HomeMy WebLinkAbout02-01-12
15056051058
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
Po sox 2ao6o1 21 10 1136
Hanisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
210-16-0864 10/19/2010 12/01 /1924
Decedent's Last Name
Minishak
Suffix Decedent's First Name
Alex
MI
J
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return 2. Supplemental Retum 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required
death after 12-12-82)
•- 6. Decedent Died Testate :_ .. 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death tm~ „~ 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
Lisa Marie Coyne, Esq. (717) 737-0464
Firm Name (If Applicable)
Coyne & Coyne, P.C
First line of address
3901 Market Street
Second line of address
City or Post Office
Camp Hill
Correspondent's a-mail address:
t`.~~5
', REGISTER OF 111f~S USE ON LY ~"
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DATE. f?f ~"D~
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State ZIP Code ___ _ _~ --- -
-
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PA 17011 `^~
Under penalties of perjury, I declare 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 prepan:r other than the personal representative is based on all information of which preparer has any knowledge.
SIGNry/p~~T~~U,R,E~/ OF PERSON RE PO SIB FOR FILING RETURN DAT
-~~~_bL -- __ __ __ -_ ------- -- --
ADDRESS
Alex Minishak, Jr. 90 Hawthorne Ave., Mechanicsburg, PA 17055
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONL7
Side 1
15056051058 15056051058
15056052059
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Alex J Minishak 210-16-0864
RECAPITULATION
1. Real estate (Schedule A) .......................................... ... 1. 149,900.00
2. Stocks and Bonds (Schedule B) ........................ . ........... ... 2. 2,768.48
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00
4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. 0.00
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 275,359.61
6. Jointly Owned Property (Schedule F) • ::; Separate Billing Requested .... ... 6. 0.00
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested..... ... 7. 57,566.69
8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 485,594.78
9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 38,891.14
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 8,476.63
11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 47,367.77
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 438,227.01
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 438,227.01
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE ...
RATES ..~__ ~•-~....-._. .~._._.m..,..._._._
......._.,.. _ ~._~ ... ... W.. ..~ __...
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 15.
16. Amount of Line 14 taxable
at lineal rate X .0 45 438,227.01 16. 19,720.22
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. 19,720.22
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059 Side 2
15056052059
802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2)
803. Your adjusted origination charges (from GFE A) 1,340.00
804. Appraisal fee to Olde Ci Lendi Solutions $450.00 P.O.C. B' (from GFE #3)
805. Credit report to Weststar Mort a e, Inc. (from GFE #3) 9.18
806. Tax service to Weststar Mort e, Inc. (from GFE #3) 45.00
807. Flood certification to Weststar Mort a e, Inc. (from GFE #3) 11.00
808. to
900. kerns Re wired b Lender to be Paid in Advance
901. Daily interest charges from from 0110412012 to 01101/2012 @ $17.01151day (from GFE #10) -51.03
902. Mortgage Ins. Premium for months to FHA (from GFE #3) 1,446.53
903. Homeowner's insurance for 12 months to State Farm Fire & Casual Co $668.00 P.O.C. B* (from GFE #11)
904. months to from GFE #11
1000. Reserves De osited vrkh Lender
1001. Initial deposit for your escrow account (from GFE #9) 440.09
1002. Homeowner's insurance 3 months $ 55.67/month $167.01
1003. Mortgage Insurance months $ 137.56/month $0.00
1004. City Property Tax months $ O.OOlmonth $0.00
1005. County Property Tax 10 months $ 27.971month $279.70
1006. School Taxes 6 months $ 108.91Imonth $653.46
1007. Aggregate Adjustment $-660.08
1100. Tkle Char es
1101. Title services and lender's title insurance (from GFE #4) 1,383.75
1102. Settlement or closing fee to $
1103. Owner's title insurance -First American Title Insurance Company (from GFE #5) 15.00
1104. Lender's title insurance -First American Title Insurance Company $1,093.75
1105. Lender's title policy limit $146,099.00 Lender's Policy
1106. Owner's title policy limit $149,900.00 Owner's Policy
1107. Agent's portion of the total title insurance premium $942.44
to Covenant Abstract Inc.
