HomeMy WebLinkAbout07-24-13 (2) J 1505610105
REV-1500°`��.">��'�
or�wuLL use aN�r
PA DePartment of Revenue � Cpnly CoCe Y�r Fk NuMx
BureauofIndlvlduatTaxes INNERITANCETAXRETURN a
ro eox�eocw�
riarr�sbu�,Pn i�uBa6oi RESIDENT DECEDENT I I 3 9 Q
ENTER OECEDENT INFORMATION BF10W
Sadel 3ecuAly Number Date of DeeN MMDDYYVY Date of Bhtli MMODYVYY
05/23I2073 04/0211924
DecedeM's Lsst Name Suflbc DecedeM's Fkst Neme MI
ROSS LEOTA r,
(M ApplleabN)EM�r Survivinp Spows's InMnnetlon BNow
Spouse's LaM Name SWfix Spouse's Fi�st Neme MI
Spouae's Sodal Securily NumDer
THIS RETURN MUBT BE FILED IN DUPLiCATE WIiH THE
REGI3TER OF WILLS
flLL IN APPROPRIATE OVAL8 BELOW
� t.Originel ReWm O 2.Supplementel Retum O 3. Remeinder RNUm(Da[e of Deetli
Prior l0 12•1382)
O 4.LlmNed Estate O 4s.Future Interest Compmmiee(dete of O 5. Fedaial Estab Tez Rslum Requked
OeaCieRerl2-12-62)
(� 8.Deoetlent OIeE Tesqte O 7.DacedeM Meinfelired a LIWng Tnist 0 8. TWeI Num6er of Sefe Depoeit Bo�ces
(Attech Copy oi Wfll) (Attaeh Copy of Trusl)
O 9.LitlpeGOn P�Received O 10.Spaueel Po�arty Cro6t(Date o/Dealh O 11. ENcibn to Terz utWx Sse.9113(A)
Bstwesn 7231-91 and 1-1-85) (AMach Schedub O)
f�lEBPOMDENf-THIS BECTON MUBT BE C0�lLE�ED.ALL CORRESPONDENCEAND CONFlDENNIL TAl(INFOR�IATION DIpUID!E DIRECTED T0:
Name Daytlme Telephone Number
RICHARD A ROSS (717)786-4058
neo�R oF Mnu.s uae ow�r
Fhst Lkie ofAddress
2532 ARCONA ROAD
s�d u�a naa�g
Ciry or Post Olfice Stete ZIP Code ��F��
MECHANICSBURG PA 17055
Corts�pond�nCs smdl addms:fros84wbIC@lBrthlink.Mt
UrMn pe'mltlN aT pwJVy.l tlecWa tlrt I hwe eoumhie0 MM ntlRn�triduAkq axartqrryln9 acM0�1N BM qaMnNnb�entl b Ms Oaet dmy knwvNdp�entl bdbf�
tt le true�canaG aM comPlsb.Dedmatlon d pM�K o1hBr Man MB D��I rep�tlVe le baeed on ell inkrmatlm a�wllidi WeWrer Ims arry knowleCgs.
316NA1}y2E OF),yEft80y��ON&�I.E FOR FILING RENRN ��� /�
1[!��e�'it.t�` U "�ca.d•
noonESs
SAME as CORRESPONDENT(above)
SI6NA7URE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
r�we we aeo�wu.sow�o�r
Side 1
L 1505610105 150561�105 �
�
� Lsas6laaos
REV-1500 EX(Fq p�rs Sociel Secviily Number
oawa.�r.N.�: ROSS, LEOTA G
RECAPRULA710N
1. Real Eafate(Schetlule A). ............................................ 1.
z. Stodcs and Bonds(Schedule B) ....................................... 2. 294,078.00
3. Cbsaly Held Cqporafbn,Paifigrship w Sole-Proprietorahip(StheAule C) ..... 3.
4. Mor�geges and Ndes ReceNede(Schedule D)........................... 4.
5. C�A,Bank Deposits and Miscelleneoua Pe�sonal PropeAy(3chedule E)....... 5. 42,38G.00
6. JoirXty Owned Property(Schedule F) O Separate BNNrg Requested ....... 6.
7. IMer-Vhos Twnafers 8 MlsceNeneous Nai-Probete Property
(Schedule G) O Seperate BIIGng Requested........ 7.
