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HomeMy WebLinkAbout03-0661 Register of Wills of CUMBERLAND County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Mildred g. Wert No. ~,- O~- u tol also known as M Ild~ l(, U).f.V"f:- ce?- , Deceased Social Security No. 196-03-7547 Petitioner(s), who islare 18 years of age or older, appJy(ies) for: (COMPLETE 'A' or 'B' BELOW:) lTI A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) islare the execut, OR named in the last WiD of the Decedent, dated November 9, 1999andcodici~s) dated.. February 16,2001 State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a chilcl born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: ~, 1LrtV I'D k, W-f/<. T cf LE~ & ~-\J od-. 2Ct(} I . II\A ~ (' LJ - (;(e e to{ 7lr-- .. I I 0 B. Grant of Letters of Administration (c.t.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search haslhave ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets jf necessary. Decedent was domiciled at death in Hampden Township, Cumberland County, Pennsylvania with hislher last family or principal residence at 5,511 Silver Creek Drive, Mechanicsburg, P A 17050 (list street, number, and municipality) Decedent, then ~years of age, died July 7, 2003 at Holy Spirit Hospital, East Pennsboro Township, Cumberland Co., PA (Location) Decedent at death owned property with estimated values as follows: ; ~5 {.wl9 (If domiciled in PAl All personal property $ (If not domiciled in PAl Personal property in Pennsylvania $ (If not domiciled in PAl Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: Franklin D. Wert, Jr. 645 Sawmill Road Mechanicsbur , P A 17055-6052 \'\- \5"8'- Prepared by the Pennsylvania Bar Assocliltfon Form RW-1 (1991) Copyright (c) 1996 form software only CPSysterns, Inc. r-jr ,- . -.- d L-.l .. .;:.=.., CT1 = I --..1 -0 ..r.~ N w Oath of Personal Representative Commonwealth of Pennsylvania County of The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent. Petitioner(s) will well and truly administer the estate according to law. ~;;;~ Sworn to or affirmed and subscribed Franklin D. Wert, Jr. before me this'" -*1 day of G.~~~ 645 Sawmill Road ,~OO3 ~~~f"~~ Mechanicsburg, PA 17055-6052 ~ . For. the Register No. ~/-D$ - l/Jibl Estate of Mildred K. Wert Deceased Social Security No: 196-03-7547 Date of Death: July 7, 2003 AND NOW, (\ll~LLDt I :1-( c2 C() ?> /' , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters [!J Testamentary 0 Of Administration (c.t.a.; d.b.n.c.t.a,; penclente lite; durante absentia; durante minoritate) are hereby granted to Franklin D. Wert, Jr. in the above estate and that the instrument(s) dated November 9, 1999 and February 16,2001 ~ described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters. . . . . . . . . . . $ OJ-tO .00 ~'5'f"\ro.-'-tY\D'ct:n~\:. ~~P'~ll ~\lA~ C\"r.o~ J..CJ'fJ~ ' Register of WI s . Short Certificate(s). . . . . $ /'),00 Renunciation. . . . . . . $ Attorney: Thomas E. Flower, Esquire Affidavits ( ) $ I.D. No: 83993 Extra Pages ( ) . $ 3q.CO Address: SAIDIS, SHUFF, FLOWER & LIND SA Y Codicil. . $ /() . 5V 2109 Market Street, Camp Hill, P A 17011 JCP Fee. $ 10.00 Telephone: 717/737-3405 Inventory. $ -tfhcl 8- 12- 2003 $L ~t:o~ Other . . ))"~-ZOO3 TOTAL. . . . . . . , . $ 4-14,50 Prepared by the Pennsylvania Bar AssOCiation CopyrIght (c) 1996 form software only CPSysterns. Inc. Form RW-1 (1991) , r"'l. '"". ..... J t .. c5 ~ . ..- lv-J ::.::=- ~"""l CJ I --J -(J :::-.. N \...oJ CERTIFICATE OF DEATH STATE FilE NUMBER NAME OF DECEDENT (FIrst. fwhdole. LilSI) SEX S0CIAl SECURITY NUMBER ,. Mildred K. Wert ., Female 3.196 - 03 - uNDER 1 YEAR UNDER 1 DAY BJRTHPlACE (C.ty and PlACE OF DEATH ICt>e<:I< 01'1... 1)(18 ->eemSlrucllOl'lSon OlMl SlOe) MonIh. ! Cay. Hours ! MM'tut.. Stale Of Fcr8J(]n CoumrYl HOSPITAL lopa'..", [Xl ERJOu/paI'lInl 0 DOAO 1 7 Scranton Pa ... . FACilITY NAME (II nOl Inllt'1\JIlon, gIVe streel and numb8r1 . 10. CUrrber land Ie. Fast Pennsboro 14. DEceDENT'S USUAL OCCUPATION KINO OF 8USINESSIINDUSTRY MARITAL STATUS. Uarried (Give kand of work done dullng mosI N.ver ....rried. Widowed. ot WOIking lite; do not use rellfed) Dtvofced (Speclty) . "Jbusewife 11b. Fl,anklin D. Wert DECEDENT'S MAJlING ADDRESS (Slreet. CilyfTown. State, Zip Code) DECEDENT'S HaIIpd~ ACTUAL 17.. Slate Oid lwp. 5511 Silver Creek Drive AESlDENCE don"" (See ,nSCructlOtl8 lWeir,. ...~chanicsburg, Pa 17050 on other SIde) CUnberland IOWnship? 17d.O ~:C='=or 17b.Coun city;1)oro FATHER'S NAME (First Middle, laSS) MOTHER'S NAUe tF'rs!. M"ldlc, Maldell Surname} ... INFORMANT'S NAME (T ypelPrint 17050 200Franklin D. Wert 2Db. METHOD OF DISPOSITION PlACE OF DISPOSITION - Nan.e of CemelffY. Cremiltofy lOCATION. CilylTown, Slale, ~ Code . Bunal ex Cremation D Removallrom Slar. 0 or OChef Place Othet (Speclfyl 11 2003 Gate of Hl~ven Mechanicsbu ,Pa 21c. 21d. LICENse NUMBER NAME AND AOOAESS OF FACILITY 1903 Market Street 2>b. 011654 L 22c. Hill Pa 1701 To the buJI 01 my knowledge. death occurred allne lime. dale and plac. stated U N UMBER DATE SIGNED (Signahlf'! and Tille) (Monlh. Day, Year) 23.. ,3<. WAS CASE REFEARED TO MEDICAL EXAUINERlCOAONER? No~ .....0 ... I Approximal. PAATII: OtfMr S9'iftcant CClrIdtIiona cooUibuting to dqlh. but : interwl tMtIw..n not resutling in the under1ying cauM given in PART I. , I oIlMI and ~.th (<.<:;(f'r..:\(, r, {"" lu~ , , .. , DUE fJOR" A CONseOUEN!E Ofl , , I: f\( I.... "_(, r\ ~ - DUE TO lOA AS A CONSE~UENCE Of): I I , - DUE TO (OR AS A CONSEOUENCE OF): I , , WEAE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT 'NORK? DESCRIBE HOW INJURY OCCURRED. AVAILA8lE PRIOR TO (Month Day. Vear) COUPlE'TIQN OF CAUSE 0 D OF DEATH? Nalural Homic~ Vas 0 NoD Accident 0 Pending Invesl!galion D NO~ Yes 0 No 0 [] o ~CE OF INJURY. At home. tar;,O:;eet. factory. office ... 3oe. Suicide Could nol be determined 2... 21b. buikling. elC. ISpecllv) ZO. 300. CERTIFIER ICheck oniy one) SIGN.IJ .CERTJFYING PHYSICIAN (PhySICian cerhtVlng cau~e 01 death when anOlhef phySIC,an has Dl'Oflouncea dealh ana compleled Ilem 23) ~.Jlb. {P. (I Tolh.bntofmyknowt.dge.d..lhoccurred due to Ihe causeCI) and manner a. Ilatect........,. .................... ........... 'PRONOUNCING AND CERTIFYING PHYSICIAN If'h...SIC~n holtl j.JrQnouncmg death and Cer1llylf'1gloCilouse 01 deathl 0 To Ihe belli 0' my knowtadge, death occurred at lha Urn.. data. ..nd placa..and due to Ihe cause(l) and m.anne, aa alated.. . MEDICAL EXAMINER/CDRONER (V, /) On the bull of examination and/or Investigation. in my opinion. death occurred al theUm., dat., and place. and due 10 the C8use(l) and manne, a. st.ted.. . . . . .. . . . . . .. . , . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. .. . . . . . . . . . . . . . . .. . . , . . . . . . ". . . . . . . . . . . . . . .. . [] , I (r-c )fj . >,", ~ 31. , ( REGISTRAR'S SIGNATURE AND ~R . tAC/ ;;:;Z _ ~-4~'iJtL-t: 1Z---- ~II ~ ,'/ [, J 3.. ../ .:2/- o~) -{,t." S-i r"~ d _...1' ~( ...1. I ~:l' -.\ W C.'r I-~ (' ~ en CJ I --.J -1:) ~ N .