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Home My WebLink About11-02-121505610101 REV-1500 °` ~°'-3O' ~ OFFICIAL USE ONLY PA Department of Revenue PennsYlvanfa County Code Year File Number Bureau of Individual Taxes ENT OF REVENUE PO BOX 28o6oi INHERITANCE TAX RETURN =°~°k ~~-~ - Harrisbur , PA 1'Ji28-o6oi RESIDENT DECEDENT 2 1 1' 2 0~ 9 6 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 8 0 5 2' 0 1 2 °08'3"1 ~1 9 1 8 Decedents Last Name : } . ~ 3 . ,~ Suffix Decedent's First Name MI . C r z .s a f ~ 1 ~i m3 ~ ~ ....N,d,.~.,, ~ ~ ~ J e. al n~ 1 ~ :+ = e ~~ ,. ~S a t ~ ~~~ ~ - R ~ ~ ~.. ~M ~ '-~ If A licable Enter Survivin S ouse' ~ PP ) g p s Information Below Spouse's Last Name ~ - Suffix Spouse's First Name MI ~ .~®.~,.~,~ ~ m.,+~,..,,,k .. ~ ~ ... , Spouses Social Security Number ' - , THIS RETURN MUST BE FILED IN DUPLICATE WITH THE . ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) (:ONRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHQULD BE DIRECTED T0: Name Daytime Telephone Number A n T h a n y L, D e L u c a E s q. '7 1 7 ~y ~ 5:' 8~ 6~3 4 4 . - - REGIST ILLS US~NLY r ; , , ; _ ~~. -~ .L' ,J First line of address ~ N ! _, + ~~ 1 1 3 F r o n t S t r e e t ~ ~~ Second line of address ~~7 '` ~ j W ' . t'T7 P` O B o x 3 5 8; ~ w ~ ~ City or Post Office _: State ZIP Code PATE FILED cx3 B o,i'l i n g S p r i n g s P;A 1 7 0 0 7 1 ~~~ Side 1 1505610101 1505610'...101 J Correspondent's a-mail address: Under penalties of perjury, I deGare that I have examined this return, including accompanying schedules and statements, and to the bgst 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. $IGNATUI~ OF PFRS(~N RFRPf1NAIRl G CnD n~ u.ir_ o~Ti+oN~ J REV-1500 EX Decedent's Name: RECAPITULATION Decedent's Social Security Number ~ 1. Real Estate (Schedule A) ............................................. 1. Q Q.~ /~~1 2. Stocks and Bonds (Schedule B) ....................................... 2. 1 3 9 , 7 6 ' 6 ~ 5 ,I'0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0 ~ 0 , 0 . 4. Mortgages and Notes Receivable (Schedule D) 4, `U 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 1 1 7 , 0 8 2 ! 0 * 3 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 1 8 , 8 6 .= 0 9 3 ,, ,-nom • ;;:< 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. i 0 ~ 0 0 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 2 7 5 , 7 0 ~ 9 s, 4 6 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 1 4 , 4 8 7 r 6 5 ~, . :r,.. x:,„, 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 1 , 6 9 3 6 7 11. Total Deductions (total Lines 9 and 10) ................................. 11. 1 6, 1 8 1 y 3 2 ~~ - 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 2 5 9 , 5 ~ 2 8 ` 1 ~4 13. Chartable and Governmental Bequests/Sec 9113 rus s or w i 13 0 "0 ' 0 an election to tax has not been made (Schedule J) ....................... . . s ~... 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... . 14. 2 5 ~ , 5 2 8 ~ 1 4 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_ . ` ,.,~ ~~' 15. ~~~~ ,,..age ~ a ~' _ 16. Amount of Line 14 taxable ° 04 5 2 5 9 5 2 8 1 4 X t l t li 16. 1 1 y 6 7 ~. 8 7 7 . ra e nea a -`~~ >~N`~, ~~} 4 ,~~_ ~ .~~~ ~~-`~~~- 17. Amount of Line 14 taxable t 17. at sibling rate X .12 ~ - ~ ~~ 18. ~ Amount of Line 14 taxable r, at collateral rate X .15 ~ ~ ~ 18. ~{ ... .. 19. ~ 1° 1 +t6 7 8 7 ~7 '~ 19. TAX DUE .................................