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Home My WebLink About07-25-05 REV-1500 EX (6-00) Rev-1500 OFFICIAL USE ONLY .. . COMMONWEALTH OF PENNSYLVANIA ................................................................................... DEPARTMENT OF REVENUE FILE NUMBER DEPT. 280601 INHERITANCE TAX RETURN HARRISBURG, PA 17128-0601 21 - 2005 0126 RESIDENT DECEDENT County Code Year Number DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- Z BLACK AliceW. 172-01-9525 W 0 DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH W U January 28, 2005 March 24,1915 REGISTER OF WILLS w 0 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER N/A . x 1. Original Return 2. Supplernental Return 3. Remainder Return (date of death prior to 12- ~.~ (/) - r-- t-- u d."" 4. Limited Estate 4a. Future Interest Comprise (date of death after 12.12.82) 5. Federal Estate Tax Return Required ~e~ - - '-- () 0.!lJ X 6. Decedent Died Testate (Attach copy of Will) 7. Decedent Maintained a Living Trust (Attach a oopy of TrUS!) 8. Total Number of Safe Deposit Boxes 0. - = 10. Spousal Poverty Credit(dateofdeathbetwOeo "-31-9' alld ""95) 011. Election to tax under Sec. 9113(A) <( 9, Litigation Proceeds Received - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: 'E NAME COMPLETE MAILING ADDRESS CL> -0 Jean D. Seibert, Esquire 109 Locust Street = 8- FIRM NAME (If Applicable) Harrisburg, PA 17101 <n ~ Wion. Zulli & Seibert C5 c....:> TELEPHONE NUMBER 717-236-9301 ,"....-, ''--' c;,::> ':J 1. Real Estate (Schedule A) (1) $0.00: . 0 OFFICI~~SE ONLY,lj '::'J'] $147,15284 : (": ' '::.J 2. Stocks and Bonds (Schedule B) (2) , -- .~G r....) ,"J $0.00: ~'-rl 3. Closely Held Corporation, Partnership or Sole-Proprtetorship (3) VI '..J Z Mortgages & Notes Receivable (Schedule D) (4) $0.00: ~~~': : ':....") 4. -rl 0 -~-- -n -" - c'S I- 5. Cash, Bank Deposits & Misc. Personal Property (Schedule E) (5) $112,437.33 : i'~,.,j In <C $0.00 : Ul -l 6. Jointly Owned Property (Schedule F) (6) :=J o Separate Billing Requested - I- a... 7. Inter-Vivos Transfers & Misc. Non-Probate Property (7) $84,633.72 <C ..........--............................................ () (Schedule G or L) W 8. Total Gross Assets (total Lines 1-7) (8) $344,223.89 0::: 9. Funeral Expenses & Administrative Costs (Schedule H) (9) $21,731.75 10. Debts of Decedent, Mortgage Liabilities & Liens (Schedule I) (10) $1,697,31 11. Total Deductions (total Lines 9 & 10) (11) $?3 4?9 06 12. Net Value of Estate (Line 8 minus Line 11) (12) $320,794.83 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) $3? 079 48 made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) $288,715.35 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax rate, or transfers under Sec, 9116 (a)(I,2) x (15) $0.00 Z - 0 $0.00 j: 16. Amount of line 14 taxable at lineal rate x (16) X<( - <(r- 17, Amount of line 14 taxable at siblin9 rate x .12 (17) r-:J a. ~ 18. Amount of line 14 taxable at collateral rate $288,715.35 x .15 (IB) $43 307 30 0 I.l 19. Tax Due $43,307.30 (19) 20. D > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < D~cede'1t's Complete Address: STREET ADDRESS 5225 Wilson Lane CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) $43,307.30 !l;4n snn nn !I;? 1:'\1 S? 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) $42631 S2 4. Total Interest/Penalty (D + E) (3) If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) $0.00 5. A. Enter the interest on the tax due. $675.78 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) $675.78 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: 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 revisionary interest; or d. receive the promise for life of either payments, benefits or care? If death occurred after December 12, 1982, did decedent transfer property within on year of death without receiving adequate consideraUon? Did decedent own an "in trust for" or payable upon death bank account or security at his or her Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? Yes No ~ EE 2. ~ B 3. 