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HomeMy WebLinkAbout02-22-13 1505610105 REV-1500 EX(w-ii)(FI) it lvania OFFICIAL USE ONLY PA Department of Revenue pe nnnsYF rv County Code Year File Number Bureau 2Individual Taxes INHERITANCE TAX RETURN BOX g, PA 17128-o6o1 RESIDENT DECEDENT o2/ 3 O~ Ha Harrisburg, 6-z0/__:5 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 100-18-4691 03/13/2012 05/03/1924 Decedent's Last Name Suffix Decedent's First Name MI Bogart Shirley I (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 iM 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 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Ellen Bogart Winters (717) 732-3515 REGISTER OF WILLS USE ONLY rn c'a First Line of Address Q 811 Anthony Drive co _V m Second Line of Address P1 r\3 M r\3 1:1 ~ :z 71-1 f1~ -13 `v..7 G7 (:bATE MED r1 City or Post Office State ZIP Code c __r m Mechanicsburg PA 17050 C:) -n ~ Correspondent's e-mail address: ellenbogart`nlinters@yahoo.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. S}GpNATURE OF PE ON RES NSIBLE FOR FILING RETURN DATE (f I) :~Z, ~1 D ESS ~fu Y 1)Yt ~~e eCAa, n 1C_9)) ' SIGNATURE OF PREPARER O. HER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J 1505610205 REV-1500 EX (Fl) Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate (Schedule A) 1. 2. Stocks and Bonds (Schedule B) 2. 3. Closely Held Corporation, Partnership or Sale-Proprietorship (Schedule C) 3. 4. Mortgages and Notes Receivable (Schedule D) 4. -5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 13,66 - 6. Jointly Owned Property (Schedule F) O Separate Billing Requested 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 7q / Q (Schedule G) O Separate Billing Requested........ 7. 73 VJl~ ( 8. Total Gross Assets (total Lines 1 through 7) 8. ~5 lJ 0.15 9. Funeral Expenses and Administrative Costs (Schedule H) 9. ~ 33 , 0 0 •-10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule 1) 10. , 1 © a, 0_1S- 11. Total Deductions (total Lines 9 and 10) 11. t9 3 3 05 12. Net Value of Estate (Line 8 minus Line 11) 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. ~ d b 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. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. IT 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 O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Shirley I Bogart STREETADDRESS 811 Anthony Drive CITY STATE ZIP Mechanicsburg ( PA 17050 Tax Payments and Credits: C~ 1. Tax Due (Page 2, Line 19) (1) 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + B) (2) 3. Interest ? $~1din~~3V~~x~Yu (3) 300 . (10 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 53 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 ❑ 69 c. retain a reversionary interest ❑ FAI d. receive the promise for life of either payments, benefits or care? ❑ N 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? E ❑ 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(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 sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (08-12) ~ pennsytvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: Ski r 1-f C 0, r t FILE NUMBER: Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly owned with right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM NUMBER DESCRIPTION OF DEATH ash 13, 00 TOTAL (Also enter on Line 5, Recapitulation) $ 3 , V If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+ (01-10) it pennsytvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERTrANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: j r FILE NUMBER '6 : :1 8 ®g0.Y If an asset became jdntltr owned wrthin one year of the decedents date of death, it must be reported an Schedule G. SURVIVING JOINT TENANT(S) NAME(S) r) ADDRESS ~R)ELATIONSHIP TO DECEDENT A. p `~M` ! yj,` ~"S $t thon(( r* v It4uCg.' h v- ►~~Ch011kVy,P o B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT 30I IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HEIR REAL ESTATE. VAL~UE, OF ASSET INTEREST DECEiDrENNT's INTEREST 1. A. `115`f9i (Was ~►,~~nal y Oook t?E?I~' &n f 1~3 al !l q I0. iDyl Sf . ,J a~~'sbu PA '7r Ctie~ ~n kccoaJ* Dta3 D~'f q 9 TOTAL (Also enter on Line 6, Recapitulation) $ 3 C~ 0.00 0 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsytvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT EgATE OF ~ f ~ ~ ~ ~ ~ ~ ~ FILE NUMBER This schedule must be completed and filled if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE R j N u. T /070 pl t~ SPA 171 a13.60 X 60 7o (7, aq 3.00 ~3()) 1.6 + TOTAL (Also enter on Line 7, Recapitulation) $ ` 3-0 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ t1,D-09j pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF j 6 ; ~ FILE NUMBER n ' C) C1 C4, 'r t Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL E PENSES: 2909.