HomeMy WebLinkAbout10-10-12 (2)I 1505610140
REV-1500 EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 0 0 8 8
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 4 7 2 0 2 9 2 0 0 1, 1 7 2 0 1 2 0 9 1 3 1, 9 2 2
Decedent's Last Name Suffix Decedent's First Name MI
B L A K E E R N E S T H
(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
Q 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - TH15 SECTION MUST 13E COMPLETED. ALL GURRESPUNDENGt AND GUNFIUtN l IAL I A1C INFUHMA 1 IUN Jt1UULU tat Ullitl: I tU I U:
Name Daytime Telephone Number
S E T H T M O S E B E Y 7 1 7 ~ 4 3 ~°-~3 4 1 ~~
First line of address
M A R T S O N L A W O F F I C E S
Second line of address
1 0 E H I G H S T R E E T
City or Post Office State
C A R L I S L E P A
.-- r . _ ,
._. -
REGIST ILLS US ~. NLY ~y`-' ;_=
~,~ _
~ C,_~ _~ ,~ ._ .
t. .
f4:
ZIP Code DATE FILED
1 7 0 1, 3
Correspondent's a-mail address: SMOSEBEY(a~MARTSONLAW.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 PERSON^^RES~/p%~(~,~~NS BL OR FILING RETURN ,/ y~~DATE
ADDRESS v ~ Y) ~J
522 WESTOVER ROAD Vim' COLUMBIA SC 2921,0
SIGNA RE OF PRF.iPARER THER T AN REPRESENTATIVE DATE
v, ~v - -~r
ADDR SS
1,0 E HIGH STREET CARLISLE PA 1,7013
PLEASE USE ORIGINAL FORM ONLY
Side 1
_~
1,5056101,40 15D56101,40
J
1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: E R N E S T H• BLAKE 2 4 7 2 0 2 9 2 0
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1 • 0 . 0 0
2 2 2 0 2 6. 1 4
2. ......................................
Stocks and Bonds (Schedule B) .
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. •
4. Mortgages and Notes Receivable (Schedule D) .......................... 4. •
6 3 2 1 3 . 3 0
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 5 0 0 • 0 0
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
arate Billing Requested
^ Se
h
l
G
S
d
7 6 4 4 0 7. 1 7
.......
p
u
e
)
(
c
e .
8.
( 9 ) ...........................
Total Gross Assets total Lines 1 throu h 7 g, 1 5 0 1 4 6. 6 1
9.
..................
Funeral Expenses and Administrative Costs (Schedule H) 9. 2 3 0 9 2 . 9 9
10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I
9 9 ( ) ....
......... 10. 1 2 6 6 . 2 7
11. Total Deductions (total Lines 9 and 10) ...................... ......... 11. 2 4 3 5 9 . 2 6
12. Net Value of Estate (Line 8 minus Line 11) ................... ......... 12• 1 2 5 7 8 7 . 3 5
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. 1 2 5 7 8 7 . 3 5
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
0
0 0
15
D.
0
0
(a)(1.2) x.o .
16. Amount of Line 14 taxable
1 2 5 7 8 7
3 5
16
5
6
6
0.
4
3
.
at lineal rate X .045 .
17. Amount of Line 14 taxable
0
0 0
17
0.
0
0
at sibling rate X .12 .
18. Amount of Line 14 taxable
0
0 0
1 g
0.
0
0
at collateral rate X .15 .
19. TAX DUE ............................................. ......... 19. 5 6 6 0. 4 3
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1,50561,0240 J
REV-1500 EX Page 3
I~pr_PCilpnt'S Cemnlete Address:
File Number
21 12 00088
DECEDENT'S NAME
ERNEST H. BLAKE
STREET ADDRESS
314 MANCHESTER ROAD
CITY
CAMP HILL STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 8,000.00
B. Discount
(1) 5,660.43
Total Credits (A + B) (2) 8,000.00
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval 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.
(3)
(4) 2,339.57
(5)
0.00
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 : ...................................................................... ^
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? ....................................................... ^ ^X
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 "intrust 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? .................................................................................................. 0 ^
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 i~
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)]. 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)].
• 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)]. 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
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ERNEST H. BLAKE 21 12 00088
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 OF DEATH
DESCRIPTION
1. Real property located at 314 Manchester Road, Camp Hill, Lower Allen Township,
Cumberland County, PA 1701 l; Parcel ID 13-23-0545-283
ASSET SUSPENDED PENDING SALE OF REAL ESTATE
TOTAL (Also enter on Line 1, Recapitulation.) I $
If more space is needed, use additional sheets of paper of the same size.
