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No, 21-80
PETITION FOR PROBATE OF WILL AND LETTERS TESTAMENTARY
in the Estate of
MAY JACOBS
, deceased.
Harold B. MCLane, Deputy
To ni(.I,l!1 d [, Al"ld~H3eR, Register of Wills for the County of Cumberland,
in the Commonwealth of Pennsylvania,
IS
Petitioner(s} ~the execut ",.. named in the Last Will and
Testament of May Jacobs dated _ September 4. ,1979.
Decedent was a citizen of the United States and a resident of
Township
~ij~~, Cumberland County, Commonwealth
Lower Allen
of Pennsylvania.
Decedent died on
Monday
the
21st
day of January
, State of
A. D. 19 80 , in the County of Cumberland
Pennsvlvania at the age of 82 years,
1alU: ~ her
Decedent has not been married and has not had children born to Jdltim
since the execution of the above described Will,
Decedent was possessed of personal property to the value of
$1,000.00 and of real estate to the value of
None
as near as can be ascertained; said real
estate situated as follows
(5l1ll1ll~
Therefore, your petitioner(g) respectfully applies for the probate
of the said Last Will and Testament and for Letters Testamentary thereon.
Dated January 31. 1980
Name and address
of Petitioner(g}
~C'~/.,.
Ray E. Jacobs
30 North 41st Street
Camp Hill, Pa. 17011
COMMONWEALTH OF PENNSYLVANIA f
ss
COUNTY OF CUMBERLAND
Rav E. Jacobs.
named in above application, being duly sworn according to law
say(s} that the statements set forth in this petition are true to the
best of
his
knowledge and belief, ~
and subscribed before J!j'V.(,f,-'CC:' :-;~
- Ray . Jac~
me January :n 19 80
1JutttfJ!T~i!;fn1', J "uepu1:~
nieAsrel [, ARelerseR. Register
0%
~wn,...n
Filed;
,;)/-{'o- 7/
February 4,
/0-..:29'-:' J
1980
Attorney: Robert L. Myers III ~
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LAST WILL and TESTAMENT
of
MAY JACOBS
I, MAY JACOBS, of Lower Allen Township, Cumberland County,
Pennsylvania, make, publish and declare this to be my Last Will
and Testament, hereby revoking and making void any and all wills
by me at any time heretofore made.
I.
I devise and bequeath all of my estate of every nature and
wherever situate to my son, Ray E. Jacobs, providing he shall
survive me by thirty days.
II.
Should my son, Ray E. Jacobs, predecease me or die on or
before the thirtieth day following my death, I devise and bequeath
all of my estate of every nature and wherever situate as follows:
A. Two-thirds thereof in equal shares to such of my grand-
children, Ray E. Jacobs, Jr. and Denise May Shuler, as
are living on the thirty-first day following my death.
Should my grandson, Ray E. Jacobs, Jr., or my grand-
daughter, Denise May Shuler, not then be living, I devise
and bequeath the share of such grandchild to his or her
issue, per stirpes, living on the thirty-first day
following my death; and should either my said grandson,
Ray E. Jacobs, Jr., or my granddaughter, Denise May
Shuler, have no such issue living on the thirty-first
day following my death, I devise and bequeath the share
of such grandchild to my other grandchild or to his or
her issue, per stirpes, living on the thirty-first day
following my death.
306
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OATH OF SUBSCRIBING WITNESS
COMMONWEALTH OF PENNSYLVANIA I 55:
COUNTY OF CUMBERLAND \
This,...,...,..,...".......~,~.~~..,.,."....,...,...,',.....,""""" day of ,..,..,",.~~~~~!:,y.,....,',..,"",..,.,',..,"",..... A.D.. 19..8.0.,.
Harold B. McLane, Deputy
before me R:.L. d E. :...d~. un... Register for the Probate of Wills and granting letters of Administration
in and for said County of Cumberland, in the Commonwealth of Pennsylvania. personally came ..............
....,...~~!?~F.~,..~.:,..!1y.~F.~,.,*;q:., ,~,r:\~t,i!.~X.S~...~..,..,~~~,~F.,~.9.~,I",.,....,..,... ",.."",...,...",..."".......,..,..,............"
the subscribing witnesses to the foregoing instrument of writing purporting to be the last Will and
Testament of ...... ,11i!Y,..;! R-.9.R!?i?...., .....""......, ......."..',.,.. ,.........,.".."........,.,.., Dated . ,l?, ~P.t.~mJ? ~F....~ ,I., J,.n~
late of.......,f!R1i.!'!F..,.M,.1.,!'!!1..,'r.R1i.nll))"i,P",....."......,.."..,.",...",..,...'...."..,.... Cumberland County Pa.. deceased
who being duly .....!'i1i.9.;r;.l:l:.......................... according to law, depose and say. that ...~)),~.Y...1i.~*.'?................
present. and saw and heard the testatrix......................,. .......Ma.y... J,a cabs...............................................
sign. seal. publish. pronounce and declare the said instrument of writing as and for h.~X'........... Testament
and Last Will. and at the time of so doing .......$.n~....................................was of sound and disposing mind
memory and understanding. to the best of ......F.n~;\.F..............................knowledge. observation and belief.
i? A AJ. ~lv{)<H__0"
...R~:f;y'~rs:..iiF..;;:;::.......,........,.
...~~.,~':'.~~'~;st;;.-;\,~,:,...............................
.........swP.z:n........................... and subscribed before
~~..E.:');qf.:?6.(.':)l..~....~~.~~:.~.,
. ~&d........v.u, RegIster . ~.
..................................................................................
AFFIDAVIT OF DEATH
COMMONWEALTH OF PENNSYLVANIA! ss:
COUNTY OF CUMBERLAND \
........Bi\y...~.,...y.fl9.9.R,i?.........................................................................................................................being duly
.........$.wpx:n............................ says that as nearly as can be ascertained the said decedent ..........................
.......JilFlY...;rA~Q);>,$......................................................................................................................................died on
....,..!i9.!}~.<:':y..,...,..,',........,....... the ...."?,~='!.t.,..........,,..,.day of ,."..~~,~~~.:!:y.......,....,.,"',............. A.D.. 19,~.Q...
at or about ........3,:.,.1.,11....................... o'clock, fI...M.
,.......S,WQX',I'l......,..,......"......,.,.....and subscribed this
....................?~,~.!:................... day of .....,~~.~~~E~..
19, ...~.9.., before
dJ'7 (/7 -
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=~3::2'}-o:d~),:!>"'-,,""",I?~!?~~.Y..
R:...I.~.J E. 1...1.8Ui1fil., Register
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA}
COUNTY OF CUMBERLAND SS:
Before me, the Register for the Probate of Wills and granting of Letters of Administration in and for
the County of Cumberland, personally came .....,).l.i\:{..);;"...y.fl.,c;:,9.RI?.................................................................
who. being duly ..,aw,o,~n.............,. do ,e.a..... depose and say that as,......Eltecutor...............,.......................
of the last Will and Testament of .......,klay..,Jacob,5......,........,.......,................................................,deceased
.........~~............ will well and truly administer the goods and chattels, rights and credits of said deceased
according to law. And also will diligently comply with the provisions of the law relating to Transfer
Inheritances. ...~~.'?!.!L........... and subscribed
before me.
~..r...........~.~~~.~...~:~...... A. D.. 19..,?,Q.....
, ,~;Q~l..~..,.".M...c.h~=......,.oeputy
RieRal i ~ "~.J~-T"'n, Register
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DECREE
Be it remembered that on the ..........~,~~....... day of ...................~~~!:~.~!:y............ A. D,. 19 ,13.0.... there
was probated and recorded the last Will and Testament of ........!1,;;1.Y...~,~g!?,9.!i..............................................
late of....~~~~!:...~~.~.7.~...~~~,~:!~,~!?........................... Cumberland County. Pennsylvania. Deceased. Letters
.....');,~~:t<.~~.lJ:t~.;:y... ......,........,.... were granted to "..~~y., "l!::"..o!.~,c;:,?~,~".,..,.,",.."..., '... "......"..,..,.,.,..........",.
Witness my hand and official seal the day and year aforesa<Mid' ,
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- " CSt,~,lG........,... .....l.L~S.(.ll~~.......~:.~~~y
" . L~nl ^""'..I...._"''''~ Register.
..... :
.. . . ..
COMMONWEALTH 01' PENNSYLVANIA
COUNTY 01' CUMBERLAND
"
55:
_. _Ray _F.:~.~~~obs __
- -.-------- .-._.._._---_._~_.._- -"--.
being duly ~wo!:~_ ___.__ according to law, deposes and ..ys that ho _J,.I).E!J:XEl.c].ltor---.- ---
.______ ___..-,-.--. _ .n. "I the Estate of --May-,Jacobs-.
late 01 T,C'lWP'- 1111 pn TC'lwn"h; p .__, Cumberland County, Pa" decea,ed and that tho
within is an inyentory made by _..Ray..E....J:ac.ops----.-, .-- --..----, the ,.id_Exe.cutox---
of the entire estate of said decedent, consisting of all the personal prop.rty and roal estate, except real e,tato oulsido
the Commonwealth of Pennsylvania. and that the ligures opposite each itom 01 the Inyentory represent it's lair yalue
as of the dato of docedent's deAth.
---- ---_._--- _.-----
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E1(ecut~MKrXNr
Ray Jacobs
30 N. 41st Street
---------..--------------
Sworn
and subscribed before me,
_ . (.,
"'--~n.{"__f--'
A .;___\.' ...
__~aIllP-H:i,lJ,,--P-a~7-0-l.L_--------
Addr.u
Joyce R, Anderson. Nolary Pubr.c
My CommiJs;on ExDlfl~S Julv 25. 1981
Lemornc. fA Cumberland (ounly
Date of Death __._._21._. _________._._J.anuar.y-.--.-.-l9.8.0--
Cay MOl'\lh Yur
INSTRUCTIONS
I. An inventory must be filed within three month~ after appointment of personal representative.
2, A supplement inyentory must be filed within thirty days of discovery of additional assets,
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act 011949.
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Inyontory of tho roal and personal estato 01
MAY JACOBS
docoa sod.
l. Silver coins (sold to Steinmetz Coins & Currency, Inc.) \$23,779 77
2. Byerly insurance refund 12 00
3. Medicare refund 25 60
4. Bell of Pennsylvania refund 7 18
5. Blue Shield refund 6 40
6. Colonial Penn Franklin Insurance Co. insurance payment 865 50
TOTAL $24,696\ 45
,
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RCC..33 1..~731
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COMMONWEALTlI OF PENNSYLVANIA
DEI'AIrt'MENT OF IlEVENlIE
BUREAU OF COUNTY COLLECTIONS
*'
...) (- S c 7/
RE51DENT DECEDENT
COUNTY OF CUMBERLAND
IMPORTANT.
