HomeMy WebLinkAbout10-04-12 1505610140
REV-1500 ~` (°'-'°'
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO Box 28oso1 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 0 9 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
0 1 0 9 2 0 1 2 0 5 0 2 1 9 2 8
Decedent's Last Name Suffix Decedent's First Name MI
G R I F F I E M A R L I N 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 ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
® 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 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 -THIS SECTION MUST BE COMPLETED. ALL
Name
S E T H T M O S E B E Y
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
City or Post Office State
C A R L I S L E P A
AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Daytime Telephone Number
7 1 7 2 4 3 3 3 4 1
REGISTER OF WILLS USE ONLY
c`
[J fv
0
~~~~~'~ r
~
Q ~ '"
ZIP Code ~
1 7 0 1 3
c.~
tv •
Correspondent's a-mail address: S M O S E B E Y a M A R T S O N L A W• C O M
Under penalties of perjury, I deGare 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.
SIGNAT E OF PERSO REP NSI LE FOR FILING RETURN DATE
ADDRESS
89 BALL PARK DRIVE GARDNERS PA 17324
SIGN R PREPgRER ER T EPRESENTATNE
1 ~~~ /1 Z
10 E HIGH STREET U CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 150561014D
o'iL~b
c~''.,~
-E.7~'
n
"7
~'3
1505610240
REV-1500 EX
Decedent's Social Security Number
decedent's Name: MARLIN J• G R I F F I E
RECAPITULATION
1. Real Estate (Schedule A) .......................................... . 1. 0 . 0 0
2. Stocks and Bonds (Schedule B) ..................................... . 2• 0 • 0 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3.
4. Mortgages and Notes Receivable (Schedule D) ......................... . 4.
6 5 8 0 4 3 3
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 5. .
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... . 6. 0 . 0 0
7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property
h
l
r
t
Billin
R
uested
S
d
G
~ S
7
1
5
9
1
2
5
7
6
g
......
(
c
e
u
e
)
epa
a
e
eq .
. .
8. Total Gross Assets (total Lines 1 through 7) .......................... . 8. 2 2 4 9 3 0 . 0 9
9. Funeral Expenses and Administrative Costs (Schedule H) ................. . 9• 2 2 3 5 8 . 4 6
10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I
9 9 ( ) ............ 10.
. 4 9 1 6 . 3 4
11. Total Deductions (total Lines 9 and 10) .............................. . 11. 2 7 2 7 4 . 8 0
12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 1 9 7 6 5 5. 2 9
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... . 13. 0 . 0 0
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... . 14. 1 9 7 6 5 5. 2 9
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 _ 0 . 0 0 16,
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 1 9 7 6 5 5. 2 9 18.
19. TAX DUE ......................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
0. 0 0
0. 0 0
0. 0 0
2 9 6 4 8. 2 9
2 9 6 4 8. 2 9
1505610240 J
REV-1500 EX Page 3
Decedent's Complete Address:
Flle Number
21 12 0091
DECEDENTS NAME
MARLIN J. GRIFFIE
STREET ADDRESS
604 PINE ROAD
CITY
CARLISLE STATE
PA ZIP
17015
Tax Payments and Credits:
1 • Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 35,000.00
B. Discount 1,482.41
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.
(1) 29,648.29
Total Credits (A + B) (2) 36,482.41
(3)
(4) 6,834.12
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT
~ r ., :~
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; .................... ........... ^
c. retain a reversionary interest; or ..................................................................................... ........... ^
d. receive the promise for life of either payments, benefits or care? ............................................ ........... ^
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" 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~{T{~O ANY OF THU#E ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
~rn~l.. .. ~~1~~F~~,:,i!ti~r~liNl{~1t~~r34 f+ ~~ ., .~~~t~~l.° ~~if~k~t~~jr~~li~~ ~t'4~#ll1i~~i~~~i~~~ ~~}11i ~!"~9.n
.,~. ~ ~ ~ ~ i.F ~~ f;.. eon
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)]. 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)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
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
FILE NUMBER:
MARLIN J. GRIFFIE 21 12 0091
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 estate located at 604 Pine Rd., Dickinson Twp., Cumberland Co., PA, known as Tax Parcel 0.00
No. 08-30-2638-015, being described in Deed dated 4/12/59 & recorded in Cumberland Co., Deed
Bk "A", Vol 19, Pg 589, being conveyed to Marlin J. Griffie &Deloris J. Griffie, his wife. Deloris
