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HomeMy WebLinkAbout04-0271 PETITION FOR PROBATE and GRANT OF LETTERS alsoEStateknown°f asJ41PlVl~ ~_-R~ck~ffa_ ~o-cO~ No ,~/-~ ~-. ~ 7/ . To Register of Wills for the Deceased County of ~.=0~ m the SoctaISe~rttyNo. I~Z ~ ~'~ ~ Commonwe~th of Pennsylv~a The petmon of the undersigned respectfully represents that Your petmoner(s), who ~s/are 18 years of age or older an the executo ( named m the last will of the above d~edent, dated ~ ~, ~ ff ~ ,19~ and codicil(s) dated Decendent was domtclled at death tn ~-_~,c~,.~ ~ County. Pennsylvania, w~kh h ~(~ last family or pnnclpal residence at (hst str~, numar ~d munc]~]ty) Decendent, then_ Except as follo&~, dec~ent d~d not marry, was not divorced and d~d not have a child bom or adopted after execution of the wdl off~r~ for probate, w~ not the victim of a kdhng and wm never adjudicated incompetent Decendent at death~w~'~operty wtth estimated valu~ as follows (If dom]c]led']n'P~) ~- (If not domiciled m Pa') Personal property m Pennsylvania $ (If not dom]cried in Pa ) Personal property in County $ Value of real estate m Pennsylvama $ situated as follows WHEREFORE, petmoner(s) respectfully request(s) the vrobate of the last will and codicil(s) presented herewtth and the grant of letters____ theron (lestamemary, admlmstrat:on c t a, admlmstrat]on d b n c t a ) OATH OF PERSONAL REPRESENTATIVE COMMONWEA,~T~ OF. PE~NNSY,,LVANIA 3 COUNTY~ ',',QFjJ"~~ j~ :~s The petmoner{s) abov$-d(rn~d swear(s) or affirm(s) that the statements m the foregoing pet:t~on are true and:corr&(to the best of the knowledge and bebef of ~titmner(s) and that m person~ represen- tat~ve{~) o[ the above~ecedent petmoner(s) will well and truly administer the estate according to law. Sworn to or a~r, rmed and subscr,bed ~ ~~ &~/ ~ before mc th~ /O~ da5 of I ' ' ~ ~ ~ Estate of -/~n' ~ ~ .~$~( (~ ~,,~ , D~ed DEC~E OF PROBATE AND G~NT OF LE~ERS AND NOW ~ /~ ~ , in co~derafion of the ~tiQon on the reverse s~de hereof, sfit~sfa~o~ proof having b~n oresented before me, IT IS DEC~ED that the instrument(s) dated ~ ~, t~ ~ ~ d~cnb~ thereto be admitt~ to probate ~d fil~ of r~ord as the l~t will of and ~tters { ~ ~ ~~ ~eherebygr~tcdto ' ' ~X ~ ~'~ ~C~ ~ ~ Probate. Letters, Etc $ ~ ~' ~ ~ ~ ~ Renunciation $. ~ ~ . ~ ~ ~ ~T A~ PHO. Vel ' 03 pU~JJ@qLLII~O h~s ~s to certify that the ~nformat~on here given ~s correctly copied from an original certificate of death duly filed w~th me as Local Registrar The original cerhflcate wall be forwarded to the State V~tal Records Office for permanent fihng WARNING: It IS illegal to duphcate th~s copy by photostat or photograph. Fee for this certificate, $2 O0 ~ ~'"'~,,.k___ ~. ~,~... ~4.~.~__,~ . __ __ ~Local Reg~str~ P 10159138 FEB 1 8 200 No Date CERTIFICATE OF DEATH aF~lej, 172 ~ 24 ~ 7824 b F~ 4, 2004 ~ R~fl J. Ja~ ~ 150 C St~t; ~rl~s~e, PA 17013 ~D 012633 L Brothors ~eral H~, Inc., ~rl~sle, LAST WILL AND TESTAMENT I, Anna Isabelle Jacoby, of ~50 C St., Carlisle, ~umberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made byme. Item I. I direct my executor hereinafter named to pay all my debts and funeral expenses. Item II. I give, devise and bequeath all my property to my husband, Richard J. Jacoby, providing he survives me. Item III. I nominate, constitute and appoint my husband, Richard J. Jacoby, as my executor. IN WITNESS WHEREOF, I have hereunto set my hand and seal this the 22nd day of March, 