1108. Underwriter's portion of the total title insurance premium $166.31
to First American Title Insurance Com an
1109. Document Transmission Fee to Covenant Abstract, Inc. $25.00
1110. Incoming Wire Fee to First National Bank $15.00
1111. Notary Fee to An ela Gadola $25.00
1112. End 1001100 to First American Title Insurance Com $50.00
1113. 3001300 to First American Title Insurance Com $50.00
1114. 90018.1 to First American Title Insurance Com $50.00
1115. ClosingSvcLtrlCL to First American Title Insurance Com $75.00
1200. Government Recordin and Transfer Char es
1201. Government recording charges (from GFE #7) 116.00
1202. Deed $52.00 Mort a e $64.00 Release $0.00
1203. Transfer taxes (from GFE #8) 1,499.00
1204. CitylCounty tax/stamps Deed $1,499.00 Mort a e $0.00
1205. State Tax/stamps Deed $1,499.00 Mort a e $0.00 1,499.00
1206. Deed $0.00 Mort a e $0.00
1207.
1300. Additional Settlement Cha es
1301. Required services that you can shop for (from GFE #6)
1302. Survey to $
1303. to
1304. Attorney's Fees to Co ne & Co ne POC
1305. Home Warranty to AHS Home Warran 574.0
1306. 1st Qtr Garb & Sewer to Ham den Townshi 150.0
'Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er.
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, d is a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction. I fuller cergfy that I have roceived a copy of the HU41 Settlement Statement.
i -~ ~1Z
Karl E. Benyo
~w ~ ~ ~
Estate of Alex Mira
Agent Alex Min' , Jr. Co Executor
The HUD-1 Setttement Statement which I have prepared is a true antl accurate account of this transaction. I have caused or will cause the funds to be
disbursed in accordance with this statement.
SETTL MENT E
/~~/~~
DATE
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010.
Previous editions are obsolete Page 4 of 4 HUD-1
REV-1503 EX+ (6-98)
SCNEDI~LE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alex J. Minishak 21-10-1136
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
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REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDI~LE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Alex J. Minishak 21-10-1136
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntlyowned with right of survivorship must be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
,4
,dV.22.201Q 9.46AM
r
We31a Fargo Advisors, LLC
Three LemoyAe Y7rive
" LetAOrne, PA 17043
3
November 22, 2oio
Coyne c~ Coyne Attorney's at Law
3goi Market Street
Camp Hill PA 17ozz-~}zx7
RE: Estate of Alex J. Minishak
DOD: October ig, zolo
Dear Ms. Coyne:
Tee n7 psi-7s~
Fax717-97b.8428
eoo-4as-ssBs
Please be advised that at the time of Mr. Minishak's death on iojigjaolq he maintained a Traditional
I account #~}7iJ~5og and a Standard Brokerage account #85ao-4b1z at Wells Fargo Advisors.
The dace of death values are as follows:
Tide:
Opened:
Account#:
DOD value:
Beneficiary:
Tide:
Opened:
Account#:
DOD V211ue:
WELLS FARGO ADVISORS
Alex J- Minishak IR.A FCC as Custodian
July 30, solo
4717-0509
s34,493.4~ 5 .
Alex Minisha .:~~~
Alex J. Minishak
March xo, Zoog
8g2o-461Z
x35,867.55
$enefzciary: na
If you require any more informatiozl please da nat hesitate to call.
Si Cerely,
Jody xuta
Client Associate
THE mFORMnTION CAN'I'ntNF.p HEREIN HAS BSEN 08TAINED FRAM 50t3RCE5 sEUEV~n RELIABLE au'r NOT NECESSARILY COMPLE'rF
AND CANNOT SE GUARANTEED. THIS REPORT LS NOT TN6 O~ICIAL RECORD OF YOUR ACC013NT. YOUR WELLS FARC,O ADVI50RS CLIENT
S~'A I f:MBNT LS'iHE OfFIC[AL RECORD of YOUK ACCOUNT.
20. 2010 2:09PM PNC BANK 412-705-2747 No, 5167 P, 1/2
~~
tcTMewAr
December 20, 2010
Lisa Marie Coyne Esq.
Coyne & Coyne
Attorneys at Law ,
3901 iviarket St
.Camp FEll, PA 17011-4227
RE: Alex J Minishak
SSN: 2100.16-0864
DOD: 10-19-2010 ~ ,
Dear Ms. Coyne:
itt xespanse to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
t~~ecking Account
Account # 5140044059 Established: 03-01-1957
ALEX J MII~iISHAK.
DOD balance: $ 41,622.05 + 0.80 accrued interest
Interest paid O 1-01-2010 thru 10- i 9-2010 $16.37 YTD
Savm~ Account
Account # 5001992956 Established: 08-12-1998
ALEX J IVIINISHAK
D(?D balance: $ 114,704.70 + 14.08 accrued interest
Interest paid 01-01-2010 thru 10-19-2010 $461.86 YTD
Account # 51301USO49 Established: 01-01-19$3
ALEX J MIl~IISHAK
DOD balance: $ 82,141.93 + 8.50 accrued interest
Interest paid O1-01-2010 thru 10-19-2010 $ 254.50 YTD
IRA Account
,.Account # 75400040423 ~ Established: 07-15-2009
ALEX J lVlIlJISHAK
DOD balance: $ 23,Ob8.14 + 5.13 accrued unterest
Interest paid O1-01 2010 thru 10-19-2010 $ 398.67 YTD
Eor bartficiary information, please call 1-888-762-4727.
