HomeMy WebLinkAbout05-14-12Exro1-101 1505610143
REV-7 500 ~ OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania coamy code vear File Namber
Bureau of Individual Taxes °F°^"*^'Ex~0F"EVE"°E
Po Box28osot INHERITANCE TAX RETURN 2 1 11 0 0 7 4 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Sociaf Security Number Date of Death Date of Birth
205 26 2422 OS 26 2011 09 23 19.t4
Decedent's Last Name Suffix Decedent's First Narr1e MI
JEFFREYS JAMES 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 Return ^ 3, Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ qa. Future Interest Compromise
(tlate of death after l2-12-a2) ^
0 -'i. Federal Estate Tax Return Required
IIqq
°f Decetlenl Dletl Testate
6. (Attach Copy of Will) ^ 7. Decedent Mainfainetl a Living Tmsl
(Attach Copy of Trust) ES. Total Number of Safe Deposit Boxes
^ 9. Litigation Proceeds Received ^ 1g. be~iween i2V3 rty91 anait (datges itleath ^ ~I1,Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED. ALL
Name
JAMES R HUFF II
First line of address
1701 5TH AVENUE
Second line of address
City or Post Office
ALTOONA
AND CONFIDENTIAL T~4J( INFORMATION SHOULD BE DIRECTED TO:
Daytime Telephone Number
8:14 946 4316
F;EGISTER OF WILLS USE ON
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DATE FIRED - - 77
State ZIP Code ~' r- ~~
PA 166022319 -._ c•~~
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Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, 9ryrect and complete. De~la[ation of preparer other than the personal representative is based on all information of which preparer has any knowledge.
ANN J. CORLE f =~-/~
ADDRESS
1105 ALLEGHENY STREET, HOLLIDA SBURG, PA 16648
SIGNATURE OF PREP EPRESENT DATE
~ JAMES R HUFF II ~- rp /,2;
ADDRES
17 - 5TH AVENUE, LTOON A 166022319
___ -! ~~ Side 1
1505610143
].505610143
J~
..J
REV-1500 EX
1505610243
oeoeaem~s Name. JEFFREYS, JAMES J
RECAPITULATION
1. Real Estate (Schedule A) ...................................................................................... . 1.
2. Stocks and Bonds (Schedule B) ........................................................................... .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ . 3.
4. Mortgages & Notes Receivable (Schedule D) ...................................................... .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested........... . 7.
8, Total Gross Assets (total Lines 1-7) ................................................................... .. 8.
9. Funeral Expenses & 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 -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 .00 15.
16. Amount of Line 14 taxable 2 8 0, 5 6 1 0 2 18
at lineal rate X .045 ,
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.
Decedent's Social Security Number
205 26 2422
50,000.00
33,313.82
225,548.40
308,862.22
27,090.71
1,210.49
28,301.20
280,561.02
280,561.02
12,625.25
12,625.25
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21 - 1 1 - 00740
Decedent's Complete Address:
E EDEN NAME
JEFFREYS, JAMES J
STREET ADDRESS
1056 W. FOXCROFT DRIVE
CITY STATE ZIP
CAMP HILL PA 17011-1235
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 12,625.25
2. Credits/Payments
A. Prior Payments 12,500.00
B. Discount
Total Credits (A+g) (2) 12,500.00
3. Interest (3) 0.00
q. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. l5) 12 5.2 5
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IIN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................._......._........._........ I, 'I x
b. retain the right to designate who shall use the property transferred or its income :.................................. ~ ~I, x
c. retain a reversionary interest: or ......................._..............................................................................._..... '~~ ~~ x
d. receive the promise for life of either payments, benefits or care? .................._.._..._............................... ~'i x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ........................_..._..............................................................................._.... ', x'~.
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?........ ~,, IX I
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................_...._.......................................................................... '~, ~. a',.
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 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 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from taz, and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 ears of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is 0 percent l72 P.S. §9116 (a) (y.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.311. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the: decedent, whether by blood or adoption.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TH% RETURN
RESIDENT OECEOENT
ESTATE OF JEFFREYS, JAMES J
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the
price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which rs jointly-owned with right of survivorship must be disclosed on
schedule F.
SCHEDULE A
REAL ESTATE
FILE NUMBER
21 - 11 - 00740
Attach a copy of the settlement sheet if the property has been sold.
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1 1056 W. FOXCROFT DRIVE, CAMP HILL, PA. 17011-1235 -see attached copy of deed for
complete legal description. Being the same premises title to which became vE:sted in JAMES J.
JEFFREYS, Single, by Deed of JAMES J. JEFFREYS and EVA V. JEFFREYSi, previously
known as EVA V. HOBART, and formerly his wife, dated AUGUST 5, 1997, and recorded in
Cumberland County at Deed Book Volume 162, Page 784. SEE copies of attached HUD
Settlement Statement and check stub for net proceeds -
50,000.00
TOTAL (Also enter on Line 1, Recapitulation) I 50,000.00
A U.9.ce..aTRMa oFaw.~NOxw ~n..a oaw,ow..Nr e. IrPE Vr LLJAn
SETTLEMENT STATEMENT 1. FHA 2 FMHA 5. CONJ. DNIN3.
Abstfect Land Associates, Inc. 4. ^ vA s. ^ coNV.INS.
3812 Market Street a. ESCROW FILE NUMBER: ]. LOAN NUMBER:
01 11 5 82 2-0 01 CER
Camp Hill, PA 17011 B. MORTGAGE IN3URANCE CASE NUMBER:
(717)763.1450
C.NOTE: This brm is bmiriedb Blue youasfatmront ofacbel wahment cosh Amoums pedband SY the wttbrtMnte9ent are ahawn.
Ibmsrnedard YP.O.OP Ram pad oatsde the clnllrp; MeyerssMRn hera/or lnbmMtionel purpows end ere rotfnclWed/n fhe rofNS.
