HomeMy WebLinkAbout01-23-14 (2) � 1505610140
REV-1500 �` �°,_,°>
PA Department of Revenue OFFICIAL USE ONLY
Bureau of individual Taxes County Code Year File Number
Po Box 2soso� INHERITANCE TAX RETURN 2 1 1 3 0 5 5 7
Harrisbum,PA���28-oso� RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death N�IADDYYYY Date of Birth MMDDYYYY
0 3 1 ? 2 0 1 3 0 3 2 5 1 9 1 6
Decedent's Last Name Suffix Decedent's First Name M�
M U L L E N G A Y L E K
(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
� 1.Original Retum � 2.Supplemental Retum � 3.Remainder Retum(date of death
prior to 12-13-82)
� 4.Limited Estate � 4a.Future Interest Compromise(date of � 5.Federal Estate Tax Retum Required
death after 12-12-82)
Q 6.Decedent Died Testate � 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Tn�st)
� 9.Litigation Prooeeds Received � 10.Spousal Poverty Credit(date of death � 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECT�N MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
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D 0 U G L A S G • M I L L E R 7 �7 2 4 � .r���5 3
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First line of address r � � � � �
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I R W I N 8 M c K N I G H T , P • C • �ac, � �° �' �-�r
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Second line of address � � ""
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6 0 W E S T P 0 M F R E T S T R E E T :.� � � � � -
City or Post Office State ZIP Code �" DATE Fq,F�p
C A R L I S L E P A 1 7 0 1 3 - °�
Correspondent"s e-mail address: _
Under penaltles of pe�jury,I declare that I have examined this retum,induding ac�companying schedules and statements,and to the best of my knowledge and bel�ef,
it is ,ooRec�and compiete.Dedaration of prepar+er o than the personal representative is based on all information of which preparer has any knowledge.
SI T OF PE SON E ONSiBLE FO G URN D E
� , D
DDRE
908 RMSTRONG ROAD CARLISLE PA 17013
SIG E REP R OT S. N REPRESENTATIVE /
ADDRESS
60 WEST POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
�
15056b0140 1505610140 J
� 15�5610240
REV-1500 EX DecedenYs Social Security Number
�ecedenes Name: G A Y L E K• M U L L E N
RECAPITULATION
1. Real Estate(Schedule A) ..... ...... ... . . ........ .... . .............. 1• •
2. Stodcs and Bonds(Schedule B) .......... ... .. .. .. ... ..... .. . ..... ... 2• •
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .... . 3. •
4. Mortgages and Notes Receivabie(Schedule D) ... ..... . ....... . .. .... .. . 4. •
5. Cash,Bank Deposits and Miscellaneous Personai Property(Schedule E).. .. .. . 5. 6 3 5 4 . 8 �
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. .. .. . 6. 1 3 4 . 8 2
7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property
(Schedule G) �] Separate Billing Requested .. .... . 7. .
8. Total Gross Assets(total Lines 1 through 7) ... ......... . ............. . s. 6 4 8 9 . 6 9
9. Funeral Expenses and Administrative Costs(Schedule H) .. . ...... .... .. ... 9• 1 6 1 2 . 0 0
10. Debts of Decedent,Mort a e Liabilities,and Liens Schedule I �o. 9 1 0 1 7 . 6 7
9 9 ( ) .. .... ...... .
��. Total Deductions(total�ines 9 and 10) .. . .. ... ... .................... 11. 9 2 6 2 9 . 6 7
12. Net Value of Estate(Line S minus Line 11) .. ...... ............... .. ... 12• - 8 6 1 3 9 . 9 8
13. Charitable and Govemmental 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. - 8 6 1 3 9 . 9 8
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. � . � 0
16. Amount of Line 14 taxable
at lineal rate X•o4s 0 • � 0 1 s. � • 0 �
17. Amount of Line 14 taxable
at sibling rate X.12 D . 0 0 ��. 0 . 0 0
1 S. Amount of Line 14 taxable
at collateral rate X.15 � • � � 1 g. � • � �
19. TAX DUE . ........... ... . . ..... .. .... .. . .. ...... .. .. . . .. ..... .. 19. � • � �
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
�
150561�240 . 1505610240 J
REV 1500 EX Pape 3 Flle Number
Decedent's Complete Address: 21 13 0557
DECEDENTS NAN�
GAYLE K MULLEN
STREET ADDRESS
442 WALNUT BOTTOM ROAD
CITY STATE ZIP
CARUSLE " PA 17013
Tax Payments and Credits:
�• Tax Due(Page 2,Line 19) (1) 0.00
2. CreditslPayments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
3. Interest
(3)