0.00
0.00
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ERNEST H. BLAKE 21 12 00088
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 551.688 shares, common, Exelon Corporation, CUSIP 30161N101 @ 39.925 22,026.14
See attached valuation.
TOTAL (Also enter on line 2, Recapitulation) ~ $ 22,026.14
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+ (11-10)
Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
F.RNEST H. BLAKE 21 12 00088
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Cash 2,502.00
2. Fulton Bank, Checking Acct. No. 3622-82053 (see attached) 34,763.46
3. United States Treasury checks from September to December 2011 not deposited until after 2,183.00
date of death
4. United States Treasury Insurance Dividend check issued 11/30/2011 not deposited until after 77.40
date of death
5. Cashier's check not deposited until after date of death 21,000.00
6. HSBC Card Services, credit balance 166.44
7. U.S. Treasury, 2011 income tax refund 1,021.00
8. Personal property 1,500.00
9. Polish National Alliance of North America, Life Insurance Certificate No. 09982230 0.00
Beneficiary: Estate; Proceeds $4,489.58
TOTAL (Also enter on Line 5, Recapitulation) I $ 63,213.30
If more space is needed, insert additional sheets of paper 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:
ERNEST H. BLAKE 21 12 00088
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. Patricia A. Bowser 101 N. Prince Street, Apt. 310 Daughter
Shippensburg, PA 17257
B
C.
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
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 INTEREST
1. A. 12/2008 2006 Saturn Relay (severely damaged in collision prior to 1,000.00 50. 500.00
death)
TOTAL (Also enter on Line 6, Recapitulation) I $ 500.00
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
ERNEST H. BLAKE 21 12 00088
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1. Liberty Life Insurance Company, Annuity #0100022348; 64,407.17 100.00 64,407.17
beneficiary: Pamela B. Vazquez
TOTAL (Also enter on Line 7, Recapitulation) ~ $ 64,407.17
If more space is needed, use additional sheets of paper of the same size.
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
ERNEST H. BLAKE 21 12 00088
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Parthemore Funeral Home 3,298.48
B.
2.
3.
4.
5
6
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s) Pamela Vazquez
Street Address 522 Westover Road
City Columbia State SC ZIP 29210
Year(s) Commission Paid: 2012-2013
Attorney Fees: Martson Law Offices
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
Probate Fees: Register of Wills
Accountant Fees:
Tax Return Preparer Fees:
7,000.00
12,000.00
323.50
7, Inheritance tax return filing fee 15.00
8, Additional short certificates 24.00
9. Cumberland Law Journal, advertising Letters Testamentary 75.00
10. The Sentinel, advertising Letters Testamentary 200.16
11. Recorder of Deeds, Copies of Deed, etc. 1.00
12. Stock valuation report 1.55
13. Postage 31.80
14. Lock Safety & Security, replace locks on residence 122.50
TOTAL (Also enter on Line 9, Recapitulation) I $ 23,092.99
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ERNEST H. BLAKE 21 12 00088
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Pennsylvania American Water, account payable 72.15
2. Lower Allen Township, trash/sewer service, account payable 139.85
3. PPL Utilities, electric service, account payable 197.66
4. West Shore Meals on Wheels, account payable 247.80
5. UGI Utilities, account payable 161.00
6. Allied Exteriors, Inc., account payable 405.00
7. Comcast, account payable 42.81
TOTAL (Also enter on Line 10, Recapitulation) I $ 1,266.27
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:
ERNEST H. BLAKE 21 12 00088
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. Patricia A. Bowser Lineal 500.00
101 N. Prince Street, Apt. 310 Sch. F, Item 1
Shippensburg, PA 17257
2. Pamela B. Vazquez Lineal 64,407.17
522 Westover Road Sch. G, Item 1
Columbia, SC 29210
3. Pamela Vazquez Lineal 6,764.47
522 Westover Road 1/9 of residue
Columbia, SC 29210
4. Michael Bowser Lineal 6,764.47
408 Temple Drive 1/9 of residue
Sanford, FL 32771
5. Stephen Bowser Lineal 6,764.47
618 Hope Street 1 /9 of residue
Pittsburgh, PA 15220
6. Katherine Vazquez Lineal 6,764.47
522 Westover Road 1/9 of residue
Columbia, SC 29210
7. Grayson Vazquez Lineal 6,764.46
522 Westover Road 1/9 of residue
Columbia, SC 29210
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, 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. I $
If more space is needed, use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
ERNEST H. BLAKE
Decedent's Name
Page 1
21 12 00088
File Number
Schedule J -Beneficiaries - 1
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
8. Morgan Bowser Lineal 6,764.46
408 Temple Drive 1/9 of residue
Sanford, FL 32771
9. Alexis Bowser Lineal 6,764.46
408 Temple Drive 1/9 of residue
Sanford, FL 32771
10. Crystal Bowser Lineal 6,764.46
618 Hope Street 1/9 of residue
Pittsburgh, PA 15220
11. Sabrina Bowser Lineal 6,764.46
618 Hope Street 1/9 of residue
Pittsburgh, PA 15220
F:\FILES\Cfients\14474 BlakeU4474.1.will
LAST WILL AND TESTAMENT
I, ERNEST H. BLAKE, of Lower Allen Township, Cumberland County, Pennsylvania, being
of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last
Will and Testament, hereby revoking any and all former Wills or Codicils made by me.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and
all death taxes (whether such taxes may be payable by my estate or by any recipient of any property)
shall be paid from my residuary estate as soon as practicable after my decease and as part of the
administration of my estate. My Executrix shall have no duty or obligation to obtain reimbursement
for any such tax so paid, even though on proceeds of insurance or other property not passing under
this Will.