1995. Anna Isabelle Ja/oby Signed, sealed, published and declared by the above named testatrix,as and for her last will and testament, who at her request, in his presence, in our presence, and in the presence of each other have hereunto subscribed our names as attesting witnesses: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, ~~~-~'~ and A~ ~ ~/ 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 testatrix .sign and execute the instrument as her last will, and that she signed willingly and that she executed it as his free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testatrix signed the will as witnesses; and that to the best of our knowledge, the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this 22nd day of March, 1995. NOTARIAL SEAL JANE)' M LAY NOTARY PUBLIC CAR~.ISLE BORO, CUMBERLAND COUNTY ~,IY COM,,~,4ISSION EXPIRES JUNE 26, 1995 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, Anna Isabelle Jacoby, 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 willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Anna ~saL~lle jac/oby ~ sworn to and subscribed to before me this 22nd day of March, 1995. ~/~JE ~ ,fz~C~ notary NOTARIAL SEAL I JANET M LAY NOTARY PUBLIC CARLISLE BORO, CU~,IBERLAND COUNTY MY~CO~IhllSSION EXPIRES JUNE 26, 1995 REV-1500 EX (6-00) REV-1500 PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN ~.~.u..E. HARRISBURG, PA17128-0601 RESIDENT DECEDENT ?-. I - O/Jr_ © 2~ COUNTY CODE . YEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I11 DATE OF DEATH (M¥-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) /"t THIS RETURN MUST BE FILED IN DUPLICATE WITH THE "' · ' 'i I w,..s L[I (IF APPLICABLE) SURVI~J~ SPO, USE'S NAME ~(LAST, FII~T, AND~DLE INITIAL) SOCIAL SECURITY NUMBER a , ~e.,~ r a. ' .~. ~._c_.o to,--( - - ,,, E~ .. Odginal Retum E~] 2. Supplemental Return E] 3. Remainder Return (date of death prior to 12.13-82) ~' "" ~L_J 4. Limited Estate E~] 4a. Future Interest Compromise (date of~eath a~ ~242-a2) E~ 5. Federal Estate Tax Return Required o, ~. Decedent Died Testate (Attach c~y of wi,) E~ 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes < ["-] g. Litigation Proceeds Received [~ 10. Spousal Poverty Credit (oate of 0~ath t~n 12-aa-9~ a~ a4-~) 11. Election to tax under Sec. g113(A) {Jutach sch o) Z m COMPLETE MAILING ADDRESS FIRM TELEPHONE NUMBER o OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely. Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages'& Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) '"7 ~ "~ "7 ~" '~ · (Schedule E)  6. Jointly Owned Property (Schedule F) (6) ['--~ Separate Billing Requested :~3 7. Inter-Vivos ?ransfers & M~cellaneous Non-Probate Property (7) i'-- (Schedulc=CG or L) ¢~ 8. Total Gross Assets (total Lines 1-7) (8) 111 9. Funeral Expenses& Administrative Costs (Schedule H) (9) ? ~} "~ ?, ~ g 10. Debts o[ Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) Total Deductions (total Lines 9 & 10) (11) 11. 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15) 16. Amount of Line14 taxable at lineal rate x .0 __ (16) 17. Amount of Line 14 taxable at sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) Decedent's Complete Address: I STREET^DO"ESS/5-O C' 5 r-. Tax Payments and Credits: , ' (1) 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund (4) 5. if Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.' (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 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 rece ving adeq.,u, ate consideration? .............................................................................................................. 