4. If Line 2 is gneater than Line 1+Line 3,enter the differ�nce.This is the OVERPAYMENT.
Fili in oval on Page 2,Une 20�o request a refund. (4) 0.00
5. If Line 1+Line 3 is gr�eater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" IN THE APPROPRIATE BLOCKS
1, Did dec�dent make a transfer and: Yes No
a. r�ettain the use or income of the property transferred: ...................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ �
c. retain a reve.rsionary interest;a ................................................................................................ ❑ �
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ �
2. If death occumed after Deoember 12,1982,did decedent transfer property within one year of death
vvithout receiving adequate c�nsideration? ....................................................................................... ❑ �
3. Did dec�dent own an"in tNSt for"or payabte-upon-death bank account or security at his or her death? ......... ❑ �
4. Did decedent own an individual retir�ement account,annuity or other non-probate property,which
oaitains a benefiaary designation?.................................................................................................. a a
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 perc;ent
[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 disdosure of assets and
filing a tax retum are still appiicable even if the surviving spouse is the only beneficiary.
For dates of death on ar 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
adopfive parent or a stepparent of the child is 0 pe�cent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the dec:edent'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)j.A sibling is deflned,under
Section 9102,as an individual who has at least one parent in common with the dec�dent,whether by blood or adoption.
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS � MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
GAYLE K. MULLEN 21 13 0557
Include the proceeds of litigation and the date the proceeds were reoeived by the estate.
All property jointly owned with right of survivorship muat be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ORRSTOWN BANK-CHECKING ACCOUNT#106002369 6,354.87
TOTAL(Also enter on Line 5,Recapitulation) s 6 354.87
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERfTANCE TAX RETURN
IZESIDENT DECEDENT
ESTATE OF: � FlLE NU�ER:
GAYLE K. MULLEN 21 13 0557
If an asset w�s made joiMly owned within one year of the de�edenCs date of d�th,it must be reporbed on Schedule G.
SURVMNG JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. ELIZABETH M. ROWE 908 ARMSTRONG ROAD DAUGHTER
CARLISLE, PA 17013
B.
c.
JOiNTLY-OVYNED PROPERTY:
LETTER D�►TE DESCWPTION OF PROPERTY %OF QATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FlNANqAL INSTITUTION AND BANK ACCOUNT NUMBER OR SINNLAR �TE�DEATH DECEDENTS VALUE OF
NUMBER TENANT �INT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 09/2012 ORRSTOWN BANK 269.63 50. 134.82
CHECKING ACCOUNT#106006278
TOTAL(Also enter on Line 6,Recapitulation) s 134.82
If more spacs is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GAYLE K. MULLEN 21 13 0557
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. FUNERAL LUNCHEON 428.50
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) ELIZABETH A. ROWE 150.00
SbeetAddress 908 ARMSTRONG ROAD
�ity CARLISLE State PA Z�p 17013
Year(s)Commission Paid:
2, Attomey Fees: IRWIN &M�KNIGHT, P.C. 750.00
3, Family Exemption:(If decedent's address is not the same as claimanYs,attach explanation.)
Claimant
Street Addr�ess
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 128.50
5 Accountant Fees:
6. Tax Retum Pr�parer Fees:
7. REGISTER OF WILLS-SHORT CERTIFICATE 5.00
TOTAL(Also enter on Line 9,Recapitulation) S 1 612.00
If more space is needed,use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
GAYLE K.MULLEN 21 13 0557
DecedenYs Name Page 1 File Number
Schedule H-Funeral E�cpenses�Administrative Costs-B1
ITEM
NUMBER DESCRIPTION AMOUNT
B. ADMINISTRATIVE COSTS:
Personal Representative Commissions:
2� Name(s)of Personal Rep�esentative(s) JANIS L.WOLF 150.00
StreetAddr�ess 12876 SUMMITVIEW CT.