( VJ I Wert, Franklin D. Sr; Codicil for Franklin , . CODICIL TO THE LAST WILL AND TESTAMENT OF MILDRED S. WERT I, MILDRED S. WERT, of Camp Hill, Cumberland County, Pennsylvania, declare this to be the First Codicil to my Last Will and Testament, dated November 9, 1999. ITEM I: This Codicil to my Will is prepared to adjust the shares of my residuary estate to take into account an advancement made to our son, DONALD R. WERT. This advancement and the adjustment described herein should be applicable whether my spouse predeceases me and my children inherit directly through my estate, or whether they inherit as residuary beneficiaries under any Trust I have established in my Will. Our son, DONALD R. WERT, made certain investments on our behalf with our funds, but in his name, in 1986 in Fairmont Associates Limited Partnership in the form of a loan. The loan was converted to stock in Integrated Health Services and then sold on January 24, 1992. Our initial investment was $25,000.00. However, when SAlOIS the investment was sold it yielded $69,103.00, for a gain of $44,103.00, on which it is SHUFF, FLOWER & LINDSEY ATfORNEYSoAToLAW estimated that he would have paid tax at 30.8%, or $13,583.74. Consequently, the 26 W. High Street Carlisle, PA amount that he held at that time on our behalf was $55,519.00. This investment was commingled in Donald's portfolio with the intent of returning the investment when a Wert, Franklin D. Sf.; Codicil for Franklin targeted asset was sold. However, in the meantime, he paid tax on the initial investment and has reported any earnings in his name from the date of the sale forward. Rather than reclaim the investment, we gifted it to him. We gifted $20,000.00 at the end of 1991, and $20,000.00 at the end of January of 1992, and the remainder in 1993. My spouse and I each gifted one-half of the total gift to him each year. Since we have made no such significant gifts to any of our other children, and in order that disbursement of our final estate be made in an equal fashion among all of our children, it is our desire to value the advancement by assuming that it would have increased in value by a rate of 6.5% compounded annually. For the purposes of this computation, the amount initially to bear interest shall be $55,519.00, and the date from which it shall be assumed to have increased in value in such fashion will be February 1, 1992. The resulting amount shall be considered to be an advancement, and each of our children shall received the same amount from either my residuary estate, or from the residuary of any Trust created under my Will prior to division of the remaining residuary which shall be paid equally to all of our children, including DONALD R. WERT. We arrived at the interest rate of 6.5% considering that it is high enough to be fair to our SAlOIS other children, but significantly lower than Donald would have paid for a commercial SHUFF, FLOWER business loan. The lower interest rate partially reflects the family nature of this & LINDSEY ATIORNEYSoAToLAW 26 W. High Street transaction, and the value of Donald's advice on the investment to us. Carlisle, PA 2 Wert, Franklin D. Sf: Codicil for Franklin Although this language also appears in my spouse's Codicil, we do not want the advancement to be duplicated, but wish for the adjustment to take place only once. ITEM II: In all other respects, I hereby ratify, confirm and republish my Last Will and Testament dated November 9, 1999, together with this First Codicil, as and for my Last Will. IN WITNESS WHEREOF, I have hereunto set my hand and seal this/'~ day of [.~d4_o.7- ,2001. ~~/-d-.0' I 2J~ Mildred S. Wert SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: SAlOIS SHUFF, FLOWER & LINDSEY AITORNEYSoAToLAW 26 W. High Street Carlisle, PA 3 I Wert, Franklin D. Sf.; Codicil for Franklin . . .. COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND I, MILDRED S. WERT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as a First Codicil to my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MILDRED S. WERT, the Testatrix, this IlQ~ day of dc-~~I , 2001, at C'cVL t~ , Pennsylvania. J /r;~~A- 1i ZU~ Mildred S. Wert, estatrix NOTARIAl.. SEAL MERl.ENE J. MAAHEVKA. NOTARY PU8UC SAlOIS " CAAUSl.E, CI.JM8ERI.Nc) COUNTY, PA , ,~: COMMISSION I!XPIAES JUNE a, 2ID02 SHUFF, FLOWER & LINDSEY ATIORNEYSeAToLAW 26 W. High Street Carlisle, P A 4 Wert, Franklin D. Sr.; Codicil for Franklin . . COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND We, James D. Flower, Jr. and Johnna J. Kopecky , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as a First Codicil to her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Codicil as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by James D. Flower, Jr. and Johnna J.Kopecky this -.J loU day of ::ddl\L~) ,2001. r~~ SAlOIS SHUFF, FLOWER & LINDSEY ATIORNEYS'AT'LAW 26 W. High Street Carlisle, P A NOTARIAL lEA&.. MERLENE J. MAAHE\IKA, NOTARY PUBLIC CAAUSLE. aJU8EIUHD COUNTY, PA MY OOIoMB8ION EXPIAE8.l1NE e, 2002 5 M t,-'";l .~ .., r r- I C'J ( f~ '" ~ !ii:: on 8 C) < ~g~~ -, ~ f- - ":' ,.:. Q CIl;1; ~ <'\ Z f- r-r- ~J~;::: ~ :':...l r- _ ,.,;j ~ s:: E c ~ ::; ~,:j x ~ g<(~~ r.fl ~ M U ~~ lto O,.,;j ~ ~~ f- ...J~ (JJ ("I'j N \0 ~ UJ - N 00 ;;:J ~ 0 '" ~ ~ ~ ~ ~ == :z:: ~ ~ ~ ~ o . ~ ~ ~ - (JJ ('. t'-- ~ :z:: ...l - - CIl r- r- ~ f-_~~ Q CIl ...l .. X ~ ~ ~ til <( < ~ <( f- ~ 'Cl U ~ '" . . . . J , 11Iast Jlill aub Ufestattttttf OF MILDRED S. WERT I, MILDRED S. WERT, of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, and revoke any and all Wills and Codicils made by me. ITEM I: I direct that all my just debts and funeral expenses, including my grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease, as a part of the expense of administration of my estate. ITEM II: I give my household and personal effects and other tangible personal property of like nature to my husband, FRANKLIN D. WERT, SR., if he survives me, together with all insurance policies thereon, if any. If my husband, FRANKLIN D. WERT, SR., does not survive me, I give such property to those of my children who survive me, in approximately equal shares. In the event of any disagreement among my children with regard to any such assets, all such disagreements shall be conclusively resolved by my Co-Executors or Executor. ITEM III: I give and bequeath the sum of Two Thousand ($2,000.00) Dollars to GOOD SHEPHERD ROMAN CATHOLIC CHURCH. ITEM IV: I give and bequeath the sum of One Thousand ($1,000.00) Dollars to MARIANIST MISSIONS. ITEM V: I give and bequeath the sum of One Thousand ($1,000.00) Dollars to OBLATES MISSIONS. ITEM VI: If my husband, FRANKLIN D. WERT, SR., survives me by thirty (30) days, I give, devise and bequeath to my Trustee, hereinafter named, to be held IN TRUST, during the life of my said husband, FRANKLIN D. WERT, SR., a sum equal to the maximum dollar amount, if any, which can then pass free, of federal estate tax in my estate by reason of the unified credit against federal estate tax allowable to my estate on the date of my death (the "credit shelter amount"), reduced by the aggregate of (1) all items includable in my estate for federal estate tax purposes which either are disposed of in previous articles of this Will or pass outside of this Will but only if such items do not qualify for the federal estate tax marital deduction or the federal estate tax charitable deduction, and (2) the amount of any administration expenses claimed as income tax rather than estate tax