HomeMy WebLinkAbout08-29-14 (2) 1
J REV-1500 EX(02-11) 1505610143 I,
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes MMRWEW OF REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 0696
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
06 01 2013 10 21 1954
Decedent's Last Name Suffix Decedent's First Name MI
KELLY WILLIAM J
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name - MI
KELLY MARY M
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return 2. Supplemental Return 3. Remainder Return(Date of Death
FX1 Prior to 12-13-82)
4. Limited Estate 4a,Future Interest compromise 5. Federal Estate Tax Return Required ,
(date of death after 12-12-82)
B Decedent Died Testate 7. Decedent a Living Trust 0 S. Total Number of Safe Deposit Boxes
(Attach Copy of Will) ro
❑ 9. Litigation Proceeds Received 10.bEhveenl2Jlr%Credditl(Dat95M Death 11.Election to tax under Sec.9113(A)
79 (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Y
JENNIFER B HIPP 717 737 8761r
n � s
REGISTER$FS41LLS USEPNLY7 q
Fn
Fn � M � O t
First Line of Address { 1
A r1m CO � O
1 WEST MAIN STREET "' � p o
C7 C-, p �: 'rt TI
Second Line of Address
r m '
DATE*ILED r'—
O 4
City or Post Office State ZIP Code CD ?1
SHIREMANSTOWN PA 17011
t
Correspondent's e-mail address: ihippCa H^^=r•h,RE ^m
Under penalties of perjury,I dedare 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.
SIGNATURF,OF PERSON RESPONSIBLE FOR FILING RETURN
ary M. Kelly Z Q
ADDRESS
4 Eastgate Drive Camp Hill PA 17011
SIGNATURE OFlin EP R R OTHER THAN REPRESENTATIVE DATE
Jennifer B. Hipp
ADDRE
1 West Street, Shiremanstown, PA 17011
L
1505610143 Side 1 15175610143 ``^\
1505110243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name. Kelly, William J.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. -
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 30 ,283 . 35
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Noo,-Probate Property
(Schedule G) u Separate Billing Requested............ 7.
8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 30 , 283 . 35
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9.
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................ 11.
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 30 ,283 . 35
13. Charitable and Governmental 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. 30 ,283 . 35
TAX COMPUTATION-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.00 30 , 283 . 35 283 . 35 15. 0 . 00
- -
16. Amount of Line 14 taxable 0 . 00 16. 0 . 00
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable 0 . 00
at collateral rate X.15 0 . 00 18.
19: TAX DUE................................................................................................................ 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1595610243 1505610243
REV-1500 EX Page 3 File Number 21-13-0696 .
Decedent's Complete Address:
DECEDENTS NAME
Kelly,William J.
STREETADDRESS
4 Eastgate Drive
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1.. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments .
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest - (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
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;............................................................................... �x
b. retain the right to designate who shall use the property transferred or its income;..................................
c. retain a reversionary interest;or............................................................................................................... x
d. receive the promise for life of either payments,benefits or care?............................................................
2. If death occurred after Dec. 12, 1962, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which ❑ ❑
contains a beneficiary designation?.................................................................................................................. x
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)(Li)(1)). .
For dates of death on or after January 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)(ip]. 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[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)]. 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-1508 EA.(11.10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC. .
DEPARTMENT OF REVENUE
INHEFUTANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kelly,William J. 21-13-0696
Include Ure proceeds of litigation and the date the proceeds were rsceived by the estate.
All property jointly-owned with tho right of suMvomhip must be disclosed on schedule F.
ITEM - _ VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members 1st Federal Credit Union-Savings Account No.262746-00. This account was not 22,666.74
interest bearing.
2 Members 1st Federal Credit Union-Checking Account No.262746-07. This account was not 7.614:61
interest beating.
As indicated in the attached letter from Members
-1 st, at the time of his passing, the Decedent was the
Trustee of the Phillips Irrevocable Trust. This trust
was established for the benefit of the children of
Mr. Kelly's sister. Upon his death, the Trust was
notified and a successor Trustee has been appointed.