Ciry NEW CUMBERLAND state PA z�P 17070
Year(s)Commission Paid:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
SUBTOTAL SCHEDULE H-61 150.00
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
°EP'°'RT"'E"T oF RE"E"�E DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES�LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GAYLE K. MULLEN 21 13 0557
Report debts Incurred by the decedent p�ior to death that remained unpaid at the dafie of de�h,including unreimbureed medkal expenaes.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. DPW CLAIM 91,017.67
CIS#780314993
TOTAL(Aiso enter on Line 10,Recapitulation) S 91 017.67
If more space is needed,insert additional sheets of the same size.
REV 1513 IX+(01-10)
pennsylvania SCHEDULE J
°��°F� BENEFICIARIES
N�ERITANt�TAX RETURN
�IT OECEDENT
E8TATE OF: FLE�
GAYLE K. MULLEN 21 13 0557
RELATIONS�iiP TO DECEDEM' AMOUNT OR SHARE�
NUMBER NAME AND ADORESS OF PER,SOf�S)RECEIVING PROPERTY Do Not Lat Tnabee(=) OF ESTATE
I. TAXABLE DISTRIBUTbNS (Indudeo�t� �and�s un�r
Sec.91�6(a(12).�
1. CHRISTOPHER S.WOLF Lineal
31230 KINGS CT.
ELLICOTT CITY,MD 21042
2. DAVID M.WOLFE Lineai
10275 MAIN ST., PO BOX 296
POTTER VALLEY,CA 95469
3. ROBERT A. ROWE Lineal
156 GLENDALE ST.
CARLISLE, PA 17013
4. ROBIN ROWE WILLIAMS Lineal
309 DIXIE DR.
TOWSON, MD 21204
5. DWIGHT D. ROWE � Lineai
20264 RAVENS END DR.
TAMPA, FL 33647 .
6. KERRI L. OWENS Lineal
357 STONEHEDGE LANE
MECHANICSBURG, PA 17055
7. ELIZABETH A.ROWE Lineal
908 ARMSTRONG ROAD
CARUSLE, PA 17013 �
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 18 OF REV 1500 COVER SHEET,AS APPROPRU►TE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAt.DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTiON TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND�OVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL PION-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ;
If mor�spac:e is needed,use addition�st�s of pape�o�the s�rie size.
Continuation of REV-15001nheritance Tax Return Resident Decedent
GAYLE K.MULLEN 21 13 0557
DecedenYs Name Page 2 File Number
Schedule J-Beneficiaries-1
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON S RECEIVING PROPERTY Do Not Ust Tru s� OF ESTATE
I TAXABLE DISTRIBUTIONS pndudeoutri�ht I distribudons and transfers under
Sec.91 i6(a (1.2).]
8. JANIS L. WOLF Lineal
1286 SUMMITVIEW CT.
NEW CUMBERLAND, PA 17070
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I, GAYLE K. MULLEN, of South Middleton Td�"ivnship,4�a �� '�t .°�.
Cumberland County, Pennsylvania, do make, publish and declare �� .
this to be my Last Will and Testament, hereby revoking all Wills ��
and Codicils by me at any time made.
I_� I direct that all inheritance and
estate taxes becoming due by reason of my death, whether such
taxes may be payable by my estate or by any recipient of any
property, shall be paid by the Executor out of the property
passing under ITEM V of this Will, as an expense and cost of
administration of my estate. The Executor shall have no duty or
obligation to obtain reimbursement for any such tax so paid, even
though on proceeds of insurance or other property not passin
. 1
under this Will,
ITEM II: I direct the Executor to pay the
expenses of my last illness and funeral expenses from the
property passing under this Will as an expense and cost of
administration of my estate.
ITEM III: I may leave a writtzn statement or
list in my safe deposit box disposing of certain items of my
tangible personal property not otherwise disposed of herein, Any
such statement �or list in existence at the time of my death shall
be determinative with respect to all items bequeathed therein.
If no written statement or list is found in my safe deposit box
or elsewhere and properly identified by the Executor within
thirty (30) days after the probate of my Will, it shall be
a
.R
Page 1 ���''
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presumed that there is no other statement or list. Any
subsequent discovered statement or list shall be ignored. An
such y
property not listed in such a written statement I give and
bequeath to my daughters, ELIZABETH A. ROWE and JANIS L. WOLF, to
be divided between them as they shall agree.
