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07-20-15
i pennsytvania 1505614105 EX(03-14)(F1) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN I F Harrisburg, PA 17128-0601 RESIDENT DECEDENT 'I I I`1 , ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY [ 06082014 04251923 Decedent's Last Name Suffix. Decedent's First Name MI FOULSON JUNE [B] (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OD 1.Original Return p 2. Supplemental Return p 3. Remainder Return(date of death prior to 12-13-82) O 4.Agriculture Exemption(date of p 5. Future Interest Compromise(date of p 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) O 7.Decedent Died Testate p 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) O 10. Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) O 13. Business Assets C=) 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number FHAEL E COULSON (702) 556-3839 First Line of Address 920 PRETTY FIRE STREET Second Line of Address n C> M'n City or Post Office State ZIP Code rri = Co - D I" N M LAS VEGAS NV 89178 r- �• M C� D r ' �S �� �- 7C C: Correspondent's email address: REGISTER O IiIiS USE OFU r— REGISTER OF WILLS USE ONLY 70 C.J DATE FILED MMDDYYYY CD rtl DAT S MP r �Y i--1-I M »� Q Cno to PLEASE USE ORIGINAL FORM ONLY n C5 -ft Side 1 `, to — M IL IIIIII VIII VIII I IX Cf) O IIIt14105 150561,4.105 oy 1505614205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: JUNE B. COULSON [ RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. 102,000.00 2. Stocks and Bonds(Schedule B) ...... ................................. 2. 7,727.80 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable Schedule D 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 3,832.35 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 56,446.46 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 170,005.81 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 30,308.80 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 11. Total Deductions(total Lines 9 and 10)................................. 11. 30,308.80 12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 139,697.01 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. 139,697.01 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 139,697.01 16. 6,286.37 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE ..................... 6,286.37 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Under penalties of perjury,I declare 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 person responsible for filing the return is based on all information of which preparer has any knowledge. SIGNATU E F /j ERSQ�IRESP N,-,4SLE FOR FILING RETURN DATE 7_6 ADDRESS 920 PRETTY FIRE STREET LAS VEGAS NV 89178 SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE ADDRESS 11Iti i tiItiaii iiiii ilii ilii Side 2 1505614205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME JUNE B. COULSON STREET ADDRESS 84 FRONT STREET CITY STATE ZIP WEST FAIRVIEW PA 17025 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 6,286.37 2. Credits/Payments A.Prior Payments B.Discount (See instructions) Total Credits(A+B) (2) 0.00 3. Interest (3) 21.02 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) 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 6,307.39 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 .............................................................................................................................. ❑ E d, receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ E 3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 0 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa 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)(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 step-parent 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. ESTATE AGREEMENT 1, MICHAEL S. COULSON,of 378 Lehigh Avenue,Palmerton, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare that I disclaim all my interests/assets, physical property and monetary that I was due to inherent from the Last Will and Testament of Billie June Coulson, also known as June B:.Coulson. The above mentioned was probated June 23, 2014, by the..Register of Wills in Cumberland County, Pennsylvania. No. 2014-00599 PA No.21 - 14-0599 N11Ci-TAE1-15._0ZNL-S_014 oT-92D Pf6fI ri re Sheet,Las Vegas, Nevada 89178, is the Executor. _2ZZI A 4f� I/ lb Michael S. Coulson bate By: LQ A Notary Date SUb3Cr bed and-swum befor8 rre;this�J..lG.... a Notary Pubii6. In and or _ State of I (Signature) -NOTARY PUBLIC ,p IVIy Commission expires:r--. 41L — , i COMMONWEALTH OP PFNNSYLVANIA NOTARIAL SEAL ! Bua EHRET.Notary Public Palmerton Koro,carbon County Nly commission Expires February'11;2019 I REV-1502 EX+(01-10) pennsylvania SCHEDULE A h DEPARTMENT OF REVENUE REAL ESTATE A C INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a'copy of the settlement sheet if the property has been sold. . ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION Frznr�� rn � � 1)®U ;�1} I��'a' Ouzo �► 00 +d 'Tan it%A L erg 7 d V !r6-00 TOTAL(Also enter on Line 1, Recapitulation.) $ boo�— If more space is needed,use additional sheets of paper of the same size. I REV 1503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN . RESIDENT DECEDENT ESTATE OF FILE NUMBER Silt-i I l " i A— a s-9 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 5-4 TOTAL(Also enter on line 2,Recapitulation) $ -7-72-7. C7� (if more space is needed,insert additional sheets of the same size) RSV-1504 EX+(1-97) SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCERESIDENT DECED DETAX CEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER i xkw e ?> (20u L_S.�--) y x — I LI — o-5019 Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporationtpartnership interest of the decedent,other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 3, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1505 EX+{fi-98}&- SCHEDULE C-'1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN RESIDENT DECEDENT STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address Date of incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D.Number Business Reporting Year 3. Type of Business Product(Service 4. TYPE{ `' ``TOTAL NUMBER OF NUMBER OF.SHARES '; VALUE OF THE STOCKPAR VALUE ,, Voting/Non Voting SHARES OUTSTANDING N, .-OWNED BY THE DECEDENT, .DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to each Gass of stock. 5. Was the decedent employed by the Corporation? ... .... ............ . ....... ...... . ❑Yes ❑ No If yes,Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ... ..... . ........... ............. .. ❑Yes ❑ No If yes,provide amount of indebtedness$ 7. Was there life insurance payable to the corporation upon the death of the decedent? . .... ❑Yes ❑No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ❑Yes ❑No if yes, ❑Transfer ❑Sale Number of Shares Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....O Yes ❑No If yes,provide a copy of the agreement. 10.Was the decedent's stock sold? ..................................................... ❑Yes ❑No If yes,provide a copy of the agreement of sale,etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ❑Yes ❑No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 12.Did the corporation have an interest in other corporations or partnerships? ............. ❑Yes 0 No If yes,report the necessary information on a separate sheet,including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATIONt WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns(Form 1120)for the year of death and 4 preceding years. C. If the corporation owned real estate,submit a list showing the complete addressees and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. List of principal stockholders at the date of death,number of shares held and their relationship to the decedent. E. List of officers,their salaries,bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year.List those declared and unpaid. G. Any other information relating to the valuation of the decedents stock. (It more space is needed,insert additional sheets of the same size) REV-1566 EX+(9-00) SCHEDULE C-2 COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCEIDT TAX DECEDENT INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address —.Business Reporting Year City State Zip Code 2. Federal Employer I.D.Number 3. Type of Business ProducUService 4. Decedent was a ❑ General ❑ Limited partner. If decedent was a limited partner,provide initial'investment$ 5 — E -. .• F - — - A. B. C. D. 6. Value of the decedent's interest$ 7. Was the Partnership indebted to the decedent? .... . .:...... .. . .... . .. . ... .. ❑Yes E3 No If yes,provide amount of indebtedness$ 8. Was there life insurance payable to the partnership upon the death of the decedent? ...:. ❑Yes ❑ No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within.one year prior to death or within two years if the date of death was . prior to 12-31-82? ❑Yes ❑No If yes, 17 Transfer ❑Sale Percentage transferred/sold Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 10.Was there a written partnership agreement in effect at the time of the decedent's death? .:.... ❑Yes ❑ No If yes,provide a copy of the agreement. • 11. Was the decedents partnership interest sold? ............................................❑Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 12.Was the partnership dissolved or liquidated after the decedents death? ... 