J. Griffie died on 8/15/2006 leaving title soley vested in Marlin J. Griffie.
2. **Real estate located at 602 Pine Rd., Dickinson Twp., Cumberland Co., PA, known as Tax Pars
No. 08-30-2638-016, being described in Deed dated 5/27/1975 & recorded in Cumberland Co.,
Deed Bk "C", Vol 26, Pg 214, being conveyed to Marlin J. Griffie &Deloris J. Griffie, his wife.
Deloris J. Griffie died 8/15/2006, leaving title solely vested in Marlin J. Griffie
**LINES 1&2 ASSETS SUSPENDED PENDING SALE OF REAL ESTATE
TOTAL (Also enter on Line 1, Recapitulation.) I S 0.00
If more space is needed, use additional sheets of paper of the same size.
REV-1508 EX + (8-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RE3 DENT DECEDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
MARLIN J. GRIFFIE 21 12 0091
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. M&T checking 607436 11,822.64
($11,822.54 + $.10 interest)
See attached
2. M&T savings 15004211794597 20,143.72
($20,141.15 + $2.57 interest)
See attached
3. Allstate Annuity GA161471138, beneficiary estate
24,317.42
See attached
4. Highmark, refund of premium 96.80
5. Comcast, refund 84.00
6. Larry J. Peters Auctioneer, net proceeds from sale of personal property 9,320.75
7. Prudential Life Insurance Policy D1201888347, beneficiary Estate ($2,212.50) 0.00
8. Express Scripts, refund
19.00
9. Century Link, refund
TOTAL (Also enter on line 5, Recapitulation) I $
(If more space is needed, insert additional sheets 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
MARLIN J. GRIFFIE 21 12 0091
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. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
QF aPPUCneLEI
TAXABLE
VALUE
1. Allstate Annuity GA0752726 130,158.12 100.00 130,158.12
Beneficiary: Diane L. Richwine, niece, 100%
See attached
2. Western National Annuity AN203896 28,967.64 100.00 28,967.64
Beneficiary: Diane L. Richwine, niece, 100%
See attached
TOTAL (Also enter on Line 7, Recapitulation) 15 159,125.76
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
MARLIN J. GRIFFIE
FILE NUMBER
21 12 0091
Decedents debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home, Carlisle, Pa
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) Diane L. Richwine
Street Address 89 Ball Park Drive
City Gardners State PA Zlp 17324
Year(s) Commission Paid: 2013
2, Attorney Fees: Martson Law Offices (estimated)
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4• Probate Fees: Cumberland County Register of Wills
5 Accountant Fees:
6, Tax Return Preparer Fees:
7. Register of Wills, filing fee
8. Cumberland Law Journal, advertising Letters Testamentary
9. The Sentinel, advertising Letters Testamentary
AMOUNT
2,395.80
9,748.00
9,609.00
315.50
15.00
75.00
200.16
TOTAL (Also enter on Line 9, Recapitulation) $ 22.358.46
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, 8~ LIENS
ESTATE OF
MARLIN J. GRIFFIE
FILE NUMBER
21 12 0091
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. M&T Bank checking 607436, outstanding checks on date of death 2,001.68
2. Manor Care Carlisle, account payable 305.76
3. Family Home Medical, account payable 37.78
4. Diane Richwine, reimbursement for expenses paid prior to date of death 2,000.00
5. Express Scripts, account payable 19A0
6. Century Link, account payable 25.24
7. Met Ed, account payable 94.34
8. Comast, account payable 71.00
9. Amerigas, account payable 202.94
11. Interstate Waste, account payable 42.60
12. Med Staffers, account payable 69.00
13. Masland Associates, account payable 30.00
14. Carlisle Reginal Medical Center, account payable 10.00
15. PA Department of Revenue, 2011 PA40 tax due 7.00
TOTAL (Also enter on Line 10, Recapitulation) I b 4,916.34
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (Ot-10i
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
MART.TN_L C:RTFFTF. ~i i~ nnoi
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 outn' ht spousal distributions and transfers under
Sec. 91 i6 (a) (1.2).]