deductions and (3) the amount of any state death taxes payable by my estate. This Trust shall be referred to and known as my Credit Shelter Trust. The aforementioned sum shall be held for the following uses and purposes: A. To pay the income to him in convenient installments, at least quarter- annually. B. The Trustee may apply the net income of this Trust for the benefit of my said husband should he by reason of age or illness be incapable of disbursing it. C. As much of the principal of this Trust as the Trustee, in its sole and absolute discretion may from time to time think advisable for the support of my husband to maintain him in the station of life to which he is accustomed at my death and after taking into consideration his other readily available assets and sources of income or during illness or emergency, may be either paid to him or applied directly for him. 2 D. Upon the death of my husband, FRANKLIN D. WERT, SR., the then- remaining principal and any accumulated or undistributed income shall be distributed as follows: 1. The sum of Ten Thousand ($10,000.00) Dollars to my sister, JOAN K. WOODBRIDGE. Should she die prior to receiving this bequest, I direct said sum to be paid to her children, in equal shares, JOHN WOODBRIDGE, STEVEN/STEPHEN WOODBRIDGE, MICHAEL WOODBRIDGE, KENNETH WOODBRIDGE, JOANNE WOODBRIDGE and GREGORY WOODBRIDGE. 2. The balance in equal shares among my six (6) children, FRANKLIN D. WERT, JR., CAROL M. SMITH, DAVID K. WERT, BARBARA J. HAGUE, DONALD R. WERT, and DEBORAH K. EMIG, or their issue, per stirpes, provided that if any beneficiary entitled to distribution shall then be under age twenty-two (22), the share of such beneficiary shall be held by the Trustee, in further separate Trust, for the following uses and purposes: a. If the beneficiary is under age eighteen (18), to expend and apply so much of the net income (any income not expended or applied to be accumulated and added to principal) and so much of the principal of each Trust as the Trustee, after consultation with the guardian of said beneficiary, shall consider advisable for the support, maintenance and education (including college education, both graduate and undergraduate). b. After the beneficiary attains the age of eighteen (18), thereafter to pay to such beneficiary the net income together with so much of the principal thereof as Trustee shall consider advisable for the support and education (including college education, both graduate and undergraduate) of such beneficiary, after taking into consideration his other readily available assets and sources of income. c. Up to the entire balance of principal and undistributed income, of the then-remaining share of such beneficiary shall be distributed to that beneficiary at or after age twenty-two (22). Distribution at or after this stated age shall be made only in the event the beneficiary requests such distribution by a writing intended to take effect during his lifetime, executed by him upon or after attaining age twenty-two (22) and delivered to my Trustee. d. If any Trust beneficiary shall die before receiving final distribution of his entire share, the undistributed balance shall be distributed to the beneficiary he names specifically in his Will, referring to this Trust. Should said beneficiary die without a Will provision specifically referring to this Trust, then his share shall be paid to his heirs at law. 3 e. In the event that any of my children predecease me, leaving no issue surviving, then whatever gift or bequest would have passed to such child shall be distributed to my surviving children, or their issue, per stirpes. E. I direct that my Co-Executors and their successors shall not elect that this Trust be included in my husband's estate as a part of the marital deduction. ITEM VII: It is my expectation that my husband shall have established a revocable Trust appointing my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., as Trustees, and paying the income to him for life. If such a revocable Trust exists as of the date of my death, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wherever situate to said Trustees, DAVID K. WERT and FRANKLIN D. WERT, JR., for the benefit, nevertheless of my husband, FRANKLIN D. WERT, SR. Should he not have established such a Trust, or should he have revoked it prior to the time this bequest takes effect, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate outright to my husband, FRANKLIN D. WERT, SR. ITEM VIII: Should my husband, FRANKLIN D. WERT, SR., fail to survive me by thirty (30) days, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate to FRANKLIN D. WERT, JR., CAROL M. SMITH, DAVID K. WERT, BARBARA J. HAGUE, DONALD R. WERT and DEBRA K. WERT, or their issues, per stirpes, provided that if any beneficiary entitled to distribution shall then be under age 22 years, the share of such beneficiary shall be held by the Trustee, in accordance with the terms set forth in Item VI, D, 2, above. 4 ITEM IX: If my husband, FRANKLIN D. WERT, SR., makes a qualified disclaimer (as defined in Section 2518 of the Internal Revenue Code, as amended) with respect to all or any portion of the interest in property given to him under any provision of my Will, I give such disclaimed property interests to the Trustee of my Credit Shelter Trust, IN TRUST, for the benefit of my said husband during his lifetime with the balance of the principal and interest passing in conformity with the terms of Item VI-D-2 hereof. ITEM X: My Co-Executors, Co-Trustees, and their successors shall have the following powers in addition to those vested in them by law and by other provisions of my Will, applicable to all property, whether principal or income, including property held for minors, exercisable without court approval, and effective until actual distribution of all property: A. To borrow money from any person or institution, including my fiduciary and to mortgage or pledge any or all real or personal property as they in their sole discretion shall choose, without regard for the dispositive provisions of this instrument, except that no property passing to the marital deduction share shall be so mortgaged or pledged. B. To reasonably compromise claims asserted by or against my estate. C. To join with my husband in filing a joint income tax return without requiring him to indemnify my estate against liability for the tax attributable to his income, and to consent to any gifts made by my husband being treated as having been made one-half by me for the purpose of federal laws relating to gift tax. D. To retain any or all of the assets of my estate, real or personal, without regard to any principle of diversification or risk. E. To sell at public sale, to exchange, or to lease for any period of time, any real or personal property and to give option for sales, exchanges, or leases, for such prices and upon such terms or conditions, as they deem proper. 