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HomeMy WebLinkAbout05-28-14 J 1505610140 REV-1500 Ex (02-11)(FI) PA Department of Revenue ., "' Bureau of Individual Taxes County Code Year File Number PO sax 280601 INHERITANCE TAX RETURN 2 1 1 4 0 2 6 7 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 3 0 8 2 0 1 4 1 2 2 3 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI W I N T E R S R A Y M 0 N D S (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 0 1.Original Return 2,Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) 4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required death after 12.12-82) 0 6, Decedent Died Testate 7.Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death E] 11.Election to Tax under Sec.9113(A) Between 12-31-91 and 1.1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number S E T H T M 0 S E B E Y 7 1 7 2 4 3 3 3 4 1 REGISTER OF WILLS USE ONLY -I N First Line of Address Ch ` 1 0 C= <:> M E A S T H I G H S T R E E T Second Line of Address rn rn cnn._I _ 00 y City or Post Office State ZIP Code DATEFILED o ' C A R L I S L E P A 1 7 0 1 3 � `= �.; m Correspondent's e-mail address: SMOSEBEY(a7,MARTSONLAW.COM H-+ Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the hest of my knowledge and bellet, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all infomtatrc n of which preparer has any knowledge. SI TURF OF PERSON RESPONSIBLE R FILING RETURN �7'E� —/ ADDRESS #�Jy— L�YL�W1.1nL, 4d 145 FAIRVIEW DRIVE CARLISLE PA 17013 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 10 EAST HIGH STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 Continuation of REV-1500 Inheritance Tax Return Resident Decedent RAYMOND S.WINTERS 21 14 0267 Decedent's Name Page 1 File Number Correspondents Name Daytime Telephone Number First fine of address Second line of address City or Post Office State ZIP Code Correspondenfs e-mail address: Underpenalties of perjury.I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. 'SIGN T-(2'OF ER jO ZE3 NSI ��-FFORR FILING RETURN DATE ADD Es' rJ/j[°jb I —t ZI 2148 WESTWARD PLACE MARTINEZ CA 94553 J 1505610240 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: RAYMOND S . WINTERS RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 , 0 0 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 1 1 0 , 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 7 9 2 6 7 , 9 1 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property (Schedule G) b Separate Billing Requested . . . . . . . 7. 1 0 0 0 . 0 0 8. Total Gross Assets(total Lines 1 through 7) 8. 8 0 3 7 7 , 9 1 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 5 1 8 7 . 5 0 10. Debts of Decedent,Mortgage Liabilities, and Liens(Schedule 1) . . . . . . . . . . . . . 10. 3 1 2 5 0 . 4 1 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 3 6 4 3 7 . 9 1 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 4 3 9 4 0 . 0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . .. . . . . . . . . . . . . . 14. Net Value Subject to Tax(Line 12 minus Line 13) . .. . . . . . . .. . . . . . . . . . . . 14. 4 3 9 4 0 . 0 0 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 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate x.045 4 3 9 4 0 . 0 0 16. 1 9 7 7 . 3 0 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 9 7 7 . 3 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑X Side 2 1505610240 1505610240 REV-1500 EX(Fo Page 3 Fite Number Decedent's Complete Address: 21 14 0267 DECEDENT'S NAME RAYMOND S. WINTERS STREET ADDRESS 145 Fairview Drive ----- - ---- CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 1 977.30 2, Credits/Payments A.Prior Payments B,Discount 98.87 Total Credits(A+B) (2) 98.87 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 1,878.43 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? ....................................................... ❑ Q 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... X❑ El 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ Q 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................--............. ❑ IXI 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 A)(I)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in V2 P.S.