1. Diane L. Richwine Collateral 174,537.57
89 Ball Park Road Sch. G, lines 1&2; 40% of
Gazdners, PA 17324 estate residue
2. Jason Richwine Collateral 15,411.81
1240 Goodyear Road 40% of estate residue
Gardners, PA 17324
3. Kimberly Lazkin Collateral 7,705.91
31 Meadow Drive 20% of estate residue
West Warwick, RI
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S 0.00
it more space Is neeaea, use aaaltlonal sneers of paper of the same size.
LAST WILL AND TESTAMENT OF
Marlin Junior Griffie
I, Marlin Junior Griffie, a resident of the State of Pennsylvania, make, publish and declare this to be my Last Will
and Testament, revoking all wills and codicils at any time heretofore made by rne.
FIRST: I direct that the expenses of my last illness and funeral, the expenses of the administration of my estate,
and all estate, inheritance and similar taxes payable with respect to property included in my estate, whether or
not passing under this will, and any interest or penalties thereon, shall be paid out of my residuary estate,
without apportionment and with no right of reimbursement from any recipient of any such. ~ iv
-r- .
SECOND: All tangible personal property owned by me at the time of my death and not specifical, is x"' ~'
Z r
};
given as hereafter as provided with respect to my residuary estate. i~ ~
N r= a-
THIRD: I make the following specific gifts of property: `--' ~ `•-f== '•~•'
~
~ ~~
~~
No specific gifts identified - ,_,,~ N
~ ~
Any specific gift made in this will to two or more beneficiaries shall be shared equally among them, unless ~.>
unequal shares are specifically indicated. All shared gifts must be sold, and the net proceeds distributed as the
will directs, unless all beneficiaries for that gift agree in writing, after my death, that the gift need not be sold.
If I name two or more primary beneficiaries to receive a specific gift of property and any of them do not survive
me, all surviving primary beneficiaries shall equally divide the deceased primary beneficiary's share unless I have
specifically provided otherwise. If I name two or more alternate beneficiaries to receive a specific gift of
property and any of them do not survive me, all surviving alternate beneficiaries shall equally divide the
deceased alternate beneficiary's share.
I give all the rest, residue and remainder of my property and estate, both real and personal, of whatever kind
and wherever located, that I own or to which I shall be in any manner entitled at the time of my death
(collectively referred to as my "residuary estate"), as follows:
(a) I give my estate to Kimberly Larkin in the amount of 20% and to Jason D. Richwine the amount of 40% to be
managed by Diane L. Richwine and to Diane L. Richwine the amount of 40%.
(b) If none of the named residual beneficiaries described in clause (a) above shall survive me, decline the gift or
are no longer in existence, (together referred to as "pre-deceased"), then equally to Gregory D. Richwine and
Jennifer J. Steigleman
(c) If none of the beneficiaries described in clauses (a) and (b) above shall survive rne, decline the gift or are no
longer in existence (together referred to as "pre-deceased"), then I give my residuary estate to those who would
take from me as if I were then to die without a will, unmarried and the absolute owner of my residuary estate,
and a resident of the State of Pennsylvania.