4. [Z] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. CJ Under penalties of perjury, I declare that t have examined this return, including accompanying schedules and statements. and 10 the best of my knowledge and belief, it is true, correct. and complete. Declaration preparer other than the personal representative is based on all the information of which preparer has any knowledge. FILING RETURN 221 Reeser Road, Camp Hill, PA 1 11 SIGNATU OF P~~ .?THER THAN REPRESENTATIVE kA.::C.l:Yi;J.be-~ ADORE 109 Lo For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. !l9116 (a) (1.1) (i)]. 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% [72 P.S. !l9116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory .om ,'.^~M'^ ,-- ..,--,-_. .-- _Z - -. ld 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 twenty-one years of age or youngel adoptive parent, or a stepparent of the child is 0% [72 P.S. \)9116(a) (1.2)]. f\J.fiPD lrent, an The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4. P.S. !l9116(a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. T A i I c-;- Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood 0 . lA...> ( 2) [72 Jer REV.1503EX = (1.97) (1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Alice W. Black FILE NUMBER 21-05-0126 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 117 shares of common stock of AT&T Corp. @ $19.745 per share VALUE AT DATE OF DEATH $2,310.16 2. 750 shares of common stock of UGI Corp. @ $41.25 per share $30,937.50 3. 508 shares of common stock of Lucent Technologies @ $3.265 per share $1,658.62 4. 1,024 shares of common stock of Bell South Corp. @ $26.75 per share $27,392.00 5. 1,010 shares of common stock of SBC Communications @ $23.51 per share $23,745.10 6. 190 shares of common stock of Comcast Corp. @ $32.495 per share $6,174.05 7. 908 shares of common stock of Verizon @ $35.60 per share $32,324.80 8. 134 shares of common stock of Agere Systems Corp @ $1.39 per share $186.26 9. 369 shares of Van Kampen Investments - U.S. Mortgage Fund A @ $13.95 $16,651.05 10. U.S. Savings Bonds - see attached list $5,773.30 TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) $147,152.84 ESTATE OF ALICE W. BLACK U.S. Savings Bonds $100 Series I No. C007624201I May 2002 $110.04 $500 Series I No. D002386086I May 2002 550.20 $50 Series E No. L2121872858E February 1978 223.64 $50 Series E No. L2130739962E May 1978 185.74 $50 Series E No.L2074005907E February 1977 250.06 $50 Series E No. L2082596155E April 1977 250.06 $50 Series E No. L2089530884E July 1977 253.02 $50 Series E No. L2103511564E September 1977 248.06 $50 Series E No. L2111500202E December 1977 228.12 $50 Series E No. L2026303992E January 1976 259.06 $50 Series E No. L2039839870E April1976 253.98 $50 Series E No. L2047489539E June 1976 256.96 $50 Series E No. L2058768804E September 1976 251.88 $50 Series E No. L2064454512E November 1976 254.34 $50 Series E No. L2010283041E August 1975 255.96 $50 Series E No. L2020329639E November 1975 258.46 $25 Series E No. Q6008101828E May 1975 130.23 $25 Series E No. Q5256297336E April 1975 128.99 $25 Series E No. Q5248874314E February 1975 128.99 $25 Series E No. Q5244281110E January 1975 131.57 $25 Series E No. Q5182565177E May 1974 129.71 $25 Series E No. Q5217487322E August 1974 130.02 $25 Series E No. Q5197894736E July 1974 130.02 $25 Series E No. Q5160514533E February 1974 128.48 $25 Series E No. Q5218672819E November 1974 131.26 $25 Series E No. Q5219128871E October 1974 130.02 $25 Series E No. Q5039891082E August 1972 128.05 $25 Series E No. Q5053171849E October 1972 128.05 $25 Series E No. Q5066383180E December 1972 128.33 TOTAL $5,773.30 REV.1508 EX + (1.S7)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIOENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-05-0126 ESTATE OF Alice W. Black Include