(70 1. 14 j QrrlfY + 11etoL I gt`mf (ve I!, cl~tk q 1 PC jj h1 tArdlor Ha vyl,4 Li ti) 300-60 5pt q key- 7S,60 bi~lrlke, 356.60 &114A.5~ Ltrge phoi05, M@.mo~00'j Meffid"41 C"A ` f loWgr<' J d,L~O 7&hk y0a nd4PS un d fo-doje)SiA Ikl Welk B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State - - ZIP _ Year(s) Commission 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant ae,----W--bt+e'+rs...._..--- Street Address- tw city [1 ~3 Anti C l ~L[~f - -J- w0 D --f j _ state zIP ~ V ~1 Uf1 Relationship of Claimant to Decedent &uft-h T r l ol1_l_C!II • W 4. Probate Fees: J 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) $ 1 33, 00 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-12) A. pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF C" FILE NUMBER 01 0.r Report debts incurr y 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 `V1lest s~o><Q M 5 l~~t~~Cal a n ao►~ ~I 10`1131 1~f 7. ?D 1 ~5+ Sh6rq its S C a 11 ~lo~a0~a c l( as8ac~ 17 ~8 %t rou, d 9/ q1 a01 a Weli,ls ;Z 2 rl4il Car e 37. r FAr50 l.- J-e c r Coo. X01 q2 I . b boy 00'~ wo(vioral 31 ? - FD ) 6- TOTAL (Also enter on Line 10, Recapitulation) $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: t FILE NUMBER: Jhir ~E a~r 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 /I© Sec. 9116 (a) (1.2).] on 1(,f e, ~1 f ~ U 8i( NO o rDYlve AA'' ~ P a n[ 15 ( t4 qq I~ JI ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF 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: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. it~l`F 12ti ~lARNf:sR. ~'UNf.?1tAl.: 1 LOR1f:. INC, 1903 MARKET STREET F1 I I T'"I°I#rPI III " CAMP HILL, PENNSYLVANIA 17011 _..;ro.A I I I=I I.I4.I m,.' 717-737-9961 717-737-4618 ROQF:RTH.IIAR\F. Ft PHONE SUPERVISOR PAX DUS.HN R. BAKER l 1(,l.A O\\\~.1).AA j)OI 1-Aj.~( :1) FUNERAL DIRECTOR March 28, 2012 Mrs. Ellen Winters 811 Anthony Drive Mechanicsburg PA 17050 Services for Shirley Bogart March 15, 2012 Cremation Package #4 $ 21450.00 Cremation Container $ 140.00 Cash Advanced Newspaper Notice/Local $ 128.00 Certified Copies 60.00 Coroner Fee 30.00 Total: $ 218.00 $ 2;808.0G Check from Insurance Company: $ 9,236.58 Refund check: - 2 808.00 Account Activity https://online.mymetrobank-coni/Accounts/Activityaspx?i=3 4/19/2012 Debit WF Consumer AUTO PAY ($839.58) $2,373.81 BOGART, SHI RLEY 4/13/2012 Credit INTEREST PAYMENT $0.47 $3,213.39 -f 4/11/2012 DFA CARD SERVICE AUTO PAY MRS ($39.28 $3,212.92 SHI RLEY*BOGART 4/9/2012 Debit UNITED OF OMAHA INS PREM SHIRLEY BOGART R'R KM PPJCi~ ($5.50) $3,252.20 4/5/2012 Debit RB FR DDA TO DDA 000542046537 ($600.00) $3,257.70 F-21 4/2/2012 Debit WERB FR DDA TO DDA 000542046537 ($110.00) $3,857.70 %F 3/19/2012 Debit WF Consumer AUTO PAY BOGART,SHIRLEY ($380.61) $3,967.70 D Technical Support: 800-204-0541 Copyright 02009 Metro Bank Online Banking. Member t: RX All Rights Reserved. - Metro Bank is a wholly owned subsidiary of Metro Bancorp, Inc. and is not affiliated with Metro Bank Ltd, Great Britain 3 of 3 2/18/2013 7:05 PM WEST SHORE EMS - BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 (800) 367-0512 Federal Tax ID: 23-2463002 Credit Statement As Of 02/1212013 Patient Name: SHIRLEY I. BOGART Patient Number: 107131 Guarantor Name: SHIRLEY I. BOGART Call Number: 22582OW 811 ANTHONY DR MECHANICSBURG, PA 17050 Date Of Call: 01/16/2012 Description of Payment / Credit _ Receipt Number Credit Date Amount Bad Debt Write Off 08/0912012 -174.88 PAYMENT - DISCOVER 08/09/2012 174.88 Bad Debt Write Off 07120/2012 174.88 Total Payments / Credits As Of 02/12/2013 174.88 Total Charges As Of 02/12/2013 174.88 Current Balance 0.00 WEST SHORE EMS - BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 (800) 367-0512 