2.
I give such items of personalty as are itemized in a certain list, if any, to the persons named
thereon, which list is signed and dated by me at the end thereof.
3.
I have intentionally failed to provide for my daughter, PATRICIA BOWSER. Insofar as I
have failed to provide in this Will for my said daughter, such failure is intentional and not
occasioned by accident or mistake.
4.
I give, devise and bequeath all the rest, residue and remainder of my estate, of whatever
nature and wherever situate, in equal shares, unto my grandchildren and great-grandchildren who are
living at the time of my death.
5.
In the event any of my said great-grandchildren have not attained the age of eighteen (18)
years at the time for distribution, his or her share shall be held by his or her parents, in trust, for the
following purposes:
a. I direct that such trustee(s) shall hold, invest and reinvest the same, collect the income
arising therefrom, and after paying all expenses incident to the management of the trust, to use and
[Initials]
Page 1 of 4 Pages
apply as much of the income and principal as may be necessary in the sole discretion of such
trustee(s) for the support, well-being and education of the beneficiary of such trust.
b. I direct that the beneficiary of such trust shall have the right of withdrawal of the
principal and any accumulated income of such trust as he or she attains the age of eighteen (18)
years.
c. Prior to the distribution of the principal, the said trustee(s) shall have the sole
discretion to invade the principal of such trust for the support, maintenance and education of the
beneficiary thereof, regardless of age.
d. To the extent that the same is permitted by law, none of the beneficiaries hereunder
shall have any power to dispose of or to charge by way of anticipation any interest given to such
beneficiary; and all sums payable to such beneficiaries hereunder shall be free and clear of the debts,
contracts, alienations and anticipations of the beneficiaries, and all liabilities for levies and
attachments and proceedings of whatsoever kind, at law or in equity.
6.
I nominate, constitute and appoint my granddaughter, PAMELA B. VAZQUEZ, as Executrix
of my estate.
7.
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.
8.
I authorize and empower my Executrix and trustee(s), in their sole and absolute discretion,
to purchase or otherwise acquire and retain any investments of which I die seized or any real or
personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or
grant options in regard to any or all property of any kind forming a part of my estate for such terms
and such prices as they may deem advisable; to borrow money for any purposes connected with the
protection and preservation of my estate; to mortgage or pledge any real or personal property forming
a part of my estate or to join in or secure the partition of same; to compromise any claims or
demands of my estate against others or of others against my estate; to make distribution in kind and
[Initials]
Page 2 of 4 Pages
to cause any share to be composed of cash, property or undivided fractional shares in property
different in kind from any other share; to employ agents, attorneys and proxies and to delegate to
them such power as my Executrix and trustee(s) consider desirable and to pay reasonable
compensation for such services as maybe rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my Executrix shall have the power to conduct an inventory of any safe deposit
box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 2nd day of September,
2011.
~~'"""~"' (SEAL)
Ernest H. Blake
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, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testator and of each other.
~a~jl J,
I LH T ^-~z
Page 3 of 4 Pages
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND
We, Ernest H. Blake, Seth T. Mosebey, and ~ ~ t,r~ 2 ~ ~S ,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 the Testator has signed willingly, and that the Testator 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 a 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.