the proceeds of liligation and the date the proceeds were received by the estate. All property jOlntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. DESCRIPTION VALUE AT DATE OF DEATH $2,000.00 Cash on hand Checking account No. 15777685 at M&T Bank I nterest accrued to date of death $7,293.60 $0.09 Savings account No. 950280270 at M&T Bank Interest accrued to date of death $15,343.44 $5.16 Checking account No. 006010-84 at Belco Community Credit Union $2,732.81 Savings account No. 006010-S1 at Belco Community Credit Union Interest accrued to date of death $5,723.79 $5.22 Savings account No. 006010-86 at Belco Community Credit Union Interest accrued to date of death Certificate of Deposit No. 29184 at Belco Community Credit Union Interest accrued to date of death $54,706.08 $53.43 $5,882.04 $91.59 Certificate of Deposit No. 30881 at Belco Community Credit Union Interest accrued to date of death $7,158.87 $74.05 Certificate of Deposit No. 78002-71096 at M&\ Bank $3,448.18 Tangible personal property: One Carat diamond ring (Munn's appraisal) Diamond engagement ring (Munn's appraisal) Hand painted chocolate set (Ensminger's appraisal) Diamond earrings (Munn's appraisal) Pearl ring (Munn's appraisal) $1,145.00 $235.00 $250.00 $220.00 $190.00 Refund on homeowner's insurance $38.00 Refund on automobile insurance $287.00 Refund on Bethany Village apartment rent $667.75 Reimbursement from Medco $1,528.13 Reimbursement from Medea $508.10 Refund for 2004 federal income tax $2,850.00 $112,437.33 TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-151O EX + {1-97)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Alic;e W. Black FILE NUMBER 21-05-0126 This schedule must be completed and Iiled ilthe answer to any of questions j through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF DECD'S TAXABLE ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH INTEREST EXCLUSION VALUE NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET (IF APPLICABLE) 1. Met Life Investors Non-Qualified Annuity Contract No. $11,275.27 100.0% 0 $11,275.27 Paid to Barbara A. Stouffer, niece as beneficiary 2. Nationwide Fixed Account Annuity Contract No. 01-1802008 $33,011.13 100.0% 0 $33,011.13 Paid to Barbara A. Stouffer, niece as beneficiary 3. Nationwide Quatm Select Annuity Contract No. 07-1159576 $40,347.32 100.0% 0 $40,347.32 Paid to Barbara A. Stouffer, niece as beneficiary . TOTAL (Also enter on line 7, Recapitulation) $84,633.72 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (1-97)(1) COMMONWEA~TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Alice W. Black FILE NUMBER 21-05-0126 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. 1. 2. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. DESCRIPTION AMOUNT FUNERAL EXPENSES: Neill Funeral Home $818.10 Brackendorf Memorials - grave marker $295.00 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Herbert L. Stouffer Social Security Number(s) J EIN Number of Personal Representative(s) Street Address 221 Reeser Road City Camp Hill Year(s) Commission Paid: 2005 Attorney Fees - Wion, Zulli & Seibert Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address $10,855.00 168-26-2891 State PA Zip 17011 $8,500.00 City Relationship of Claimant to Decedent State Zip Probate Fees and short certificates $404.00 Accountant's Fees Tax Return Preparer's Fees Advertising - Cumberland Law Jounral The Sentinel $75.00 $122.51 3-8-05 M& T Bank - safety deposit box rental $21.50 3-23-05 Munn's Diamond Gallery - appraisal of jewelry $250.00 3-28-05 $25.66 Staples - office supplies 3-28-05 Staples - Photocopies of correspondence for stock sales $2.42 TOTAL (Also enter on line 9, Recapitulation) $21,731.75 (If more space IS needed, insert additional sheets of the same size) CONTINUATION PAGE SCHEDULEH_ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TN< RETURN RESIDENT DECEDENT ESTATE OF Alice W. Black FILE NUMBER 21-05-0126 ITEM NUMBER DESCRIPTION 12. 