HomeMy WebLinkAbout08-01-13 (2) --J REV-�sao IX���7 1606610743
OFFICWL USE ONLY
PA Department of Revenue penns ta �,uMyG,a, v..� Fib NuMMr
Buroau M IndiWdual Taxea ��+ATM�+*�a�
Pa eox.ze4eo� FNHERI7ANCE TAX RETURN 2 1 13 0 0 5 6 8
Hamaburg,PA 17128-0607 RE$lDENT DECEDENT
ENTER DECEDENT INfORMATION BELOW
Sxiai Secur}ty Number Date af Deaih Dete of Blrth
05 10 2013 OB 05 1922
Dacedent's Laat Name SufPoc pecedenPS Firat Name MI
BARRICK MAgZg g
�If AppRCabie)Enter Surviving Spowe's Intom�atlon Below
Spovae's�ast Name SufAx Spouse's Firat Name
MI
� Spouae's Social Securily Number
THIS RETURN MUST BE FILEp IN DUPLICA7E WITH THE
REGISTER OF WILLS
FfLI 1N AI+PttOPR1A7E 4VAL5 BELOW
� t. CkigMeiRotum ❑ 2, SuppiementadfkeWm � 3.�ti�R�(DalsolDaath
❑ 4. Lim�ed Eatale [] 4a.�a���1� Q S. Fetlerei Eate�Tmc Raium RequNetl
� �, o.aaerxoi.arew,�e p �. wr.waen�m:nmMen.i.m�nTNn 4 9. roro�Nwnneratsarooepauem�as
�nn.cncopyavnq S�camar�,r+q ---
❑ 9. I.ttgaliat Praceeds Received j,� td.SPw+sN Pov�C'adit lDab W D�th � 11 Eisction to iac under Seo.9i 13(A)
� 6etvwen 12-31 1 and 1-1� (AMach Sduedule O)
C911RESPON[fENT-TH�B SECTION MUST�E COMPLE7ED.ALL.CCIRRL°SpONpENCE At�CONWI�'NTi1LL 7A�°DRkUliipM � O BE,�RECTED TO;
NN11R ��Z��^" � �
RO$ERT G FREY 71t56 �A3 �3l,� a
�'� = c� � cn a
��fF Y�RLLS U t�.Y
Rrst i.irte af Address O � � � O O
:"� O -p.§ � -ri
5 SOUTH HANOVER BTREET `� � � "� cs
,a ..� o � rn
se�,d une a na�eu x- .r cn o
o -n
C#y ar Post dRice SUte DATE FILED
21P Code
CARLI3LE PA 17013
correapondenrsea»Waa�au: rtrty�lr�ytiity.aom
U,dM Pe�alliss of W�11�+Y�i deda»tlwt t Mw tieamFbd Cds Mum.tncMMi�O xcmnpanY?^Q cdtsduW and afakmsMe�and b tlro Mrt ot my knaNedpm end bafie(,
M is Mre�canecl m�tl camplNe.DecYiafbn M preparor dhar then the Pewo/w�reP���e ia baaed on aM inlamelion d whbh p'sp�a�er I+as wy kncvAedpe.