5 F. To make loans to, to sell to, and to buy property from my or my husband's executor or administrator or my Trustee. This shall not be construed as a command to exercise these powers under any circumstances. All sums payable to the Trust established in Item VI hereof from whatever source shall be utilized for such loans or to purchase assets from my Co-Executors at final federal estate tax values. G. To exercise any law-given option to pay death taxes in installments, the payment of interest due on such installments to be a charge against principal of my Credit Shelter Trust. H. Notwithstanding any power granted expressly or impliedly herein, such shall be void and of no effect as to the marital gift if such would either eliminate said gift or reduce it below that elected by my Executor. ITEM XII: All shares of principal and income hereby given shall be free from anticipation, assignment, pledge or obligation to the beneficiaries and any of them, and shall not be subject to any execution, attachment, levy or sequestration or other claims of the creditors of said beneficiaries or any of them. ITEM XIII: All federal, state and other death taxes payable because of my death, with respect to the property passing under this Will and forming my gross estate for tax purposes, including any interest or penalty imposed in connection with such tax, shall be paid out of the non-marital residue of my estate, if any. Any such tax, including interest or penalty imposed, due by virtue of taxable property forming my gross estate, passing under this Will shall be paid directly from such property and shall not be paid out of the marital or charitable deduction share of my estate. It is my specific command and intent herein that no property forming part of the marital or charitable deduction share of my estate be 6 utilized to payor be reduced by any federal estate or Pennsylvania (or other state) inheritance or estate taxes. ITEM XIV: I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., to serve as Co-Trustees under this Will. Should either of my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., fail to qualify or cease to act as Co-Trustees, I appoint my daughter, DEBORAH K. EMIG, as successor Co-Trustee of this my Last Will and Testament. Should both of my remaining son and my daughter, DEBORAH K. EMIG, fail to qualify or cease to act as Trustee, I appoint FIRST UNION NATIONAL BANK, to serve as successor Trustee under this Will. I direct that a majority of my then-surviving children shall have the right to remove FIRST UNION NATIONAL BANK as fiduciary and appoint a successor corporate fiduciary. ITEM XV: I direct that no Executor, Trustee or their successors serving hereunder be required to post bond or enter security in any jurisdiction. ITEM XVI: I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., or the survivor of them, as Co-Executors of this my Last Will and Testament. Should both my Co-Executors, DAVID K. WERT and FRANKLIN D. WERT, JR., fail to qualify or cease to act as Co-Executors, I appoint my daughter, DEBORAH K. EMIG, as Executrix of this my Last Will and Testament. ITEM XVII: As Guardian of any property which passes under or outside of my Will to a minor and with respect to which I am authorized to appoint a Guardian and have not 7 specifically done so outside of my Will, I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., or the survivor of them. ITEM XVIII: All references herein to the singular or the masculine shall include the plural or the feminine respectively, where appropriate throughout this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this Ii y-t day of IV 1) ~ Iu- ,1999. I .~ ~ 2t/~ /;, kL./~ )(//, , Mildred S. Wert SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: -?r~ q). -Ji&~) ~~ .~ J'J~d?L .. 8 COMMONWEALTH OF PENNSYLVANIA : ss COUNTY OF CUMBERLAND I, MILDRED S. WERT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the 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. Sworn or affirmed to and acknowledged before me, by MILDRED S. WERT, the Testatrix, this q-t.i\ day Ofl. /~U.,Q -r~ kJ1..A. . ,1999. I )J7~~ xi, ZU~ Mildred S. Wert, Testatrix wJ NOrAFllAL lEAL MERLENE J. MAfHM(A. NOrNff PUaJC CARUSl.E. CUI&JI.AND COUNTV, PA MY COMMISSION EXPIE8.ue I, IDOl 9 . COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND We, James D. Flower, Jr. and Linda Jumper , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by James D. Flower, Jr. and Linda Jumper this --.Q ~ day ~ yy\j:;W" 1999. /~M'Q.~~o .~ ~ c VV,ness ~nd~ !)v--n'--~ Wit~ss NOTMlALIIAL MIIJIUNe J. MAAHE\1(A, HDrNft IIt&IC CAAuU. CUMI&I.AND COUNTY, PA '. MY COMMISSION !JCPIfI!B JUNI!"IDOI 10 (.,\ .- "~:"T I ~_.J ._ cD I g U ...... p.; p ~ >:' '" ~ :..t:: .... 0 ~ en ,... E-i o ,.. ~ Z ~ .... p::; .... ~ Z ~ ~ ~ o-l ~ ~<:: ~ ~ ~ 1 . ~ " '" t.4 (,J ~ s ~ '+4 t. ~ ,.. ~ Q o '" ~ -< . l !:il o-l~~ ~ p::; ~ .... '" Q ~....~ H H ~ U ~ ~ ~ 0 o-l ~ . ~ REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Mildred S. Wert Date of Death: July 7, 2003 Will No. 2003-00661 Admin. No. 21-03-0661 To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above- captioned estate on January 11, 2004. Name Address Good Shepherd Roman Catholic Church 3435 Trindle Road, Camp Hill, P A 17011 Marianist Missions, Mount St. John, 4435 East Patterson Road, Dayton, OH 45481-0001 Oblates Missions 323 Oblate Drive, P.O. Box 659432, San Antonio, TX 78265-9432 Franklin D. Wert, Sr. c/o Franklin D. Wert, Jr., Trustee, 645 Sawmill Road, Mechanicsburg, P A 17055-6052 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except none I [T' C(' Date: t ~ t Cj --- () ~/ j ~L~ C. / ' (f\,l),---c/ ~ Thomas E. Flower, Esquire SAIDIS, SHUFF, FLOWER & LINDSAY 2109 Market Street Camp Hill, P A 17011 (717) 737-3405 Capacity: _Personal Representative -.X Counsel for Personal Representative Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 6/06/2005 FLOWER THOMAS E 2109 MARKET STREET CAMP HILL, PA 17011 RE: Estate of WERT MILDRED S File Number: 2003-00661 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO. SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 7/07/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~,l~(?A/ ~~/~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge eM . . Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 . Name of Decedent: ~. l\ J f'e~ S UJel! c- Date of Death: 07 /07 / 20&'3, ( f Estate No.: 260 '3 - ooG(91 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State rer administration of the estate is complete: Yes No .Et 2. If the answer is No, state when the personal representatiye reasonably believes that the administration will be complete: s.o d1i"..J, A" /) 7 2. I:) 0 )' , I 3. If the answer to No.1 is Yes,state the following: a. Did the perso~tative file a :final account with the Court? Yes 0 No - b. The separate Orphms' Court No. (if any) for the persona! representative's account is: . c. Did the perso~sentative state an account informally to the parties in interest? Yes No 0 c. Copies of receipts, releases,joinders and approval offormal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. . ;t;;a~JA.:. )h,t~!J, Date: o~/ 3D / :1eo S~ ; Si ature F iTa 11\ kllY\ D . l\l n't , JV'I , Name &" 'f c;- 5Ct.WII1i,',11 eel; Address . /-; P/1 (70 f:)' /vte c fAo I/l fCS Vt V''J. ( Telephone No. &, 9/ 30'-10 Capacity: ~sonalRepresentative o Counsel for personal representative crX Cumberland County - Register Of Wills One Courthouse Square Carlislel PA 17013 Phone: (717) 240-6345 Date: 6/22/2007 FLOWER THOMAS E 2109 MARKET STREET '2 ~O Q~~o -r> r-- ~:~~ _qo '. )C...