- ---
This return l11USI he COntll)Clcd in dCluilllull filed in duplkllte. wilh llllutlllChcll. with the Itcgislcr of Wills of the
County where dcccdclll resided; J{l'(tlrll is lIlIe "ilhill 1111I1.' 1I\IIIIths "fll" dale 'If t.lclllh. unless un extension is ~fUl1lcd
hy the Secretury of RC'oIcnuc. (Section 71);\ uf the InhcrllllllCC nlld E~tntc Tux ACI uf 11)61.)
IN TilE MATTER OF TilE ESTATE OF
} AFFIIlA\'IT OF
EX EClITOR
XI(l)ll{QI~
County
MAY JACOBS
ISTATE FUl.L NAME OF DECEDENTl
Lote of
Cumberland
5'al..f Pennsylvania
C.unly.f Cumberland
)u:
~w
RAY E. JACOBS.
of the ntate of the above-named decedent being duly Iworn, depoUl S
Executor
and soy S
Decedenl died JanUary 21,
lMONTHI
Name and oddre.. of attorney or }
other authorized repr.santotIYt' 10 whom
all correspondence Ihould be mailrod.
19~J lOllate leaYing 0 10lt will, copy af which II hereto attaChed..}
IYEAR) ~JOMK
{DAyl
ROBERT L. MYERS III, Esquire, 320 Market Street,
P. O. Box 324, Lemoyne, Pa.
17043
That as such Executor depnnent is familiar with the affairs of said estate and the property constituting
I EXECUTOR-ACMINISTRA TORI
the assets thereof and their fair market value.
That at the time of death there was nn safe deposit bux registered in decedent's individual name, or jointly with, or
as agent or deputy of another, or in decedent's individual name, with right of access hy .mother as agent or deputy, with the
exception of the following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN WHICH DECEDENT RENTED A S."FE DEPOSIT BOX
THIS SAFE DEPOSIT BOX RENTED
IN NAME OR NAMES OF
REl.ATlONSHIP OF JOINT
HOLDERS TO DECEDENT
That the contents of said safe deposit hox or boxes arc itemized under Schedules
wi th the exception"of the following, for the reasons hereinafter set forth:
of this return,
Thai Schedule A allached hcrelo and madc pari hcrcof scls forth fully and in detail alllhe real properly
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgagc encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, datc, rate of intcrest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of dale of dealh or decedcnl.
That Schedule B allached hcrcto and madc pari hereof scls fOrlh fully and in detail all personal property
wheresover situatcd owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediatc possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whethcr indh'idually, or in trust for any other person or persons
giving also separately the accrued interest thereon, if any, down to the last intcrest day prior to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
savings. treasury certificates or notes and other evidence of indebtedness of the United States to the de-
cedent; all obligations, whether by statute or agreement they are designated as tax frec, of the Unite\t States,
or any state, or political subdivision thereof. or of any foreign country, which are owned at the lime of dea"th;
all ,,,'caring apparel, jewelry, silverware, pictures, hooks, works of 3rt, household furniture, horses, carriages,
automobiles, boats, and any and all othcr personal chattels uf whatsocvcr. kind or nature, left by decedent',
together with the fairly estimated market valuc thereof; all honds and mortgages held hy decedent and of all
claims due and owing decedcnt it( the time of de:llh, and all promissory notes or other instruments in Writing
for the payment of money of which decedent died possessed, of whatsocvcr naltlre, with interest thereon, if
any, giving the face value and estimated f<lir market value thereof, and if stich estimated fair,market value be
less than the face value, it sels forth briefly the reasons for such depreciation as to each item; all moneys
payable to the estate from life insurance policies carried hy decedent; all annuit}' and endowment contracts
the proceeds of which were payable upon thc dealh of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as of the date of death, honds llnd accrued inlcrest thereon to the date of decedent's
death and other investment securili~:s owned hy the decedent at the time of death, with the market value there-
of at such time.
]n the case of sccurltJc~ of' close or fumtly corporutfolHi, the vulucs rerlorll~ct nru us far as
l'osAtble S\lb5tttntl/lt'~11 hr I'lnltllcllll stlltl'lIlcnl!; 01' the cor)lorl'tlnns, sho\ll'III& tho tlssets und 11uhillt1es
tht.!reot~ tl5 of tile dUll' of' .h~nth. 1'hl' selj(~dllll' tl) So sets forth the 1llter('st of' dl!Cf!tJmlt nt. tile time of
death tn Itllr co-pltrtnershtll nl' husIIH'ss, /lIltl In sUPJlort of' the \'ulup of stlch tnt.erest l!lerl' is nlllll~xed to
said schednlt!, f'lrlllllclnl s1nt.f'nll!llt~ sl111wlnr,theuSfWls un1 Ilnhllltlf!s of snld co-pnrtlll!rshlp or ~lUsIIW6S.
A cop)' of the> cfl-pnrln'~rshlJ1 ttp;rf!t~ml.'nl, (If or/iI, fl. stntC'lIlf!nt sf'ttlnA forth Ow Ilntllr" of' the lI~reemcnt)
togt~ther \II'llh tl stlt.lf~lT1t!nl setttrl~ f'ol.th tlw cl1nractl!r of thl~ llllslrlf'ss, its locutllJn, UIIII Sitch other filets
pertllinlns; to the hllSllwss /IS nUl)' hI!' Jl'~I.tllll~lIt to It fnlr And .Just flpprulsul of' the 11!'Cf!df~IIr.IS Interest
therein must be SllIJnllttl~(I. It shuuld /II~Cl set f'nrth In Itl!Jnlzl!11 f'urm, to~t!l.hf~r \II'lth lhl! "ulr mttrket vulue
thcreuf, An~' other properl~' tH'illI~iI or het)lllJllt.lWtl hj' thl! dect'f1l}'U. fit the lImH nl' clf!t1t.Il.
The Sct>f.'dl.//~ C nttllched Ilerl!to ulld "Huh! purt ht!rf!ol' sets forth /I trill! IIIlSII'f!r to ench inquiry
contained therein I1ml In till! COSt~ of' transfers Qt'propcrtj', real or personul, within two ':"Clll'H of' dp.cedont's
death, in contemplation 01' .Iece(hmt' S rlellth, ur Intellfled to vJke ef'f'ect in IlossessJotl or enJuyment at or
after rlenth, sulrl SClll'dule sets forth lilt! nuturf! llrll! \'nlIW of' such JlrOlH!rtj', to whom t.I'lulsf'erred, the
relationshtp Qf the trlUlsf'crecs to t11l~ tleccfhmt, till'! proportiQnate shure received hj' cllch trlllll'iferec and
all other fncls of It 1l(!rtJnent IHlture rnv.llrrlillJ!: sulct lrnnsfers. In the CIlS" nt' trunsf'p.rs intended to
take effect In possession or en.1oynwllt Ilt 01' nrter rteuth, there Js n]so lltt.nchell to f.hp. sc/wclllle a cony
or the decrt, trust. ttg:rf'cmcnt or other Instrument crcllting the trust. Thor.~ Is nlslJ snt forth In soid
schedulc a 1 tst of nIl pr(Jpert~', rCllI find p~rsonul, with its vnluc, which rl1l~ses Ilt decedent.' s rtcllth h3-'
virtue of the exercise bj' decedent, either 1rul1vlduully, or Joint.ly with another, nr tul~' 1'(}l't'cr of' uJlJlQint-
ml;!nt vested in decedem" clUH!J' Indlviduully Qr .1olntl).', b}' ttlC Will, rtcerl, or other Instrument of anQther,
with a COpj' of the instrument crellt!ng such PQwer nttnched to the schedule.
Thnt Scl>edule 0 8ttncIHHJ hereto /lnd mnde purL hereof' sets forth t1w Il:tmes ull,l udctrnsses ot' nIl
persons lleneflclfjll~. Interested III this estute at lhe time of' decertent's rlenth, the I1ntUI't! 01' l.1u!lr res-
pective Intt!rests, theIr relntiollshlp, 11' llllj', to the decedent, together with the ngf's fl.'- the time of'
decedent's death of' ull minors, nnnuitants and henef'lclllrics f'or ]jfe muier rfecedcl1t.'s \\'111. It also
contains II stutemcnt showing which Qf' the hcnertcinries flllmerJ In the flBceflont's will, f f lillY, died prior
to decf!dent., tile elutes 01' their df~nth, their Issue, lUHI the rp.lutionship of such issue to tllP. Imnef'lelllry.
That S.:I>edule E nttncherl hereto !lnd mnlle n pnrt hereof' sets f'orth Il] 1 propertj', rell] lUllI per-
sonal, O\\'nert b~' t.he decerlcn t .I oln tJ y w J th RnQ ther or others, inclucJlng Intan~1 hI e, s tundillA I n the name
of' the decerlent. nnd nt.llt'rs, plus the dute nnd pIneo of' rccorrt Qf' instruments e('f'ecttn~ Ull~ vcstJ ture of
renl estate nnrl t.he dute of I1CflulsitJon of' personnltj', plus the name, uctrlress nnrl rl!Jut,iollShlp, if any,
of CO-O\llTIcrs to the decedent.
That Scl>edule F nttnched hereto "nd made Il part hereof sets forth rull~' and III c1etllU all debts
and deductions claimed for nnn on behlll f' Qf this decedent's estate, inclurllnp; f'uflcrul t~xpenses paidj
fa.mU;y exemption, where appllcuhlej costs of arlmlntstrnUQn of' this estate; (~ollnsel fees nnd f'urtictary' 5
commissions paid or to he pl\idj cost expended for burinl trusts, tombstones or J;rnvp.mllrkt~rs, unci reli-
gious services, in conserluellce of the rlellt.h of the decedcnt; debts nnd clatms owing nnrl IlnJl1l1rl nt time or
deathj taxes accruetl chnrgeable for period prior to rtecedent's rtenth (except those allo.....ed under Section
651 or the Inherltnnce and Estate Tnx .'ct); together with n statement of collateral ple(lged for obliga-
tions, if Iln~'. It is agreerl th/lt the fiduciary will present proof of snld claimed ohl1gllt.tnns upon re-
quest, thut if thp. nmollnt f1ct.un))~' palrl in settlement Qr nny f'ee, comm1ssion or deht Is lp.ss than the
est1mntcrl nmo\lnt cllllmlng nnrJ allowed, thut the sume will he reported to the HegJstl~r of' Wills, l1nd thnt
the amQunt of lax ussesscrl cun he rellssessed In uccorrlnnce therew1 tho
That the totftls or the npproprinte columns in Scher1ulcs "A", "8", "en, "Jo:" , unct "Fit us f1lrl~l:tccl therein,
ha.ve been curr1erl. forWArd nnrJ properly rc~lsterecl in the Sununnry.
Subscribed and sworn to before me this
,
::~~-:::et
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camrCi~i~h;~;:~.;a:1S~~)l"", ',...,.."...."
..........;d..,L..:t:b '
, dny of '-:*'~~..,(,,':"~""(;' ,..... 19....8..Q,..
...~=::;~;!;t..'.~..I..,..