§9116(a)(1)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)1.A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE 7NHE97ANCE TAX RETURN STOCKS & BONDS S RESIDENT DECEDENT ESTATE OF FILE NUMBER RAYMOND S. WINTERS 21 14 0267 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1 I shares,Cumberland Valley Co-op 110.00 TOTAL(Also enter on Line 2,Recapitulation) $ 110.00 If more space is needed,insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE INHERITANCE TAX RETURN CASH, BANK DEPOSITS & MISC. RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: RAYMOND S. WINTERS 21 14 0267 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. M&T Bank Checking Account No.9851859851 5,397.66 ($5,397.63 +$0.03 interest) See attached 2. M&T Bank Savings Account No. 15004224503670 72,677.55 ($72,676.60+$0.95 interest) See attached 3. Hollidaysburg Veterans'Home Member's Fund Account 313.70 4. 2013 1040 personal income tax refund 658.00 5. 2013 PA40 personal income tax refund 221.00 TOTAL(Also enter on Line 5,Recapitulation) $ 79 267.91 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER RAYMOND S. WINTERS 21 14 0267 This schedule must be completed 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 RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECUS EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IIFAFHID UQ VALUE 1. Karen Winters,daughter; cash- 9/07/13 3,000.00 100.00 3,000.00 0.00 2. Barry Winters,son;cash- 9/07/13 4,000.00 100.00 3,000.00 1,000.00 3. Deb Winters,daughter-in-law; cash-9/7/13 1,000.00 100.00 1,000.00 0.00 TOTAL (Also enter on Line 7,Recapitulation) $ 1,000.00 If more space is needed,use additional sheets of paper of the same size. REV-1521 EX+(06-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER RAYMOND S.WINTERS 21 14 0267 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Years)Commission Paid: 2, Attorney Fees: Martson Law Offices(estimated) 4,754.00 3. Family Exemption:(if decedent's address is not the same as claimants,attach explanation) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4, Probate Fees: Register of Wills,Cumberland County 223.50 5 Accountant Fees: 6. Tax Return PreparerFees: Accounting Offices of Kayieen Clemens-Preparation of 2013 Federal 125.00 and PA Income Tax Returns 7. Register of Wills,Cumberland County-Oaths on Petition 10.00 8. Register of Wills,Cumberland County-AdditionaI Probate Fees 75.00 TOTAL(Also enter on Line 9,Recapitulation) $ 5,187.50 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FIlE NUMBER RAYMOND S.WINTERS 21 14 0267 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Department of Miliatry Veterans Affairs-Hollidaysburg Veterans'Home,maintenance fees claim 31,050.41 2, M&T Bank checking 9851859851,outstanding check on date of death 200.00 TOTAL(Also enter on Line 10,Recapitulation) $ 31 250.41 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RAYMOND S.WINTERS 21 14 0267 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 prollude outright spousal distributions and transfers under Sec.9116(a)11.2).] 1. Judy Kocon Lineal 14,646.67 76-6246 Alii Drive#304 113 of residue Kaiiva-Kona,HI 76740 2. Barry Winters Lineal 14,646.66 145 Fairview Drive 113 of residue Carlisle,PA 17013 3. Karen Winters Lineal 14,646.67 2148 Westward Place 1J3 of residue Martinez,CA 94553 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. U LAST WILL AND TESTAMENT OF RAYMOND S. WINTERS I,Raymond S. Winters,a resident of Carlisle,Pennsylvania declare this to be my Last Will and revoke all former Wills and Codicils. ARTICLE I Identification of Family I At the present time I am unmarried. In making this Will I have in mind my children,Judy Kocon, born 1942,Barry Winters,bom 1948,and Karen Winters, born 1955, but does not include any children hereafter bom to or adopted by me. Any reference to a"child of mine"or"my children"shall include the persons named or referred to in this Article. ARTICLE II Disposition of Remains I direct that my remains be buried in the family plot next to my wife,Rhea. I would like a simple ceremony,officiated by the pastor of First Assembly of God Church in Shippensburg, PA. I wish to be buried in a suit with no tie. I authorize my Executor to carry out these directions and wishes,particularly those for the disposition of my remains. ARTICLE III Appointment of Fiduciaries A. Appointment of Personal Representative. I appoint my daughter,Karen Winters and my son,Barry