s+ u n
�� C:i. (�?nC��r E`��1' tori A.8andsr _,�13(J(3
rooAC�s
931 Hamikon 8tro�t,Garlisis, PA 17073
SIGFLt OF � ESENTATIVE DATE
Robert o Fny � / (.3
,�e�as
Fny and TiNy
b South Hanovsr8troat, riisk, PA 77015
Sic�1
� 1606818143 1805610143 J
J 160661Q243
REV-1500 D(
DetxdsM's Sodai Security Number
�=wR. BARRtCK, MARIE R
RECAWTULATiON
7. Real Effiek(SChedWe A)..........................._..........,.................................................. t.
2. Smcka and eonds(Scheduid B)............................................................................... 2. 3 , 3$7 . 12
3. Cleae#y Held Coqmratbn,Partr�erahip or Sok-i+mpde�rshtp(S#redWe C}.......... 3.
4. Mortgages&Notes Receivabk(Schedule D).................................................._...... 4.
5. Cash,BaMC Depasite&NBsceilaneous Personai Property(8cheduis E)................ 5. 13 � O 1 5 . $6
6. Jointly pwnad Prope�ty(Schedule F) p Separate&IYng Reque&ad............. 8.
�. Inter-Vlvos Tronafera 8 Mixellaneoua Nan-Probate Pro dy
(Scheauie G} ❑ separate ning Requeated............. 7. 15 d , 9 0 0 . 0 0
8. Total Oross Asaets{toha�li�s t through 7).......................................................... 8. 17 1 , 3 0 2 . 9$
9. Funerai Expenses and AdmiNshadve Costs(SOhedule H)..................................... 9. 5 . 5 91 . 5 9
t 0. DeMs of Dacedent,MoRga�UebfUdes and lia�(Schedule!}............................. 10.
11. Totai Deductions(Mtel Linea 9 and 7 0).................................................................. �}, 5 , 5 9 Z . 5 9
t 2. Net YaWe at Estate{tine 8 mMUa line t t}................._.......................................... 12. 2 6 5 , 711 . 3 9
13. CherNaMa and Govsrtmenta!BequestarSec 9113 Truats fot which
an electbn tp tax has not been made(SChedule J)......................_......................... 13. -
14. Net VakMS 8ubject to Tax(Une f 2 minus Line 13)................................................. 14. 1 6 5 , 71 1 . 3 9
TAR COMpUTA710N•SLE iNSTRUCTIQN3 FOR APPI.ICABLE RATES
15. AmcuntofUne74taxaWe
at tM apoueal te�t rate,ar
transfew under Sec.9176
{a}(12}X.00 15.
16. AmouM 61'lhte 14 ta7tai�
at rnea�rate x 045 16 5 , 71 I . 3 4 �s. 7 , R 5� . 01
17. Arrwunt of Line 14 tescaWe
atsibiinprateX .�2 17. '
18. AmouMOflina'l4t�ebte
at collaierai rate X .15 f$�
19. Tnx DUE................................................................................................................... 19. 7 , 4 5? . 41
20. FILL�I TME OVAL iF YOU At�REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Slds 2
� 1bd6610243 1608610243 �
REV-1500 EX Page 3 Fiir Nuneer 21 - 1 S � 04b88
ti�aedsnYs Compisb Addrsss:
Barriak, Maris R
STREETA66RESS
831 Hamilton Strast
cin STA7E ziP
Cariisis PA 1T013
Tauc Pay�»nts and Credits:
1. Texpue{Page2,LirretB) (1} 7,46T.81
2. CreditdPayrrreMs
A. PdorPayme�ts 7,Q84.00
B. Diacount $72.$4
Totatcre�ts(A +97 {2} 7,458.84
9. tnte�
(�? Q,QO
4, if Line 2 is greaterthan Line 1+Line 3,eMertha dif/erence. This isthe OVERFA'YMEN7. �4)
Gheck box on Page Y.I.pu�to request a refurM
5. If Line t +tine 3 is groaMrthan Lina 2,eMer the diHersnce. This is the TA7(DUE. (5) 0.�7
Make Check Payable to: REGI$TER OF 1ML.W, AC�ENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACtNG AN"X" IN THE APPROPRlATE BLCCKS
t. 6fd�cadont make a trarreter and: Yes No
a. retai�lhe uae or lxome of the proPert'!har�ferted:.................................................................................. � �
b. retein tho right W dea�nete who ahap ucu tlw Pr�PeriY kanutemd or its ituome�.................................... z
c. retaln a n+veraionery in0ereat;or..........._..__............................................................................................... x
d, receive the promise tor II/e of eithar payments,berwftte or care?.............................................................. x
2. it deaEl� occurrea after Dec. 12, 1982. did decsdent trans(er property withln one year of deafh without
receivir�g adequcM coneideratlonl....................................................................................................................... � ❑
3. OW decedent orm an"in Wat toY' or papaWe upa7�ath bank ac�outd ar aepuNy at hie or her deaNt9......... � Q
4. Did decedent own an individual retlrement aaount,annuHy,or other noirprotsste property which
coMetris a beneRCiary deaignadon?............................................................................_............................._......... ❑ 0
�7HE ANSWER Tq ANY pF TME AB4VE QUESTiON81S YES,YOU MUST COMPLEfE SCHEDUL,E O AND FILE IT AS PAR7 OF THE ftETURN.