-n \':':l~ --I }2 r-,.) = c= -- L c:: Z N C]'\ :r> ::1: .-TJ ,'rl C) <=) ~:u r ) . '1 '-:) ~\C? -rMl i:=j p, CAMP HILLI PA 17011 (j\ RE: Estate of WERT MILDRED S File Number: 2003-00661 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES I NO. 103 SUPREME COURT RULES DOCKET NO. 11 for decedents dying on or after July 1, 19921 the personal representative or his counsell within two (2) years of the decedent's deathl shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 7/07/2007 please feel free to contact this office with any questions you may have. If you have already filed your Status Report I please disregard this notice. SincerelYI $~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) J Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 6/22/2007 WERT FRANKLIN D JR (; s:;; 0 h5;g ',,0 r'.~ )::- r:;; >: :'""" ::D /. ..J) ^ c:~) C) 0 - ) cJ "I" -~c : -' ::0 'u-1 :t> ,..." = => --' <- c= Z N 0" 645 SAWMILL ROAD MECHANICSBURG, PA 17055-6052 :J;::oo ::it (-)c-:) -.", ~--;., ---, (:=S CT"' C) --. 'I (]'\ RE: Estate of WERT MILDRED S File Number: 2003-00661 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 7/07/2007 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, /'1. V ,.b-L.__lJ ~~J~~-' ; J/,/ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel ~ Pa. D.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Name of Decedent: MILDRED S. WERT Date of Death: JULY 7, 2003 File Number: 2003-00661 Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. i2I Yes D No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is YES, state the following: a. Did the personal representative file a final account with the Court? . . . . . .. DYes i21No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? ............................... laYes D No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date 06-28-07 ~~ Signature of Person Filing this Form Capacity: DPersonal Representative Ii2ICounsel THOMAS E. FLOWER Name of Person Filing this Form \id ';'~;"'.,_, J I '1"">(', '\ (', t," " . 'I' J..G J",\J ,)/'J'li:ddQ :10 >18318 Address 2109 MARKET STREET , ~ : 11 W~ Z - lnr LGDl CAMP HILL, PA 17011 (717) 737-3405 Telephone ~ ;i, i" :i~~-~JY{~~; fty!i11J. f3dJ6 - ,-,,~..'J;-...J'..I\~,....JU &. 5056051058 F ~ REV-1500 Excos-o5> PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number INHERITANCE TAX RETURN """" Po Box 280601 21 03 0661 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth _. 196-03-7547 ' 07/07/2003 Decedent's Last Name Suffix Decedent's First Name MI FILL IN APPROPRIATE OVALS BELOW Ctl~ 1. Original Return C 2. Supplemental Return t 3. Remainder Retum (date of death prior to 12-13-82) ~ 4. Limited Estate C 4a. Future Interest Compromise (date of C3 5. Federal Estate Tax Return Required death after 12-12-82) C~3 6. Decedent Died Testate 7. Decedent Maintained a Living Trust _,._~,._ 8. Total Number of Safe Deposit Boxes (Attach Copy of III) (Attach Copy of Trust) <"_ 9. Litigation Proceeds Received C~ 10. Spousal Poverty Credit (date of death C:'~ 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 THOMAS E. FLOWER (717) 737-3405 ............._.... _......... Firm Name SAIDIS, FLOWER & LINDSA First line of address 2109 MARKET ST Second line of address _ __ _ City or Post Office CAMP HILL Correspondent's a-mail address: State ZIP Code PA 17011 _. USE __.._._, Pt'1 I t"; a ~ ~_ ~. ? '" -"' t , - -7 '~? N M Under penalties of perjury, I deGare that I have examined this return, inGuding 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. SIGNATU~~ ~SPONSIBLE R FILING RETURN ~ DATE ,~-- ! Z- 03 /G FRANKLIN D. WERT, JR, 645 SAWMILL RD., MECHANICSBURG, PA 17055 SJI ~RE OF PREP '~j~~ THAN REPRESENTATIVE DATE / /A /A i i ~~~y l///~L I - / ?~ I L079-~ SAIDIS, FLOWER & LINDSAY, 2109 MARKET ST., CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 REV-1500 EX Decedent's Name: MILDRED 15056052059 Decedent's Social Security Number _.. __ . _ S WERT 196-03-7547 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 298,447.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) i~ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ ~'~~~ ~~~~mm~ ~~w~~'~~~~~`~ (Schedule G) t Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 298,447.00 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. 298,447.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which -°-°--~ - --...._. ~.~.... _..____,._.~_~.•. an election to tax has not been made (Schedule J) ........................ 13. 4,000.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. '; 294,447.00 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 00 294,447.00 '. 15. 0.00 i 16. __.,.._w._.~._____._......___.. ~.__.M ~ _.___, Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable ~~~~~ ~~~~~~~~~ ~~~~~~ ~~~~~~ ~~ at sibling rate X .12 ___ ___.__.___ ._ ~ 17. 18. _ Amount of Line 14 taxable ~ . at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: FI~Number ~ _, ____, 21 03 ' 0661 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER MILDRED S WERT 196-03-7547 STREET ADDRESS 645 SAWMILL ROAD ~In' STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable - D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non•probate property which contains a beneficiary designation? ........................................................................................................................ ^ 0.00 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 p2 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) p2 P.S. §9116(a)(1)j. 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. 0.00 0.00 REV•1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MILDRED S. WERT 21-03-0661 All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ .1770.198 SH. GABELLI FUND @ 16.07 28,447.00 2.; ' WACHOVIA SECURITIES ACCOUNT #86730433 270,000.00 TOTAL (Also enter on line 2, Recapitulation) E , 298,447.00 (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 MILDRED S. WERT 21-03-0661 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distritw8ons, and transfers under Sec. 9116 (a) (1.2)1..... II 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES t5 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE FRANKLIN D. WERT, SR., 645 SAWMILL RD., MECHANICSBURG, PA 17055 294,447.