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HomeMy WebLinkAbout07-20-12 (2)150561143 -~ REV-1500 Ex(°'-'°' .: PA De artment of Revenue -~ OFFICIAL USE ONLY p pennsylvania County Code Year File Numbar Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 80X.280601 INHERITANCE TAX RETURN 21 12 0 0 7 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 168 14 3600 01 06 2012 05 21 1923 Decedent's Last Name Suffix Decedent's First Name MI GOOD MARY A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return ^ 4. Limited Estate ® g Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ 4a. Future Interest Compromise (date of death after 12-12-82) ^ ~ Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 3, Remainder Return (date of death prior to 12-13-82) ^ 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephgrt4 Number c~ HAMILTON C DAVIS 717 53213 ^' ~~ First line of address 20 EAST BURD STREET Second line of address SUITE 6 City or Post Office SHIPPENSBURG ~- ~.. rr ~? . C r'T"1 r ~ G _J ~.~? j{,S` USE 01~_Y REGISTER O "-` t -:-' `i ~% -te ~ ~,.', ' , O r. ,~ s '~ i r-. ~~'.. "LT ..i' ~ ~ ~ i.n ~. N ~ D~ W O _ ~ DATE FILED State ZIP Code PA 17257 Correspondent'se-mail address: hdaVlS@ZUllinger-DaVIS.COm 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. SIGNATURE OF PERSON RESPONSIBLE F; FILIN RETURN DATE (~t,{ry"~, ~ ~`,~-~~-~, WAYNE A. GOOD ~~t~ ~ Q. ~lL. ADDRESS ~ U U ~ 12724 STONEWALL ROAD, SHIPPENSBURG, PA 17257 v SIGNAT E OF PREPARER OT R THAN REPRESENTATIVE ATE ~1 C ~ ---~-- Hamilton C Davis 7 ~ b ADDR SS 20 East Burd Street, Shippensburg, PA 17257 Side 1 1505610143 1505610143 J i n~~ REV-1500 EX 150561243 DecedenrsName: GOOD, MARY A. 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. Decedent's Social Security Number 168 14 3600 47,689.45 5,400.75 53,090.20 3,058.25 4,163.11 7,221.36 45,868.84 45,868.84 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 at lineal rate X .045 4 5, 8 6 8. 8 4 16. 17. Amount of Line 14 taxable at sibling rate X ,12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ................................................................................................................... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1525610243 2,064.10 2,064.10 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 12 - 0073 DE ED N NAME GOOD, MARY A. STREET ADDRESS 210 BIG SPRING ROAD CITY NEWVILLE STATE PA ZIP 17241 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2,064.1 0 2. Credits/Payments A. Prior Payments 1 ,700.00 B. Discount 89.47 Total Credits (A + B) (2) 1,789.47 3. Interest (3) 0.00 4. 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. (5) 2 7 4.6 3 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................... ^ 0 c. retain a reversionary interest; or .................................................................................................................. ^ 0 d. receive the promise for life of either payments, benefits or care? .............................................................. ~ 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................................... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... ^x ^ 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 tax, and the statutory requirements for disclosure of assets and filing a tax re urn 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)]. • 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)1. 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. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF GOOD, MARY A. 21 - 12 - 0073 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 M&T BANK CHECKING ACCOUNT NO. 97260169 (SEE ATTACHED VALUATION) 45,621.27 2 NEWVILLE FIRST CHURCH OF GOD DONATION 191.39 3 MILLENIUM PHARMACY REFUND 315.00 4 CHAMBERSBURG HOSPITAL REFUND 100.00 5 PRESBETERIAN HOME REFUND 348.79 6 2011 IRS REFUND FOR PERSONAL INCOME TAX RETURN 1,113.00 ~ TOTAL (Also enter on Line 5, Recapitulation) ~ 47,689.45 COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF GOOD, MARY A. FILE NUMBER 21 - 12 - 0073 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM ( NUMBER DESCRIPTION OF PROPERTY j DATE OF DEATH I Include the name of the transferee, their relationship to decedent I VALUE OF ASSET I ~ OF EXCLUSION DECD'S (IF APPLICABLE) TAXABLE VALUE I ~ and the date of transfer. Attach a copy of the deed for real estate. ~ INTEREST ~ ~ -- 1 ORRSTOWN BANK -IRA PREMIUM STATEMENT I~ ss2.2~ 692.27 SAVINGS ACCOUNT NO. 96563 (SEE ATTACHED VALUATION) I ~ i I 2 I ERIE FAMILY LIFE INSURANCE -DEFERRED a,~os.aa ! I i 4,708.48 ANNUITY -ACCOUNT NO. EE557309 -PAYABLE j ~ I I I TO ESTATE AS NAMED BENEFICIARY I i I I I I I I II I I I ~ I i j I I ;I i ! I ~, I I I I ~ I I ~I, i I ~~ ~ I ICI i I~ '~ ! I ~~, ~ I i j ~ I i I I I TOTAL (Also enter on line 7, Recapitulation) 5,400.75 °` SCHEDULE H FUNERAL DCPENSES & COMMONWEALTH OF PENNSYLVANIA 1~+ o/~ /~^~+~+ INHERITANCE TAX RETURN ADMINISTRATIVE ~VJ 1 J RESIDENT DECEDENT ESTATE OF GOOD. MARY A. FILE NUMBER 21 - 12 - 0073 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER FUNERAL EXPENSES: ! A. 1 PRE-PAID B. ;ADMINISTRATIVE COSTS: ~. ~ Personal Representative's Commissions j Name of Personal Representative(s) ! i Street Address i City State Zip Year(s) Commission paid ~'~ 2. Attorney's Fees HAMILTON C. DAVIS, ESQUIRE 2,700.00 ! i 3. ! Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant j i Street Address ~ City State Zip I Relationship of Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 178.50 5. I Accountant's Fees 6. Tax Return Preparer's Fees 7, Other Administrative Costs ' I 1 LEGAL ADVERTISING -THE NEWS CHRONICLE i 104.75 TOTAL (Also enter on line 9, Recapitulation) 3,058.25 r COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF GOOD, MARY A. Schedule H Funeral E~gx~r~ses & Administrative Costs continued 2 LEGAL ADVERTISING -CUMBERLAND COUNTY LEGAL JOURNAL FILE NUMBER 21 - 12 - 0073 Page 2 of Schedule H 75.00 SCHEDULEI ~~ DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS INHERITANCE TAX RETURN ~ RESIDENT DECEDENT - - __ FILE NUMBER ESTATE OF GOOD, MARY A. 21 - 12 - 0073 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 MILLENIUM PHARMACY 1,545.82 2 GREEN RIDGE VILLAGE 2,349.19 3 ~ ACME STORAGE ~ 128.10 4 ~ DR. DARRYL GUISTWITE ~ 140.00 TOTAL (Also enter on Line 10, Recapitulation) ~ 4,163.11 REV•1513 EX+111-081 ' SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES I NHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER GOOD, MARY A. 21 - 12 - 0073 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 WAYNE A. GOOD 'Son 1/4 OF RESIDUE 11,462.2' 12724 STONEWALL ROAD SHIPPENSBURG, PA 17257 2 PATRICIA A. HOCKENSMITH 'Daughter 1/4 OF RESIDUE 11,462.2' 1601 WALNUT BOTTOM ROAD NEWVILLE, PA 17241 3 JAMES W. GOOD ~ Son 1/4 OF RESIDUE 11,462.2' 1308 BALTIMORE STREET PLEASAN HILL, MO 64080 Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 REV•1513 EX+ (9-00) ' SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER GOOD, MARY A. 21 - 12 - 0073 i RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 4 GARY L. GOOD 'Son 1/4 OF RESIDUE 11,462.2 28832 VIA LEONA i SAN JUAN CAPISTRANO, CA 92675 ~ I I i i '~ i i i i i i I i, i i I i i i i i i I Page 2 of Schedule J Q M8T Bank 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 July 5, 2012 Law Offices of Zullinger-Davis Hamilton C. Davis, Esq. P.O. Box 40 Shippensburg, PA 17257 Re: Estate of Mary A. Good Social Security: 183-18-6893 Date of Death: January 6, 2012 Dear Sir or Madam: Per your inquiry on June 27, 2012, pease be advised that at the time of death, the above-named decedent had on deposit with this bank the following: l . Type of Account Account Number Ownership (Nantes ofl Opening Date Balance on Date of Death Accrued Interest Tonal Checking Account 97260169 Wayne A. Good(POA) Mary A. Good Ralph E. Good 01!28/1980 $45, 621.27 $ .27 $45, 621.54 For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the King Street at 717-532-4132. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement. Sincerely, Valarie Mercer Adjustment Services lJtiKa 1 V VV 1V BANK A Traditio~i of Excelle~zce June 28, 2012 Law Offices of Zullinger-Davis Hamilton C. Davis, Esquire 20 East Burd Street PO Box 40 Shippensburg, PA 17257 Fax: 530-5222 Re; Estate of Mary A. Good Social Security Number 168-14-3600 Date of Death 1/6/2012 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE FOLLOWING ACCOUNT WITH ORRSTOWN BANK: IRA ACCOUNT Account No.- Accowit Type- Date Opened- Joint Account (name/date)- Balance- Accrued Interest- 96563 IRA Premium Statement Savings 12/31/1993 No $692.27 $0.05 Best Regards; LUY~~~ fQ ~,~U(.e.l J 1 R. Worthington Deposit Processing Clerk 2695 Philadelphia Avenue Chambersburg, PA 17201 1.888.ORRSTOWN @J!!4lgPY~tra~ d"9'~~S&~f1~S"d.C63 0~'2 Erie Family Life ~~ Insurances STATEMENT OF POLICY VALUES STATEMENT PERIOD of JANUARY 01, 2012 -MARCH 31, 2012 CONTRACT INFORMATION OWNER: MARY A GOOD ANNUITANT: MARY A GOOD POLICY NUMBER AY006103 PRODUCT NAME SINGLE PREM DEFERRED ANNUITY TAX QUALIFICATION NON-QUALIFIED ANNUITY DATE OF ISSUE FEBRUARY 05, 2008 THANK YOU FOR CHOOSING ERIE FAMILY LIFE AS A PARTNER IN BUILDING YOUR SECURE FINANCIAL FUTURE. IF YOU HAVE ANY ADDITIONAL INSURANCE NEEDS, PLEASE CONTACT YOUR AGENT OR OUR OFFICE AT THE NUMBER LISTED AT THE BOTTOM OF THE PAGE. CONTRACT ACTIVITY ACCUMULATION VALUE AS OF DECEMBER 31, 2011 $4,682.50 SURRENDER VALUE AS OF DECEMBER 31, 2011 $0.00 PREMIUM RECEIVED DURING CURRENT PERIOD $0.00 ROLLOVER/TRANSFER/1035/RECHAR/CONVERSION $0.00 INTEREST CREDITED FOR CURRENT PERIOD $25.98 ROSS DISBURSEMENTS (INCLUDING SURRENDER CHARGES, FEES AND WITHHOLDING) $4,708.48 4000MULATION VALUE AS OF MARCH 31, 2012 $0.00 SURRENDER VALUE AS OF MARCH 31, 2012 $0.00 Agent name: MICHAEL A. STARR INS., INC. 1110 KENNEBEC DRIVE CHAMBERSBURG, PA 17201-2809 (717) 263-1752 lF WE CAN BE OF ANY ASSISTANCE, PLEASE CALL YOUR AGENT OR CALL US AT 1-800-458-0811 OPTION 3. MemUer Erie Insurance Group • Service Center ~ P.O. Box 83026, Lincoln, NE 68501 • Toll free 1-800-458-0811 • tax 866.567.1219 • www.erieinsurance.com LAST WILL AND TESTAMENT OF MARY A. GOOD I, MARY A. GOOD, of the Borough of Shippensburg, Cumberland County, Pennsylvania,. being of sound and disposing mind, memory and understanding do hereby make, publish and declare this as and for my Last Wi 11 and Testament, hereby revoking al 1 other Wi 11 s and Codicils thereto, heretofore, made by me. FIRST I direct the payment of my debts and the expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. In the event I am not the owner of a cemetery lot at the time of my death, I direct my Executor to J purchase such lot with a contract for perpetual care and to improve the lot and have erected thereon a suitable monument and ' marker, using therefor funds from my estate in such amount a.s she in her sole discretion shall deem advisable. ~`-_' J SECOND I glue, devise and bequeath all my property, wlietli''cr re~.l yr ~~ personal, tangible or intangible, together with all insurance t\C \ policies thereon, unto my husband, RALPH E. GOOD, provided he shall survive me by thirty (30) days. In the event my husband fails to survive me by thirty (30) days, I then give, devise and bequeath all my estate whether real or personal property, tangible or intangible, together with all insurance policies thereon unto my children, provided they shall survive me by unto my children, provided they shall survive me by thirty (30) days, in as nearly equal shares as possible. In the event any of my children fail to survive me by thirty (30) days, I give, devise and bequeath my deceased child's share unto said deceased child's spouse and children, in as nearly equal shares as possible. THIRD I give, devise and bequeath all the rest, residue and remainder of my estate unto my husband, RALPH E. GOOD, provided he shal 1 survive me by thirty ( 3 0 ) days. In th.e event my husband fails to survive me by thirty (30) days, I then give, devise and bequeath all the rest residue and remainder of my estate, in as nearly equal shares as possible, unto such of my children as shall survive me by thirty (30) days, provided that the share my oldest child, Gary Good, shall receive, shall be reduced by the sum of Thirteen Thousand Dollars ($13,000.00) to reflect sums 1 paid by me for his college education. In the event any of my children fail to survive me by thirty (30) days, I give, devise and bequeath my deceased child's share unto said deceased. child's .