HomeMy WebLinkAbout09-15-05
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REV-1500 EX '(6-00)
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REV-1500
INHERITANCE TAX RETURN
RESI DENT DECEDENT
FILE NUMBER
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OFFICIAL USE ONLY
~~
YEAR
'i2, L3
NUMBER
COUNTY CODE
ORSIN FRANCIS C.
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
SOCIAL SECURITY NUMBER
717-09-9038
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
Copyright (el 2000 form software only The Lackner Group. Inc.
04/06/2005 02/03 1921
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
X 1. Original Return
4. Limited Estate
6. Decedent Died Testate
Supplemental Return
Future Interest Compromise (date of death after 12-12-82)
Decedent Maintained a Living Trust
(Attach copy of Will)
D 9. Litigation Proceeds Received D 1 Q.
3. (date of death
. Remainder Return prior to 12-13~82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
(Attach copy of Trust)
Spousal Poverty Credit D 11. Election to tax under Sec. 9113(A)
(date of death between 12-31-91 and 1-1-95) (Attach Sch 0)
TffI$S!;(::TION'M 'j"'Eli;.eQMPLEtEOIAl.I:.CQFtRESPONDENCE&COt.lFIDEN'l'iAl.f;rAXiNFQRMA;rjON$.HQI..ILDiElEOiREC'l'EPTO:
NAME COMPLETE MAILING ADDRESS
DOli 1as G. Miller Es .
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
60 West Pomfret Street
West Pomfret Professional Bldg.
Carlisle, PA 17013
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717
1, Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Deceden!, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charrtable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Sub'ect to Tax (Line 12 minus Line 13)
.)
(1)
(2)
(3)
None
None
None
OFFICIAL USE ONLY
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(4)
(5)
None
1,591.41
~.........
(8)
1,591.41
(6)
None
(11)
(12)
(13)
96,375.02
(94,783.61)
None
780,00
95,595.02
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)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18, Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
0.00
0.00
0.00
0.00
x
X
X
X
.0 0
.0 45
12
.15
(14)
(94,783.61)
(15)
(16)
(17)
(18)
(19)
0.00
0.00
0.00
0.00
0,00
Form REV-1500 EX (Rev. 6-00)
"
Decedent's Complete Address:
STREET ADDRESS
1000 WEST SOUTH STREET
CITY
Carlisle
STATE
PA
ZIP
17013
Tax Payments and Credits:
,. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
Total Credits (A + B + C) (2)
0.00
3. InterestlPenalty if applicable
O. Interest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. 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)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B, Enter the total of Line S + SA. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
0,00
0.00
0,00
0.00
0.00
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IN"'fHE'APP'FfOPRiATifsLocKs""""
Yes No
~~
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 reversionary interest or . ....,.....
d. receive the promise for life of either payments, benefits or care? . . . .
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
wrthout receiving adequate consideration? . D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death? . . . . . . . . . . . . . . . . . . . . . . . . D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation? . . . . . . 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
IT]
IT]
IT]
Under penalties of perjury. I declare that I have examined this return, including accompanying schedules and statements. and to the best of my knowledge and belief, it is true.
correct and complete. Declaration of pre parer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN GAYLE D . DAY
103A PARTRIDGE CIR
-----------------------------------------------------
Carlisle, PA 17013
IRWIN & McKNIGHT
60 West Pomfret Street
-----------------------------------------------------
Carlisle, PA 17013
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For dales of eath 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. 9116 (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. 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 twenty-one 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% [72 P.S. 9116 (a) (1.2)j.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2)
[72 PS 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% [72 P.S. 9116(a)(1.3)j. 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.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
,
REV-1508 EX' (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
FRANCIS C. ORSIN SS# 717-09-9038 04/06/2005
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
DESCRIPTION
M & T BANK - CHECKING ACCOUNT - 403057821
VALUE AT DATE
OF DEATH
1,591.41
TOTAL (Also enter on line 5, Recapitulation) $ 1,591.41
(If more space is needed, insert additional sheets of the same si2e)
Copyrighl(c) 1996 form soflware only CPSyslems, Inc. Form REV-1508 EX (Rev. 1-97)
. .
