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The Law Office of
MA1m:LLE F. HAzEN
Certified Elder Law Attorney*
An Estate Planning and Elder Law Firm
2000 Linglestown Road
Suite 202
Harrisburg, PA 17110
TEL: (717) 5404332
FAX: (717) 540-4313
www.hazenelderlaw.com
Marlelle F. Hazen, JD, C~ *
Jeta C. Combs, ParalegaJ
Jessica A. HoUand, P egal
Catherine M. Semon, P egal
Kim M. Smith, Office A tor
October 25, 2005
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013-3387
Re: Estate of Mildred Hershberger
Inheritance Tax Return
File No. 21-05-0238
To: The Register of Wills:
Enclosed for filing please find the original and one copy of the above-reference
Inheritance Tax Return, along with a copy of the first page of the Inheritance Tax Return.
Please date stamp the copy and return it to our office in the enclosed self-addresse
envelope.
Also enclosed are a check for the inheritance tax in the amount of $4.47 and
check in the amount of$15.00 for payment of the filing fee.
If you have any questions or require any additional information, please do no
hesitate to contact me.
Sincerely,
1 Combs
Paralegal
:Jcc
Enclosure
cc: Barbara Marvel, Personal Representative
Ed Hershberger, Personal Representative
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"Certified Elder Law Attorney by the National Elder Law Foundation as authorized by the Pennsylvania Supreme Court
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128.0601
II
REV-1162 EXI11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAZEN MARIELLE F
2000 L1NGELSTOWN ROAD
SUITE 202
HARRISBURG, PA 17110
___~u__ fold
EST A TE INFORMATION: SSN: 200-22-5419
FILE NUMBER: 2105-0238
DECEDENT NAME: HERSHBERGER MILDRED I
DA TE OF PAYMENT: 10/26/2005
POSTMARK DATE: 10/25/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/25/2005
NO. CD 00$935
ACN
ASSESSMENT
CONTROL
NUMBER
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AMOU~T
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101 I $4.4 7
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TOTAL AMOUNT PAID:
$4.4 i
REMARKS:
CHECK# 1011
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
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GLENDA FARNER STRASBAUpH
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REGISTER OF WILLS 1
,
REV-I500 EX" (6-00)
.' COMMONWEALTH OF
, PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAl)
Hershber er Mildred I.
DATE OF DEATH {MM-DD-Year}
DATE OF BIRTH (MM-DD-Year)
, \
OFFICIAL USE ONLY
FILE NUMBER
2 1 -05 0 2 3 8
COUNTYCciiiE --VEAR- -- NUMBER--
SOCIAL SECURITY NUMBER
2 00- 2 2 - 5 4 1 9
THIS RETURN MUST BE FILED IN i DUPLICATE WITH THE
REGISTER O!F WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Retum (dF of death prior to 12-13-82)
o 5. Federal Estate Tax R~tum Required
_ 8. Total Number of Safe peposit Boxes
o 11. Election to tax underlsec. 9113(A) (Attach Sch 0)
COMPLETE MAILING ADDRESS
2000 Linglestown Road, Suite 202
6,632.44
"~--)
0.00 X _(15) 0.00
99.31 x .045 (16) 4.47
0.00 x .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 4.47
01/25/2005 07/07/1926
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
IX! 1. Original Retum
o 4. Limited Estate
IX! 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12.12-82)
o 7. Decedent Maintained a Living Trust (Allach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
-y.
(")
r1
0.00
(8)
6,632.44
NAME
Marielle F. Hazen
FIRM NAME (If Applicable)
Law Office of Marielle F. Hazen
TELEPHONE NUMBER
717 -540-4332
Harrisbur PA 17110
6,533.13
(11)
(12)
(13)
6,533.13
99.31
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
IX! 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 Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(14)
99.31
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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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
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Com lete Address:
STREET ADDRESS
702 Hummel Avenue
CITY
Lemoyne
STATE
PA
ZIP
17043
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4.47
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( 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. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check to: REGISTER OF WILLS, AGENT
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; ........................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0
c. retain a reversionary interest; or ...................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ............................................................. 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
3 :'"' ,.;::: ~~:::::,,:;d:~:~ ;;;;;;;;;;;;;;;;;~;;;;~r;~ ~~;;;;;~~;;;;,?: B ~
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4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 00 OJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF tHE RETURN.