Page 1 of 2
,2G. 2014 ~:"CPM PNC BANK 412-7u5-2747 No. 5767 P. 2/2
Please note that this o$ice provides date of death balances for deposit accounts (IRAs, CDs, Checking and
Savings}. We do not process any iinancial~n$actfotls or provide statement. If you need assistance with
any of these items, please call l-$SS-PNC-B NK (l.-8$$-762-22b5) or stop by Your local PNC Bank branch
office.
Sinccrcly,
National Financial Services Center
~'NC Bank, N.A.
Member FDIC
This message is fntended fnr the Lse of the tndividurrl or entity to which tt is addressed and may ,
contain information that isprivileged eart~rclesttial and exempt, from disclosure Larder applicable law.
If the reader of this message is not the intended recipient or the employee or agent resporuihle far
delivering this message to she intended recipient, you are hereby notified that arty disseminatiar~
distribution or copying of this communications is strietlyprohibited Ifyau have received this
communication in error, please notify me immediately by reply or by telephone at 80D-762-1775 and
immediately destroy this faxed document.
Page 2 of 2
REV-1510 EX+ (08-09)
Pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alex J. Minishak 21-10-1136
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME Of THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
%OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
I• Wells Fargo IRA (beneficiary is son, Alex J. Minishak
Jr.}
, 34,493.42 100 34,493.4:
2 PNC IRA (Beneficiaries are children, equally)
23,073.27 100 23,073.21
TOTAL (Also enter on Line 7, Recapitulation) ; ~ 57,566.69
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (12-99)
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alex J. Minishak 21-10-1136
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~ ~ Musselman Funeral Home 1,060.00
2• Reception 500.00
a. Honorarium 100.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City .State Zip
Year(s) Commission Paid:
2. Attorney Fees 11,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 323.50
5. Accountant's Fees 500.00
6. Tax Retum Preparer's Fees
~. Cumberland Law Journal -legal advertisement 75.00
s. Patriot New -legal advertisement 123.38
s. Inheritance Tax Return Filing Fee 15.00
10. Postage 88.00
11. Recorder of Deeds -fee for copy of deed 1.50
12• Total from Page 2 of Schedule H 25,104.76
TOTAL (Also enter on line 9, Recapitulation) ($ 38,891.14
(If more space is needed, insert additional sheets of the same size)
ESTATE OF ALEX J. MINISHAK
--- CONTINUATION OF SCHEDULE H
-- -- -
~
T
---- - --- --
Number Item:
+ -
Value:
_
12 '~ Settlement charges for sale of real estate $ 13,015.87
13 Buchanon & Erb -- cleaning of furnance and plumbing repairs to real estate $ 254.00
- ~ _ _
14_
- _ ~ Kerry's. Lawn & Garden Equipment -- repair to lawn mowers
+__ i $ 627.46
15 I Keith Stone -- repair of concrete on front steps and driveway of real estate $ 850.00
16 I Archer Pest Control -- treatment of real estate for ants and spiders $ 106.00
17 Robert Kulp -- replacement of 3 windows at real estate $ 372.10
18 Schultz's Landscaping $ 775.00
Robert Kulp -- replacement of shower head at real estate _ i $ 113.68
20 i Allied Exteriors -- repairs to roof and down spout at real estate
I $ 350.00
_ _
Tom Miller Pamtmg -- patc mg an painting interior o rea estate; painting
'
j
-
-
21 ~ fence, shed and garage door $ 2,200.00
22 Repairs to the air conditionin
unit at real estate ' $ 162
00
g
,
__ -- _
- _ .
-
23
_ ( .
Real Estate taxes
$
1,616.44
24 'I Mileage for Executors @ $0.55/mile $ 330.00
25 Cleaning, Cleaning Supplies and Trash Removal for Sale ', $ 500.00
26 i
Llhaul Rental to Remove Items
$
300.00
27 ..Alex Minishak, Jr. -- reimbursment for repair supplies
___
- $ 81.85
_ _ 28 - - -r
Estate checks _ __._ _ _ ______ ____ ___ _ _'~
- _ i
$
- -
67.50
-
29 '~ Materials from Home Depot and Lowes _
' $ 102.69
30 ,
~Dutys Lock
$
11.13
_ _ 31 Bank fees_ _ _ _ _ _ _ _ I, $ 194.31
32
Office Max
$ --
74.73
32 '~, Reserves $ 3,000.00
TOTAL: $ 25,104.76
REV-1512 EX+ (12-08)
Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alex J. Minishak 21-10-1136
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
Ir more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (11-08)
'~ Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Alex J. M inishak 21-10-1136
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 distributions and transfers under
Sec, 9116 (a) (1.2).]