,?...........t\,~I.......--:\........4.:..........,
JO'l~~ rt ~;jd~..sL1n. Nol<1ry Public
1"1 Cc-m;r::.a;r:l1I L:t;:iw J"/1 25. 19a3
Ltrr.:1r.~. ~A (t;,.I~:Il~J,:J (O:.::..IV
SOTE.: BI~rOrf! sl~nfng afTJdn\'lt. mllke sure nIl hlnllk splices In U.c nf'flcJll\'lt. nnd schradulp.s annexed ure
rUled in w1th d~t.lllls or tile word "SOIl~", anrl in case the Ilssets Include rllre /lnd unlfstetl securJtJcs,
securities' 01' close or I'nmlly cOl'porntJons or /111 Interf!st in nn~' co-pltrtnershlp Qr busIness, tllut the
data nnr) s t.rl t.('men ts re fill I rr'c! un de I' the lHII'Il~rllI'h nhQ\'p re] n ling to Scherful e "8" lIr'! 11 ttllcllerl. ,\1 so mnkc
certltln thltt column #1 III tl:(! "Slllllmlu'~'" IIlIs l11~ell propcrlj' completer! llS nhovc-fllrf!ctec1.
.
,\
. )
Rce-'.I4-1I1
COMlolOMW!AL TH OF PENP;SYLVANIA
DEP....RTMENT DF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECEDEtlI
SCHEDULE "A"
REAL PROPERTY
*
Real property in Penn5ylyania, with stotement of mortgage encumbronce5 upon each parcel at death of dece.
dent. Property held by the decedent as lenont in common with another or other, should be identified
os to quantum of interest and the estimated yalue should be that of the decedent's interest only. (Property
held as joint tenont5 with right of 5UryiOr5hip or tenancy !'y entireties should be reported on Schedule "E.")
The rial property located In tho Commonwealth of Pennsylvonlo should bo (1) (2) (3\
described by lot and block numbor, stroot and .treet numbor. tagathor with Dr,PARTMENT
o genoral doscrlpllon of tho property, with 0 roference to tho record of tho ASSESSED VALUE VALUA TIO,,",
convoyoo(O by which the decedont took tltlo; If a form .toto numbor of a. FOR YEAR OF E5T1MA TED CAUTION
crol; 0110 .tatoment of mortgage oncumbrancfll upon oach po reel at doath DECEDENT'S MARKET YALUE (Do not writ.
of docodont. ToxDc, Olles.mont., accruod Interost on mortgogos, efe.,ore DEATH In this space)
to bo IIstod on Schodule "Ft! and must not b. deductllld from thl. schedule.
NONE
.
" , , NhLU
Insert thIS total OpposIte
"As Reported" col umn on
real property' ,Schedule 'A"
the last page of this return,
In the X X X X X
..PJ9~
I .
RCC -~5
\'
~~~
..-.1
. ....-~.I
,t. _ -',1"11', ,\
..... '4~t. ,
l...I'J;::"'.........
"r:I(I"~'VI-'"
r,OM\IOXWK\L'l'1I OF I'ESXSYI.nx I ,\
'l'1\.\NfH'EII INIIEIII'l',\SCE TAX
IlESlIlEST IlECEIlI':S'l'
SCIII':IlI:I.I': "II"
PEHSUS'\ L PHIII'EHTY
lSSl'IH'C'l'IOSS: TillS Sell,'dull' mllst, .llsl-lust! 1111 Iilll}.:,il,tl~ ;Ulll illtall;~i\Jll' 11l'I'Sl.ual p"t1p,'rty /,-,':I,',l illllivlllll;dly
hy tjo,' ,\,.,,,,,1.'111.. al 'I", """, ,,\' his oI"a,lI. 1'I'''I'''I''~ """',\ h~' ,I... ,[..",'01"11' .I"III,ly.llIl "",,'1,,," .". ".h"rs
must hl~ list.t~t1 \1l1dl~t" Sclwdull' "E". llllun~ihl.' )1I'rsIlIl1l1 PI'UP,'I'I.Y, titl",! ill 1,lw Willi" of 1.111' Ih~t'''ltl'llt, hill
1'1I)'alllo lit oloatl. I." "",,ti,,'T IIr IItl",rs, IlIdwlllll'. 11111. ",,1. 11",""ol '00 1',11,1>. l:. S, S,,\'I,,~S 1I.""ls ,,",1 I..'nl.a-
live trust. uccuuut.s, mllslUl' listl~lt. tll'spill' tht' fnet {hut 1.1l"~' III'" Il(I\' 01' 1.111' 1I,lmlTlisLI'I'I.,t I'Sllllt'.
'l'llIIl!,ihll1 lH'rsnllul PI't)I"!rt.y slluuld he llstyd I'tI'St, (I~.'!,. .I10In.ll'Y. wl'"rlll~ Itppnrl'l, hClllSI!lu,ld
good:;, /Iud fUI'nlsllln,!,s, hou\o;s~ Plllnt.lllJ!,s, h1ltllmt)hlll~S. huutS. l!tC.)
Intnn~lhlc pl~rsollul prnl)l~I'ty, stich liS howts, U'I!IISlll'Y l:r'I't,i1'\Cht.!S, cnsh on 11IulII ullcl In IJltTlk,
stock!;, l1Iort.l;ngt!s, llol~S, ttlJ.!,elher with UCl.::l'lIcd Int.I~I'I~sl 01' Ilt\'lllt!lllls, ~iltlltrtl's fir wuv,t!S, lnslII'/U1C1! PI1Y-
able to tll" OStllt" or flclo.c1nq' 111 s.<t.1 cal'nclty. pa"l.o,','shlp Inl.<'r,'''';, 11I1."r"st III any 1111<1 1 stl'l IInto"
estnto 01' 0" Incn"," \'I'om any !,I'op"rt.y II,'J" 'n t.'IISI. 1111,1"1' U", wIll ,," a~r",,","nt o\' ,011,,1.11,,1', ,,\''''. tllon~1I
lO';8.tt:'t! ouLslt\c of' the SUttl!, nt Ow tlml! 01' denlll, sllUultl Ill" llstl~ll 111 this sehptl1l11~.
Item ITKII IISIT I,ST1\l.\l'EIl llIoJ',\lI1'\IE~"l' 1'.\l.UNI'lON
NO. L'st Rl1Il descrlhe t'u) ly VALljE \I,\1IKIIT VALUE (Uo 1I0t. write In
this spnce)
1- Silver coins (sold to Steinmetz coins &
Currency, Inc, ) $23,779.77
2. Byerly insurance refund 12.00
I
3. Medicare refund I 25.60
I
I
4. Bell of Pennsylvania refund I 7.18
\
5. Blue Shield refund 6.40
I
\
,6. Colonial Penn Franklin Insurance Co,
insurance payment 865.50
\
,
I
I
\
I
I
\
Insert this total opposi tc "Pt~rsonnl ProperlY", Schellu! e "U" III X X .1.4 (P 'II". t.j$
the "As neJlort.~tl" l!oltJmn 011 the Inst )luge 01' t.hls return. $24,696.45
I ) .lI~
p.cc-,s
~ \'... ,
.,)~;+~~t
-c,; ,._.., ,
",,, ',"'/ >A
".... ,1il",. ~,
(1....\~i.'.;......_1
"j,'_ ,......~j.~..~'.l...,
l'II\'\ld\I.,t.'I\t:~.1t tW I'L'X\'~YI.\".'\I,\
rltA\:-:F~'n I\C'''!~ll.~\'t'F '1'\\
"'I' I lFlIl 'I.!'; .'{'"
lq\'....Tl-:l:~
i:~>': 1 Il:':\' I' 1""(T1l!.'\']'
(1) Uid dl'I'I'dl'lll. wllldn ,"U ~"':Il'~"I'.I"illh. m.d," all~' 1I':1I1<.;!'I',' of' :i1I.\" 11l:11I'I'jal ;IHI'! III' ILls I'SliIIY, ~'Ithullt.
rt'L'I'h'ln~ II valll,,"l.' 111:01 adl'qtlltlt' 1'''Il~ld''I';'llnl1 Ihl'l'''!'U!"',' (\IIS....-..'. ~'I'!'. ill' 1I0)-:!e~
(~) 111.\ ,10''''',1,'"" _I'IlI" "," ,\O'''''s ..,' "",,'ll. Io'"''SI',''' 1"'''1'''''';' I'."m Illms"l!' ,,, 100m"'II' "",I """llo". ".'
l.tl\i'rs (11l.-tlllIIUl!; II SpOllSI') III .Iolu: 1II'oIIl'I'slllp',' (,\IIS"'!'I' p.... IlJ' 110) Ye..?_
(:1) II' tilt,' IlIlS~"!r lit (1) 0" (:!) 11I1fl\'!' is III Iii" 1l1'1'11'11l1l11\'l~ Sl:lt.':
(Ill .\~!;I' of' d"f~..c1I'nt. :11. 11m" nl' U'lIWi!'i'('
(II) St.lltl' nl' Ih'I~l'dl'llt's 1I1'1I)tlllll. 1.11111' fIr 1l1/1klll!!, Ih" I.rallsf'I."'. (SOll'I),
(c) C IIl,SI' II l' ,11'1:1'11"111,' s dl'" 111. (SuU' t J .
(.1) Old dl'cf'lh'nl, III his 1Ift.tlml', IUllkl' illlY II'IIIISI'..,' Ill' P""llI'l'ty v..ll,htHlI. t"'I:.'I\'IIll!, a \",dulIh)!! HI' 1Il1lJljuIlle
cCll1sllh~rlltlllll t.lwrd'lll' which ""liS I.u Illk.. I'l,!".,:t III 1lossl'ssllllI or "II.1UYIlI"IIl. Ill. or II!'tn,' Ills dl~lllh?
