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Home My WebLink About08-03-09r w 1 15U5607120 J REV-1500 FJ( (06-05) OFFICIAL USE ONLY PA Department of Revenue county coos veer File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX.280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 0 9 4 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 193 24 0138 12 21 2008 02 28 1927 Decedent's Last Name Suffix Decedent's Firsf Name MI JACOBY RICHARD J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number DAg D _x Cn City or Post Office State ZIP Code CARLISLE PA 17015 ~~ ? --' N ~ -_`? Correspondent's a-mail address: ,"* Untler penalties of perjury, I tledare that I have examined Nis return, inUUtling aaompanying schedules and statements, end to the best of my knowledge antl belief, it is true, coned and complete. DeUareaon of preparer oNer than the personal representative Is based on all information of which preparer has any knowledge. SIGNAT E OF PERSON RESPONSIBLE FOS,FILING RETURN DATE ~~~~m , (` `~~~~~ Diane M. Eichhorn 8~3~~1 ~/ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum 48. Future Interest Compromise (Jere of Jealh Baer 12-12-82) T, Decedent Maintaine0 a Living Trust (Atlem Copy of Trusq 3. Remainder Retum (date of tleath prior to 12-13-92) I~ 5. Federal Estate Tax Retum Required 1 9. Total Number of Safe Deposit Bozes 9. Litigation Proceetls Received ~ j 10. ~olwe~en iYal B1 anEl71 99ar Jeam G 11. Election to taz under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTIONMUST BE COMPLETED. ALL CORRESPONDENCE AN_ D CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name ~ ~ Daytime Telephone Number PATRICIA R. BROWN ESQ. 717 249 6333 Firm Nama (If Applicable) SALZMANN HUGHES PC REGISTER OF WILLS USE ONLY First line of address e C 354 ALEXANDER SPRING ROAD, SUITE 1 r >., Second line of address O ~ ~ r 41 r• C-; (Anach Copy of WNI) FILL IN APPROPRIATE OVALS BELOW i~ 1. Original Retum 4. Limited Estate a Decedent Dietl Testate 408 Glenn Avenue, Boiling Springs, PA 17007 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ~w~~~:..-~ yP - Patricia R. Brown Esq. ~~~~~ enno«< 354 Alexander Spring Road, Suite 7, Carlisle, PA 17015 Side 1 L 1505607120 1505607120 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Jacoby, Richard J. 21-09-0094 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Signature #2 Name Patricia K. Grove Addreasl 23 N. Acorn Drive Addreas2 City, State, Zip Boiling Springs, PA 17007 Date 8/ 3 ~~ ~ 1505607220 REV-1500 EX oeceaem~s Name: Richard J. Jacoby _ - Decedent's Social Security Number 1 9 3 2 9 0 1 3 8 - ~--~-- RECAPITULATION _--- - 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule 8) ............................................................................... 2. 2 2 0 9 9 8 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ................ 5. 1 9 3 7 7 2 1 2 6. Jointly Owned Property (Schedule F) [~ Separate Billing Requested ............. 6. 7. Inler-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7, 3 3 4 0 2 6 0 g. Total Gross Assets (total Lines 1-7) ....................................................................... B. 2 2 9 3 8 9 7 0 9. Funeral Expenses 8 Administrative Costs (Schedule H) ......................................... 9. 1 6. 7 2 8 9 1 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .......:........................ 10. 2 ' 1 7 9 7 9 11. Total Deductions (total Lines 9 8 10) ...................................................................... 11. .- 1 8 9 0 3 1 5 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. _ 2 1 0 4 8 1 5 5 13. Charkable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .....................................:........... 13. 14. Net Value SubJect to Tax (Like 12 minus Line 13) ................................................. 14. 