13 Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 13.Was the decedent related to any of the partners? .............:..................... ❑Yes ❑ No If yes,explain 14.Did the partnership have an interest in other corporations or partnerships? .............. ❑Yes ❑No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION • WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedents partnership interest. -B. Complete copies of financial statements or Federal Partnership Income Tax returns(Form 1065)for the year of death and 4 preceding years. C. If the partnership owned realestate,submit a list showing the complete addresses and estimated fair market Values.If real estate appraisals have been secured,attach copies. D. Any other information relating to the valuation of the decedents partnership interest. REV-150?EX+(1-97) 4$ SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER v CkyjLS0, j aI - 1L1- d All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ! ,4 TOTAL(Also enter on line 4,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1508 EX+(ii-io) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH rA&ti►r : 3 P� cL) IM►3c L �'YQe�c.7zY`i} ��/Zrt'► ji I TOTAL(Also enter on Line 5, Recapitulation) $ ' 5 If more space is needed,use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE F _ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: :31'/e- -x:s C-0ULS4!7-J 1- 114 - Q5- If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH mag FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. TOTAL(Also enter on Line 6, Recapitulation) $ --� 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 'w 66 iW0-14_� 21- 1 i/ 6_9 � 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. ITEMDESCRIPTION OF PROPERTY DATE OF DEATH %OF DECO'S EXCLUSION TAXABLE INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE) VALUE 1. JUC 6/6 ,-la,���• �o �G���1 S•�,,.�LcY �t�ar� , tt�:�'�rsn� /a�)�'I�j, TOTAL(Also enter on Line 7, Recapitulation) $ I7 If more space is needed,use additional sheets of paper of the same size. REV-151;EX+(10-09) bepennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER —� 600 L-s Z):-,) Decedent's debts must be reported on Schedule I. . ITEM NUMBER DESCRIPTION: AMOUNT A. FUNERAL EXPENSES: 1. 5 cJt c i:/L/YC_ �vri W?-lrti— Tsr,.+�.►vet � �'� '^" . wk Fra ver�S 1 O� B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions:. Name(s)of Personal Representative(s) Street Address City State ZIP Years)Commission Paid: 2. Attorney Fees: -702; 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 3 !� S� 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. xk_XV11_V&� P"SaS I-A s V,%C-A% N� -7. � 5 Tntcx u�.i ��vv� n TOTAL(Also enter on Line 9, Recapitulation) $ 30 30 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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, TOTAL(Also enter on Line 10,Recapitulation) $ 'If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: - FILE NUMBER: ., U e•J'iL� r1 (�L.s C"J I — ) Li — Q�:�q 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 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. REV-1514 EX+(12-03) SCHEDULE K 4& LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER tr *,JS su t s©.J a 1 - ) %-( - i This schedule is to be used for all single life,joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to th ax return. ❑ Will ❑ Intervivos Deed of Trust her CALCULATIONLIFE ESTATE INTEREST NAME(S)OF LIFE TENANT(S) DATE OF BIRTH NEAREST AG TERM OF YEARS s DATE OF D TH LIFE ESTATE IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 7Z ❑ Life or ❑Term of Years ❑Life or ❑Term of Years 1. Value of fund from which life estate is payable ..... ...... ..... ..... . . .................. .$ 2. Actuarial factor per appropriate table .. ..... ........... . .... .... .... ...... ..... ...... Interest table rate—❑3 1/2% ❑6% ❑ 10% ❑Variab Rate % 3. Value of life estate(Line 1 multiplied by Line 2) ... .... ........... ............ ...... .$ CALCULATIONANNUITY INTEREST NAME(S)OF LIFE ANNUITANTS) „, DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE ❑Life or ❑Term of Years ❑Life or ❑Term of Years ❑Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fun/perpednod a uity is payable ...... .... . .. ... ....... ........... . ...... . . .$ 2. Check approelow and enter corresponding(number) .... ............ ........ .. Frequency oWeekly(52) ❑ Bi-weekly(26) ❑ Monthly(12) ❑ QuaSemi-annually(2) ❑ Annually(1) ❑Other( ) 3. Amount of priod ..... ........ ..... . ................ .. ..... ............. .$ 4. Aggregate aent,Line 2 multiplied by Line 3 .......... ...... ............. ...... 5. Annuity Factor(see instructions) Interest table rate—❑3 1/2% ❑6% ❑ 10% ❑Variable Rate 6. Adjustment Factor(see instructions) . .. ....... . .... . .... ...... . ...... ...... ....... . ... 7. Value of annuity— If using 31/2%, 6%, 10%,or if variable rate and period payout is at end of period,calculation is: Line 4 x Line 5 x Line 6 .. ............ ............$ If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3 .................... ....... ............. ..........$ NOTE:The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return.The resulting life or annuity interest(s)should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size) REV-1644 EX+ (01-10) ! petlnsytVania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L INHERITANCE TAX RETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST CORPUS I. ESTATE OF FILE NUMBER P I — IL( This schedule is appropriate only for estates of decedents dying on or before Dec. 