Fw r�tas of deaih on ar aRer Jui9 i,1 AS4 and bePore Jan.1,1995,the tax rate Impoaed on the net valw of hanafero to or far tha uas ot the surviving
spowe is 3 percam[72 P.S.§8118(a){1.1){i)].
For daCes o!dmath on or aRer Jenuary 1,1995,tM tax rats impoaetl cn Uro�t velue of 2ran�rs to or for ttro ws of khe awvivinp spo�is 0 perceM
jt2 P.S.§9i 18(a}(1.1 j(ii)j. TM stafub dqss not exumpt a 1r#nsfer t0 a wrviVing spquee from tax,and Ihe statufory requiromaMs for dieclowre nf
asaMs and flling a tax rehim are dNl appNCab�evsn M Na wrviving npouae 3s Me oniy benefldaty.
Far�t�4!�sth rm ar at�r July t,2000:
•Tt»tnx rate imooead on tM r�et velus at trantlens from a decaased#+iiid 21yea re of ago ar younger at death M or for the use o1 a naturoi peient,an
adopNve parent,or a steppereM of tlte chfld Is 0 perceM[72 P.S.§9118(a){7.2j]. �
�The tax rats Imposed cn khe net velue ot transfere to cr tor ttre use of the decederrt's li�al beraei�rtea�4S pereeM,except as noted in -
[�2 P.S.get t8 ta}�t)j.
•The taz rate impoaed on Me net velua of hanskru to or iqr the use ot the decederd's siWi�e is t2 pereent(!2 P.S.591 f 6{a){7.311. A
�b��k c�6�d undsr Seawn 4102,as an ina#viduai who has at feast one parerrt in common with ths decedeM,wfietY�er b��bl0oa or adoptbn.
�.,��.,,�,
SCHEDULE B
�+wEUn+orr�sr�vi„w STOCKS 8t BONDS
N1IEPRNICETA%RENRN
flE90BIlOECEOBli
ESTATE OF garrick, MB�I@ R FILE NUMBER
21 - 13-00568
a�WMxrtYl�tlyowned wkh rlgM of surviwiship musf be discl�ed p�gery��e F,
ITEM
NUMBER DESCRIPTION UNIT VALUE ��UE AT DATE OF
1 US savings bonds, itemization attached DEATH
3,387.12
TOTAL(Also�nter on line 2, Reeapltulatbn) $ 387.12
�
_
� ; psnnsylvania SCHEDULE E
oEau�rra�Kr�etvErx�
INHERITANCBTAXREfURN CASH, BANK DEPO$ITS AND M13C.
`��'�Ni°�DC�" PERSONAL PROPERTY
FIIE NUMBER
ESTATE OF BBITICk, Marie R 21 - 13-0058$
Indude the proceeds of litigation and the dete the proceeds were received by the estate.Alt�opertyJointlyrnrned with Nre riqM af
snrvivorslrlp muat be disclosed on schedula F.