2 1 0 4 8 1 5 5 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable . at the spousal lax rate, or transfers under Sec. 9116 (a)(1.2) X .00 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 2 1 0, 9 8 1 5 5 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 D 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 16. 19. Tax Due ................................................. .................................................... ............... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505607220 0.00 9,971.67 0.00 0.00 9,471.67 1505607220 REV-1500 EX Page 3 Decedent's Complete Address: FIIe Number 21-09-0094 DECEDENTS NAME Richard J. Jacoby _ _ STREET ADDRESS 423 First Street CITY ~ STATE Carlisle i PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPaymenls A. Spousal Poverty Credit B. Prior Payments C. Discount 9,000.00 473.58 Total Credits (A + B + C) (1) 9,471.67 (2) 8,473.58 3. InteresVPenalty if applicable D. Interest E. Penalty Total InteresVPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 1.91 Check box on Page 2 Llne 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. ~ (5) q, Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is4he 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: Yea No a. retain the use or income of the properly transferred :......................:........................................................... [] b. retain the fight to designate who shall use the property transferred or its inwme :.................................... ~ ~ [x~ c. retain a reversionary interest; or .................................................................................................................. ^ C d. receive the promise for life of either payments, benefits or care? .............................................................. 2. If death occurred after December 12, 1982, did decedent transfer property whhin one year of death without receiving adequate consideration? ....................................................................................................................... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... r] x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... ~ l~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 p2 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 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 tour and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)j. 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. Rav-160J EXF (8-9a) COM.IONN'EALTM OF PENNBTLVMIN INHERITANCE TAI(REIURN RE9mENi OECEOENL All property (olMlyawnsU vMh right 0/ survivorship must W IIIaclosaE on $chsCNle F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 24 - Z50 U.S. Treasury Series EE Bonds -Principal 600.00 Accrued interest on Item 1 through date of death 1,230.74 2 3 - 5100 U.S. Treasury Series EE Bonds -Principal 150.00 Accrued interest on Item 2 through date of death 229.24 TOTAL (Also enter on Line 2, Recapitulation) 2,209.98 (I! more space is neetle4 atltligonal pages o! the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) SCHEDULE B STOCKS & BONDS ESTATE OF (FILE NUMBER Jacoby, Richard J. 21-09-0094 Rav-1909 E%. (8.99) ,. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COM.gNWEFLTN OF PENNSYLVANN INNERRRNCE TR%RETURN RESIDENT DEOEDENi ESTATE OF Jacoby, Richard J. LE NUMBER 21-09-0094 InUUtle the pracea0s of s[Igation aM the Este the proceetls were receiveC M the estate. All property JolMlyownstl wllh the A9M of suMVOnhIp must W tll9eloea0 on sehetlule F. NUMBER DESCRIPTION 1 M&T Bank, Checking Account No. 713902 2 M&T Bank, Savings Account No. 15004200919551 Accrued interest on Item 2 through date of death 3 1992 Oldsmobile Cutlass Ciera -VIN 1G3AL54N4N6340075 at proceeds of sale 4 Motorized Scooter 5 Comcast -refund 6. Haritha Vanem, LLC, DBA College Park Apartments =refund 7 Nationwide Mutual Insurance Company -refund of unsued automobile insurance premium OF DEATH 43,989.58 148,701.45 20.20 200.00 500.00 19.79 200.50 140.60 TOTAL (Also enter on Line 