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Home My WebLink About05-08-07 (2) ...J 1505b041147 EX (06-05) PA Department of Revenue Bureau of Individual Taxes ~ PO BOX.280601 ~ Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death REV-1500 OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN 21 06 RESIDENT DECEDENT File Number 00719 Date of Birth 183122872 08112006 12171910 Decedent's Last Name Suffix JACOBS Decedent's First Name ROBERT MI L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW !Xl 1. Original Return 2. Supplemental Return D 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate D 4a. Future Interest Compromise 00 5. Federal Estate Tax Return Required (date of death after 12-12-82) lKJ 6. Oecedent Died Testate D 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received D 10 Spousal Poverty Credit ~date of death D 11. Election to tax under Sec. 9113(A) . between 12-31-91 and -1-95) (Attach Sch. 0) ~ORRESPONDENT. THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Number IVO V OTTO III 7172433341 Firm Name (If Applicable) MARTSON LAW OFFICES REGISTER OF WILLS US!; ONLY First line of address 10 EAST HIGH STREET ,:::-,-':" --' Second line of address C.:~ -n City or Post Office CARLISLE State PA ZIP Code 17013 ____J I DATgfILED -.-i f') w. Correspondent's e-mail address: Under penalties of pe~ury, 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 preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN OAT r Elizabeth J. Jamieson 296 Sterling lace - Apt. 10, Brooklyn, NY 11238 S~T~~. ~RER OTHER~THAN REPRESENTATIVE ~ ~ =- IVO V OTTO III ADDRESS DATE \ ~\..? 01 1 0 East High Street, Carlisle, PA 17013 Side 1 L 1505b041147 1505b041147 ---I J PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER JACOBS, ROBERT LEE 21-06-00719 Under penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Name Address1 Address2 City, State, Zip " 14-9 ~ Ann J. Compton P.O. Box 173 Signature #2 Date Southern Pines, NC 28388 ~ -I 15056042148 REV-1500 EX Decedent's Name: ROBERT LEE JACOBS RECAPITULATION Decedent's Social Security Number 183122872 1. Real Estate (Schedule A}..................................................................................... 1. 137,500.00 2,876,594.35 44,250.00 2. Stocks and Bonds (Schedule B)........................................................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D)....................................................... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E}.............. 5. 586,432.99 6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 Separate Billing Requested............. 7. 54,000.00 8. Total Gross Assets (total Lines 1-7}.................................................................. 8. 3,698,777.34 9. Funeral Expenses & Administrative Costs (Schedule H)...................................... 9. 170,566.52 67,835.21 238,401.73 3,460,375.61 10,000.00 3,450,375.61 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)............................... 10. 11. Total Deductions (total Lines 9 & 10}................................................................. 11. 12. Net Value of Estate (Line 8 minus Line 11}.................:........................................ 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J).............................................. 13. 14. Net Value Subject to Tax(Line 12 minus Line 13}.............................................. 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2) X .00 16. Amount of Line 14 taxable at lineal rate X .045 17. Amount of Line ~ble at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 o .00 15. o . 0 0 16. 153,016.90 17. o .00 18. 7,500.00 19. 160,516.90 o .00 3,400,375.61 50,000.00 19. Tax Due............................................................................................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. D Side 2 L 15056042148 15056042148 -I REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME ROBERT LEE JACOBS STREET ADDRESS 3620 Logan Court File Number 21-06-00719 CITY ] STATE PA IZIP Camp Hill 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 160,516.90 145,000.00 7,631.58 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 152,631.58 Total Interest/Penalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thEOVERPA YMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is theBALANCE DUE. (3) (4) (5) (5A) (5B) 7,885.32 7,885.32 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;............................................................................. b. retain the right to designate who shall use the property transferred or its income;................................ c. retain a 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 without receiving adequate consideration?................................................................................................................ x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death:?....... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?............................................................................................................... x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Yes No iX ~ ~ IX L!'. 1.:' x x For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [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 zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)]. The statutedoes 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 zero (0) percent [72 P.S. ~9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116 1.2) [72 P .S. ~9116 (a) (1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev.1S02 EX+ (6-98) *' SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 All real property owned solely or as a tenant In common must be reported at fair market valuliair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller. neither being compelled to buy or sell. both having reasonable knowledge of the relevant facts. Real property which's )olntly-owned with right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Residence - One-half interest in residence situate in Camp Hill, Hampden Township, Cumberland County, PA, known as Parcel No. 10-21-0275-363-UC00200; being described in Deed dated June 28,1996 and recorded in Cumberland County, PA, Deed Book 142, Page 107, and being conveyed to Robert L. Jacobs, single man and Betty P. Hafer, single woman, as tenants in common. Value is actual sale value, see attached Settlement Sheet. 137.500.00 TOTAL (Also enter on Line 1, Recapitulation) 137.500.00 (If more space is needed. additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 6-98) Rev-1603 EX+ (6-98) . SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 All property Jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 88579Y101 1,200 shares of 3M CO - Com 68.655 82.386.00 2 002824100 2,100 shares Abbott Labs - Com 47.365 99.466.50 Accrued dividend on Item 2 through date of death 640.00 3 00845V308 40 shares Agere Sys Inc, New 14.59 583.60 4 019228402 6,954 shares Allied Irish Banks P L C - Spon Adr Ord 50.215 349.195.11 Accrued income on Item 4 through date of death 4.444.00 5 00206R102 335 shares AT& T Inc 30.26 10.137.10 6 053499109 125 shares Avaya Inc - Com 9.06 1.132.50 7 071707103 400 shares of Bausch & Lomb Inc - Com 45.11 18.044.00 8 079860102 180 shares of Bellsouth Corp - Com 39.352 7.083.36 9 142339100 878.170725 shares Carlisle' Companies Inc. 81.14 71.254.77 10 20030N101 291 shares of Comcast Corp New - CL A 34.090 9.920.19 11 263534109 1,000 shares of Du Pont E I De Nemours & CO - Com 39.07 39.070.00 12 264399106 2,000 shares of Duke Energy Corp - Com 29.68 59.360.00 Accrued dividend on Item 12 through date of death 640.00 13 35687M206 231 shares of Freescale Semiconductor Inc - CL B 29.07 6.715.17 Total of Continuation Schedules See attached pages TOTAL (Also enter on Line 2, Recapitulation) 2.876.594.35 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule B (Rev. 6-98) Rev-1i03 EX+ (6-98) . SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP ! VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 14 369604103 4,000 shares of General Electric Co - Com 32.600050 i 130.400.20 15 427866108 1,200 shares of Hershey Foods Corp - Com 52.485 62.982.00 16 438516106 1,500 shares of Honeywell Inti Inc. - Com 37.205 55.807.50 17 441060100 210 shares of Hospira Inc - Com 34.33 7.209.30 18 456866102 1,800 shares of Ingersoll Rand Co - Com 37.135 66.843.00 19 478160104 2,000 shares of Johnson & Johnson - Com 63.595 127.190.00 20 549463107 2,500 shares of Lucent Technologies Inc - Com 2.12 5.300.00 21 55261F104 674 shares of M & T Bank Corp - Com 121.40 81.823.60 22 590007100 2,000 shares of Meritor Svg BK, PA 3.985 7.970.00 23 620076109 2,100 shares of Motorola Inc - Com 22.69 47.649.00 24 693475105 410 shares of PNC Financial Services Group Inc - Com 70.50 28.905.00 25 69351T106 1,520 shares of PPL Corp - Com 34.555 52.523.60 26 743263105 780 shares of Progress Energy Inc - Com 43.395 33.848.10 27 767754104 2,000 shares of Rite Aid Corp - Com 4.41 8.820.00 28 780259206 800 shares of Royal Dutch Shell PLC 70.365 56.292.00 Accrued dividend on Item 28 through date of death 504.64 i T Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1S03 EX+ (6-98) . SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP I VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 29 880306105 21 shares Tenajon Resources Corp - Com .36 7.56 30 902124106 2,000 shares of Tyco Inti Ltd New - Com 25.50 51.000.00 31 92343V104 140 shares of Verizon Communications - Com 33.91 4.747.40 32 92857W209 2,187 shares of Vodophone GP, PLC, ADS, New 20.695 45.259.97 33 929903102 3,797 shares of Wachovia Corp 2nd New - Com 53.375 202.664.88 34 984121103 500 shares of Xerox Corp - Com 14.445 7.222.50 35 98956P102 2,000 shares of Zimmer Holdings Inc - Com 67.76 135.520.00 36 00362PD45 Abington Twp PA DO Bds - 25000 units 98.693 24.673.25 Accrued income on Item 36 through date of death 298.06 37 1073855M4 25000 units Allegheny GO - C BE @5% 103.979 25.994.75 Accrued interest on Item 37 through date of death 388.89 38 108479JS6 25000 units Allentown PA Wtr Rev GTD 99.211 24.802.75 Accrued interest on Item 38 through date of death 270.83 39 021789DV1 10000 units Altoona GO BE - @4.625% 102.019 10.201.90 Accrued interest on Item 39 through date of death 248.26 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule B (Rev. 6-98) Rey-1503 EX+ (S-98) *' SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION . UNIT VALUE OF DEATH 40 021789DV1 15000 units Altoona GO BE @4.65% - 100.89 15.133.50 Accrued interest on Item 40 through date of death 277 .06 41 109754AJO 15000 units Bristol Boro PA Sch Dist GO Bds 97.288 14.593.20 Accrued interest on Item 41 through date of death 203.33 42 152735PB6 10000 units Central Bucks PA Sch Dist GO Bds 97.559 9.755.90 Accrued income on Item 42 through date of death 86.00 43 157882GD7 25000 units Chambersburg PA Area Sch Dist GO Bds 98.786 24.696.50 Accrued interest on Item 43 through date of death 411.11 44 165573QC3 50000 units Chester Cnty PA GO Bds 97.951 48.975.50 Accrued income on Item 44 through date of death 757.78 45 165573RB4 50000 units Chester Co GO BE @ 4.5% 102.167 51.083.50 Accrued interest on Item 45 through date of death 531.25 46 165573QW9 50000 units Chester Co GO BE @ 4.5% 103.682 51.841.00 Accrued interest on Item 46 through date of death 531.25 47 250057 JS6 25000 units Derry ASD - C @4.15% 100.125 25.031.25 I Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule B (Rev. 6-98) Rev.1103 EX+ (6.98) *' SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH Accrued interest on Item 47 through date of death I 501.46 48 276590KK1 15000 units Eastern Lancaster Cnty PA Sch G 0 98.903 14.835.45 Bonds Accrued interest on Item 48 through date of death 162.30 49 302024HB3 25000 shares Exeter Twp PA Sch Dist 98.161 24.540.25 Accrued income on Item 49 through date of death 185.14 50 396370AY4 25000 units Greenville PA REF DO Bd 99.612 24.903.00 Accrued interest on Item 50 through date of death 175.00 51 477547DK6 50000 units Jim Thorpe ASA A - @ 5.25% 102.319 51.159.50 Accrued interest on Item 51 through date of death 1.150.00 52 477547CSO 50000 units Jim Thorpe ASD - A - @ 3.75% 108.127 54.063.50 Accrued interest on Item 52 through date of death 1.079.17 53 477547FG3 25000 units Jim Thorpe PA Area Sch Dist GO Bds 98.788 24.697.00 Accrued income on Item 53 through date of death 354.86 524808BK7 15000 units Lehigh Cnty PA Indl Dev Auth P. Rev Bds 98.21 I 14.731.50 54 Accrued income on Item 54 through date of death 130.21 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1603 EX+ (6-98) . SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH i 55 621813JV7 25000 units Mount Lebanon PA GO Bds 100.093 25.023.25 Accrued income on Item 55 through date of death 25.00 56 021789DV1 50000 units PA ST GO BE - @ 4 5/80;0 102.381 51.190.50 Accrued interest on Item 56 through date of death 366.15 57 709141FF7 50000 units of Penn GO 2 Ser BE - @5% 103.086 51.543.00 Accrued dividend on Item 57 through date of death 911.20 58 709141JV8 40000 shares Penn St GO-3rd BE - @ 5% 103.992 41.596.80 Accrued interest on Item 58 through date of death 294.44 59 50000 units Pittsburgh SID BE - @ 5.38% 100.068 50.034.00 Accrued interest on Item 59 through date of death 1.134.72 60 30000 units Radnor Twp. SID BE @4.0% 97.236 370.00 Accrued interest on Item 60 through date of death 370.00 61 50000 units Solanco Sch Dist @5% 100.634 50.317.00 Accrued interest on Item 61 through date of death 1.278.33 62 905811CX1 5000 units Union City PA Area School District 99.042 4.952.10 Accrued income on Item 62 through date of death 10.83 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1i03 EX+ (6-96) *' SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM CUSIP i VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 63 953470KS9 30000 units West Jefferson