REV-1511 EX' (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FRANCIS C. ORSIN
FILE NUMBER
SS# 717-09-9038
04/06/2005
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
B.
ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees IRWIN & McKNIGHT
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
500.00
4. Probate Fees
5. Accountant's Fees
6.
Tax Return Preparer's Fees
250.00
7,
1
Other Administrative Costs
Register of Wills - FILING FEE
30.00
TOTAL (Also enter on line 9, Recapitulation) $ 780,00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
, .
REV-1512 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FRANCIS C. ORSIN
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
FILE NUMBER
SS# 717-09-9038
04/06/2005
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
Department of Public Welfare - Medical Assistance
AMOUNT
94,012.10
2
Mobi1ex - MEDICAL
39.12
3
Prudential Financial - Reimbursement of Pension Payment
434.20
4
Sarah A. Todd Memorial Home - Nursing
1,109.60
TOTAL (Also enter on line 10, Recapitulation) $ 95,595.02
(If more space is needed. insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-t513 EX '(9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FRANCIS C, ORSIN
SS# 717-09-9038
04/06/2005
NUMBER
I,
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
1
Gayle D, Day
103A Partridge Circle
Carlisle, PA 17013
2
Chester F. Orsin
P.O. BOX 10630
State College, PA 16805
3
Edward Orsin
4669 Long Run
Loganton, PA
Road
17747
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Daughter
Son
Son
FILE NUMBER
AMOUNT OR SHARE
OF ESTATE
1/3 REMAINDER
1/3 REMAINDER
1/3 REMAINDER
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON- TAXABLE DISTRIBUTIONS'
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
0.00
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1513 EX (Rev. 9-00)
rm M&rBank
499 Mitchell Road, Mlilshoro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
April 27, 2005
Law Offices
Irwin & McKnight
West Pomfret Professional Building
50 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
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Re: Estate or Francis C Orsin
Social Security: 717-09-9038
Date of Death: Avril 06, 2005
Dear Sir or Madam:
Per your inquiry dated April 21, 2005, please be advised that at the time of death, the above-named decedent had on deposit
with this bank the following:
l. Type of Account Checking Account
Account Number 40305782/
Ownership (Names oj) Francis C Orsin, Harriet A Orsin, *
Gayle Day, Edward Orsin, POA's
Opening Date 02/01/91
Balance on Date of Death $1,591.41
Accrued Interest $ 0.00
Total $1,591.41
Please be advised, there was no safe deposit box found for the above decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc" please call
the Woodward Office # 570-748-2957.
Sincerely,
" '''"/
--7fV ;;'?/ c:: ?";;'!)
Nancy Clagett
Records Management
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRIS8URG, PA 17105-8486
April 27, 2005
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IRWIN & MCKNIGHT
DOUGLAS G MILLER ESQ
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE PA 17013
1. .R: -, ;~,,, f ('"1 J, l'''-r;
'~,- "').. l-'*',.1f1 :3.
Re: FRANCIS ORSIN
CIS #: 030340299
SSN: 717-09-9038
Date of Death: 04/07/2005
Dear Attorney McKnight:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $94,012.10 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $21,439.32, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $72,572.78, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available,
Sincerely,
~f~
Ara K. Danchick
Claims Investigation Agent
717-772-6608
717-705-8150 FAX
Enclosure
PAGE: 1 S932
.J~ 0 b i 1 e x USA
The Highlands
920 Ridgebrook Road
Sparks, Maryland 21152
STATEMENT DATE
AMOUNT DUE
ACCOUNT #
l 04/15/05
39.12
1244072
J
FORWARDING SERVICE REQUESTED
NURSING HOME:
DATES OF SERVICE:
01/07/04 - 04/05/04
...............**......**...........
005339 1 AB 0.301
FRANCIS ORSIN
GALE DAY
103A PARTRIDGE CIR
CARLISLE PA 17013-8759
1."111",111".,.,11,,11,1,,1.1,,,1.1.1,1,1,.11..,.,11,,11,,1
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Mobilex USA
P.O. Box 17452
Baltimore, MD 21297-1452
AMOUNT OF PAYMENT: (
)
Please detach here. and enclose this portion with your prompt payment. Thank you!