5, Recapitulation) I 183,772.12 (If more space is neetletl, atltlitional pages of Ne same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Forth PA-1500 Schedule E (Rev. 6-98) Rev-1610 EXi (S-ea) ,. CONTIONWFALTH OF PENNSTLVPNW INNERITANLf TA%RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Jacoby, Richard J. 21A9-0094 Thu schetlule must be completetl entl glatl g the answer to any of quasticro 1 through d qn the reverse sitle of Iha REV-1500 COVER SHEET Is yes. ITEM NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 AIG Annuity Insurance Company -Contract No. 28,656.48 100.000 28,656.48 VP223731, primary beneficiaries are decedents daughters: Beverly A. Jacoby, Diane M. Eichhorn and Patricia K. Grove 2 Sovereign Bank IRA 167178738 -primary 4,746.12 100.000 4,746.12 beneficiaries are decedents daughters: Beverly A. Jacoby, Diane M. Eichhorn and Patricia K. Grove TOTAL (Also enter on Line 7, Recapitulation) I 33,402.60 (If mwe apace is needed, additional pages of the same size) Copyright (e) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1181 E%+ 11288) ,. SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & IN RESIDENTEDECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Jacoby, Richard J. 21-09-0094 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached 10,591.63 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City Slate Zip Year(s) Commission paid 2. Attorney's Fees ~ SALZMANN HUGHES PC 5,000.00 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 353.00 5. Accountant's Fees 6. Tax Return Preparer's Fees, 7. Other Administrative Costs 783.78 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 16,728.41 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) .. I SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Jacoby, Richard J. 21-09-0094 __ ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Beverly A. Jacoby -reimbursement for expense paid to Cumberland County 1,335.00 Memorial Gardens for grave opening 2 Beverly A. Jacoby -reimbursement for funeral expenses 784.88 3 Ewing Brothers Funeral Home -funeral services 8,227.72 4 Patricia K. Grove -reimbursement for funeral expenses 244.03 H-A subtotal 10,591.83 Other Administrative Costs 5 Cumberland Law Journal - Legai advertising 8 Motorized Scooter -donated to charity 7 The Sentinel -Legal -Legal advertising H-B7 Subtotal 75.00 500.00 208.78 783.78 Copyright (c) 2002 form software only The Lackner Group, Inc. Forth PA-1500 Schedule H (Rev. 6-98) Rev-1613 ex+ (8-w) ,. SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEN.TH OF GENNSYLVFNIF INNFAITPNCE TF%RETURN RESIDENT DECEDEM ESTATE OF FILE NUMBER Jacoby, Richard J. 21-09-0094 Include unrolmburoetl madleel axpenws. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Beverly A. Jacoby -reimbursement for cable, meals on wheels, rent and phone 745.43 service 2 Embarq -phone service 33.87 3 Patricia A. Rosendale, CPA -preparation of 2008 income tax returns 105.00 4 Pennsylvania Department of Revenue - 2008, PA40 income tax due 47.00 5 PPL Electric Utilities -electric service 41.64 8 United States Treasury - 2008, 1040 income tax due 1,202.00 TOTAL (Also enter on Line 10, Recapitulation) I 2,174.74 (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. 6-96) ,. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacoby, Richard J. 21-09-0094 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY Do Not Lbt Trupa s (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright sppousal distributions and transfers under Sec. ~116(a)(1.2)] 1 Diane M. Eichhorn Daughter 70,160.52 408 Glenn Avenue Boiling Springs, PA 17007 2 Patricia K. Grove Daughter 70,160.52 23 N. Acorn Drive Boiling Springs, PA 17007 3 Beverly A. Jacoby Daughter 70,160.51 2491 Winding Road Hatboro, PA 19040 Total 210,481.55 Enter dollar amounts for distributions shown above on lines 5 throw h 16, as appropr iate, on Rev 1500 cove r sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-150D