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HomeMy WebLinkAbout07-20-12 (2)J 1505610140 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box zsosol INHERITANCE TAX RETURN Harrisbur PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 5 4 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 2 0 1 1 8 2 8 8 8 0 4 2 8 2 0 1 2 1 0 0 4 1 9 2 7 Decedent's Last Name Suffix Decedent's First Name MI C L I N E L L O Y D M (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 0 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of prior to 12-13-82) ~ 5. Federal Estate Tax Return Required OX 6. Decedent Died Testate (Attach Copy of Will) ~ death after 12-12-82) 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received ~ (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name : Daytime Telephone Number J O H N B F O W L E R I I I ,~ 7 1 7 2 ~d 3 ~4 1~ ~; First line of address M A R T S O N L A W Second line of address 1 0 E H I G H S T City or Post Office C A R L I S L E O F F I C E S State ZIP Code P A 1 7 0 1 3 Correspondent's a-mail address: J F O W L E R a M A R T S O N L A W• C O M ~~ fTl ~~ REGISTER d,'S USE • l :~ ;; -Z-j :J -`fir 7 ~._, _ C ... ~__ ~ •. . =t; ~ ~~ Gry DATE FILED 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, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNf~,7{j~E OF PERSON ~ESP(aJV,gIBL~E FOR FILING RETURN ~y DATE S/~Y'W..~_~J(..,1. C,{~ %1M1~_iILV_U, ( zL! ~z ADDRESS 304 N• MIDDLETON ROAD CARLISE PA 17013 SIG A UR F PREP E O ER N REPRGCFtirATIVE D TE D ss ~ ~ ~ ~ ~7 Zv Zvi Z E HIGH STREET 1505610140 CARLISLE PLEASE USE ORIGINAL FORM ONLY Side 1 PA 1701 1505610140 J (~, `b Continuation of REV-1500 Inheritance Tax Return Resident Decedent LLOYD M. CLINE Decedent's Name 21 12 0541 Page 1 File Number Correspondents Name Daytime Telephone Number First line of address Second line of address City or Post Office State ZIP Code 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, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. cinr.i r'PAior ~+~ ~ ~~~~+ ~ GJr MY JIDLC f VR rILIIV IJ KCI UKN DATE _ .o n ADDRESS ~ 516 MOUNTAIN ROAD BOILING SPRINGS PA 17007 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: L L O Y D M• CLINE 2 0 1 1 8 2 8 8 8 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 7 6 4 5 0, 0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. 1 2 4 8 9 3, 1 8 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. , 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous N~Probate Property (Schedule G) Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 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 CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.0 _ 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 4 2 0 7 6 9 0 5 1s. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 D 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. TAX DUE ......................................................19 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1 1 0 4 9 5. 8 7 6 4 5 2 0. 3 7 7 0 9 0 3, 9 4 4 4 7 2 6 3, 3 6 2 6 1 7 8. 0 0 3 1 6. 3 1 2 6 4 9 4. 3 1 4 2 0 7 6 9. 0 5 0. 0 0 4 2 0 7 6 9. 0 5 0. 0 0 1 8 9 3 4. 6 1 0. 0 0 0. 0 0 1 8 9 3 4. 6 1 0 1505610240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 12 os41 DECEDENT'S NAME LLOYD M. CLINE STREET ADDRESS 422 WALNUT BOTTOM ROAD CITY STATE CARLISLE Zlp PA 17013 Tax Payments and Credits: ~ • Tax Due (Page 2, Line 19) (1) 2. Credits/Payments 18 934.61 A. Prior Payments B. Discount 946.73 Total Credits (A + B) (2) 3. Interest 946 73 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0 00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 17 987.88 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRI ATE 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; .............................. . Q ^ c. retain a reversionary interest; or ................................... . ........................................................... . ^ a d. receive the promise for life of either payments, benefits or care? ................. ..................................... . ^ a 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receivin ade uate consideration 9 4 ..................................................................................... . ^ 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ........ . ^ X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ................................................................................................. . © ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent (72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)J. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)J. 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. REV-1502 EX+ (01-10) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT wixi~vr: FILE NUMBER: LLOYD M. CLINE 21 12 0541 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER DESCRIPTION OF DEATH Undivided 1/2 interest in real estate located at 165 Garland Dr., Carlisle, Cumberland Co., PA, 76,450.00 known as Tax Parcel No. 04-23-0600-034 and being described in Deed dated 3/24/95 & being recorded in Cumberland Co., Deed Bk. 119, Page 1200 & being conveyed to Lloyd M. Cline & Frances G. Cline, Trustees of the Lloyd M. Cline Trust dated 2/21/95. Value is assessed value. See attached deed and Assessment. TOTAL (Also enter on Line 1 Recapitulation) I $ 76 450 00 If more space is needed, use additional sheets of paper of the same size. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT tJlAlt Uh FILE NUMBER LLOYD M. CLINE 21 12 0541 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. 8569 shares ACNB Corporation @ $14.575/share See attached TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 124,893.18 18 REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MSC, INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER LLOYD M. CLINE 21 12 0541 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 1. Orrstown Bank, checking account No. 106000104 OF DEATH See attached (Less $1,000.00 security deposit held in account and refunded to tenant of Sch. A. 6,824.91 Item 1 property, after date of death.) 2• Wells Fargo, savings Account No. 12000294101510 See attached 1,938.10 3 • US Treasury, 2011 1040 refund 549.00 4. Blue Cross, refund of premium 269.79 5. (Members 1st CD 0000378683 I See attached 100,909.07 6. I Members 1st, savings 0000378683 I See attached 5.00 TOTAL (Also enter on line 5 Recapitulation) I $ 110 495 87 (If more space is needed, msert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: LLOYD M. CLINE 21 12 0541 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Wanda E. Gehr B. C 304 North Middlesex Road Carlisle, PA 17013 Daughter JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PRO ITEM NUMBER FOR JOINT TENANT MADE JOINT PERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S IN TEREST 1. 2. A. A 3/2010 3/2010 Members lst CD 0000247232-41 See attached Members 1st savings 0000247232-41 123,543.69 5,497.03 50. 50. 61,771.85 2,748.52 TOTAL (Also enter on Line 6, Recapitulation) I $ 64 520 37 If more space is needed, use addiLonal sheets of paper of the same size. REV-1510 EX+ (OS-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER LLOYD M. CLINE 21 12 0541 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY NUMBER ~NCLTHE DATE OF TRAM FER.~SACH A CDPYIOF THE DEED F)OR REAL ESTATE. ND 1. Wells Fargo IRA 3054-7766; Beneficiaries: Wanda E. Gehr, daughter, 50%; Debra M. Lebo, daughter, 50% ($1,404.94 -cash; $263.78 accrued interest; 68,000 shares GE CAP FINL INC CUSIP 3610XVL8 - $69,23 DATE OF DEATH % OF DECD'S EXCLUSION VALUE OF ASSET INTEREST (IF APPLICABLE) 70,903.94 100.00 TOTAL (Also enter on Line 7 Recapitulation) ~ $ If more space is needed, use add)t)onal sheets of paper of the same size. TAXABLE VALUE 70,903.94 70,903.94 REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER LLOYD M. CLINE 21 12 0541 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: 1. Ewing Brothers Funeral Home, Carlisle, PA 2. Rustic Tavern, funeral luncheon 3. Ministerial honorarium 4. Cumberland Valley Memorial Gardens, gravemarker B. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 7,251.00 375.00 125.00 1,826.00 2, Attorney Fees: Manson Law Offices (Estimated) 16,072.00 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) Claimant Street Address City State Zlp Relationship of Claimant to Decedent 4• Probate Fees: Cumberland County Register of Wills 100.50 5 Accountant Fees: 6. Tax Return PreparerFees: 7. Filing fee, Inheritance Tax return 15.00 8. Additional Probate fee 350.00 9. Cumberland County Recorder of Deeds, recording fee 63.50 TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. AMOUNT 26,178.00 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE( DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ~~ i rai ~ yr FILE NUMBER LLOYD M. CLINE 21 12 0541 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VAOF DEADHTE 1. Orrstown Bank checking 106000104, outstanding check on date of death 208.69 2. IPPL, account payable I 94.93 3. (Millennium Pharmacy, account payable I 12.69 TOTAL (Also enter on Line 10, Recapitulation) I $ 316 31 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: LLOYD M. CLINE 21 12 0541 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. Wanda E. Gehr Lineal 242,644.71 304 North Middlesex Road Sch F, lines 1&2 Carlisle, PA 17013 1/2 estate residue 2. Debra M. Lebo Lineal 178,124.34 516 Mountain Road 1/2 estate residue Boiling Springs, PA 17007 ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV 1500 COVER SHEET AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO 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. I $ 0 00 If more space Is needed, use addltlonal sheets of paper of the same size. REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: 18.934 61 Discount: 946.73 Interest Table Year Days Delinquent this time period Balance Due this year Interest this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throw h 1991 1992 1993 throw h 1994 1995 throw h 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty LAST WILL AND TESTAMENT OF LLOYD M. CLINE I, Lloyd M. Cline, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and revoke all Wills and Codicils previously made by me. ITEM I: I direct that all my legally enforceable debts and funeral expenses, including 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 the administration of my estate. ITEM