('\IlSIH!r y'~s ur 1111) No
(II) WitS t1ll'rp allY JllIsslhlllty t!L;tI, till' prllp"rly l.I'llfIsf""'rl~d mli!,lLt 1"~tUI'1l to l.rllllsf','rf!r or his
,'stlltl' ur III' sllh.ll't:t, 1.0 his pll~"'l' lit' ,llsposltlllu't (,\IlSIlI'r Y"s nr 1\1,) No
(II) Wha l. ....'HS th,! tl'1II1sl'l~rl~I~t s II~I' III 1.1 fliP Ill' ,tp!:p,Il!Il!.' S lh!uth? No
(M IUd dec('dl.'nt III his 1 I 1'1' tImt' mllkl' /illY trilllsf'l'r wlt.huut rf!eld\'ill~ 11 \'lilWlllll'llndllllt'llltlltl.' cunsJderlltlnn
lherf~f/)r uud"r ..11'.'11 I. rllusf"J'ur ,'xIII"ossJ,\' I))' I rnpl JpllJ.r J'eser\'l'S f'or II I s I J fl! nr flllJ' 'll~rj 1111 wh! eh Iloes
lint III 1'1I1~t !'wl t,,'l'ol'1' Ills 111'11111:
(II) '1'111' !lnssl'sslllll (II' f'II.1(l~.Ill'!JlI. of' Ill' till! l'l~lll I.U Incolll(! fl'olll till' J1rflll\'I't,~' trllnsferrl!d',
C\lIs",pr :'Of'S Ill' UU) No
(h) Till' l'l~ll1. to .h'sl~"llt(! t)ll~ )H!rSUIlS wile I shill I )llISSI'SS or I'n.loy till! Jlrl)Jlel't.~' t.rllllsf'el're,1 or
11lCOIllI' tlll'I.(.j'rol1l'l ('\Tlsvwr ~'I!S 01' no) NO
(G) U' Uw ltnS'l\'pr tll (rn (h) lIho\'!! Is In t.he Ilff'lrlllatl\'e, st.ltte ",hl!thl'r th~~ rl~ht. ",us rnserv(!(( In decedent
lllonf! or ntlH'rs
(7) DlrI clccClfcnt III his 111','tll1l'! malw H t.rllllsl'l'!'. 1111.' enllsl'lt~rlltiOIJ 1'01' which ~'IIS trnnSfl!ree'S promise to
PIlY Jncoml! t.o Of' I'or t.lle 111.'111'1'11. (II' c:nre nl' transferor" (,\Tlsw('r yr's 01' Tlo) No
(t:U Uifl rlececlcnt, Ilt all.\' llIllP, lI'lllIst'f'r l"'ni'erl.y. 1111.' hen(~I'lcilll pu.ln)'llIellt 01' which was suh.lcct to chnnge,
hee'UISI! 01' :l I'(!ser\'(',l I'"WI'f' l.n al ""I', IIIllHIIII. fIr rl'\'nl~I', or wltl(!j, eOllif! 1'.!Vt'I'" to .1.!(:edC'nt. under terms
n f' t.rnns fl!r 01' h)' nlll~rll t lUll Ill' III\\"! Uns......'. ~'llS or 1111) No
(9) If t111~ IlUSWI!r to (Pi) al,ov" Is In tlw al'l'll'llIlll1\'e, WIlS th" pn\\'I~I' tl) 11111'1', UIlll'IIlI. or l'l~Vllke t.lle inter-
est 01' tile hell'~I'I,~llIr~' 1'llS.'f\'I',1 III 1Ill' dt'clllhmt allltle rlr th-' (It~C""l'lIt :11111 uth(!I'S?
(Answer ~'es or nu)
SOTE1: The lltlSWCrS to t.h~s" lllll~stlnlls SIIIJlIIII h.! SlIlllH)l'ted h~' nf'('lllttvl thy l.hn IItt.l~nflinJ.!; p)l~'stctun ns
wp.IJ us It cOJl~' 01' thH Ilnat.ll r:1'1.t.II'I'~Ht.e.
SOTE~: If' unSh'er to /lny ul' l.II1! Ilho\'f! IIIlHStlullS Is ~'f~S. Sl't I"o:'1.h b'!low II Ch!Sf'I'lptlofl 01' t.he Jlr()llert~.
trnnsferrl:'fl, it.' s rill,' Ill;trket. \'111111' III, dltt.e 01' Ilellt.ll, _Iull's 01' trallsl"~rs IllId to ....holll trnnsl'erre,l, with
relallonshlp of' t.rllnsl'f'I'I"'S 1." e1.'cl'llent, If' /lny. Suhmlt eOllY of' 1I1l~' tl'IISI, .h'ed UI' Insl.l'uln1mt., if trans-
fers nre claimed to he 1I011-1.IIXIII1I0, IIlsn SlIllllllt dlllllll",II SIIlt.t!I'II~Ilt. nf' ('aets 'Ill wlliell SHift clntm is hnsed.
SOTE:J: List ")lpl il:llhh~ 11I'ClI1l'r1.~' hnluw III lnlllllll!r in willc~h III'O\.tdf~.1 ill SC'lll'd1l1'~s '\, B. or E.
ITEll
IIESCltIltl'II'S
.\tl\llKET V.\J,l1E
(l~sl.ll11llt.nll)
DEPT. VAJ.lWf IOS
(l)el1l. Ollly)
1. L that certain lot of ground situate in $2,640.00v
the Borough of Camp Hill, in the County of
umberland, State of Pennsylvania, bounded
and described as follows:
EGINNING at a point one hundred twenty
(120) feet south from the southwest corner
f Second Street and sixteenth Street;
thence westwardly along the southern line
f Lot No. 157, one hundred fifty-five (15 )
feet to a twenty (20) feet wide alley; the~ce
outherly along said alley forty (40) feet to
F point; thence eastwardly along the north rn
~'ne of Lot No. 155, one hundred fifty-fiv
(155) feet to a point on the western line f
ixteenth Street; thence northwardly along I
e western side of Sixteenth street, fort~
j( 40) feet to a point, the place of BEGINNliG.
~EING Lot No. 156 on a Plan of Lots known ~s
r'Greater Harrisburg", Estate of Jackson Free,
~ecorded in the Office of the Recorder of D~eds
in and for the County of Cumberland,
~foresaid, in Plan Book 1, Page 20.
Said lot was conveyed from the decedent to
her grandson, Ray E. Jacobs, Jr. for no
consideration by Deed dated September 4,
~979, and recorded September 6, 1979, in th
~ecorder of Deeds Office of Cumberland Cou y,
~n Deed Book Q, Vol. 28, page 309. The
assessed value for th~ n~cen~nT'~ npp .
InSf!rt$Blqg.l,~t,lIJ Ul'!ll1sIU' "l'l':ll1sl'l~r:;", SI:h'ldul.' "e" III till'
"I\S Itf?porlnil" l:flI UIlDI nil till' I Wi!. P'\I~" nl' t.hls r.!t.lIrll.
l'l\\Wl\\'.~l:,\l:;'1I Ill" \'t'\\~Y :.\ .\,\ I
r,,'\\~F~.'n l\r~"l~IT:.\rF T\\
PAGE 2
~ITI-'II1'1.I': ",
T!l\'\"TE1:~
\'...
~1; ,', if
~~,.--~. '.
I'~,,""-':":': .\
(,,,,1.;::..',,,,,
..,.....'....,.~I...,
. .....\.' .
pcc- ,s
;;':~~ IIW\T 1l\,:n:illYI'
(1) 1l1.1 ,1"",'01,'11', .1.10111 .." y"".'s",.."""Io. ""II", ,II'Y ",,,,,s""" ",. ,."y '''''..'..." ;'''''' ,,(' IoH ,'SI""'. .111"",1.
r<,0:,'1\'11I~" \,,,1...,101,, ,,,:01 ,,,1"'111"'" ""liS I,,,,.'" , 1..11 .10".,..,'",,'1 1\lIs."" Y"s "" ",,)--
(~) 11I,1 ,\0'0:,.,1"11', .\1101" ,,,,, Y"""' ,,(' 01",,'10, I1'''IIS''''I' 1'''''1'''1'' Y ,."."n 100ms..II' 1." 10 I ",sod " '11,,1 '11"'1.1...1' "1'
.,1 ho:l's (1110:\ \ll1I1I~ " SI"""") 111.1" 111:' ,,'II,','sh II"! (,\"S""" Y"s ,,1' 11")
l:I) It' the uIlS.....I~r HI (1) UJ' (:..:) 01110\'" Is ill Ill" nITll"ltli\l,I\"! SUlt.'.:
(II) A~!;" of ll,'c,'.hml al I. 1m.! Ill' U'llllst"l!r
(h) HULl." "" ,\>,o:",\O:III.'S ho:"lth "I. 1.1"," "" m"';\"~ 11,0: 1.1'''IIS'''''', (S"I.O: 1).
(e) tUllSP flf .I'!(:I!c1I'nt'S lil!lIth. (:\nl,(! I).
(,\) 11I<I ,Icce<lolll., 111 hi s \I fell",O, m"I;I, "IIY 1\""1S ,.,,,' ",. I'r "1'0: l' 'Y .1.10"11', 1'0:0:,,1 \'I,,~ a \'',,11I,,101e "I' ",IO:'I'1!ll.e
cOllsl.lo:ralloll I.h"I'O:""" which W"S I," .""" """"0:1. 111 1"'''0:''1'''' ",' "II,;"y""!II1. a' ,,1' ,,1'1.0:1' his ,le"l.h'!
(Allsw~r res 01' ",,)
(,,) II"s lI,,'r" "Ill' l'"sslhl\lI.Y th'" 1I'" I'I'''I'''I'',\' 1\.""s,.,'.'r"" ml",I,', "0:1.111'11 I." 1.1'""s"o:"O:1' "I' his
,'sl."I.', ,,1' ho slIh.l"O:1. I." his I'"W"I' "" ,IISI'"sltl"II'1 (.IIIS'O:I' \,"S or \II,)
(h) \\hal waS 1.1... tl'alls"O:I'o:e' S a~" 01. 1\mO: "I' ,1,',:0:010:111.' s """I.h? '
(3) Ill<l <leco,\>"'1. 111 his 11,.""1,,," ,.,,"0: OilY 1.1'0IlSt'.'1' wlth"lIt 1'00eo:l\'III~" \,,,1 lI"hl " "0'\'''''''111''1.'' "III1SI"el'allnll
1.1"'l'el'.... 11"'''''' .hld, I.I'''"S''''I'''I' ,'xl'l'"ssl)' or 1"'1'11,',11)' .'o:sc\'\'o:s "0" his lit", 111' lOllY 1"'1'10<1 which ,lues
not In ('/lel 1'11.1 h~f'()I.t' ili.. .leal.li:
(,,) Th" l'osSO:SSI011 or ,....loY1I1CIII. lit' ,,1' 1.1", r1~hl. tu \1,.,II111e "1'0111 1.1... I'rol'''l'l.)' I.l'a"s"O:I'."..I'/
(.\lIs",,~r ~'I'S fir lIO)
(h) Tho: 1'1~"1. 1.0 'I"sl~n"t" I.ho 1'O:I'Sll1lS who shall possess nr <'II.10Y t.he I'rol'el'l.Y I.l'ansl'cl'l'e.1 or
illconle t.hl~1"f!rrom? (.\nswer yes or no)
(0) II' I.he an<'''1' 1.0 (5) (h) "",",'0: Is In I.he afl'll'",,,l1\'e, sl.al.O: whel.hcl' U.e 1'1.~ht waS l'o:scl'\,,',1 In "eceelenl.
nl 01\f~ or uthers
(7) Ill" ,lec",lenl. In "Is I I I'et1"'" ''','''' " I.l'ansl'''I', I.he "ollsl,lel'nllon 1'01' .hle" w"s tl'onsl'croc'S promise 1.0
pal' Incu",c 1.0 or ('or 1.1", I"",el'll. 01' o:al'e 01' tl'allsl'o:I'OI'? (.Inswe,' )"'S "" no)
(8) Ill'\ "Oc"elenl., "I. any 1.\111", I.l'allSI'''1' 1'1'01'''1'\.)'. "'" "",,,,I'lclal en,\o),,,,o:nt 01' "hId. was snh.lccl. to ehangc,
hecanse 01' a l'osO:\,\',.,1 1"''''1' 1.0 aller, 0""",,1, "1' I'.,.""e, or whl"" co"I'\ .'e\'l'I'1. I.n .1"eo:,lenl. un,lel' I.el''''s
or lrnnsl"er or h~' o)lI!ration u(' laW'! C\nsw.~r yes or IIU)
(n) If I.he anSwer I.n (H) al",VO: Is In I."" "1'\'II,,,,al.\\'o, was II... I'owc,' 1.0 01'0:1', a",on,l, or I'.woke I.hc Inl.er-
esl. of I.ho hen....I"lar)' ,'o:s"l'v,',1 In 1.1,,' ",'co:elelll. ,,1'''''' nl' the ,1o:eo,lenl. ,,,..1 ol.hors?