COVER SHEET I 0.00 Copyright (c) 2002 forth software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) 1. LAST WILL AND TESTAMENT I, Richard Jacoby, of the Borough of 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 by me. Item I. I direct my executrix hereinafter named to pay all my debts and funeral expenses. Item II. I give, devise and bequeath all my property, both real and personal to my children, Beverly A. Jacoby, Diane M. Echhorn, and Patricia K. Grove, in equal shares per stirpes. In the event any of my children should die without issue, their share will go to my remaining living children. Item III. I nominate, constitute and appoint my daughters, Beverly A. Jacoby, Diane M. Eichhorn, and Patricia K. Grove; as my executrices, and I direct that they should all serve without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ,3 D day of ~y (~' ,np2004.` ~~'Cf~''*~l SEAL Richard acoby Signed, sealed, published and declared by the above named testator, as and for his last will and testament, who at his request, in his presence, in our presence,. and in the presence of each other have hereunto subscribed our names as attesting witnesses: /" ~. l' 4w Ci `y - -~O r.S ,.~ 7• - c_ ~, ~_ _ _ . ~.? - : _- ~~,,'. ~' ~ - ~ V COMNSONWE ALTH OF PENNSYLVAi~IIA COUNTY OF CUMBEPLAND i 1 it ~~ We,,' ~' '~ - r 1``~ °'-. and vhose names are signed to the attached or foregoing instrument, being dul qualified according to law, do depose and say that wee were present and saov to tator sign and execute the instrument as his last will, and that he signed willingly and that he executed it as his free and voluntary act for the purposes therein contained, 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 mind and under no constraint or undue influence. Sworn to and subscribed before me this ~ v day of - ~~ ~ , 2004. L.~-/V'~ ~ -Notary j Notarial Seal ~~~ Anne M. Cox, Notary Public Carlisle Borough, Cumberland County PAv Commission Expires Juw 14, 2005 COIvIbIONWEALTH OF PENNSYLVANL~ COUNTY OF CUIv1BERL.AND I, Richard Jacoby, whose name is signed to the attached or foregoing instrument, having been duly qualified according to laws, 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. Richard Jacoby Sworn to and subscribed before me this the day of '~G Imo, 2004. rte,/ ~ . i i'~'`~-~ ~~ Notary Notarial5eat a Anne M. Cox, Notary Pubilc p G rllsle Boropgh, Cumberland County i M? Gommisslor, Expires July 14, 20D5 TITLE) MAKE OF VE MODEL A PA WN ON H C' ^ l S P A IO~~~~ I r~ ~~ ~ ~ ~ ~ ~7 S " , 1 (See NoW Re veESel an ~fvn a • _ • J • ('u wu CONDITION VE HICLEIDE TIFICATIONNU M B R N F >6 { l n ( ( LESS TRAUE-IN ~ • I ~ I ' I ( ~ { I ' fC, ~' 1~~~"~r `~ R.1 ~. `I l/O~S OGOOD :7 FAIR OPOOR B•w LAST NAME IOR U B SINESB'y ) 1 ~f I h FfL;Si NAME \ MIDDLE NAME {VG ~`r{~f•LY`CLiJ J A%ABLF AMOUNT /~ qq~~ , I~/IPA 1 l l w LO SELLER '~j l + V - 1. SALES TAX DUE C TH ST NAME (OR FULL BUEMESS NgME) FIRST NAME MIpOLE NAME PA DUPHOTO 10# S a rvg an%Re ersell ~B /~ l/J' / OR (0# I ~ j e w ` ~~ ~ I ~~ ~ ~ ~~ , ! w j ~ j` f V~ 1A E%EMPTION ': i f lF I REASON COOE.(musl z CO-PURCHASER LAST NAME FIRST NAME MIDDLE NAME PA DLJPHOTO ID# UATE OF BI TH be a number frpm'1 b w w 23 pr O{ K z 1B FIRST iB SECOND-. '° ~ STR ET E -~ COUNTY CODE ASSIGNMENT .. ASSIGNMENT' ~~~ //~~~~ + , / c /n~A ' / "// ~ ~ ~ ~~ ~ ~ ~ ' ~ ''- \ ' ~ 'v T l.