3. Did decedent own an in trust for' or payable upon death bank account or secudty at his or her death? .............. [] 4.Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have exam ned this retain including a. ccompany!.ng...~ dulls and. ~[a[~,,~nts, .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 inmrmation o! which preparer'nas any Knowledge. SIGNATURE,O~: PERS_,ON RESPO, N~[L~OR FILIN ~C~ETURN DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 RS. {}9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 RS. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. 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-150~ EX + (1-97) SCHEDULE E co,~.~T, oF ~..s~w.~ CASH, BANK DEPOSITS, & MISC. INHE~T~CE T~ ~U~ .~s,~c~.~ PERSONAL PROPER~ Include ~e ~ of I~a~n a~ ~ da~ ~ p~s w~ ~ by ~e ~. All ~ ~in~ ~ ~ ~N of suwbomhi mu~ ~ d~c~ on ~h~u~ F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF D~TH TOTAL (Also enter on line 5, Recapitulation (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATEOF /~D~ J~ ~~(~((~-- ~ ~C~ b~ FILENUMBER ~bts of d~edent must ~ reposed on Schadule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State __ Zip Year(s) Commission Paid: 2. Attorney Fees ~'~c~ ~ ~ ~ ~,. S [ O.t.~J (~ '~'~ 1 t-~..__ ~00'(~0 3. Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent 4. Probate Fees ~.~,- ~ ~ ~L.J, ~'L_~ 5. Accountant's Fees 6, Tax Return Preparer's Fees (If more space is needed, inse~ additional sheets of the same size) ~.,~,3~.,,_9~ ~ SCHEDULE J co. Mo.w~.T. o~ ~E..s~.v^.~ BENEFICIARIES ,..E..T~cE ~ ~ ~SI~NT DECEDE~ ESTATE OF FILE NUBBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DO Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributiofls) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART [! - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) STATEMENT PERIOD: PAGE:;. 71:5866 CLASSIC CHECKTNG JAN.lq-FEB.I'~;2OOq, 1 OF 1 O0 00q319fl Nfl 017 757S6 A ZSABELLE dACOBY CARLISLE PA 17015-1918 HIGH STREET-CARLISLE ,, ACCOUNT SUMMARY i i :: i i ?B~G;I. NNZN~i.i:i ii! i ;:i !; ill i i ii ! i ;!i:i. i DE~Z~:~:! i&'i i iii ii :: ............. :::::::':::: ....... :::':'::::. ...... : ........ O~HER : ........ · ...... ~RR~ ...... ~Z~ .... 5;q56.99 I 326. O0 0 O. O0 O. O0 0. O0 ~;782.99 T ACCOUNT ACTXVI,, :: Are::.::, .... ::; ::::::TRA~ACTX~DE~RXPTX~ ;: ; ~:~:~:~:~:~.;O~HER~X~: : ::~ ~t~ ~ ~?:~E~:~ :~ o1-1~-~ BEOI~I~ BAL~E ~5; qS6.99 0~-0~-~ ~ TR~SURY ~0~ ~ SEC ~6.00 ~;782.99 ~ BAL~E ~S ~ 782.99 ~E CA~, ~ ACC~S. VZTH Y~R HIT CHE~ CA~ OR ATH CA~; Y~ CAN ~ ACCE~ UP TO: q C~Z~ A~S~ ~ STAT~ SAV~ OR ~EY ~ A~S A~ 2 LINES OF CREDIT AT THE ATH. ~ THERE ZS ~T ~E ~ TO ~RRY ~ ~T ~E PE~L ~ZFZ~TZ~ ~ER. TO R~E~ER. TO LZ~ VITALLY ALL OF Y~R ACC~S TO ~T ~E CA~ SZHPLY VISIT ~Y H&T BA~ B~H OR CALL THE HIT TELEP~E C~ER AT 1-800-7~-~0. I 288458.I18- ] L~ Manu~rem and Traders Trust Company .issued by integrated i~y~ Systems inc., Engtew~x~d. C~ BUFFALO, N.Y. 14240 Bank O~e, NA, Denver, Colorado DRAWER: M & T BANK ./T" /~ TO THE m ORDER OF -- I '"~'"'* ~"'--~I~I~IZE~I~'~TURE '~ ES~A!E OF' A. .'