3-29-05 U.S. Postal Service - 8 registered letters for sale of stocks VALUE AT DATE OF DEATH $90.68 13. 4-1-05 U.S. Postal Service - registered letter to Met Life Ins. $10.58 14. 4-5-05 Robert Ensminger - appraisal of chocolate set $25.00 15. 4-11-05 U.S. Postal Service - registered letters to VanKampen and Agere $19.97 16. 4-14-05 U.S. Postal Service - registered letter for Mellon Investor Services $10.97 17. 5-5-05 U.S. Postal Service - mailing of one (1) carat diamond ring $21.35 18. 5-23-05 Herbert L. Stouffer - U.S. postage paid by Herbert L. Stouffer $109.01 19. Reserve for copies. postage $75.00 TOTAL REV-1512 EX + (1-97}(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Alice W. Black FILE NUMBER 21-05-0126 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT $50.00 1. 3-8-05 East Pennsboro Ambulance 2. 3-12-05 Alert Pharmacy Services $1,344.31 3. 4-5-05 PA Department of Revenue - 2003 tax year payment $159.00 4. 4-5-05 PA Department of Revenue - 2004 tax year payment $144.00 TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, Insert additional sheets of the same size) $1,697.31 REV-1513 EX + (9-00)) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT BENEFICIARIES ESTATE OF Alice W. Biack FILE NUMBER 21-05-0126 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)] 1. Babara A. Stouffer Niece Diamond earrings and 220 Reeser Road pearl ring; and 40% of Camp Hill, PA 17011 estate 2. Mary Ann Thomas Niece 10% of estate 879 Pondarosa Drive South Daytona, FL 32119 3. John Frith Nephew 20% of estate 16178 Stillman Valley Road Killeen, TX 76542 4. Charles Frith Nephew 10% of estate 80201 Overseas Highway Islamorada, FL 33036 5. Joan Fleck Niece One carat diamond 210 Rolling Acres Drive ring; & 10% of estate Nicholasville, KY 40356 6. Gloria Fox No relation Chocolate set and 500 Walnut Street, Apt #4, Lemoyne, PA 17043 diamond engage ring ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTiONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Paxton Presbyterian Church 10% of estate 3500 Sharon Street Harrisburg, PA 17111-1857 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $0.00 (If more space IS needed, insert additional sheets of the same size) - 1lIn~t 3WIill nnu QJclltament OF ALICE W. BLACK ('2 I, ALICE W. BLACK, of Lower Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby u. declare this as and for my Last Will and Testament, hereby revoking all Wills and Codicils previously made by me. 1. I direct the payment of my debts and expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. 2. I direct that my articles of personal or household use, including any automobiles I own at the time of my death, be distributed as follows: ~ (a) I give and bequeath my one carat diamond ring to my husband's cousin, JOAN FLECK, ofFrankston, Texas; (b) I give and bequeath my diamond engagement ring and hand painted china 2 chocolate set to GLORIA FOX ofLemoyne, Pennsylvania; (c) I give and bequeath my diamond earrings and my pearl ring to my niece, ~ BARBARA A. STOUFFER, of Mechanicsburg, Pennsylvania. j ,-.) (d) I direct that any remaining articles of personal or household use I own at the time '..J of my death, be divided among my nieces and nephews, namely MARY ANN THOMAS of South Daytona, Florida; JOHN FRITH of Killeen, Texas; CHARLES FRITH of Islamorado, Florida; and BARBARA A. STOUFFER of Mechanics burg, Pennsylvania, and my husband's niece, JOAN FLECK, in as nearly equal shares as they can agree. Any items not desired by any ofthese named individuals shall be converted to cash as my Executor deems best and the proceeds therefrom added to the residue of my estate. 