(,\nswer yes () r no)
SOTEl: The auswers I." I.hes" '11I"s tI "n5 sh",,1 ,\ ,,,, snl'l"'I'I."eI hy al'l'I,I"v 11. 1')' I.he 01.1."",1 i ng I'h)'S I clan as
well us It COllY 01' thl'! .'eat." (:I~il.II'lcal.i.!.
~OTE~: 11' ,tns"'1' 1.0 "ny nl' I.ho: ahovo' 'p",sllons Is yos, s"'- ",,"I.h Iwlo' a elosll1'l1'1.10n 01' I.ho prol'ol'l.Y
t.l'ansI'Cl're", II.' s I'alr ,,,'rk"1. \'"Ino: al. ,101." 01' ,1""l.h, ,"""o:s 01' I.l'ansl'OI'S "n,1 I" wh"m I.l'ansferl'e,l, wll.h
relal.lonshlp nt' I.l'ansl'el""'s I." ,\>,e",I"nl., II' any. Hnl,,,,Il, ""1')' 01' any 1."IISI. ,1"0" ,,1' Insl.l'nmclIl., 11'1.1'"ns-
I'ers arc clal",o:,1 1.01", non-I."xnhle. "Iso snl",11. <1cWllo" slal.O:1I1onl. 01' l'a"l.S "n which s"I" c1ul", Is has eel.
~Om 3: 1,lsl. appli,,,,hlO 1"'''1'''1'1.)' hO]"W In ",allno:r In .hld, pl'o\'ldo'l In ""he<l"l'" .1, ll, ,,1' I':.
I1ESCIt 1 \11' lOS
~\,\m\.lO:T VALUE
(Est111111tClt)
m~P1" VAI.U.\TlOS
(llepl. Only)
ITEII
2. Defense Activities Federal credit Union
Savings Account No. 22354-9 in the names
of May B. Jacobs "0rn Ray E. Jacobs, opene
July B, 1979 $31,lBO.79
3.
CNB Bank, N. A.
39-032-4 in the
nd R. E. Jacobs
Checking Account No.
names of May B. Jacobs
opened June 21, 1979
330 .14
\
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I
I
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Ins'''1. l.'IIs I.OI.!d 01'1'''511.'' 'Tl'ansl"'I'S', "d".""I" 'C' In U...
"As af!l'()rll~t1" 1:.""flUl on UtI' I liSt. P'l~l' Ill' tltl"; l'j'(.UI'II.
$34,150.93/J1;/J-O.1.J
.<ftlf
REV:"" (11.78)
CmtdONWEALTlI OF I'ENNSYLV,\/o,1.\
TRANSFER INHERITANCE T,\X
RESIDENT DECEDENT
,~} @.
~'~D.
.~,;... . . ~.'i .
'~"IC.P'!t t~ii~,-
SCIIElJUU, "Il"
BENEfolCIARIES
, -
BENEFICIARIES AND ,\lJnRI<SSES RELA TIONSIIlI'
(Sill Ie full nnmes and addresses of nil .....ho (If slep-c:hiWttm or SUR VIV En DATE \:-:TEREST 01'
hDye un intcrest. vested. contingent or other. illegitimate childn'l1 DECEDENT OF IlENEFICI^R~
wise. in estute) are invulved, set STATE YF$ IllIITII liS ESTt\TE
forth this fact.) OR NO
Ray F.. .TacobS ,,~~ VOQ 1,,-0..,.. '00%
.
30 No 41st Street
Carnn HilL Pa. 17011
I
I
-
- ------ - - -
D~ponent further says that all the above.onamed beneficiaries arc living at this time except below:
NAME
DATe OF Ci:"'iii
RESIDENCE
~
9 ~:::
g~ U:
.' "
'c ~ e
.- ~ =
e- -
..,c..C
,e"
i' 0 ..
'"':J ;;,
,S.... 'lJ
:s:ll ....
u c ~
ye g,
y. :J
= ~
SUMMARY
Real property
Personal Property
Transfers
(Sdl. UA")
(Seh. UB")
(Sell, "e")
Gross Taxable Estate
(I)
(As Repnrted)
$
$
$
$
$
$__,..
QJ
!- "" I-l
... Z " "M
" tJ,J . ::l
" .:e ~ 0'
... "
tJ,J " !Jl
\ '" " -' ril
- Q <t
...: '"
0:: tJ,. .~ :< H M
i:-
i:- 0 m s:: ;; '" H ....
...: "tJ,J I1l GJ 't:I , '" H+' 0
" 0 ~ s:: '" ClJ r-
-= tJ,J -=!- ~ ~ <1l ;.. .0: 1Il QJ ~
<5 !- !-...: v,
:: ....!- ..: ~ e c ~l:l....
z. c: !- t') I-l ~
0", "
tJ,. tJ,J I-l ClJ "- >om N .
0 ~ ClJ ~ '"5 I- :s M III
., :3 '" +' p.,
.2 0:: 0 -5 0 . ClJ X
- tJ,J H () '" H ~ 0 -
"
... i- ;,; w +' I-lI1l ClJ
"in !- ~ ~ '" III s::
C
'c -<: ~ 1-l:S . >0
::;: c ;:. C ClJ 00
_'s " ;; E .00 S
:-::""=' ;:; c Ii ON . ClJ
:::< ...l u U ~Mp.,H
.
(2)
(As Determined)
$
$
$
$
5
$
RCC.Jll
COMMONWEALTII OF I'ENNS\'L\'ANIA
TRANSFER INIIERIT,\NCE TAX
RESIDENT DECEi.ENT
SCIIEIJULE "E"
JOINTL\' OIl'NEIJ I'IWI'ERT\'
f.' ~~.
"'~ '" ~ ~
...\ 'I _
INSTI~l!('TIlJ~S: TIll s "l~lll'lhlll' milS t. II 1 sc I liSt. 1111 prop.'r t)', 1"'11) a'I.1 pel'slllla I, ~1O'd !Jy I hI' I!PI'l'rj'.'111. ,1llllll.l Y
"1111 1lI1111111'r ',r 1I1Ill.,..... lll,'llllllll~ IIII.IUlJ:llJII!s, stl.lldl~lJ.'; In tit" 1111111" of tILl' dl'l~,'d"llt lIlHI Utlll~I'S. I.ist
rt.'al l'stull' l'lrsl. ItS f~lIllr.'til's, 01' .Iulut tf!lIll1lIS, J;J\'!IIJ.'; IIrl"J' dl!scrlpUoll. itS ITld!PIII..,t1 willI' I' SClll!dule
".\". pltls till' lllllt' Itlld I'llIel~ 01' rl!enrll n1" IrH;I.I'lI/1ll~1I1 .!l'ft'l:tJIIj!, n's!.J t1II"~, hilt 110 11111. lllCIIHll~ I~ntlrf!l.les
or nul nl' ~t;ll.l' r"HI l~stl1tl, Vllllll! In estutf' VU1WIllun l'lllumll. p'!I'SOIlIII prop!.'!'t)' shuulll hl~ Ilsl(!1i liS In
:iich....clull! "B", pillS dUI.L' nt' aeljlllsllJoll, UIIII th'~ nllllll', Ilcldrl!ss /llIrI r(!Jlll.1ull...1l11' (It" /lll,y) of cu-owrwrs to
r he Ih-cl'lh'lIl.
~
~
nl!scrllHlulI (If Prnllf'rt.y, Un!.t! nf' ,\cqlllsltllln, SlIml!
'\llclrl'ss IUlll Ih~lllttnnslllp of Cn-O"'nl!rS, llnel Pl11CI!
nl' Hl.enrll of' 11I"l.rUml!lll.. wllere> Ih~l1l Est.l1le.
X> '~'X>,(~XX~1!:~~'m' :"Y'~':; Wf%2::q;-;b,:::~/;/>;'~"$3~'z, ',:'</';f;0~;0:0:
:>0C<X x C~ ~-9-x$%0 6?~'?,g{ ;<'<<0 <<', >' ;l;.s; :&'Z.:k<,~'
, ~'V',,~. ,//,;Yx> .' '. A"./1.. y,<<~ ,x;./ ,..0:;;, ,^ .
Clllt
VII 1 liP.
pf!rCl-'llt Ill!,fl
SlIlll'f'
EsltlU!
VIIJUllttllll
NONE
1-
Insl:!rt this tutul OPflosltl:! ".Jotlltl~' O"'l1cll I'I'ulll.:!rtj'", Schclillle "E"
In tile "As Hp. )()rl.cll" COllWUI on till! last. pll;l;l! ai' this return.
D~J',\1I1'IlEST V,\W,\TIOS
C.\lJTION-Do not Wrl t.c
I n 11~t.! ~ 'U~f!.
Vlll'le of .nllle of
Entlr(! nl~CtHICllt' 5
PrOIJf~rL~' IlIl<<:!J'f:!st
NONE
/!/ntV
'&~fl.
File Number
INHERITANCE T.^_X SU',~',\I..r;'o/ ''il-:;::T
(B~~AU__USE ONL.'{)
21-80-0071
REV0484 EX" (3.80)
Estate Namc _._____ __ .JACOB_S,-May
Date 01 Death
01/21/80
Social Security Numbcr
REPORT OF INHERITANCE TAX APPRAISER
I, the undersignod duly appointed Inheritancct Tax Apprai !ocr in and for tilt) County of _C_UI1lQer.land
Pennsylvania, do respectfully report that I have appraised the recl and pcr~onol property 05 reported in the foregoing
retum at the values set forth opposite each item in the last column to the ril)ht in Schedules IlA", "B", IIC", and "E"
Doted:
April 17, 1980
jL{~lt.J~ilL\ ,~ )
INt1L-r:IT..r;,-:. f/,;'" Af>"Hf"~C."
5
None
24,696
None
r~-~ -- ---.----.-------.-.