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of ears Income or Annuitant(s) of Election or A ity is Payable C. Assets: Complete Schedule L-1 1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . .$ 3. Closely Held Stock/Partnership . . . . . . . . . . . . .$ 4. Mortgages and Notes . . . . . . . . . . . . . . . . . . . .$ 5. Cash/Misc. Personal Property . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . .$ 2. Unpaid Bequests ... . . . . . . . . . . . . . . . . . . .$ 3. Value of Non Includable Assets . . . . . . . . . . . . .$ 4. Total from Schedule L-2 . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ E. Total.Value of Trust Assets (Line C- minus Line D-4) . . . . . . . . . . .$ F. Remainder Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G. Taxable Remainder Value ( Itiply Line E by Line F) . . . . . . . . . . .•. . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Re pitulation) III. INVASION OF CORPUS• A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Remainder Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) REV-1645 EX+ (11-09) pennsy(vania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L-1 INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -ASSETS- 1. ESTATE OF FILE NUMBER II. ITEM NO. DESCRIPTION VALUE A. Real Estate (Please describe.) Total Value of Real Estate (Include on Section II, Line C-1 on Schedule L. B. Stocks and Bonds(Please list.) Total Value ojttocks and Bonds (Include og6ection 11, Line C-2 on Schedule L.) C. Closely Held Stock/Partnership- PI se list. (Attach Schedule C-I and/or C-2.) . 7 Total Value of Closely Held/Partnership (Include on Section 11, Line C-3 on Schedule L.) D. Mortgages and otes (Please list.) Total Value of Mortgages and Notes $ (Include on Section 11, Line C-4 on Schedule L.) E. Cash and Miscellaneous Personal Property (Please list.) Total Value of Cash/Miscellaneous Personal Property $ (Include on Section 11, Line C-5 on Schedule L.) III. TOTAL (Also enter on Section 11, Line C-6 on Schedule L.) $ If more space is needed, attach additional sheets of paper of the same size. REV-16.46 EX+ (11-09) pennsylvania INHERITANCE TAX� DEPARTMENT OF REVENUE SCHEDULE L-2 INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- ESTATE OF FILE NUMBER � r Co a l` �c 1 - ! 6 i' 7 II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) i Total Unpaid Liabilities $ (include on Section II ine D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Report on Schedule L-1 (please list) Total Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Ass is Reported on Schedule L-1 (other than unpaid bequests listed under"B" ove) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV-1647 EX+(02-10) pennsylvania SCHEDULE M DEPARTMENT OF REVENUE FUTURE INTEREST COMPROMISE 4 INHERITANCE TAX RETURN Check Box 4a on REV-15oo RESIDENT DECEDENT ) ESTATE OF FILE NUMBER Q% This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. ❑ Will ❑ Trust ❑ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATEBIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. S. II. For decedents who died on or after July 1, 1994, if a surviving spouse a cised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below nd attach a copy of the document in which the surviving spouse exercises such withdrawal right. ❑ Unlimited right of withdrawal ❑ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Value of Line 1 exempt from.tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) . . . . . . . . $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . .. . . . . . . . . . . . $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate(12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line 1 taxable at collateral rate(15%) (Also include as part of total shown on Line 18 of REV-1500.) . . . . . . . . $ 7. Total value of future interest(sum of Lines 2 thru 6 must equal Line 1) . . . . : . . . . . . . . . . . . . . . . . . $ If more space is needed, use additional sheets of paper of the same size. AV-1649 EX+(08-09) pennsylvania SCHEDULE O DEPARTMENT OF REVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC.2113(A) RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS) ESTATE OF, FILE NUMBER _1 u��` 3 Call Sc� a l 1 1 �7 Do not complete this schedule unless the estate Is making the election to tax assets under Section 2113(A) of the,Inheritance and Estate Tax Act. If the election to more than one trust or similar arrangement,a separate form must be filed for each trust. This election applies to the Trust(marital,residual A,B,by-pass,Unified Credit,etc.). If a trust or similar arrangement meets the requirements of Section 2113(A)and: r" a.The trust or similar arrangement is listed on Schedule 0 and I/ b.The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,then the transferor's personal representa- tive may speafic ally identify the trust(all or a fractional portion or percentage)to be included in the election to have such trust or similar proper- ty treated as a taxable transfer in this estate.If less than the entire value of the trust or similar property is included as'a taxable transfer on .Schedule 0,the personal representative shall be considered to have made the election only as to a fraction of the trust'or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0.The denomi- nator is equal to the total'value of the trust or similar arrangement. 