ITEM IV: I give the sum of TEN THOUSAND
($10, 000) DOLLARS to each of my grandchildren living at the time
of my death. This bequest to each grandchild shall be adeemed tv
the extent that I have made a lifetime cash gift to such
grandchild in the amount of TEN THOUSAND ($10, 000) DOLLARS after
the execution of this Will. My Executor may delay payment of the
gifts under this ITEM IV until the sale of my real property
located on the Carlisle Pike in Cumberland County, Pennsylvania
if the Executor deems such delay advisable.
ITEM V: I give, devise and bequeath all the
rest, residue and remainder of my estate, not disposed of in the
preceding portions of this Will, to my daughters, ELIZABETH A.
ROWE and JANIS L. WOLF, in equal shares. If either of said
daughters is not living at my death, the share of said deceased
child shall be paid to the then living issue of said deceased
daughter, per stirpes.
ITEM VI: In the. s�ttlement of my estate, the
Executor shall possess, among others, the following powers:
(a) To retain any investments I ma.y have at my
death, including specifically those consisting of stock
of any bank even if I have named such bank as the
Executor herein, as long as the Executor may deem it
advisable to my estate so to do.
,f;?
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Page 2 ��
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(b) To vary investments, when deemed desirable by
the Executor, and to invest in such bonds, stocks,
notes, real estate mortgages or other securities or in
such other property, real or personal, as the Executor
shall deem wise, without being restricted to so-c�.11ed
"legal investments" , and without being limited by any
statute or rule of law regarding investments by �
fiduciaries.
(c) In order to effect a division of the
principal of my estate or for any other purpose,
including any final distribution, the Executor is
authorized to make said divisions or distributions of
the personalty and realty partly or wholly in kind, and
to allocate specific assets among beneficiaries
hereunder so long as the total market value of any
� share is not affected by such division, distribution or
allocation in kind. Should it appear desirable to
partition any real estate, the Executor is authorized
to make, join in and consummate partitions of lands,
voluntarily or involuntarily, including giving of
mutual deeds, recognizances or other obligations, with
as wide powers as an individual owner in fee simple.
(d) To sell either at public or private sale and
upon such terms and conditions as the Executor may deem
advantageous to the estate, any or all real or personal
estate or interest there�in owned by the estate
severally or in conjunction with other persons or
acquired after my death by the Executor, and to
consummate said sale or sales by sufficient deeds or
other instruments to the purchaser or purchasers,
.�
Page 3 �, . ��
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conveying a fee simple title, free and clear of all
trust and without obligation or liability of the
purchaser or purchasers to see to the application of
the purchase money or to make inquiry into the validity
of said sale or sales; also, to make, execute,
acknowledge and deliver any and all deeds, assignments,
options or other writings which ma.y be necessary or
desirable in carrying out any of the powers conferred
upon the Executor in this paragraph or elsewhere in my
Will. . _
(e� To mortgage real estate, and to make leases
of real estate.
(f) To borrow money from any party, including the
Executor, to pay indebtedness of mine or of my estate,
expenses of administration or inheritance, legacy,
estate and other taxes, and to assign and pledge assets
of my estate therefor. '
(g) To pay all costs, taxes, expenses and charges
in connection with the administration of my estate.
(h) To make distributions of income and of
principal to the Aroper beneficiaries thereof, during
the administration of my estate, with or without court
order, in such manner and in such amounts as my
Executor deems prudent and appropriate.
{i� To vote any shares of :stock which form a part �
of the estate, � and otherwise to exercise all the powers
incident to the ownership of such stock.
,��
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(j) In the discretion of the Executor, to unite
with other owners of similar property in carrying out
any plans for the reorganization of any corporation or
company whose securities form a part of the estate.
(k) To disclaim any interest in property which
would devolve to me or my estate by whatever means,
including but not limited to the following means: as
beneficiary under a will, as an appointee under the
exercise of a power of appointment, as a person
entitled to take by intestacy, as a donee of an inter
vivos transfer, and as a donee under a third-party
beneficiary contract.
(1) To do all other acts in the Executor's
judgment deemed necessary or desirable for the proper
and advantageous management, investment and
distribution of the estate.
ITEM VII: Any person who shall have died at
the same time as I shall have, or in a common disaster with me,
or under such circumstances that the order of our deaths cannot
be established by proof, or within thirty (30) days of my death,
shall be deemed to have predeceased me.
