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Home My WebLink About04-08-14 . . � 1505610105 REV-1500 EX�o2_��,�F�,,� PA Department of Revenue pennsytvania OFFICIAL USE ONLY °��^^�^F��°��F^°� County Code Year Fiie Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX z8o6oi - Harrisburq,PA 17i28-o6oi RESIDENT DECEDENT =� � �`7'� `�5� ' ENTER DECEDENT INFORMATION BELOW Sociai Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 172-26-9585 01/17/2013 02/25/1924 Name Suffix DecedenYs First Name MI Holler Daniel (If Applicable)Enter Surviving Spouse's Information Below 5pouse's Last Name Suffix Spouse's First Name MI Spouse's Social Securiky Number ThiS RE i t1RiJ flriUS�8E FILE[7 iN DUPLICATE WITH THE _ _ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Originai Return p 2.Supplemental Return p 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate p 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) f� 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 Scheduie O} CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name _ _ _ _ Daytime Telephone Number Andrew C. Sheely, Esquire 717-697-7050 � o _ __ _ _ _ �_ _ --� _ z rn REGISTER OF W S�¢E ONLY� � C7 "U "�T 't^� O � S C'� � U7 �1 First Line of Address __ _ __ � � tT1 t� t'TI 127 South Market Street -G- �' "`' � � ° c7 � �`' .� <� o S�cond Line of Address _ � C 'i7 � � �'t P.O. Box 95 • � c,a '= r' -o --t rr-- R' City or Pcst Office Siate ZIP Code DATfiFILED Q � "►1 Mechanicsburg ' PA 17055 ' CorrespondenYs e-maii aaaress:andrewc.sheely@verizon.net Under penalties of perjury,I deciare 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 ali information of which preparer has any knowledge. SI ATURE OF PER�ON RESPONSI L FOf3 FILING RETURN DATE ��/� �D f� l�2 C7z 7 C �. �- r--•-••-•-_.� � ADDRES � August A. Holler, Exe trix, 307 Pinewood Drive, Shiremanstown, PA 17011 SIGN RE OF PREP ER T TH R RESENTATIVE AT y° �, !��` ESS Andrew C. Sheely, Esquire, 127 South Market Street, P.O. Box 95, Mechanicsburg, PA 17055 PI.EASE USE ORIGINAL FORM ONLY Side 1 � 15D5610105 7,505610105 J � � . . J 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: HOII@f, Daniel RECAPITUTATION 1. Real Estate(Schedule A). . .. . . . .. .. . . .. . . ... .. . .. . .. . .. ... .. .. . .. . . .. 1. ' 2. Stocks and Bonds(Schedule B) . . . . .. . .. . . . .. .. . .. .. . . .. . . . .. . . . .. . . .. 2 ' 3. Closely Held Corporation, Partnership or Sole-Proprietorship{Schedule C) .... . 3. i 4. Mortgages and Notes Receivable(Schedule D). . .. . . . .. . .. . . . . .. . .. . .. .. . 4. ' 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. .. . 5. ' 6. Jointiy Owned Property(Schedule F) O Separate Billing Requested . . . .. .. 6. ' 7. inter-Vivos Transfers&Miscellaneous Non-Probate Property " (Schedule G) O Separate Biliing Requested.. . . .. .. 7. ', 15,270.00 i 8. Total Gross Assets(totai Lines 1 through 7}. . . .. .. . .. ... .. . . .. . . . .. .. . .. 8. ', 15,270.00 ` 9. Funeral Expenses and Administrative Costs(Schedule H).. . .. ... .. . . .. .. . .. 9. 593.50 ' 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . ... . . . . . . .. . 10. ' 11. Total Deductions{total Lines 9 and 10). .. . . .. .. . .. ... .. .. . . . .. .. . . . .. .. 11. ', 593.50 `. 12. Net Value of Estate(Line 8 minus Line 11) .. .. . . ... .. . . . ... . . .. .. .. . .. .. 12. ' 14,676.50 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. ' 14,676.50 " TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfejs under Sec.9116 _ _ 14 676.50 ' 15. _ _ 0.00 ' �a?(1.2 X.0 0 � 16.. Amount of Line 14 taxable ' i at lineai rate X A_ , ' 16. ' 17. Amount of Line 14 taxable at sibling rate X.12 ' 17. ' _ _ 18. Amount of Line 14 taxable at collateral rate X.15 ' �g. ' 19. TAX DUE . . . . .. .. . . .. .. . .. . .. . .. .. . .. .. . . . . .. . .. . . . .. . .. .. . . .. . .. . 