{~ Iv` c%,lJ 2. TITLE FEE fem. / ' ~ ~ ' / r •-1 V CITY STATE ZIP CODE GATE OUIRED REFER TO COUNTY CODES ~j / n /•~ C (7 {7 r / ~. '~~'3 P~ / ry/( LISTING ON 0.EVERSE SIDE l~ ' ) yy-~„ L r ~/ ~ OF YELLOW COPY 3. LIEN FEE p LAST NAME IOR FULL BUSINESS NAMEI FIRST NAME MIDDLE NAME PA UPHOTO I Dp PATE OF BIRTH OR BUS. 10# A 4. REGISTRATION OR / ~ PROCESSING FEE ~ L ~./(,. r CO-PURCHASER LAST NAME FIRGT NAME MIDDLE NAME Pq pUPHOT010# DAT OF BIRTH w w FEE E%EMPT NUMBER f < AS A9516NED BY TIE ~ ~ DEPARTMENT w e STREET COUNTY CODE a i ~ 5. DUPLICATE REG ~ O FEE NO. DF z s ~ LARDS CITY STATE ZIP CODE DATE ACOUIREUI PURCHASED REFER TO COUNTY CODER fi. TRANSFER FEE LISTING ON REVERSE SIDE OF YELLOW COPY E MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER T. INCREgBE FEE ~o u~ ' ; Sy MODEL YEAR ~ ~ RODY TYPE (CP, TK. ETC) CONDITION B. REPLACEMENT FEE O GOOD O-FAIR O POOR rDTAL Pmo °" t0' F O TRANSFER DF PREVIOUSLY ISSUED PLATE (ADD 1 THRU S) I~ . O PLATE TO BE ISSUED BV V DEPARTMENT (PROOF-OF Q TRANSFER B RENEWAL OF PLATE 1t. GRAND TOTAL SEND ONE CHECK IN INSURANCE MUST BE ~ O TRANSFER B REPLACEMENT OF PIATE (AD09610) 7X15 AMOUNT "q /~ ~(J•~ ATTACHED.) O TRANSFER OF PLATE d REPLACEMENT OF STICKER CHANGE PLATE TORE REASON FOR REPLACMENT CUED BY DEPARTMENT $ ^ LOST O DEFACED O STOLEN Q NEVER RECEIVED (Lost+n Meip TEMPORARY PLATE ISSUED EXPIRES NOTE'. If "NEVER RECEIVED" block is checked, applicant must mmpale Form MV44. K BY FULL AGEM Mantn Year LL ~ . TRANSFERRED FROM TIRE N0. VIN i i ~ 6 y { A HFB 4 9 Q 9 SIGNATURE OF PERSON FRO WHOM SIGN HERE RELATIONSHIP TO gPPLICANT J u S 3 S 3 2 , PIATE 16 BEING TRANSFERRED BF a ¢ OTHER THAN APPLICANT) ' < vcnN~t PURCHASED WEIGHT GV R UNLADEN WEIGHT RED. REG. GROSS W;. RE REG G OSS COMB. WP. F t IF v INSURA ~ P FECTI 5 Y N ( ' Y I J~ gTTAC N ER 1 PATE (CERTIFY THAT ON MONTH DAY YEAR ED D ISSUING GE(JT (PRINT E7 ~.~~ 1 ~~~ \ ~ / AGE ~ A ~ ) -. ISSUING I HAVE CHECKED TO DETERMIN TAT iNE VEHIC I NSUR APP ICANT IN 7 V J G ' ~ AGEM INFORMATION , L ISSUED TEMPORARY REGISTRATION TO THE ABOVE COMPLIANCE WITH ALL APPLICABLE PROVISIONS OF THE VEHICLE IB G GENT SIG ATURE ` j~~. ~ 1 L TiLEPH / C ~- 77 CODE AND DEPARTMENT REGULATIONS. r ~1 1-~~L. r INJE CERTIFY THAT INJE HAVE E%AMINED AND SIGNED THIB FORM AFTER ITS COMPLETION AND THAT THE INFORMATION GIVEN IS TRUE ANU ~ RECT IF ANY EXEMPTION IS CLAIMED, THE PURCHASER FURTHER CERTIFIES THAT HEISHE IS AUTHORIZED TO CLAIM THIB EXEMPTION. IIWE ACKNOWLEDGE THAT IIWE MAY LOBE UR OPERATING PRIVILEGEB(B) OR VEHICLE REGISTRATIONISI FOR FAILURE TO MAINTAfN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. INJE ACKNOWLEDGE THAT IIWE MA1' ~ 000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY FALSE STATEMENT THAT LANE MAKE ON THIS FORM. BE SUBJECT TO A FINE NOTE%CEEDING 35 . 9 lure Flrs a or AUthoAZ iHOphone Nc. u 1ST '~ ASSIGN- MENT Signawre of Co-PUrcpaserRille of Authorized Signer (~(T~ 7 7 ~ Y3 ~ W . .. - 0 3Np SlgnMUre Df Semntl PurcAaser or AUtnodzed Signer Teiepnona No. ASSIGN- MENT i9nawre o ..o- urcheser me a utnwrz ~gnar I s H NOTE: IFACO-PURCHASER OTHER THAN YOUR SPOUSE IS LISTED AND YOU WANT THE TITLE TO BE LISTED AS"JOINTTENANTB WITH RIGHT OF SURVI'JORSHIP"(OIJ DEATH O'r ONE OWNEk. O G 2 w r TITLE GOES TO SURVIVING OWNER.j CHECK HERE ^. OTHERWISE. THE TITLE WILL BE IBSUED A$ TENANTS IN COMMON' (ON DEATH OF ONE OWNER. INTEREST OF DPEABEU OWNER O~G p r ~ GOER TO HIBIHER HEIRS OR ESTATE.( O ~ ~ r~ NOTE IF THE VEHICLE IS TO BE USED AS A DgILV RENTAL Oft LEASED VEHICLE CHECK THIS BLOCK G. IF BLOCK IG CHECKED COMPLETE ANU ATTACH FORM fdW 1L. Q S NUMBER. 1. BUREAU OF MOTOR VEHICLES .. p~ 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888)502-4349 Fax (302)934-2955 February 17,2009 Salzmann Hughes, P.C. Attorneys at Law 354 Alexander Spring Road Suite 1 Carlisle, Pennsylvania 17015 Re.• Estate of Richard J Jacoby Social Securiri~ : 193-24-03138 Date of Death: December 21. 2008 Dear Sir or Madam: Per your inquiry dated January 23, 2009, p lease be advised that at the time of death, the above-named decedent had on deposit with this bank the following: ' I. Type of Account Checking Account Account Number 7!3902 Ownership (Names oJJ ~ Richard JJacoby' Opening Date 9/1/67 Balance on Date of Death $ 43,989.58 Accrued Interest $ 0.00 Total _ _ _. $ 43,989.58 2. Type of Account Savings Account Account Number 1500420091965] Ownership (Names ojJ Richard JJacoby' Opening Date 5/17/90 Balance on Date of Death $148,701.45 Accruedlnterest $ 20.20 Total _ __ _ __ $148,72L65 3. Type of Account Account Number Ownership (Names o~ Opening Date Balance on Date of Death Accruedlnterest Total Sm~ings Accound Holiday Club 25004920111428 Richard JJacoby* 3/21/94 $ 0.00 $ 0.00 $ 0.00 Please be advised, there was no safe deposit box found for the above decedent " If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information an the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contaM our High Street Carlisle Office # 717-240-4536. Sincerely, ~~'L1~2C ~. ~~~ Trade Hare Adjustment Services O ~ N C •~ ~ Q G rno °o~ N C '- C ~~ O ~( O. ~ W C .