~L~5~8,' ~080OOq?q~: &BOOZBGLSB~BD,' 5 ., rN 6o-~8 ~ ~ ~ ARE ~LY ~SEZ ~ o DOUGHS ~W OFFICE IOLTA ACCOU~ ~ P,O. BOX 261 717-24~1~ = 27 WEST HIGH STRE~ ~ CARUSL~, PA 170~3 THE BANI( OF N'EW YORI~ P.O. Box 19561 Newark, NJ 0719,5-0561 ACCT,: 1722~ PLAN#: G5S055 PAY DATE: 02/01/2004 CHECKt: 28105201 ISABELLE JACOBY 150 C STREET CARLISLE, PA 17013 'lease use. the reverse side of statement for changes. Acct#: 1722~i Plan #: 055055 · DESC.__._~RIPTION CURRENT AMOUNT YTD AMOUNT DESCRIPTION CURRENT AMOUNT Y'rD AMOUNT =TIRENENT BENEFIT ~i6 . ~¢i 93 . 28 ~ q6.6~-~'~"'~"~.~;'~ tOTAL DE UCTIONS: 0.0-~----------- fAC NET: P~ea'se D~ ii. 881,0 580 I,.' ':0 8 ~.0000 l, BI.' "'000000 58 I, 5.' 04-14-2004 Time Inquiry Next Display: ,1,2. 30-0700-10 10: 18: 22 History Display DSPBR01703 Account number: 1723013842 Start date: ,0,0,0,0,0,0, Short name: JACOBY DECD ANNA I Type: TIME OPEN ACCOUNT Eff date TC Trans description Amount Type Prin balance Post dte Check # / l~eason cd Iht balance 1-14-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 2.88 1-21-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 3.29 2-04-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1. 140 1. 140 INT RATE 4.12 2-11-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1. 140 1. 140 INT RATE 4.54 3-17-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 6.62 3-17-04 92 EARLY REDEMPTION 1907.60 PRINCIPAL .00 1. 140 U 6.62 INT PAID .00 .00 Penalty .00 Forfeiture F3=Exit F15=Restart History display complete REV4 500 EX COMMONWEALTH OF REV-1500 PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURNFILENUMBER ?..!-oq. / HARRISBURG, PA 17128-0601 RESIDENT DECEDENT CO N COOEYEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Z -- -- LU DATE OF DEATH (MlyI-DD-YEAR) DATE OF BIRTH (ME-DD-YEAR) ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE "' I "! t w,.s I.U (IF APPLICABLE) SURVI~LG SPOUSE'S NAME ,(LAST, F~_g!gST, AND,._~DLE INITIAL) SOCIAL SECURITY NUMBER -, ~.. O~ginal Return [~] 2. Supplemental Return ~] 3. Remainder Return (date of death p~'to 12.13-82) ~1 I 4. Limited Estate [] 4a. Future Interest Compromise (date of ~ a~' 12-12-82) U 5. Federal Estate Tax Return Required ZOO 0 ~ ~ ~ Decedent Died Testate (Attach copy of VV'~0 E~ 7. Decedent Maintained a Living Trust (Attach copy of T~t) __ 8. Total Number of Safe Deposit Boxes < E~ 9. Litigation Proceeds Received [~ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) E~] 11. Election to tax under Sec. 9113(A) (Attach Sch O) z '" COMPLETE MAILING ADDRESS TELEPHONE NUMBER O 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely. Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages'& Notes Receivable (Schedule D) (4) 5. Cash, ~ank Deposits & Miscellaneous Personal Property (5) "7 ~ % "'l. ~ ~ (Schedule E)  6. Jointly Owned Property (Schedule F) (6) ._j Separate Billing Requested ::::) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ~ (ScheduleeBor L) " ' .... <C 8. Total Gross Assets (total Lines 1-7) (8) Iii 9. Funeral Expenses& Administrative Costs (Schedule H) (9) ? ~ ~ ?. ~ 10. Debts of Dec.~lent, Mortgage kiahil~es, & Liens (Schedule I) (10) 11. Total Deductions (total Lines O & 10) (11) <:~:::) 12. Net Value of Estate (Line 8 minus Line 11) (12) .---' l'::J' ~2-, 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES  15. Amount of Line 14 taxable at the spousal tax ~._ rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)  16. Amount of Line 14 taxable at lineal rate x .0 __ (16) O~ 17. Amount of Line 14 taxable at sibling rate x .12 (17) (.) 