Federal Tax ID: 23-2463002 Credit Statement As Of 0211212013 Patient Name: SHIRLEY 1. BOGART Patient Number: 107131 Guarantor Name: SHIRLEY I. BOGART Call Number: 226440W 811 ANTHONY DR MECHANICSBURG, PA 17050 Date Of Call: 02/07/2012 Description of Payment/ Credit Receipt Number Credit Date Amount Bad Debt Write Off 08/09/2012 -147.90 PAYMENT - DISCOVER 08109/2012 147.90 Bad Debt Write Off 06/04/2012 147.90 Denied by Insurance - FEP (electronic) 03/09/2012 0.00 Denied by Medicare 03/02/2012 0.00 Total Payments / Credits As Of 02/12/2013 147.90 Total Charges As Of 02/12/2013 147.90 Current Balance 0.00 LOCAL REGISTRAR'S CERTIFICATION O DEATH WARNING: It is illegal to duplicate ti`a& copy by photostat or photogt aph, Fee 'wi this cernf iciiw, `x;6.00 (t) c'tsI '.t t ! .t 4d ~/Lltt-~~ P 18161167 MAR I 4 Certification Number Type/Print in COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE OF DEATH Black Ink State Fife Number: 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell M Shi-rle Bo art emale 100-18-4691 cih 2012 i So. Age-Last Birthday (Ym) 5b. Under 1 Y.ar Sc. Under 1 Da 6. to of Birth (MO/Day/Y.ar) (Spell Month) 7'.W place (City and State or Foreign Couniryj Months Days Hours Minutes rnin W 87 May 3 1924 7b. Birthplace (County) go. Residence (State or Foreign Country) Bb. Residence (Street and Number - Include Apt No.) Bc. Did Decedent Lire in a Township? Penns lvania MYes, decedent lived in HaLapden t. Bd. Residence (County) 811 Anthon rland Be. Residence (Zip Code) Dr . C3 No, decedent lived within limits of city/b, RE". Armed Forces? 10. ,Iarltal Status at Time of Death r3 Married Wldowed 11. Surviving Spouse's Name (if wife, give name prior to first marriage) 0 Yes M No 0 Unknown Divorced 0 Never Married 0 Unknown 12. Father's Nama (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Arthur Bo Jan Eunice Coon 14a. Informant's Name 14b. Relationship to Decedent 1114, . Informant's Mailing Address (Street and Number. City, State, Zip Code) Ellen Winters Dau ter 811 M110 Dr. Mechanicsburg, PA 17050 ,~i, •---•i---.f D.e..a1.th - Oc . c.u.r r red ed S S.om ec..on a ewh¢re Other Than a HosPitai_... If Death Occurred In a Hospital: Inpatient : Ocrh Hosplc. Facility Decedent's Ham. Emergency Room/Out atlent Dead on Arrival ) Nursing Home/Long-Term Care Facility Other (Specify) lSb. F.cillty Name ()f not Institution, give street and number] 15 A. City or Town, State, and Zip Code 15d. County of aath 811 -Anthony Dr. Mechan3csbur , PA 17050 Cumberland • 16a. Method of Disposition Q Burial Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or ,her place) E3 Removal from State 0 Donation Other 5 IfV1 3/15/2012 Hollinger Crematory 16d. Location of Disposition (City or Town, State, and Zip) 17a. afure of Funeral Service nsee son i ar of Interment 17b. License Number Mt. Holly Springs, PA 014819 E 17c. Name and Complete Address of Funer Facility s ers-Hamer FLl.. Home Inc. 1903 Market St., Camp Hill, PA 17011 18. Decadent', Education - Check the box that best describes the 19. Decedent of Hispanic Origin - Check the 20. Decedent's Race - Check ONE OR MORE races to indicate what highest degree or lave[ of school completed at the tlm, of death. box that best describes whether the d...dent the decedent considered himself or herself to be- E3 Bth grade or less Is Spanish/Hispanic/Latino. Check the "No., White 0 Korean 0 No diploma, 9th - 12th grad. box If decedent Is not Spanish/Hispanic/Latino. Black or African American 0 Vietnamese 0 High school graduate or GED completed IN No, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native E3 Other Aalon }ff Som. college credit, but no degree 0 Yes, Mexican, Mexican American, Chicano 0 Asian Indian 0 Native Hawaiian ~j Associate degree (e.g. AA, AS) 0 Yes, Puerto Rican 0 Chinese 0 Guamanian or Chamorr< E3 Bach.i.e. degre. (e.g. BA, AS. BS) 0 Ys Cuban 0 Filipino 0 Samoan 0 Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) 0 Yees, , other Spanish/Hisp..WLatino 0 Japanese 0 Other Pacific Islander 0 Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) 0 Other (Specify) e. - MD DDS OVM LLB JD 21. Decedent's Single Race Self-Designation - Check ONLY ONE to Indicate what the decadent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of -o IN White - Japanese 0 Samoan done during most of working life. DO NOT USE RETIRE[ E3 Black or African American 0 Korean 0 Other Pacific Islander 0 American Indian or Alaska Native C3 Vietnams. 