SID - @4.75% 104.623 31.386.90 Accrued interest on Item 63 through date of death 672.92 64 953470KX8 30000 units West Jefferson SID @4.75% 101.908 30.572.40 Accrued interest on Item 64 through date of death 672.92 65 97959HD06 10000 units Woodland Hills Sch Dist PA Ref DO bd - 97.164 9.716.40 @3.1% Accrued interest on Item 65 through date of death 137.78 TOTAL (Also enter on Line 2, Recapitulation) 2.876.594.35 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule B (Rev. 6-98) Rev.1Ai03 EX+ (6.98) *' SCHEDULE C CLOSEL V-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship, See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER DESCRIPTION 1 177 shares Frog Switch Manufacturing Company - @$250 per share VALUE AT DATE OF DEATH 44.250.00 TOTAL (Also enter on Line 3, Recapitulation) 44.250.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule C (Rev. 6-98) Rev-10508 EX+ (6-98) *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bowmansdale Lodge #1179, IOOF, death benefit 970.00 2 Citizens Bank checking Account #610073-129-4 41.546.86 3 Citizens Bank Premium Growth Money Mkt Account #620580-353-8 79.198.66 4 Delta Dental, refund 71.00 5 Express Scripts, Inc., refund 36.00 6 Hershey Trust Temporary Investment Fund, cash balance 14.363.37 Accrued interest on Item 6 through date of death 23.10 7 M&T Bank Preium Interest Account #98121480 57.954.68 Accrued interest on Item 7 through date of death 30.95 8 M&T Bank savings account #15004200053673 23.961.66 Accrued interest on Item 8 through date of death 56.81 9 MetUfe, final payment of long term care insurance 6.300.00 10 Morgan Stanley Investment Account # 616002984020 - Cash balance 348.132.00 11 Residence - Tax proration, school taxes 325.90 12 Household goods and personal property, Camp Hill residence 12.500.00 13 Jewelry, appraised value 962.00 TOTAL (Also enter on Line 5, Recapitulation) 586.432.99 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule E (Rev. 6-98) Rev-1t10 EX+ (6-98) *' SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ThiS schedule must be completed and filed ilthe answer to any 01 questions 1 through 4 on the reverse side 01 the REV-1500 COVER SHEET is yes. ITEM ~ .~ _,' r DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 Ann Blaine Holland, granddaughter, 7/15/06 12.000.00 100.000 3.000.00 9.000.00 2 Ann J. Compton, daughter, 1/1/06 12.000.00 100.000 3.000.00 9.000.00 3 Elizabeth J. Gallagher, granddaughter, 7/15/06 12.000.00 100.000 3.000.00 9.000.00 4 Elizabeth J. Jamieson, daughter, 1/1/06 12.000.00 100.000 3.000.00 9.000.00 5 James Grover Holland, IV, grandson, 7/15/06 12.000.00 100.000 3.000.00 9.000.00 6 Wendell J. Jamieson, grandson, 7/15/06 12.000.00 100.000 3.000.00 9.000.00 TOTAL (Also enter on Line 7, Recapitulation) 54.000.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc, Form PA-1500 Schedule G (Rev. 6-98) REV4151 EX+ (12-99) *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT See continuation schedule(s) attached 8,861.87 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Elizabeth J. Jamieson Ann J. Compton Social Security Number(s) I EIN Number of Personal Representative(s): Street Address 296 Sterling Place - Apt. 10 City Brooklyn State NY Year(s) Commission paid 2007/2008 Zip 11238 75,000.00 2. Attorney's Fees Martson Law Offices'(estimated) 74,590.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees Cumberland County Register of Wills 2,049.00 5. Accountant's Fees Boyer & Ritter, Carlisle, PA (estimated) 800.00 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached 9,265.65 TOTAL (Also enter on line 9, Recapitulation) 170,566.52 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule H (Rev. 6-98) Re....1502 EX+ (6-98) *' SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM NUMBER DESCRIPTION AMOUNT 1 Ann J. Compton - travel expenses for family from North Carolina to plan and attend funeral 1.847.39 2 Carlisle County Club, funeral reception 2.192.08 3 Elizabeth J. Jamieson - travel expenses for family from NY and CA to plan and attend funeral 1.229.40 4 Ewing Brothers Funeral Home, Carlisle, PA 2.910.00 5 Ewing Brothers Funeral Home, Carlisle, PA - grave marker inscription 418.00 6 Georges' Flowers 265.00 Subtotal 8.861.87 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1102 EX+ (6-98) *' SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM NUMBER AMOUNT DESCRIPTION 1 Citizens Bank checking Account #610073-129-4 - Outstanding checks on date of death 7.976.85 2 Computershare Trust Co. of Canada, stock handling fees 18.00 3 Cumberland County Register of Wills, filing fee, Inheritance Tax Return 15.00 4 Cumberland Law