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. I
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. I
SIGNAT E OF P,ERSON RESPONS LE R FILING RETU D TE \,....-
(6 dl57 b!:J
306 N. Market St.
Elizabethtown
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
PA 17022
DATE
ADDRESS
2000 Linglestown Rd., Suite 202
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
[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.
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 retum are
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
or a stepparent of the child is 0% [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%, except as noted in 72 P.S. 99116(1.2) P.S.99116(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. 99116(a)(1 ,3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hershberaer. Mildred I.
FILE NUMBER
21 05
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.
023~
ITEM I VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Union National Bank 5,582.50
Acct#0000307858
2. Coin Collection 921.71
3. Bankers Life Ins. 128.23
Refund Check
4. Outdoor World 0.00
Camp Site (No value)
TOTAL (Also enter on line 5, Recapitulation) $ 6 632.44
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
ESTATE OF
Hershber<;ler. Mildred I.
FILE NUMBER
21 05
02381
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is ~s.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST VALUE
(IF APPLICABLEI
1. National Western Life Annuity#F0606 172,127.88 100. 172,127.88
Edward Hershberger, Kay Bream, Barbara Marvel &
Diann Hershberger, Children & Benef.
2. Bankers Life Annuity#7806837 5,020.37 100. 5,020.37
Edward Hershberger, Kay Bream, Barbara Marvel &
Diann Hershberger, Children & Benef.
***See below & PA 1500 File No. 21-05-0238
PLEASE BILL BENEFICARIES DIRECTLY FOR ANNUITIES
Edward Hershberger, 702 Hummel Ave., Lemoyne, PA 17043
Barbara Marvel, 306 N. Market St., Elizabethtown, PA 17022
Kay Bream, 302 N. Market St., Elizabethtown, PA 17022
Diann Hershberger, 226 N. Market St., Elizabethtown, PA
17022
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TOTAL (Also enter on line 7 Recapitulation) $ 177 148.25
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EST ATE OF
Hershberger Mildred I.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule l.
FILE NUMBER
21
0238
05
ITEM I
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Matinchek & Daughter Funeral Home - total bill of $6,457.00 4,900.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Marielle F. Hazen 1,301.00
3. Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
,
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills - Shorts 8.00
5. Accountanfs Fees
6. Tax Return Prepare~s Fees
7. Cumberland Law Journal - Legal Ad 75.00
8. The Sentinel - Legal Ad 234.13
9. Register of Wills - Inheritance tax filing fee 15.00
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TOTAL {Also enter on line 9, Recapitulation} $ 6533.13
(If more space is needed, insert additional sheets of the same size)
'~""": ".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
I.
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.
Edward Hershberger
702 Hummel Avenue
Lemoyne, PA 17043
Barbara Marvel
306 N. Market St.
Elizabethtown, PA 17022
Diann Hershberger
226 N. Market Street
Elizabethtown, PA 17022
Kay Bream
302 N. Market Street
Elizabethtown, PA 17022
Larry Hershberger
290 YummerdalJ Rd.
Lititz, PA 17543
2.
3.
4.
5.
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
Lineal
Lineal
Lineal
Lineal
Lineal
20%
20%
20%
20%
20%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 VER 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.
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)
dl-6g- 6~3~
LAST WILL AND TESTAMENT
(pour-Over Will)
OF
MILDRED I. HERSHBERGER
IDENTITY
I, MILDRED 1. HERSHBERGER, residing in the County of Lancaster, Commonwe lth of
Pennsylvania, being of sound mind and memory, and not acting under duress or undue influence of any
person whomsoever, hereby declare this to be my Last Will and Testament, and I do hereby rev ke all
other former Wills and Codicils to Wills heretofore made by me. My Social Security Number is 00-22-
5419.