3. I direct that all the rest, residue and remainder of my estate be divided into ten (10) equal shares, these shares to be distributed to the following individuals and charitable < ~'it"!';"',.,_ 1 ~ d entity as follows: 1) One (1) share to MARY ANN THOMAS of South Daytona, Florida; 2) Two (2) shares to JOHN FRITH of Killeen, Texas; 3) One (1) share to CHARLES FRITH oflslamorado, Florida; 4) Four (4) shares to BARBARA A. STOUFFER of Mechanics burg, Penosylvania; 5) One (1) share to JOAN FLECK ofNicholasville, of Kentucky; and 6) One (1) share to PAXTON PRESBYTERIAN CHURCH, of Pax tang, Pennsylvania in memory of my parents, Mr. and Mrs. L.A. Webster, and my sister, Betty Frith. 3. I direct that any and all inheritance, estate and transfer taxes imposed upon my estate, passing under my Will or otherwise, shall be paid as a part of the expense of administration, payable out of my residuary estate. 4. In addition to powers given it by law, my Executor acting hereunder shall have the fullest power and authority in all matters and questions and to do all acts which I might or could do if living, including, without limitation, complete power and authority to invest (without restriction to investments permitted by law), sell (at public or private sale, for cash or credit, with or without security), mortgage, lease and dispose of and distribute in kind, all property, real and personal at such times and upon such terms and conditions that it may deem advisable. 5. I nominate, cO!lstitute and appoint my niece's husband, HERBERT L. STOUFFER, as Executor of this, my Last Will and Testament. In the event of the 2 az~ w~ (SEAL) renunciation, death, resignation or inability to act for any reason whatsoever of Herbert L. Stouffer, I nominate, constitute and appoint my niece, BARBARA A. STOUFFER, as Executrix of this, my Last Will and Testament. 6. I hereby relieve my personal representative from the necessity of posting security in connection with his duties as such in any jurisdiction in which he may be called upon to act insofar as I am able by law to do so. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of three typewritten pages, the first two of which bear my signature in the margin for the purpose of identification, this ~~y of ~~ ,2004. Alice W. Black Signed, sealed, published and declared by the above-named Testatrix, Alice W. Black, as and for her Last Will and Testament, in the sight and presence of us, who, at her request, and in her sight and presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. hl2 "-R.~~~ Name , {}~Qdf:~1/' Nfr '1 \ '" C( .,~...... c.:u. to. f.... .;~>_ ~ P.... Address ' 9tj ~;2.(. #{/rJt-fflL~ <fI. Address 3 < Commonwealth of Pennsylvania : 88 VVe, Alice W. Black , G /&vAJI0 ,R. Cod r" n ,and County of Dauphin :!'e.A--0 D , Se,' 1e.-r , the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn and qualified according to law, do hereby declare to the undersigned authority that we were present and saw the Testatrix sign and execute the instrument as her Last VVill and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the VVill as witnesses and that to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence, and I, the said Testatrix, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament, that I signed it wiIlingly, and that I signed it as my free and voluntary act for the purposes therein expressed. Ci'.f;fA i.J. ~ Testatrix ~~~~ VVitness . . (};ib?u~4~ VV~ Subscribed, sworn to and acknowledged before me by Alice W. Black the Testatrix, and subscribed and sworn to before me by t:-k",.. q J:, /-v /,,,,.. and ,);:;",/1 I). "",;1..,+ ,witnesses, this~dayof ]":,,,,e ,2004, LL ,~' i.Az'~v~L- NOtary Public NOTARIAL SEAL JOHN R.E. BOWEN. NOTARY pUBUC LOweR ALAN TWP.. COUNTY OF OUMBEIIlANll MY COMMISSION EXPIRES MARcH 25, 2006 < 02/14/2005 15:29 WION ZULLl&SElBERT .. 13029342955 NO. 801 003 DAVID A. WlON FRANCIS A. l.ULU JENl D. SEIDIIlT LAW OFFICES ,~~.~~ 1 all LOCUST STlllET P.O. IilOX 1121 HARRISBURG. PENNSVLVANIA 1" D8.1 1 21 (711') 286.93D1 (111') au. 1 488 'AX (117) 236.6100 "l'/IllI/: wnOmlllclap,lng.oo", ! FEB 25 2005: IIICTOR A. BIHL Of' COUllllEL 113 EAST MAIN STREET HUIIMELST'OWN, PA 11(11. (7'71 56&.2$01 Estate of d;;,;. ~ If). 