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HomeMy WebLinkAbout05-25-111505610101 REV-1500 Exc°i_i°~ ~' PA Department of Revenue Ptrnnsylvartia OFFICU\L USE ONLY Bureau of Individual Taxes Po Box zso6oi °"""'"`"'°`""`"°° INHERITANCE TAX RETURN Coun Code Year tY ~'''~'~ File Number Harrisburg, PA i~~6-o6oi _ RESIDENT DECEDENT ~ L! I_uJ ~ ~ ~ 7 5 ENTER DECEDENT INFORMATH~N BELOW Social Security Number ~-~-~ Date of Death MMDDYYri d o ~ ~fO3l/I~I~II o 6 i o Decedent's Last Name Suffix C ~ S (H Applicable) Enter Surviving Spouse'a Information Below Date of Birth MMDDYYYY / o ! 193 Decedent's First Name " MI ~- _ - Spouse s Last Name Suffix Spouse's First Name MI ~ ®ITi'1"T' ^ ^ Spouse's Social Security Number ® THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRU-TE OVALS BELOW ~ 1. Original Return O 2. Supplemental Retum O 3. Remainder Return (date of death prior to 12-13-62) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 8. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number First line of address Second line of address a5 ;QF-WILLS Uri ONLY ,... ~ f !V C ~ - C ~ .. City or Post Office State ZIP Code I ATE E C H ~4 N/ 8 U R ©L:LLo s 5 '.L' L~S' Correspondent's a-mail address: C GS ~ 7 G /d s 3 Under penakies of perjury, I declare that 1 have examined this return, it it is true, correct and complete. Declaration of preparer other than the SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN o~u m. ~A~eo ~ s 333 'omcast net accompanying schedules and statements, and to the best of my knowledge and belief, d representative is based on all information of which preparer has any knowledge. DATE iJ ~ _ ..-- ---- ~ ..... ,., DATE x /~ I S/iT~i~ ADDRESS (~1kR,~S ~' SH/EGOS I!C (o iJouse~ rPd. ' 6 /TGs PLEASE USE ORIGINAL FO ONLY Side 1 1505610101 1505610101 REV-1500 EX 1505610105 Decedent's Name: J t4 m~ llCi JfF Co ~? 1. Real Estate (Schedule A) ..................:........................:. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separete Billing Requested........ 7. 8. Total Gross Asaats (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12 13. Dharitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13 14. Net Value Suhielet'ko Tax (Line 12 minus Line 13) ........................ 14 TAX C~CULATI tt$EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amtiunt o t xable at4tib spo~~ te, or trari tiers er ~ 9116 16. Amount of Linel9~l'liexable r, __ at lineal rate ~0 ~~ ` Y/. ArppUnt of Line 1~(axable at sibling rate X .12 18. Amount of Line.14 taxable at collateral rate X .15 Decedent's Social Security Number ~ i t i~r w m a 0 0 D D 0 7 7 0 i o z ~ 4 / 7 9 5~ 9 3 ~ 6 a 7 S 7 0 p O D O 15. 16. 17. 18. 19. TAX DUE ..................................................:.:.... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 O REV-1500 EX Page 3 Decedent's Complete Address: FIIeNumb•r ~~~~~~ i' IS DECEDENTS NAME TA-rnE5 ,~,__ J~4CoBS (ftieelv~s Mosr STREET ADDRESS ~ ma•I.n 7ltf RA"N6E _. ttoa.D 333 (~. S-rtrtpsoN sT. "~'~'~ ~-~+ Cfr,l,,ntiant /1']E'CH~A//crSBG~t'6, PA f'loss' v n~ CRY ~ 1 c.L.S BLL/Q6 STATE ~ ~ ZIP /70/~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) ~ 2. CreditslPayments c A. Prior Payments _ B. Discount p 3. Interest Total Credits (A+ B) (2) a (3) O 4. If Line 2 is greater than Line 1 + Line 3, enter the difrerence. This is the OVERPAYMENT. ~ FIII In oval on Page 2, Line 20 to request a refund. (q) 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) o Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWMIG QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decadent make a transfer and: Yes No a. retain the use w inwme of the property transferted :.................................................... b. retain the right to designate who shall use the Property transferred or its income : ............................................ ^ c. retain a reversionary interest; w .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................. ^ ............................................. 3. Did decedent own an "in trust for" or payab-e-upon-0eath 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? ........................................................................................................................ ^ 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 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 21 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 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 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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. RE1F18A! IX • (tA7) it SCHEDULE E coMMa+wEanloFt~rmsnvArtln CASH, BANK DEPOSITS, 81 MISC. ~ '" ~ ""~ TA>< `~''' PERSONAL PROPERTY ~ ESTATE OF FILE NUMBER ~/4('.OBS, Ste.^tr.~ ~ .Z.~ - /0 - /7.S- Indude the proceeds of Ntlgatlon and the dale the proceeds were received by the estele. IU property pMyornnd vdtlr UN ripM of wrvivorsMp rrarst bs dkoloud on F. ITEM NUMBER DESCRIPTION VALUE AT DATE AF DEATH ~• P/d G BA#Ik ,~ eel. No, So 7 003 /Sf I/ .-. G~IEgE;n~ red: ,non-in)''r~ct f (, 2. S3 v~.q,ri-t.4 Csu /~t/LtLt~7~r~1 ~G~tr sgieG/rt~/) J ~. u'6 Ist Fcd. Cnrd;~ 4ninn Mtolb /4.) Savings /!'~l.~: Nr. 133 Q3o-oo p8S7,y/ 8, T.,~lt. a.car. rd d.o.d. •n ~ ..off C. C huk: ~ /4tel'. Nn. 133 830 - 11 (n.a-;n1'ertst bu~ri n3) >r 1 2 7l, 17 CSet, YR,Iaa1~'on le,ffa' a~'atlrcl.+~) 3. Salt s~ ~sto•-feel ~Drti..,r anal rel.~.1-~/ iltiGr~ !: .I~Iti ~r•e~rl ~/ 00 Oe Shrr Bf Kvrr~rsliar+~, ~'i4 ~tcc r~~ • q/fFitc~~ , 0 . 'r't• /'1t. ChFCk of a y J n•3/ l'~rio~ Rl••/3, ~o% {irohr Da+~ }3nwyj Sho ~S6G fl '~ 6 9S.o p acjrsl) (yul' b,.s:s) ~ a S. 1498 Ord Sw V~-J ~~mz/1~11F7wBD 337/3 ~' SB.S, vv 6_ Ge~sin~cr Qk.d~Ty op~,',ns, ~,,,.