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Home My WebLink About01-28-13 (2)1505610143 --~ REV-1500 ~`'°'~'°) PA Department of Revenue pennsylvanta Bureau of Individual Taxes DEPMIMEIR OF REVENUE Po Box.26~1 INHERITANCE TAX Harrisburg, PA 17128-0601 RFQIr11FNT nRf'_s Socal Security Number 439 38 4891 Decedent's Last Name BENDRY n Date of Death 04 28 2012 tff Applicable) Eater Surviving Spolree's Information Below Spouse's Last Neme OFFICIAL USE ONLY County Coda Year File Number 121 12 00538 Date of Birth 02 06 1920 Suffer Decedent's First Name MI THOMAS p 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 APPROPRUITE OVALS BELOW ® 1. Original Retum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death prior to 12-13-92) ^ 4. Limited Estate ^ 4a. F~1Ae ~ntereat Compromlee ^ 5. Federal Estate Tax Retum Required (date a deem at~r t2-12A2) ® 9. Decedent Duo Tenets ^ 7. Receded Malnlafned a LtYn9 Ttuat 3' 9. Total Number Of Safe (Attach Copy of Win) (Attach Copy of Trust) Deposit Boxes ^ 9. Litigation Proceeds Received ^ 10. Slxx+aai Pova~Creds (date a deeu, 11. Electbn to tax under Sec. 9113 A between 1231- tend -1-95) ^ ( ) (Attadl Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number DEBRA R MALLET 717 737 1300 Flrst line of address 24 NORTH 32ND STREET Second Ilse of address City or Post Office CAMP HILL Correspondent'se-mailaddress: WalletdA Under peneltles of oeriurv, I declare Ctat 1 have examirtad 1F Isom REGIS'~t OF WILLS~E OeIbY~ 3; O ~ L~ ~ n ~ Q t7o ~ , ~ ~ aam ~~ cb ~~ ~ . X ~ ~ 47 -~ `T'i "rl O E FILER-~ = C') ---i r-- 3> y N .~ schedules and statements, is based on all mformadon Sandra LeAnna H. Bowman best W mY epererhas 3 Northfleid Way, Mechanicsburg, PA 17050 SIGNATURdE ~OF PREPARER OTHER THAN REPRESENTATIVE DATE era '{f, b,~M,r,,,,+- Debra K WalletDebra K Wallet~2~13 ADDRESS 24 North 32nd Street, Camp Hill, PA 17011 Side 1 L 1505610143 1505610143 ~~ State ZiP Code PA 17011 J 15d'5~10343 REV-1500 EX oead«n~sNa~: HENDRY, THOMAS O. RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. Decedent's Social Security Number 439 38 4891 228,200.00 3,631.00 3. Closet' Reid 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. 4 , 3 5 5 . 6 9 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6. 3 6 , 8 12.13 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Pro rty (Schedule G) ^ Separate filling Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 2 7 2, 9 9 8. 8 2 9. Funeral Expenses 8 Administrative Costs (Schedule H) ......................................... 9. 13 , 6 2 9 . 3 9 10. Debts of Decederrt, Mortgage LiabilRias, & Liens (Schedule I) ................................ 10. 5 , 10 4 . 4 4 11. Total Deductions (total Lines 9 810) ...................................................................... 11. 1$ , 7 3 3 . 8 3 12. N~ Value of Estate (Line 8 minus Line 11) ............................................................. 12. 2 5 4 , 2 6 4 . 9 9 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. 2 5 4 , 2 6 4 . 9 9 TAX COMPUTATION -SEE IN8TRUCTION3 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 2 5 4, 2 6 4. 9 9 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. 