19. ' �.00 ' 20. FILL IN THE OVAI IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610205 15D561�205 J REV-1500 EX(FI) Page 3 File Number DecedenYs Complete Address: 02(- l�- ,��D DECEDENT'S NAME Daniel Hoiler _..._ - _.._. ___ _ _. _..... __ STREET ADDRESS --- 307 Pinewood Drive _ __ ___ -_.. __... _ _..... ___ _ _ _.. CITY __ - - __...._ __ _.....__ STATE -_ _........ 1 ZIP Shiremanstown PA I 17011 Tax Payments and Credits 1. Tax Due(Page 2,Line 19) (t) 0.00 2. CreditslPayments A.Prior Payments ____.___ _.. -.... B.Discount --- — --------- Total Credits(A+B) (2) 3. inferesi ---- -- 4. if Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (3� Fill in oval on Page 2,Line 20 to request a refund. �q� 5. If Line 1 +Line 3 is greater 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 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 ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec. 12, 1982,did decedent transfe�property within one year of death without receiving adequate consideration?...................... ........................................................................................ � 3. Did tlecedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did tlecedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? .................. � � ................................................................................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDi1LE 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,antl the statutory requirements for disciosure 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 chiitl 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 decedeni'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 tlecedent's sibiings is 12 percent(72 P.S. §9116(a)(1.3}].A sibling is tlefined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. _ . _ . _ _ REV-i510 EX+(08-09? �� x pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND - INHERITANCE TAX RE7URN MISC. NON-PROBATE PROPERTY � RESIDENT DECEDENT ESTATE OF FILE NUMBER Daniel Holler 21-14-256 This schedule must be compieted and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELAiIONSHiP TO DECEDENT AND DATE OF DEATH %OF dECD'S EXCLUSION TAXABLE NUMBER � iHE DAiE OP TRANSfER. ATfACH A COPY OF THE DEED FOR RFAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICpBIf) VALUE � 1, Santander IRA,Plan Number 0317-0057-818-0000035-Beneficiary:Estate of Daniel Hoiler,307 Pinewood Dr,Shiremanstown,PA 17011 15,270.00 100 15,270.00 TOTAL(Also enter on Line 7, Recapitulation) $ 15,270.00 If more space is needed,use additional sheets of paper of the same size. , , � • �15�7b1� . �? MA1-MB3-02-10 TD/IK ✓ INDlVIDUAL RETIREMENT ACCOUNT P.O.BOX 841005 BOSTON, MA 02284 For inquiries Please Call:(877)768-2265 Bank FIN 23-1237295 �"'"�° a�:�+�,a;'�' � � �'«- , a ��;r� �: ��°�. °�`��° � ` � �� ; — 0317-0057-818-0000035 0 3 4 4 B 491830 1 OZ ATM 52.57.12 °��' ' ��. �� ^E �S .s�ar+�+ �n ��+;'� �8 � �� 01/21/2014 �y� � . '�.� s.; &a t�`a � e r „� DANIEL HOLLER ,�� ,p,��g��{ �.��.<��^�u; 307 PINEWOOD DR ,�:,;;. ' ,;� 01/01/2013 SHIREMANSTOWN, PA 17011-6528 �� ` € �. , ��..<....�....�.r.�:.:;.�,�..::z:�, 12/31/2013 I��IIL��IIL��JI��IIJI��I�I��LII��LII��L��I��LII Page 1 of 2 ,.. A ��...� w ,�._ . �... ,, � �'� � ��%� , � . wF�, �,,� y ._ . . .. � .. . , t�rrV! rs 4��.�,r. &G . �y��'.r��,�y�, �'��».� '.�. FAIR MARKET VALUE AT THE END OF 2013: 15,640.49 THE FAIR MARKET VALUE INFORMATION IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. _ .. -� � .. .,.�.. u:.: -. �.., �,; �,; : � � �� : . k-- ��- ?:. � ,:� x _ w ��,�:�?��; : ,,,. ,. � ::�..,�:�ry�..>. - :.. " ".. T � � �. � � :� , ..., .. �; � �,��"� ��r�,...�^ � ��; Prior Cash Balance 15,222,g2 - , ... Plus Credits 0.00 0.00 Plus Interest 417.67 �= ,� � �,. : 0.00 �ess Debits 0.00 0.00 „ ��.:. .� New Cash Balance 15,640.49 �y _ �;, ' o.OQ Totat Pian Value 15,640.49 J � � � 4 " O.00 �� ` _� ��` �i .�,,. .��,.. < 0.00 �st� �� " < a��.-� - .,.,. . ,� ,._.. � d,�x .� w:�: �~� .� ..�: �.�.•� _ .�_� .� E � ��.. _ . _ _ �. 0.00 - --_ -. --. � ..:,� � . - -._ .._... __ .. ; �`�� .