0 Don't Know/Not Sur. Sec- 0 Asian Indian O Other Asian 0 Refused 22b. Kind of Business/Industry L3 y E3 Chinese 0 Native Hawaiian 0 Other (Specify) may 0 Filipino 0 Guama plan or Chamorro SOC1.a1 .S, ecllrlty AC~min . ITEMS 2111a - MU E COMPLETED 23a. Date Pronounce Dead Mo Day r 23b. Signature o e on Pronouncing Death (Only wh¢n app icable) 23c. LI N er BY DEATH PRONOUNCES OR Q/. / (ty~~. 23d. Date Bign.d (MO/Day/Yr) 24. Tim1 of Death/"' - Z_ Was Medical Examiner or Coroner Cont.cted? Yes No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events-diseases, Injuries, or complications-that directly caused the death. 00 NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary Onset to Deal IMMEDIATE CAUSE !S T'-r GS ZJ .STY't/c--~`a-ti'C=-a.•r...v l~'7 ~'-'C s..GL (Fine) disease o ndldon Due to (o as a consequence of): resulting in death) b. Sequentially list conditions, Due to (or as a consequence of): If any, leading to the cause I lsted on line a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): fi (disease or Injury that initiated the events resulting d. In death) LAST. Due to (o as a consequence of): 26. Part 11. Enter othersignificant conditions contributing to death but not resulting in the underlying cause given in Part 1 27. Was an autopsy performed? s p Yes No 2B. Were autopsy findings available m to complete the cause of death? D Yes No 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death 0+'N Ot pregnant within past year Q'Tes 0 Probably [a-ilritural 0 Homicide C3 Pregnant at time of death 0 No 0 Unknown 0 Accident 0 Pending Investigation [3 Not pregnant, but pregnant within 42 days of death 0 Sulcide E3 Could not be determined i- 0 Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (Mo/Day/Yr) (Spell Month) Q 0 Unknown if pregnant within the past year 33. Time of Injury O 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury at Work 37. 1PTransp1rtatlon Injury, Specify: 3g. Describe How Injury Occurred: E3 Yes 0 Driver/Operator 0 Pedestrian E3 No 0 Passenger 0 Other (Specify) ~.r~tIfT (Check only one): I~ c.ertifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated 0 Pronouncing a Certifying physician -To the best of my knowledge, death occurred at the time, data, and place, and due to the cause(s) and manner stated 0 Medical Examiner/Coroner - On the basis of examination, and/or investigation, In my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner state Signature of certifier: S Title of c.rtifler: yn License Number: ~pbS.`3 7 ~"+L 39b. Name, Address and Zip Coda of Person Completing Cause of ~a Lf, item 26 CC N 39c Dafe Signed (MO/Day/Y0 GREG R. EHGARTNE ~ egistrar s District Number 41. Registrar's 5 Cure 42. Registrar File Date (MO Day/Yr) 43. Amendments -143 06 70911 Disposition Permit No___. REVHIO07/20 07/2011 LAST WILL AND TESTAMENT (Pour-Over Will) OF SHIRLEY BOGART IDENTITY I, SHIRLEY BOGART, residing in the County of Cumberland, Commonwealth of Pennsylvania, being of sound mind and memory, and not acting under duress or undue influence of any person whomsoever, hereby declare this to be my Last Will and Testament, and I do hereby revoke all other former Wills and Codicils to Wills heretofore made by me. My Social Security Number is 100-18-4691. I have the following child: Ellen Winters, born September 21, 1954 and currently residing in Mechanicsburg, Pennsylvania. DEBTS, TAXES AND ADMINISTRATION EXPENSES I have provided for the payment of all my debts, expenses of administration of property wherever situated passing under this Will or otherwise, and estate, inheritance, transfer, and succession taxes, other than any tax on a generation-skipping transfer that is not a liability of my Estate (including interest and penalties, if any) that become due by reason of my death, under THE SHIRLEY BOGART REVOCABLE LIVING TRUST executed on even date herewith (the "Revocable Trust"). If the Revocable Trust assets should be insufficient for these purposes, my Executor shall pay any unpaid items from the residue of my Estate passing under this Will, without any apportionment