I ADJU~TMENTS
~~~L~~~~URG USE, ONLY)
45 10+
REMAINDER APPRAISEMENT
CODE
INVENTORY
VALUE AS APPRAISED
Real Property (Schedule A)
Personal Property (Schedule B)
Jolnt.Held Property (Schedule E)
Transfer. (Schedule C)
92+
20+
TOTAL GROSS ASSETS
34,150 93 ~O+: , '
___58'84'.~~~_.._I___
---,--- ------r
93-
Len D.bts and Deductlons
(SCHEDULE F)
CLEAR VALUE OF ESTATE
Valuation of life estatlts ar
annultl.s. . . . . I . I I I . . . .
RATE
FACTOR
PRINCIPLE
VALUE
CODE
~
FOR USE OF REGISTER ONLY
TaJC on $
9llii
COMPUTATION OF TAX
S
S
S
6"
"
TaJC on S
15%
ToJC on $
T OJC on S
$
Tax on $
EJCemptlons
Total Estate
TOTAL TAX
INTEREST FROM
BALANCE
TO
5 _.-
S
5
Less Credits
DATE OF PAYMENT
AMOUNT PAID
OISCOUNT
IN T E RE S T
,TAX !=~
S
+ S
$ ~
s
+
=
BALANCE
$ ------.------.
INTEREST FROM
BALANCE DUE
TO ______ __ $
$
REV.457 (1.80)
COMMONWEALTH OF PENNSVLVANIA
D'ePARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
INHERITANCE TAX
APPRAISEMENT
..
Estate 0 f
Jacobs, May
File No.
21-80-0071
County
Cumberland
Date of Death
01/21/80
In the event thet any future Interest In thllestatel. tranrlerred In possonion or enioyment to coliotornl hairs of the decedent aftor tho expiration of any
estate for IIf8 or for yoars, the Commonwealth hereby expressly roservftS tho right to apprlll~ and asscss transfor inharitance taX81 at the lawful collateral rllte
on any such future Interest.
PROPERTY REPORTED BY THE ESTATE
DEPARTMENT'S
APPRAISED VALUE
None
1. TOTAL REAL PROPERTY - SCHEDULE "A" . ,
2. TOTAL PERSONAL PROPERTY - SCHEDULE "B"
3. TOTAL TRANSFERS - SCHEDULE "e" . . . ,
4, TOTAL JOINTL V OWNED PROPERTV - SCHEDULE "E"
24,696.45
34,150;93
None
TOTAL REPORTED PROPERTY
58,847.38
PROPERTY NOT INCLUDeD IN RETURN BUT APPRAISED BY THE COMMONWEALTH
TOTAL UNREPORTED PROPERTY
None
TOTAL GROSS ASSETS
58,847.38
LIFE ESTATE OR ANNUITY CALCULATION
I do hereby certify that the above appraisement is made in conformity with Pennsylvania law and has been filed this day
with the Register of Wills.
(~/: ' .;";; / )
,..z... /... 'ff'} /. ,/1' .} ,'r/
APPRAISER
04/17/80
DATE
""
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- 0
10.
10. -
0 ~
~ 10. 0
10. 0
fo- 0 '" :z: 0
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REV449 (8.78)
;N-$O-7/
COMMONWEALTH OF PENNSYLV AN! ^
DEPARTMENT OF REVENUE
eUREJ\U UF FIELD OPER/\TIONS
SUPPLEMENTAL
-
*'
COUNTY OF._CU!'1~EJ~Ll'.t'lIL-
RESIDENT UECEDEIH
IMPORT ANT:
This r~t\lrn 11\\1"1 hI" l.:umph'll'l! Illl!t.t:'llllmllllcl1 illl11.1lll1l':Ih', ",illt nil atllu:hl'll, '.\1111 lhe Itq;lstt'l tie Wills uf ll\l~
('nullly \~ht'IC i1r.ccl,knl u'sHkd. H,t'tutll I:. dill' nillUllllllH' l\ll>lllh.. :Irln alale lie lkalh, links.; UlIl'xlcnsioll I'" grll111cd
lIy thl.' SCl.'rClilIY ue !tC\lCtHh'. ISl.ctItl1l10.11,llhl. Inlli"lilam::l' lU111 Fslale Tali. ACII)f Itl61,I
-~_---.---_._-
. . . - - - .' . ..'-
-.
IN TilE MArl EIt OF TilE EST HI' OF } AFFIIlA \'IT lII'
_MAY JACOBS _ .____--- EXEl'UI'IlIt
tSTATF. F'ULL NAtolr OF' OECEUEN11
>>>>~lGltKXN~
Lot. of __C.umberland-------.-.------ C"unl,
State of
pennsyl Vq,!:I.iJL
t
J ."'
Elll:CUtui
County ol.-Cumberl.and
..RAY-E---.JACOBS,-- ------
of tho IIlllala or lho oboveonomcrd docedenl bolng duly '....oln. depou 5 ond soy 5
, 19.-80 __J laltote leoving a 10.t ....ill. Cf>PY t)f which I, hereto attached.)
ty~MaU'K
~""
Decedellt died Januarv 21,
IMONTHl
Name and odd'.... of attorney or }
olh.r outhorlit.d ropnsentatlve to whor,l
all canupondoRcD should bo moiled.
IOf,VI
ROBERT L. MYERS IIIJJ.s..9W.J:.eJ_3.2.OJ1arket: S..t:re.et:.
P. O. Box 324, Lemoyne, Pa. 17043
That as suchJ~..cY.tor depnnenl is familiar wilh the affairs of said eslale and Ihe properlY cunstilUling
t EY.ECUTOR.,\OMINIST RA. TOR,
the assets thereof and their fair market value.
That al the time nf dealh lhere was nn safe dCJH1Sil box regislered in deceJenl's individual name, or jointly with, nr
as agent nr deputy nf aonlher, or in decedent's indiyidual name, wilh right of accesS by annlher as agent m deputy. with lhe
exception of the foHowin~: -
N....E 'NO AoonES> OF BAN< OR OTHE" INSTITUTION I THIS SAFE DEPOSIT BOX ~
IN WHICH OECEDENT RENTED A SAF'E DEPOSIT BOX IN NAME OR I>lAMES OF
RELATlON!iHIP OF JOINT
HOLOI!RS TO DECEDENT
~
That lhe contents of !laid safe deposit box or boxes arc itemized under Schedules
with the er.ccption of lhe fol1owins, for the rcasons hereinafter set forth:
of lhis return,
That Schedule A allached hereto and made pari hereof sets furth fully and in detail all the real pmperty
in the Communweallh of Penosylvania of which decedenl died ha\'ing an intere.. lherein, It also setS forth the
mortgage encumbrances upon each p;.rccl of real property al Ihe date nf death, giying lhe amounl still due at
death, name uf mortgagte, dale, rate uf ioteresl, and book and page of record Ihen:nf, It also sets forth in lhe
eolunUlS pro\'ided Iherefore lhe assessed valualion of each of said parcels, Ihe estimated market value thereof
as of dale of dealh or decedent.
That Schedule B auacht:d here III ,wd made part hereof sets forlh fully and in detail all personal properlY
where:;over situalod o"'ned by Ihe deeedenl al lhe time of death; all muneys left by lhe decedent al the lime of
de"th, whether in decedent', Immediale I,o",e<sion, slandin~ 10 deeedent's credit iu hanks of depusil, s,wings
banjos, trusl cumpanies, or olher Im;li,"liuns, whether individually. or in trusl fur any other persun or persous
giying also separately the accruell intcresl Ihercun. if any, down 10 the last inleresl day prier (01 decedent's
dealh in lhe case of savings bauks, and lu Ihe dele of decedent'" death in all other case,; all uonJs. posl:ll
savings, treasury certificates or nOlles and other evidence of in:lebtedness of Ihe United Statcs 10 the de-
cedenl; all Olbligaliuns, whelher by stalule or agn.cmenl they arc designated as lax free, of Ihe UnilOJ Stales,
ur any state. or polilical suhdivisiOln thereOlf, or of auI' foreigu cuuntry, which arc uwned at Ihe time of ,ll,,,tll;
all wearing nppalel, jewelry, silverware, pielures, buoks. works uf art, hnusehold furuilure, hurses, carriages,
automobiles, boats, and any and all Ollher personol challels of whatsoever kind or nature, lefl by deeedenl,
logether with the fairly eSlimated mcrkel value lhereof; all Il<lnds and mortgages held by decedent and of all
claims due and ,.wing decedenl at lhe lime of death, and a\l promissory notes or other instrumenls in writing
for lhe payment of money of which decedent died pussessed, nf whatsnever natur., wilh interest lhereon, if
any, giyiull Ihe face value and eslimaled fair maJkel yalne thereof, ,wd if such estimated fair market yalue be
less than the face value, it sets forth briefly lhe reasons for such depreeiatiun as to each item; a\l moneys
payable to the eslale from lire i"suranec policies carried by decedent; all annuity and endowmenl eonU'aets
th. proceeds ur which were payable upun lhe death of the decedent; all and the corporate stocks and diyidends
due thereon and unpaid es of Ihe dale "f death. bonds and accrued inlerest lherenn 10 the dale of decedent's
death and olher in\,estment securities owned by the decedent at tbe lime of death, with Ihe market value lhere-
of at such time.
In t.he case 01' s~etlrttles of' ClOfit' or l'lImli y r.ol'pcrutions, the vltlues report~rl Ilre tiS far llS
I'osslult! subsllmttntert by l'ln'ulcl'\l st.t\tenumts of the corporflllulIs, shnwln~ I.ht~ ~S'i.:!'t.~ nnel ltflblltt.lcs
llwreof liS of the dnt.e of l,.,,\t~h. 'fhH scl..~c1111l' nlso Silts forth thf! Intere:H. (If dt~cp.(lcnt at. the tIme or
IIt!nt.h In tl.nr co-p"rtnershll' or IJUslnm~sl RI1II In ~lIrt)()rt. of' tr\l~ Vll\UC of c;'h~h interest there 15 tUmp.x~d to
snjl! SClll'lhllt', f'innnct'tl ~t"lt('ml'tlt.s showln~ thl!!\s~wtq lUll! t~'lhlllt'I'S of' snld cn-p.'lrt.rwr5hij) or hll!'Oln~'is.
A copy or thl' co-pllrtnershlp llJ~r(~(!ml'nt, (If ornl, tl st.ntl'll1f'ut. s."'tl.ln~ forth the '1flt.1H'l~ ot' t.ht! "lJ.;rl~l!ment)
to~"t'\('r volth tI statement settlll~ forth th~ cl1nrnctcr of t,II'" tllISlll"':;"', Its locnlltJO, tincl such other fIlets
p('rtlllnln~ to the hllslnC'ss ns nlll}' Ill' Jlf~rtlllpnt to Il f'fdr Ilru\ .tust Ilpprntsltl 01" t,he rlecfHtentls lnt..~rest.
th(,l't~ill must he suhmltlf!ll. It should ulsn SHt forth In ltt!mllf'ft form, r.f)~etlll~r with tllt~ fair mtlrkot vuluo
thereof, Itll)>' other propert). oWllml fir bequHnl.hmt hy t.h{~ .!l!CI'lh'lll. 11 t tilt. t 1m.! nf' denth.