-. .' £.- - -_ _. �•�, �... ,;:. --O.Oa �"�y 0.00 ,. .. ,�:,. : „ ,�:- _ �� :.�,� x �.._ . . ,: , ' - >� +�� L ?;s: �u4"T„� .u4r:....H �'�* .-'�� '� '.'S' 3� : h .wk' '�;...." �.: ',b '�'��4 i1 `�" �`fa;� 5,j r..: ...,. V„ ,. .,w_, . .. � .. . . .��.:�.. �_....��... .,..>_.-.; .� _ .... .. ... .�.'.� ,p��q � ,44` � ... _ ..:.. - .. �.,F.abf`.£s.ay, , a: ,:;...F ...., . �„� _,� 15222.82 �:. �� :� 05/03/2015 _ .�,�.�,�n�� Description �� ':..� ��,, IRA CD Interest Credit Date Amount Balance IRA CD Interest Credit 01/31/2013 47.18 15,27Q.00 IRA CD Interest Credit �y2812013 30.72 15,300.72 IRA CD Interest Credit 04/01/2013 34.08 15,334.80 IRA CD interest Credit OM30/2013 33.06 15,367.86 IRA CD Interest Credit 05/31/2013 34.23 15,402.09 IRA CD Interest Credit 07/01/2013 33.20 15,435.29 IRA CD interest Credit 07/31/2013 34.3g 15,469.67 �IRA CD Interest Credit 09/03/2013 34.46 15,504.13 Continued on next page. 09/30/2013 33.42 15,537.55 _ _ __ _ . __ _ ' r�EV-i'slr �x+ ��o-o{>> � pennsylvania SCHEDULE H �� DEPARTMENTOFREVENUE FUNERAL EXPEN SES AND INHERITANCE TAX REfURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Daniel Holler 21-14-256 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES; 1. e. ADMINISTRATIVE COSTS: 1, Personal Representative Commissions: $0.00 Name(s)of Personal Representative(s) Augusta A. Holler street address 307 Pinewood Drive - __ _.. _ city Shiremanstown _.state PA 17011 _ __..._.__ZIP _ ___ _...._ _...... Year(s)Commission Paid: - __. -_ - __ 2• Attorney Fees: $450.00 3• Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation.) Claimant Street Address _...- -_ _.. _. _.. - City -._. __ _ _.._______._State ZIP _ __ Relationship of Claimant to Decedent 4• Probate Fees: $143.50 5• Accountant fees: 6� Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 593.50 If more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date : 3/20/2014 Cumberland County - Register Of Wills Receipt Time : 10 :42 : 19 One Courthouse S quare Receipt No. : 1077358 Carlisle, PA 17613 HOLLER DANIEL Estate File No. : 2014-00256 Paid By Remarks : AUGUSTA A HOLLER DB1 ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN Check# 3779 $143 . 50 Total Received. . . . . . . . . $143 . 50 REV-1513 EX+(Qi-SO) ; � ,:`pennsylvania SCHEDULE ) DEPANTMENT OFqEVENUE � INHERIiANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Amy K. Moore 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 Sec.9116(a)(1.2).] i. Augusta A. Holler,307 Pinewood Drive,Shiremanstown, PA 17011 Spouse 100% Rest, remainder 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, LAST WILL AND fiESTA.MENfi OF DAIVIEL HOLLER I, DANIEL HOLLER, of 307 Pinewood Drive, Shiremanstown, (Lower Allen Township), Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoldng a11 other Wills and Codicils heretofore made by me. FIRST: I direct that all inheritance, estate, transfer, succession and death taxes, as well as my just debts and fizneral expenses, of any kind whatsoever, which may be payable by reason of my death, shall be paid out of the �rincipal of my estate as the same can conveniently be done. SECOND: I give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any � � ,�'---"��y�-` .� c��tr:�e�rt°arrc� to t11er�wz�i axi=_ . . ._ ��ap� � ��.�� r Fi� ge r .� insurance policies thereon, unto iny wife, AUGUSTA A. HOLLER, provided , � she survives me by thirty (30) days. � THIRD: Should AUGUSTA A. HOLLER predecease me or die :� i, on or before the thirty-first (31 st) day following my death, I give, devise and �- bequeath all the rest, residue and rema�nder of my estate of whatever nature � � and wherever situate, including any property over which I hold power of �� appointment and together with any insurance policies thereon, to my daugh- ter, HEIDI M. HOLLER, of Carneige, Pennsylvania, provided that should HEIDI M. HOLLER predecease me, I give and bequeath the rest, residue and remainder of my estate o£whatever nature and wherever situate, unto my