D. NAME OF BORROWER: PO%CfOR TOWnFI0U68 A890CIat88
ADORESSOF BORROWER: P060%666
GamD Hill PA 17001
E. NAMEOF SELLER: E9late 0l JemB9 ~. Jeltfaye
ADDRESS OF SELLER: 11 BS Allegheny Street
F. NAME OF LENDER:
ADDRESS OF LENDER:
G. PROPERTY LOGTION: 1856 N/BSt I"OXCfO(t DfIVe
Camp HIII, PA 17011-1235
Cumberland County 47-1 B-1302-1 B5
H. 3ETTLEMENT AGENT: AbstfBCt Land ASSOGate9, 1110.
PIACE OF SETTLEMENT: 3812 Market $tre8t, Camp HIII, PA 17811 _
I. SETTLEMFNrDATE 6/12/2011 PROMTION GATE: 6/12JZO11 DISBURSEMENT pATE'. 811212O~N
101. Ca Wed Sabe Pdce 50,000.00 401. Conlmd Sebe Pdce :10,000.00
102. Penwnel Property 402. Pereonel PropeRy
103. Se8lenrent dlalgw to eormwat (9na 1400) 50,248.22 403. __
104. 404. __
105. 405. _
ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVAN CE: ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE:
108. CI /Town Texea 408. Bann Tsxw
107. Cou Tazw p&12/11 to 12/31A1 283.93 407. Court Tazw 08!12/11 to 12/31/11 283.93
108. Aewaements 405. Aaewameda _
109. SMOOl lase 0&12/11 fo OB/30H2 994.21 409. School hxa Ofl/12/11 la Ofi/30/12 984.21
110. 470. __
111. 411.
112. 412. _
113. 413.
114. 414.
115. 415. _
120, GROW AMWIR WEFROM B011ROWER: 101,508.36 429. ORp99 AMOUNT DUE TO SELLER: 51,258.14
2G1. QBp089 Or wR19al mOf19y 591. E%Caw d II aw IN1NCtlOM
202. Pdndpsl emoUM W new loan(s) 502. Setdemenl cha w to Seller Ilna 1400 0.00
203. Exbtlfg IoaMa) tdten sub}ad to 503. Edson bens taken sub d fo
20t. 501. Pa Rdflret mo a eloan
205. 505. Pe aRdwcarW mon lom _
20fi. 508. _
207. 507. _
208. 508. _
209. 509.
210. CltyROwn Texas 510. CI /Town Taxes
271. CounryTaxae 511. Court Taxes
212. Aeeeasmenta 512. Aawsamenla
213. 513. _^
214. 514.
215. 515. __
216. 516.
217. 51'7.
218. 578.
219. 518.
220. TOTAL PAID SYIFOR BORROWER: 0.00 520 TOTAL REOUCTION8 a1 AMOUNT DUE SELLER: 0.00
307. Grow emaud due from BormRar (line 120) 101,508.36 fi01. Gross anwud due ro Seller (Nne 4201 51,258.14
302. Lew amount pad byHor eonowar (Ilne 220) 0.00 802. Lwe redudion In amoud due Seller (Ilne 520) 0.00
303. OABH(®FROM)I ^ TO)BORROWER: 101,508.38 603. CASH(^FROMI (®TO)BELLER: 51,255.14
~r~s t,.
TM HU0.1SeltlemmR Sbbmae v+NCM1l here mepemtlieaeue eM a¢urWe e¢ant Mleiiemetllu.l wtl¢wiluw be Nntls bbe aepuastlHe¢pManm Wm Nls
`dea`°` ~,~1~~~ ~
Settlemem Apant _Veb
Abatrad LeM Awpdalea, Inc.
WARNINCy the•cnmeb pbWrbymeye falteahtenlenbb Me Unibtl SiN®uMb many simlerbrm Poneltlee Upon cmvbtlan can hdutleefM eM Ynpnsmmam. FortlmeY eae:
Title 19 U.S. Gatle ssnm 1 Opt eM Se¢bn 1010.
I MVe mrtMyrs+bxatl Vie HU6l SetlbnMntSmmmntaM btM eee`mmy kroxletlpe antlMW,it le•weaM xwnm ebtmnemmVl aM tlleWiwllarM naMpn my
ecmuM Or by nw in Mi traneactlu. INrtlgr mHity bYlhero muivetla mpy oltln HU0.15eWmneM Sietenent ~
~'
COMMONWEALTH OF PENNSYLVANIA
INXERITANCE TP% PETURN
RESIDENT DECEDENT
ESTATE OF JEFFREYS, JAMES J
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 - 11 - 00740
Include the proceeds of litigation and the date the proceeds were received by the estate. All propeirty jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1
2
3
4
5
6
7
8
VALUE AT DATE
DESCRIPTION OF DEATH
Cash in wallet - 206.00
Proration of County taxes from 8/12/11 to 12/31/11 -collected at time of sale of real estate - 263.93
See attached HUD -
Proration of School taxes from 8/12/11 to 06/30/12 -collected at time of sale of real estate - 994.21
See attached HUD -
Stuckey Ford -Sale of 2011 Chevrolet Impala -see attached statement reflecting purchase 16,500.00
price -
GMAC Mortgage -refund -see attached statement of 9/2/11 - 1,222.31
Erie Insurance Group -premium refund -see attached statement - 457.00
METRO BANK -balance in decedent's checking account on date of death - sF:e first page of 13,084.37
attached bank statement for relative time period and Metro Bank correspondence of 3/30/2012 -
Internal Revenue Service - 2011 personal income tax refund - 586.00
TOTAL (Also enter on Line 5, Recapitulation) 33,313.82
A ua oarArRwror,wuza wouuw FevelorNert e.