1505610243 Side 2 11,441.92 11,441.92 1505610243 J REV-1500 EX Page 3 File Number 21 - 12 - 00538 Decedent's Complete Address: Hendry, Thomas O. STREET ADDRESS 34 Linda Drive CITY Mechanicsburg STATE PA ZIP 17050 Tax Payma+tts and Credits: 1. Tax Due (Page 2, Line 19) (1) 1 1,441.92 2. Credits/Payments A• Prior Payments 10,000.00 B. Discount 526.32 Total credits (A + B) (2) 10,526.32 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q) Check box on Page 2 Lirre 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) 9'I 5 , s Q 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 end: Yes No a. retain the use or income of the property transferred :.................................................................................. ^ 0 b. retain the right to designate who shall use the properly transferred or its income :.................................... ^ c. retain a reversionary interest; or .................................................................................................................. ^ 0 d. receive the promise for life of efther payments, benefits or caro? .............................................................. ^ 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?......... ^ ~~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which cxntalns 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 rete imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent p2 P.S. §8116 (a) (1.1) (i)]. For dates of death on or after January 7, 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. §9118 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disGosure 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 21yg ars of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the chikl is 0 percent [72 P.S. §9116 (a) (1.2)]. • The tau 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) . A sibflng is defined under Section 9102, as an individual who has at least one parent in common with the decedent, wfiether by blood or adoption. SCH~'DULE A OOMMONWEALTN OF PETIN9TLVANIA REAL ESTATE INNERD'ANCE TAX RENRN pEe~ENT DECEDENT ESTATE OF Hendry, ThOmaS O. FILE NUMBER 21 -12 - 00538 All reel property owned solely or es a tsnant in common must be ropo~~ at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a wi1Mg seNer, rtefther tieing crompeNed to buy or sell, both having reasonable knowk~dge of the relevant facts. Reel property whlch is jointly-owned with right of survivorship must be disclosed on scFtsdule F. Attach a copy of the settlement sheetrf the property has been sold. Include a copy of the deed showin® decedent's interest if owned as tenant in common. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 34 Linda Drive, Silver Spring Township, Mechanicsburg, PA (based on assessed value x 228,200.00 common level ratio) TOTAL (Also enter on Line 1, Reeapitulatlon) I 228,200.00 C04MONWEALTH OF PENNSYLVANIA SIHERRANCE TA%RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Hendry, Thomas O. ALE NuI~sER 21 -12 - 00538 Ali property jointly-0wned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION NUMBER 1 MetLife Insurance Stock UNIT VALUE VALUE AT DATE OF DEATH 36.31 3,631.00 TOTAL (Also enter on Iine 2, Recapitulation) 3,631.00 SCHEDULE E CASH, BANK DEPOSITS, & MISC. +E"'TMOF~1N81ti°u+~^ PERSONAL PROPERTY WHERRAHC6TAX RERIRN RE&DENT DBDBpENT FILE NUMBER ESTATE OF Hendry, Thomas O. 21 -12 - 00538 Include the pproceeds of litigation and the date the proceeds were received by the estate. All property Jofrrtly-owned with the Hght of survivorship must he disclosed on schedule F. ITEM DESCRIPTION NUMBER 1 Furniture in residence and at Cumberland Crossings 2 Hammond Organ 3 Wedding ring and miscellaneous personal effects 4 Dishware, kitchenware, glass serving ware, flatware, silver plate utensils 5 Books 6 Tools 7 Refund from Cumberland Crossing 8 Cemetery burial space in St. John's Cemetery (on top of wife's grave) and cemetery lot in Monroe, LA VALUE AT DATE OF DEATH 3,000.00 500.00 75.00 200.00 20.00 100.00 210.69 250.00 TOTAL (Also enter on Line 5, Recapitulation) ~ 4,355,68 SCWEIJULE F CCMMDNwEALTH OF PENNSVLYANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hendry, Thomas O. FILE NUMBER 21 -12 - 00538 It an asset was marls joint wlthln one year of the decedent's