1 PART A:Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 2113(A) trust or similar arrangement. Description Value Part A Total $ PART B: Enter the description and value of all in ests included in Part A for which the Section 2113(A) election to tax is being made. D ' 'on Value Part 8 Total $ If more space is needed,use additional sheets of paper of the same size. REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA No. 2014- 66,99 PA No. 21- 14- 0599 Estate Of: JUNEB COULSON (First,Middle,Last) alk/a: BILLIE JUNE COULSON Late Of: EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY Deceased C) Social Security No: WHEREAS, on the 23rd day of June 2014 an instrument dated June 3rd 2005 was admitted to probate as the last will of JUNEB COULSON (First,Middle,Last) a/k/a BILLIE JUNE COULSON late of EAST PENNSBORO TOWNSHIP, CUMBERLAND County, who died on the 8th day of June 2014 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, LISA M. GRA YSON, ESQ. Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: MICHAEL E COULSON who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYL VA NIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 23rd day of June 2014. �- eglster of 1 Lp e tY **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAST WILL AND TESTAMENT A of , A` BILLIE JUNE COULSON z.. I; BILLIE JUNE COULSON,also known as JUNE B.COULSON 084 Pron?StrRtf :c v> Co -n West Fairview, Pennsylvania,being of sound and disposing mind,memory and understanding,do make,publish and declare this as and for my Last Will and Testament,hereby revoking and making void all former wills and codicils by me at any time heretofore made. 1. I direct that the expenses of my burial and all my debts be paid as soon after my death as may be convenient to my Executor or Executrix hereinafter named. 2. I give,devise and bequeath all the rest,residue and remainder of my estate,whether real or personal, of whatsoever nature and kind, and wheresoever situate, unto my husband, HAROLD V.COULSON,SR.,provided that he survives me by sixty(60)days. 3. In the event that my husband,HAROLD V.COULSON,SR., predeceases me or dies on or before the 60'day following my death,I give and bequeath the following items to my son, HAROLD V. COULSON,JR.: Coleman generator;electric bed;mahogany gate leg table with red lamp;mahogany 3-drawer desk; mahogany large dresser with mirror; mahogany table with leaf; 6-drawer high-boy; grandfather clock;stereo;all Emmitt Kelly,Jr.Clowns(4 large,2 small);glass 3-way lamp; one cane chair (square bottom seat - flat arms); kitchen table and six chairs; my wedding band and my husband's wedding band. 4. In the event that my husband,HAROLD V.COULSON,SR,predeceases me or dies on or before the 60' day following my death, I give and bequeath the following items to my grandson, MICHAEL E.COULSON: 12 gauge Ithaca(473065-2); Mahogany four poster bed; large dresser with mirror; maple chest of drawers; mahogany armoire; mahogany barometer; one cane chair(round bottom seat); ladderback chair and desk. 5. In the event that my husband,HAROLD V.COULSON,SR.,predeceases me or dies on or before the 60'day following my death, I give and bequeath the following items to my great- grandson,MICHAEL SCOTT COULSON: All three(3)eagles;car;solid mahogany bowl;mahogany stool;small solid chestnut table; clock and matching dog;wooden calendar;picture old man in candy store window;all coins and one and two dollar bills in steel box;30.06 Remington gun(477606);30.06 Remington gun(479516); 35 Remington gun(136631);High Standard 22 caliber gun(930960W-100); 22 caliber 140 pellet Crosman gun; 177 caliber Power Master 760 BB E pellet gun. 6. In the event that my husband,HAROLD V. COULSON,SR.,predeceases me or dies on or before the 60`h day following my death, I give, devise and bequeath the remaining cemetery lots at Mount Olivet Cemetery to my son HAROLD V.COULSON,JR. T In the event that my husband,HAROLD V.COULSON,SR., predeceases me or dies on or before the 60`'day following my death, I give and bequeath my retirement account at Dean,Witter,Reynolds,Inc.,unto Dauphin Deposit Bank and Trust Company,as Trustee,in Trust, for the benefit of my great-grandson,MICHAEL SCOTT COULSON,for the following uses and 2 - r f purposes: (a) The Trustee shall have,hold,manage,invest and reinvest principal thereof,and shall expend and apply so much of the net income(any income not expended or applied