TOTAL(Also enter on Line 5, Recapitulation) 30,283.35
(If more space is needed,additional pages of the same size) ,
copyright(c)2610 form software only The Lackner Group,Inc. - Fonn PA-1500 Schedule E(Rev.-11-10)
S�
MEMBERS Pt
FEDERALCREDU UMON
WILLIAM J KELLY DBA: EXECUTIVE INSIGHTS
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 262746-00
Date Account Established 04/07/2005
Principal Balance at Date of Death $22,668.74
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $22,66814
Name of Joint Owner None
CHECKING ACCOUNT:
Account Number/Suffix 262746-07
Date Account Established 08/16/2007
Principal Balance at Date of Death $7,614.61
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $7,614.61
Name of Joint Owner None
PHILLIPS IRREVOCABLE TRUST
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 436784-00
Date Account Established 10/21/2011
Principal Balance at Date of Death $5.00
Accrued Interest to Date of Death $0.00
'Total Principal and Accrued interest $5.00
Name of Trustee William J Kelly
CHECKING ACCOUNT:
Account Number/Suffix 436784-1 i
Date Account Established 10/21/2011
Principal Balance at Date of Death $450.92
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $450.92
Name of Trustee William J Kelly
MEMBERS 11 STr FEDERAL�CREDIT UNION
Tessa L Klugh
Lending Insurance Support Specialist
August 5, 2014
Estate of: WILLIAM J KELLY
Date of Death: 06/01/2013
Social Security Number: 18946-6344
5000 Louise Drive • P.O. Box 40 1 Mechanicsburg,Pennsylvania 17055 (800) 283-2328 www.memberslst.org
REV-1513 EX-(0110)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN BENEFICI/�°RIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kelly,William J. 21-13-0696
NUMBER NAME AND ADDRESS OF DECEDENT RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S)RECEIVING PROPERTY (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Mary M. Kelly Wife Rest, residue
4 Eastgate Drive and remainder
Camp Hill, PA 17011
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 oIn Rev 1500 cover sheet,as a Op riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
Copyright(c)2010 form software only The Lackner Group, Inc. - Form PA-1500 Schedule J(Rev.01-10)
N
C,
LAST WILL AND TESTAMENT
OF
a ;
> M rti -r, rn
WILLIAM J. KELLY r- - �' �- o
1, WILLIAM J. KELLY, of Cumberland County, Pennsylvania,bc�`t�f sand and.1
disposing mind and memory, do make, publish and declare this to be my L%fTWill and re%&ei
any Wills and codicils previously made by me. �, o
C,0 -n
ARTICLE ONE
Specific Bequests of Tangible Personal Property
I give and bequeath all of my tangible personal property, including, but not limited to, all
my automobiles, furniture, furnishings, books, pictures, jewelry, china, linen, silver, clothing,
household effects and personal effects, and other tangible personal property of like nature (not
including cash, securities and other property used for the production of income), together with any
existing insurance thereon, to my spouse, Mary Kelly (hereinafter my "Spouse"), if my Spouse
survives me; or, if my Spouse does not survive me, to my children, Emily Morris Kelly and Faith
Hai Mary Kelly, who survive me, in equal shares; provided, however, the then-living issue of a
deceased child of mine shall take, per stirpes, the share their parent would have taken had he or
she survived me. . If 1 am not survived by my Spouse, my children, or issue, then and in that
event only, I give, devise and bequest all the rest, residue and remainder of my property as
follows: the first One Hundred Thousand Dollars ($100,000) to my nephew, Patrick J. Kelly,
and the remainder to my sister-in-law, Meg Morris Aabbaken.
ARTICLE TWO
Residuary Estate
I give, devise and bequeath all the rest, residue and remainder of my property of every
kind and description (including lapsed legacies and devises) wherever situate and whether
acquired before or after the execution of this Will to my Spouse, if my Spouse survives me;or, if
my Spouse does not survive me, to my children, Emily Morris Kelly and Faith Hai Mary Kelly,
who survive me, in equal shares; provided, however, the then-living issue of a deceased child of
mine shalt take,per stirpes,the share their parent would have taken had he or she survived me.
ARTICLE THREE
Pavment of Taxes,Debts and Administr ative Expenses
I direct that all estate, inheritance and other death taxes (other than generation-skipping
transfer taxes), and all interest and penalties thereon imposed by reason of my death with respect
to property subject to such taxes by reason of my death, whether such property passes through
my probate estate or outside of my probate estate; and payable to any federal, state or foreign
twine authority, whether payable by my estate or by any recipient of such property: and all my
legally enforceable debts, funeral expenses and estate.administration expenses, shall be paid to
the extent possible out of my residuary estate passing under ARTICLE TWO hereinabove, prior
to its division into shares for the beneficiaries.