8. Total Gross AssNS(total Lk�es 7 Mrough 7)............................. B. 3SO�18Z.00
9. Fun�al expenses and qdminishauve Coeta(Schadule H)................... 9. 11,789.00
io. oeeis a oe�eaerrt.Mon9aee uawnnes ara uens�sa,aa��e q............... io. 9,378.00
11. ToFal Deducdont(Mtal Lhres 9 and 70)................................. 11. E7�1B7.00
�2. Nst va�w ot Est�a(une 8 m�nus une t�).............................. �2. 315,295.00
t3. Cheritade and Govem�l Bequeate/$ec 9113 Truats for which
an eleaion to mx hae not been made(Sdiedule J) ........................ t3. 31,530.00
�a. N.e wms sue�.ce w rax�une iz minue�ine�s> ........................ �a. 283.766.00
TAl(CALCULATION•SEE INSTRUCTIONS FOR MPUCABLE RATES
15. lvnount of Lifre 14 tarzable
at the spousal tex rate�w
trerrefers under Sec.9116
(axt2)X.0_ 15.
�s. a,mamc a ur�e�a r�ene
et nneal rate x.0 45 283,788.00 �g, 12,768.47
��. a�wM a u��a r�aa
��on���e x.�z n.
78. Amount of Une 141axable
al cdlaBeral rete X.15 18.
�s. r�x�ue......................................................... �e. 12,789.47
20. FlLL IN THE OVAL IF YOU ARE REWlESTN6 A REFUND OF AN OVERPAYM6NT �
Side 2
� 1505610205 1505610205 J
REV-1500 EX(FI) Ppe 3 iIN Numb�r
DecedenYs Complete Address:
LEOTA G. ROSS
--------- --------
STREETADDRESS --------- — - -----
222 MESSIAH CIRCLE N&D
---- --- --____ _ _
cm STA7E na
MECHANICSBURG PA 17055
Tax Payments and Credks:
1. Ta�c Due(Page 2,Line 19) (1) 12,789.47
2. CreditalPayments
A.Prior Payments
B.Diecount 638.47
Total Credtts(A+B) (2) 838.47
3. Interest
(3)
4. N Line 2 is gr�ter than Line 1+�3,emer Ihe dMerence. This it the OVERPAYMENT.
Fn�In wa�on r.p.2�un.ZO 6o nqua►a wrund (a)
5. If Line 7+Line 3 is greater then Line 2,eMer tl�e dHference.This is the TAX DUE (5) 12,131.00
Make check payable to: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X"IN THE APPROPRIATE BLOCKS
1. Did decedent rr�ke a transier ard: Yes No
a. retain the uae a incane of the pioperly 6a�sterted.......................................................................................... ❑ �
b. retain the rigM b designaEe who ahaq use Ihe propMy transferred a ils inmme............................................ ❑ �
c. retein a reveroiaiary ir�rest.............................................................................................................................. ❑ �
a. re�re n�e pranree r«�ife a eitl�peymena.nener�ts or cere�...................................................................... ❑ ■
2. H dealh accurred afler Dec.12�1982�did decedent harofer property within one yesr d death
witlwut receiving adequeM conakle�edon?.............................................................................................................. ❑ �
3. Did deoedenl oxm an'in cual for'or payeMaupaMeeth benk axouM a secudty at his a her death?.............. ❑ �
4. Did decedeM own an indiuidual�etiremeM accouM,armuity or dher twn-Probele WoPeKY,which
conteins a benBfiCiery deaignelion? ........................................................................................................................ ❑ �
IF THE/UISYYER TO AN1`OF THE ABOVE QUESiWNS IS YES,YOU MUST COMPLEiE SCHEDULE G AND FlLE R AS PART OF THE RETURN.
For dates o(death on a aRer July 1,1994,and befae Jan.1.1995,tlre fax rate imposed on the net value of trans(ers to a fa Ihe use of the aurvivirg spouse
is 3 perceM[72 P.S.§9116(a)(1.1)(i)]•
For dates of dealh an a afler Jan. 1, 1995, the tax rate imposed on the net value ot transfers W a for Mie uae of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(if)].The staWte does not exempt a transter fo a survNkig spouse from tax,and the statutay requirert�en(s for disdosure of assets and
filing a lax retum are stiN applicaMe even'rf tlie surviving spouse is tt�e ony be�iaary.
Fa dates of d�di an a aNer July 1,2000:
• The ta�c rate imposed on the net value of hansfers from a deceased child 21 yeaB of age or younger at deatli to a for tl�e use M a natural pareM,an
adoptive parent a a stepparent oi the child is 0 percent�72 P.S.§9116(a)(1.2)�.