~ a`0 N C O m ~ d ~ .. ~ o ~ 2 V ~ U w y V Q ~O ~O l0 to m m < m r < r < .r < r W m aD im QI < IQ) < . 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N`U CZ y•.O-t _ ' ~ m O ~ ~ d ~ o w ~~ an d d a~ x.10 ~a C,OOXO ~ E c ctia c~'° o wrn1O$'~ y T U 3 d ~ E n a « U a _C CO O C N N 2 a a ay,~~ y Xar~~ w$rn Za ~Z~~a L ~ ~ N 2 llyqq 'N ry~ V y O p ~ y ~ C C'~ N ~._._~ 3 ~ d d ~ C Oly ~ C O C y y L ~ C -'- U ~ f0 N NX Uv33W ~~wwc coda ~ - - L a y y y d d d l0 ~y'~U Q (q rn y "! m m 3 W y y.0 C as a°~ ~a;' w 0 d N a N C ~~ 5,,r~w L ~~~~ .. ~ ~: _7~ E ~y~~'I`lFIB'~[T,?L~'I'~~~I~l~~f~ijTCy"~•v~`~~~j, ~IS SUE DATE 3. /.~.r...~~,-3':S wrvlcN Is n~E wusT i~N. aF RICKAPiD J JAC09Y 524 WEST tAUTHER ST CARLIStE PA' 17013-221.3 OR A!7NA TSABEtLE JACDBY DEC 14&4 .~I .al 193-24-013fi"" 411168 1932401321 26 ' DEC ~~.~o.IE~-~4 o.r,..o =..~ 172-24-7824 USPS.NY PDC 0193689285'" ----"~ FT TMf NTJt11TY YEPEOF WALL PNV ~~~I~'.~`-TiP~i?T~~r 1~.~~~' W ISSUE DATE ,F ca. 'Y \I s,'I 1~ IOSUL UNIL ~~\, ;~ I~Z1 ~~A~. C~~ c I rv~,` 3\_{-~ wX.~[H ~5 L4L F,PS f IIAV l~ SEP 2°&k 293-24 -0 Y"°'~~~ - r~.Ar 411165 1Q324C1s8 19 SE,r^ 21 i4P4'• 172-24-7924 USPS. hY~~PiC" 0180176178. Tii RICHAP,D J JAC09Y 529 WEST LAUTHER ST CARLISLE PA I7013-2223 eR ANNA I544EtLE JACCBY ~. 'n:ICHA~;D J JAG~EY ~[~' n'~S? LAUTNER ST CArLI~LE rt. 1.7013-2213 a~a AtiF:A ISAEsEttE JAC~BY ^!A? 1985 41115 8 1 43 4'J 138 Ob !-+Ac ~a rgPS .bm--~ .,.e~, 172-~4-764 USr^5 NY PDC C?~ 024 607 I 7 . _. ~~ ~~~ SERIES ~~ .. ~ g-_.,>,~4~.. Y EE ..... ~. .zrM ~. ~ER~ES EE RICHARD J JACQBY 529 NEST LAL'THER ST CARLISLE FA I?C13-2213 ISASEtLE JACO€Y L 214 555 595 EE ATy~ir":C~~MrATIIPITV N~CPEOF WILL VPV~'~ ~' ~- ..IS ..sl"1. ~Cj tLl'~G ,~'1`~ w"cSSI, E'D ATE or y.. .1~S,;e,r Tn - ~ .. SEP 1965 - --o"------_- awl-- RICHARD J JAC09Y 193-24 0238 ~~ 529 WEST LAUTHER ST 4I 1166 193240138. CARLISLE PA 17013-2213 20 QCT~.• ~ x,885, Q.R ANNA ISA6ELLE JACOBY 172-24-762'4 USPS•,NY P.CC CZ 2.9090649 - c "=oaiv4~-; .We. L /} r ~ (, n rVI {-~ '~. `~' E E SERIES EE " ~ ~~ ~ ~......~ SP.Pn L ~ cx Ymwrrq S [T, r ~31~ i~~Y~~cYcA 193 24 01.38 12 ` 19B5" ~~;. ~ Ta 529HN~STJLAU7HER ~S7 CARLI~LE PA 170 1 3-2 2 1 3 .•~,; ~"' II€C 27 198'5 USP'S""FCT`"PO ANtiA ISA.BELLE- JACCIBY_ 172.24 .7;32 4 2685 ~ 193 24 0138 , ;~ ~r11168 ~,'025321BI03 . ~ "~ L2~321$103EE; ~•nnfln 9flfln'7 ~_f1 ~" " ~ n a'k ~?1R'i f1 3n^ ISSUE DATE NtiICH i51uF {'IflST DtT pI Jua 1 sii5 193-24 =X3'38====: ~K=° - 41]1L6 ,-19324013& I3 JL'N 26 19I;5 ~~w"~.o•.,-~ 172-2.4-7824 U' 021455: ~4 1 'S ~~~ 1'33 `24 tiI38 ` 07 1' 7:, R?CHAR) J JACCBY `` ~ ~ 9~4 hEST LAUTHE2 Si "" CA.RLISLL RA JL"L 11 ' ti"7 17013-2213 - ~ USr~S°"Nl" ~d ~y k ~ ~. ~ ~~, 02^92: AMFNA ISABELLE JACE~E3Y. ~~ ~, ~•~" 172 24 7ii24 . 1486 ` 193 24 038 ~„ ..,.,.~~..,.~~~.,,,,,..,.., T. ~~....,yw>.w, . r , ; ;'~~ ~ ~ ~ ~lii3 [ ~~a3r~i~ ~~~~jt~n1~l~lil~d~~j wE~fI _ ~ _~a.LL, ~ ~~ ~ .~ .' T;aa~s~ r~~sx~x~aca-~aa ~s .;; , ... . ' 193 24 Ol'ti OI. Tii FcICHIetiG J JGCCEY '" ~ 529 xLST LAtTHER ST' ~"' -, Ll.r"iLISLf F. 17033-2ZI3 ASP ~, v k~ r 'a' y : ~.' ~{ QCl ~ V rhg f,,. AthiA ISArELIE :~ACt~9Y ,, 372 24 ?£2q CZ87 193 24 ~i38 `` `. ~~~~x~r~r,vn' ~ 4II]l~~. 031~40[40~6 ~' ~~~- L31'~a2 r" ~:000090007~:03 ''` t 03340 240 56~~' 9000 7~:Q 3: '~ ~0 3~i:7Q'78 209~i' r~~ «~~~i~ ~~~~~:a~.