or reimbursement. hi the alternative, my Executor may demand in a writing addressed to the Trustee of the Trust an amount necessary to pay all or part of these items, plus claims, pecuniary legacies, and family allowances by court order. PERSONAL AND HOUSEHOLD EFFECTS It is my intent that all my personal and household effects were transferred to the Revocable Trust as a result of the Declaration of Intent signed this date. If there are any questions regarding the ownership or disposition of these assets, it is my desire that such assets pour into the Revocable Trust, signed by me this date in accordance with the provisions of the section titled "Residue of Estate." RESIDUE OF ESTATE I give, devise and bequeath all the rest, residue and remainder of my property of every kind and description (including lapsed legacies and devices), wherever situated and whether acquired before or after the execution of this Will, to the Trustee under that certain Trust executed by me on the same date of the execution of this Will. The Trustee shall add the property bequeathed and devised by this item to the corpus of the above described Trust and shall hold, administer and distribute said property in accordance with the provisions of the said Trust, including any amendments thereto made before my death. If for any reason the said Trust shall not be in existence at the time of death, or if for any reason a court of competent jurisdiction shall declare the foregoing testamentary disposition to the Trustee under said Trust as it exists at the time of my death to be invalid, then I give all of my Estate including the POUR-OVER WILL Page 1 Testatrix . residue and remainder thereof to that person who would have been the Trustee under the Trust, as Trustee, and to their substitutes and successors under the Trust, described herein above, to be held, managed, invested, reinvested and distributed by the Trustee upon the terms and conditions pertaining to the period beginning with the date of my death as are constituted in the Trust as at present constituted giving effect to amendments, if any, hereafter made and for that purpose I do hereby incorporate such Trust by reference into this my Will. EXECUTOR I hereby nominate and appoint Ellen Winters to serve without bond as my Independent Executor of this my Last Will and Testament. Whenever the word "Executor" or any modifying or substituted pronoun therefore is used in this my Will, such words and respective pronouns shall be held and taken to include both the singular and the plural, the masculine, feminine and neuter gender thereof, and shall apply equally to the Executor named herein and to any successor to substitute Executor acting hereunder, and such successor or substitute Executor shall possess all the rights, powers, duties, authority, and responsibility conferred upon the Executor originally named herein. EXECUTOR POWERS By way of Illustration and not of limitation and in addition to any inherent, implied or statutory powers granted to executors generally, my Executor is specifically authorized and empowered with respect to any property, real or personal, at any time held under any provision of this my Will: to allot, allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, contract with respect to, continue any business of mine, convert, deal with, dispose of, enter into, exchange, hold, improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise options with respect to, take possession of, pledge, receive, release, repair, sell, sue for, make distributions in cash or in kind of partly in each without regard to the income tax basis of such asset and in general, exercise all of the powers in the management of my Estate which any individual could exercise in the management of similar property owned in its own right upon such terms and conditions as to my Executor may seem best, and execute and deliver any and all instruments and do all acts which my Executor may deem proper or necessary to carry out the purpose of this my Will, without being limited in any way by the specific grants or power made, and without the necessity of a court order. My Executor shall have absolute discretion, but shall not be required, to make adjustments in the rights of any