HomeMy WebLinkAbout08-14-14 (2) J REV-1500 �� 1505610105
PA Department of Revenue )(FI) o-vania
Bureau of Individual Taxes "4^' OFFICIAL USE ONLY
PO BOX 280601 INHERITANCE TAX RE TURN County Code Year_ File Number _
ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT I�-I 14
00569
Social Security Number _ Date of Death th MMDDYYYI' J
r -- - Date of Birth MMDDYYYY
- J 05/23/2014 10/03/1926
Decedent's Last Name
-__ � ____ _ _
suffix -_ __ _
I Davis Decedent's First Name
F- _ -- - _ MI
I Virginia -
(If Applicable)Enter Surviving Spouse's Information Below M
Spouse's Last Name
Suffix Spouse's First Name
MI
1
_Spouse's Social S_ecudty_Number -
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE LJ
FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS
ONO 1. Original Return O 2.Supplemental Return
O 3. Remainder Return(Date of Death
O 4.Limited Estate i O 4a.Future Interest Compromise(date of Prior to 12-13-82)
death after 12-12-82) O 5. Federal Estate Tax Return Required
(Attach Copy of Will) (Attach Copy of Trust.)
6. Decedent Died Testate O 7. Decedent Maintained a Living Trust
8. Total Number of Safe Deposit Boxes
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death
Between 12-31-91 and 1-1.95) O 11. Election to Tax under Sec.9113(A)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIO SHOULD BE DIRECTED TO:
Name
William W. RUnyeon, Esq. -- Daytime Telephone Number
(610) 378-9002
RR-M -`LY
First Line of Address_P.O. BOX 8514 - - -- - -Second Line of Address - --- — - - 'City or POSl Once Readin State ZIP Code g --
! PA 119603- ,9 0
L
Correspondent's e-mail address: tC
Under penalties of perjury,I declare that I have examined this return,InUudin aaom an
It Is We,comeU and complete.Dedareton of preparar other than the 9 P Nn1 schedules end statements,and to the best of my knowledge and belief,
personal representative is based on all Information of which prcparer has any knowledge,
SIGNATURE OF PE SON RESPONSIBLE FOR FILIN
G RETURN
2905 Daniel Drive, Sinking Spring, PA 19608
SIGNATU OF PREPARER O R THAN REPRESENTATIVE
' � �" DAT
ADDRESS
P.O. Box 8514, Reading, PA 19603 / Y
PLEASE USE ORIGINAL FORM ONLY
L Side 1
1505610105
1505610105 j
_J 1505610205
REV-1500 EX(FI)
Decedent's Name: VIfgINlB M. Davis Decedent's Social Security Number
RECAPITULATION
I. Real Estate(Schedule A).
2. Stocks and Bonds(Schedule B) N28,768-05
2
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3
4. Mortgages and Notes Receivable(Schedule D)
..................... a.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5.
6. Jointly Owned Property
P rty(Schedule F) O Separate Billing Requested ...... . 6,
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.8. Total Gross Assets(total Lines 1 through 7)
6. 212,135.98 1
9. Funeral Expenses and Administrative Costs(Schedule H)......
9. 16,191.48
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)........ 10
11. Total Deductlons.(total Lines 9 and 10)................................. 11. 1,647.28
12, Net Value of Estate(Line 8 minus Line 11 17,838 76
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12
194,297.22
an election to tax has not been made(Schedule J) ......,
• .... 13. 0.00
14, Net Value Subject to Tax(Line 12 minus Line 13) .......
TAX CALCULATION-,SEE INSTRUCTIONS FOR APPLICABLE RATES 14 194,297.22
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.Q_ i 1 I
16. Amount of Line 14 taxable 15.
at lineal rate X.0 45
17. Amount of Line 14 taxable 194,297.22 I 16.
---_ 8,743.37
at sibling rate X.72
18. Amount of Line 14 taxable i��'------ -�I 17'
at collateral rate X.15
19. TAX DUE ...... 8,743.371... ...................... .......................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
L
1505610205 Side 2
1505610205 J
REV-1500 EX(FI) Page 3 Fife Number
Decedent's Complete Address:
DECEDENT'S NAME
Virginia M. Davis
STREETADDRESS
5225 Wilson Lane
CITY STATE ZIP
Mechanicsburg p
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (i) 8,74137
2. Credits/Payments
A.Prior Payments
B.Discount 437.46
Total Credits(A+B) (2) 437,46
3. Interest
(3)
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 2D to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (S) 8,305.91
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.........................._................ ❑ I♦
c. retain a reversionary interest ...................................._......_......_............................_.._..................................