II: I bequeath any automobiles or motor vehicles I may own at my death, my personal effects, such household goods if any as may be my individual property and not the property of my wife or owned jointly by me with her, and other tangible personal property of like nature (not including cash or securities), together with any existing insurance thereon, to my wife, Frances G. Cline, providing she survives me by thirty (30) days. Should my said wife predecease me or die on or before the thirtieth day following my death, I bequeath such tangible personal property and insurance thereon to such of my daughters, Wanda E. Blair and Debra M. Lebo, as are living on the thirty- first day after my death, to be divided between them in as nearly equal shares as practical and as they shall mutually agree. I direct that any of the foregoing articles about which there is no agreement shall be sold at public or private sale by my personal representative(s), and I further direct that the net proceeds thereof shall be administered and distributed as a part of the residue of my estate. ITEM III: I devise and bequeath the residue of my estate of every nature and wherever situate to the Trustees of that certain r s Trust known as the "Lloyd M. Cline Trust" and created by me on the 21st day of February, 1995, to have and to hold, IN TRUST, for the uses and purposes and subject to the terms and provisions thereof, including any alterations or amendments thereto, or any other trust which may hereafter be substituted therefor. ITEM IV: All Federal, State and other death taxes payable because of my death with respect to the property forming my gross °State for taX ''~L1rnoSeS ~ of or n ~Y,.,,~o r r ~ ~h_.,h.._ r.assing r this Mill or otherwise, including any interest or penalty imposed in connection with such taxes, but not including any assets taxable in my estate for Federal Estate tax purposes under Sections 2044 and 2056(b)(7) of the Internal Revenue Code, shall be considered a part of the expense of the administration of my estate and shall be paid out of the principal of my residuary estate without apportionment or right of reimbursement; provided that any or all bequests, claims, taxes and expenses in connection with the settlement of my estate may be paid from the assets of that certain Trust created by me and referred to in Item III hereof as provided therein; and provided further, that any taxes and increased administration expenses in my estate on any portion of the marital deduction trust of that certain Trust known as the "Frances G. Cline Trust" and created by my said wife on the 21st day of February, 1995, shall be paid from the assets of that Trust as provided therein. ITEM V: In addition to those powers given them by law, all fiduciaries acting under this Will, whether or not named herein, shall have all of the powers more fully set forth under Article VIII of that certain Trust created by me and referred to in Item III hereof, which said powers are incorporated herein by reference thereto, applicable to all property, including property held for minors, whether principal or income, exercisable without court approval and effective until actual distribution of all property. I further authorize my personal representative(s) to disclaim any interest in property, in whole or in part, passing ~A~ Y~,. ~De~ to or for me under any will, trust, or otherwise, including but not limited to such property under that certain Trust created by my said wife and referred to in Item IV hereof. ITEM VI: I declare that Article IV of that certain Trust created by me and referred to in Item III hereof is intended to qualify "Trust A" created thereunder for the qualified terminable interest property provision set forth in Section 2056(b)(7) of the Internal Revenue Code, and my personal representative(s) are hereby directed to make the election to qualify if such qualification will reduce the Federal Estate tax in my estate. ITEM VII: I appoint my said wife and daughters, or the survivor(s), Executrices of this my last Will. ITEM VIII: I direct that all fiduciaries acting under this Will, whether or not named herein, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal, this ,,~~-~'~ day of February, 1995. [SEAL] The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the Testator, was on the date thereof, signed, published and declared by Lloyd M. Cline, the Testator therein named, as and for his last Will, in the presence of us, who, at his request, in his presence and in the presence of each other, have subscribed our names as witnesses hereto. COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND We, Lloyd M. Cline, John B. Fowler, III, and Mary M. Price, the Testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his last Will and that he has signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~Y1, Testator ~-v~ Witness ~' ~ %~ ~7 ~~1 ~ Witness Subscribed, sworn to and acknowledged before me by Lloyd M. Cline, the Testator, and subscribed and sworn to before me by John B. Fowler, III, and Mary M. Price, the witnesses, this ~/t'" day of February, 1995. .,,,~T~~~A~ ~~~~ Notary - blic ~~y"!I~ ~. COYLY, 10TF;RY r~iSeLiC ~;h ci~ir, .c• ,rT) _r? 1r. 1908 ~