18. Amount of Line 14 taxable at collateral rate x .15 (18) _~ 19. Tax Due (19) Decedent's Complete Address: I Tax Payments and Credits: .. . 1. Tax Due (Page 1 Line 19) ' ' (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + SA. This is the BALANCE DUE.' (5B) 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: Yes No 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; ............................................ [] (:. 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? .............................................................................................................. [] 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? .............. [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contain, s a beneficiary designation? ........................................................................................................................ ~ [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penallJes of pedury, I declare that I have examined this return, including accompany!ng s, chedul~s and statements, and tu the best of my knowledge and belief, it is true, correct and complete. DedarelJon of preparer other than the personal representative is based on all information of which preparer'has any knowledge. SlGNATURE~O~' PERSON RESP~OR FILING/~ETURN DATE _ ADDRESS . . , · SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS For dates of death on or alter July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 RS. {}9116 (a) (1.1) (ii)]. The statute does not exemot 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 benefidary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the usa of the decedent's lineal beneficiaries is 4.5%, 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 12% [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. SCHEDULE E CO"MO"W~'T. OFPE..SYLV~,^ CASH, BANK DEPOSITS, & MISC. INHERIT~CE T~ ~ .~s~.~c~.~ PERSONAL PROPER~ Include ~e ~s of I~a~n a~ ~ da~ ~ p~ w~ ~ ~ ~e ~a~. All ~ ~i~ ~ ~ ~M of su~omhi ~ m~ ~ d~cb~ on ~h~ub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF D~TH TOTAL (Also enter on line 5, Recapitulation $ "~ "~ "~7' ''~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) ,~ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ~s of d~edent must ~ repealed on Sch~ule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State __ Zip Year(s) Commission Paid: 2. Attorney Fees %c.~ 0 ~ ~,.s Jo, au, (~ -~-I~ i ~._~...__ ~00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent 4, Probate Fees ~~.[~1" ~ ~ ~' ~'L~ 5. Accountant's Fees 6. Tax Return Preparer's Fees I0. , -~ - , ~ ~ - ~ ~ TOTAL (Also enter on line 9, Recapitulation (If more space is needed, inse~ additional sheets of the same size) SCHEDULE J CO. LT. BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE [. TAXABLE DISTRIBUTIONS (include outright spousal distributions) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART []- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insed additional sheets of the same size) 71386~ CLASS]:C CHECK]:NG JAN.1q-FEB.13,,200q I i OF I ~ oo o o~, ~ o~7 75756 A ISABELLE JACO~Y 150 C ST CARLISLE PA 17015-1918 HTOH STREET-CARL'rSLE iiiii:!ll, Ee~IN~'K;!!:ii:i:i!.i. ii! .'ii!!:: DEPOS:3C~:::~':::: ..... ::: ACCOUNT ounn~r~· $;q$6.99 I 326. O0 O O. O0 O O. O0 O. O0 ~; 782.99 ACCOUNT ~:VZ~T Oi-lq-N BEGZ~ BALA~E 02-03-N ~ TR~SURY 303 ~ SEC 326.00 S,782.99 ~X~ BAL~E ~Sj 782.99 ~E CA~; ~ ACC~S. ffXTH Y~R HIT CHE~ CA~ OR ATH CA~; Y~ CAN ~ ACCE~ UP TO: 4 C~' A~S; ~ STAT~E~ SAV~ OR ~EY ~ A~S ~ 2 LXNES OF CREDXT AT THE ATH. ~ THERE XS ~T ~E ~ TO ~R~ ~ ~T ~E PE~L ~XFX~TX~ ~ER TO R~E~ER. TO LX~ VX~LLY ALL OF Y~R ACC~S TO ~T ~E CA~; SXHPLY VXSXT ~Y H&T BA~ B~H OR CALL THE HIT TELEP~E B~X~ C~ER AT 1-800-7~-~0. , DRAWER: M & T BANK ~' '"'~ DATE '~ ~ ORDER OF ........... -.