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 GOOD SHEPHERD ROMAN CATHOLIC CHURCH, 3435 TRINDLE RD., CAMP HILL, PA 17011 2,000.00 2 MARIANIST MISSIONS , 4436 E. PATTERSON RD., DAYTON, OH 45481 1,000.00 3 OBLATES MISSIONS, 323 OBLATE DRIVE, PO.BOX 659432, SAN ATONIO, TX 78265 1,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ;'`' 298,447.00 , (If more space is needed, insert additional sheets of the same size) '~ ~tt~t ~i11 ~n~ C~TPSt~ OF MILDRED S. WERT I, MILDRED S. WERT, of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, and revoke any and all Wills and Codicils made by me. ITEM I: I direct that all my just debts and funeral expenses, including my grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease, as a part of the expense of administration of my estate. ITEM I1: I give my household and personal effects and other tangible personal property of like nature to my husband, FRANKLIN D. WERT, SR., if he survives me, together with all insurance policies thereon, if any. If my husband, FRANKLIN D. WERT, SR., does not survive me, I give such property to those of my children who survive me, in approximately equal shares. In the event of any disagreement among my children with regard to any such assets, all such disagreements shall be conclusively resolved by my Co-Executors or Executor. ITEM III: I give and bequeath the sum of Two Thousand ($2,000.00) Dollars to GOOD SHEPHERD ROMAN CATHOLIC CHURCH. ITEM IV: I give and bequeath the sum of One Thousand ($1,000.00) Dollars to MARIANIST MISSIONS. ITEM V: I give and. bequeath the sum of One Thousand ($1,000.00) Dollars to OBLATES MISSIONS. ITEM VI: If my husband, FRANKLIN D. WERT, SR., survives me by thirty (30) days, I give, devise and bequeath to my Trustee, hereinafter named, to be held INTRUST, during the fife of my said husband, FRANKLIN D.' WERT, SR:, a sum equal to the maximum dollar amount, if any, which can then pass free of federal estate tax in my estate by reason of the unified credit against federal estate tax allowable to my estate ~on the date of my death (the "credit shelter amount"), reduced by the aggregate of (1) all items includable in my estate for federal estate tax purposes which either are disposed of in previous articles of this Will or pass outside of this Will but only if such items do not qualify for the federal estate tax marital deduction or.the federal estate tax charitable deduction, and (2) the amount of any administration expenses claimed as income tax rather than estate tax deductions and (3) the amount .of any state death taxes payable by my estate. This Trust shall be referred to and known as my Credit Shelter Trust. The aforementioned sum shall be held for the following uses and purposes: A. To pay the income to him in convenient installments, at least quarter- annually. B. The Trustee may apply the net income of this Trust for the benefit of my said husband should he by reason of age or illness be incapable of disbursing it. C. As much of the principal of this Trust as the Trustee, in its sole and absolute discretion may from time to time think advisable for the support of my husband to maintain him in the station of life to which he is accustomed at my death and after taking into consideration his other readily available assets and sources of income or during illness or emergency, may be either paid to him or applied directly for him. 2 D. Upon the death of my husband, FRANKLIN D. WERT, SR., the then- remaining principal and any accumulated or undistributed income shall be distributed as follows: 1. The sum of Ten Thousand ($10.,000.00) Dollars to my sister; JOAN K. WOODBRIDGE. Should she die prior to receiving this bequest, I direct said sum to be paid to her children, in equal shares, JDHN WOODBRIDGE, STEVEN/STEPHEN WOODBRfDGE, MICHAEL WOODBRIDGE, KENNETH WOODBFtIDGE, JOANNE WOODBRIDGE and GREGORY WOODBRIDGE. 2. The balance in equal shares among my six (6) children, FRANKLIN D. WERT, JR., CAROL M. SMITH, DAVID K. WERT, BARBARA J. HAGUE, DONALD R. WERT, and DEBORAH K. EMIG, or their issue, per stirpes, provided that if any beneficiary entitled to distribution shall then be under age twenty-two (22), the share of such beneficiary shall be held by the Trustee, in further separate Trust, for the following uses and purposes: a. ~ If the beneficiary is under age eighteen (18), to expend and apply so much of the net income (any .income not expended or applied to be accumulated and added to principal) and so much of the principal of each Trust as the Trustee, after consultation with the guardian of said beneficiary, shall consider advisable for the support, maintenance and education (including college education, both graduate and undergraduate). b. After the beneficiary attains the age of eighteen (18), thereafter to pay to such beneficiary the net income together with so much of the principal thereof as Trustee shall consider advisable for the support and education (including college education, both graduate and undergraduate) of such beneficiary, after taking into consideration his other readily available assets and sources of income. c. Up to the entire balance of principal and undistributed income, of the then-remaining share of such beneficiary shall be distributed to that beneficiary at or after agetwenty-two (22). Distribution at or after this stated age shall be made only in the event the beneficiary requests such distribution by a writing intended to take effect during his lifetime, executed by him upon or after attaining age twenty-two (22) and delivered to my Trustee. d. If any Trust beneficiary shall die before receiving final distribution of his entire share, the undistributed balance shall be distributed to the beneficiary he names specifically in his Will, referring to this Trust. Should said beneficiary die without a Will provision specifically referring to this Trust, then his share shall be paid to his heirs at law. e. In the event that any of my children predecease me, leaving no issue surviving, then whatever gift or bequest would have passed to such child shall be distributed to my surviving children, or their issue, per stirpes. E. I direct that my Co-Executors and their successors shall not elect that this Trust be included in my husband's estate as a part~of the marital deduction. ITEM VII: It is my expectation that my husband shall have established a revocable Trust appointing my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., as Trustees, and paying the income to him for life. If such a revocable Trust exists as of the date of my death, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wherever situate to said Trustees, DAVID K. WERT and FRANKLIN D. WERT, JR., for the benefit, nevertheless of my husband, FRANKLIN D. WERT, SR. Should he not have established such a Trust, or should he have revoked it prior to the time this bequest takes effect, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate outright to my husband, FRANKLIN D. WERT, SR. ITEM VIII: Should my husband, FRANKLIN D. WERT, SR., fail to survive me by thirty (30) days, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate to FRANKLIN D. WERT, JR., CAROL M. SMITH, DAVID K. WERT, BARBARA J. HAGUE, DONALD R. WERT and DEBRA K. WERT, or their issues, per stirpes, provided that if any beneficiary entitled to distribution shall then be under age 22 years, the share of such beneficiary shall be held by the Trustee, in accordance with the terms set forth in Item VI, D, 2, above. 