~ A ~
Ernest H. Blake, Testator
~,
J~
Witness
i
Witness
Subscribed, sworn to and acknowledged before me by Ernest H. Blake, the Testator, and
subscribed and sworn to before me by Seth T. Mosebey and r'r t `-- e ~- . ~ e ,
the witnesses, this 2nd day of September, 2011.
COMMONWF~4LTH OF PENNSYLVANIA Not ry blic
Notarial Seal
Mary M. Price, Notary Public
Carlisle Bono, Cumberland County
My Commission Expires Aug. 18, 2015
MEMBER, P! VANU A5S(N~ATIQN OF NOTARIES
Page 4 of 4 Pages
Estate Valuation
Date of Death: 01/17/2012
Valuation Date: 01/17/2012
Processing Date: 03/22/2012
Shares Security
or Par Description
1) 551.688 EXELON CORP (30161N101)
NYSE
01/17/2012
Total Value:
Total Accrual:
Total: $22,026.14
Estate of: Ernest H. Blake
Account: 14474.1
Report Type: Date of Death
Number of Securities: 1
File ID: 144"14.l.exelon
Mean and/or Div and Int Security
High/Ask Low/Bid Adjustments Accruals Value
40.40000 39.45000 H/L
39.925000 22,026.14
$0.00
$22,026.14
Page 1
This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions,
please contact EVP Systems at (818) 313-6300. (Revision 6.4.1)
~, +- ,. ...,1 j
-_..- _~ t~ ~ ~ 1
LISTENING IS JUST THE BEGINNING.
March 9, 2012
Ernest H. Blake Estate
Pamela B. Vazquez, Executrix
c/o 10 East High Street
Carlisle, PA 17013
Dear Ms. Vazquez,
RE: Ernest H. Blake, deceased January 17, 2012
In response to your recent inquiry concerning the accounts maintained in the name of the
decedent, please be advised that the following accounts were open at the date of death:
Checking #3622-82053 Date of death balance $34,763.46,
opened 3/15/05,
titled in his name alone with Pamela B. Vazquez as
Power of Attorney
Safe Deposit Box #20 Opened 9/2/11 at the New Cumberland branch,
held solely in his possession with Pamela B.
Vazquez as Deputy
If you have any other questions, please feel free to contact me at (717) 327-2497.
Sincerely,
~Jl
Joshua A. Groff
Credit Confirmation Processor
COPJFfDE~TI~L
`i',.s ~~#~;~~ticn i~ ~rnis+~tit# ~s ~ to ~tt9rt ~ ~usinass cx~artesy
i;~ ~~~;~ 30 ~°~;~~r < ~ ~uiay, ~~ is tsar ~~c~!r #itial use only.
i i,e t;anK ?`.~~`i"tl~i"if^~ B~~?S ir';~r~~~ziG'il cis rout rent pr
_'~`'.!w,~z?~3~ t~~ ~i~a,ra;,~, ct~:ieter~~ss or reii~.~ifity Of the
.,~s ~r«-, rz'a;';.~jt ~s,~. ~~¢~ r~~~'l~i~`filit"~ iS d~SUi#1?~ ~ t~l~'
any car ~;~ t~ ~ ~;'r~, ~~flio~ rr res. dry e;~~irian
i~~erein e~;~ras3ev i~ 5t~~~ect tr, ci'3an~e ~vitfiout ncticP
1.800.FULTON.4 fultonbank.com
Fulton Bank, N.A. Member FDIC. Member of the Fulton Financial Family.
Fax Server
L~berly.
3/2/2012 9:11:53 AM PAGE 2/002 Fax Server
Liberty Life Insurance Company PO Box 19087 Greenville, SC 29602-9087
March 2, 2012
Martson Law Offices
Attn: Corrine L Myers
Fax No: 717-243-1850
Subject: Annuitant: Ernest H Blake
Contract: 0100022348
Dear Corrine L Myers:
1.800.234.5514 ^ Tradi6onaUFixed Annuities
1.800.423.9398 ^ Variable Life/Annuities
Thank you for your recent request concerning the above referenced annuity contract.
Since this contract was an Annuity, we do not believe a Form 712 is applicable.
Therefore we are providing this statement instead.
The value of this annuity contract was as follows:
Issue Date 09/11/2006
Premiums Received $79,036.63
Date of death value $64,407.17
Accumulation Value at time of payment $64,626.61
If you have any questions please feel free to call us at 1-800-234-5514.
Sincerely,
Customer Care Center
~~ j ~~ 1 ~ ~ ll~~~--