~ Rc;nbuirer-rrlt erl a~ris ~ . , ~~~ >< -7; ~Pu' ins wr, - 1Qe~.,Ond a." Ca.r ~-, s K r. I~ $'Z6.bp ~ S' s : o t . $. ~¢ssrrtcd Bgscbu,ll aMd Foel-bdlt Cards, as~;m. valr~a ~ d;SCUSS~r-, w;}f~ Card Sfttd:urrl, 37/S Wa.lnwl' S~f;, We.rfi5{rctr4 ¢4~.sa `1, /RS Rs-~*.~.rsd ,7009 ~ersovt.~l ~S.c. ~K,c J ~ lo• zn-~II~~y ~ ~'S 0na,~k q{(~LOy~d I, 004. o0 ~ (Oeccslen{' Wt•S -aos~~:rt4 tv:'F'~l Jmo'I'Rer ~( {lasl no CalSl+ o / :m 68.25' i n / /. Per CaP:t'a ~'rs~+r~b~loh et= Shams .f Cas; ao rro e«/s ~ East'rl„ Qtsrld o$ Chcrollee .Znel~uls ~` ~, 7os,oD /A. IRS J~e~w,d ew ctosrz-amt lobo ~+ yam.- ~/o f sga.~n ~ -r , ' iN~ ~w~: ~-c{~/ ~ins;.~r..~.h:M s~i.w~ ,,, ~.~~ ruc,~/. ti~ / ~ ~ ~ Q /_it~t/s c~liwts rt- ~.t/iu' ~Ories !viii ~Ir ine/rrds/ /ITi~}p Se./ts ~~flllMifilw,, Fig yK S~oiro /brie iS AC/1ro/ ~Cels ~9r~rs recrrrl ~r etT..G' TOTAL (Also enter on litre 5, Reppitulatlon) _ /D, 7'7 ~ g 4 to more spacers neeaea, Insert additional streets of the same size) MEMBERS 1# F&DBRALCRI~n'UNION SAVINGS ACCOUNT: Account NumbedSufOx Dab Acoourlt Esbblshed Principal Balance at Date of Death Accrued Interest to Date of Death Total Princ9pal and Accrued Interest Name of Joint Owner CHECKING ACCOUNT: Account NumberlSufRx Dab Account Estat>~Shed Prindpal Balance at Date of Death Acxnlsd Interest to Dab of Death Total Principal and Accrued Inbrest Name of Joint Owner 133830-00 07!12/1993 5857.41 5.04 5857.45 None 133830-11 12/12/1996 51,278.17 5.00 51,278.17 None M BERS 1 ~ FEDERAL CRyE~D~ U~N~IO~N 1.X/~nL~ Denielk A. Kline Lending Insurance Support Specialist April 29, 2010 Esbb of: JAMES R. JACOBS Dab of Death: 02/06/2010 Soda! Security Number. 2074-6108 • •- ~, 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmembersist.org ~v a-aawawy ULLGGr , Harrisburg, PA 17109 Jsmes R Jacobs Check Data FeDrny 19, 2010 Padad 13agi Jruamrty 31,2010 F~Pbj+es Tiumtier 3 Period Fadfarg_. lte6rs~t713, 3910 Bala C!>edc Numbat 26216 Net Pay 69509 Fa_~~Q81 Rata um.. woamt y~t~ sue. YTD Amt es T r' Cheolc Amount ' 693:09 al 8tdc ~ anMe Y'rD Amt Rag 10.50 23.00 262.50 230.00 2413.00 Medicare 934:58 13.36 33:64 Com 0.00 2L08 V 0 0 0 249:55 OASDI 934.58 57.94 229.34 sc 1 .5 62.0 631.00 69.00 l 934.30. PA 8t3i • EL+ 934.38 0.75 2.96 co . 100.00 i oavet Paadoulb'1' 934 38 TOtal Gras pay s7.00 934.5$ 319:00 3699.os . I.awa Pa>Qm->il'I' . 934.SH 2:OQ 11.6$ 8.fl0 4b.23 Par~y>-8Y'L`W 934.58 28:69 113.Sb ~ HO; 231.49 X1333 818 Amaot 1C7D.Amt ~oli~ 2$:00' 2'24.0 Df:IMidtf Aa~eeanf Amt T0~fa1 ~08s 18:00 #14.00 NO ~TlCt t8 x'00000 26 2 i6~' ®D 3 i 3008 341: 00 5 i 178 2ir ~ REMOVE DOCUMENT ALONG THIS PERFORATION ~ ~ REMOVE DOCUMENT ALONG THIS PERFORATION ~ F/c~is'a. Z~-io-l7.~' 7NVE/I/Toti' y vF /~G~SoN/tGYY f,~_ _. r~lES _. /Z .SD .__._. ._ _._.__ ~ ls ,,,,__ JJ JJ'' _ G~..T~~4.._ ____-_ __.__ ~ _ ~ so ~ __ ~~. __ Did _ Cr~c~,,¢. __.____. . __ .__._ ___ ...__.. _ . _ _ _.. .___ .. __ .__ .. __ .__ . f• °~' __._ 1<~ Ds~ ~ld y _ -- - . - - -. .___ /' F __ ____ ~/ ..:_ L7iSG_/%,r ,~r G'4r..zS,a!J'Cs.. S•7S"' _. !2 ~/~ !, ___..