4 ITEM IX: If my husband, FRANKLIN- D, WERT, SR., makes a qualified disclaimer (as defined in Section 2518 of the Internal Revenue Code, as amended) with . respect to all or any portion of the interest in property given to him under any provision of my Will, I give such disclaimed property interests to the Trustee of my Credit Shelter Trust, IN TRUST, for the benefit of my said husband during his lifetime with the balance of the principal and interest passing in conformity with the terms of Item VI-D-2 hereof. ITEM X: My Co-Executors, Co-Trustees, and their successors shall have the following powers in addition to those vested in them by law and by other provisions of my Will, applicable to all property, whether principal or income, including property held for minors, exercisable without court approval, and effective until actual distribution of all property: A. To borrow money from any person or institution, including my fiduciary and to mortgage or pledge any or all real or personal property as they in their sole discretion shall choose, without regard for the dispositive provisions of this instrument, except that no property passing to the marital deduction share shall be so mortgaged or pledged. B.' To reasonably compromise claims asserted by or against my estate: C. To join with my husband in filing a joint income tax return without requiring him to indemnify my estate against liability for the tax attributable to his income, and to consent to any gifts made by my husband being treated as having been made one-half by me for the purpose of federal laws relating to gift tax. D. To retain any or all of the assets of my estate, real or personal, without regard to any principle of diversification or risk. E. To sell at public sale, to exchange, or to lease for any period of time, any real or personal property and to give option for sales, exchanges, or leases, for such prices and upon such terms or conditions, as they deem proper. F. To make loans to, to sell to, and to buy property from my or my husband's executor or administrator or my Trustee. This shall not be construed as a command to exercise these powers under any circumstances. All sums payable to the Trust established in Item VI hereof from whatever source shall be utilized for such loans or to purchase assets from my Co-Executors at final federal estate tax values. G. To exercise any law-given option to pay death taxes in installments, the payment of interest due on such installments to be a charge against principal of my Credit Shelter Trust. H. Notwithstanding any power granted expressly or impliedly herein, such shall be void and of no effect as to the marital gift if such would either eliminate said gift or reduce it below that elected by my Executor. ITEM XII: All shares of principal and income hereby given shall be free from anticipation, assignment, pledge or obligation to the beneficiaries and any of them, and shall not be subject to any execution, attachment, levy or sequestration or other claims of the creditors of said beneficiaries or~any of them. ITEM XIII: All federal, state and other death taxes payable because of my death, with respect to the property passing under this Will and forming my gross estate for tax purposes, including any interest or penalty imposed in connection with such tax, shall be paid out of the non-marital residue of my estate, if any. Any such tax, including interest or penalty imposed, due by virtue of taxable property forming my gross estate, passing under this Will shall be paid directly from such property and shall not be paid out of the marital or charitable deduction share of my estate. It is my specific command and intent herein that no property forming part of the marital or charitable deduction share of my estate be utilized to pay or be reduced by any federal estate or Pennsylvania (or other state) inheritance or estate taxes. ITEM XIV: I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., to serve as Co-Trustees under this Will. Should either of my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., fail to qualify or cease to act as Co-Trustees, I appoint my daughter, DEBORAH K. EMIG, as successor Co-Trustee of this my Last Will and Testament. Should both of my remaining son and my daughter, DEBORAH K. EMIG, fail to qualify or cease to act as Trustee, I appoint FIRST UNION NATIONAL BANK, to serve as successor Trustee under this Will. I direct that a majority of my then-surviving children shall have the right to remove FIRST UNION NATIONAL BANK as fiduciary and appoint a successor corporate fduciary. ITEM XV: I direct that no Executor, Trustee or their successors serving hereunder be required to post bond or enter security in any jurisdiction. ITEM XVI: I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., or the survivor of them, as Co-Executors of this my Last Will and Testament. Should both my Co-Executors, DAVID K. WERT and FRANKLIN D. WERT, JR., fail to qualify or cease to act as Co-Executors, I appoint my daughter, DEBORAH K. EMIG, as Executrix of this my Last Will and Testament. ITEM XVII: As Guardian of any property which passes under or outside of my Will to a minor and with respect to which I am authorized to appoint a Guardian and have not 7 specifically done so outside of my Will, I appoint my sons, DAVID K. WERT and FRANKLIN D. WERT, JR., or the survivor of them. ITEM XVII1: All references herein to the singular or the masculine shall include the plural or the feminine respectively, where appropriate throughout this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this _day of ~ !~ H.~ilk (~.~ , 1999. ~~ ` --, Mildred S. Wert SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: -~ ~~ 8 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss I, MILDRED S. WERT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the 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. Sworn or affirmed to and acknowledged before me, by MILDRED S. WERT, the Testatrix, this ~ day of 1999. Mildred S. Wert, Testatrix Public NO~TARIAL8EAt. MERLENE J. MARNEVKA, NOrrARY PUBLIC CARLISLE, CUMBERLAND COUNT1f, PA MY COMMISSION EXPIREB JUNE 8.8002 9 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss We, James D. Flower. Jr. and .Linda Jumper , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatritc sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for th.e purposes therein expressed; that each of us in -the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to befo~rey~me by James D. Flowex, Jr. and Linda Jumper this `~-~ day 1999. blic NO~TAIEl11. SEAL MISRLWVE J. MA~VKA, NC?ARYPU®UC CARLISLE, CUMBERLAND COUNTY. PA MY CCMMl8810N EXPIRES JUNE s. SD02 10 Wit ss Wert, Franklin D. Sr; Codicil for Frank CODICIL TO THE LAST WILL AND TESTAMENT OF MILDRED S. WERT I, MILDRED S. WERT, of Camp Hill, Cumberland County, Pennsylvania, declare this to be the First Codicil to my Last Will and Testament, dated November 9, 1999. ITEM I: This Codicil to my Will is prepared to adjust the shares of my residuary estate to take into account an advancement made to our son, DONALD R. WERT. This advancement and the adjustment described herein should be applicable whether my spouse predeceases me and my children inherit directly through my estate, or whether they inherit as residuary beneficiaries under any Trust I have established in my Will. Our son, DONALD R. WERT, made certain investments on our behalf SAIDIS CHUFF, FLOWER & LINDSEY ATTORNEYS•AT•LAW 26 W. High Street Carlisle, PA with our funds, but in his name, in 1986 in Fairmont Associates Limited Partnership in the form of a loan. The loan was converted to stock in Integrated Health Services and then sold on January 24, 1992. Our initial investment was $25,000.00. However, when the investment was sold it yielded $69,103.00, for a gain of $44,103.00, on which it is estimated that he would have paid tax at 30.8%, or $13,583.74. Consequently, the