�T�� VAI,UE AT QATE OF
NUMBER DESCRIPTION d�,�.H
1 M&T Bank Account No. 402001 8,901.17
2 Welis Fargo Accoant 932d 2,820.59
3 Members tst Account 20253-Od 1,044.16
4 Pe. Departme�t of fiavenue Homeowner's Rebate 250A�
TOTAL(Also entar on Une 5,RecapitulaHCn} 13,015.86
REV.1319 tl(t(Oefie)
pennsytvania
ownar�rJroFRe�NU� +�p SCHEDULE G
tNli6i(ThNCETAXREfURN . �N 1 Gfl-VIVOS TRANSFERS 8�
RE�"T�� MISC. NON-PROBATE PROPERTY
E3TATE OF g���, (�arie R FlLE NUM9ER
29 - 13-d0588
This schedule must bee oompNeted and Nled it the answer to�y of q�stions 1 throuph 4 a�pape 2 is}res.
ITEM OESpbPf10NOFPRaPER7Y wreoF�nrH x� o�+a�N TAXA9LEVALUE
NUMBER �navww�.rr�av.anr.a.�s,nwrMm�r,roeoae�ws,t VALUEOFA.4SET �'S pF.u�ucna�
antltheCksdwesfm. AfbchacoPYrAthetlWfarreNesmts. INTH2EST
1 931 Hamifton Street, Cariisie,transferred 5/$/13. �5�,9��� 100% 3,O�OAQ 154,940.OU
Assessed Value attached
TdTA1(Aiso mter an flne�,Racapituiation) 154,800.00
REV-t6H IX+�t0A9}
pennsyivania SCF��ypt�1tF�H���p�
. C£PM7MENf OF REVENiJE �G1rG1�1G7/7�v
IN��RN CE�URN A1Yi�x��
lY-0AI��I I f V"1
FfLE NUMSER
ES7ATE OF BatriCk, Marie R 21 - 13-00568
GecedenCs debts must be reportad on Schedule I.
ITEM
NUMBER Ft7NERAL EXPENSES: DESCRlP7ION AMOUNT
A 1 Hoffman Roth Funera�Home 683.55
8. ADMINI57RATIYE COSTS:
t, Paraona!RspreaaMadve's Commiaebns
Neme o!Porsonal ReproxMadve{s)
Shest Addreas
Glty Stete Zip
Year(s)Commiseion Paid
z. Attorney'a Fees Frey&Tiley i3Od0.00
3. Famity F�cem�: {if tlecedtM's addrass is trot tfx same aa ctaimartYS,aHaeh e�ianatfon}
C�a�marn Lori Bencler 3,500.00
�,�q,�� Hamilton�reet
ciry Carlisle state PA zip 17013
Reiaaor,sn�potc�aimarntaosaedeM Granddeughter
4. ProbaM Fees Filing fees 163.54
Advertising 284.54
5. AccountanPS Feea
8. Tax Retum Prcparers Fese
7. Other Admin"ratratiVe Coats
�
TOTAL(Alao an�r on It+�e 9, R�ec�itutation) 5,5$f.$9
nev-�s�a art{m-tq
pennsylvania SCHEDULE J
DEPARTMENf aF REYENUE
iw+�w*Ar�c�T,�cR�rUar� BENEFICIARlE3
r��Nro�cm�Hr
ESTATE OF � FIIE NUMBER
Barrick, Merie R
2i - 13-OOS88
RELATIONSHIP TO SHARE OF ESTATE AtJ10t1NT OF ESTATE
NUMSER NAME AND ADORESS OF PERS4N(Sj DECEDENT (Words) (aga)
RECEIVING PROPERTY wt�otU�tt+ust�(q
I, TAXA6LE DISTRIBUTIONS(induds outrlgM I
disMtwtions arni�lers
under See.�116{a){t��
1 Lari A. @ender,931 Hamiltan Streef,Cartisie, Gt�anddaughter 1d096
PA 17Q13
EMar doltar amaiMa/or diafib�rtbna ehown above on Iines 15 fhrqugh 18 wf Rev t 50Q eover s1»et,as appropriate.