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 fdEV-1500 E9C Page 3 Decedent's Complete Address: Fiie Number 21 -1 2 - 0 9 61 DECEDENTS NAME Jean S. Crisafulli STREET ADDRESS Emeritus at Creekview 1100 Crandon Wa _ CIT~f Mechanicsburg STATE Zip ' , PA , 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _ - 0 - B. Discount $ 5 8 3.9 4 (1) $11,678.77 583.94 -0- 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval ort Page 2, Line 20 to request a refund. Total Credits (A + B) (2) (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $1 1 , 0 9 4 _ 8 "~ 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 : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ nX d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 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? .............. ^ 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)]. 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+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Jean S. Crisafulli 21-12'-0961 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, If more space is needed, insert additional sheets of the same size. RE1l-1503 EX+ (6-98) SCNED~ILE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jean S. Crisafulli 21-12-0961 All property jointly-owned with right of survivorship must be disclosed on Schedule F. tir more space is neetletl, insert additional sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF Jean S. Crisafulli FILE NUMBER 21-12-0961 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted fnr cMe-nrnnrlarnrcnine ~~~ nwia sNace is neeaea, msen appiuonal sheets of the same size) REV;1507 EX+ (1-97) ~` a SCNEDt~LE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT tslwle ur FILE NUMBER Jean S. Crisafulli 21-12-0961 All property jointly-owned Wlth right of survivnrshin mutt ho .~~~..i.,wa .,., e..~...~..i,. ~~~ ~~~~~~ ~ra~~ ~~ ~~~~u~~, risen aaumonai sneers of the same size) . t REV•1508 EX • (1.87) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Jean S. Crisafulli FILE NUMBER 21-12-0961 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of ITEM NUMBER DESCRIPTION t. must be disclosed on Schedule F. VALUE AT DATE FI OF DEATH 1. Savings Account, #9830243110, at M&T Bank $ 605.38 2. Savings Account #15004198357963, at M&T Bank 34,504.71 3. Money Market Account #1992-1033, at Charles Schwab 71,062.65 4. Checking Account, #80-1969-6905, at PNC Bank 2,346.51 5. Series E $100.00 US Savings Bond issued July, 1978 427,88 6. Series E $100.00 US Savings Bond issued August, 1978 427.88 7. Series E $100.00 US Savings Bond issued October, 1978 ', 427.88 8. Series E $100.00 US Savings Bond issued December, 1978 ' 433.08 9. Series E $100.00 US Savings Bond issued December, 1978 ' 433.08 10. Series E $100.00 US Savings Bond issued November, 1978 431.92 11. Series E $100.00 US Savings Bond issued January, 1979 433.12 12. Series E $100.00 US Savings Bond issued February, 1979 '~ 433.12 13. Series E $100.00 US Savings Bond issued March, 1979 433.12 14. Series E $100.00 US Savings Bond issued Apri1,1979 433.12 15. Series E $100.00 US Savings Bond issued May, 1979 437.32 16. Series E $100.00 US Savings Bond issued June, 1979 ' 438.36 17. Series E $100.00 US Savings Bond issued July, 1979 438.36 18. Series E $100.00 US Savings Bond issued August, 1979 438.36 19. Series E $100.00 US Savings Bond issued September, 1979 438.36 20. Series E $100.00 US Savings Bond issued October, 1979 438.36 21. Series E $100.00 US Savings Bond issued November, 1979 442.48 22. Series E $100.00 US Savings Bond issued December, 1979 442.48 23. Series EE $200.00 US Savings Bond issued June, 1981 587.60 24. Series EE $200.00 US Savings Bond issued July, 1981 146.90 TOTAL (Also enter on line 5, Recapitulation) ~ 5 1 1 7, 0 8 2.0 3 (It more space is needed, insert additional sheets of the same size) REV-~w9 Ex.l~-sn SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jean S. Crisafulli 21-12-0961 Han asset was made joint within one year of the decedents date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Diana L. Moscato 7 Meadowood Place Daughter Boiling Springs, PA 17007 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 identNying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 2006 Checking Account #1000820314933, $13,631.0'. 