Journal, advertising Letters Testamentary 75.00 5 Elizabeth J. Jamieson - Reimbursement of expense for delivery of household goods 95.00 6 EVP, online stock valuation 51.15 7 Hershey Trust Company, management fees 553.18 8 M&T Bank, wire transfer fee 12.00 9 Mountz Jewelers, appraisal fee 140.00 10 PA Department of Public Welfare, certified mailing 2.32 11 119.86 Postage 12 The Sentinel, advertising Letters Testamentary 144.29 13 UPS mailings 63.00 Subtotal 9.265.65 Form PA-1500 Schedule H-B7 (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev.1512 EX+ (6-98) *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 Include unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Bankcard Services, account payable 202.28 2 Bowmansdale Lodge #1179, IOOF, account payable, dues 30.00 3 Brockie Pharmatech, account payable 93.83 4 Elite Staffing Services, nursing care, account payable 17.272.00 5 Elizabeth White, nursing fees 500.00 6 Homeland Nursing Home, account payable 2.345.44 7 Knollbrook Farm, lawn care NC property, account payable 122.00 8 Martson Deardorff Williams & Otto, balance due for estate planning 25.00 9 PA Department of Revenue, 2006 PA40 tax due 4.172.00 10 Progress Energy, account payable 94.71 11 Residence - County tax proration 42.18 12 Residence - ERA-NRT, Inc., transaction fee 82.50 13 Residence - ERA-NRT, Inc., real estate commission 8.250.00 14 Residence - Transfer Tax @ .5% 1.375.00 15 State Employees' Retirement System - prorated reimbursement of August benefit 3.654.40 16 US Treasury, 20061040 tax due 29.159.00 17 West Shore County Club, account payable 414.87 TOTAL (Also enter on Line 10, Recapitulation) 67,835.21 <If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule I (Rev. 6-98) REV.1513 EX+ (9-00) ESTATE OF NUMBER I. 1 2 3 4 5 *' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT JACOBS, ROBERT LEE NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal C1istributions~ and transfers under Sec. l:I116(a)(1.2)] Ann J. Compton P.O. Box 173 Southern Pines, NC 28388 FILE NUMBER 21-06-00719 SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) RELATIONSHIP TO DECEDENT Do Not LIst Trusteels) Daughter One-half of estate residue 1,706,687.81 Elizabeth J. Jamieson 296 Sterling Place - Apt. 10 Brooklyn, NY 11238 Daughter 1,706,687.81 One-half of estate residue Elizabeth J. Gallagher 103 Northridge Place Los Angeles, CA 90004 Betty Page Hafer 530 Bridgeview Dr. Lemoyne, PA 17043 Granddaughter 5,000.00 Friend 50,000.00 Ann Blaine Holland 505 35th Avenue North Myrtle Beach, SC 29577 Granddaughter 5,000.00 See continuation schedule attached Continuation 10,000.00 Total 3,483,375.62 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS See continuation schedule(s} attached 10,000.00 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 10,000.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule J (Rev. 6-98) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: ROBERT LEE JACOBS 183-12-2872 08/11/2006 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 James Grover Holland IV 8416 Framingham Court Raleigh, NC 27615 7 Wendell John Jamieson 29 Tiffany Place, Apt. 6E Brooklyn, NY 11231 Grandson 5,000.00 Grandson 5,000.00 Total 10,000.00 1 ReY-1S02 EX+ (6-98) . SCHEDULE J-IIB CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JACOBS, ROBERT LEE FILE NUMBER 21-06-00719 ITEM NUMBER DESCRIPTION AMOUNT 1 St Johns Episcopal Church 10,000.00 Subtotal 10,000.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J-IIB (Rev. 6-98) F 'FllES\DATAFIlE\Estate Plannmg\J043.codicil CODICIL I, ROBERT LEE JACOBS, of Hampden Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be a Codicil to my Last Will and Testament dated August 17, 1998. 1. I give the sum of Ten Thousand Dollars ($10,000.00) to ST. JOHN'S EPISCOPAL CHURCH, Carlisle, Pennsylvania. 2. In all other respects, I ratify and affirm my said Last Will and Testament dated August 17, 1998. IN WITNESS WHEREOF, I have hereunto set my hand and seal this IJ./o/It.. day of ~ ,&b?~. (SEAL) SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testator, as and for a Codicil to his Last Will and Testament dated #, in the presence of us, who at his request, have hereunto subscribed our names as witnesses thereto, in the presence ofthe said Testator and of each other. \.. -1 . 