6k/"'~. Date of Death /-~,/'-tlS Checking .Accounts, N1JJlIber Date opened Balance at O.te of Death Int. to Date of Death' Joint owner, if any 2 f/50 ;.I10,:} 10 'th 'Y/;;v 'i.bJed .J/~/o~ ( .- . J,'1 .. I ~!;), .,,~w 5.;1., 3 - .- Savings Accounts; Number Date Opened Balance at Date of Death Int. to Date of Death. Joint Owner, if any .1 2 3 Certificates of Deposit; 1 2 3 Number Date Value at Date of Death Int. to Date of Death Joint Owner, if any Maturity Date Interest Rate Interest Paid Ouarterly, Semi-Annually, etc. Debts: Others; /VI ~ T !3ClllG Na\1le of Bank ~i. Savings Date; ~;7~Jo 5 I ' Association '. DAVID A. WI ON FRANCIS A. ZULLI JEAN D. SEIBERT LAW OFFICES ~g~<f<Q/~ 109 LOCUST STREET P.O. BOX 1121 HARRISBURG, PENNSYLVANIA 17106-1121 (71 7) 236-9301 (717) 232-1488 FAX (717) 236-6100 Email: wzs@mindspring.com VICTOR A BIHL OF COUNSEL 113 EAST MAIN STREET HUMMELSTOWN, PA 17036 (717) 566-2501 Estate of r/:f/L:L aJ. ~. Checking Accounts: Number Date Opened Balance at Date of Death Int. to Date of Death Joint Owner, if any Savings Accounts: Number Date Opened Balance at Date of Death Int. to Date of Death Joint Owner, if any Certificates of Deposit: Number Date Value at Date of Death Int. to Date of Death Joint Owner, if any Maturity Date Interest Rate Interest Paid Quarterly, Semi-Annually, etc. Debts: Date of Death /-,;?j'-cr..5- 1 ()6 ~616 - 5 tJ \..l- n Kf\()w tV tJ 'I'.? '3-' I/( J (')- tI D (l e..- 2 3 1 6~{P() It) .-$ V }fb/'7~ be :;C:;1J;'2)1'7f s. ~ -:A '.)Dn f 2 00 ~ 0 I 0 -- S t, u n K n p (,0(\/ 54, 'lv', og' 53,43 Non ~ 3 1 ~ (H~'-\ 1~/~q 103 ~ B8~. 0,+ '11.5'1 No~e .;z/lo os ;Z.o<> M .".u.. t y 2 :3S11~::-' 1 -r I \ 5 e ,'bl ilt,oS No,", € ::1..//t>! ().S I. SS ~~ t\..l Y 3 Others: 'BfL-CJJ COrnfVl('(/lI~ Cy~difun'-J/ Name of Bank or Savings Association H ~;,,-, CtlJu.. C(fiLuj~k Signature and Title of Bank or Savings Association Official Date: j _ f'J- ~ot>5 Suppar..t Srnlces POBox 1119 Appleton WI 54912-1119 Bank Response Form MAY 0:2 2005 Bank: M & I Bank, FSB TO: Wion, Zulli & Seibert Law Offices 109 Locust Street POBox 1121 Harrisburg, P A 17108-1121 This form is being provided to you in response to your request on the above named individual. Below is a listing of the accounts andlor other services which, according to our records are in the name ofthe individual. We hope this information will be of assistance to you. The dollar amounts are through January 28, 2005. Date: April 29, 2005 Re: Alice W Black Deposit Accounts:. None on File [ ] Type of Account Certificate of Deposit Account #/10# 78002710961D#1 Account Title Alice W Black Balance 3,448.18 Accrued Intercst 2.63 Interest Paid YTD 4.80 1099 Interest Reported 4.80 TIN# 172-01-9525 Other Information Int Rate 1.640% Mat. Date 02/14/2005 Type of Account Account #/10# Account Title Balance Accrued Interest Interest Paid YTD 1099 Interest Reported TIN# Other Information Type of Account Account #/10# Account Title Balance Accrued Interest Interest Paid YTD I 099 Interest Reported TIN# Other Information 'r 1 Additional accounts on attached sheet. .Note: Early withdrawal penalties are waived when closing accounts for a deceased account owner. [ ] See enclosed letter ou requirements for interest reporting. SAFE DEPOSIT BOX: Lessee(s) None on File [ X Box # Location LOANS: In the name of None on File [ X Loan #/Note # Type Balance ADDITIONAL SERVICES RELATED TO ACCOUNT OWNER: ACCOUNTS CLOSED DURING TAX YEAR: Account # Type of Account Date Closed . ADDITIONAL COMMENTS: Completed By: Sandra Wallace Phone 1-800-236-6736 OPT #3 or extension #3403 G:\Data\SSC\Special Services\! acct - Revision Date 02/17/03 " REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of: Alice W, Black, Deceased No,: 21-05-0126; 00126 of2005 Date of Death: January 28,2005 Social Security No.: 172-01-9525 Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of the Inventory, 1 verify that the statements made in this Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. ID.No.: PA41713 Name of Attorney: Jean D. Seibert, Esquire Address: 109 Locust Street Harrisburg, PA 17101 Dated: . ) 7/ tJe I~O;:-'~ -2 '"'" C::"); :~~ r... .