50~ $6,815.52 at Wells Fargo 2, p, 2006 Savings Account, #1010058870967, $20,117.1 50$ 10,058.57 at Wells Fargo 3. A 2006 Checking Account, #80-1969-5419, $ 3,973.68 50~ 1,986.8.4 at PNC Bank TOTAL (Also enter on line 6, Recapitulation) I S 1 8, 8 6 0. 9 3 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) ~ i~' Pennsylvania SCHEDULE G ~ DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NU BER Jean S. Crisafulli 21 -1 2-096~i 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 I EXCLUSION i (]F APPLICABLE) TAXABLE VALUE i. NONE -0- TOTAL (Also enter on Line 7, Recapitulation) $ I -0- If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE M FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Jean S. Crisafulli 21-12-0961 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t• Gravestone/Inscription $2,595.00 2. Luigi's Restaurant & Bar - Funeral Dinner $1,743.89 3. Michael Cris~fulli - Flowers Reimbursement 1,080.00 4. Refreshments during visiting hours 100.00 5. Italy's Best Pizzaria - Food during visiting hours 275.48 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zi Year(s) Commission Paid: 2~ Attorney Fees Anthony L. DeLuca, Esquire 3• 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 4• Probate Fees 5~ Accountant's Fees 6• Tax Return Preparer's Fees ~. Legal Advertising-Cumberland Law Journal 8. Legal Advertising - The Sentinel -0- 7,500.00 -0- 377.50 500.00 -0- 75.00 210.78 TOTAL (Also enter on fine 9, Recapitulations I $ 1 4 , 4 8 7. 6 5 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12.03) SC6°IE®ULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~ ESTATE OF Jean S. Crisafulli FILE NUMBER -----~^- ----- a 1-1 2- 0 9 61 .Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreir>~bursed medical expenses. ITEM - _NUMBER _ _ DESCRIPTION VALUE AT DArE OF DEATH 1 Emeritus Senior Living - Nursing Home 2. MDO Home - House visit $1,504.00 45.70 3. Carlisle HMA Physician, Management 40.10 4. Verizon Wireless 34.06 5. Omnicare Pharmacy Services of Eastern PA 69.81 `----- --------------------._-._._.._._-___-_-•_-. - __ __ TOTAL. (Also enter on line 10, Recapitulation) $ 1 , 693.67 ^(If more space is needed insert additional sheets of the same size) -~ ~- - _ _ _ REV-1513 EX+ (i1-08) pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF ' FILE NUMBER Jean S. Crisafulli 21-''12-0961 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. 2116 (a) (1.2),] 1• Michael Crisafulli Son 1/3 4 Corinne Court Jackson, New Jersey 08527 2. James Crisafulli Son 1/3 57 Glendale Court Effort, PA T8330 3. Diana L. Moscato Daughter 1/3 7 Meadowood Place Boiling Springs, PA 17007 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ -~- it more space is needed, insert additional sheets of the same size. r_ _ ~. ~J V :> ~+3 -.~ -- _~.. ~. _ __. C-'~ ~~:: ~._ Q ~ ~~ 'Jd 4~ ~ i _ ,. ._. ; Y ~~..~ ~~tt~~ mill ttx~b ~PS~ttrYtPn~ of _, ~. i ;_,,_e r.Y'. ~_ JEAN S. CRISAFULLI !~: ~ t1 r ~'~ ~ ~ I, JEAN S.. CRISAFULLI , also known as Jean S. Crisofulli, now res ding in the t~ ... . ~ip~ity~o~l~e:mov~aslwi~l'arl~€~unt3~oi~non~aud~tate~Jersey.