~.' . ~ ~ ~ 'Five fi'~c, us~nd~. Seven Hundred EightY. T~c, x~ a~ E and ??/I00 [~X~lia~-s , ~~ ~ ~ ~ ~ $1o,~.~ m ~ I'~ 6o.45o38 r-,* ITEMS L.._J_...J ARE PROPERLY DOUGHS ~W OFFICE P.O. BOX 261 717-2~1~ IOLTA ACCOUNT 27 WEST HIGH STRE~ CARLISLE, PA 17013 ~m:O~ ~ ~ 50~m: ~0~ THE BAN'K OF N'E~7 YOIZK P.O. Box 19561 Newark, NJ 071950561 ACCTe: 17226 PLAN#: G55055 PAY DATE: 02/01/200~ CHECK~: 28105201 ISABELLE JACOBY 150 C STREET CARLISLE, PA 17013 'lease use the reverse side of statement for changes. ~'I .ENEN, BENEFIT '~-~'~ 04-14-2004 Time Inquiry Next Display: 1,2, 30-0700-10 10: 18: 22 History Display DSPBR01703 Account number: 1723013842 Start date: ,0,0,0,0,0,0, Short name: JACOBY DECD ANNA I Type: TIME OPEN ACCOUNT Eff date TC Tr_~n~s description Amount Type Prin balance Post dte Check # / Reason cd Iht balance 1-14-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 2.88 1-21-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 3.29 2-04-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1. 140 1. 140 INT RATE 4 . 12 2-11-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 4.54 3-17-04 74 INDEX RATE CHANGE 0 INT RATE 1907.60 1.140 1.140 INT RATE 6.62 3-17-04 92 EARLY REDEMPTION 1907.60 PRINCIPAL .00 1. 140 U 6.62 INT PAID .00 · 00 Penalty .00 Forfeiture F3=Exit F15=Restart History display complete CERTIFICATION OF NOTICE UNDER RULE S.6(a) Date of Death: ~-] 1"'[' [ 0 t"[- Will No. ~-- I --0 ~-' '"' O~ I A~in. No. To ~ Register: I ~ ~at aofice of (~nefidM Mte~) ~m~ a~~fio~ r~uired by Rule 5.6(a)of~e[O~h~f,~ ~]~C°~ Rules w~ se~ed on or mailed to the following benefici~es of ~e above-caPtioned estate on · N~e Address Notice has now been given to all persons entitled thereto under Rule 5:6(a) except 'Sig nature Address Telephone Capacity: ~ PerSonal Representative C / If ' ounse or personal representative NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA IN RE: ESTATE OF ANNA ISABELLE JACOBY, DECEASED TO: NO. 21-04-0271 Richard J. Jacoby 150 C St. Carlisle, Pa 17013 Please take notice of the death of decedent and the grant of letters to the personal representative named below. You may have a beneficial interest in the estate under the last will and testament of Anna Isabelle Jacoby. Name of decedent: Anna Isabelle Jacoby Last known address of decedent: 150 C St., Carlisle, PA 17013 Date of Death: Feb. 14, 2004 Place of Death: Carlisle, Pa. County of Grant of Original Letters: Cumberland Decedent died testate Name, address and phone number of all personal representatives: Richard J. Jacoby 150 C St. Carlisle, PA 17013 Name, address and phone number of counsel: William P. Douglas, Esquire 27 W. High St. Carlisle, Pa. 17013 Phone: 717-243-1790 Additional information may be obtained from the undersigned: Douglas law Offico\ . /' By William P. Douglas, Esqt~ire,~ 27 W. High St. Carlisle, Pa. 17013 717-243-1790 Dated: March 22, 2004 LAST WILL AND TESTAMENT I, Anna Isabelle Jacoby, of 150 C St., Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made byme. Item I. I direct my executor hereinafter named to pay all my debts and funeral expenses. Item II. I give, devise and