__ _.. „a. ___._. _ . . .......- .._ .. IIL.~,JII [~/.T ~~U11p~ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPEN5ES & INHERITANCE TAX RETURN RESIDENT DECEDENT A~M~N~STRATNE COSTS ESTATE OF J.~ C G ~S ~ T~n1 E$ le, FILE NUMBER Debts of decedent must be reporMd on Sehedub L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. Hollin~•.r FKnu~l kDMtL ~ Crama.t~h~ , Zna. •~ htF. Holly Springs, a4 r.1, 33v. 37 w- u. C . I-?ar6k ~ Grxn ate works r` 80. P/ B. ADMINISTRATIVE COSTS: 1. Personal Represenbtive's Commissions Name of Personal Representative(s) TO/E11~ M. J~ CO B,$ ~7 SB, Op streetAddrase 333 1t1. cS//p,~s~N ST. city nI ECIYAM/CSl4 k~G smte n/1' zip l7 o SS Year(s) Commission Paid: 2. Attorney Feee cN~F-a.t~ F sHiRVS ~ ~~ ~ saw i~~ s/l~T ~ a, ~ a/.37 FBF ~ rTSt ~y(jS. . 3. Family Exemption: (If decedent's address is not the same as daimant's, attach explanation) Claimant ~TO/9-[(~ ~, TjQ.(~~s ~3/5~,00 sweet Address 3 33 w . al M PSdJ sT. city ~1(1E~Ni}NIC56uRG state ~f~~p I -7o ss Relationship of Claimant to Decedent ~D'~I 1E~Q 4• 1 Probate Fees ~ sti5jr~~ ISi~tt ~ prrr~-4~e CGT-~%C~.~Y_t t~~~.SD 5. Accountant's Fees - H+ R f31~~K , 2DOQ }~'~Se'hta Sf~cehr~ Tiyc ~r~ r' ~~~ s• Tax Return Preparer's Fees N4 tt glo~!'r IoYo, P/4 rlo clesea~'s~ P~ ~/~ ~Ot/l~ ~. f ' ~. /¢dvert:si~tq ~ a.Kberla~ ~a../ Toarnwl D' 9~ 7S, 00 ~¢d/srf:s;+t' St~tf:nt/ ~l3y,y ~. ~ ~:n.g Fe:e - Qe7iS~tr' i~ Lv:%/S '/S;ao ~o• ~il(diiSi~ ProdkTt F+x -- /Q~i~- a~ Gii ~/s j3 p o0 . l~• /~'lislrf ~LL~!ll,~lf~ - /eG~>3/~Gr e~ Lsiil~S / ~/ ~ ®, D p ~~re ~'oafi~. sh«t) TOTAL (Also enter on line 9, Recapitulation) ; /O~ 57Si, ~~j ter more space is neeoeo, insert aoditional sheets of the same size) ~.2 --------- --~_..____._~_ C.nfi~. er~ S['UyE p !~~ -EST. oF_ .JA.Co~s,- .;LEES . iP_ -~---- --------~lG~ No. d/- ~a - ; ~riw;cc_ N~ ah ,aes/`.__.r.~ PAC lf~sslt ~`//. ~~ ------------ !3. ~ !~J4^s~h!rt~.~ ''~+--~[•s E _ .~i%elct~s 1 Tp%. ~.rw - _ ~ t~ ----------_. -------- ----- ~ . , -- d ~ sf.~ eerb~S'ed ' ' 1.-_.__. ~sa;-----1P/~!~_~_s_~ L_`~rfi~rs as ~ nol~/ccs, e~~,;~s '-~~ Q-,~-'~--- D~t/' o'f .rMa.~~aN . C~1ElkS. e~ . (GS~iiX _ '--~- ASS. - - -- -------------------- ------- ---------- -- I - --- -- -- ----- pF JA~ir~S, ,7it~E3 _ _ ~ -.--- - /Va T s ~ ~ a/- l o /~s --=--- ------------ ~ -------------- ----- - --- - r-- -- -- -----_---~ - - - -- ---- / p ~ --- At tO~n tu/s ~ u {~J' .J~.e~~~- d0 ~r `ioVk,rr_ __I -- --- -- 'war t~ yS'.,u ~,~xd~~_~_-~eC~_ /._~c__~ 've -- -~--~---/~'S C e rrP,~on c ~~ (~a!!s ~d L~ a:i~rs . ,~~- _ ' 7 7 -,r `-J~-ll~~~C~t~ 1~L-~~L~c~/ a~ ~i 6e--~4~~~~ -- - --- ~Hl~ / ~~_1~_ _~l~Sf..---93 /3 7. SS ---- -- - -- - -- St C f/F ~ /S N!/ ~M 7C _. --~4P~ l L d e C L_ /AYs l _ 1 ~4 ~M ~/fl -' _ -- '~n ~ I J ~ ~ ~ ~ j ~ ~ ~ ~ ~ ~ ~ ~ ~~ / ~ ,. j _ re s ~ ------ -- --- _- _ _ - - -~~1 SG~.---- i REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & DENS ESTATE OF '..