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BLACK, STRANICK & CELLA, P.C.
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BY: DAVID R. BLACK, ESQUIRE ~~ c Uzi
ATTORNEY LD. N0.24405 ~ ~
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327 WEST FRONT STREET ~-- _
P.O. BOX 168 c: r~. c
MEDIA, PA 19063-0168
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(610) 566-8500 Attorne~f
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
REGISTER OF WILLS
IN RE: ESTATE OF ELIZABETH ANN VICE, DECEASED
Will No. 21-12-0025
Supplemental Disclaimer and Renunciation
I.
Pursuant to PA Statutes, Title 20, Chapter 62, the undersigned, John H. Vice, in his
capacity as beneficiary/legatee, chooses to exercise his right to disclaim an interest in certain
property described in the following paragraphs.
II.
I, John H. Vice, have an interest in the above-captioned Estate of Elizabeth Ann Vice
(decedent), who died on December 23, 2011 ("The Estate"). The Last Will and Testament of
Elizabeth Ann Vice was probated with the Register of Wills on January 9, 2012.
III.
Pursuant to the provisions of Item III of decedent's Last Will and Testament dated March
21, 2011, (the "Will'), I am named as the primary beneficiary of The Estate.
IV.
I, John H. Vice, hereby exercise the rights granted to me in Chapter 62 of the Probate
Estates & Fiduciaries Code, Pa. C.S.A. Secs. 6201-6207 and the Internal Revenue Code of 1986,
and I hereby renounce and disclaim all my right, title and interest as a person interested in the
Estate of Elizabeth Ann Vice, whether by will or operation of the laws of intestacy of the
Commonwealth of Pennsylvania, in and to the following property (contained in the Charles
Schwab account ending in #1295 belonging to the decedent) as listed below:
Halliburton Co. -stock
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V.
I hereby release, remise and discharge the Executors and their successors of the Estate of
Elizabeth Ann Vice of and from any and all liability and responsibility to me with respect to their
obligations and duties with respect to the above-referenced property, including the right to
demand an account of said estate and to have some or all of the property listed above distributed
to, and further direct said Executors and their successors to distribute the same to the Disclaimer
Trust set forth in the Last Will and Testament of Elizabeth Ann Vice.
VI.
The above-listed properly identified in paragraph IV of this Disclaimer devolves to the
Disclaimer Trust pursuant to Article IV of the Last Will and Testament of the decedent.
VII.
It is not my intention to disclaim any rights, title or interest I have or may have to any
other items contained in the Charles Schwab account ending in #1295 (except items which have
been identified in other Disclaimers previously filed by me) nor is it my intention to disclaim any
rights, title or interest I have or may have in any property owned by me as tenants by the
entireties or jointly with Elizabeth A. Vice.
VIII.
This Renunciation and Disclaimer shall for all purposes be deemed to relate back to the
date of decedent's death and is an irrevocable refusal to accept the above-listed property effected
hereby and is deemed to be delivered to the Executor of the Estate of Elizabeth Ann Vice to be
placed in the Irrevocable Disclaimer Trust under the Will of Elizabeth Ann Vice, John H. Vice,
Trustee.
Dated this / ~ ~i day of ~~ {~o ,~ z r 2._
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gnature
Printed Name
Commonwealth of Pennsylvania
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County of ~'~Cu~-v\,4~ ~ ~anc~ :
On this, the __~~~day of ~(~ ~ ~ , 2012, before me a notary public, the
undersigned officer, personally appeared John H. Vice, known to me (or satisfactorily proven) to
be the person whose name is subscribed to the within instrument, and acknowledged that he
executed the same for the purposes therein contained.
In witness hereof, I hereu o set my hand and official seal.
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~ Z COMMONWEALTH OF PENNSYLVANIA
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Nota ub is ua-a~ ;yea, Notary Pubilc
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My Common Explros Ap1118 2016
MEMBER, pENNSYtYAA11A ASSOCIAflOM bF NOTARIES
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