ITEM VIII: If at any time any beneficiary
under the age of twenty-one (21) years shall be entitled to
receive any assets hereunder, that person selected by the
Executor (including the Executor) shall receive such assets as
Custodian under the Pennsylvania Uniform Transfers to Minors Act
for that beneficiary. Such Custodian may receive and administer
all assets authorized by law, and shall have full authori�y as
Page 5 �L'� �j.
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provided in the Pennsylvania Uniform Transfers to Minors Act to
use such funds in the manner it deems advisable for the best
interests of such beneficiary. In addition, said Custodian shall
have all the rights and privileges as to the Custodianship and
its assets as are herein granted to the Executor as to my estate
and the assets therein. I also designate said Custodian as
successor Custodian of any proper�y for which I am custodian
under any Uniform Gifts to Minors Act, or Uniform Transfers to
Minors �Act.
ITEM IX: I hereby nominate, constitute and
appoint my daughters, ELIZABETH A. ROWE and JANIS L. WOLF, to be
the Executors, herein collectively referred to as °Executor" . In
the event of the death of both of said individual Executors, or
their i�nability or refusal to serve, I nominate, constitute and
appoint my grandchildren, ROBIN E. ROWE and KERRI L. WOLF, to be
the Executor. The Executor and Custodian are specifically
relieved from the duty or obligation of filing any bond or other
security.
IN WITNESS WHEREOF, I have set my hand and seal to
this, my Last Will and Testament, consisting of this and the
preceding five (5) pages, at the end of each page of which I have
also set my initials for greater security and better
identification this v`� day of C'� � , 19 ��
/`�
. �
�J (SEAI,)
AYLE= . MULLEN
We,� the undersigned, hereby certify that the foregoing
Will was signed, sealed, published and declared by the
above-named Testatrix as and for her Last Will and Testament, in
the presence of us, who, at her request and in her presence and
� , � , .
in the presence of each other, have hereunto set our hands and
seals the day and year first above written, and we certify that
at the time of the execution thereof, the said Testatrix was of
sound and disposirig mind and memory.
(SEAL) Res iding at ��• �E7G /c�
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(SEAL) Residing at� . �
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ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA )
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COUNTY OF `� ��, •�.�� )
�L
I, GAYLE K. MULLEN, Testatrix, whose name is signed to
the attached or foregoing 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.
�
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. � �SEAL�
G�1�YLE:�'� . LEN
r
Sworn to and subscr,�bed
before m� � is _� � , ay
of � 7 , 19 �.
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Not ry Public
My Commission Expires:
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AFFIDAVIT
COMMONWEALTH ,OF PENNSYLVANIA )
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COUNTY OF '�� � )
We, t� �-.5� � - �t h '� , �
and �—� , the Witnesses whose name re
signed the attac�`i or foregoing instrument, being duly
qualified according to law, do depose and say that we were
present and saw Testatrix, GAYLE K. MULLEN, sign and execute the
instrument as her Last Will and Testament; that Testatrix signed
willingly and that she executed said Will as her free and
voluntary act for the purposes therein expressed; that each of us
in the hearing and sight of the Testatrix signed the Will as
Witnesses; and that to the best of our knowledge the Testatrix
was at that time eighteen (18) or more years of age, of sound
mind and under no constraint or undue influence.
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CODICIL TO THE LAST WILL AND TESTAMENT OF GAYLE K. MULLEN
DATED: June 28,2005 �
I,Gayle K.Mullen,being of sound mind request the following additional distributions be
made by my executor(s)from my estate: �
$1,000.00 each to my grandchildren: (1)Robin Rowe Williams,(2)Robert A.Rowe,
(3)Dwight D.Rowe, (4)David M.Wolf, (5)Kerri L.Wolf,and(6)Christopher S.Wolf.
I also request that$500.00 be distributed to each of my great-grandchildren,the legal
cluldren of my grandchildren listed above. �
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Any taxes on these distributions should be paid by my estate. ��o `'' � �+
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The�rest of my will stands as originally written. � a r"- � � �
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Gayle I�.Mullen � ` o ,."`�. ,a
Dated:-June 28,2005 `-� `'�
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A Tradi�i'on of Excellence
. August 16, 2013
Irwin&McKnight,P.C.
Law Offices
West Pomfret Professional Building .