SETTLEMENT bTTTEMENT 1 FHA 2
Abstract Land Associates, Inc. 4. ^ vA 5.1
3912 Market Street e. ESCROW FILE NUMBEF
01115822-001 CER
Hill, PA 17011
7631450
C.NOTE: TMa brm Mbmlahsdb plus puaatetemerNO/eobN aeBMmeMOwh AmourNaPldb arrd by FTe sBMmerN Spent sre shown
IMme marled YP.O.C.)' wart psM outdde The clwirp; IhPJ'an alwen hole /orMbmMSoneipugoseaerMere mtlndWedln tlIe toMM.
D. NAME OF eDRRDWER: FOXCfOft TOWf1110M68 A880CI81B8
ADDIIESS OF BORROWER: PO BOX 686
Camp HIII PA 17001
E NAMEOF SEDER: Estate 01 James J. JBRreye
ADDRESS OF SELLER: 1105 Allegheny Street
HolBdavsbum. PA 18648
F. NAME OF LENDER
ADDRESS OF LENDER
c. PROPetrv LncnmoN: 1056 W esl FDxcrpft Drfva
Camp Hill, PA 17011-1235
Cumberland CDUntY 47-18-1302-195
N. HETTLEMENTApENT: Absiracf LeDd A880CIa1e8, InD.
Puce dF 9ErTLEMENr: 3912 Market Street, Camp Hill, PA 17011 _
I. SETRA101TOATa 6/12/2011 PROMTON DATE: 8/172011 DISBURSEMENT GATE: 8117/20'11
J. SUM YOFS OWER' TRAN TION K sUMMARV OF 9ELLEIt'BTMNSACTON
701. Conbad Belae Para 50,000.00 401. Conned Sete Rlce 50,000.00
702. PenolMl Ploparty 402 Penonel Property
103.
SeWemMd dtelpea to Borrower Akre 1400)
50,248.22
403. _
1D4. 404.
105. 405.
ADJUSTMENTS FOR ITEMS PAID BY 9ELLER IN ADVAN CE: ApJU3rMENTB FOR ITEMS PAID aV HEELER IN ADVANCE : _
108. /town Terre 4W. /70Nm Tenn
107.
C Teza Ofl112/17 to 12/37/11
283.83
407.
ODM TmMe 08/72/71 b 12/37/17 _
263.93
708. Aeeeeamente 405. Aeaeeammle
709. Srhad faze 08H2/77 to OBY30/12 894.21 409. Shcool ten 0&17/77 m 08/30/12 984.27
110. 410.
771. 411.
71z a7z.
113. 473.
174.
414. _
-
775. 415. -
120. OR089 AMOUNT WEFROM aORROW6R 701,506.35 420. OROBa AMOUNT OIIE TOBELLER: 51,255.14
201. Oapoak or eemeet monry 607. Esau tle oNl see inatmedons
202 Prtndpal amount of new ban(e) - 502 Settlement the n 4 Sallar Ina 7400 0.00
203. Ezletln8loan(e) taken aubjad to W3. Fide a taken sub adto
204.
504.
P of tget mo a e loan _
205. 505.' P RNeaWM nro a loan
206. 506.
207. 507. -^
208. 508.
-
208. 508. -
ADJUSTMENTS FOR f7EMS UNPAIp BY SELLER: ApJUSTMENT3 FOR ITEMS UNPAXI BY SELLER:
21D. ClryRown Tema 570. /town Tana
277.
CDUnry Tazee
511.
C Tone _
212.
Ansaenmante
512.
Aeaeeamanle _
213. 573. -
214. 574.
275. 515.
216. 576.
217. 577. --
278.' 578.
219. 518.
220. TOTAL PAID eYIFgt BONROWER 0.00 52D TOTAL REWCmONB IN ANdlNT DDE aELLER: 0.00
307. rimes amount due from Bormeer (line 720) 701,508.38 807. Gross emoum due la Boller (Brp 420) 51,258.14
302 Leas amount paid DyRor Bonoxer (Ilse 220) 0.00 802. Lees ratludlon in amount tlue Seller Nile 520) 0.00
303. OABH (FROM) ( ^ TO)aORROWEII: 707,506.38 603. CABN(^ FROM) (® TO)BELLER: 51,858.14
O IBS III
nr HU0.t 3tlnnna sbbma[wftbbl havepePwetl is •hue ad vsureM •oomnt tli•Innodlm.l mee arwk puce ki•bnEe bbe dtlunmbcntlenm Wb tlJn
eblemNt
sedemem Apem ~ (f/II
Abetrad Lantl Hsaodalea, Inc '
WARNIN¢ kb•cdneb krownpymdottm sbtmnbbblba UNbtl Sbtm mNb Q•nyInlrbrm Poremr upanmmbtlm mn icMle•tM aM inprYa•nart FmdebM eea
na.le ~.s. ad. s•mm t ml •,d sedlon tmo.
I Iwm mreAty rw6wetl Ma HU0.t Settlmmm SbIRmN nN biM bet at mY knoMetlpe•nJ bt V, Itl•• Due •M•ocueb •btmm~td sl ieglyb and debunemeiN m,tle on my.
acmmtarby m•Inbb trens•otlm. IM1aawr mNlytlN lbave nmlveEe mgotlbe HU615egemeN SMement //~
To Whom It May Concern:
Ann J Corle came to our dealership on July 28, 2011 and sold 3ames J Jeffreys 201 ]
Chevrolet Impala. VIN number 2G1 WBSEK4B1206790. We purchased this vehicle for
$16,500.00.
anks you, I'
1
Jennifer uffman
Business Manager
Stuckey Ford/ Subaru
(814)695-9862
GMAC Mortgage
JAMES ). IEFFREYS
1105 ALLEGHENY ST
HOLLIDAYSBURG PA 16648-2407
RE: Account Number 002LOAN NUMBER 0450807813
Deaz Mortgagor:
~~~~~~
°~
Congratulations! Your account is paid in full. It has been our pleasure to service your financial needs.