• The fax rete imposed an the net value of transfers to afar tha uae of Ihe decedeM's I�ber�Ciaiies fs 4.5 percent,except as nMed in(72 P.S.§9116(aHt)j.
• The fax rate imposed on tl�e net value of transfeis W or for tlie use of the decedenPs�Wings is 12 percent[/2 P.S.§9116(a)(1.3)].A sibling is defirred,
under Section 9102,�an individual who has at least one perent in common wilh fhe decedent,whether by blood or adopUai.
�-15a3IX+(8a1)
'�pennsytvania BCNEptILE B
OBAFMBlf OF PEVBIUE
INHER[TANCETAXRERAiN STOCKS & BONDS
RESIOEfVf DECEDEfJI'
ESTATE OF FiLE NUMBER
LEOTA G ROSS ( 2�-�3.p5gp
�YroMKY 1drMY mwned wMh ripM M wMvonldp muR be N�on Sd�k F.
ITEM VALUE AT DATE
NUMBER DESC0.IP'RON OF DEATFI
i. Weaee tefer b the aMadied"SNAPSHOT by Wells-Faigo(MeY�-MeY 31,2013),
"shows Tot�value of 376,058.35_minus 21,962.01 Cash&sweep=294,W8(raxMed) 294,076.00
Ic�n a�na�ere u�rod o�s�d���
TOTAL(Also enter on line 2,RecapiNladan) ; 284,076.00
[f mare space is neMed,insert addltlonal shee[s ai the same sitt
� Q� .
" $ LO �
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REV-t5o8 EX+(o8n2)
�pennsylvania SCM�p11LE E
DEPANiMENTOFPEVENUE CASN, BANK DEPOSITS � MISC.
INHEMANCE TN(RETUIIN PERSONAL PROPERTY
RESiDENfDECEDENT
ESTATE OF: FILE NUMBER:
LEOTA G ROSS ( 21-13-0590
[nclude Me proceeds of Ittigation a�tlre date the praceeds were received by Me estatc.
�MoP�Y 1aM1Y ownad wkh ApM of wrvlvanMp muR ba dbtla�ad on SdNduN F.
17Er1 VALUE AT DATE
NUMBER DESCRiFf[ON OF DEATH
1. Cesh end aweep in We9s Fargo(pbaae aee aUadtment Eo SChedule B) 21,982.00
2. P�����9�M(����) 9,047.00
3. PNC BaMc rtwney merket(50-02055781) 10,157.00
4. PeK!!�(aPProX•) 150.00
5. ��1�rY���9 N,d�c,etc.(�in her small,aemi-privaEe toom in Nursin9�) 500.00
[everytliing elee v�s d�hributed...saon aftx ahe hed 6o be moved hMo Nursfng Care�
6. F��T��� 550.00
TOTAL(Also enter on Line 5,Recapituiatlon) ; 42,386.00
If mare space is neWeG,�se aaamonai�n�a��r a n,e�m�m.
PEV-1511 EX+(10-09)
p�nsylvarria SCHEDULE H
UEMNTMEHTOFNEVENUE FUNERAL EXPENSES AND
'""�T""�T"'��"" ADMINISTRATIVE COSTS
nES��xr o�oerr
ESTATE OF FILE NUMBER
IEOTA G. ROSS ( 21-13-0690
D�adanc's dabb muK ba roparNd on SdiMula I.
ITEM
NUMBER DESCRIP'fION AMOUNT
n. FUNERALEXPENSES:
1. OaWaries bY�reene CouMy A�ertro�d Park 70.00
z. Travel E�ense 1,719.00
a. Washinpton Street United Metlwdist Churc;h;Wayneeburg,PA 300.00
e. ADMIN[STRATIVE COSTS:
1. Porsonal RepresenUtive Commissians: 8,085.00
Name(s)of versonai Represenwtive(s) RICHARD A. ROSS _
strect address 2532 ARCONA ROAD ____
�ty_MECHANICSBURC� ____ ____ 5tate?A_ZtP_��055
Year(s)Commisslon Paid: 2013 ____
2• Attomey Fees:
3. Famlly Exempdon: pt decedmt4 addras is not the same as claimaM's,attach explanatlon.)
GaimaM_.___ _ _
Street Address . _ __
GN State___ZIP
RelationshiD of Gaimant to Decedent
4. Probate fees: 615.00
5. AaoumaM rees: 500.00
6. Tax Retum Preparer Fees: 500.00
7.