These charges are billed airectly to the patienl because a copay, deductible IS due om your claim was denied by your
Insurance company. It IS the patient's responSibility to provide current insurance information (see reverse side).
_. ... .. 1IImD~"'_.
- ---:..
I I I '
01/07/04 71010 CHEST 1 VIEW 55.0 I
01/07/04 ALLOWANCE WRITE DOWN 24.96 J
03/18/04 CARE PENN PAYMENT 20.79
03/18/04 ALLOWANCE WRITE DOWN 4.05 5.2
1,11/15/04 TRANSFER .00 5.20
YOUR INS HAS NOT PAID CL 1M/PLEASE REM T
SET UP FEE X RAY 23.od
ALLOWANCE WRITE DOWN [I
CARE PENN PAYMENT
ALLOWANCE WRITE DOWN
TRANSFER I
YOUR INS HAS NOT PAID CL IM/PLE SE
118.41
9.441
2.17
.00
01/07/04
01/07/04
03/18/04
03/18/04
11/15/04
Q0092
.02
2.2
2.21
I
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I
29.d
29.61
I
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201
01/07/04
01/07/04
03/18/04
11/15/04
R0070
TRANSPORT X RAY 1 PT SEEN
ALLOWANCE WRITE DOWN
CARE PENN PAYMENT
TRANSFER
yOUR INS HAS NOT PAlO
175.0
26.99
i
IH1/PLEItSE
.00
I
04/05/04
04/05/04
,08/02/04
08/02/04
71010
CHEST 1 VIEW READING
ALLOWANCE WRITE DOWN
S CALIFORNIA MEDICARE
ALLOWANCE WRITE DOWN
27.0
17,00
7.98
I
l
39.12
.00
.00
.00
39.12
BALANCE D.~_..l..-
/49". 12 J
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PA'T'TF:N'T' pF:c;pnNc;TRTT.T'T'Y'
CURRENT 30-
29-
29-
OVER 120
CALL BETWEEN THE HOURS OF 9:00 A.M. AND 6:00 P.M. EST
TELEPHONE 1-800-786-8015
Account 60 days past. Remit immediately!
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Prudential ~ Financial
-
Pnjoentlal Retirement
The Prudential Insurance Company of America
oDO Main Street, Dubuque IA 52001
May 17,2005
Irwin & McKnight
Douglas Miller
West Pomfret Professional Building
60 West Pomfret Street
Carlisle PA 17013-3222
Telephone 800-224-4624
Facsimile 860-731-3352
RE: Francis Orsin
Group AnnLlity Contract: 4641
Pefs{",n"l Identification NlImher' POOS 79388
Dear Mr. Miller:
Please accept our condolences on the death of Mr. Orsino
Mr. Orsin had chosen a 5 Year Certain and Life Option with payments guaranteed through
July 1, 1989 or for his lifetime. There are no further benefits due under this plan.
Prudential Retirement issued a pension payment in the amount of $434,20 to Mr. Orsin on
May 1, 2005 which was deposited into his bank account at Northern Central Bank. His death
occurred before the period covered by this payment, and we have requested reimbursement
from the bank in the amount of $434.20. This amount will automatically be deducted from
his account if sufficient funds are available.
Please feel free to call our Participant Service Center at 800-224-4624 during our business
hours of 8:00 a.m. to 9:00 p.m. Eastern Time on Monday through Friday if you need further
assistance.
Defined Benefit Administration
JDl
LAST WILL AND TESTAMENT
I, FRANCIS C. ORSIN, of the Borough of Carlisle, Cumberland County, Pennsylvania,
being of sound mind, disposing memory and full legal age, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made
by me.
ONE. I direct my Executor or Executrix, as the case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. I direct that
my body shall be cremated and the ashes interred, and that the expense thereof be reimbursed out
of my estate as a funeral expense. Furthermore, r direct that all state, inheritance, succession and
other death taxes imposed or payable by reason of my death and interest and penalties thereon
with respect to all property composing of my gross estate for death tax purposes, whether or not
such property passes under this Will, shall be paid by the Executor or Executrix of my estate.