bequeath all my property to my husband, Richard j. Jacoby, providing he survives me. Item III. I nominate, constitute and appoint my husband, Richard j. Jacoby, as my executor. IN WITNESS WHEREOF, I have hereunto set my hand and seal this the 22nd day of March, 1995. Anna Isabelle Ja~oby Signed, sealed, published and declared by the above named testatrix,as and for her last will and testament, who at her request, in his presence, in our presence, and in the presence of each other have hereunto subscribed our names as attesting witnesses: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND 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 testatrix sign and execute the instrument as her last will, and that she signed willingly and that she executed it as his free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testatrix signed the will as witnesses; and that to the best of our knowledge, the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this 22nd day of March, 1995. notary JANET U. LAY NOTARY PUBLIC CARLISLE BORO., CU~BERLAND COUNTY I~:Y CO~mlSSION EXPIR. ES JU____NE 26, 199.._~5 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, Anna Isabelle Jacoby, 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 willingly; and that I signed it as my free and voluntary act for the purposes therein expre s s ed. Sworn to and subscribed to before me this 22nd day of March, 1995.  notary CA~USL£ ~0~0., CUt~,~£R[~ND COUNTY IN RE: ESTATE OF IN THE COURT OF COMMON PLEAS ANNA ISABELLE JACOBY OF CUMBERLAND COUNTY, PENNA. ORPHANS' COURT DIVISION NO. 2104 0271 PETITION FOR THE SETTLEMENT OF AN ESTATE TO THE HONORABLE, THE JUDGES OF SAID COURT: Richard J. Jacoby, Executor of the Estate of Anna lsabelle Jacoby, through his attorney, William P. Douglas, Esquire, of Douglas Law Office, respectfully represents: 1. Anna Isabelle Jacoby, the wife of Richard J. Jacoby, who resided at 150 C St., Carlisle, PA 17013, died testate on February 14, 2004. 2. Letters Testamentary were granted to Petitioner on March 19, 2004. 3. The assets in the estate were as follows: 1. M&T Bank Check account #713864 5,782.99 2 Bank of New York, retirement check frown Foot Locker 46.64 3 Waypoint Bank, IRA 1907.60 Total $7,737.23 4. Expenditures as follows have been made on behalf of the said Anna isabelle Jacoby Estate: Ewing Brothers, funeral $ 6,514.00 Georges Flowers, funeral $ 143.10 Cumberland Valley Memorial Gardens $ 995.00 William P. Douglas, Esquire, attorney fee $ 800.00 Register of Wills, probate fee $ 71.00 Cumberland Law Journal, adv. $ 75.00 Sentinel,adv. $ 108.95 Register of Wills, filing fees $ 24.00 West Shore EMS $ 111.50 Sarah Todd Memorial Home $ 895.00 Total expenses $ 9,737.55 5. This is an insolvent estate and no inheritance tax was due. A copy of the Notice of Appraisement from the Department of Revenue is attached hereto as Exhibit A. 6. The said Anna lsabelle Jacoby was survived by her husband, who is the petitioner herein, and three adult children, RECAPITULATION Total Assets: $ 7,737.23 Total Debts $ 9,737.55 Insolvent WHEREFORE, your Petitioner prays that Your Honorable Court approve this Petition, and prays that the said Executor, Richard J. Jacoby, be discharged from the duties of his appointment. Douglas Law Office,_ , Attorney for Petitioner Dated: July 16, 2004 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND William P. Douglas, Esquire, attorney for the Estate of Anna