Your refund check is attached below. Please cash the refund at your earliest convenience as it is valid
for only 60 days, .
If you are utilizing a military allotmem, or third-party company to make payments on your behalf, please
cancel your service for this account.
If this account was escrowed for the payment of taxes and/or insurance and the due or delinquency date
of a bill is on or after your date of loan payoff, please do not assume the bill has been paid. Please check
with your escrow/title company to determine if they paid or verified payment of any bills,. or contact our
office at the toll free number provided on your monthly statement or your coupon book. FAILURE TO
PAY ANY BILLS ON OR AFTER THE PAYOFF OF THIS LOAN, INCLUDING ANY SUBSEQUENT
PENALTIES, IS YOUR RESPONSIBILITY.
A Statement of Mortgage Account showing year-to-date activity and/or an IRS Form 1098 will be mailed
to you no later than January 31st. This is the only statement you will receive and it should be retained for
your records. Please notify us of any change of address.
A Deed of Reconveyance/Satisfaction of Mortgage will be forwazded to the appropriate county recorder's
office for recording. If you would like a copy, please contact your county recorder 12-24 weeks after payoff.
If you have any questions, please contact Customer Caze at the toll free number provided on your montly
statement or coupon book.
NOTICE OF PREMIUM REFUND - %a,eac vo,
Erik Insurance DATE
Group MO. DAY YR
lao Erie Inc. PL • Erie, Pn ssoa OS O1 11
REFUNDAMOUNT S4S7. OO '
- POLIGV NUMBER Q~4 1~D5$D1 H
AGENT NO. AA7571
AGENT'S NAME DRAKE INSURANCE INC.
REASON 1
REF. NO. A813339
-' ~ CHECK NO. X1$13339
ESTATE OF TAMES J SEFFREYS AA7571
_1105 ALLEGHENY ST
HOLLIDAYSBURG PA 16648
o S I NON-NEGOTIABLE
~l
5
~-
~NETRO
BANK
Metro Bank
3601 Paxton Street
Hanisburg PA 17111-1418
1-868-937-0004
mymetrobank.com
>01702 6972409 001 092140
JAMES J JEFFREYS
1056 W FOXCROFT DR
CAMP HILL PA 17011-1235
r
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We're here 7 days a week, 24 hours a day at f-888-937-4004.
50 PLUS CHECKING 0032024168
SERIAL NUMBER: 0709 400431090697393
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SERIAL NUMBER: 0722 400447761674313
5 Cvele Page 1 Of 6 Memo-eo~~
Transactions By Date
05N2N1 PAWC PAYMENT 541.11 514,096.21
METRO
BANK
March 30, 2012
3801 Paxton Street
Harrisburg, PA 17111
Sullivan, Forr, Stokan, Huff & Kormanski
1701 6`h Ave
Altoona PA 16602
RE: Estate of: James J. Jeffreys
Tax Identifltation Number: 205-26-2422
Date of Dea[h: May 26, 2011
888.937.0004
mymetrobank.com
To Whom It May Concern:
This letter is in reference to decedent account information you requested forthe individual listed above
We are able to provide the following:
Account Type: Checking
Account Number: 23024168
Date Opened: 08/02/1991
Primary Owner: James J. Jeffreys
Date of Death Balance: $13084.37
Account Type: Time Deposit
Account Number: 102479
Date Opened: 02/25/2008
Date Closed: 02(25/2010
Primary Owner: James J. Jeffreys
Date of Death Balance: $0.00
Account Type: Time Deposit
Account Number: 102383
Date Opened: 08J74J2007
Date Closed: 02/24/2010
Primary Owner: James J. Jeffreys
Date of Death Balance: $0.00
Please feel free to Contact me at (717) 412-6122 if I may be of further assistance.
Sincerely,
Diana Reynolds
Metro Bank
Support Associate/Deposit Services
y
COMMONW EALTH OF PENNSYLVANIA I SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIpENTpEpEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF JEFFREYS, JAMES J FILE NUMBER
i 21 - 11 - 00740
This schedule must be completed and filed if the answer to any of questions 1 ttlrough 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY ~I pATE OF DEATH %OF EXCLUSION
NUMBER Include the name of the transferee, their relati°nshlp to decetlen[ VALUE OF ASSET DECDB (IF APPLICABLE) TAXABLE VALUE
and the date of Vans(er. Attach a copy of the tleed for real estate. i INTEREST
1 I Fidelity Investments -IRA of decedent, No. 225sa8.ao ~ 100% 225,548.40
Y91-062383 with daughters, Ann J. Corte and Carol
R. Scott, as the named beneficiaries, each to receive
50% of said IRA -see copy of attached statement - II
TOTAL (Also enter on line 7, Recapitulation) 225,548.40
-,l~i~de/~tyc
December 09, 2011
JAMES R HUFF II
C/O SULLIVAN FORR STOKAN HUFF & KORMANSKI
1701 FIFTH AVENUE
ALTOONA, PA 16602-2319
Deaz James R Huff II:
We aze responding to your request for information regarding James J Jeffreys's Fidelity Investments
account(s). The beneficiaries of the IRA account are: Ann J. Corle - 50% and Cazol R Scott - 50%.
All information in the enclosed valuation report(s) is (aze) based on assets in the Fidelity account(s) as of
the date indicated on the report(s). Valuation information is provided through .a third party valuation
service provider. Fidelity does not warranty the accuracy of this information for any particulaz purpose,
nor does Fidelity provide legal or tax advice. Consult with an attorney or tax professional regazding any
specific legal or tax situation.