Winters as Co-Executors of my estate, but if either is or becomes unable or unwilling to serve,the other may serve as sole Executor. B. Bond; Court Supervision. My Executor shall have the right to serve without bond and to administer and settle my estate without the intervention or supervision of any court, except to the extent required by law. Nothing herein shall prevent my Executor from seeking the assistance of the court in any situation where my Executor deems it appropriate. Will of Raymond S.Winters Page i of lnitiais'�ate:l j �L� ARTICLE Iv Disposition of Residue A. Provision for Descendants. I give all of the rest and residue of my estate, wherever located(hereafter referred to in this Article as"residue"),to my descendants if they survive me per stirpes. 1. Provision for Others. If I am not survived by any of my descendants,I give the entire residue to my heirs. ARTICLE V Alternative Methods of Distribution A. Purpose of Article. Recognizing that under certain circumstances the terms of this Will may direct that property be distributed outright to a person who is under age twenty-one(21)or under a legal disability;I make the following provisions to facilitate the distribution of property to such persons. B. Alternative Methods. Whenever the terms of this Will direct my personal representative(referred to in this Article as the"fiduciary")to distribute property outright to a person who is then under age twenty-one(21)or under a legal disability, the fiduciary may retain pursuant to Paragraph C.of this Article or distribute all or any portion of that property in any one or more of the following ways: 1. Delivery directly to the beneficiary; 2. Delivery to the parent or stepparent of the beneficiary; 3. Delivery to the guardian of the beneficiary's person or property; 4. Delivery to any Custodian for the beneficiary under the Uniform Gifts to Minors Act; 5. Delivery to any then existing trust created for the beneficiary; fi. Deposit in a financial institution in an account established in the name of the beneficiary alone pursuant to the laws of the State of Pennsylvania; 7. Storage of any tangible personal property in safekeeping with the costs of storage to be borne by the beneficiary; or 8. Sale of any tangible personal property and delivery of the proceeds in any manner permitted by this Article. Will of Raymond S.winters Page 2 of 6 Initials-J�Date: IoC ot7 /Lt Provided the fiduciary acts in good faith,upon delivery of any property in accordance with the provisions of this Article, the fiduciary shall be discharged from all responsibilities in connection with the property. C. Discretionary Trust Any property not distributed as provided in Paragraph B. of this Article shall be retained by the fiduciary in trust for the beneficiary on the following terms and conditions: During any period in which the beneficiary is under a legal disability or under twenty-one(21)years of age,the fiduciary shall pay to or apply for the benefit of the beneficiary so much of the income and principal of the trust as the fiduciary, in its sole and absolute discretion, determines is advisable for the beneficiary's health,support,education and general welfare. At such time as the beneficiary is neither under a legal disability nor under age twenty-one(21),the fiduciary shall distribute any remaining trust assets to the beneficiary. If the beneficiary dies before all of the trust assets have been distributed,the fiduciary shall distribute any remaining trust assets to the beneficiary's estate. ARTICLE VI Administrative Provisions A. Powers and Duties of Personal Representative. My personal representative shall have all of the powers and duties granted to or imposed upon personal representatives serving with non-intervention powers pursuant to the laws of the State of Pennsylvania. B. Debts and Expenses. All expenses of administration chargeable to principal,the expenses of the disposition of my remains,and all my legitimate debts, if and when paid,shall be paid from the principal of my residuary estate. No debt need be paid prior to its maturity in due course and except as otherwise provided in this Will no interest in any property passing under this Will need be exonerated. C. Taxes. All estate, inheritance or other similar death taxes,together with any interest or penalties