�i NON-TAXABIE dISTRIBUTtONS:
A SPOUSAL DISIRIBUT]ONS UNDER 88CTI4N 9113 FOR WHICH AN ELECTfON T6 TAX iS NOT TA3�N
B.CHAR17A8LE ANd GOVERt�ulENTAI DIS7RIBUTIONS
TOTAL OF PART fi-ENTER TOTAL NON•TAXASLE DISTRIBUTONS ON LiNE 73 OF REV-150p COVER SHEET � O.QO
Property Mapper
Cumberiand County, PA
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[opyri9ht 2Qii Esri.Aii ri9hts reserved.Wetl 7ui II 2013�3:68:05 AN.
29-19-1639-153
SitC AddreSS:4}1 HAMiISON 51REET
Deetlbook:261315306
Qwner:BENO@R,�O0.i A&7EFFREV K
WOd Use CAae:101
Properry rype:R
Acrea9e:0.37
§9uare feeL 1493
Tdxable SfatuS:T
�leen&Green StdtaS:
Wnd A55¢ssed ValUe$:J6100
Building Astessed Value#: 121900
Tota)As3essed Vaiue$: 157960
SaIE Prl[e$: 2
i Sale Date:Wed May 8 2013 08:00:00 PM
Year euik:1450
MunIGp811ty:NORTH MEDOLETON TWP
Helqht in Stotles:
Typc of Oweiling:DfTACH
Pnmary Exlerbr:BriCk
Elasement Per[entage: 300
Ak CorM�namng:n[
TMafAaom5: 5
Bedrooms:2
Fmi sam: i
Halt 8ath:
p ��r��:�
499 Mitehell Roed,Millsboro,DE 19966 Adjustment Services
Phone 888-902�1349
F aac (362)934-2435
May 23,20I3
kYey & Tiley
Attorney ak Law
5 South Hanover Street
Cariisle,PA 1'7013
Re: Estate af Marie R. Barrick
Sociat Secwiri: 196-14-0135
Date of Death:May 10,2013
Dear 5ir ar Madam:
P'er your iaqniry an May 24,2013,please be advised d�at at the time of deadr,the above-named decedent had on
daposit with ihis bank the fallowing:
l. T'ypeofAccount Checkr�Account
.4ccourrt Number 4020D1
Ownership(Nomes o� Mr�rie R Bra'rick
Lt,ri r3.ae,�der(POA)
ClpenrngDate 09/01/1967
Batance on Date of Death $8,90t.77
Accrued Interest $ .00
_. . _... __..__ .
Tatal $8,901.11
For sey fddWomi iaform�tion on thc abave accaume,inclading owoonhip and aey e6rugee,doenree andlpr reimburoemcot nt fnndn,
plC�x all thc I�g6 Street C�rIWe at 717-549�4536.
We were uoabk to locate�ay aRfe depoat bo:tor t6e N6uva-�ationed decWeaf.
11�ktber dats mt f�Clndt aoy a¢caas�ie w�ia616e dao9cd may heve bceo Ha6di es Nmver oP AMOroey,CiWOdhn ot Udtarm Trmeiera,
RcprexotativtPsyet,ar Tn�t oeder a Wcitteo Agneemcat
Sincerely,
Valarie Mercer
Adjushnent Services
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MEMBERS 1'�
PEDERAL CRHDIT UNION
REGULAR SAVINGS ACCOUNT•
Account Nurc�beNSuffix 20253-00
D-ate Account Established 02/23/1978
Principal Balance at Date of Death $1,044.12
Accrued Interest to Date of Death $.04
Total Principal and Accrued Interest $1,044.16
Name of Joint Owner None
M ERS1111ST�FED��Ep�,7y�rylpN
� VI 1 ,
��x, l \J S,1,�,
�_��.,.