~~~ S 1•~MES R• FILE NUMBER 2l-ro- I?S" Report debts intoned by the decedent prior to death which remai~d unpaid as of the date of death, including unreimbursed medical expena9a. NUMBER 1_ DESCRIPTION 1. Ch4SG /iS4 Card Nom. ~ifl7 ~2Z2 a?2I0 d.44S ~, C~~~ba~.K Maskr Cwt No. Syis 87oz boat 36,4 3. Chase tllasfL-L-'drd No, S~f22 ~13~0 S/o9 9376 `~. ~~ vis,~ Cs.td (~iR«4'A~ri«) No. Y~~~ a96o ~~Fo/ 61sz S. /~innwcle /ltn.ltl /11tri. sirvicts ~~ o{'{,~t visit .f r/z7/ro e~ ~-ee.~. n~b_ ~7.~ 338 6a~rat~e dae 6t• ~zlrtnt.' (e, /~:nnacle fka/f~ flaspi fa.ls ~,- servl~es renders.! e.t f/zr/ig elo . A'>" +~ ,vo. /oo /189 8 93 ,ha l~ du¢ L~ pe~'errf 7 /~sy •Sp~rf /SIeS/S•1!~l ~r a5~o.~ StrviGcS /~rorided an 2,/G~,ZD/o ~~ ivm, 36~f 4 S~ $ z 8 (Utsf ~/C T~ $t~a•u ~ 2ot9q ~-sa«a1 Tnc. T~ ~ P~ 4~ aoo9 Pusoro/ sett • ~~x /b • /~G/!/+2• '"tip" ~ ~ /Qt'dG~fU~ {or dZp/D /~o~ ~it.c• !Mo //, ~JerF~ ~5~sa l~ ~xirar~ ~. ao/a ~s~so~r/ mac. 7-~c, VALUE AT DATE ~/'E, 707. ?,~ ~ S, 3'E!. Sz ~7, 73~•~7 '~3; an, . 3s 'r~fo. 00 ~8,a. so ~7S.alo ~ ioo. sb ~`~s'doo ~~3. no X.~3.d,7 TOTAL (Also enter on line 10, Recapitulation} ; I 3.3, ~ tii(e . 2~ (If more space is needed, insert additional sheets of [he same size) •REV-1513,Ek+ (9-00) SCHEDULE J COMMONWEALTH of PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF~~~aS, ?~1-r-~.E3 R. FILE NUMBER 2 ~_ !O- /7.S' RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not LfstTtusbe(s) OF ESTATE I TAXABLE DISTRIBUTIONS [uicNids ouU)ght spousal distr~bu6ons, and transfem lu~der Sec. 9116 (a) (1.2)) ,. ; o~av m. SA~COps 333 w. Simpson ~. /'h.o~..r boo To f'Yle~haritc3~axr9~ P~ I'in55'- i ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET It NON-TAXABLE DISTRIBUTIONS: i A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE L II B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. i TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (M more space is needed, insert additional sheets of the same size) ~ ~ 0 -n ~ Ca ~ ® ~ a N ~ E ~ J ~ O W ~ p ~ ~ tWL ~ ~ ~ OO W ~ ~- ~ N l R C7 ~,., y ~ E ~ r t9 ~ F- ~ M ~ Z M . yNU --o _ J _ _~of~r-_= 0 N ~ fQ N. W r ' V ~ n ~ U ~ ~ LL ~=a O Q O ~~~~~ ~ Z _ a ~ ~W N= a ~ ~ m ~ J C7~Op~ g oCUUV a wow _°`~ .. V / te A fn W (J J ~ Q a moo= , N ~~~ CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG. PA 17055 GEORGE M. HOUCK (1912-1991) May 24, 2011 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of James R. Jacobs No. 21-10-0175 Deaz Register of Wills: TELEPHONE (717) 766-0209 FAX (717) 795-7473 Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Raymond E. Wall Estate as well as Check No. 103, in the amount of $15.00 for the filing fee and Check No. 107, in the amount of $30.00 for additional Probate due. Thank you for your kind attention to this matter. Very truly yours, Chazles E. Shields, III Attorney-At-Law CES/mj j Enclosures ~. tv ~ a `~ i r • ~~