.... ❑
d. receive the promise for life of either payments,benefits or pre?...................................................................... ❑
2. if death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
1 Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death?........
..... ❑
4. Did decedent 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 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)(1)[,
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
172 PS.§9116(a)(1.1)(ii)).The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements fordisdosure 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)(11)).
• 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 decedents siblings is 12 percent(72 P.S.§9116(x)(13)).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.ISM EX.(8.12),
-Pennsylvania
INHERITANCE TAXRUETURN STOC SDU BONDS
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Virginia M. Davis
14 056
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
1. 210.85059 Sharea OF DEATH
$185.94
IBM
39,205.56
2 5,000 Par
® $106.354
Bank of Am Corp Internotes
5,317.70
3 350.751 Shares
$4.56
Lord Abbett Short: Dur Inc
1,599.42
4 85.002 Shares
® $50.75
MetLife
4,313.85
TOTAL (Also enter on Line 2,Recapitulation) y
zwasse z.000 - If more space is needed,insert additional sheets of the same size 50,4 36.53
REV-I5ea EX.(W,2)
pennsylvania SCHEDULE E
MPARTNENTOF REVENUE
MNERRANCETAXRMRN CASH, BANK DEPOSITS & MISC.
MWENTDECEDENT PERSONAL PROPERTY
ESTATE OF:
Virginia M. Davie FILE NUMBER:
Include the proceeds of Iltigaticn and the date(he proceeds Were received by the estate. 14 00$69
All ro artJointly owned with d ht of sumbiorshl must be disclosed on Schedule F.
12Asbury
VALUE AT DATE
DESCRIPTION OF DEATH
ward Jones Money Market Account #270-06649-1-1
345.50
Communities, Inc. , entrance fee refund
79,648.36
3 2002 Chevrolet Tracker
2,000.00
i
TOTAL(Also enter on line
2w46AD 2.000 5,RZItulation) S 83 . 993 86
If more space is needed,use additional sheets of PaOer of the some she.
REVA509 0(.(01-10)
pennsylvania SCHEDULE F
OB/AtuENreE REYETUE
INHERITANCE TA%RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Virginia M. Davis 14 00569
If an asset became Jointly owned Within one year of the decedent's date of death,it must be reported on Schedule G
SUMMING JW TBNVINT(S)NANRS) ADDRESS RB.ATtONSWTO DECE7BJf
A Davis, Alan t4 2905 Daniel Drive, Sinking Spring
PA 19608 Son
JOINTLY OWNED PROPERTY:
IETTER DATE DESCRIPTION OFFROPetTY %OF DATEOFDEATR
Mw EcRruN1 MADE wuuRE rwcaRxnxauwnrc,R,w�xRVxx,,awxr mnREa wewua DATE OF MTH DECEDWrS VALLEOF
NUMBI r Nr JOINT axrmwom vosa rRwo EORnm a oxa urxrc. VALLEOFASSET INTMEST DECFDeif'S INIetEST
1 A 4/29/2005 Members let Federal Credit
Union savings Account
#263990-00 23.00 50.0000 11.50
2 A 4/29/2005 Members let Federal Credit
Union Checking Account
#263990-11 6,563.28 50.0000 3,281,64
3 A 4/11/2008 Belco Community Credit
Union Savings Account
#754090 7,846.05 50.0001 3,923,03
4 A 10/15/1999Belco Community Credit
Union Holiday Club Account
#754090 725.07 49.9993 362.53
5 A 4/24/2009 Belco Community Credit
Union Checking Account
#754090 2,065.89 50.0002 1,032.95
6 A 6/7/2011 Belco Community Credit
Union Certificate of
Deposit #31001 3,191.22 50.0000 1,595.61
7 A 10/29/2007 Fulton Bank Checking
Account #3623-28369 52,286.21 50.0000 26,143.10
To al from c ntinuation schedules . . 14,587.18
TOTAL (Also enter on Une 6,Recapitulation) $ 50,937.54
IrMaAE 2.000 If more space is needed,use additional sheets of paper of the some size.
Estate of; Virginia M.. Davis
14 00569
Schedule F Part 2 (Page 2)
Item Joint
No. Cot. Date Description DOD Value of
Perc DOD Value of
Asset Int.