anie . Kline
Lending Insurance Support Specialist
May 29, 2013
Estate of: MARIE R. BARRICK
Date of Death: 05I10/2013
Social Security Number: 796-14-0135
5000 Louise Drive • P.O. Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org
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CtxNsie,Pennsylvania 17Q13
� 717.243.4511
toii free 1.866A51.4511
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'� / Ft3NE12AL HOME 6� CREMATORY, INC. ��m�
; ; rr�,+oC�tm�rrom.c«n
June 13,2d13
Jeffrey L. Bender
H31 Namiiton Sireet
Cariisie, PA 17Q13
Statement of F�neral E�tpenses for. Marie f2. Barrick
Data of Death: Mey 10, 20!3 Account Id: 168T8-S 19
PACKAGE:
Traditional Funerei Service
TRAd}TIONAL FUNERAL SERYICE PACKAGE $ d,850.00
Sub Total: S d,$50.00
MERCHANDISE:
CaskeY Colemen $ 2,230.00
Outer Gontainer. ManticeAo $ 1,62Q.Op
Sutr Tcrtai: S 3,850.�
TOTAL FUNERAL HONAE CHARGES: t B,�OO.OQ
CASH ADVANCES.
WestminsterCemetery $ 1,90fi.04
14 Gectified Death Certficates at$6.00 each $ 60.00
Newspaper Notice-Sentinei $ d5123
Ffowers $ 159.Q0
Hairdresser $ 40.OQ
Add'1 Fiowers $ 23.32
' $ub Totak S 2 639.55
Tot�t Funaral Expems: E 11,339.55
Totai Paymer�fs Made: S 10,876.00
Paymer�Made:
Nicro Data$ystems Check 937$2 Jun 13,2013 9,d73.64 �
PreNeed Dfsc Check PreNlCont Jun i3,2013 1,242.36
Baiance: S
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Wii! far Adutt With No Child(ren)
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Will of Marie Rose Barrick � � { � �
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I, Marie Rose Barrick, a resident of 931 Hamikon Street, Caz2isle, of C���d "' a �,°,
jcountyJ, State ofPeansylvania, declaza that this is my will ° ; 4? � � �
? � �v r- rn
2. Re�aeataaa.I revoke ali wills that I have previously made. � --f r, 'r„ o�
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2. Marital Status.I am Single(mamerllsingteJ.
3. Specifie Gifts. I make the following sp�ific gi$s:
I leave my house and property at 43 t fIamihon Street, Carlisle, PA and all including
assets in and aut of ttte hame including fiuniture,jeweIry,bank accounts,life
insurances and atl contents belanging to myself to Lori Ann Doversp�7ce or, if she
(hetsheltheyJ does not(does natldo norJ survive me,to Alisha Marie and Johnathon
Ralph Doverspike.
4. Reslduary Estate. T leave my residuary estate,that is,#he rest of my property not
atherwise speeifically and validly disposeti of by this wiii, inclw3ing iapsed or failed
gifts, to Lori Ann Doverspike or,if she[helsheJtheyJ does not[does natldo notJ
survive me, to Alisha Marie and Johnati�n Raiph Doversp�ce.
5. Beneficiary Provisions.The following terms and conditions apply ta the benefieiary
clauses o f this will.
A. 4S-Day Survtvarshlp Periad. As used in this will,the phrase"survive me"
means to be ativo or in existence as an organization on the 45th day after my
dcath Any beneficiacy, except any alternato residriaty benaficiary, must survive
me ta take praperty under t}sis wilt.
B. Shared Gifts. If I leave property to be sharecl by two ar more heneficiaries, it
shall be shared equally by them unless this will pmvides otherwise.
, If any beneficiary of a shared specific gift le8 in a single pazagraph ofihe
Specific Gifts clause, above, does not survive me, the gift shall be given to the
surviving bene$ciaries in eqnal sl�ares.