1. Alex J. Minishak, Jr. son 1/2 of residual
2. Tamea M. Kulp daughter 1/2 of residual
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN A80VE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, $
If mare space is needed, insert additional sheets of the same size.
ti.
LAS`Y' WI~.~, ANA ~Y'~S~['AM~NT'
®~
ALEX .~. M~N~S~~A~
I, ALEX J. MINISHAK of the Township of Hampden, Cumberland County, Pennsylvania,
Tare this to be my Last Will and revoke any will or codicil previously made by me.
ITEM 1: Upon my demise, I direct my body be cremated and my ashes be disposed of in
with directions of my personal representative.
ITEM 2: I direct that all my just debts and funeral expenses be paid as soon as practical
my death.
ITEM 3: I direct that all taxes and interest and penalties thereon that may be assessed in
onsequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from
iy residuary estate as a part of the expense of the administration of my Estate.
ITEM 4: I give, devise and bequeath my 1999 Mercedes Benz automobile to my son,
J. MINISHAK, JR. of 890 Hawthorne Avenue, Mechanicsburg, Cumberland County,
x
H
z
H
h
w
a
lvania.
ITEM 5: I give, devise and bequeath all the rest, residue and remainder of my estate of
nature and wheresoever situate, together with insurance thereon, in separate equal shares, to my
ALEX J. MII~lISHAK, Jr. of 890 Hawthorne Avenue, Mechanicsburg, Pennsylvania and
'AMEA M. KULP of 239 North 24`h Street, Camp Hill, Pennsylvania. Should either of my children
me, then I give, devise and bequeath that child's share to my surviving child. Should both of
children predecease me, then I give, devise and bequeath all the rest, residue and remainder of my
wherever situate, together with insurance thereon to my brother, JOHN J. MINISHAK of 32 South
r
Road, Orwigsburg, Pennsylvania 17961-9656.
Page 1-of 3
~.
ITEM 6: Until distributed, no gift or beneficial interest shall be subject to anticipation or
'y or involuntary alienation.
ITEM 7: I appoint my Son, ALEX J. MINISHAK, JR. and Daughter, Tamea M. Kulp, Co-
rs of this my Last Will.
ITEM 8: I direct that my personal representative or their successors shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
IN WITN~E/SS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, this" ~Y day of ~ , 2003.
. %~
ALEX J. M AK
Signed, sealed, published and declared by the above-named Testator as and for his Last Will and
:nt in our presence, who, at his request, in his presence and in the presence of~ each other, have
> subscribed our names as attesting witnesses.
,.G:_ residing at /~if ~L~ cr.,,i't S~7y~i ~~' ! ~D-s",f`
%Y~-1. `~'I ,,( ~.~.~ residing at ~ p '7al
w
Page 2~of 3
~.
MMONWEALTH OF PENNSYLVANIA )
ss:
LINTY OF CUMBF,RLAND )
We, ALEX J. MINSHAK, L - Sa w1 /i~J 2 (_. ,/,,,~ and
. r_ 1~~. O 3rL Nri !ice ,the Testator and the witnesses respectively, whose names are
gned to the attached or foregoing instrument, being first duly sworn, do hereby declare to the
gned authority that the Testator signed and executed the instrument as his Last Will and that. he
signed willingly, and that he executed it as his free and voluntary act for the purpose therein
and that each of the wifiesses, in the presence and hearing of the Testator signed the will as
and that to the best of his or her knowledge, the Testator was at the time eighteen (18) years of
lder, of sound mind and under no constraint or undue influence.
EX J. M SHAK
~~~
W~ ess
Witness
Subscribed, sworn and acknowledged before me N~ ,C y /r/ ~~ y~ c- by ALEX J.
~IISHAK, the Testator, and subscribed and sworn to before me by
L t S ~ /1'~ g ti J t ~ y ~:., and ~ ~ ~ c M • ~~' -~ ~~~-- the witnesses, this
~ i,
day of f ' 1.~tit v ~ e ~ , 2003.
Notary Public
.r
NOTARIAL Si=r1l.
HENRY F. COYric, Notary Public
H~mpd®n Twp., Cctnbariand County
!~y E>~res June 7, 2004
Page 3 of 3
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