FOURTH: I appoint Diane L. Richwine to be my executor. If Diane L. Richwine does not survive me, or shall fail to
qualify for any reason as my personal representative, or having qualified shall die, resign or cease to act for any
reason as my executor, I appoint Jennifer 1. Steigleman as my executor. To the extent permitted by the laws of
the State of Pennsylvania, this will is intended as and shall be construed to be a nonintervention will and, after
the probate of this will, no further proceedings in court shall be necessary other than to comply with the
statutes relating to the handling of estates under nonintervention wills. No bond or surety or other security
shall be required of any Personal Representative serving hereunder. The decision to administer my estate
independently or under court supervision shall be made solely by my personal representative.
FIFTH: Whenever any beneficiary of my estate is under a legal disability or, in the judgment of my Personal
Representative, is for any reason unable to apply any distribution to the beneficiary's own best advantage, my
Personal Representative may nevertheless make the distribution directly to the beneficiary or to the
conservator of the beneficiary's property or to a person with whom the beneficiary resides at the time of the
distribution in whatever manner my Personal Representative shall deem best. In the alternative and if the
beneficiary is under twenty-one years of age, my Personal Representative may, in the discretion of my Personal
Representative, distribute the property to a custodian for the beneficiary under a Uniform Transfer or Gift to
Minors Act. The receipt by the beneficiary, conservator, custodian or other person of any distribution so made
shall be a complete discharge to my Personal Representative regarding the distribution.
Page 1 of 3
SIXTH: I grant to my personal representative all powers conferred on personal representatives and executors
wherever my personal representative may act. I also grant to my personal representative power to retain, sell at
public or private sale, exchange, grant options on, invest and reinvest, and otherwise deal with any kind of
property, real or personal, for cash or on credit; to borrow money and encumber or pledge any property to
secure loans; to hold property in bearer form or in the name of a nominee; to divide and distribute property in
cash or in kind; to exercise all powers of an absolute owner of property; to compromise and release claims with
or without consideration; to execute and deliver deeds and other instruments, including releases; and to
employ attorneys, accountants and other persons for services or advice.
The term "executor" wherever used herein shall mean the personal representatives, executors, executor,
executrix or administrator in office from time to time. The term "trustee" wherever used herein shall mean the
trustees or trustee in office from time to time. Each personal representative and trustee shall have the same
rights, powers, duties, authority and privileges, whether or not discretionary, as if originally appointed
hereunder.
SEVENTH: Each beneficiary shall be deemed not to have survived me unless the beneficiary is living on the
thirtieth day after the date of my death.
IN WITNESS WHEREOF, I, Marlin Junior Griffie, sign my name and publish and declare this instrument as my last
will and testament this 2~~Sday of oZ , 20 ~,. I also have affixed my initials on the bottom of each
of the preceding pages hereof.
Marlin Junior Grif ie
We, the witnesses, at the Testator's request, sign our names to this instrument, being first duly sworn, and do
hereby declare to the undersigned authority that the Testator signs and executes this instrument as the
Testator's will and that the Testator signs it willingly, and that each of us, in the presence and hearing of the
Testator, hereby signs this will as wi4ness to the Testator's signing, and that to the best of our knowledge the
Testatrix is eighteen years of age or older, of sound mind, and under no constraint or undue influence.
~S'z`~/hut ~C~'WI yjV° of ~~ a Y ~~ m~ ~ .
Wit ss
~yi n ss 00
Witness
Page 2 of 3
T
AFFIDAVIT OF WITNESSES
STATE OF Pennsylvania, COUNTY OF Cumberland, ss.
Before me the undersigned authority, on this day personally appeared:
the Testator,
Marlin Junior Griffie having an address at, 604 Pine Road, Carlisle, PA 17015,
and each of the undersigned witnesses,
Stella Richwine having an address at, 1240 Goodyear Road, Gardners, PA 17324,
and
Dennis Richwine having an address at, 89 Ball Park Drive, Gardners, PA 17324,
and
Jeromy Steigleman having an address at, 400 Pine Grove Road, Gardners, PA 17324,
respectively, being individually and severally duly sworn, did depose and say that:
The foregoing last will and testament was subscribed in our presence and sight by Marlin Junior Griffie, the Testator
named therein. The undersigned witnessed the execution of said will of Marlin Junior Griffie, on this day.
