NotaryPu6lc
tower glen ~., ~'~ CaxKy
My ComnlScJon E~Ires May 10, 2011
Pennsylvania Assoclatlon of
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLJAND )
WE, ~~~ t 1 ,~ -~ and ~ ~ ,; "~ ~ , ~ ,the
witnesses whose names are signed to tree attached or foregoing instrumen ,being duly qualified according
to law, do depose and say that we were present and saw the testator sign and execute the instrument as his
last will; that he signed it willingly and that he executed it as his free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the testator signed the will as witnesses; and
that to the best of our knowledge, the testator was at that time 18 or more gears of age, of sound mind,
and under no constraint or undue influence.
acknowledged
_ day of
2007.
Notarlat seal
K s>~, Notary PutNc
tAwar Allen Txp., C1inb9rtarb Cgirty
My Corrrr~~bn E~ires May 10, 2011
lnnsylvanla Assodatlon of Noterii