TWO, My Executor or Executrix may, at his or her discretion, compromise
claims, borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or she may
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authorize and empower my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale
therefor, in fee simple, as I could do if living. My Executor or Executrix is authorized and
empowered to engage in any business in which I may be engaged at my death, for such period of
time after my death as seems expedient to said Executor or Executrix.
Initial 1-.C: - c:!'
THREE. I gIve, devise and bequeath all of my estate of whatever nature and
wherever situate in equal shares to my children, EDWARD ORSIN, GAYLE O. DAY and
CHESTER F, ORSIN. In the event that any of my children predecease me, then I give, devise
and bequeath their share to their spouse, if any, In the event that that there is not a surviving
spouse, then I give, devise and bequeath their share to their children, if any, per stirpes, which
provides that the child or children of any deceased beneficiary shall take the share their parent
would have taken if living.
FOUR In the event of a common disaster causing the death of myself, my
children, EDWARD ORSIN, GAYLE O. DAY and CHESTER F. ORSIN, their spouses, and my
children's surviving issue, all within a period of sixty (60) days, then I give, devise and bequeath
all of my estate of whatever nature and wherever situate as follows:
A 1/3 to my niece, LEE ELLEN SHEASLEY, per stirpes, which provides
that the child or children of any deceased beneficiary shall take the share their parent
would have taken if living;
R 1/3 to my nephew, JOHN PUTMAN, per stirpes; and
C. 1/3 to my niece, GINA PUTMAN, per stirpes,
FIVE. If, under any of the provisions of this Will, any principal becomes vested
in a minor, my Executor or Executrix, as the case may be, including any administrator c.ta., shall
have the discretion either to pay over such principal or any part thereof to any parent of such
minor, any guardian of the person or estate of such minor, or any person with whom such minor
resides, or to retain the same as trustee of a power in trust for the benefit of such minor during his
or her minority, Any of the principal thus retained, and any of the income therefrom, including
Initial 7'. c{J <1
2
the whole thereof, may be paid to or applied for the benefit of such minor from time to time in
the discretion of the trustee of such power. When such minor reaches majority, the funds so held
shall be paid over to such person, or, if he or she shall sooner die, to his or her legal
representatives, In so holding any principal or income for any minor, the trustee of such power
shall have all the rights, powers, duties and discretions conferred or imposed upon my fiduciaries
acting under this Will. I further direct that no bond shall be required from any person receiving a
payment hereunder and receipt from such person shall be a full discharge to the trustee of such
power who shall not be bound to see to the application or use of such payment. The trustee of
such power shall be entitled to commissions at the rates and in the manner payable to a
testamentary trustee,
SIX. I nominate and appoint my daughter, GAYLE O. DAY, to be the
Executrix of this my Last Will and Testament. In the event she has predeceased me, failed to
qualify or is not able or does not serve for whatever reason, I then appoint my son, EDWARD
ORSIN, to be the Substitute Executor of this my Last Will and Testament. In the event he has
predeceased me, failed to qualify, or is not able or does not serve for whatever reason, I then
appoint my son, CHESTER F. ORSIN, to serve as Substitute Executor of this my Last Will and
Testament, whereby the said substitute personal representatives shall have the same powers as
are given to the original Executrix hereunder.