Interest
8 A 10/29/2007 Fulton Bank Savings Account
#1371-87123
52 9.71 50.0009 264.86
9 A 12/14/2007FUlton Bank Option Savings
Account #0691-41606
' 7 00.00 50.0000
10 A 9/7/2005 Fulton Bank Certificate of 350.00
Deposit #052-0197160
5,713.13 50.0001
11 A 11/13/2008 Fulton Bank Certificate of 2.856.57
Deposit #052-0276112
5,203.04 50.0000 2,601.52
12 A 5/15/2010 Fulton Bank Certificate of
Deposit #052-0361655
10.929.39 50.0000
13 A 5,464.70
5/20/2011 Fulton Bank Certificate of
Deposit #930-0161011
3,053.12 50.0000 1,526.56
14 A 5/20/2011 Fulton Bank Certificate of
Deposit #930-0161753
3,045.95 49.9998 1,522.97
Total (Carry forward to main schedule)
14,587.18
REV-1540 EX+(08-03) SCHEDULE G
pennsylvania
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC.NON-PROBATE PROPERTY
RESIDENfDECEDENT
ESTATE OF FILE NUMBER
Virginia M. Davis 14 00569
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 �DESCRI DAN OaFP PROPERTY TOE nI� DATE OF DEATH %OFOEC[PS EXCLUSfON
TAXABLE
NUMBS F VALUE OF ASSET INTEREST OF APPIJCABL VALUE
1 Fulton Bank Certificate of
Deposit #052-0339643 4,062.81 100.0000 0.00 4,062.81
2 Fulton Bank Certificate of
Deposit #052-0361681 10,929.39 100.0000 0.00 10,929.39
3 Fulton Bank Certificate of
Deposit #930-0161386 3,028.65 100.0000 0.00 3,028.65
4 185.847 Shares
@ $16.01
Lord Abbett Affiliated Ed 2,975.41 100.0000 0.00 2,975.41
5 167.477 Shares
@ $15.80
Lord Abbett Calibrated Ed 2,646.14 100.0000 0.00 2,646.14
6 88.317 Shares
@ $11.01
Lord Abbett Core Fxd Inc Ed 972.37 100.0000 0.00 972.37
7 48.67 Shares
@ $15.26 <
Lord Abbett Fund Eq Ed 742.70 100.0000 0.00 742.70
8 86.738 Shares
@ $14.01
Lord Abbett Intl Core Eq 1,215.20 100.0000 0.00 1,215.20
9 207.111 Shares
@ $10.60
Lord Abbett Total Ret Ed 2,195.38 100.0000 0.00 2,195.38
TOTAL(Also enter on line 7,ReColulation)S
28 768.05
If more space Is needed,use addlllonel sheets of paper Of the name stra.
OW46AF 2.000
REV 1571 EX-(
pe SCHEDULE H
Pennsylvania
OEPMib¢NTOF REVENUE FUNERAL EXPENSES AND
MERI'TANCE TAX RETURN ADMINISTRATIVE COSTS
RESOENTOECEDENr
ESTATE OF 1 FILE NUMBER
Virginia M Davis 14 00569
Decedents debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL.EXPENSES:
1. The Garden Bouquet, funeral flowers 165.36
2 Pianist 125.00
Total from continuation schedules . . . . . . . . . 2,654.38
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representatives)
Street Address
city State ZIP
Year(s)Commission Paid:
2. Attorney Fees: 12,691.82
3. Family Exemption:(If decedent's address is not the same as claimant's,attach e)ptanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 310.00
6, Accountant Fees:
6. Tax Return Preparer Fees:
1
7.
1 PennDOT, car title fee 65.00
2 The Sentinel, estate advertising 179.92
t TOTAL Also enter on Line 9,Recapitulation) $ 16,191.48
3w46AC 2.000 If more space Is needed,use additional sheets of paper of the same size.
Estate of: Virginia M. Davis
14 00569
Schedule H Part 1 (Page 2)
Item
NO. Description
Amount
3 Funeral lunch
4 Obituary 104.38
5 Musselmen Funeral Home, funeral bill 275.00
2,275.00
Total (Carry forward to main schedule)
2,654.38
REV-151,3 Ex s(12-12)
pennsylvania SCHEDULE t
OEPARTMOTT OF REVENUE DEBTS OF DECEDENT,
O M1IEWMCETAx RETORN MORTGAGE LIABILITIES& LIENS
REEA.1ENr OEMOENT
ESTATE OF FILE HUMBER
Virginia M, Davis 14 00569
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unmimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. The State Employees Retirement System, refund of
overpayment 64.43
2 Checks clearing after date of death 1,579.56
3 Medicine Shoppe 2.99
TOTAL(Also enter on Line 10,Recapitulation) $ 1,647.28
2W46AH 2.000 if more space is needed,insert additional sheets of the same size.