date of death, It must be roportsd on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT Sandra LeAnna H. Bowman q 3 Northfield Way Mechanicsburg, PA 17050 Daughter Linda Lee Myers g 1002 Baythome Drive Mechanicsburg, PA 17050 Daughter JOINTLY OWNED PROPERTY: ITEM LETTER NUMBER FOR JOINT TENANT DATE MADE JOINT Include name o nan al ins n an bank account numbs or similar idenli n number. Attach deed for olnd -held real ~ 9 i Y estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1 A & B 06/02/2009 M&T Bank 2,o~s.sa 33.3°~ 672.23 Checking Acct. #950743220 2987 I 2 ~ A & B 12/20/2010 Mid Penn Bank ~oa,ats.8o 33.3°l0 36,139.90 i i I I I Checking Acct. #1800802 9050 I I i I I I I TOTAL (Also enter on line 6, Recapitulation) I 38,812.13 COMMONWEALTN OF PENNSYLVANIA ttJF1ERRANCE TAX RETURN REeIDENT DECEDENT SCh~U.E H ~Fl~Bil1LDS~ /~A~i7~B 1 EV~~ ESTATE OF Hendry, Thomas O. FILE NUMBER 21 -12 - 00538 Debts of decedent must be reported on Schedule 1. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Malpezzi Funeral Home 5,479.85 2 Expenses after graveside services for food, etc. 538.59 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees Debra K. Wallet, Esq, 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 l~vedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Proparer's Fees 7. Other Adminlatrative Costa 1 Postage, photocopies, mileage, etc. 3, 500.00 424.50 30.00 TOTAL (Also enter on line 9, Recapitulation) 13,629.39 ScF~dI~eH COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~'^F~ ~w ~ ~ ~,,,.,ai,..~~ a.1A 11~ Rmrf ESTATE OF Hendry, Thomas O. flLE NUMBER 21 - 12 - 00536 2 Tri-State Movers (furniture move out of Cumberland Crossings) 411.12 3 Robert C. Grove Insurance Agency (homeowner's insurance) 916.66 4 PP&L 677.60 5 Verizon 538.67 6 Penn Waste 38.20 7 Tuscarora Wayne Insurance (house & liability) 1,074.20 Page 2 of Schedule H SCH~DULEI DEBTS OF DECEDENT, MORTGAGE CO1Ah1ONY/~TMOF/'~`~"""~" uwENrt~NDErocREfUr1N LIABILITIES & LIENS s RESIDENT DECEDENT FlLE NUMBER ESTATE OF Hendry, Thomas O. 21 -12 - 00538 Report debts incurced by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Continuing Care RX (prescription medications) 417.96 2 Hanger Inc. (cervical collar ftom emergency room visit) 16.69 3 Department of Veterans Affairs (prescription medications) 15.00 4 Verizon ~ 264.74 5 Buchanan and Erb (air conditioning repair) 220.00 6 Buchanan and Erb (oil) 693.03 7 Penn Waste 82.55 8 Reimbursement to Social Security 1,363.00 9 Reimbursement to Federal Pension 139.61 10 Cumberland Valley School District real estate taxes 1,891.86 TOTAL (Also enter on Line 10, Recapitulation) ~ 5,1i94.44 REV-1617 p(a (11-0!) ~ SCHEDULE J COM NHENRITANCETAXRETURNAN~ BENEFICIARIES RESIDENT DECEDENT ESTATE OF Hendry, Thomas O. FILE NUMBER 21 -12 - 00538 NUMBER NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO DECEDENT SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) _. RECEIVINQ PROPERTY Do Not uu Tn~s) I~ TAXABLE DISTRIBUTIONS [include outright s ousel d~stributlons and transfers under Sec. X116 (a) (1.2)] 1 Sandra LeAnna H. Bowman Daughter Hammond Organ, 3 Northfield Way Metropolitan Life Mechanicsburg, PA 17050 stock, and real property and _ fumiture contained therein at 34 Linda Drive, Mechanicsburg 2 C. Grainger Bowman, Esq. Son-in-Law Real property and 3 Northfield Way furniture contained Mechanicsburg, PA 17050 therein at 34 Linda Drive, Mechanicsburg Enter dollar amounts for distributions shown above on lines 1 51hrough 18 on Rev 1500 cover sheet, as appropriate. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 REY-1615 EX+ 19.00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hendry, Thomas O. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIV{N(3 PROPERTY ]<+ TAXABLE DISTRIBUTIONS[indude.outriyht usai diatribuhons and~nsfers under Sec. i~116 (a) (1.2)j 3 Linda Lee Myers 1002 Baythorne Drive Mechanicsburg, PA 17050 4 Peter Goodrich 2534 W. Walnut Street Colmar, PA 17815 RELATIONSHIP TO DECEDENT Do Not List Tnab~(s) Daughter Grandson FILE NUMBER 21 - 12 - 00538 _ SHARE OF E37ATE AMOUNT OF ESTATE (Words) ($$$) Residuary Estate Tools Page 2 of Schedule J I,AS~' VVgI,I. A.1~TD 'T~S'~'P~~~N'~° ®F TIC®l~~S ®. H]El®TD~Y I, THOMAS O. HENDRY, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory, and understanding, do hereby make, publish, and declare this to be my Last Will and Testament and hereby revoke all other Wills and Codicils, if any, that I have made. FIRST: It is my wish, and I direct, that after my death my body be cremated and that a suitable burial of my ashes be made at the convenience of my Executrix. SECOND: I give and bequeath to the individuals whose names are set forth in the Schedule attached to this, my Last Will and Testament, the respective legacies described on the said Schedule. I have signed this Schedule in the margin for purposes of identification. Should any of these individuals fail to survive me by thirty (30) days or should said person for any reason be unable, or otherwise refuse, to accept the gift, then that gift shall become a part ~ of my residuary estate. THIRD: I give, devise, and bequeath my real property and the furniture contained therein at 34 Linda Drive to my daughter, SANDRA LEANNA H. BOWMAN, and my son- in-law, C. GRAINGER BOWMAN, both of Mechanicsburg, Pennsylvania, so long as at least one of them shall survive me by thirty (30) days. Should my daughter, Sandra, and her husband fail to survive me by thirty (30) days, but be represented by children then living, these children shall take this real estate and furniture, per stirpes. Any unequal distribution of my worldly possessions should not be construed as a difference in my love and affection. To the contrary, I love and cherish both of my daughters equally. FOURTH: I give, devise, and bequeath all the rest, residue, and remainder of my Estate, of whatever nature and wherever situate, to my daughter, LINDA LEE MYERS, of Mechanicsburg, Pennsylvania, so long as she shall survive me by thirty (30) days. Should my daughter fail to survive me by thirty (30) days, but be represented by children then living, these children shall take, per stirpes, the share to which my daughter would have been entitled if then living. FIFTH: All interests of any beneficiary in the income or principal of this Estate, while undistributed and in the possession of my Executrix, even though vested and (~~t \1 distributable, shall not be subject to attachment, execution or sequestration for any debt, contract, obligation or liability of any beneficiary and, furthermore, shall not be subject to n pledge, assignment, conveyance, or anticipation. SIXTH: All inheritance, estate, and succession taxes (including interest and any penalties thereon) payable by reason of my death shall be paid out of and be charged generally r against the principal of my residuary estate, without apportionment or right of reimbursement from any person. In the event that a substantial portion, as determined in the sole and absolute judgment and discretion of my Executrix, of the non-probate assets such as an annuity or mutual funds are duected to be paid to a beneficiary or beneficiaries, so that the taxes referred to herein would be paid out of the probate residue passing to the beneficiary or beneficiaries of this will (whether or not the same as the beneficiary or beneficiaries under the non-probate assets), my Executrix, in the Executrix's sole