We hope this information is helpful. If you have any questions about account holdings or need
instructions on how to transfer the ownership of the accounts, please visit us a1: Fidelity.com and seazch
under "Change Account Registration" or call us at 800-544-0003. Fidelity Inheritor Services
Representatives aze available Monday through Friday from 5:00 a.m. to 6:30 p.m. Eastern time.
Sincerely,
Carla Goins
Cazla Goins
Fidelity Investments Account Re-Registration Services Representative
Our file: W822169-02DEC11
LGLTR2lDDODCNFM 531298.1.0
DEC 1 ~ ~f
Brokerage Services provided by Fidelity Brokerage Services LLC Member NYSE, SPIC
Clearipg, custody and settlement services by National Financial Services LLC Member NYSE, SPIC
_ _ P.O. Box 770001, Cincinnati, OH 45277-0034
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,~" SCHEDULE H
x FUNERAL D~EIVSES &
COMMONWEALTH OF PENNSYLVANIA ~~~~~
INMERI1gNLE TFX RETURN
RESIDENT OECEf)ENT
ESTATE OF JEFFREYS, JAMES J FILE NUMBER
I 21 - 11 - 00740
Debts of decedent must be reported on Schedule I.
ITEM II
NUMBER FUNERAL EXPENSES: DESCRIPTION
A. 1 Timothy A. Berkebile Funeral Home, Inc., Bedford, PA. -funeral bill of decedent -see
attached statement -
2 Loving Touch Flower -flowers for funeral - I
3 Ed's Steakhouse, Bedford, PA. -funeral luncheon -
4 Engraving charge to place year on tombstone -
5 Charge to plant grass on grave site -
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
AMOUNT
8,658.22
303.04
274.99
116.00
15.00
Street Address
City State Zip
Year(s) Commission paid
2. Attorney's Fees SULLIVAN FORR STOKAN HUFF & KORMANSKI - 6,421.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant I
Street Address
City State Zip
Relationship of Claimant to Decedent
a. probate Fees Cumberland Co. Reg. of Wills -grant of Letters Testa., Short Certs., 108.50
5. Accountant's Fees Income tax preparation -decedent's final personal income tax 55.00
6. ', Tax Return Preparer's Fees Hileman's Tax Service -prep of final 2011 personal tax 55.00
7. Other Administrative Costs
1 Cumberland County Law Journal -advertising grant of Letters Testamentary - 75.00
TOTAL (Also enter on line 9, Recapitulation) 27,090.71
. Sd>edule H
~I Ft.eieralE>q~erlses&
COMMONW EALTH OF PENNSYLVANIA //~~~~.,,.,,~~,,,~..~~yy,~,~//~~~~,,,.,,~~.,~...,....1.,,~~,~q
INHERIT{WCE TAH RETURN /YJI^I ~JII gY~IG IiWI.I ~.lA N11LR.1
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF JEFFREYS, JAMES J 21 - 11 - 00740
2 Spitzer Appraisal Services -appraisal of real estate -see copy of estate check number
117 -
3 UPS -overnight fee to send deed to realtor -
4 7115!11 gasoline expense - to Camp Hill, PA. to clean residence -
5 PA Turnpike toll expenses 7/14 & 15/11 -
6 Food for cleaning crew -
7 3 keys for residence -
8 Gasoline expenses regarding moving property from residence in Camp Hill, PA. -
9 PA Turnpike tole expense - 8/6/11 -
10 Matt Mathias -payment for help in move -
11 U-Haul -rental of unit to remove items from decedent's property in Camp Hill, PA. -see
attached statement -
12 PA American Water -return check charge -
13 .Mailing charge to return Medical Alert equipment to Connect America with $360.00
insurance coverage on said equipment -
14 PA Turnpike - 7/6/11 toll to Cumberland County, PA., for will probate -
15 US Postal Service - 8/26(11 -Priority Mail to Malabar, FI. 32950 - $5.35 and
postate - $8.80 -
16 PPL -electricity provided to residence of decedent prior to sale -
17 The Sentinel -advertising expenses regarding publication of grant of Letters
Testamentary -
400.00
13.08
40.00
12.90
42.79
4.74
202.47
5.35
40.00
428.04
20.00
17.20
5.35
14.15
164,81
189.54
Page 2 of Schedule H
~ Schedule H
. ~ .; FLlneral E1q~es &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TA%RETDRN ~l'titllsb'~We ~SCOt1UIlUed
RESIDENT DECEDENT
ESTATE OF JEFFREYS, JAMES J FILE NUMBER
21 - 11 - 00740
18 Pennsylvania American Water -debt of decedent for water leak at residence from 336.90
6/23/11 through date of sale -
19 County of Palm Beach, FL. - Ad Valorem Taxes and Non-Ad Valorem Assessments - 512.54