to be accumulated and added to principal) and so much of the principal of the Trust as the Trustee shall consider advisable for the health, maintenance, support and education (including college education, both undergraduate and graduate) of MICHAEL SCOTT COULSON,until he attains the age of 21 years. Thereafter,the Trustee shall distribute on a monthly basis the net income of the Trust and may expend so much of the principal as it shall consider advisable for the health, maintenance, support and education (including college education,both undergraduate and graduate)of MICHAEL SCOTT COULSON, after taking into consideration his other readily available assets and sources of income,until he attains the age of 25 years. (b) When MICHAEL SCOTT COULSON attains an undergraduate college degree,the Trustee shall distribute to him 3 8%of the then remaining principal balance of his Trust. When MICHAEL SCOTT COULSON attains the age of 25 years,the Trustee shall distribute to him the balance of the Trust principal and any accrued and undistributed income free of Trust. (c) If at any time before the final distribution of the Trust, MICHAEL SCOTT COULSON dies, the Trust shall be divided into as many shares as there are issue of his living and maintained for the benefit of each of his issue until they attain 21 years of age at which time the Trust shall terminate. The Trustees then shall distribute the balance of the principal and income to each such issue free of Trust. If MICHAEL SCOTT COULSON - 3 - dies without issue before final distribution,the Trust shall terminate and its assets be divided and paid,5/8ths thereof to HAROLD V.COULSON,JR.,and 3/8ths thereof to MICHAEL E.COULSON,provided that both survive MICHAEL SCOTT COULSON. In the event that both HAROLD V. COULSON,JR., and MICHAEL E. COULSON do not survive MICHAEL SCOTT COULSON,then 1/4th of the Trust shall be distributed to ROBIN L. COULSON,and the balance thereof to the survivor of HAROLD V.COULSON,JR.,and MICHAEL E.COULSON. If neither HAROLD V.COULSON,JR.,nor MICHAEL E. COULSON survive MICHAEL SCOTT COULSON,then the Trust shall be distributed in equal shares to ROBIN L.COULSON,and KRISTEN D.JONES. (d) Except as otherwise expressly provided in this Will,no beneficiary of any Trust provided for in this Will shall have any right,power or authority to alienate, encumber or hypothecate his or her interest in the principal or income of such Trust in any manner, nor shall such interest of any beneficiary be subject to claims of his or her creditors or liable to attachment,execution or other process of law. (e) In the settlement of my Estate and during the continued existence of the foregoing Trust, my Executor and the Trustee shall possess, among others, the following powers to be exercised for the best interests of the beneficiaries: (1) To retain any investment I may have at my death so long as my Executor or Trustee may deem it advisable to my estate or Trust so to do. (2) To vary investments,when deemed desirable by my Executor or Trustee, and to invest in such bonds,stocks,notes,real estate mortgages or other securities or in such other real or personal property as my Executor or 4 - Trustee shall deem wise, without being restricted to so-called "legal investments." (3) In order to effect a division of the principal of my estate or a Trust or for any other purpose, including any final distribution of my estate or any Trust,my Executor or Trustee is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind,said assets are required to be divided or distributed at their respective values on the date or dates of their division or distribution. (4) To sell either at public or private sale and upon such terms and conditions as my Executor or Trustee may deem advantageous to my estate or any Trust,any or all real or personal property or interest therein owned by my estate or any Trust severally or in conjunction with other persons or acquired after my death by my Executor or Trustee,and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all Trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor or Trustee in this paragraph or elsewhere in my Will. 5 - (5) To mortgage real estate, and to make leases on real estate. (6) To pay all costs,taxes,expenses and charges in connection with the administration of my estate or a Trust.My Executor shall pay expenses of my last illness and funeral expenses. (7) To vote any shares of stock which form a part of my estate or Trust and to otherwise exercise all the powers incident to the ownership of such stock. (8) In the discretion of my Executor or Trustee,to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of a Trust or of my estate. (9) To assign to and hold in any Trust an undivided portion of any asset. (10) In the discretion of my Trustee, if the size of any Trust herein established shall become so small that it is impractical or uneconomical to continue said Trust, my Trustee may distribute all