and absolute judgment and discretion, shall have the right to allocate the full or partial payment of the taxes to the beneficiazy or beneficiaries of the non-probate assets. SEVENTH: In addition to all rights and powers conferred by law, I authorize and empower my Executrix and her successors, in her absolute discretion and without necessity of obtaining court approval: A. B. ~ C. D. w`,~ E. To buy investments at a premium or discount. To hold property unregistered or in the name of a nominee. To give proxies, both ministerial and discretionary. To compromise claims. To join any merger, consolidation, reorganization, voting trust „_ ~ plan, or any other concerted action of security holders and to delegate discretionary duties with `~ respect thereto. \\ F. To lend to, and buy from, my estate. ~ ~ G. To borrow and to pledge real and personal property as security therefor. ~:~ ~., H. To sell at public or private sale for cash or credit or partly for each, to exchange, or to lease for any period of time, any real or personal property, and to give options ~ for sales, exchanges, or leases. I.. To exercise any option permitted by law which she believes to be advantageous from the viewpoint of overall tax reductions, including, without limitation of the foregoing, power and authority to claim administration or other expenses either as income tax deductions or inheritance or estate tax deductions, without regard to whether they were paid from principal ox income and without requiring adjustments between principal and income for any resulting effect on income or estate taxes, and a deduction of such expenses for income tax purposes shall be given effect in computing the respective shares of all persons interested in my estate set forth herein, even though the effect is to increase the share of one beneficiary or class of beneficiaries hereunder at the expense of another; and to make such adjustments, if any, between beneficiaries with respect thereto as she shall deem appropriate in view of the nature of the transaction and the amounts involved. 7. To distribute in cash or in kind or partly in each. K. To employ agents, legal counsel, bxokers, and assistants, and to pay their fees and expenses as she may deem necessary or advisable to carry out the provisions of this Will or any Trust. The powers granted hereunder shall be exercisable with respect to all real and personal ~ ` property, including, but not limited to, income and principal held for minors or disabled beneficiaries at any time, until the actual distribution of all property. All powers, authorities and discretion granted here shall be in addition to those granted by law and shall be exercisable without leave of court. However, nothing herein shall be interpreted or construed to encourage, authorize, empower, or permit the Executrix to act or cause anyone to act in a ` i manner contrary to or inconsistent with acce ted standards of ortfolio diversific ti ~j P p a on and risk management. EIGHTH: I nominate, constitute, and appoint my daughter, SANDRA LEANNA H, BOWMAN, of Mechanicsburg, Pennsylvania, as Executrix of this, my Last Will and Testament. In the event of the renunciation, death, resignation, or inability of my daughter to act for whatever reason in this capacity, then I nominate, constitute, and appoint my son-in- law, C. GRAINGER BOWMAN, of Mechanicsburg, Pennsylvania, as Executor of this, my Last Will and Testament. I direct that no representative named above shall be required to post security for the faithful performance of his/her duties in any jurisdiction insofar as I am able by law to relieve him/her of such obligation. Any of my representatives shall be entitled to reasonable compensation