4~~ / ,/7 ,- L{, ~7''''r ~ I (. Page I of 2 Pages COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) (i We, Robert Lee Jacobs, IVO V. Otto III, and m~-c ta...'j, ~~; nLP +Z")l , the I Testator and the 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 a Codicil to his last Will dated #, and that the Testator has signed willingly, and that the Testator executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing ofthe Testator, signed the Codicil as a witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Witness ~ 1tf^ - / t.0~ Witn ~s l' ~'f 't~ Subscribed, sworn to and acknowledged before me by Robert Lee Jacobs, the Testator, and subscribed and sworn to before me by Ivo V. Otto III and '--Z'YI1t rCJI.t Y. (! 'i \,....n.r~ I the witnesses, this/''t~ay of ~ ,2002. /11Vl./~,(~~~ ~raiy Public V Page 2 of 2 Pages F IFILES\DA T MILE\ WILLSI3043-H W1L copy LAST WILL AND TESTAMENT I, ROBERT LEE JACOBS, of Hampden Township, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and all former Wills or Codicils by me made. 1. I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any property) shall be paid from my residuary estate as soon as practicable after my decease and as part of the administration of my estate. My personal representative(s) shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. It is my intention to have all legacies or bequests pass free of tax. 2. I give the sum of Five Thousand Dollars ($5,000.00) unto each of my grandchildren: ANN BLAINE HOLLAND, JAMES GROVER HOLLAND IV, WENDELL JOHN JAMIESON and ELIZABETH JAMIESON GALLAGHER. 3. I give the sum of FIFTY THOUSAND DOLLARS ($50,000.00) unto my dear friend, BETTY PAGE HAFER. 4. I give my Certificate of Membership in the Country Club of North Carolina, together with any and all benefits accruing thereto, to my daughter, ANN J. COMPTON. 5. I give, devise and bequeath all the rest, residue and remainder of my estate, both real Page 1 of 4 Pages ~ and personal property, in equal shares, unto my daughters, ELIZABETH J. BOYLE and ANN 1. COMPTON, absolutely; provided, however, that my daughter, ANN 1. COMPTON, shall have the right to take my real estate in Moore County, Southern Pines, North Carolina, in kind, as part of her residuary share in my estate. Ifmy said daughter should so choose, it shall be taken at its value as appraised for Federal Estate Tax purposes, less the sum of Twenty Thousand Dollars ($20,000.00). 6. I nominate, constitute and appoint my daughters, ELIZABETH J.BOYLE and ANN 1. COMPTON, or the survivor of them, as Executrices of my estate. In the event that both of my said daughters are unwilling or unable to serve in such capacity, then I appoint WILLIAM F. MARTSON as Executor of my estate. 7. I direct that my Executrices(or) shall not be required to file a bond to secure the faithful performance of their duties in any jurisdiction. 8. I authorize and empower my Executrices( or), in their sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or grant options in regard to any or all property of any kind forming a part of my estate for such terms and such prices as they may deem advisable; to borrow money for any purposes connected with the protection and preservation of my estate; to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my estate; to make distribution in kind and to cause any share to be composed of cash, property or undivided fractional shares in property different in kind from any other Page 2 of 4 Pages share; to employ agents, attorneys and proxies and to delegate to them such power as my personal representative considers desirable and to pay reasonable compensation for such services as may be rendered by such agents, attorneys and proxies; and to execute and deliver such instruments as may be necessary to carry out any of these powers. In addition, I direct that my personal representative shall have the power to conduct an inventory of any safe deposit box necessary to the administration of my estate. IN WITNESS WHEREOF I have hereunto set my hand and seal this J 7~ day of A"fY'~r ,1998 (SEAL) SIGNED, SEALED, PUBLISHED AND DECLARED by the a ove-named Testator, as and for his Last Will and Testament, in the presence of us, who at his request, have hereunto subscribed our names as witnesses thereto, in the presence of the said Testator and W:i 1fII-J~ q~ 7' G>>y'to::. Page 3 of 4 Pages COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) I, Robert Lee Jacobs, Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingl . and that I signed it as my free and voluntary act for the purposes therein expressed, ih Sworn or affirmed to and acknowledged before me by Robert Lee Jacobs, the Testator, this 11 day of ~5T .199~ (!dJA.k.....