accumulated income and principal to the beneficiaries of the Trust. (11) The right and discretion to elect the most propitious settlement options for any employee benefit options payable to any Trust assuming such election shall be in accordance with procedures established by the plan's administrator, as the case may be. 8. In the event that my husband, HAROLD V. COULSON,SR., predeceases me or dies on or before the 60'day following my death,I give, devise and bequeath all the rest,residue - 6 - R and remainder of my estate as follows: (a) 4/8ths (one half) thereof unto my grandson, MICHAEL E. COULSON, as Trustee for my son,HAROLD V.COULSON,JR.,if he survives me.If he predeceases me, I give, devise and bequeath his share unto my great-grandson, MICHAEL SCOTT COULSON. (b)3/8ths thereof unto my grandson,MICHAEL E.COULSON,if he survives me. If he does not survive me, I give, devise and bequeath 1/8th of the residue unto my son, HAROLD V. COULSON, JR., and 1/4th of the residue unto my great-grandson, MICHAEL SCOTT COULSON.In the event that either HAROLD V.COULSON,JR., or MICHAEL SCOTT COULSON do not survive me,I give,devise and bequeath his share unto his issue who survive me,per stirpes. (c) 1/8th to my great-grandson,MICHAEL SCOTT COULSON. In the event that I am survived by no issue,I give,devise and bequeath all the rest,residue and remainder of my estate in equal shares unto ROBIN L. COULSON and KRISTEN D. JONES. 9. I appoint my husband,HAROLD V.COULSON,SR., to be the Executor of this my Last Will and Testament.In the event that she shall predecease me,or fail to qualify,or cease to act as Executor,I then appoint HAROLD V.COULSON,JR.,and MICHAEL E.COULSON,or the survivor of them, as Executors. In the event that both HAROLD V. COULSON, JR., and MICHAEL E. COULSON predecease me, or fail to quality, or cease to act as Executor, I then appoint MICHAEL SCOTT COULSON,if he is of legal age,if not ROBIN L.COULSON, as the alternate Executor/Executrix of this my Last Will and Testament. 7 - 10. No Executrix,Executor,or Trustee shall be required to furnish any bond or other security-in any jurisdiction, or if a bond be required,neither shall be required to furnish any surety thereon. IN WITNESS WHEREOF,I, BILLIE JUNE COULSON have hereunto set my hand and seal to this,my Last Will and Testament which consists of Ltypewritten pages,this day of 2005. BILLIE COULSON Signed, sealed,published and declared by the above-named,BILLIE JUNE COULSON, as her Last Will and Testament in the presence of us,who at her request,in her presence and in the presence of each other hereunto'subscribed our names as witnesses. of ca'ty itness `n a, of ��� Witness 8 - ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) ) ss. COUNTY OFit� I, Billie June Coulson, Testatrix, whose name is signed to the attached or foregoing instrument,having been duly qualified according to law,do hereby acknowledge that I signed and executed this 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. BILLIE COULSON Sworn or affirmed to and acknowledged before me,by Billie June Coulson,the Testatrix,this day of 2005. . ! ✓ "C7 Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Anne Marie Seshore, Notary Public City of Harrisburg, Dauphin County My Commission Expires Apr.5,2008 Member,Pennsylvania Association of Notaries - 9 - AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) ��.. ) ss. COUNTY OF ib-I,:,�oh,'? ) We, f V h ,and�(L��L-1-f lir�.l� the witnesses whose names are signed to the attached and foregoing instrument,being duly qualified according to law, do depose and say that we were present and saw Billie June Coulson, the Testatrix, sign and execute the instrument as her Last Will;that she signed willingly and that she executed it as her free and voluntary act for the purpose therein expressed;that each of us in the hearing and sight of Billie June Coulson,the Testatrix; signed the Will as witnesses; and that to the best of our knowledge, Billie June Coulson, the Testatrix, was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by these witnesses,thisAil day of 2005. t Vif NESS WITNESS Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Anne Marie Beshore, Notary Public City of Harrisburg, Dauphin County My commission Expires Apr.5.2008 Member,Pennsylvania Association of Notaries 10 - Q_iri RHANS' CG► $5.75 00-t4q, M, q,2., 8'k P F Origin:89148 13.4002. Jul 18,161006 /'/[11�J 1I'l"�f .i Forpomestle 3148970019.09 + i and Intemat/onal Use AIMA IL PRIORITY MAW 2-DAY f Uv ITEDSTATESPOSTALSERVICE. :�= Q•� Mr Michael Coulson { From 920 Pretty Fire St @ V Las Vegas, NV 89178 $ Expected Delivery Day:07/20/15 USPS TRACKING NUMBER TO �- � G�r1c.�-n►c ci+r' o�P1�ra�vS� Cnv2► �► r 161 CSR 2 I-,25 c e 1701S L.abe171.8,January 2008 9505 5112 0084 5199 4062 55 I i WHEN 1 i A,CUSTOMS DECLARATION LABEL MAY BE REQUIRED. EP1 •F July 2013 VISIT US AT USPS.CO Me UNITEDSTA7. PS00001000014 0D2.5 x 9.5 ,ORDER FREE SUPPLIES ONLINE �POSTZILSER t