thereon,arising by reason of my death with respect to any property includable in my taxable estate,and any adjusted taxable gifts, whether passing under or outside of this Will, shall be paid from the principal of my residuary estate without reimbursement from the recipients or beneficiaries of such property,provided, however, that in the event any proceeds of insurance upon my life or any property over which I held a power of appointment are included in my estate for purposes of determining the federal estate tax liability of my estate,then the residue of my estate shall be entitled to receive from the recipients of any such proceeds or property the portion of such federal estate tax liability attributable to such proceeds or property determined in accordance with IRC §§2206 and 2207. Will of Raymond S.Winters Page 3of6 lmtials:Z�__ Date: ARTICLE VII Miscellaneous A. Number and Gender. Unless the context indicates a contrary intent, the plural and singular forms of words shall each include the other,and every noun and pronoun shall have a meaning that includes the masculine,feminine and neuter genders. B. Survival. To"survive" me, as that term is used in this Will, a person must continue to live for thirty(30)days after my death. C. Descendants. The"descendants"of an individual include only the following: 1. All such individual's biological descendants, except any person not born in lawful wedlock and his descendants,unless the biological parent who would otherwise cause him or her to be a descendant has acknowledged paternity or maternity in legitimation proceedings,or in an unambiguous signed writing identifying such person by name,or by raising such person in the same household; and 2. Persons adopted by such individual or one of his or her descendants,and their descendants. If the parent,who would cause a person to be a descendant as defined above, is replaced in an adoption proceeding,such person shall remain a descendant unless such parent voluntarily consents to the relinquishment of his or her status as parent in connection with such adoption proceedings. D. Heirs. The term "heirs"shall mean those persons entitled to inherit under the then-applicable laws of the State of Pennsylvania governing the descent of an intestate's separate estate. They shall inherit in their statutory proportions. E. Exclusion of Pretermitted Heirs. tither than as set forth in this Will, I make no provision for any child of mine or descendant of a deceased child of mine. I specifically make no provision for any person(whether now living or hereafter born), other than a child named or referred to in Article I or a descendant of mine as defined in this Will, who may be entitled to claim an interest in my estate under the laws of the State of Pennsylvania. F. Legal Disability. A person is under a legal disability if my personal representative determines, in good faith, that the person is incapable of managing his property or of caring for himself, or both, or is in need of protection or assistance by reason of physical injury or illness, mental illness,developmental disability,senility, alcoholism, excessive use of drugs, or other physical or mental incapacity. Will of Raymond S.Winters Page 4of6 Initiala:r' 1Qaw G. Title to Real Property. Upon my death,title to any real property passing under this Will shall vest in my personal representative in his fiduciary capacity and shall remain so vested until my personal representative distributes or sells that property, at which time title shall vest in the distributee or purchaser. H. Disclaimer. Except as may be otherwise specifically provided in this Will,in the event that any beneficiary disclaims an interest arising out of this Will or any trust created herein it is my intention that the interest disclaimed shall be distributed in the same manner and at the same time as if the disclaiming beneficiary had died immediately preceding the event pursuant to the laws of the State of Pennsylvania. L Governing Law. The provisions of this Will shall be interpreted in accordance with and in light of the laws of the State of Pennsylvania. J. Corporate Successors. Whenever a corporation or other business entity is referred to herein,the reference shall include any successor organization. K, References to Statutes. In this Will,the abbreviation "IRC" shall refer to the Internal Revenue Code of 1986 as amended, Will of Raymond S.Winters Page 5 of 6 lnitials: JM/Date:���GF I have initialed and dated for identification purposes all pages of this�,[�ty Last Will,and have executed the entire instrument by signing this page on th T a'y of 66 20 lb,at 'C-AC t-t�i LE- Pennsylvania. Raymond S. Winters Attestation and Statement of Witnesses Each of us declares under penalty of perjury under the laws of Pennsylvania that Raymond S. Winters, the Testator, signed this instrument as his Last Will in our presence,all of us being present at the same time, and we now,at the Testator's request, in the Testator's presence,and in the presence of each other, sign below as the witnesses, declaring that the Testator appears to be of sound mind and under no duress, fraud, or undue influence. jWimessSi'fWure] [Witness Si ature L a,. /e, JyC1 r tF (Print Name] [Print Name] Residing at Sf r Cr- e e k lea Residing at ( ,)E5 i PJ 6-FEZ i7oi - _ � +It2lltJl 1-70 t '� Will of Raymond S.Winters Page 6 of 6 Initisfs�bate:'.� SELF-PROVING AFFIDAVIT STATE OF PENNSYLVANIA } } ss. COUNTY OF C!. [af i�f.tLtAAJ 6 } 1,the undersigned, an officer authnri7vri to adm;nicter nathc, certify that Raymond S.iWinters, the Testator,and.. fAt2L L . ,lg7 LEE ,and U A YZ.C.I Ei A . Itl�A L- the witnesses, whose names are signed to the attached or foregoing instrument and whose signatures appear below,having appeared together before me and having been first duly sworn,each then declared to me that: 1)the attached or foregoing instrument is the last will of the Testator;2) the Testator willingly and voluntarily declared,signed and executed the will in the presence of the witnesses;3) the witnesses signed the will upon request by the Testator,in the presence and hearing of the Testator, and in the presence of each other; 4)to the best knowledge of each witness the Testator was, at that time of the signing,of the age of majority(or otherwise legally competent to make a will),of sound mind and memory,and under no constraint or undue influence;and S)each witness was and is competent and of the proper age to witness a will. a � � /} and S. Winters / [Witness S turre] I gas ignatur&e 1 ter JAS /Ei^ l/NNJJI#�rJJ_ [Print Name] [Print Name] Residing t i y e-e°e!f /?.:.t' $ � Residing at -"gv 1'r /e 1°,4 , yam, Section for Notary;Public: Subscribed, sworn and acknowledged before me by the said Raymond S. Winters,L Testator, and by the said EaK-L- y2l LF-12..-y and 1af1r le- B R1 t t,,• witnesses thi a of jb tit'i W-2p lb. COMMONWEA AS AL PENNSYLVANIA pp � A K C "l NQTAn#AL$EAL .fF t'lLt .f'li � CAMELAJ.MANGES,Notary Public [Sig of Notary Boro of Carlisle,Cumberland COMO l My Commission Expires June 27,2074 [Print or stamp name of Notary] © M&T Bank 499 Mitchell Road.Millsboro,DE 19966 Adjustment Services Phone 888-5024349 Fax (302)934-29,55 Martson Deardorff Williams Otto Gilroy & Faller April 1,2014 Martson Law Offices 10 East High Street Carlisle,PA 17013 Re: Estate of Raymond S Winters Social Security- 196-14-4643 Date of Death: March 08 2014 Dear Sir or Madam: Per your inquiry on March 25, 2014,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1 Type ofAccount Checking Account Account Number 9851859851 Ownership(Names of) Barry R. Winters(POA) KarenL Winters(POA) Raymond S Winters Opening Date 1011412010 Balance on Date of Death $ 5,39763 Accruedlrtterest $ 03 Total $5,39266 2• Type ofAccount Savings Account Account Number 15004224503670 Ownership(Names ofJ Barry R. Winters(POA) Karen L Winters(POA) Raymond S Winters Opening Date 1011412010 Balance on Date of Death $ 72,67660 Accrued Interest $ .95 Total -------- - -- $ COMMONWEALTH OF PENNSYLVANIA GOVERNOR'S OFFICE OF GENERAL COUNSEL April 7,2014 Karen Winters 2148 Westward Place Martinez,CA 44553 Re: Estate of Raymond S. Winters Dear Ms, Winters: The Office of Chief Counsel, Department of Military and Veterans Affairs, represents the Hollidaysburg Veterans' Home (HVH). HVH's records list you as the next of kin or representative of Raymond S. Winters, who passed away recently. Please accept the sincere condolences of the Department of Military and Veterans Affairs for your loss. When a resident or former resident of a state veterans' home passes away, there are financial obligations that must be