REV-1513 EX+(Ot-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REWNUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF:
Vir inia M. Davie FILE NUMBER:
14 00569
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
I TAXABLE DISTRIBUTIONS Include mtd ht s Do Not List Trustees) OF ESTATE
I 9 p0usal distdbutions and Iransfere under
Sec.9116(a)(1.2).]
1. Alan W. Davis
2905 Daniel Drive
Sinking Spring, PA 19608
All of Residue: 194,297.22
Son 194,297.22
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:
7.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART It-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
BW46AI 2.000 If more space is needed,use additional sheets of paper of the same s @e. 0.00
C
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L
rn
AST WILL AND TESTAM rn ; r � `n "
tm rn
:.a
OF ` C) -rl —o n
C) �
aa ry r rn
VIRGINIA M. DAVIS cl� n
cn
I, VIRGINIA M.DAVIS, Social Security Number 162-22-4386, of the Commonwealth
of Pennsylvania, declare that this is my LAST WILL AND TESTAMENT and I revoke all other
wills and codicils previously made by me.
I. I appoint my son,ALAN J.DAVIS of Pennsylvania as my Personal Representative
concerning this Will.
A. I request that my Personal Representative be permitted to serve without bond or
surety thereon and without the intervention of any court, except as required by law. I direct that
my Personal Representative act in unsupervised administration so as to administer my estate with
a minimum of court supervision. If it becomes necessary to have ancillary administration of my
estate in any jurisdiction where my Personal Representative is unable or does not desire to
qualify as ancillary legal representative,I appoint as such ancillary legal representative such
individual or corporation as my Personal Representative shall designate, in writing.
B. I direct my Personal Representative to pay the expenses of my last illness, the
expenses of a funeral appropriate to my station in life and custom of living(including a suitable
monument or marker for my grave), and written charitable pledges which I have made. I grant
my Personal Representative the power to extend or renew any debt for such time as my Personal
Representative shall deem appropriate.
C. All estate, inheritance, succession and other death taxes with respect to all property
passing under this my Will shall be paid from and borne by the principal of my residuary estate,
without regard to reimbursement, as if such taxes were administration expenses. My Personal
Representative may pay such taxes at any time deemed advisable,whether or not then due and
payable.
D. My Personal Representative is requested to settle my estate as soon after my death as
may be practicable, and to pay or deliver every legacy or bequest to my beneficiaries without
waiting any time that may be believed to be customary in probate matters.
i
Last Will and Testament of VIRGINIA DAVIS
( Page I co /J �7
E. I may leave a letter of intent with the executed copy of this Will for the purpose of
giving guidance to my Personal Representative concerning the distribution or sale of certain
items of my property. I request, but do not require, that my Personal Representative honor my
wishes therein expressed.
II. I give, devise and bequeath, absolutely and forever, all of my estate and property of
which I may be seized or possessed, or to which I may be entitled,at the time of my death,
wherever situated or of whatever nature, be it real, personal, or mixed, to my son, ALAN J.
DAVIS of Pennsylvania as his sole and absolute property if he shall survive me.
III. Except as otherwise provided in this Will,I have intentionally failed to provide for any
other relatives or other persons,whether claiming to be an heir of mine or not. Insofar as I have
failed to provide in this Will for any of my issue now living or later born or adopted, such failure
is intentional and not occasioned by accident or mistake.
IV. Any beneficiary who fails to survive until One Hundred and Twenty(124)hours after
my death shall be deemed to have predeceased me, and the gift to that beneficiary shall be
disposed of accordingly.
V. The term "Personal Representative" as used in this Will shall have the same meaning as
Executor, Executrix,Independent Executor, or any other title of like import which is used to
describe such a fiduciary.
VI. In addition to any powers granted by the laws of the jurisdiction in which this Willis
probated, I hereby authorize and empower the fiduciaries named in this Will, to the extent of the
discretion herein granted,to sell, exchange, convey, transfer, assign,mortgage,pledge, lease or
rent the whole or any part of my real or personal estate, to invest, reinvest, or retain investments
of my estate,to perform all acts and to execute all documents which my fiduciaries may deem
necessary or proper in regard to my property. If any of my fiduciaries elect to receive
compensation for services, such compensation will be that allowed by law.