TOTAL(Also enter on line 9,Recapitulation) ; 11,789.00
If mwe spece Is needed,use addidonal sheeta of paper of the same siu.
___.___ . . . .. .. .
REV-1512 EX+ (12-12J
�pECiilSy�Ydl3�8 SCN�dU�.� _
°E'""'ME"ro"'�"�E DEBTS OF DECEDENT,
INHEMMK4 TAX NFNRN MORtGAGE LIIIBII.ITIES�LIENS
Rf57DEHT0ECE0EHf
�TATE# FIEE titlMBER
LEOTA C3, ROSS � 21-13-0690
xeport aebb iMUmd h1'tl�e dxadant v�o�io eath tfiet rameMed nnpaW rt th+�ANe M da�h,tnepediap w�rdmburrad ieMiat a�nw.
� Vt�AT DATE
NUMBER DESCYiIP710N OF pEATFI
1' ����Y���Y SP��9s�Pel f 73.00
2. Me�slr tiFaweya Flane Care(Med�enicatwry�Aa) 2,443.C10
3. Messi�Lifevreys at Messiah ViNage in Nursntg C�e(AM�dianicsdmg,pa) 8,802.00
70TA1(Also cnter on tine f0,R�ittdntiar} $ 9,378.00
If more spaa Is needed,Inurt aOdPoonal sheets of the same size.
REV-1513 D(+(O1•10)
pennsytvarria SCHEDULE ]
UFPRPTMENT OFqEVENUE
IN�r,vx�nvc n�upN BENEFICIARIES
�xr oea�wr
ESTATE OF� fiL!NIMI!!R:
LEOTA G. ROSS ( 21-13-0590
rt�unaasNU To ueceoerrt AMOUNT OR SNME
NUMBER NAME ANO AUDRE55 OF VERSON(S)RECEIVING PROPERiY po Not LYR Tmt�a(�) OF�TR7E
I TAXABtE D[SiRIBUT[ONS[indude ouhiqht spoueal disMbutlons and transfers under
Sec.9116(a)(1.2).j
i. J.RONALD ROSS-243 ATIANTIC RD;GLOUCESTER,MA 01930 Firet SON 18%
2. RICHARD R0.SS-2532 ARCONA RD;MECHANICSBURG,PA 17055 Secaw!SON 18%
3. WILLUM ROSS- 1714 HUNTERS WOODS DR;HAGERSTOWN,MD ThiM SON 18%
4. TIMOTHY ROSS-4590 EAST 13�h PLACE;THORNTON,CO 80602 FouAh SON 18%
5. CATHEWNE(ROSS)RAHTER-eddresa is GO Sarah Rahter»» Only DAUGHTER t B%
>»>1281EASTALLEN SiREET;LANCASTER,OH 43130
EN7ER DOWVI AMOUNTS F0R D15iR1&RIONS SHOWN ABOVE qi LIflES 15 THRWGH 18 OF REV-I500 COVER SHEEf,0.S APPROPRIATE.
II NON-TNGBLE DISIAIBURd15
A. SPOUSAL DlSTR[BUilONS UNDER SECTION 9113 WR WHICM AN EIECIiON TO TAX[5 NOT TAKdI:
1.
8. CHARIfABLE AND GOVERNMENTAL DISTRIBUf[ONS:
1.
BRETHREN IN CHRIST FOUNDATION"-GRANTHAM,PA 17027 {"10%of Net which=31,530) •'31,530
'"'fOR FURTHER DISTRIBUTION TO EIEVEN,CHARITABI.E/fAX-EXEMPT ENTITIES
TOTAL OP PART II-ENTER TOTAL NON TAXABLE D1SrRIBUTIOMS ON L[NE 13 OF HEV-l500 COVER SHEEi. S $37,530
lf mort spate I5 needed,use addltlonal sheeGt of paper of Mt same slte.
��$ '
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LEOTA G. ROSS,
a/k/a LEOTA H. ROSS
LAW OFFICES
BRINSER, WqGNER & ZIMMERMAN
6 EAST MAIN STREET-SECOND FLOOR
P. O. BOX 323
PALMYRA, PENNSYLVANIA 77078
(717) 838•6348
�`.�,ti`.� � .. ..z l ?;_s�;. , ^Xf:.� �:'e , 9. ..z;�::°�"�'es+s��x""..