brother-in-law; RUDOLPH OSWALD, of Munich, Germany and my sister- in-law, ELFRIEDE GSCHLOESSL, of Ohlstadt, Gerxnany, share, and share alike. FOURTH: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applica.ble to all property, exercisable without court approv- a1 and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition. � (B� To partitxon, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivision, improvement, zoning or c �`� management of real estate and to impose or extix�.guish restrictions on real ,` estate. )� _ (C) To compromise any claim or contxoversy and to abandon any �� ro e which is of little or no value. P P �Y �. �� (D) To invest in all forms o�property, including stocks, common u. � trust funds and mortgage investment fixnds, without restriction to investments authorized for Pennsylvania fiduciaries, as are deemed proper, without regard to any principle of diversification, risk or pra-ductivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. �� (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, per-sonal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named beneficiaries in cash or in �dri.d or partly in each. (H) To bonrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent pxovided for by the plan or the law. FIFTH: I nominate and appoirtt my wife, AUGUSTA A. HOLLER, Executrix, of this, my Last Will and Testament. In the event of � �y\",'� the death, resignation ox inability to serve for any reason whatsoever of ?� AUGUSTA A. HO �� LLER, I nomui.ate and appoult HEIDI M. HOLLER, as ,, �'`' Executrix, of this, my La.st Will and Testament. I direct that my Executrix _�_ v and her successors shall not be required to post security or a bond for the ... 3 perfonmance of her duties in any jurisdiction. IN WITNESS WHEREOF, I havE hereunto set my hand and seal to this, my Last Will and Testament, this�a day of February, 2001. � �c�� -� (S EAL) DANTEL HOLLER _ ._ • , -��c�de�Yax�ed by the above-named � , Testator as and for his Last Will and Testament in our presence, who, at his request, in his presence and in the presence of each othex, have hereunto subscribed our names as attesting witnesses. /iz /►/. ��Sf�.�� ,�Ii, I� i��, � Address Name .� ^ �� -��i��f��I�S��,t�� `-°--� �-= ' S-�� Adciress Name 4 COMMONWEALTH OF PENNSYLUANIA 1 : SS COUNTY OF CUMBERLAND ) I,DANIEL HOLLER, Testator,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 instnunent as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act and deed, for the purposes contained therein. �� Daniel Hollex Swom and aff'irmed to and acknowledged before me by, Daniel Holler, the Testator, this 22nd day of Februaty, 2001. ;.. . _. . ,_ � . �I`��'iN.��i$�3€� __ . � 1, `- � � .= ---. �_ �- ��iosr��,�n�rt�id!'�+.�� - ' - MY�nml�it��i��.29�� :� COMMONWFALTH OF PENNSYLUANIA ) -- - ' - : SS - -- - - COUNTY OF CUMBERLAND ) We,the undersigned, ��2'cJ ��ccGt� and �l'LYG��Cf�=S�Pf'/y , ! the witnesses whose names aze subscribed to the attached or£oregoing instrument,being firs duly swom and qualified accordingly to law, do hereby declare to the undersigned authority that we were present and saw the Testator, Daniel Hollez, sign and execute the instrument as his Last'Will and Testament, and that the Testatoz, Daniel Holler,signed willingly, and that he executed his Last Will and Testament as his free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing o£the Testator, signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen (18)yeazs of age or older, of sound mind and under no constraint or undue influence. �w"' �� Andrew C. Sheely I 12 North 30th Street Camp Hill, PA 17011 1�� . Harold E. Sheely 706 Apple Drive Mechanicsburg, PA 17055 Sworn and affirmed to and acknowledged before me,by Andrew C. Sheely and Harold E. Sheely, the Witnesses, this 22nd day of February, 2001. �4 �#3TA1�,�9. €��ic C,C-�� _� � _ � - - � . �- . ' A�1fU.MiAii�I�Y - , ':�� :a:��:��r�B�Q��''�:;�Lb � - - _ _ - . ?;�mm�t�Exp�S S'�.�,� � — - _�,_-.