I have the following children: Edward L. Hershberger, born October 23, 1943; L rry J.
Hershberger, born January 17, 1945; Kay E. Bream, born August 14, 1950; Barbara S. Marve, born
September 17, 1955; Diann K. Hershberger, born May 4, 1967; and Dennis Jv. Hershberger, dec ased.
I
I have provided for the payment of all my debts, expenses of administration of property w erever
situated passing under this Will or otherwise, and estate, inheritance, transfer, and succession tax , other
than any tax on a generation-skipping transfer that is not a liability of my Estate (including inten st and
penalties, if any) that become due by reason of my death, under mE MILDRED I. HERSHBE GER
REVOCABLE LIVING TRUST executed on even date herewith (the "Revocable Trust"). If the
Revocable Trust assets should be insufficient for these purposes, my Executor shall pay any unpai items
from the residue of my Estate passing under this Will, without any apportionment or reimburse 1. In
the alternative, my Executor may demand in a writing addressed to the Trustee of the Trust an a ount
necessary to pay all or part of these items, plus claims, pecuniary legacies, and family allowances b court
order.
DEBTS, TAXES AND ADMINISTRATION EXPENSES
!
PERSONAL AND HOUSEHOLD EFFECTS I
I
It is my intent that all my personal and household effects were transferred to the Revocabl1Trust
as a result of the Declaration of Intent signed this date. If there are any questions regarding the own rship
or disposition of these assets, it is my desire that such assets pour into the Revocable Trust, signed y me
this date in accordance with the provisions of the section titled "Residue of Estate."
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RESIDUE OF ESTATE
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I give, devise and bequeath all the rest, residue and remainder of my property of every ki: and
description (including lapsed legacies and devices), wherever situated and whether acquire~ befj fe or
after the execution of this Will, to the Trustee under that certain Trust executed by me onth~-s~me ~. te of
the execution of this Will. The Trustee shaH add the property bequeathed and devised by this' item: 'p the'
corpus of the above described Trust and shall hold, administer and distribute said propertyjin accot ance
with the provisions of the said Trust, including any amendments thereto made before my death. .:.'~
If for any reason the said Trust shall not be in existence at the time of death, or if for any re:ron a
court of competent jurisdiction shall declare the foregoing testamentary disposition to the Trustee der
said Trust as it exists at the time of my death to be invalid, then I give all of my Estate includi the
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POUR-OVER WILL
Page 1
~*.f
II
residue and remainder thereof to that person who would have been the Trustee under the Tt-ust, as
Trustee, and to their substitutes and successors under the Trust, described herein above, to ~e held,
managed, invested, reinvested and distributed by the Trustee upon the terms and conditions perta' ing to
the period beginning with the date of my death as are constituted in the Trust as at present con tituted
giving effect to amendments, if any, hereafter made and for that purpose I do hereby incorpora e such
Trust by reference into this my Will. i
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EXECUTOR
I hereby nominate and appoint Edward L Hershberger and Barbara S. Marvel to serve ithout
bond as my Joint Executors.
In the event that one of the Joint Executors shall predecease me, or is unable or unwilling t act as
my Executor for any reason whatsoever, then and in the event I hereby nominate and appo'nt the
remaining Joint Executor to serve without bond as my Independent Executor.
Whenever the word "Executor" or any modifying or substituted pronoun therefore is used in this
my Will, such words and respective pronouns shall be held and taken to include both the singular nd the
plural, the masculine, feminine and neuter gender thereof, and shall apply equally to the Executor amed
herein and to any successor to substitute Executor acting hereunder, and such successor or su stitute
Executor shall possess all the rights, powers, duties, authority, and responsibility conferred u n the
Executor originally named herein.