~~~~~ ~F.I~IES ~;~; ~~,~n-S~r~aac~~~~ 193 24 0138 10 7987': ~%~ :RICHARD J JACOBY ,,-~~ ''-., ~,, 529 NEST LAUTHER ST -, CARLISLE PA 17013-2213 o.C7 ~~b ],p 87 • USP~ Tt1~f PDG " ANNA ISABELLE JACOBY 172 x:4,7824 2187 193 24 0738 9 411'i,d8 0338657491 .: L33S651491Ef ~~nnnngnno7~:03 *,°~~~°~~8651491~~' 33"?~~ ~"~~~ ~d~a A_~: Sr +.~ 1Y,#'S `~^G 4~d'~u * ~'P 3\ sEa~rFS EE ^ . 193'24 0138 01 1988 3 *-: ~~%~ R?CHARD J J.4COBY f .,~ 529 WEST LAUTN"cR ST - CARLISLE PA 17013-2213' JAN 22, 1988 +::+~- . USPS MN PDC ., ~' Chi"-0772 ~x ~ ~N ' ~ . _ ~ &` NA ISABELLE YACOBY- % ' ~ 172 Z4 7824 02:88 :' 143 24 Oi38 E ~' , ,, 411153 0355838625 ~,' e = ~ ~ L356838626EE ~L n f - ~~., ,r;~~-~. , ~ , ~ ~ 000090007:03 `T'' ~O356838626~ '_` i' ..__., ..y. . « . ' ' '4`.III3 i~sk~`i`1'i)JSlU1~3ti; ~,lfi~a3' ~AIifS^I,ii~:~ ~ ~ _ .~ s~r~iES EE t rrt err~rsix r..~xa~s 193' 24 0138 04 1988 %~ RICHARD J JACOBY 524 NEST LAUTHER 5T CARLISLE PA 17013-2213 APRF,,'~5,~,1488 asps t~N ~C'C o~ a°9::a~i"t z ; ANNA SSA6ELLE JACOBY~ __ .172 2A 7824 GBSE 143 24 6138 41.115E 037Z81504D ~ -= L3~2$16O4OEE` ,~t l ,.,,,,~.,_,.,. ~:000090007~;03 ~'~ D3728i6O4Oi~' s~~, ~ ~ ~ irs.~ ~ ~I`i`Ia) ~It~"i q,~ ~~~~ ~~I~ r~ga~ ~a; ~~~i.~Es EE fi 193 24 0138 07 19E8 ~ ~<~ RICHARD J JAG06Y "~ k;. 529 NEST LAUTHER ST ~ ~ ~ gg~~. CARLISLE PA 17D13-2213 IJJSPS2M~IPDC ;% ~ "~ ~~ OR 09=~~7~2 ~ ~ ~ ANNA ISABELLE JACOBY ,.• ~ 172 24 7824 1588 193 24 0138 ~~,~~„~,r„~~ %^ 411158 0381z74211 ~ L~$iG~4~11EE ~ ~~= ~, `, _,.,.MUM,.~... ~:OOOO9OOO7e:O3 ~~~,~~ O38~2742:i~~' ,,~ ~ ~ `- 'l lib 1 \,I'1_Irl),Sdi l+I (3~S 1~3h ~W11:F [.IY ,A_ ~'., t';, t~," _ 4T~I~i"1 ~FYD;~Cr;iG.ld,~j ""-- t~ 193 24 .013a ~ ~~ %~ 529HWESTJLAUT4ER 57 ~; CARLISLE PA 17013-2213 }~: . ': S+EFIES 1C 19EE L1C77; ~~~..luB.g USfS MM 'FDC r~,F D9=~~72:", t' O R ~r ANNA ISABELLE JACOBY' 172 24.7824 2288 1.93 24 0138 \` %wsvdsy3m~~~''' 4111 G8` G397329485 w ,-~~~- L39~329485EE ~:000090007~:03 ~ 0~~39~A73~29485~i' >.,~~ ~ ,i~~~, ca~~~i~r :~~ ~~~~r~~sa~; ~~.~~~s~~~,, SERIES EE ,: '* ..193 24 Oi36 01 19E9 U,. ~,~' 1:, %%~ RICHARD J'JACOBY ~„ ' S29 ,'r1E5T LAUTHER ST CARLISLE PA 17013-2213 JAN, n ~~84- ~; < USPS~iS"rDG r H );, ~ ~ ~ D~'-'t~ 7'72 . ~~ ~t '. OR s ANNA ISA3ELLE JACOBY '~~ ~, 172 24 7824 0269 14.3 24 D13R ~,,,,,g.~~ 4111~a o4oDG37s39 L400631539EE ~~- ~:000090007~:03 °'` 104DD637539ii• `"~ ~rv~~a~a ~p;~;~~~~ 4 ra~'r~~ ~~~a~~^~~a~,~~+r ~<; .SERIES E' E' ~.~ai~~ as ~%iu~r ~~~.~~~ 1S3 24 6138 04 i9E9 %~ RICHpp,,RD J JA.CDBY 529 WAS'( LAUTHER ST CARLISLE PA 17013-2213 APR ~8 X98.9 LISPS' `NfFf 1'Dt 0~'~Y17"l2 OR ANNA ISARELLE''JACDBY 172 24 7824- D989 :193 24 0138 4111 G$ C4G12Z815Z ~~;, ~=--- L401228152EE r.. .•r~r~nnnnnn n.~n ] ° nl n 1 7 7II t C ]u^ '~g`' 'i'I1P ~i'\t 1`I~I1~~siL,tl~I'~(II, ~ I:I 3~(~: ~. ~ a ~ ~ ~_ ~_, ~. sE~lES EE 193 24 0138 07 1989 ~`~ ~%, RICHARQ J JACDBY 529 HEST LAUTHER 57 ' ~` ~` CARLISLE PA 17013-2213 AUG, Q4'a989 USP~°'M1Ff 'PDC 09'='0`x'7"2 ANNA ISABEILE JACOBY _ ~', 172 24 7824 1689 °193 24 0138 ' ,~,.,~~• 411168 0414762733 ~~~_ L.~}14162133EE ~:000090007i:03 0414762733~~• ~ ~~~~,~-~a;+~t~~~~~~~vs~.~~~, SERIES EE . ~ ... ~~r~~~~s~Y~~c~+:~.~s ~- ~. 193 24 0138 10 1989 ' ' %" RICHARD J. JACOBY "CARLISLE PAUT17013i2213 OC16,~,27E,1,98,9' USPS MN'PDC. ~~ ~ 09-0772: ,.. ANNA ISABELIE JACOBY' .172 24 7824 2289 193.24 0138 ~~ ' ' u~~~sx~n `' 4tttba o43szees8s ~ ,~ L435268585EE - 8.~~.,. /Mu wi.y ~:000090007~:03 ''' 404 3 5 268 58 5~~' ~~Ir~~~,1.~xa,~r~t;~s;~~~~~r~~a~~~~:,tt~~~~ sERIES EE 193 24 0138 O1 1990 /~ RICHARD J JAGOBY ~-- 529 id LQUTHER ST CARLISLE PA 11013-2213 FEB Q2 90 USP'~°"7~TiT" POC OR 04"='772 ANNA.ISABELLE J0.COBY 172 24 7824 0390 '193 24 0138 4111b8 o~3ssz3119 ~, y ,~ L't36823119EE 1 nl~ry~M.n~v nN ..nnnn nnnn ~.•n ~ ~ 7f1L 3.~,R 7 ~ 119u' ,. ~, ~ ~;rrr,; L ~a~ap~~r~~~~~~~ I~~ t~Ia ~~~'.~~~:~, SERIES ~'.~ ~. ' --•-,"~lext~""sue l Irti;'-i~I~iv)Tcf•.r1i~s~ 193 24 0138 OS 1990 ~x~ '"~ ~~ %ii RICHARD J JACOBY - x ~~ 529 W LOUTHER ST ' • .~a~' .