~~A4 J Notary Public COMMONWEALTH OF PENNSYL VANIA Notarial Seal ! Corrine L. Myers, Notary Public 1 Carlisle Boro, Cumberland County 'Ay Commission Expires May 27,1999 COUNTY OF CUMBERLAND ) : SS. ) We, fA) /// I~rn F. fY)"rkcm and rn~rG4.. y t't':'V-hn-( the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified ) according to law, do depose and say that we were present and saw Robert Lee Jacobs, the Testator, sign and execute the instrument as his Last Will; that the Testator signed willingly and that the Testator executed it as his free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the Testator, signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time 18 or more years of age, of sound m' and under no constraint or undue influence. ~~(;.~~ Ad s / =; ~;lj. de': 1 -. ~A 17007 Sworn or aIlinned to and subscribed before me this 17 ff.day of ~f;r . 199 8 Page 4 of 4 Pa2es Notarial Seal Corrine L. Myers, Notary Public Carlisle Boro, Cumberland Countv ~AI~ f"'....__:__!_ _ . 77 43869 0540'45 pm 02-26-2007 2/3 tom! HUI)..1 C3I86)ref Handbook 4305.2 A. Settlement Statement U,S, Department of Housing and Urban Development B, T VDe of Loan OMB Anoraval No. 2502-0265 lexoires 9130/2006) 1. DFHA 2, DFmHA 3, DConv, Unins, I 6, File Number I 7. Loan Number 18, Morl9age Insurance Case Number 4, OVA 5, DConv, Ins. 28412RlCHEY C.Note: _In. .1 glve~as~.~ora~l_se11J8me!K~~_'~"!8palU oancDymese!Hmen ~elll_ar~l/lI~n. I TitleExpress Settlement System "en merk.ed (p.o.c.T were paid outside the c108I1'tg; they are sl10wn here for mformation purposes and are not mcluded in the totals. :=:'~~~i~=:,: ~ ~c:J~~=~~:~ F'::n~Bts':~T8~~~.S~~= r~~lno~:ds~:ti:rm'l~~nalties upon Printed 02/26/2007 at 14:49 CLT D. NAME OF BORROWER: ELIZABETH G. RICHEY ADDRESS: 2840 Sunset Drive Camp Hill PA 17011-1631 E. NAME OF SELLER: ESTATE OF ROBERT LEE JACOBS and BEm P. HAFER ADDRESS: 3620 Loaan Street Ext. Unit 2-C Camp Hill PA 17011 F, NAME OF LENDER: ADDRESS: G. PROPERTY ADDRESS: 3620 Logan street Ext., Unit 2-C, Camp Hill, PA 17011 HamDdim Townshia H. SETTLEMENT AGENT: Cedar Cliff Abstract Agency, Inc., Telephane: 717.774-7435 Fax: 717.774-3869 PLACE OF SEffiEMENT: 414 Bridae street New Cumberland PA 17070 I. SETTLEMENT DATE: 02/2812007 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER 101. Contract sales orice 275,000.00 401. Contract sales Drice 275000.00 102. Personal Prooertv 402. Personal Property 103, Settlement char!les 10 borrower IIine 1400\ 5 209.25 403. 104. 404. 105, 405, Adiustments for items oaid bv selier in advance Adiustments for items oaid bv seller in advance 106. Citvllown taxes 406. Ci1vltown taxes 107. County taxes 407. County taxes 108 School taxes 02/28/07 to 06/30107 651.81 408. School taxes 02/28/0710 06130/07 651.81 109, 409. 110, Quartlv common expenil!ll28J07 to 03130/07 416.66 410. Quartlv common expenil!ll28J07 to 03130/07 416.66 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 281.277.72 420. GROSS AMOUNT DUE TO SELLER 276 068.47 200. AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. Deoosn or eamest money 10 000.00 501. Excess Deoosn (see instructions) 202. Princioal amount of new loans 502. Settlement charaes to seller IIine 1400) 19,415.00 203 Existino Ioantsltaken subject to 503. Exlstino Ioan(s) taken subject to 204, 504. Payoff of First Mortaaoe Loan 205, 505. 206. 506. 207. 507. 208. 508. 209. 509. Adiustments for items unDaid bv seller Adiustments for items unDaid bv seller 210, Citvltown taxes 510. Citvltown taxes 211. Countv taxes 01/01/071002/28/07 84.36 511. County taxes 01/01/07 to 02/28/07 84.36 212, School taxes 512. School taxes 213. 513 214. 514, 215. 515. 216. 516. 217. 517. 218, 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 10 084.36 520. TOTAL REDUCTION AMOUNT DUE SELLER 19.499.36 300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLER 301. Gross amount due from borrower (line 120\ 281 277.72 601. Gross amount due to seller (line 420\ 276 068.47 302. Less amounts paid bylfor borrower (line 220\ 10 084.36 602. Less reduction amount due seller (line 520\ 19,499.36 303. CASH FROM BORROWER 271193.36 603. CASH TO SELLER 256 569.11 SUBSTITUTE FORM 1099 SELLER STATEMENT: The informalion contained herein is important lax information and is being ~rni&hed 10 the Intemal Ravenue SaMce. If you are required 10 file 8 return, ~,~~::'~~~~~=~~~~:c 1r:=~IS item IS requirad to be reported and the IRS determineslhat It has not been reported. The Contract Sales Price d85Cribed on ~~.r~u~':i.:~=I';:~::I~~I:~(i~~X~~I:~ Under penajlieSOf~-:: 1~~~J,a:~~~=:nth:=~~tUi:~no~~:au:.rcc:=:ax:~~~~tion TIN:_-~.~/~.~._ SEllER(S)SIGNATURE(S): SElLER.