EXECUTOR POWERS
By way of Illustration and not of limitation and in addition to any inherent, implied or s tutory
powers granted to executors generally, my Executor is specifically authorized and empowere with
respect to any property, real or personal, at any time held under any provision of this my Will: t allot,
allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, c ntract
with respect to, continue any business of mine, convert, deal with, dispose of, enter into, exchange hold,
improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise tions
with respect to, take possession of, pledge, receive, release, repair, sell, sue for, make distributions i cash
or in kind of partly in each without regard to the income tax basis of such asset and in general, exer ise all
of the powers in the management of my Estate which any individual could exercise in the manage ent of
similar property owned in its own right upon such terms and conditions as to my Executor may see best,
and execute and deliver any and all instruments and do all acts which my Executor may deem pr er or
necessary to carry out the purpose of this my Will, without being limited in any way by the specific ants
or power made, and without the necessity of a court order.
My Executor shall have absolute discretion, but shall not be required, to make adjustments in the
rights of any Beneficiaries, or among the principal and income accounts to compensate fi r the
consequences of any tax decision or election, or of any investment or administrative decision, th t my
executor believes has had the effect, directly or indirectly, of preferring one Beneficiary or gr up of
Beneficiaries over others. In determining the Federal Estate and Income Tax liabilities of my Esta , my
Executor shall have discretion to select the valuation date and to determine whether any or all f the
allowable administration expenses in my Estate shall be used as Federal Estate Tax deductions or as
Federal Income Tax deductions. :
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POUR-OVER WILL
Page 2
SPECIFIC OMISSIONS
I have intentionally omitted any and all persons and entities from this, my Last W~' I and
Testament, except those persons and entities specifically named herein. If any person or enti shall
challenge any term or condition of this Will, or of the Living Trust to which I have made reference in the
sections "Household and Personal Effects" and "Residue of Estate," then, to that person or entity, give
and bequeath the sum of only one dollar ($1.00) only in lieu and in place of any other benefit, ant,
bequest or interest which that person or interest may have in my Estate or the Living Trust and its E tate.
S~ULTANEOUSDEATH
If any other Beneficiary should not survive me for sixty (60) days, then it shall be conclu~ivelY
presumed for the purpose of this my Will that said Beneficiary predeceased me. I
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MILDRED I. HERSHBERGER
Testatrix
This instrument consists of 5 typewritten pages, including the Attestation Clause, Self-Proving Cause,
signature of Witnesses, and aclmowledgment of officer. I have signed my name at the bottom of e ch of
the preceding pages. This instrument is being signed by me on this '7 da of
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POUR-OVER WILL
Page 3
ATTESTATION CLAUSE
The Testatrix whose name appears above declared to us, the undersigned, that the foregoing
instrument was hislher Last Will and Testament, and he or she requested us to act as witnesses to such
instrument and to hislher signature thereon. The Testatrix thereupon signed such instrument ,in our
presence. At the Testatrix's request, the undersigned then subscribed our names to the instrumentin our
own handwriting in the presence of the Testatrix. The undersigned hereby declare, in the presepce of
each of us, that we believe the Testatrix to be of sound and disposing mind and memory. i
,
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Signed by us on the same day and year as this Last Will and Testament was signed by the
Testatrix. i
WITNESSES:
ADDRESSES:
e to. 6J l<.. e<.,l J.J.n.l~<l J
E the. { R, C h a (' ( ~$
(printed Name of Witness)
.250 ~o fnr,fQ 9Ju'f-
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City, State, Zip i
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c71e-p I//LL7#j:J Vle-~ 1.Vf-.r
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City, State, Zip "
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Geb~ W I!.t)/VIJRA/t/. ?:e,
(Printed Name of Witness) ,
POUR-OVER WILL
Page 4
~,
COMMONWEALTH OF PENNSYL VANIA
COUNTY OF LANCASTER
SELF-PROVING CLAUSE
BEFORE ME, the undersigned authority, on this day personally appeared MILD
HERSHBERGER, GJtp ,C-6 d C!u.'\J.:?~J .;:[/L and
;t.-fJ,/JnL- C. ,,1vhvl..-/:: ~ , mown to me to be the Testatrix and the witn sses,
respectively, whose names are subscribed to the foregoing instrument in their respective capacitie , and
all of them being by me duly sworn, MILDRED I. HERSHBERGER, Testatrix, declared to me and 0 the
witnesses, in my presence, that the instrument is hislher Will and that he or she had willingly ma e and
executed it as hislher free act and deed for the purposes therein expressed; and the Witnesses, each n his
or her oath, stated to me in the presence and hearing of the Testatrix, that the Testatrix had decla ed to
them that the instrument is his Will and that he or she executed the same as such and wanted each 0 them
to sign it as a witness; and upon their oaths, each witness stated further that he or she did the sam
witness in the presence of the Testatrix, and at his request and that he or she was at that time eightee
years of age or over and was of sound mind, and that each of the witnesses was then at least fourtee
years of age.