Beneficiaries, or among the principal and income accounts to compensate for the consequences of any tax decision or election, or of any investment or administrative decision, that my executor believes has had the effect, directly or indirectly, of preferring one Beneficiary or group of Beneficiaries over others. In determining the Federal Estate and Income Tax liabilities of my Estate, my Executor shall have discretion to select the valuation date and to determine whether any or all of the allowable administration expenses in my Estate shall be used as Federal Estate Tax deductions or as Federal Income Tax deductions. POUR-OVER WILL Page 2 Testatrix SPECIFIC OMISSIONS I have intentionally omitted any and all persons and entities from this, my Last Will and Testament, except those persons and entities specifically named herein. If any person or entity shall challenge any term or condition of this Will, or of the Living Trust to which I have made reference in the sections "Household and Personal Effects" and "Residue of Estate," then, to that person or entity, I give and bequeath the sum of only one dollar ($1.00) only in lieu and in place of any other benefit, grant, bequest or interest which that person or interest may have in my Estate or the Living Trust and its Estate. SIMULTANEOUS DEATH If any other Beneficiary should not survive me for sixty (60) days, then it shall be conclusively presumed for the purpose of this my Will that said Beneficiary predeceased me. SHIRLEY B WART Testatrix This instrument consists of 5 typewritten pages, including the Attestation Clause, Self-Proving Clause, signature of Witnesses, and acknowledgment of officer. I have signed my name at the bottom, of each of the preceding pages. This instrument is being signed by me on this G~i 1•~ day of rykC POUR-OVER WILL Page 3 z ATTESTATION CLAUSE The Testatrix whose name appears above declared to us, the undersigned, that the foregoing instrument was his/her Last Will and Testament, and he or she requested us to act as witnesses to such instrument and to his/her signature thereon. The Testatrix thereupon signed such instrument in our presence. At the Testatrix's request, the undersigned then subscribed our names to the instrument in our own handwriting in the presence of the Testatrix. The undersigned hereby declare, in the presence of each of us, that we believe the Testatrix to be of sound and disposing mind and memory. Signed by us on the same day and year as this Last Will and Testament was signed by the Testatrix. WITNESSES: ADDRESSES: 110 1( (Printed ame of Witness) City, State, Zip z Z/- 3,5-/,3 (Printed Name of Witness) City, State, Zip POUR-OVER WILL Page 4 Testatrix a COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SELF-PROVING CLAUSE BEFORE ME, the undersigned authority, on this day personally ap eared SHIRLEY BOGART, Z and C j M. ( ,known to me to be the Testatrix and the witnesses, respectively, whose names are subscribed to the foregoing instrument in their respective capacities, and all of them being by me duly sworn, SHIRLEY BOGART, Testatrix, declared to me and to the witnesses, in my presence, that the instrument is his/her Will and that he or she had willingly made and executed it as his/her free act and deed for the purposes therein expressed; and the Witnesses, each on his or her oath, stated to me in the presence and hearing of the Testatrix, that the Testatrix had declared to them that the instrument is his Will and that he or she executed the same as such and wanted each of them to sign it as a witness; and upon their oaths, each witness stated further that he or she did the same as a witness in the presence of the Testatrix, and at his request and that he or she was at that time eighteen (18) years of age or over and was of sound mind, and that each of the witnesses was then at least fourteen (14) years of age. 44_D8__1_r ~ 2 SHIRLEY BOG W Testatrix Witnes wU t~ 2 SGI,- (Printed A me of Witness) C /c"Ae 4 /Li 24,s,o (Printed Name of Witness) SUBSCRIBED AND ACKNOWLEDGED before e by SHIRLEY BOGART, Testatrix, and subscribed and sworn to before me by V' -Z- and 'C >m - k t witnes es, this the day of No ary Public, Cld onwealth of Pennsylvam n~G01-,nrs~" !n Ex Rres May 3, 2004 1 POUR-OVER WILL Page 5