At the time the instrument was so subscribed, the Testator declared said instrument to be their last will and
testament. The undersigned thereupon signed their names as witnesses at the end of said will at the request of the
Testator, in the presence of the Testator and each other. At the time of so executing said will, in our respective
opinions, the Testator was at least eighteen years of age, and was of sound mind, memory and understanding,
under no constraint, duress, fraud or undue influence, and in no respect incompetent to make a valid will. In our
respective opinions, the Testator was able to read, write and converse in the English language, and was not
suffering from any defect of sight, hearing or speech, or from any other physical or mental impairment which would
affect their capacity to make a valid will. Each of us was acquainted with the Testator, and we make this affidavit at
their request. Said will was shown to us at the time this affidavit was made, and we examined it as to the signature
of the Testator and our signatures. Said will was executed as a single, original instrument, and not in counterparts.
t or
Wit ss
~• vwriM-.+
Wi e
Witness
Subscribed, sworn to and acknowledged before me by" /!Q//gin rlt0-' 'iri~' ^ ,the Testator,
and subscribed and sworn to before me by the said ~ ~ 'chwine~
and j znr~IS _~iCr~wi.n~,, ,and ~.~erpm\ '4'e.l as witnesses,
this~~ ay of ~ 20~.
~~
NOTARIAL SEAL
star is - JILL L KULAWIECZ
Notary Public
y commission expires on CARLISLE BOROUGH, CUMBERUWDCOUNi
My Commisalon Explras Auk 4, 2011
LAST WIL AND TESTAMENT OF ~IQY ~~d1 c ~,L(IiOY' t~l(it}je
Dated: fUtlr , 20~.
Page 3 of 3
p ~s~x
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302)934-2955
February 16,2012
Manson, Dearforff, Williams, Otto, Gilroy and Faller
10 East High Street
Carlisle, PA 17013
Re: Estate of Mazilin J Griffie
Social Security: 197-22-0439
Date of Death: January 9, 2012
Dear Sir or Madam:
Per your inquiry on February 4, 2012, please be advised that at the time of death, the above-named decedent had
on deposit with this bank the following:
1. Type of Account
Account Number
Ownership (Names o, fl
Opening Date
Balance on Date of Death
Accrued Interest
Total
2. Type of Account
Account Number
Ownership (Names o, fl
Opening Date
Balance on Date of Death
Accrued Interest
Total
Checking Account
607436
Marlin J GrifJ`ie
01/02/82
$11,822.54
$ .10
$11,822.64
Savings Account
15004211794597
Marlin J GrifJ`ie
1122/06
$20,141.15
$ 2.57
$20,143.72
~Ilistatea~
You're in good hands.
January 12, 2012
Shawnee E. Smith
M 8 T Securities, Inc.
631 Holly Pike
Mt. Holly Springs, PA 17065
va Email: ssmith1l~mtb.com
Re: Marlin J. Griffis
Contract No: GA16147138
Dear Ms. Smith:
We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form
712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain
date (usually the owner's date of death or date of transfer of the contract).
Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
following information for estate purposes:
Date of Death: January 9, 2012
Annuity Value as of Date of Death: $ 24,317.42"
Cost Basis: $ 0.00
Named Beneficiary: The Estate of Martin J. Griffis
*The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
If you have any questions, please contact me at 1-877-499-6418 Ext. 24522.