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. � - . . _ ._ �` ,��"I n 'b., .x
YYILL
UF
GE01"A G. ROSS
I, LEOTA G. ROSS, a/k/a LEOT�� H. ROSS, currently of Upper AlJen Township,
Cumberiand County, Pennsylvania, being �['sound mind and dispvsing memory, realizing
the uncertainty of this life, but with confldence in God and trust in His Son, nny Lord and
Savior, Jesus Christ, who died for m}� sins upon the cross and rose again to redeern me
and give me eternal life, do hereby make. publish and dec2are this to be my Last Wi1l anc�
Testarnent, hereby ravoking any and all prior Wilis and Codicils made by me.
L I direct that all my jnsi debts and fuoeral expenses be paid fram the asseES af my
estate as soon as practicable after my demise.
TT. I direct that atI estate and inherihance taxes that may be assessed in consequence of
my death, shall be paid out af the principai of my general estate to the same effect as xf said
tazces were expenses af administration ard alt praperty includable in my tsxable estate
whether or not passing under this Wilt shalI be free and clear thereof.
TIZ I intend to keep with this my Will a separate memorandum cancerning disposition
of certain items of tangibte personal property. I bequeath the items on said mecnorandum to
the persons designated.
TV. I bequeath the remainder of my tangible personal praperty unto my children, to be
divid�d among themselves as they agree upon.
V. All the rest, residue and rernainder of my estate, af whatever nature and whearever
situate, including property over which I hold a power c�f appoinunent, T devise and bequeath
as folipws:
A. Ten percent (10%) unta the Brethren in C:hrist Foundation.
Grantham, Pennsylvani�, to be used for the charitable purposes F intend ta
auttine ta it by way of separxte instcvctions.
B. Ninety percent (94°!0}to be divided equully amang my ohiidren,
name2y, J. Ranald Ross, Richarci Ross, Witliarn Ross, Catherine Rahter and
Timothy Ross, or their issue per stirpes,
� i
-'fc'��/.'7i; -1- �" ��'�� E {� /✓��f''��'l;t�+�„_f
-, �
"�E t,�i� �' ,� .+.�'._�-
-- ° ,�. . -
Provided, however, the share of my daughter, Catherine, shall be
held in trust for her benefit by my hereinafter-named Trustee pursuant to the
terms and conditions set forth in Paragraph VI below.
VI. In the event that any assets of my estate pass into a trust fund for the benefit of my
daughter, Catherine, as set forth above, said assets shall be held pursuant to the following
specific terms and conditions:
A. The primary purpose of this Trust is to provide for the support,
maintenance, welfare and comfort of my daughter, Catherine, beyond what she
may receive from Governmental agencies. However, my Trustee may, in his
sole discretion, also make expenditures from it for the benefit of my other
chiidren as he deems necessary and proper.
B. My Trustee may make a one-time distribution to my daughter,
Catherine, in the amount of One Thousand Dollars($1,000). This provision is
to be exercised in his sole discretion and is not mandatory.
C. Any amounts distributed at the sole discretion of my Trustee to
or for Catherine's benefit may be used onlv to supplement but not supplant
any governmental benefits to which Catherine may be otherwise entitled. In
the event that any govemmental agency, federal, state or local, would require
distribution of either income or principal on her behalf, or in the event that
government funds to which she would otherwise be entitled would be
terminated because of this Trust, or in the event this fund would preclude her
from receiving said government funds, this Trust shall immediately terminate
and be distributed pursuant to Subparagraph D below. The Federal
iGovernment, Commonwealth of Pennsylvania and State of Ohio, and any
4 subdivision thereof, or their agencies and departments, are specifically
� prohibited from taking any income or principal of this Trust.
3 D. Upon Catherine's death, any funds then remaining, both
+� principal and income, shall pass unto her issue per stirpes. If she is not
I survived by any issue, the balance shall pass as though she had predeceased
�
s me.
t
VII. In addition to such other powers and dnties as may have been ganted elsewhere
herein, my fiduciaries hereunder shall have the following powers and duties:
�
5
� -�z�� -2- ���� `���� �
� �-
�
�
A. To invest any funds at any time held in trust, in any stocks,
bonds, notes, mutual fund shares, or other securities or properties, reai or
personal, or in one or more common trust funds, or collective trust funds
established by the Trustee, or in securities issued by the Trustee,
notwithstanding that such investments may not be of the character allowed to
fiduciaries by statute or general rules of law, it being my intention to give him
the broadest investment powers possible, inciuding the power to retain any
property which is placed in trust hereunder.