60 W Pomfret St
Carlisle,PA 17013-3222
Fax: (717)249-6354
Re: Estate of Gayle Mullen
. Sociai Security Number 17405-0131
Date of Death 3/17/2013
TI'I5 HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE
FOLLOWING ACCOUNT WITH pRRSTOWN BANK:
CHECKUVG ACCOUNT
Account No.- 106002369
Account Type- 50+Interest Checicing
Date Opened- 12/14/2001
Joint Account(name/date)- No
Balance with interest $6,354.87
�HECKING ACCOUNT
� Account No.- 106006229
Account Type- 50+Interest Checking .
� Date Ope.ned- 07/19/2012
Joint Account(name/date)- No
, Balance with interest $203.00
Date Closed . � 09/19/2012
CHECKING ACCOUNT �
Account No.- 106006278
Account Type- 50+Interest Checking
Date Opened- 09/19/2012
Joint Account(name/date)- Yes,Elizabeth M Rowe. Lega1 Custodian
BaIance 269.63
2695 Philadelphia Avenue•Chambersburg,PA 17201
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Best Regards,
`,�(,�- � ����_'"
Lisa R Kline
Deposit Processing Clerk III
S� �"�'"��i"�$�°� Statement,of Accounts
5000 Louise Drive
PO 8�t 40
"�'°"'`�'"'"�,P"10� May 18, 2013 thru May 24, 2013
www memberslstorg
AAain Switchboard: (800)283-2328
Q c���: c�,�ss�-a��2 0�ceoo�2e��2 Account Number: 507187
TDD: (71�697-5312 or(800)283-2328 ext.5312
� TeleBranch: (800)237-7288 ���
MEMBERS ist Balances at a Glance: ----
�n�.c�rr vrnox Checking: 5,156.20
�s5s � A� 0.360 �sss-�5ss Savings: 5.00
;� ii���i��ii�i��liili�ii�i��������i������i�ill�iiill�iri�lll��lil�i Certi�icates: o.00 _
� ESTATE OF GAYLE K MULLEN Loans: O.00 �_
C/O ELIZABETH M ROWE M011@ Mana ement: �.(�
+� 908 ARMSTRONG RD y g
;� CARLISLE PA 17013 Swipe 5 YTD Reward: �.(�
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Go paperless and sign up for eStatements today!
See the enclosed insert for more details.
CHECKING ACC4UNTS
0011 -CHECKING
Date Tr�u� De�cti�tion Additions Subtractfons Balenoe
A�y f8 B� Fa►r�►d � 0.00
May 18 Deposit by Check 5.584.70 5,584.70
May 23 Check 001001 Tracer 0000393.�i85 4,28.50- 5�156.20
A�y 24 Frra��rg�nrae � 5�156.ZO
� CHECK SUMMARY
Chedc # Amount �te Chedc # Amount Dete
001001 428.50 May 23
SAVINGS ACCDUNTS
0000-REGULAR SAVINGS
�te Trer�saction Descri�tion Additior�s Subtractbns Balanve
A�y f8 �nrae Fo�d 0.00
May 18 Deposit by Check 5.00 5.00
I{�y 24 F�dh�g►�ai�ixas 5.00
YTD SUMMARIES
TOTAL DMDENDS PAID : .
0000 REGULAR SAVINGS 0.� ` '
0011 CHECKING _ 0;00
Total Year To Date Dividends Paid 0.00
NOTE: Total includes closed shares
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��'f OFElC��
]uly 10, 2013
IRWIN & MCKNIGHT LAW OFFICES
ROGER B IRWIN ESQ
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE PA 17013-3222
Re: Gayle Mullen
CIS #: 780314993
SSN: ###-##-0131 ..
Date of Death: 03/17/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Irwin:
Under State and Federai law, the Department of Public Welfare (the Department) is
required to recover medical assistance (MA).reimbursement from the probate estates of
deceased individuais who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S: § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Aithough the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of�91.017.67 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medicai expense, namely $27.193.85, was incurred during the last
six months of the decedent's life; therefore, it is a Ciass 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $63,823.82, is to be entered as a priority Ciass 5.l claim against the estate.
You shouid refer to Section 3392 for a more complete explanation of the priority rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of ciaim
for that injury-related lien must be requested separately.
Bureau of Program Integrity� Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg,Pennsyivania 17105-8486
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