(S) NEW MAILING ADDRESS: SELLER(S) PHONE NUMBER.S: {H} (W) ~fl."J~~ Ai e I 77 43869 054130 pm 02-26-2007 3/3 form HUo.1 (3188) ref Handbook 4305.2 PAGE 2 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SETTLEMENT STATEMENT File Number: 28412RICHEY TiUeExnress SetUement Svstem Printed 02/2612007 at 14:49 CL T L. SETTLEMENT CHARGES PAID FROM PAID FROM 700. TOTAL SALES/BROKER'S COMMISSION based on orice $275 000.00 llll6.000 = 16500.00 BORROWER'S SELLER'S Division of commission lIine 700\ as follows: FUNDS AT FUNDS AT 701. $ 16 SOO.OO to Era-Nlllnc. SETTLEMENT SETTLEMENT 702. $ to 703. Commission naid at Settlement 16 SOO.OO 704. Transaction Fee to Era-Nrt Inc. 165.00 165.00 aOO.ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Oriaination Fee % 802. Loan Discount % 803. Anoraisal Fee 804. Cred~ Re""rt 805. Lende(s Insoection Fee 806. Mortoaae Arlnlication Fee 807. Assumntion Fee 808. 809. 810, 811. 900. ITEMS REQUIRED BY LENDER TO BE PAlD IN ADVANCE 901. Interest From to @$ Idav 902. Mortoaae Insurance Premium for to 903. Hazard Insurance Premium for to 904. 905. 1000. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard InSlJrance mo. Q) $ Imo 1002. Mortoaae Insurance mo, ID$ Imo 1003. clt; Prooertv Tax mo. IH Imo 1004. Countv Procertv Tax mo. Q)$ 43.49 Imo 1005. School taxes mo. ID$ 162.51 lmo 1009, AM ""'ate Anal""is Adiustmenl 0.00 0.00 1100. TITLE CHARGES 1101. Settlement or closino fee 1102. Abstract or title search 1103. Hie examination 1104. Title insurance binder 1105. Document Preoaration 1106. Nolarv Fees 1107. Attorney's fees (includes above ijems No: \ 1108. Tille Insurance to Cedar Cliff Abstract Aaencv. Inc. 1.733.75 (includes above items No: ITI- Baslcl \ 1109. Lende(s Policv 1110. Ownefs Policv 275.000.00 - 1 733.75 1111. 1112. 1113. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recorctino Fees Deed $40.SO . Mortn""e$ . Release $ 40.50 1202. Citv/Counlv taxlstamos Deed $2 750.00 ; Mortoaae $ 2 750.00 1203. State TaxlstamllS Deed $2 7SO.00 : Mortaane $ 2 750.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Survev 1302. Pestlnsnection 1303. Initialion Fee to Loaan Lane Court Association SOO.OO 1304. Wire fee to Stone Lafaver & Shekletskl 20.00 1400. TOTAL SETTLEMENT CHARGES {enter on lines 103 SecliOl1 J and 502 Section K\ 5 209.25 19415.00 HUO CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUQ..1 ~ Statement and 10 !he best of my knowledge and belief, " 18 Ell b\lv and accurate statement of an receipts end disbutHmenta mllde on my account or by me In lhis transaction. I further caI1if'y that I have received a copy of the HUD-1 Settlemenl Statement. t:l14^01:.11'1U, 1'(1\.,;1'11;; T ESTATE OF ROBERT LEE JACOBS uy: 1:.L.ILADl:.IM J. -'^M11:;)vN ...."'UA/'\lN J. lAJft/ll"'IUN. ~Ar:""UI!"tII"II::;:;' Ut;l j, ,....l"1IV"t:1'( WARNING: ~T IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ~V SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE ANO Ifo1PRISONMEN,. FOR DETAILS SEE TITLE 18: U.S. CODe SECTION 1001 AND SECTION 1010. The HUD.1 Settlel't'Mmt Statement which I have prepared Is 8 true ard accurate account of this transacUon. I have C8l.1aed or will cause the funds to be disbursed In accordance WIth this statement SETTLEMENT AGENT, DATE: ~~ Citizens Bank' Account Number 6100731294 Account Title ROBERT LEE JACOBS Date Opened 6/6/1966 Account Type Checking Principal Balance as ofDOD $41,546.86 Interest from Last Posting to DOD $.00 Account Balance as of DOD $41,546.86 YTD Interest to DOD $371.84 cStMdJ, _ ~ ;2 .., ~~ Citizens Bank Account Number 6205803538 Account Title ROBERT LEE JACOBS Date Opened 5/5/2004 Account Type Checking Principal Balance as ofDOD $79,198.66 Interest from Last Posting to DOD $.00 Account Balance as ofDOD $79,198.66 YTD Interest to DOD $1,279.86 y~~ A~3 08/31/2006 09:06 302-934-2136 M AND T BANK RECORDS PAGE 02/03 m1 M&fBank 499 Mitchell Street, 'Millsboro, DE 19966 August 31, 2006 Revised Martson, Deardorff, Williams & Otto 10 East High Street Carlisle, PA 17013 RE: Estate of Robert Jacobs Date of Death: August 11, 2006 Social Security No.: 183..12-2872 Dear Ms. Otto: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account 1Ype. ... ,m. .............. ....Savings Account Account Number.......... -.. ......... .15004200053673 Ownership (Names oj)..... ......... .Robert Lee Jacobs Opening Date.......... ...... _.. _..... ..11/25/91 Balarwe on Date of Death.. -..... ..$23,961-66 Accrued Interest $ 56.81 Total............... ...................... .$24,0 18.47 2. Account 1Ype...... .................... . Checking Account Account Number....................... 98121480 Ownership (Names oj)..... ... ....-- .Robert Lee Jacobs 1, )~8 J~1 Opening Date_ -- .. .. ... ... .. - . ... ... .. ..1 0 (29 / 98 Closed. 08/ 15/06 Balance on Date of Death..... .....$57,954.68 Accrued Inierest $ 30.95 Total...__.............. -......... ... ...... .$57,985.63