-%4WATV6fi70N11001 w, LAST 97ILL & TESTAMENT OF WILLIAM✓ KELLY
ATTORNEYS AT LAW - Page I'of 7 .
ARTICLE FOUR
Protective Provisions
The principal of my estate and the income therefrom, so long as the same are held by my
Executor, shall not be subject to anticipation, assignment, pledge, sale or transfer in any manner,
nor shall any beneficiary have power in any manner to charge or encumber his/her interest in my
estate, nor shall the said interest of any beneficiary be liable or subject in any manner while in
the possession of my Executor for any liability of said beneficiary, whether such liability arises
from said beneficiary's debts, contracts, torts, or other engagements of any type.
ARTICLE FIVE
Powers of Executor
In addition to and without limiting the powers conferred by case law, by statute, and by
other provisions hereof, my Executor shall have the following rights and powers exercisable
without the need for court approval:
(A) Accept and Retain Investments. To accept and retain any form of real or
personal property received by transfer, devise, bequest or otherwise without being required to
diversify and without being limited to the types of investments in which fiduciaries are
authorized by law to invest. This authority shall specifically include the authority to accept and
retain any stock of a corporate fiduciary hereunder, or in any corporation which controls or is
controlled by it, or any other corporation in which it holds any ownership interest, together with
any stock dividends received thereon, or any stock acquired in the exercise of subscription rights,
or received by reason of any consolidation, merger or reorganization, without liability for such
retention.
(B) Invest. To invest and reinvest in any form of real or personal property without
limitation by any law applicable to investments by fiduciaries.
(C) Voting Rights. To vote a security in person or by proxy, to participate in or
consent to any merger, reorganization, dissolution, liquidation, voting trust plan, or other action
affecting any securities held hereunder, and; to exercise conversion, subscription, and other
rights of whatever nature.
(D) Title To Property. To register or hold securities and/or other property in the
name of a nominee or nominees, including that of a clearing corporation, a depository, in book
entry form, or to retain securities and/or other property unregistered or in a form permitting
transfer by delivery.
(E) Sale, Lease and Other Dealings with Property. To sell, from time to time, at
public or private sale, exchange, lease, encumber, option or otherwise dispose of all or any
portion of assets held hereunder; to make, execute and deliver deeds, mortgages, leases,
assignments and other documents necessary to carry out any of the powers granted hereunder,
which shall specifically include the authority to grant leases which extend beyond the period
authorized by law, and; to partition, subdivide, improve and impose any restrictions on real
estate held hereunder and enter into agreements concerning the partition, subdivision,
improvement, zoning or management of any such real estate.
(F) Borrow. To borrow money from any person or institution and pledge property
as security for repayment of funds.
13KABI a 1h&MNAKITI Ai, LAST WILL & TEST,4MENT OF WILLI,4MJ.. KELLY
ATTORNEYS AT LAW
Page 2 of 7
(G) Distributions in Kind. To make distributions in cash or in kind, or partly in
each, and; to allot different kinds of property to different shares without regard to differences in
the income tax basis of such property. Any such designation, division, allocation, apportionment
or valuation of property shall be binding and conclusive on all parties.
(H) Power to Distribute Outri ht. In any instance where property would be
immediately distributable to a beneficiary of a trust, distribution may be made directly to such
beneficiary without funding such trust. The receipt of any such distribution by any such
beneficiary shall be a full acquittance of the fiduciary making such distribution as to any
amounts so distributed.
(I) Settle Claims. To institute, prosecute and defend any and all legal proceedings;
and compromise, release, adjust and/or settle any debt or claim.
(J) Employment of Aeents. To employ agents including attorneys, accountants,
and others to perform administrative duties.
(K) Disclaimer. To disclaim any interest in property which would devolve to me or
to my estate by whatever means, including but not limited to the following means: as a
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/beneficiary of an inter vivos transfer, as a
beneficiary under any insurance policy, as a beneficiary under an individual retirement.account
or annuity, and as a beneficiary under any qualified or non-qualified retirement plan.