see attached statement -
20 GMAC Mortgage -June, July & August, 2011, mortgage payments at $561.3:1 per 1,684.05
month -
21 Comcast -cable bill -auto deduct from decedent's checking account after death - 67.41
22 PA American Water -water bills of decedent -auto deduct from decedent's checking 243.63
account after death -
23 Verizon -phone bill -auto deduct from decedent's checking account after death - 44.27
24 METRO Bank -returned check charges against decedent's checking account after 111.00
I same was closed -
25 PPL Electric -electric bills -auto deduct from decedent's checking account after death 236.76
26 Sears -auto deduct from decedent's checking account after death - 37.00
27 .Borough of Wormleysburg -sewer and trash -owed by decedent - 210.51
28 Universal Property and Casualty Insurance Company -homeowners insurance on 597.83
Florida Property -
29 I Expenses incurred in cleaning expenses, etc., incurred in getting Florida property 472.03
ready for sale - I
30 La Quinta Inn, Pittsburgh Airport -charge for room prior to flight to Florida regarding 78.65
Florida property sale -
31 II United Airlines - 2 Round Trip Tickets from Pittsburgh to West Palm Beach for 705.40
decedent and spouse-
Page 3 of Schedule H
Sd~edule H
'"° Funeral E~erlses &
COMMONWEALTH OF PENNSYLVANIA
INHERITP.NCE TA%RETURN ~~~~~~~
RESIDENT DECEDENT
ESTATE OF JEFFREYS, JAMES J
32 Car Rental in Florida -
33 Cresthaven Villa -Florida maintenance fees -
FILE NUMBER
21 - 11 - 00740
34 Florida Power -light bills at Florida residence -
35 'Cumberland County Register of Wills -additional probate fee based upon probate
assets -
36 Cumberland County Register of Wills -fee to file Pa. Inheritance Tax Return -
37 Cumberland County Register of wills -fee to file Inventory -
373.99
3,378.65
122.92
165.00
15.00
15.00
Page 4 of Schedule H
Timothy A. Berkebile Funeral Home, :[nc. ~ ~I
214 South Juliana Street ' (t a~
Bedford, Pennsylvania 15522 ' ~ `~
Timothy A. Berkebile Telephone 8t4-623-6317 Aazon W. Berkebile
Funeral Dvector Supervisor
Mrs. Ann L. Coyle
1105 Allegheny Street
Hillidaysburg, PA 16648
Services Rendered For: James J. Jeffreys
SERVICES INCLiIDING MERCHANDISE SELECTED:
June 20, 2011
Professional Services $ 2,465.00
Use of Facilities & Equipment $ 325.00
Automotive Equipment $ 645.00
Caskee Provincial $ 3,380.00
Vault: Monticello $ 1,120.00
Register Book ~ $ 35.00
TOTAL $ 7,970.00
CASH ADVANCE ITEMS:
Certified Copies of the Death Certificate ($6.00 a piece) $ 120.00
Cemetery Charges $ 350.00
Newspaper Notice /Bedford $ 20.72
Newspaper Notice / Alxoona $ 197.50
TOTAL $ 688.22
Complete total $ 8,658.22
Total Due $ 8,658.22
Less $86.58 if paid within 10 days/net 30
COUNTY OF PALM BEACH: NOTICE OF AD VALOREM TAXES AND NON-AD VALOREM ASSESSMENTS
NUMBER YEAR CMC
~-0070 2011 20
R 5 - 283295
JEFFREYS JAMES J
1105 ALLEGHENY ST
HOLLIDAYSBURG PA 16648-2407
~~II~IIh~~hI~IhII~PIIh~~~III~IIhIII~IIPpllup~~l~plull
5 -3 9
561-740.7000
561-627-3386
561-659-1270
561-434-8837
561-434-8837
561-686-8800
561-686-8800
COUNTY
COUNTY DEBT ,~ ~~~,
~
~ 561-355,$996
~51-3~5 399 ~~ ~7, 000~~, ~~~
1Oa~
FIRE/RESCUE MSTU ~'`
~`': ~-35b. p(=b,.w^
O
LIBRARY
LIBRARY DEBT ~ ~..h.; ' -5~~
~ ~
O
9
1 00~
CHILDRENS SERVICES COUNCIL
Ip F.I. N.D.
PBC HEALTH CARE DISTRICT
p SCHOOL LOCAL
- SCHOOL STATE
SFWMD EVERGLADES CONST PROJECT
SO FLA WATER MANAGEMENT DIST.
SO FLA WATER MGM~.~~OKEE. ~- ry. ~„&~
:., .
EXEMPTIONS
SEE REVERSE SIDE FC
MORE INFORMATION
BLDG 1
LEGAL DESCRIPTION
VILLAS COND NO 32 PAR
ANNE M. GANNON, CONSTITU'iIONAL TAX COLLECTOR SERVING PALM BEACH COUNTY
PAY ONLINE: Go to our secure'website at
www.taxeolleetorpbe.com. The website has easy instructions to
follow and allows you to print your receipt.
17,
17,000
17,000
17,000
17,000
17,000
17,000
17,000
^'~~ l 611. 8Q ~" tsS.a~~1 00 ~ ~~
~~
7 090 4.7815
~.
%~
7,000 },'g 0.2110
_
1
7r1~001s , 3.4581
~E7Jaob<~ 0.5491
f7, o0 0.0590
17,000 0.7475
17,000 0.0345
17,000 1.1250
17,000 2.4980
17,000 5.6820
17,000 0.0624
17,000 0.1785
,~17 100 ;. ~0 18:54
~£
<.,~ ::.