lsabelle Jacoby, being duly sworn according to law, deposes and says that the averments of the within Petition are true and correct to the best of affiant's knowledge, information and belie~. Sworn to and subscribed before me V~illiam~. D~uuglas * -~ -' '~ Thi~ Not-ag'y r4otarial Seal Anne M. Cox, Notary Public ?:,,",isle Borough Cumberland County f~,-;mi%:onEx~)iresJuly14 27;5 COMHONWEALTH OF PENNSYLVANIA BUREAU OF ENDEVIDUAL TAXES DEPARTNENT OF REVENUE IHHERITAHCE TAX DIVISION DEPT. ZBO6D! HARRISBURG, PA ]7lIB-D601 NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 06-1fi-ZOOq ESTATE OF JACOBY ANNA 1 DATE OF DEATH OZ-lq-ZOOq FILE NUNDER Z! 0q-027! COUNTY CUMBERLAND WILLIAM P DOUGLAS ACN 101 DOUGLAS LAW OFFICE 27 W HIGH ST Amoun* Remitted CARLISLE PA 17015 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS REV-IS47 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF JACOBY ANNA I FILE NO. Z1 0q-0271 ACN 101 DATE 06-1q-200q TAX RETURN NAS: ( X ) ACCEPTED AS FILED [ ) CHANGED RESERVATZON CONCERNING FUTURE ZNTEREST- SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN l. Real Es~a~e (Schedule A) (1) .00 NOTE: To insure proper 2. S~ocks and Bonds (Schedule B) (Z) .00 cpedi~ ~o your account, 5. Closely Held S~ock/Par~nership In(eres~ (Schedule C) (5) .00 submi~ ~he upper por~on q. Mor~gages/No~es Receivable (Schedule D) (q) ,00 of ~h~s form wi*h your $. Cash/Dank Deposits/Misc. Personal Proper~y (Schedule E) (5} 7~757.25 ~ax payeen(. 6. Jointly Owned Proper~y (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. To'al Asse~s (8) 7,737.23 APPROVED DEDUCTIONS AND EXEMPTIONS= 9,679.66 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) {9) lO. Deb~s/Nor~gage Liabilities/Liens (Schedule l) (10) .00 11. Total Deductions ill) 9.679.66 12. Ne~ Value of Tax Return (12) I~gfi2.4$- NOTE: Z~ an assessment ~as issued previeusly~ lines 14, 15 and/er i6~ 17~ 18 and lg reflect ~igures that inc/ude the total of ALL returns assessed to date. ASSESSNENT OF TAX: TAX CREDITS: TOTAL TAX CREDIT .00 DALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 TF PAZD AFTER DATE TNDTCATED~ SEE REVERSE ( TF TOTAL DUE ZS LESS THAN $1~ NO PAYMENT TS RE~UTRED. FOR CALCULATTON OF ADDTTZONAL INTEREST. TF TOTAL DUE TS REFLECTED AS A "CREDTT" (CR)~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THTS FORM FOR INSTRUCTIONS.) 1N RE: ESTATE OF IN THE COURT OF COMMON PLEAS ANNA ISABELLE JACOBY OF CUMBERLAND COUNTY, PENNA. ORPHANS' COURT DIVISION NO. 2104-02'71 ORDER OF COURT I? AND NOW, this day of ,2004, after a review of the within Petition, the Petition for thcg~ettlerrl~nt of this Estate is approved and distribution directed as set forth in the said Petition. w This Estate is closed and Richard J. Jacoby, is excused from his duties of Executor of the Estate of Anna Isabelle Jacoby. By the Court, STATUS REPORT UNDER RULE 6.12 Name of Decedent:. Date of Death: Will No. ~-~-~ O~--O~,-~ i admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captiOned estate: 1.State whether administration of the estate is complete: Yes ~ No__ 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the followings a. Did the personal representatiye file ~ fica account with the Court? Yes b. The separate Orphans ( y the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to .~rt. Date: ~~~/0 ~ Signabure Name (Pl'ease type Address Tel. No. Capacity: _Personal Representative _~Counsel for personal (MAH:rmf/AM3) / - representative