VII. If any part of this Will shall be invalid, illegal, or inoperative for any reason,it is my
intention that the remaining parts, so far as possible and reasonable, shall be effective and fully
operative. My Personal Representative may seek and obtain court instructions for the purpose of
carrying out as nearly as may be possible the intention of this Will as shown by the terms hereof,
including any terms held invalid, illegal, or inoperative.
Last Will and Testament of VIRGINIA DAVIS
Page 2
rl�)
This document was prepared under the authority of Title 10 U.S. Code, section 1044, and
implementing military regulations and instructions,by DAVID W. STARRATT, a member of
The Judge Advocate Legal Service, United States Army,who is licensed to practice law in the
Commonwealth of Pennsylvania. /
IN WITNESS WHEREOF,I have at Carlisle,Pennsylvania, on =� ! 1?9 p
set my hand and seal to this my LAST WILL AND TESTAMENT,consisting of 4 typewritten
pages, each page bearing my handwritten signature.
IRGINIA M. DAVIS
The foregoing instrument was,at Carlisle,Pennsylvania,on c?3 19
signed, sealed, published and declared by VIRGINIA M. DAVIS,the testator, to be her LAST
WILL AND TESTAMENT in the presence of all of us at one time, and at the same time we, at
her request and in her presence and in the presence of each other, have hereunto subscribed our
names as attesting witnesses,and we do so verily believe that the said testator is of sound and
disposing mind and memory at the date hereof.
AOL �
Soc.Sec.No. Soc.Sec.No. Soc.Sec.No. f�
of of ,"—� of
f7ot3 174d ' !'701 j
Last Will and Testament of VIRGINIA DAVIS
Page 3
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ACKNOWLEDGMENT
1, VIRGINIA M. DAVIS,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 instrument as my Last Will; that I signed it willingly; and that I signed it as my
free and voluntary act for four the purposes therein expressed.
`�i`��..-i-,�,_ ,��.e��a• (SEAL)
VIR IA M. DAVIS
AFFIDAVIT
We, E57Le---,C Ci-c afz6E Lit t lets 'tZ25 and
oS4 & the witnesses, sign our names to this instrument,being duly
qualified according to law,do depose and say that we were present and saw the testator sign and
execute the instrument as her Last Will;that the testator signed willingly and executed it as her
free and voluntary act for the purposes therein expressed; that each subscribing witness in the
hearing and sight of the testator signed the will as a witness; and that to the best of our
knowledge the testator was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
tf de � .
WITNESS WITNESS ITNESS
Subscribed, sworn to and acknowledged before me by VIRGINIA M.DAVIS, the testator,
and subscribed and sworn to before me by esfi-'E-it ,
and �?,",4 4- 0e7717--Iftofi, the witnesses,
on // f
— �'� E�l'Ga'L
NOTARY PUBLIC My Commission Expires: Nolarlaf Soai
o y tandr[dgs,Notary PuOlic
Carlisle Born,Cumberland County
My Commission Expires May 14,2061
6n .+t_,. �angr�o'c?ia k=3OCieti0f1
Last Will and Testament of VIRGINIA DAVIS 0!Notaries
/I Page 4
Auto Renn Kirby Chevrolet Buick
55 Expedition Trail
Gettysburg, PA 17325
Appraisal Voucher
Customer Information Appraisal Information
Name: Allen Davis Completed Date: 6/19/2014 3:34 PM
Address: Appraised Vali $2,000.00
City: Appraiser: Jaime Bogley
Region: Salesperson:
Postal Code:
Home Phone: (6 10) 8 - 77
Vehicle Description
Year: 2002 —0-do-meter: 73,357
Make: Chevrolet IN: 2CNBJ734926904609
Model: Tracker Color: red
Series: L
Owner Acknowledgement
The owner acknowledges that the information is correct and that any issues with this vehicle are noted below.
Vehicle Salvaged Flood Damage Factory Buyback
Yes❑ No® Yes❑ No® Yes❑ No
Previously Damaged Emission Systems Verified Odometer Replaced
Yes❑ No® Yes❑ No® Yes❑ No
Owner Signat a Date
Sales Manager
Appraiser
1