TO'iAL AD VALOREM 332.90
~n~ ~ ~ ¢~ern~rvc RATE
SOLID WASTE AUTHORITY 561-697-2700 163 00
LAKE WORTH DRAINAGE~• IST IC NT 19-5
h ~ F~~ ~c a
_~~ .~..~
TOTAL NON-AD VALOREM
TOTAL AD VALOREM AND NON-AD VALOREM COMBINED
$517.88 $523.22 ~ $528.56 ~ $533.90
TAX AMOUNT
81.29
3.59
58.79
9.33
1.00
12.71
0.59
19.13
42.47
96.59
1.06
3.03
3.32
AMOUNT
163.00
38.00
201.00
533.90
HERE ••SEE REVERSE SIDE FOR INSTRUCTIONS AND INFORMATION^ DETACH HERE
WebBES7" Receipt
Page 1 of 1
U-HAUL EQUIPMENT CONTRACT r In-Town Return (IN)
ContracT No.: '.34955792 U-Haul Moving & Trailer Hitch 1800 Valley View Blvd (814)946-3682
Sunday 8/7/2011 12:11 PM Center of Altoona ALTODNA, PA. 16601
(611057)
Customer Name: Cust Ph -Email:
Robert Scott 814-643-1768
2208 ACORN CIRCLE
HUNTINGDON, PA 16652
Rental OatejTime: 81672011 4:29 PM
Return Oata/Time: 8/7/2011 12:11 PM
Chargeable Rental Periods: 2
Equipment MI Out I In Mf Ra[e MI Charge overa a Mlssin or Damage Charge: Rental Rate ental Cha a dual Cha
14' TRUCK 04694A 05020.0 0.99 X 326.0 322.74 afeMOVe $20.00 $0.00 $19.95 $39.90 $390.64
DC 60597
Plate: AA92640
fate: AZ ~„- i
FUEL TANK CAPACITY: 36 GALLONS Enviroementai Fee: $2.00
~~ SubTOtal: $392.64
!St/
IE ~ ii~4 ~a ~/P2 ~ 71{ T4 1= Motor VehlGla Tax: $$4.00
' ( ~ ~' (I ~' (I ~ ) I ~ ~ Rental Charges: $428.Oa
Previous Pald: $0.00
Card Type: Attount: Auth: Cradle Card Payment: $357.48
V XXXXXXXXXXX%X3772 03624C
Card Type: Account: Au[h:
Crodit Card Payment:
$70.56
V XXXXXXXXXXXXX3772 01627C
Net Paid Today: $428.04
• I confirm that tluring [he term oP my rental Mere was no[ an accltlent Involving the rented U-Haul equipment and no incidence where this equipment
struck or otherwise caused damage to any person or property either while on a public road or private property. There was no in)ury or damage
sustained by me or any other drivers or passengers of this equipment.
y,j ~ rick. acne
Customer Signature - (Robert Scott)
How are we doing? Please go to http:///www.uhaul.comtreview and let
us know if you received the level of quality and service you expect from
this U-Haul location.
https:/lwebbest.uhauldealer. com/ContractPrinting/receipt.aspx?source=printin~;_obj acts&sa... 8/7/2011
' ~:
COMMONWEALTH OF PENNSYLVANIA
INHERITAWCE TA% RETURN
RESIDENT DECEDENT
ESTATE OF JEFFREYS, JAMES J
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
FILE NUMBER
21 - 11 - 00740
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Verizon -phone bill owed by decedent - 44.27
2 West Asset Management -payment of Chase Bank USA, N.A. -Account Number: 636.27
54016830830308049-
3 C. Brian Peffer, D.P.M. -debt of decedent for medical care - 25.50
4 The Danbury Mint - 2011 Annual Sheltie Ornament -debt of decedent - 25.90
5 The Gaughen Management Group - Foxcroft Homeowners ssociation dues $'125.00 plus 150.00
$25.00 late fee -
6 C. Brian Peffer, D.P.M. -medical care of decedent ($13.05 and $25.50) - 38.55
7 IFAW - Ck. # 713 -Donation -check not cashed until after decedent's death - 25.00
8 Jennifer Scott, Granddaughter - Ck. # 712 -check for good grades -not casheed until after 200.00
decedent's death -
9 USOC - Ck. # 714 - 2 windbreakers purchased by decedent -check not cashed until after 40.00
decedent's death -
10 MDA - Ck. # 717 -Donation -check not cashed until after decedent's death - 25.00
TOTAL (Also enter on Line 10, Recapitulation) 1,210.49
REV-1513 EXt (11-0B) ~.
~ SCHEDULE J
COMMONWEALTH OE PENNSYLVANIA ~ BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF JEFFREYS, JAMES J
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT
RECEIVING PROPERTY Do Not list Trustee(s)
I. TAXABLE DISTRIBUTIONS[include outright spousal
dlstnbutlons, and transfers
under Sec. 9116 (a) (1.2)]
1 ANN J CORLE .Daughter
1105 ALLEGHENY STREET
HOLLIDAYSBURG,PA16648
FILE NUMBER
21 - 11 - 00740
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
it °
150% residue
2 CAROL R. SCOTT Daughter 150% residue
2208 ACORN CIRCLE
HUNTINGDON, PA. 16652
I
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate.
Ij. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
I
I
'B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET O.OQ
LAST WILL AND TESTAMENT
OF
JAMES J, JEFFREYE
I, James J. Jeffreys, presently residing in Camp Aill,
Cwnberland County, Pennsylvania, being of sound and disposing
mind and memory, do make, publish and declare this to be my Last
Will and Testament, hereby revoking all Wills and Codicils
previously made by me.
ITEM I: I direct that all inheritance and estate taxes
becoming due by reason of my death, whether such taxes may be
payable by my estate or by any recipient of any property, shall
be paid by my Executor out of the property passing under this
Will, which is not specifically devised or bequeathed, as an
expense and cost of administrationof my estate. My Executor
shall have no duty or obligation to obtain reimbursement for any
such tax paid by my Executor even though such tax was paid on
proceeds o£ insurance or other property not passing under this
Will. If the assets not specifically devised or bequeathed are.
not adequate for the payment of all such taxes, then the
recipients of the property specifically devised and bequeathed
shall each pay a pro rata portion of any such tax based upon the
valuation of the property received by each such recipientas
finally determined for Federal Estate Tax purposes, or if no such
determination is made, then for applicable State Inheritance Tax
purposes.
- fTEM II :. I hereby exercise all powers of appointment
which I may have at the time of my death in favor of my Executor,
PAGE 1 OF 5 PAGES
and all property subject to all such powers of appointment shall
be included in my estate.
ITEM III: I hereby give, devise and bequeath all of my
estate, whether real, personal or mixed, of whatsoever nature or
kind and -wherever located, unto my daughters, Ann J. Corle and
Carol R. Scott, per st irpes; provided that they survive me-by
thirty (30) days.
I'PEM IV: In the event that either Ann J. Corle or Carol
R. Scott predeceases me or does not survive me by thirty (30)
days, then the share of my estate which that deceased daughter
would. haves received hereunder I give, devise and bequeath unto
the survivor of the two.