Sincerely,
Lin Breckler
Sr. Claim Examiner
Allstate Life Insurance Company
Llte and Annuity Claims
P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523
'~ ~~- `11'~ ~ w ~
Form 712
(Rev. May 2000) Life Insurance Statement OMB No. 1545-0022
Department of the Treasury
Internal Revenue Service
Decedent-InSUfed (To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or
Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)
1 Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death
Marlin J Griffie (if known) 197-22-0439 01/09/2012
5 Name and address of insurance company
The Prudential Insurance Com an of America PO Box 13902 Philadel hia PA 19176
6 Type of policy 7 Policy number
Limited Pay 20716746
8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name. Attach copy of 11 Date assigned
attach copy of application. assignment.
12/05/1956
12 Value of the policy at the 13 Amount of premium (see instructions) 14 Name of beneficiaries
time of assignment iane L Richwine Executor Of The Est Of
$24.37 arlin J Griffie
15 Face amount of policy 15 $ 1 000 .00
16 Indemnity benefits 16 $
17 Additional insurance 17 $
18 Other benefits . 18 $
19 Principal of any indebtedness to the company that is deductible in determining net proceeds 19 $
20 Interest on indebtedness (line 19) accrued to date of death . 20
21 Amount of accumulated dividends 21 $ 1, 156 .22
22 Amount of post-mortem dividends 22 $ 35.97
23 Amount of returned premium 23 $ 2 0 .31
24 Amount of proceeds if payable in one sum 24 $ 2 , 212.50
25 Value of proceeds as of date of death (if not payable in one sum) 25 $
26 Policy provisions concerning deferred payments or installments.
Note: If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the
insurance policy.
27 Amount of installments
28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
29 Amount applied by the insurance company as a single premium representing the purchase of //
installment benefits 29
30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.
31 Were there any transfers of the policy within the three years prior to the death of the decedent? ^ Yes ^ No
32 Date of assignment or transfer:
Month Day Year
33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? ^ Yes ^ No
34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by
him/her at the date of death? ^ Yes ^ No
35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.
The undersigned officer of the above-named insurance company (or appropriate Federal agency or retirement system official) hereby certifies that this statement sets
forth true and correct information. ~,,/~ ~//~~}/~. ~ /,~' Vice President,
Signature - ~W'~~ ' "~` ~ Title - Customer Service Office Date of Certification I- 04 / 19 / 12
Cat. No. 10170V Form 712 (Rev. 5-2000)
~.
I sate
You're in good hands.
January 12, 2012
Shawnee E. Smith
M 8~ T Securities, inc.
631 Holly Pike
Mt. Holly Springs, PA 17065
Via Email: ssmith1t~mtb.com
Re: Marlin J. Griffis
Contract No: GA0752726
Dear Ms. Smith:
We received a request to complete IRS Form 712 for the above referenced contract The purpose of Form
712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain
date (usually the owner's date of death or date of transfer of the contract).
Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
following information for estate purposes:
Date of Death: January 9, 2012
Annuiiy Value as of Date of Death: $130,158.12"
Cost Basis: $ 82,423.38
Named Beneficiary: Diane L. Richwine
`The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
If you have any questions, please contact me at 1-877-499-6418 Ext 24522.
Sincerely,
Lin Breckter
Sr. Claim Examiner
Allstate Life Insurance Company
Life and Annuity Clalms
P.O. Box 94212, Palatine, IL 80094-4212 Phone 877-499-8418 Fax 88B-835-4523
WESTERN J NATIONAL
Life I n s u r a n c e C o m p a n y
i f.,o~,r71
+m~.ii;lli~, Te<n~ 791(15-0871
February 10, 2012
Victoria Otto
FBO: Diane Richwine
10 East High Street
Carlisle, PA 17013
Re: Annuity Contract AN203896
Deceased Marlin Griffie
Dear Ms. Otto:
Thank you for your recent inquiry regarding the above referenced annuity contract. We would
like to take this opportunity to respond to your request.
The accumulated value of this contract as of January 9, 2012, the date of death, is $28,967.64.
Ms.Otto, we appreciate the opportunity to assist you. Should you have any questions, please
contact our Client Care Center at 1-800-424-4990.
Sincerely,
Alyssa Lindsey
Annuity Claims Department