~ CARLISLE PA 17013-2213 MAY 11 194A U S P'5""1?N"' P D C 09'-0'T72 . ~'~'~ ANNA ISABELLE dACOBY ~ 1.72.24-7824 1090 ':193 24 0138 ,,.,~~,A~,,,, 411168 0455600833 ,~,~~ '' L455600833EE ~0000090007~C03 ~'' 9045.56.008.3 iii' ~I~IJrs~s9~i ~~~~ ~~~~im~l~~~~ .SERIES ~~' --ei~sr,~t~~~~ ~ ~s 193 24 0138`- 07 1990' i~,! %ii RICHARD. J JACO6Y ,.- +~. 529 W LOUTHER S7 CARLISLE PA 17013-2213 AUG Oz 1990 Gw~`> ` LISPS " M11P `P D,C i D R OS'~~772 ' ANNA ISABELLE JACOBY ~ 172 24 7824 1640 193 24 0138 `~~- a 41.11b8 0450233972 ~, ~ ,~ L4602339~2EE' ~:000090007~:03 :~,` 30460 2 3 39 7 2i~' am; ~ 1~ ~ a ~ ~i~I 42i~_!~~, 1~,1 di 91i~ 11~~i~I~~,~R_,,i"~~~i~il S~'.1~1}~S ~~ J} gg {~~ rH H~~\~ ~'('~y * x4i4 Y \, y y y y4Y ~v]~j~ (*~rrrii .(7Tw£=Y'~ `¢'~dll i \.tz~yh \I ,l, f.oA 1'[U_ 6 d ~l~ INTCfl EST CEl.5 E5 ]O VEPPS PPOM ISSVE GATC 11 1990 .193 24 01.38 -~ ,. ~" ~,, w ' " i, RICHARD JJACOBY ..'~ ~,'~ ~ 529 W LOUTHER ST CARLISLE PA 17013-2213 , 1 PDL `M1Y USPS' a ' . , 9aT~47~2 r~. :. : M 0 R ' ~ ANNA ISABELLE JAC09Y " N 172 24 7824 0491 193 24 0138 ~; ,~ ,a„~ ~,~,, '~~ 411168 0278s9o767 ~ / C2~85909b1EE ~:OOD090007~:04 'Y" 80 2 78 590 76 7~~' M~ .f. T' ]•~ YA '~ ~ TE EST LCPSES .O YEwR•v ~.na ~=. ~ ~ ~ c~~, a ~~IJv~l) Iaorcr ~~ .., SERILS ~' ~~.¢'v 5}~1;~.+gal _ '".. r.Y+vv~~°"^~~i r'~"~S'~"'Z^~ FROM ISEVC OPTE 193 24 0138- OS 1991 %2 ~,~~ ~, ~-"" ~ /.> RICHARD J JACOBY :, >M~ ~. ,~ .~~ s" ''~ «~' CARLISLE PA 17 01 3-1 91 8 AUG ~,6 '991 ~` ~~ ~ USES" Y+t15" PDG +~. ';. OR 0`9T-b7'72 -,, ~* ANNA ISABELLE JACOBY- n ~' 1'72 24 7824 1791 193 24 0138 '- .v±a>,~„„vMal 411168 0313045151 -- ~ ,<-~„_, ~-, C313045151EE I ~:000090007~ 04 -- S03i3045i5iii'. 1'f+f':~_, *; ?kf~k E3A °:``E S;vi F~~t~°a' *~~~~'Iv"!I~Su 4~~~~5 ~!~ dE~;~(.~'@~tf~'!y"~[b },b(30.1.,.A9'~tii.. INT cEPflES no.EPRS NOM 59Vf OA'E 143 24 0138 11 1991 ,, RICHARD J JACOBY 150 C ST CARLISLE PA 17013-1918 F~9 14 1992 USPS"`MN"'PDC Lniilu,llln,u,ll,iiln,illl,l„„rlllul,lrltrl 09'-0?72 OR ANr;A ISASELIE JACJBY 172 24 7824 0492 193 24 0138 411168 0315174441 ~~`,;~•, C 315114 9 41 E E .•nnnnonnn~rnt_ i,`ACl3i5LA74941ii' AIG Annuity INSUAANCECOMPANY AIG Anndty Insurance Company A Stock Company 203 East 10th Avenne AmariDo, Texan 79101-3346 Telephone: 800.421.4990 February 12, 2009 ,~ ~ ,~ .~~ Patricia R. Brown, Esquire Salzmann Hughes, P. C. 354 Alexander Spring Road /Ste 1 Carlisle, PA 17015 Re: Name of Deceased: Richard Jacoby Contract Number: VP223731 Beneficiary: Diane K. Eichorn, Patricia K. Grove, B2verly A. Jacoby Deaz Sir or Madam: We have received notification of the death of Richazd Jacoby, the owner/annuitant of the referenced contract. On behalf of AIG Annuity Insurance Company, we wish to express our sincerest condolences for your loss. The following items are enclosed: I) Claims Checklist - A list of items required to initiate a claim for this, contract. 2) Beneficiary options page - A list of claim options available to the referenced beneficiary. 3) Applicable documents for completion. The value of policy on the date of death was $28,656.48. We appreciate your prompt attention to this matter. Should you have any questions or require further assistance, please contact our Client Care Center by using our toll free number of 1-800-424-4990. Sincerely, ~ `~~~ ~ B.M. Graves Annuity Claims Manager Enclosures AIGA Cvr Ltr DOD ~.~ Sovereign Bank ESTATE OF Richard J. Jacoby SOCIAL SECURITY #: 193-24-0138 DATE OF DEATH: December 21.2008 Account #: 1678179738 Type: IRA Open date: 8/31/1989 In the name of: Richard J Jacoby Date of Death Balance: $4,693.87 Int.(YTD) from 1/1/2008 to 8/31/2008 $173.09 Accrued interest to date of death: $52.25 Other Info: Primary Beneficiaries:Beverly Jacoby, Diane M Elchhom & Patricia K Grove-dau~lrkc5• Page 1 of 1 ESTATE OF RICHARD J. JACOBY TO: PAT FROM: TAMMY DATE: 07-29-09 Please review the Inventory and the PA Inheritance Tax. ,. ~~r., - Iwill make any corrections as needed. We can then set up a time for Patricia and Diane to come in -review and sign the returns for filing. Thank you!