SUBSCRIBED AND ACKNOWLEDGED before me by MILDRED I. HERSHBER
Testatrix, and subscribed and sworn to before me by C;; '\... - It... CJ.'U JP,4..'" / .:r.
and M/hL. Cthd-A--l-fC'<'" , witnesses, this the 7 da
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of
NOTARIAL SEAL
ROBERT J. WEAVER, Notary Public
Horsham Twp., Montgomery County
M Commission Expires March 28, 2005
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POUR-OVER WILL
Page 5
III
LIFE INSURANCE COMPANY
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_eNATIONAL
WESTERN
April 26, 2005
Marielle F. Hazen
Attorney at Law
2000 Linglestown Rd.
Harrisburg, P A 17110
Subject:
Annuity Certificate 0101044077
Annuitant: Mildred Hershberger
Dear Ms. Hazen:
We are providing the following information with respect to your request of April 14,
2005:
1. Annuity Certificate Number 0101044077
2. Owner/Annuitant: Mildred I. Hershberger
3. Date of Death Value as of January 25,2005:
o Accumulation Account Value: $172,127.88
o Cash Surrender Value: $129,095.91
4. Non-Qualified Flexible Premium Annuity
5. Cost Basis: $140,000.00
6. Original Contribution 04/11/03: $147,548.35
Interest: $24,579.53 l
7. Beneficiary Designation: Edward Hershberger, Kay Bream, Barbara Marvel, an~
Diann Hershberger
Please contact the Policy Benefit Department at 8005-531-5442 if you need additional
information.
Cordially,
1)U7AN1(,L~~
Donna Rogers
Policy Benefit Department
-
850 EAST ANDERSON lANE . AUSTIN, TEXAS 78752-1602 . 512-836-1010
AUTOMATED VOICE RESPONSE TOll-FREE 888-695-5001 . WATS 800-531-5442
CLIENT SERVICES DIRECT WATS LINE 800-922-9422 . CLAIMS 800-531-5442
BANKERS LIFE AND CASUALTY COMPANY
Life Division · 222 Merc/Jlmdise Mart P1aza
Chialgo, II. 6tJ654-21HJ9 . Telephone: 312-396-6000
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The Law Office of Marielle Hazen
2000 Linglestown Rd STE 202
Harrisburg PA 17110
September
Policy
7,806,837
ATTENTION: Jeta Combs
RE: Mildred Hershberger, Deceased
Dear Ms. Combs:
We are writing in response to your letter dated September 1, 2005. I
Mildred was the owner and annuitant of the policy. As of January 2 ,
2005 the cash value of the policy was $5,020.37, of which $20.37 is tax-
able. The policy was issued on December 27, 2004 with a cost basis of
$5,000.00.
If you have any questions or concerns, please feel free to contact s.
Your friends at
BANKERS,
u-~
D. Infantino
Life/Annuity Claim Department
LCGS 632197
For local service, contact:
Branch Sales Office 1051
2300 Vartan Way Fl 2
Harrisburg PA 17110
Phone (717)545-7999
Agent Edward L Hershberger
BLOOI] (07/12)
10/24/2085 13:48
71 771'42235
CSE
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established 1981
COPENHAVER COIN EXCHANGE
Qpen :vl-Thurs. 10- 5 FrL 12-4
BUY.SELL-APPRAiSE
2.54. W"'SI :vI'lln Street
HLlrll.lnillstown PA 17036
Phon", (717)566-91:7
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