The SCht?dule C nttachlHl llC'retll unct mlule llRrt. hf'I'('o(" !HH.s fnrth /I t.rlle 'lns.....er t.o eflch iOllulry
COlltnlnnd thereJn nnd In t1w C6S~ 01' trnnsfers orl'l"nJl('rt~., renl or personnJ, within t.wo yenrs of decedent's
df!llth, in contemplut.1un 01' ctecf'dcnLtS ftenth, or Jn1.('nded to tJlkn l~rrP.ct tn rJO~sp.sslon or en.loJ'7l)(!nt Ilt or
after deuth, said schpdule sets furth the nnture nncl vlllur~ nl" such properlY, 1.0 whom t.rnnst'errerl, the
relatIonship of the transferees to the lleccch~nt, till! pro[lOI't.tnnnt.c shure recelverl by chch transf(>ree llnd
till other fucts of n pertinent. nllt.ure rcgnrrlJIlA suln t.rllnsfers. In the CIlSf~ of trnnst'ers intended to
tak':!' effect in possession m' enjoyment lit.. 01" l\fter clent.h, therl"' is III so IltlllC"hcH! lo the schedule 11 COllY
of' the deed, trllst agreement or other instrument cl'enttng thf~ trust.. 'l'hl~rl' Is also set. forth in said
schedule f\ list of nIl property, renl find personal, wit.h its "nIue, 'tI'hleh }lll~ses nt decetlC'ntts dt~nth by
virtue of the exercise by decedent., either Indlvirluully, or.1nint.ly w"ith another, or any power of Appoint-
ment vested In decedent, eIther InfltvIduall}' or JoIntly, by the will, deed, or other instrument of' another,
with 11 copy of the instrument crentlnp; such power nttucheci tn tht' schedule.
Thot Scht!dvlt! 0 nttochcrl hereto /lnd mucic purl. herf!c}l' sets forth tht! nflmes nn,l addresses of R.Il
persons heneficilLlly interested In thts estntc ut the time nf" decerlent' s dCllt.h, the nature of their res-
pective interests, their relationship, 11' uuy, to the rlecettellt, t.uv;ether with the ages tit the time of
decedentts denth of nIl minors, annuitants onel heneficlnrles for life unriHr ttecedent's WIll. It also
contains Il statement showing which of the heneficillries nlUT\NI 111 the decedent's wIll, 11' any, died pr10r
to decertent, the nates of their dellth, tl1C'lr tssue, und the rell1tlonshlp of stich Issue to the beneficiary.
Thtlt Sc/ledule E aLttlched hereto and mlHle n part. hereof sets forth all property, real and IJer-
sonnl, ol'l'lled b~' the decedent Jointly with anothel' or others, including 1nt.angible, sttlndlng in the nanle
of the decedent. tinct others, plus the date ItOd plllCe of record of Instruments effecting the \cstiture of
real estnte lillet the dat.e of tlCCluIslt10n of personalty, plus the nnme, netrlress and relationship, if tiny,
of co-owners to the deceden t.
That Sc/lt'dule F attuched hereto hnd mnde a part hereof sets forth fully and in detail all debts
and deductions clllimed for and on behnl I' of this elecerlcnt's estnte, inclurting funeral expenses paid;
fum"U~' exemption, where nppllcable; costs of ndmln1straUon of this estl1tc; counsel fees and fuelicillryls
corranissions paid or to be paIdj cost expended for burinl trusts, tombstones or gl'nvemnrkers, anll reli-
gious services, in consequence of t.he death of the decenentj debts and cltlims owing and l1npaIti Ilt time of
death; taxes accrued chargellble fOl' period prior to decenent' 5 lleuth (cxctJpt those allowed under Section
651 of the lnheritlU\Ce anel l<:stnte Tux Act); together with u stntement of collateral pledged for oblign-
tions, if nny. It Is agreed thnt the fiduciary wlll present p1"oof ot' sllld claimed obligations upon re-
quest, that if the amount actun]]~' pllid In settlement of any fcc, commission or debt 1s less than the
estimnted lUnount clnimlng nnd nllowed, thnt the same will he reportecl to thp- HC'gistcr of Wills, and that
the IlInount of tax nssessed Clm he rcnssessed In nccorclnnce thcrewi th.
Thnt the tot.nls of the npprol'rlltte cl)lunuH. in Scheclules "A", "B", "e", "E", nnet "F" tiS dil'ected therein,
hnve llCp.n curried f"orwnrd Ilncl Jlrol'erly registered in the Summllr~',
~~~----
.....,::::;...,-.;>1;,"",":,"- t-:2....A ._,,-=L_~__.. ........ ...R<l,yK~~g.Q.~:.~~..4.1.s.:t.....S.tJ:.e.et
( Street Number)
Toyto R. Andorson. Notary Publi,
M'I CO:tl1nia:cn Ex~irCi Jul'1 25. 1981 "~~I?..?.;"~"~J'''_'~'~''~'''.'H...J.7..QJJ.............."...."...".............-.
Lc:no~'nc. PA Cumllt;t1olnd Counl't (City or Town and State)
SOTl'.:: Ih~fore signing lltTiclnvtt make sure ull hlnnk spoees in the nt'fidnvlt unci schedule~ annexed are
filled In wIth det.ails or the .....ord "NOlie", nncl In cuse the assets include rurc nnn unlisted securtt.ies,
securities of close or fnmll)' corf1orntIon~ or nn Intert~st In lmy co-partnership or business, thnt the
dnt~ fiTlrl statements requirt'!clundcr the pnruf;l'aph above relnting to SChl~cllIle "B" are tlttncherl. Also make
cl!rl1Jln thut. column #1 in thl'! "Sttnrnal'Y" has heen pr()p~rly completcrl us fthove-t!lrecterl.
SubSI:rir.ed and sworn to before me thiB ....1.8..th .........
. . day of .. Apr il t...
..... .......... 19....80...
REV.4~1 (8.78.
.~
, '
, ,
:<". 'Ct.
COMMONWEAL TH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "B"
PERSOHAL PROPERTY
INSTRllCTIONS: This Schedule l1lu:-.t discluse all tllllg,ihle and intilng,ihle personal property uwned individually by Ihe
decedent. OIt the time uf his de.llh. ProperlY owned hy the decedent jllintly with another ur ulhers must he listed
under Schedule liE". Intllng,ihle perHon:d property, titlell in the llilllle uf the lIecedent. hul p:lYlIhlc ilt death to anolher
or uthers, inclulling hut not limitcdltl P.O.Il. U.S. Sa\'ings BlllUb illld ten tati\'c trust aeellllnts, must he lislet.!, despite
the fact that they arc nul of the administered estate.
Ttlllgibte persun,,1 prul,erly should he listed first (e.g. jewelry, \\'earin!: :lpp.arel, huusehllld gUilds, and
furnishings, hooks, paintings, auttll1lOhilcs. boats, cte.)
Intangible 11ersunal prnpcrty, slleh as bonds, HC:lsury ccrtificitIC:-', eash un hand :Ind ill hank, slllcks,
mortgages, nntes, together with accrued interest or dividends, sal;arics ur wages, insufill\ce l1aYilhlc tll the estate or
fiduciary in said capacity, p:ulnership inlerests, interest in any undistrihuted estate IIf or incume frum un)' property
held in trust under lhe will or agreement of another, e"en though IClcated outside I)f the Stale, at the lime of ueath.
should he listet.! in this sdtcdule.
Item I1ml UNIT ESTI~IA TED DEPARTMENT
No. List and describe fully Vt\l.,UE MA.RKET VALUATION
VALUE (Do nnt write in
thi fi space)
1- Colonial Penn Franklin Insurance Co.
insurance payment $ 60.75
2. Blue Ridge Haven West - refund 212.05
Insert thi fi Inial opposite "Persnnal property", Seheuule uB" in XX $272.80 .t 7.2, SO
the liAs Reported" column on the lasl p:lge of this return. -!I~
REV-484 EX'" (3.S0)
INHERITANCE TAX SUMMP.RY SHEET
SUl'l'LEHENTAL (BUREA~_ USE ONLY)
File Number
21-80-0071
Estate Nome _.Jlay_J acobs- -----
-~_._-----_._------
Dote 01 Death
1/21/80
Social Seeur; ty Number ._-
._-~_._--
REPORT OF INHERITANCE TAX APPRAISER
I, tho undersigned duly appointed Inheritanc. Tax Apprai..r in and far the County of r~"11b~rl "nrl
Pennsylvania, do respectfully report thot I have appraised the real and personal property as reporte in t e foregoing
return at the values set forth opposite each item in the last column to the right in Schedules "A", "B", "C", and HE"
Dated: -l4-ay e. 1geo
..-ifP ex " , } f( '0" n , ~ )
INHEFUTANCt.: TAX APPRAISER
INVENTORY
ADJUSTMENTS
VALUE AS APPRAISED CODE (HARRISBURG USE ONLY)
S None 00+
272 80 10+
tin 2.H
Ilone 30+
Real Propert)' (Schedule A)
Personal Property (Schedule B)
Jolnt.Held Property (Schedule E)
Transfers (Schedule C)
TOT AL GaOSS ASSETS
--2-72080 _n_ --- - -----
40-
Leu D.bt. and Deductions
(SCHEDULE F)
CLEAR VALUE OF ESTATE
Valuation of life estatu or
annultl.s. . . . . . . . . . . . . .
~
FACTOR
PRINCIPLE
FOR USE OF REGISTER ONLY
Tax on S
CODE
6'.
"
Tax on S
\5%
Tax on $
Tax on S
Tax on S
Exemptions
Total Estate
TOTAL TAX
INTEREST FROM
BALANCE
TO
Ll!!lSs Credits
DATE OF PAYMENT
INTEREST
AMOUNT PAID
DISCOUNT
S
+ S
S
+
INTEREST FROM
BALANCE DUE
BALANCE
TO
S
S
S
REMAINDER APPRAISEMENT CODE
VALUE
COMPUT A TION OF TAX
S
S
$
$-
5
S
$
S
TAX CREDIT
=
$
=
92+
93-
CODE
I
'*
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPEflAlIOr.:S
P. o. BOX 2370
HAR RISBURG
17105
IN YOUR REPLY PLEASE
REFER TO
Inveltlgatlon Olvlllon
REV.5J813.79)
NOTICE OF FILING OF APPRAISEMENT
RayE. Jacobs
30 North 41st Street
Camp Hill PA 17011
(Exocutor or Administrator)
In Re: Estate of
rtay Jacobs
Cumber1 and
County-FileNo. 21-RO-0071
Dear r~r. Jacobs:
You are hereby notified that the supplemental
appraisement in the estate of M~y .1~,.nh~
has been filed in the office of the Register of Wills of r.lImh",.l ~nti
County on M ~y R ,19-80., Said appraisement reflects the following valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
Nonp
2 72 . 80
None
None
272.80
As to such tax that is paid within three months from date of death, a five (5%) percent
discount is allowable. As to any tax that remains unpaid after nine (9) months (fifteen months
when death occurred from December 22, 1965 to June 16, 1971, inclusive; and twelve months
when death occurred prior to December 22,1965) from date of death, interest at the rate of six
(6%) percent per annum is charged.