Q 2005 Nob WH!fa Ad�dt W(th No CMIA(rcn} page 1 �
If any beneficiary of a shared residuary gift does not survive me, the residne
shall be given to Ehe surviving residuary beneficiaries in er�ual shares.
C. Eneumbranees. All property thet T leave by this will shall pass subject to any
encumbrances or liens on the pmperty.
6. Ezecutor.I name Lori Ann I?overspike as eatectitor, to serve wiShout band. If she
[he/sheJ does not qualify or ceases to serve, I name as
executor,also ta serve without bonfl.
I direct that my executor take all actions le$ally permissible ta probate this will,
including filiag a gekition in the appro�iata court far the indepcndent�lministraziun
af my eatate.
I grant ta my exet�tor the�rlTawiatg pawes,to be exercised as the�ecutar deems
to be in the best itrterests af my estate:
A. To r�ain property, without liability fiar Ioss or dcpreciatioa resulting fram
such ret�tian.
B. To sell, lease, or e�cchange property and to receive or administer the pmceeds
as a part of my estate.
C. To vote stack; convcrt bonda, aotes,stadcs,or atlxr securikies belanging to
my estate into other seeurities;aad to e�ccereise all other righ#s acui privileges
of a persan owning similar property.
D. To deal wikh and settle claims in favor of or against my estate.
E. To asntinuc, maurtain,oPera�e,ar parkicipate ia any busi�eas w3�ich is a pert
of my estate and ta incorpormte, dissolve,or othawise�hange the form af
arganizatian af the business.
F. To pay all debts and taxes that may lae assessed against mq estate, as pmvided
wxier state law.
G. To do all ather acts tl�at in the executar's judgmcnt may be nece�cary ar
appmpriate for the proper a�d advaxatageous manage�ncnt,investmcnt, and
distn'bution of my estate.
� p 2005 Ndo - Wiil ftx kdidt Wtkh No Ctdld(ren) Fage 2
These powers, authority, and discretion are in addition Lo the pawers, authority, and
discretion vested in an axecutor by aperation oflaw and may be exercised as often as
deemed necessary, wit�ut apgrovai by any court in any jurisdictian.
Signatnre
I substxibe my narne to this will thss 8 day af Novea�tsec, 2414. At�tnbcrland jcaunty),
State af Pennsylvania,
I decIare that it is my will, that I sign it willingly, that I execute it as my free and
voluntary act for the purposes e�ressed, and that I am af the age af maajurity or
otherwise Tegally empowered to make a will and under no constrain#or undue influence.
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WIfriC3SCS
On this f � day of �� ,��,the testator,
�f 4 Q.. �Y f�C�.declared to us,the undersignecl,that this iastrument was
�jhislherJ witl and requested us to act as witnesses to it. Tlae teskator signed this
will in our presence, all of us being present at the sazne time. We now, at the t�tstor's
request,in the testator`s presence and in the presence af each other, subscnbe our names
as witnesses a�l each declare that we are of sourui mind anc!of graper age to witness a
wilL We fiuther declare tliat we understand tlais to be the testator's will, and that to the
best of aur knowle�lge tk�testator ss af the age af majarity, or ss athezwise legally
empowcred to malce a will, and appears to be of sound minfl and under no constraint or
undue influence.
Wa declare under penalty of gerjury that the faregaing is tnse and corr�,this
� day af_���,_ �(�, at
�� rr"1 i��_/�Q �C'�count}'1, State of_���,�
Witness 1
Signature:����� � �,.---
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Typed or printed name: � Y�2 Y'
Residing at: � ��
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Witness 2
Signature��� �,���-�Y_
Typed or printed name: �S$����Q
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Witness 3
Signatute: �
Typed or printed name:
Residing at: �✓�
city, scace, zip: , ( [b '�
SWORN AND SUBSCRIBE� .'
TO BEFOR ME THIS . .
l�,,,..,DAY OF� ZG�I p
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p 2005 Nolo Will far Adult With No Chi�d(ren) Page 4