for the performance of the duties set forth here. IN WITNESS WHEREOF, I have hereunto set my hand and seal this Z~ K day of December, 2009, on this, the fifth of five typewritten pages. I have also signed the left-hand margin of the first four of these pages and the attached Schedule for purposes of identification only. h ~'Z17G4~ lJ, '2~.Gra G~ THOMAS O. HENDRY SIGNED, PUBLISHED, and DECLARED by the Testator, THOMAS O. HENDRY, as his Last Will and Testament, in the presence of us, who at his request, in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses. ~~. --~ Hso au~,, ~,~..,., ac. VhGGArIwA'sSiv~ ~ S~o1~3 SCI-IEY~ULE OP SPECIAL EEQIJESTS TO LAST WILL ANI~ TESTAMEleTT OP THOMAS ®. IIEllTI~RY ,~ a. My Hammond Organ to my daughter, SANDRA LEANNA H. BOWMAN, of Mechanicsburg, Pennsylvania. R b. My tools to the husband of my granddaughter, PETER GOODRICH, of Colmar, Pennsylvania. `~ c. Any shares of Metropolitan Life Stock which I own at the time of my death to my daughter, SANDRA LEANNA H. BOWMAN, or should she fail to survive me by thirty (30) days, to my son-in-law, C. GRAINGER BOWMAN, of Mechanicsburg, _ Pennsylvania. AFFIDAVIT Commonwealth of Pennsylvania County of Cumberland We, Debra K. Wallet and ~cbiL~~ F~ w~ )~~ ,the witnesses whose names are signed to the attached instrument, being duly qualified according to law, depose and say that we were present and saw the Testator, THOMAS O. HENDRY, sign and execute the instrument as his Last Will and Testament; that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that, to the best of our knowledge, the Testator was at that time 18 years of age or older, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by ~~~ ~, 1~~t2c~- and ~f1bs~^~ 1-. ~ I ~st~ witnesses, this o'~~~'` day of ~1~` Co mks- , 2009. ~. n Notary Public COMMONWEALTH OF PENNSYLVANIA Noharial Seal Mary M. Loper, Notary P~lic Camp Mli 8oro, Cumberland Cotmiy My Corrardssion Expires Oct 27.2017 Membor. Pennsylvania Assocfaflen cf NctaMas ACKNOWLEDGMENT Commonwealth of Pennsylvania County of Cumberland I, THOMAS O. HENDRY, Testator, whose name is signed to the attached 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. eJ~~-in 4Q-` V y o THOMAS O. HENDRY Sworn or affirmed to and subscribed before me by THOMAS O. HENDRY, the Testator, this ~~9~' day of I~,~m~-mss-- , 2009. ~~ Notary Publ' COMMONWEALTH OF PENNSYLVANIA IVY Seal Mary M. Loper, Notary Pu~c Camp 41i1 Bono, CtxrlberFand Cowdy My ~ Expirea t7d 27, 2011 Member, Pennsylvania Association of Notaries 1. I am ratifying my existing will prepared by attorney Debra Wallet and signed by me on December 29, 2009, and witnessed by Robert Wallet and notarized. 2. Any writing signed by me on September 5th, 2010 regarding the disposition of my ashes and regarding any other aspect of my estate administration and property bequests is revoked. 3. Any other writing signed by me except my December 29, 2009 will regarding my estate administration and property bequests is also revoked. c Date ~ ~ /d Witness Witness ~~.-~/z~d(~ rev. ~~~~ Commonwea rh of Pennsylvania ~ ~ • County of ~ ,~ • • On this, the I ~-1 i~ of 6~, 20 ~ o ,before . me ~ ,J~-~ the undersigned officer,- . personally ap cared ~ , Known tome (or satisfactorily proven) to be the person _ whose name _ ~ subscribed~Co the iw thin instru.riment, and acknowledged that ~ executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand And official seals. 'No Pu 'c • C ,MMONWEALTH OF PENNSYLVANIA • Notarial Seal Mary J. Goutfer, Notary Public CanoU Twp., Farry G mnty _ My ComfNailCn Expires Noy. 1 Y, 2011 • °r Pannaylvanie Rsaodatlon of Notaries • ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: 3y V.I~DA Dlt. rMcchhJ;csb~.s~ ~A ~'l-o,so ' NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME: ~cbr~ 1~. I.