amount that he held at that time on our behalf was $55,519.00. This investment was commingled in Donald's portfolio with the intent of returning the investment when a Wert, Franklin D. Sr.; Codicil for Frai targeted asset was sold. However, in the meantime, he paid tax on the initial investment and has reported any earnings in his name from the date of the sale forward. Rather than reclaim the investment, we gifted it to him. We gifted $20,000.00 at the end of 1991, and $20,000.00 at the end of January of 1992, and the remainder in 1993. My spouse and I each gifted one-half of the total gift to him each year. Since we have made no such significant gifts to any of our other children, SAIDIS iHUFF, FLOWER & LINDSEY ATT°RNEYS•AT•LAW 2G W. High Street Carlisle, PA and in order that disbursement of our final estate be made in an equal fashion among all of our children, it is our desire to value the advancement by assuming that it would have increased in value by a rate of 6.5% compounded annually. For the purposes of this computation, the amount initially to bear interest shall be $55,519.00, and the date from which it shall be assumed to have increased in value in such fashion will be February 1, 1992. The resulting amount shall be considered to be an advancement, and each of our children shall received the same amount from either my residuary estate, or from the residuary of any Trust created under my Will prior to division of the remaining residuary which shall be paid equally to all of our children, including DONALD R. WERT. We arrived at the interest rate of 6.5% considering that it is high enough to be fair to our other children, but significantly lower than Donald would have paid for a commercial business loan. The lower interest rate partially reflects the family nature of this transaction, and the value of Donald's advice on the investment to us. 2 Wert, Franklin D. Sr.; Codicil forFrai Although this language also appears in my spouse's Codicil, we do not want the advancement to be duplicated, but wish for the adjustment to take place only once. ITEM II: In all other respects, I hereby ratify, confirm and republish my Last Will and Testament dated November 9, 1999, together with this First Codicil, as and for my Last Will. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~ day of ~",~~A~~~-° -~ , 2001. ~~- ~ Mildred S. Wert SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: SAIDIS SHUFF, FLOWER & LINDSEY A7TORNEYS•AT•IAW 2G W. High Street Carlisle, PA 3 /,/ Wert, Franklin D. Sr.; Codicil forFre COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss I, MILDRED S. WERT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as a First Codicil to my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MILDRED S. WERT, the Testatrix, this _~ ~ day of ~~~. h.~ , 2001, at ~~ ~,,,~ ,Pennsylvania. Y Mildred S. Wert, estatrix se..-~ ~ e NotarX~' ublic SAIDIS SHUFF, FLOWER & LINDSEY ATTORNEYS•AT•LAW 2G W. High Street Carlisle, PA NOTARIAL SEAL ~ MERLENE J. Cv1AgpIEVK/` NOTARY PU81JC GiRU81E. CUti1BEF1lANp COUNTY, PA ~` MY fSgION EXPIRES JUNE B, 2002 4 Wirt, Franklin D. Sr.; Codicil for Fla COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We James D. Flower, Jr. ss and Johnna J. Kopecky the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as a First Codicil to her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Codicil as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by James D. Flower, Jr. and ~~ J~~o((h~nna J. Kopecky this day of ~~~KL L_ , 2001. fitness SAIDIS iHUFF, FLOWER & LINDSEY ATTORNEYS•AT•LAW 2G W. High Street Carlisle, PA ~~ Notaru,~"ilblis NOTARIAL BEAL MERLENE J. MARHEVKA, NOTARY PUBLIC CARUSIJ:, CUMBERLAND COUNTY, PA MY COMM118810N EXPIRES JUNE 8, 2002 5 '~ LAW OFFICES JOHN E. sLIxE ROBERT C. SAIDIS JAMES D. FLOWER JR CAROL J. LINDSAY JOHN B. LAMPI DANIEL L. SULLIVAN ALBERT H. MASLAND DEAN E. REYNOSA THOMAS E. FLOWER MARYLOU MATAS JASON E. KELSO SAIDIS, FLOWER & LINDSAY A PROFESSIONAL CORPORATION 2109 MARKET STREET CAMP HILL, PENNSYLVANIA 17011 TELEPHONE: (717) 737-3405 -FACSIMILE: (717) 737-3407 EMAIL: tflower®sfl-law.com www.sfl-law.com December 4, 2009 Cumberland County Register of Wills and Clerk of Orphans' Court 1st Floor, Room 102 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Mildred Wert, deceased File No. 2003-00661 Dear Register of Wills: ~~ ~ ~ ~. ; = z c s s-~ t r=te- s"~~+ ~ '3 J ~ cn ~ .~! ' s . ~_ ~~ ~ ~ Please find enclosed the Inheritance Tax Return for the above-referenced estate, as well as the filing fee of $15.00. Please contact our office should you have any questions. Very truly yours, SAIDIS, FLOWER & LINDSAY Yv nne M. Sersch, Asslstant to mas E. Flower, Esquire CARLISLE OFFICE: 26 WEST HIGH STREET CARLISLE, PA 17013 TELEPHONE: (717)243-6222 FACSIMILE: (717)243-6486 REPLY TO CAMP HILL :yms enclosures ~~ ` 3Jd1S~Od sn ~, oM ;s c~ ~- ~ '~ o ~ ~ ~~ ~: r ~ '~ a '- ro :~ o b3l°;f/Fi f. ~s -~ ~~:.s.w tIEC -7 PM 59 ~M U ~ ~ A O ~ 5 " ~ ~ ~+ ~ ~ w a i U W W - ,.d a~ ~a ~ E ° ~ ~ `~ ~ v"O O ~ W ~ ~ ~ a c o ~ ~ o _ ai ~ '~ ~w o bo ~, U~•~UU O H NOTICE OF INHERITANCE TAX ~, ~(-"~~~ E'I~T, ALLOWANCE OR DISALLOWANCE BUREAU OF INDIVIDUAL TAXES f ~ i.,: ,/ ~„ INHERITANCE TAX DIVISION ., ,:.17F' ~ ~`f'IONS AND ASSESSMENT OF TAX PO BOX 280601 r<, LI„ w ~ ~,~~' ~ ~`iL:. ~, HARRISBURG PA 17128-0601 ~`'~ ~Q! 0 MkY 11 P~ 2~ ~2 ~~~~~ ~~ Q~~~~~ ~~~~~ THOMAS E FLOWEI~;(~~,~~~1~'_,~~;~~ ~;~_~„ P~ SAIDIS FLOWER 8~ LINDSAY 2109 MARKET ST CAMP HILL PA 17011 pennsylvan~a ~ DEPARTMENT OF REVENUE REV-1547 EX AFP C12-09) DATE 05-10-2010 ESTATE OF WERT MILDRED S DATE OF DEATH 07-07-2003 FILE NUMBER 21 03-0661 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 07-09-2010 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT-ALONG-THIS-LINE-- ~ RETAIN-LOWER-PORTION-FOR YOUR RECORDS- --- ----- ---- ---- --------------- ----- ------- ---------------- ~ - ----- ----------------- REV-1547 EX AFP C12-09) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: WERT MILDRED SFILE N0.:21 03-0661 ACN: 101 DATE: 05-10-2010 TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) C1) •0 0 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) C2) 298,447.00 credit to your account, 3 Closely Held Stock/Partnership Interest (Schedule C) C3) .0 0 submit the upper portion . of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) •0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) .0 0 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G) (7) .0 0 8. Total Assets C8) 298 , 447.00 APPROV ED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) .0 0 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) .0 0 11. Total Deductions C11) .0 0 12. Net Value of Tax Return C12) 298,447.00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) 4,0 0 0.0 0 14. Net Value of Estate Subject to Tax (14) 294,447.00 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) 294,447.00 X 00 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) .0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate C17) .00 X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 15 = .0 0 19. Principal Tax Due C19)= .0 0 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX UE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. (~