~a 2x,Carolina `~ -' Street, being ofsound and disposing mind, memory and understanding, hereby revoke Wills and Codicils heretofore made by me and declare the following to be my Last Will and Tes went: l ARTICLE ONE I direct that all my just debts, my funeral and testamentary expenses be p~id as soon as practicable after my death. ARTICLE TWO I give, bequeath and devise the rest, remainder and residue of my estate, w ether real, petsomal or mixed, wheresoever situated or to which I may be entitled at my death, to ~iy beloved Husband, PH1I,lP N. CRISAFULLI ,also known as Philip N. Crisofulli, absolutely. ARTICLE THREE In the eve o I give,bequsath and devise lie en " - F : to t;::. '.. _ ,. ,, _... situated, to mybeloved Childreq DIANA L. MOSCATO, currently residing in Staten I land, New York, MICHAEL CRISAFULLI, currently residing in Jacksoq New Jersey, d JAMES CRISAFULLI, currently residing in Effort, Pennsylvania, in equal shares, share ands alike. In the event, that any of my beloved children should predecease me, I give, be~ueath and devise the deceased child's share equally, to whomever of their issue are living at the une of my death, per stirpes. ', ARTICLE FOZfR All estate, inheritance, legacy, transfer, succession and other death taxes and dutie ,including interest and penalties thereoq assessed or imposed by reason of my death and upon or 'th respect to property passing under this' Will or property not passing under this Will, shall be pai out of my residuary estate as an expense of administration. No part of said taxes shall be app rtioned or prorated to any legatee or devisee under this Will or any person owning or receiving p operty not passing underthis-Will. -1- AxTicr.>~ > = t I hereby nominate, constitute and appoint, my beloved Hus~a `; as sole Executor of this my Last Will and Testament. If my said Husband~s$o _ otherwise be incapable of acting as sole Executor, then and in that event, I nominate, consti }~ ~ aad appoint my beloved Daughter, DIANA L. MOSCATO, to act as alternate Executrix in his stead and place. I direct that no bond or other security be required of my sole Executor or alternate Executrix, as the case may be, for the faithful performance of their duties as such, either in the State of New Jersey or elsewhere, where-it:malC~be-nacessat3~~or convenientxt~nnake.proof of this my Will or to act in settlement of my estate. . ARTICLE S1X Inthe eventthat a~Beneficiary or Executor or Alternate Executrix under this Will shall die with me in a common disaster or die with me under such circumstances that it shall be impossible ~ difficartt to determine which of us died first, or in the event that any such person shall die within sixty days of my death, I direct that such person predeceased me. IN WITNESS WHEREOF, I have Signed, Sealed, Published and Declared the foregoing instrument as and for my Last Will and Testament this t6 th day of Tw l~ , 1998. L '' JEAN S. CRIS ,Testatrix -2- ~.. _ i names as attesting witnesses, hereto, this t e th day of ~~-Y,yy~ , re~a 1, o ,Witness /I ' ..~../l ~~irj a{1st '$. ~.yY10 , W1tneSS µ_ _ STATE OF NEW JERSEY) ss. COUNTY OF UNION ) JEAN S. CRISAFULLI, the Testatrix herein, and the witnesses, Andru,~ ~ •~t ~na+1.~ and A~b.. 8 • P°g^-~.. ,whose names are signed herein this instrument, being first dul}~ sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument herein as her Last Will and Testament, signed willingly as her free and voluntary pct for the purposes therein expressed, each witness signed this instrument in the presence and hewing of the Testatrix and to the best of each witness's lrnowledge, the Testatrix was over the age of ~ 8 years or more, of sound mind and under no constraint or undue influence. .~4s o on JEFRREY Nl: AAGao E5Q Mme. ~.,,,e.,~,. <,.~,. -3-