~ spouse and children, in as nearly equal shares as possible. ~ FOURTH I give, devise and bequeath any minor child's share to be invested in an interest bearing account at Dauphixi Deposit Bank & Trust Company, Shippensburg Office, until such child is eighteen (18) years old. FIFTH I hereby direct that all inheritance, estate or transfer taxes imposed upon my estate, whether passing under this my Last Will and Testament or otherwise,, be paid out of my estate. 2 SIXTH Any and all sum or sums, whether in cash or in kind and whether for principal or income, payable to the beneficiaries, or any of them, shall be made upon the sole receipt of the respective individual to whom the payment is made and free from anticipation, alienation, assignment, attachment or pledge and free from control by the creditors of such. beneficiary. All shares of principal and income herein given shall be free from anticipation, assignment, pledge or obligation of any beneficiary and shall not be subject to any execution or attachment. SEVENTH I nominate, constitute and appoint my husband, RALPH E. GOOD, Executor of this my Last Will and. Testament. In the event of the death, resignation, renunciation or inability to act for ~~-~~ reason whatsoever of my said husband, I nominate, constitute and appoint WAYNE A. GOOD and/or PATRICIA A. HOCKENSbSITH Co- Executors of this my Last Will and Testament. My executors may be compensated for their services up to three (3) percent, in total of my estate, to be divided equally between them. I hereby relieve my Executor from the necessity of posting security in connection with his duties as such in any jurisdiction in which he may be called upon to act, insofar as I am able by law to do so. 3 IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, consisting of three (3) typewritten pages, the first two ( 2 ) of which bear my signature in the margin for the purpose of identification this ~_ day of 19 8 (, . ~- Ma y A. od Testatri SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testatrix, MARY A. GOOD, as and for her Last Will and Testament, in the presence of us who at her request and in her sight and presence and in the sight and presence of each other have hereunto subscribed our names as witnesses: .~~~~.~ ~~~_ R~~~ COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF FRANKLIN I, MARY A. GOOD, the Testatrix whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed.. Mary A. G d Testatrix `~ Sworn or affirmed to and acknowledged before me by Mary A. Good, Testatrix, the ~_ day of 198. Notary Public ~~I~R1~;~.~c'~i!r~~G~`~'s~l~., ~'~:s"c'f;f.~E' G~PlFdly,, COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF FRANKLIN We , t a r~s ~ ~ /~ t~~°-rs and f~a ~~'s ,~>`i~..~r~ witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw MARY A. GOOD, Testatrix, execute the instrument as her Last Will and Test ament, th.a.t she signed it willingly and that she executed as her free act and. voluntary act for the purposes therein expressed; that each of us in the G hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen or more years of age and under no constraint or undue influence. v ~ ~- a,~ Sworn to and subscribed before me by -- e~r~~~~" /~ ~~JA e~ and f~r,s ~f~,~~G witnesses, this ~,~~( day of ~~~~~,~~;.-,~ , U 198 ~ . Notary ~~lal c My Ct~xnmission Expires: ~~ ~~~~~€~€s~E~r;~ `1 ~~E~~~ A ~~~. ~, ~~a~ rr,R~~:~b~r, ~~r~~zSyVbars€a !;~s~ociat'sosa of "votaries 6 ~