~ -TJ , '," I ~;"") -."'") 'i) :~'l:'~ '_J , C) ';'l -~ . (-) fT'", Telephone: 717-236-9301 c..'l ,.-..... Description -'J V alue ~.~. \ .~. j 117 shares of common stock of AT&T Corp. @ $19.745 per share ,'~ $ 2,310.1&-: 750 shares of common stock ofUGI Corp. @$41.25 per share 30,937.50 508 shares of common stock of Lucent Technologies @ $3.265 per share 1,658.62 1,024 shares of common stock of Bell South Corp. @ $26.75 per share 27,392.00 1,0 I 0 shares of common stock of SBC Communications @ $23.51 per share 23,745.10 190 shares of common stock of Comcast Corp. @ $32.495 per share 6,174.05 908 shares of common stock ofVerizon @ $35.60 per share 32,324.80 134 shares of common stock of Agere Systems @ $1.39 per share 186.26 1,193.624 shares of Van Kampen Investments - U.S. Mortgage Fund A @ $13.95 16,651.05 I \j-, U.S. Savings Bonds - see attached list 5,773.30 " Cash on hand 2,000.00 Checking account No. 15777685 at M&T Bank Interest accrued to date of death 7,293.60 .09 Savings account No. 950280270 at M&T Bank Interest accrued to date of death 15,343.44 5.16 Checking account No. 006010-S4 at Be1co Community Credit Union 2,732.81 Savings account No. 006010-S1 at Belco Community Credit Union Interest accrued to date of death 5,723.79 5.22 Savings account No. 006010-S6 at Be1co Community Credit Union Interest accmed to date of death 54,706.08 53.43 Certificate of Deposit No. 29184 at Belco Community Credit Union Interest accmed to date of death 5,882.04 91.59 Certificate of Deposit No. 30881 at Belco Community Credit Union Interest accrued to date of death 7,158.87 74.05 Certificate of Deposit No. 78002-71096 at M&I Bank 3,448.18 Tangible personal property: One carat diamond ring (Munn's appraisal) Diamond engagement ring (Munn's appraisal) Hand painted chocolate set (Ensminger appraisal) Diamond earrings (Munn's appraisal) Pearl ring (Munn's appraisal) 1,145.00 235.00 250.00 220.00 190.00 Refund on homeowners insurance 38.00 Refund on automobile insurance 287.00 Refund on Bethany Village apartment rent 667.75 Reimbursement from Medco 1,528.13 Reimbursement from Medco 508.10 Met Life Insurance policy no. 013493932A 2,226.14 Refund for 2004 income tax paid 2,850.00 Total $261,816.31 .. . ESTATE OF ALICE W. BLACK U.S. Savings Bonds $100 Series I No. C007624201I May 2002 $110.04 $500 Series I No. D002386086I May 2002 550.20 $50 Series E No. L2121872858E February 1978 223.64 $50 Series E No. L2130739962E May 1978 185.74 $50 Series E No. L2074005907E February 1977 250.06 $50 Series E No. L2082596155E April 1977 250.06 $50 Series E No. L2089530884E July 1977 253.02 $50 Series E No. L2103511564E September 1977 248.06 $50 Series E No. L2111500202E December 1977 228.12 $50 Series E No. L2026303992E January 1976 259.06 $50 Series E No. L2039839870E April 1976 253.98 $50 Series E No. L2047489539E June 1976 256.96 $50 Series E No. L2058768804E September 1976 251.88 $50 Series E No. L2064454512E November 1976 254.34 $50 Series E No.L2010283041E August 1975 255.96 $50 Series E No. L2020329639E November 1975 258.46 $25 Series E No. Q6008101828E May 1975 130.23 $25 Series E No. Q5256297336E April1975 128.99 $25 Series E No. Q5248874314E February 1975 128.99 $25 Series E No. Q5244281110E January 1975 131.57 $25 Series E No. Q5182565177E May 1974 129.71 $25 Series E No. Q5217487322E August 1974 130.02 $25 Series E No. Q5197894736E July 1974 130.02 $25 Series E No. Q5160514533E February 1974 128.48 $25 Series E No. Q5218672819E November 1974 131.26 $25 Series E No. Q5219128871E October 1974 130.02 $25 Series E No. Q5039891082E August 1972 128.05 $25 Series E No. Q5053171849E October 1972 128.05 $25 Series E No. Q5066383180E December 1972 128.33 TOTAL $5,773.30