, Any party in interest who is aggrieved by this notice may object thereto within sixty
days after receipt of said notice as provided by Section 1001 of the Inheritance and Estate Tax
Act of 1961, 72 P. S. 2485.1001, P. L. 373.
Date
May 8. 1980
.il/f'._4 !l' J R~!ttl-l"d )
Signed
Title Chief ^ppraiser
NOTE: This is not a bill.
.
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: Received by
! NOTE: In accepting the rronder inheritance 10. on fulure luloles, prior 10 the deolh of Ihe lile
\ 'enonl or lononl fOf years, 0$ evidenced by this receipt, il is understood thaI the Commonwealth sholl
nol be precluded Of prevented from hereaher auening additional inherilonce 10' ollhe dealh of the
life lononl or lenonl lor yeof' whene....er il appears thai luth additional lax may be legally due onJ
collectible fOf any rllOIon whOlloe..er.
t----------- ---- - ----- -- ----- -------- -------------
j
..-.....-__ ~__....... _ r.;:JL ..... __ r... -.-...~ .'P"l~>>_""
!tl RCC4(11/78) ,'. ' COMMONWEALTH OF PENNSYLVANIA
lNOJ' 063026 DEPARTMENT OF REVENUE
f, ' OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX
II
"
; RECEIVED
II
= From,
lI'l(
, .ddress
or
~
I.
~
fI F;le No.
S Date of Payment
i Nome 01 Decedenl M~ JIlCOaq
-.-
~
-.u-~~
~,.'.
~,
Ray I. 07&C:o);)8
alo Robert L.
P.O. Box :124
TWBNTY. HIe IlUNDRBD DOLLARS _ _____________<l>>.!!ors
representing Pennsylvania Inheritance or
Estate Tax due from the following estate:
Myex-a, III, B
.
2'" Tax on
s
s
LeIIIOyne ,
Pa.
17043
6% Tax on
s
s
21-80-71
Dole 01 Deolha 1-21-1980
15'iC Tax on
s
s
April 21,
19S0
~ Tax on S
Estate Tax, Act of
Mey 7, 1927
s
~
e
s
County
CWIlberland
TOTAL TAX CREDIT
Less five percenturn of lox if
paid within three months ofter
dole 01 deolh
Plus interest 01 the rale of
_%from
s
"I,O"2,!;"
Remarks:
s
152.U
.PAm ON ACCOUNT"
10
s
'iJ'OO~[p~~@ill'jj'rn
5 E A L
TOTAL AMOUNT PAID
s
2,900.00
NOTE: This Triplicate Receipt to be retained for audit purpose..
OF CUMBERLAND COU NTY
ANa AGENT OF THE COMMONWEALTH
. j,/,)
j'
~ /.14
. / ,I 1,' .
DEDUCTIONS ALLOWED IN
THE SUM OF 5 P:;.k, f{f:"
"I c) /f<"/'I
D~H APPR~VED,L.L~t~~ ' ~ (
!J~ , / I. I I) . ".,,(, ,,' " .
;f).: ' IlEOISTr:R 01'" WIl.l.S, AGENT
.,/.,
DFF ICE OF THE
REGISTER OF WILLS
.,/-~. ~)/
-- /) L
STATEMENT OF DEBTS
AND DEDUCTIONS
REV-C8t1 U-711'
ESTA TE OF
MAY JACOBS
LATE OF Lower AllelL.Township. Cumberland
County, Pa.
DATE OF DEATH --'1."nnar:l 21 llB.O....
.
DATE NO. OF NAME OF PAYEE REMARKS AMOUtlT
VOUCHER
1/"I1/Rn Reqist;.er of Wills Probate 11 nn
.
2/12/80 Medicare Patient Aid Cente Medical Expenses 60 00
2L19.l-11.D Mvers Funeral Home Inc. Funeral 1,471 00
Gi~h M~mnrials Gr,.2.ve Marker 6,n nn
Patriot-News Co. Advertise Letters 19 38
~umberland Law Jou~nal Ad",'..tiso 18 00
Reaister of Wills File RCC D & D & Inventor\ 9 00
IMo.taJ:.~e D"~ n <. n r. ,+-"..u /I <;n
Ray E. Jacobs F~ilY Exemption .2J.QQQ ..QJL
Robert L. Myers III Leaal Services ' 23.4 -D.!L
. -
.
I
,
---1 TOTAL Is 5 . 44..6..iJUL
n . n -
DATE OF FILING APPRAISEMENT
COMMONWEAL TH OP PENNSYLVANIA
COU N TY 0 F .J;;UMBERLAND
I, _Ray....E..-Jac.Obs HEREBY CERTIFY, THAT TO THE BEST OF
MY KNOWLEDGE AND BELIEF, THE FOREGOING 1$ A JUST I.ND TRUE STATEMENT OF DEBTS, FUNERAL EXPENSES AND
EXPENSES OF ADMINISTRATION SUBMI TTED TO THE ESTATE OF --May .T"cobs
DECEASED, AS DEDUCTIONS FOR INHERITA~.CE TAX PURPOSES.}" ." [\ 'j
I't",j. /' \ , .; C . /,.,. ,}
I / 'I' _ J ':i-- " (..-V..x.---
Ra Jacobs
j
SS,
(L.S.)
SWORN AND S,,!lSCRIBED BEFORE ME THIS ,) C h~ _ DAY OF
..:( ., ,. ~'""..'" 19 !ilL.
<~~ '. "Cl i . -
~_~... ~~;."...~~.,,- ....,_. __......~\. .:1 c-.....--
. -
, . Joyce R. And,rson. notary Pubfic
.. Mv Comrninion Ex~i,c' Ju!v 2.5. 198]
Lemoyne. PA (umLc:rI4nd (oonl1
OFF ICE OF THE
REGISTER OF WILLS
02/-a) ~ 7/
STATEMENT OF DEBTS
i AND .REDUCTIONS
t'J"d.:' /l~_itj!,~/,IC;t{)
SUPPLtMENTAL
OEOUCTIOHS ALLOWEO IN
THE SUM OF $ / (, '/. 00
OAn APPROV.ED '7/14[1 )( 11Vd
1 UA.<'.d .6 r'4(C;)G:~
fJil",j REGISTER OF WILLS. AGENT
REV.4~' (a-711'
OF CUMBERLAND COUNTY
ANO AGENT OF THE COMMONWEALTH
ESTATE OF MAY JACOBS
LATE OF Lower Allen Township. Cumberland
County, Pa.
DATE OF DEATH .T"n"",.y" , qRn
DATE OF FILING APPRAISEMENT
DATE NO. OF NAME OF PAYEE REMARKS AMOUHT
VOUCHER
2/19/80 Reverend Robert Rhine Funeral Services 20 00
3/5/80 Harrisbura Hospital Blood 90 00
4/17/80 Dr. H. R. Brooks Medical Expenses 45 00
File Supplemental RCC and
R"aist-er of wills D .. D " nn
"'~~ .....--, ., Di"'i'" ~~,. " r. " ., nn
-
"'''''' " T. S'''4 nn
COMMONWEAL TH OP PENNSYLVANIA}
SS:
COUNTY OF CUMBERLAND
I. Rav E. Jacobs HEREBY CERTIFY. THAT TO THE BEST OF
MY KNOWLEDGE AND BELIEF. THE FOREGOING IS A JUST AND TRUE STATEMENT OF DEBTS. FUNERAL EXPENSES AND
EXPENSES OF ADMINISTRATION SUBMITTED TO THE ESTATE OF Mav Jacobs
DECEASED. AS DEDUCTIONS FOR INHERITANCE TAX PURPOSES. ..1'1 Q ..
",,; ~7~ ,J~
(L.S.)
SWORN AND SUBSCRIBED BEFORE ME THIS 18th
APril 19 80
.-~
-- ,..--- .
.
p
^~ ,
.......
Jov,e R. Andorson. NDI,ry Publi,
,,~v ColTtmiuion b.,iret Julv 25. 1983
. le,norn::, rA (umb~,lilnd County
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
'*
OFFICIAL NOTICE OF
INHERITANCE TAX
ASSESSMENT
COUNTY FILE NO:
-:/
/-': -
. , . /' cll/{j
/// l/~.j / J- L:.
I '
;//{; '.U-~r.-C;~
.f ''-
..:;'j :,?-/J - 7/
,/ / / ,.
i ___(.t:J.',/(r~c..<A..."1_~
'.-. '7' /'
.( {., - I
DATE
_i (.J. ;i
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tc.-V<-<.") .. ///i/.:-~o/ /f../.
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( -/ .. L / ,/"..J;:v/ '-'.:./ T
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,0-<://;Lr<.t '..r. ,(/'" / /tJ -"/.3
Ap6raised Vqfue of Estate:
,
Real Estate
ESTATE
,.
v.......:,:.-f
,..('
FILE NO.
COUNTY
DATE OF DEATH
/-.":(/-j?J
s
Personal Property
+
Jointly Held PropenylTransfers
+
Total Gross Estate
s
Total Approved Deductions
Clear Value of Estate
s
Less: Approved Charitable Exemptions
Clear Value of Estate Subject to Tax
s
Amount Taxable @ 6% Rate
s
tax due
s
Amount Taxable @ 15% Rate
tax due
TOTAL PENNSYLVANIA INHERITANCE TAX DUE
s
/:;-1 ;e
* * . * * . A five percent discount totaling S
will be granted if the Inheritance Tax is paid by
Less Credits:
DATE OF PAYMENT
AMOUNT PAID
$ 157 '/3
DISCOUNT
INTEREST
TAX CREDIT
=
$ /j '7 J?
5 :! r
- /> - I' ,)
+
s
$
+
=
+
=
Interest accrues at the rate of six (6) percent per annum
on the unpaid balance of Inheritance Tax from
to date of payment. Interest due if paid by
is
~/ __./ .:/i 1'/' '
s(--":'/,.-;/" /7.J/(/C;<-L~
BALANCE OF PENNSYLVANIA INHERITANCE TAX OUE
'/j~ . /"... v(.L/ /
. L"./ /L...:z.-.'
Assessed by: k'L 1/.1 Ct-c-
See Informal Ion on Roverse Sldo Agenl,for..~,~co~:z:we~ lh y1 ,'I. J . ~ /" /
II-:!,?/... '-V, l..u,~
/ \ ~_/ ,.co. "
I,lllll,; , \ " ",/
~_~i~~~~t::~!li!!...~~'.....,..""'l,",,"""'~~.. _~i