SEVEN. No person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty (60) days,
EIGHT. No Executrix or Executor acting hereunder shall be required to post bond
or enter security in this or any other jurisdiction,
Initial ;t .c;. t1t
3
NINE. No beneficiary may assign, anticipate or pledge his or her interest in any
income or principal held or distributable hereunder, and no beneficiary's creditors may levy,
attach or otherwise reach any such interest
TEN. My Executor or Executrix shall have the following powers, in addition to
those vested in it by law, for my property held for the benefit of my children or beneficiaries
pursuant to Paragraph Five hereof, whether income or principal, exercisable without court
approval and effective until the distribution of all property under the terms of said provision:
My Executor or Executrix, at his, her or its discretion, may compromise claims,
borrow money or retain property for such length oftime as he, she or it may deem proper,
sell lease, pledge, mortgage, transfer, exchange, convert or otherwise dispose of or grant
option of all or any portion of trust property for such prices and on such terms in public or
private transactions as he, she or it may deem proper; and invest trust property and
income without restrictions to legal investments. The determination of the Executor or
Executrix with respect to the advisability of making payments out of the income or
principal to any child or beneficiary inheriting hereunder shall be conclusive and binding
on all persons howsoever interested in the respective trust Further, the Executor or
Executrix shall be authorized to receive additions to the respective trust of any kind or
any property whatsoever from sources other than my estate and at any time in the sole
discretion of the Executor or Executrix,
ELEVEN. If any person or institution entitled to share in any distribution under the
terms of this my Last Will and Testament becomes an adverse party in any proceeding to contest
the probate of this Last Will and Testament, such person or institution shall forfeit his, her or its
entire interest inherited hereunder and all provisions in favor of such person or institution shall
Initial 1: d. t!
4
be declared void and of no effect. The share of such person or institution so forfeited shall be
distributed as part of the residue pursuant to Paragraph Three hereof except that if such person or
institution is entitled to share in the said residue, that interest shall be distributed proportionately
to the other residuary distributees.
[THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK]
Initial ;t-- t"!:.&
5
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 1 th day of March,
2003.
~.,....:.. c. ~c.:- (SEAL)
FRANCIS C. ORSIN
Signed, sealed, published and declared by the above-named person as and for a Last Will
and Testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
~~ 2J~~
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6
ACKNOWLEDGMENT AND AFFIDAVIT
WE, FRANCIS C. ORSIN, TRACI D. SMITH and CHERYL L. CLELAND, the
testator and witnesses respectively, whose names are signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the testator signed and
executed the instrument as his last will and that he had signed willingly, and that he executed it
as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the will as a witness and that to the best of their
knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under
no constraint or undue influence.
COMMONWEAL TH OF PENNSYL VANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by FRANCIS C. ORSIN, the testator
herein, and subscribed and sworn to before me by TRACI D. 8M TH and CHERYL L.
CLELAND, witnesses, this 17th day of March, 20 3,
Notarial Seal
Jacqueline L. Drawbaugh, Notary Public
Carlisle Boro, Cumberland County
My Commission Expires Aug. 14, 2003
Member, Pennsylvani) AssociatlOnotNotar!ee
COMMONWEALTH OF PENNSYLVANIA
: SS
COUNTY OF CUMBERLAND
Gavle D, Dav
, being duly sworn according to law, deposes and says that she is a Beneficiary of
the Estate of
Francis C. Orsin
, late of Carlisle Borough
, Cumberland County,
Pennsylvania, deceased and that the within is an inventory made by
Gavle D. Dav
, the said Beneficiary of the
entire estate of said decedent, consisting of all the personal property and real estate, except real estate outside the Commonwealth
of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value as of the date of decedent's death.
NOUll'laJ Seal
Karen S Noel, Nrtury Public }
Cll'lille Bora, Cumb~rland County
My Commission Expires Dec. 8, 2007
Date of Death 06
Day
~~k.o.g~
. ayle D. Day, Beneficiary
Sworn and subscribed before me,
r '2.1{1-.- .5J f-le m ( ,
this Lr... day of ~,2005.
103A Partridge Circle
Carlisle, PA 17013
Address
04
Month
2005
Year
INSTRUCTIONS
.,
f....."
,-:-....:)
,.--...
1. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets,
3. Additional sheets may be attached as to personalty or realty.
J"J
4, See Article IV, Fiduciaries Act of 1949.
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Inventory of the real an personal estate of
FRANCIS C. ORSIN
, deceased
1. M & T Bank - Checking Account - 403057821 . . . . . . . . . . . , . . . . . . . . . . .
TOTAL. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. .. .. .. .. .. .. .. ..
$1,591.41
$1,591.41