(L) Property Distributable to Minors. Any property (whether income or principal)
distributable to a beneficiary of my estate who is under the age of 25 shall be distributed to a
person selected by my Executor to serve as custodian for the beneficiary under the Pennsylvania
Uniform Transfer to Minors Act and such custodian shall hold the beneficiary's share in a
custodial account until the beneficiary reaches the age of 25 and in accordance with
Pennsylvania Uniform Transfer to Minors Act. The receipt of such distributions by the
custodian shall constitute a full acquittance of my Executor as to any amounts so paid.
(L) _Property Distributable to Minors. Any property (whether income or principal)
distributable to a beneficiary of my estate who is under the age of 25 shall be paid directly to the
parent or guardian of such beneficiary, to a custodian selected by my Executor under the
Pennsylvania Uniform Transfer to Minors Act or under a similar act of any other state, or to
persons caring for or having custody of such beneficiary (other than my Executor), or may be
applied for such beneficiary's benefit by payment to such other persons, organizations or
institutions (other than my Executor) as my Executor may select. The recipient of any such
payments by any such person shall be a full acquittance of my Executor as to my amounts paid.
ARTICLE SIX
Fiduciaries
(A) Appointment of Executor. I appoint my Spouse as Executor of this Will (my said
Executor and any successor Executor or co-Executors shall be referred to herein as my "Executors"
or "Executor''). Upon the death, renunciation or resignation of my Spouse, I appoint Laura Martin
as my Executor.
(B) Guardian of Minor children. In the event that my Spouse does not survive me, I
nominate, constitute and appoint Jeanne Virtue, now of 40 Dawn Hearth Circle, Littleton CO
80127 and Meg Morris Aabakken, now of 1277 S. Independence St., Lakewood, CO 80232, or
S,KAR1AMS&7a3 0C1i Lw LAST WILL & TESTAMENT OF WILLMMJ KELLY
ATTORNEYS AT LAW Page 3 of
the survivor of them, to act as testamentary guardians of the persons and estates of my minor
children. If either of them shall decline to serve as Guardian, the other shall serve alone.
(C) Miscellaneous. Any successor Executor or Guardian shall succeed to the capacity
of its predecessor without re-conveyance or transfer of property and have all of the rights, powers,
authorities and discretion conferred upon the original Executor or Guardian. No successor Executor
or Guardian shall be obligated to examine the accounts, records, or acts of a previous Executor or
Guardian, as the case may be, nor shall any such successor Executor or Guardian in any way or
manner be responsible for any act or omission to act on the part of any such previous Executor or
Guardian, as the case may be. No Executor or Guardian serving hereunder at any time shall be
required to file any bond or enter security in any Court or jurisdiction in which such fiduciary may
be called upon to act.
ARTICLE SEVEN
Interpretation
(A) Child. Children. Grandchild Grandchildren and Issue. Whenever the terms
"child," "children," "grandchild," "grandchildren" and "issue" are used herein, such terms shall
be interpreted to include adopted persons as well as natural persons, provided in each instance
that the adoptee is under the age of eighteen (18) years at the time of adoption. Such terms are
also intended to include persons in gestation at any pertinent time under this Will, provided such
persons survive birth by thirty (3 0) days.
(1) Issue, per stirpes. In applying any provision of this Will which refers to
a person's "issue, per stirpes", the children of such person are heads of their respective
stocks of issue, whether or not any child of such person is then living. For example, a
disposition in this Will to a person's "issue, per stirpes" shall be deemed to require a
division into a sufficient number of equal shares to make one share for each child of such
person living at the time such disposition becomes effective and one share for each then
deceased child of such person having one or more descendants then living, regardless of
whether any child of such person is then living, with the same principle to be applied in
any required further division of a share at a more remote generation.
(2) Issue, per capita. In applying any provision of this Will which refers
to a person's "issue, per capita", the phrase shall mean the division of an estate by giving
an equal share to each of a number of such person's descendants, all of whom stand in
equal degree to such person, without reference to their stocks or the right of
representation. Issue, per capita is the antithesis of issue, per stirpes. For example, a
disposition in this Will to a decedent's "issue, per capita', assuming that both of the
decedent's two children (X and Y)predecease the decedent, two grandchildren (A and B)
predecease the decedent (each with surviving issue) and three grandchildren (C; D and E)
are living at the time such disposition becomes effective, shall be deemed to require a
division into three equal shares for each grandchild (C, .D and E) who are living at the
time such disposition becomes effective. In the previous example, if instead we assume
that one child (X) was living at the time such disposition becomes effective, that child
(X) would take the entire disposition even if the decedent is survived by issue of the other
child (Y) who predeceased the decedent.