~a1ltF' ESQ. STREET ADDRESS: ~ CITY: STATE: ZIP CODE: ~~/ N. J~.Jrt . S-. t:Mwa N ~ 4r. YA 1'}0 t ~ NAME, ADDRESS AND RELATIONSHIP (fF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: _ SA.Jal4 ~.iaahJA ~. ~aJr~r-rJ ~Y-4ybrTtlC STREET ADDRESS: CITY: STATE: ZIP CODE: 3 Noei'11~ric(~1 Ww~ Yyrc-v1,/~csLw~, tea' ~~oSo b. NAME: RELATIONSHIP: _ ~ t b fw Y . I.~a.U t l~ Q Ny fl- r klr><Q . STREET ADDRESS: CITY: ~ STATE: P ZIP CODE: 1y Iv. 3?.k. St. A~' NIfr4 L ,~ Boll c. NAME: RELATIONSHIP: STREET ADDRESS CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: Fw~tu.~ 3nr~ft STREET ADDRESS: CITY: S+'TjA4TE: Z~~CO L ?u GrUSk P, a ti- t,uo Y~e.eh~wr NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY 1.6 A~r~-4 1~1. 3~ ye.A.J 1?. ~ 10 9 ~ yo A M DATE OF CONTRACT TO RENT BOX ' NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REQUESTED .~Tw ~, .~ooS (~ ai ~pRr-Ti1Y Ht~/JR NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: b. NAME: .SRJAR,a. I.c AN.vh N. ~WN4.J I.~~ORM.N'1YCRS - Da.y •rar' STREET ADDRESS: STREET ADDRESS: ID ~b 8..r+al~tJt at . CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY D~~r~ ~t. Ml..u r - A ~ Woc c . WAS A WILL IN THE BOX? ^ YES .181 NO If yes, a. Date of will: b. Name and address of personal representative, if named In the wlll ', 1 NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: c. Name and atltlress of attorney, it any NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: 48500041046 4850041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page ~ Gf .Z INSTRUCTIONS (1) Cash: Report total only. {2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of y.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designatbn. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks; State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, ate: List and describe as fully as possible. {7) Deeds, Mortgages, Current Insurance Polietes or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280801 HARRIS6URG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION ~txd. - ~ber«.~.J 'b Kt„t R+f - DAti+) sY 1540 cta ~eelc '~ il4 t~Rtt vr(Si- f~•r11•d~l. [p . Dw.t• e, 2 Cr.«.~rer (at feu? lee Z~ Ste+r: yA . 7etiJ's LNllorw•I C .r S :r~w.s.JS ~ 'P hMet s 44etr: w w,a ~R ~4.J A e~,lA.l .eh~.r • s ACti, - F7eotrww.t fo N 7A.1. !3 !'t? ~TCOrac.l. 3•er k?l pi16E `i S • C~w.h.r Co WyTf ae~c ib F;rst ~J ~e _ SA 'Ike NaJ. 1 IRh. S r-: GI• S 1'tiGtra I:rwJ l:fa. I„rty~.rl:c G. ~ ~4. IY, 1~~ . ~ a lfMute L~~ ~•f, Owl "fl+~.,vs 0. kca! Ds L, t~c.rtr Tr}) .}y `}~ ;1 `mss { far !. M~J~f.~ T lrtc io ' } v 1 .SvJ ~ {~h L. cr cylital ~ - M~1lrranh ~ ~-}wr. fi 14 ~ - +'tirY L ~ Q, EI n-~Lr Acct >z t?~S- 0 33 Vf. w- i t belt - CD ~N[,r ~.. q t o r Accf' ~ 3teo3 r a I? Y '•w r s _ sH Mw Iq'io;t 1 CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD 18 PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNATUR~Epp~~ ~~ Wu'~S ~ 6.~0.1~- ESQ SI TORE PRINT NAME P INT NAME A ECK APPROPRIA B BELOW: PRINT TITLE DATE CkECK APPROPRIATE BOX: Atty, fur ElreG. ~~` ` I (,~ xecutor(tdx) [] Adminfstretor(trix) Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/z" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c){2)(C){i), to require disclosure of Sodal Security numbers in connection with administering state tax laws. The Department uses the Sodal Security number to Identify the decedent and personal representatives of the estate. The Commonwealth may also use the informaton in exchange of tax information agreements with Federal and local taxi autlmrities. The state law prohi6iis the Commonwealth's personnel from disciosirg conflrkntial tax information except for oSicial purposes.