B. To retain or to lease, sell, exchange or otherwise dispose of any
property, real or personal, at any time held by him, for cash or upon credit, in
such manner and on such terms and conditions as he may deem best, and no
person dealing with him shall be bound to see to the application of any moneys
paid.
C. To bonow or loan money for any purpose in connecdon with
the administration of the property held by him upon such terms and with such
security as he may determine necessary.
D. To make any distribution hereunder in cash, in kind or partly in
cash and partly in kind.
E. In general, to exercise all powers in the management of property
hereunder which an individual could exercise in the management of similar
property owned in his own right upon such terms and conditions as he may
deem best, and to execute and deliver all inshvments and to do all acts which
he may deem necessary or proper to carry out the purposes of the trust.
VIII. No interest of any beneficiary of my estate, either in income or principal, shall be
subject to anticipation or to pledge, assignment, sale or transfer in any manner, nor shail any
beneficiary have power in any manner to charge or encumber his interest, either in income or
principal, nor shali the interest of any beneficiary be liable or subject in any manner while in
the possession of my fiduciaries hereunder for the liability of such beneficiary, whether such
liability arises from his debts, contracts,torts or other engagements of any type.
IX. Any amounts which are payable to a beneficiary under this Will may, at the
discretion of my fiduciaries hereunder, be paid to the guardian of the person and/or property
of such beneficiary, to the person who has custody of such beneficiary, or directly to such
beneficiary, or may be applied for the use or beneflt of such beneficiary. The receipt of such
guardian, custodian, or beneficiary or evidence of the application of such amounts, shall be a
full and complete discharge of my fiduciaries hereunder to the extent of such payment or
appli tion. This paragraph shaii be applicable to payments of income as well as principal.
L/ -3- Ci���-��'�� .
—_
i
iX. I appoint my son, J. Ronald Ross, Executor of this my Will. In the event that he fails
to qualify or ceases to act as Executor, I appoint my son, Richard A. Ross, Executor of this
my Will.
; XI. I appoint my son, J. Ronald Ross, as Trustee of any trusts created by this my Will. In
the event that he fails to qualify or ceases to act as Trustee, I appoint my son, Richard A.
Ross, as Trustee in his place.
XII. I direct that no bond be required of my fiduciary for the faithful performance of his
'I
duties in any jurisdiction.
IN WITNESS WHEREOF, I, LEOTA G. ROSS, herewith set my hand to this my
Last Will, typewritten on four (4) sheets of paper including the attestation clause and
signatures of wimesses,this �1��� day of `-(')'�;p;� , 2010.
' ��������
' LEOTA G. ROSS
Signed by LEOTA G. ROSS, by her declared to be her Will in our presence, who
have hereunto subscribed our names as witnesses in her presence and at her request,this
��`u". y of "f1r�t,tt.,'t� , 2010.
�
� � residing at ��_ �., �
��Yt�-�u�.� � �G�� residing at ' .L�-..wL� �
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COMMONWEALTH OF PENNSYLVANIA .
COUNTY Ok' .
WE,LEOTA C3. ROSS, CtfiRALD J. BRINSER end F��L'f{fFrip FF , ROaS ,
the te.vtatrix and tho witnwses, rospectively, whose namos are signed to the attached or
foregoing ins4vment, being first duly affirmed, do hereby declare to the undersigned
suthority d�at the teststrix aigned and executed the insdtunent as her Lest Will aad that ahe
sigiud willingly(or willingly directed another to sign for her),end that she acecuted it as her
frx and voluntery act for the.purposas therain exprossed, and thst each of the witna9ses; in
the presence and hearing of the testaMx, signed the Will as witnesses and that to the best of
our knowledge the testatrix wes at thnt tima aighteer► yaera of age or older, of sound mind
and under no constraint or unduo influence.
d�✓� ����
OTA C3. ROSS
� D `
W�Y IJSSS
�Lcc�,� �•i��'�cu./i
�ITNE3S
Subaeribed, sworn ar affirmed and acknowlodged before me by LBOTA O. R033,
the testatrix,(}BRAI.D J.BitINSBR end P11�F1/}I�P f} . fjOSS , witnesses,this I Gq'''
day of �A/IC4t , 2010.
�Q �SSAL)
Notary Public
i
NoTARNl8�EA1.
WEt�Y l.CRAYYfORD,NW�ryPubNo
PMnyni Boro..4�an Coun
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