&WNA}t I LAST 11111L & TESTAMENT OF WILLIAM.I KELLY
ATTORNEYS AT LAW Page 4 of 7
(B) Survival Clauses. If any beneficiary.hereunder should die within thirty (30)
days after my death or within thirty (30) days after any other person the survival of whom
detennines such beneficiary's rights hereunder, then such beneficiary shall be deemed to have
predeceased me or such other person, as the case may be, for all purposes hereunder
(C) Governing Law. This Will shall be construed and governed in all respects by
and in accordance with the laws of the Commonwealth of Pennsylvania.
(D) Gender and Number. Where appropriate except where the context otherwise
requires, whenever used herein, the singular includes and plural, the plural the singular and
words of any gender shall be applicable to all genders.
(E) Headings/Captions. The headings/captions of Articles, Sections and Paragraphs
used herein are for convenience of reference only and Shall have no significance in the
construction or interpretation of this Will.
IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this my Last
Will and Testament, consisting of Sc?vC..t ( ) typewritten pages, including this
attestation clause and the following Acknowledgment and Affidavit, to be executed, declared and
published this : Lt day of 1"1 c,y 2011, at Harrisburg, Eerrnsylvania.
`WIL J,.'KELLY
On this A I day of 2011, WILLIAM J. KELLY, the Testator,
declared to us, the undersigned, that e foregoing instrument was the Testator's Last Will, and
requested us to act as witnesses to the ame and to the Testator's signature thereon. The Testator
thereupon signed said Will in our presence, we being present at the same time. We now, at the
Testator's request, in the Testator's presence, and in the presence of each of us, hereby subscribe
our names as witnesses thereto. By so doing, each of us declares that he/ she believes the Testator
to be of sound mind and memory.
Witnesses: Address:
4 4yk h - " IS 2 5- /J• Frrrrt+ S+, 9201
it
Vlmess ticcinsbwr4 PA (')tUt
1".)
��� �
Witness `
.%kR1A R13&7ANAFJ0i ur LAST TVILL & TESTAMENT OF WILLIAMJ KELLY
ATTORNEYS AT LAW Page 5 of
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF DAUPHIN )
1, WILLIAM J. KELLY, the Testator, whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law, does hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it willingly and that I signed it as my free and
voluntary act for the purposes therein expressed:
ILLt��'t I L�
r .'
Sworn or affirmed to and acknowledged before me by WILLIAM J. KELLY, the Testator
this;J I' day of__�/1CLy ,2011.i
l "a 1�;�A�� _(SEAL)
Notary Public
My Commission Expires:
NOTARIAL SEAL
HEATHER A SWANSON
Notary publIc
JONESTOWN BORO., LEBANON COUNTY
MY Commission ExpUts Jun 10,2013
a6it.1TTZ�t13t�G 1 r LAST WILL & TESTAMENT OF I-VILLIAMJ KELLY
ATTORNEYS AT LAW - Page 6 of 7
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF DAUPHIN
We, -BY;4je�' K- Wt� , tly and--- — e0 1 /MY�Fli� the
witnesses, whose name's are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw WILLIAM J. KELLY, the
Testator, sign and execute the instrument as the Testators free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the Testator signed the Will as
witnesses; and that to the best of our knowledge, the Testator was at the time eighteen (13) or more
years of age, of sound mind and under no constraint or undue influence.
'Witness"
OWitness
Sworn or affirmed to and acknowledged before me by
and ,�eo N�C! �Q�V_,the witnesses,thisdL day of Mao 2011.
( l/�(SEAL)
`-rotary Pu blic
My Commission Expires:
NOTARIAL SEAL
HEATHER A SWANSON
Notary Public
JONESTOWN BORO..LEBANON COUNTY
My Commisalon Expires Jun 18,2013
AiAB VP>&71DGkP1(31 gar LAST WILL & TESTAMENT OF WILLMM.L KF,LLY
ATTORNEYS AT LAW Page 7 of 7