ITEM V: In addition to such other powers as my
Executor may be granted by law, or under previous portions of
this Will, he shall have the following powers:
a) To retain investments I may have at my death so long ~'
as my Executor may deem it advisable to my estate or
trust to do so.
b) To vary investments, when deemed desirable by my
Executor, then to invest in such bonds, stocks,
notes, real estate mortgages, or other securities, or
in such other property, real or personal, as he shall
deem wise, without being restricted to so-called
" legal investments " .
cJ In order to effect a division of the principal of my
estate or of any trust or for any other purpose,
including any final distribution, my Executor is
authorized to make said divisions or distributions of
the personalty and realty partly or wholly in kind.
If such division or distribution is made in kind,
said assets are required to be divided or distributed
PAGE 2 OF 5 PAGES
at their respective values on the date or dates of
their division or distribution.
d) To sell either at public or private sale an3..4ppn
such terms and conditions as the Executor may deem
advantageous to the estate, or any trust, any or all
real or personal estate or interest therein owned by
the estate or trust severally or in conjunction with
other persons or acquired after my death by my
Executor, and to consummate said sale or sales by
sufficient deeds or other instruments to the
purchaser or purchasers, conveying a fee simple
title, free and clear of all trusts .and without
obligation or liability of the purchaser or
purchasers to see to the application of the purchase
money or to make inquiry into the validity o£ said
sale or sales; also, to make, execute, acknowledge
and deliver any and all deeds, assignments, options
or other writings which may be necessary or
desirable, in carrying out any of the powers
conferred upon my Executor in this paragraph or
elsewhere in my Will.
e) To mortgage real estate, and to make leases of real
estate.
f) To borrow money from any party, to pay indebtedness
of mine or of my estate or of a trust,
expenses of administration or inheritance, legacy,
estate and other taxes. ~
g) To pay all costs, taxes, expenses and charges in
connection with the administration of my estate or
trust. My Executor shall pay the expenses of my last
illness and all funeral expenses. -
PAGE 3 OF 5 PAGES
h) To vote any shares of stock which form a part of the
estate or of any trust, and to otherwise exercise all
the powers incident to the ownership of such stock.
i) In the discretion of my Executor, to unitewith other
owners of similar property in carrying out any plans
for the reorganization of any corporation or company ~~
whose securities form a part of the estate or of any
trust.
ITEM VI: Any person who shall have died at the same time
as Testator, or in a common disaster with him, or under such
circumstances that it is difficult or impossible to determine who
died first,or who shall have died less than thirty (30) days
after the death of Testator, shall be deemed to have predeceased
him.
ITEM VII: I hereby nominate, constitute and appoint my
daughter, Ann T. Coyle, to be the Executrix o£ this my Last Will
and Testament. My Execut;ix is specifically relieved from the
duty or obligation of the filing of any bond or bonds in this or
any other jurisdiction.
ITEM VIII: Where appropriate throughout this my Last
Will and 'Testament, all references herein to the singular or the
masculine shall include the plural or the feminine, respectively.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
to this my Last Will and Testament, consisting of this page and
thepreceding four (4) pages, this ~~~day of Ss/ivuw.u~W ,
1997. U
P/J ' ~ ~~
<~- ames S. ef~ eys I
PAGE 4 OF 5 PAGES
We, the undersigned, hereby certify that the foregoing;
Will was signed, sealed, published and declared by the above-
named Testator, as and for his Last Will and Testament, in the
presence of us, who, at his request and in his presence and in
the presence of each other, have hereunto set our hands and seals
the day and year above written, and we certify that at the time
of the execution thereof, the said Testator was of sound and
disposing mind and memory.
\!JV'^.yNA/ O! ~ w~ jsEAL)
~ ~(,Yl.! (SEAL)
Residing at ~Ay4~ ~;ri 2~Q,
~P! ~1 7 (([ GG~~ `R{~
Residing at ~T r\)Un1~l LJl~rco "~~`rt`"~
~~.r l~ s(c-; ~lH x'70 l 3
(SEAL) Residing
PA ~E 5 OF 5 PAGES
COMMONWEALTH OF PENNSYLVANIA
COUNTY Of" DAUPHIN
7:, James J. Jeffreys, the Testator 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 ihstrument as my Last Will; and that I signed it
willingl}~ and as my free and voluntary act for the purposes
therein eexpressed.
Sworn to or affirmed and acknowledged before me by James
Jeffreys, the Testator, this I~~-day of ~y7~S:e•.i 1997.
James J. Je s
~~estator
OF PENNSYLVANIA
\' \~A~ \ .'VW/Yl\a/\
Notary Public
My Commission Expires:
Notarial Seal
Mercle A. Chismar, Notary Public
Lower Paxton Twpp. Dauphin County
AFFIDAVIT M Commission Ez~frea Jen. 8, 2001
COUNTYOF' DAUPHIN )
~n~A~ c~~~ ~~ ,
We, ,
and - , 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 the Testator sign and execute the instrument as
his Last Will; that the Testator signed willingly and executed it
as his free and voluntary act for the purposes therein expressed;
that each subscribing witness, in the hearing and sight of the
Testator, signed the Will as a witness; and that, to the best of
our knowledge, the Testator was at that time 18 or more years of
age, of sound mind and under no constraint or undue influence.
Sworn ptgo /o1r affirmed a subscribed) to before me by
J~~IAwJ ~- .A~!(-Cc~l-v ~ay(i ~ ,~~tlii~~ and
witnesses, this ~~~ day of
S`~ , 1997.
Witness
~~, ~. ~~~
Witness
tness
(SEAL)
r~ro ~. Cri,~~,.,.o_
Notar~ Public
My Commission Expires:
Notarial Seel
Mercla A. Chlsmar, Notary Public
lower paxtan Tw ., Dauphin County
M mmisslon ~ res Jan. 8 2001