addressed. The purpose of this letter is to describe these obligations and to begin the process of addressing them. This letter contains important legal information. I encourage you or the executor or administrator of the estate to consult with an attorney about these matters. If an attorney represents you or the estate in this matter, take this letter to your attorney at once. The costs of caring for a resident of a state veterans' home are considerable. No eligible veteran is turned away because of lack of assets or income. State veterans' homes do not require residents to sell all their assets in order to pay for the on-going costs of their care. Instead, the state veterans' home collects appropriate amounts based on ability to pay while the resident is alive. We call the amounts paid during the resident's lifetime the maintenance fees, In most cases, the maintenance fees collected during the resident's lifetime represent only a fraction of the cost of the veteran's care. Our veterans' homes defer collection of the balance of unpaid total costs of care until assets are available after the veteran's death. This arrangement was explained to Mr. Winters, or his representative, at the time of his admission to Hollidaysburg Veterans' Home, and annually, when the maintenance fee was recalculated. It's important for you to understand that the amount of the Commonwealth's claim represents a claim against the estate of Raymond S. Winters. This is a claim against the estate only, and only the estate is obligated to pay it in whole or in part. It is the responsibility of the executor or administrator(personal representative)to pay this claim on behalf of the estate to the extent of the estate's ability to pay. This is not a claim against you personally or any other survivor or relative of Mr. Winters. Office of Chief Counsel I Department of Military and Veterans Affairs pE1'tnsytvania B(6,3 7-36 1 Fort Indiantown Gap I Annvitie,PA a 003-5002 DEPARTMENT OF MILITARY Phone:717-8611-8 5031 Fax:717-86t-&2651 www.dmuastate.pa.us AND VETERANS AFFAIRS Karen Winters April 7, 2414 2 1 it <r _ I am requesting that you assist me by providing the name of the executor or administrator of the estate. I also ask that you forward this letter to that person. To assist you in providing this information to me, I am sending you a form entitled`=Acknowledgement of Claim." Please complete the Acknowledgment of Claim form and return it to me in the envelope provided. Tile information requested on this form will help us move forward with addressing the financial obligations of the estate of Raymond S. Winters. If you are the person who will serve as the executor or administrator of the estate of Raymond S. Winters, this Ietter is a formal legal claim against the estate for the amount of$31,050.41. Under Pennsylvania law, 20 Pa.C.S. § 3392(3), $31,050.41 of the HVH claim is a Class 3 cTau`n—which must be afforded the priority of payment required by law. Additionally, when Mr. Winners died, he had a balance of $313.70 in his Member's Fund Account at HVH. This money belongs to Raymond S. Winters's estate, and it will be promptly turned over to the duly-appointed executor or administrator of the estate upon demand. If you are the person who will serve as the executor or administrator (personal representative) of the estate of Raymond S. Winters, please provide me with a copy of the "Short Certificate" that shows you have been appointed as the executor or administrator, I will then have Hollidaysburg Veterans' Home send you a check for the money in the Member's Fund Account. If you prefer, you can apply the money in the Member's Fund Account in partial payment of HVH's claim. If no executor or administrator is appointed for the estate of Raymond S. Winters, the $313.70 in Mr. Winters's Member's Fund Account will, one-year after Mr. Winters's death,become the property of HVH by operation of law. If you or the estate are represented by an attorney, your attorney will handle contacting my office with questions. Otherwise, please feet free to call me at 717-861-8503 if you have questions. All correspondence pertaining to the estate of Raymond S. Winters should be sent to me at the address shown at the bottom of page 1. Very truly yours, 1 .� ) > i�- Stephen J.Bushinski Enclosure cc: Lori Hampton, HVH