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HomeMy WebLinkAbout01-23-13J 15~56101U5 OFFICIlLL USE ONLY REV-1500 ~`°~-""~' PA Department of Revenue Pennsylvania Bureau of Individual Taxes """~~"""-""` ounty Code Year Flle Number INHERITANCE TAX RETURN ~ " "~" "` PO BOX 280601 Harrisburg PA 17[28-06ot RESIDENT DECEDENT I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Beth . _MMDDYYYY . '11/28/2011 '.04/05/1947 _ _. Decedent's Last Name Suffix Decedent's First Name MI Jacobs _._._,___ Harold O ' _ _._ _ _ (If Applicable) Enter Surviving Spouse's Information Below Soouse's Last Name - Suffix Spouse's First Name !Jacobs _ __ Spouse's Social Security Number FILLIN APPROPRWTE OVALS BELOW OD 1. Original Retum _ _ .Shirley THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI A' O 2. Supplemental Return O 3. Remainder Relum (Date of Death Prior to 12-t3-82) O 4. Limited Estate - O 4a. Future interest Compromise (date of death after 12-12-82) ~ 6. Decedent Died Testate O T. Decedent Maintained a Living Trust (Attach Copy of Wiil) (Attach Copy of Trust.) O 9. Utigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death Between 1231-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENT Name Michael Cherewka Esq. First Line of Address 624 North Front Street Second Line of Address Qry or Post Office Wormleysburg O 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes O 11. Election to Tax under Sec. 9113(A) (Attach Schetlule O) AL TAX INFORMATON SHOULD BE DIRECTED T0: Daytime Telephone Number (717) 232-4701 - ~ RF~'(~t OF WILLLS USE C~Y~, W -~ -- ~ rv " n-1 - ~ t }' r i r r :. _._ .. ~ r 1_.. ' u:~a : ::;; i... ;... 1+1 ... .__.....,., ____._-...: """'DATE FILED State ZIP Code ~ , "' ~~ ,.J PA ', '17043 Correspondent's a-mail address: Under penalties of perjury. I declare Nat I have examined this return, inclutlirg accompanying schedules and statements, and to the best of my knowledge and belief, R is We, comet[ and complete. Declaration of Preparer other than Ne personal representative is based on all intonnatkm of which preparer has arty knowledge. SIGfJATURE OE PERSON RE®PON$IgLE FOR FILING RETURN DATE 524 North TFiird Street, Wormleysburg, PA 17043 624 North Front Street, Wormleysburg, PA 17043 PLEASE USE ORIGINAL. FORM ONLY Side 1 15D5610105 150561D1U5 J J 15056102175 REV-1500 EX (FI) Decedent's Social Security Number oaceaenYS Name. Harold O. Jacobs 193-36-4883 RECAPITULATION 1. Real Estate (Schedule A)..... _ .................................... .. 1. 172,200.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2 '. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. '. 0.00 4. Mortgages and Notes Receivable (Schedule D) . . ....................... .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)_ ... .. 5. ' 3,600.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ' 33,042.05 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property ~~ (Schedule G) O Separate Billing Requested...... . 7 ~ .. _._ ~ 0 00 ~~ 8. Total Gross Assets (total Lines 1 through 7) ..... . .. . . .... . 8 208,842.05 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. '. 13,941.12 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. '. 42,641.96 11. Total Deductions (total Lines 9 and 10) ......... ......... ....... .. 11 55,583.08 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12 152,258.97 13. Charitable and Governmental Bequests(Sec 9113 Trusts for which ~ ~ ~ '~ an election to tax has not been made (Schedule J) . ........ ........ .. 13 0 00 14. Nat Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 152,258.08 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.z) x .0 45 152,258 OS 1s 0 60 16. Amount of Line 14 taxable " - --_ _. ...... ...__. ....... at lineal rate X .0 _ i6. 0.00 17. Amount of Line 14 taxable .._. ... _..._ ._... ...... at sibling rate X .12 17. 0.00 18. Amount of Line 14 taxable -.._ _..... ..._. ...._ ._ ._.. 0 00 at collateral rete X .15 18 . 19. TAX DUE .. .......... .................... ....... . 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 155610205 151]5611721]5 J REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Harold 0. Jacobs STREETADDRESS i 524 North 3rd Street CITY STATE ZIP Wormleysburg PA 17043 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 0.00 2. CreditslPaymeMs A. Prior Payments 0.00 B. Discount 0.00 3. Interest 4. If Llne 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fiil in oval on Page 2, Line 20 to request a refund 5. If Line i + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (3) Total Credits (A * 6 j (2) 0.00 0.00 (4) 0.00 (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. _, , ~, ,. ~ `.. u,'i v g, .. 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 transfemed or its income ...................................... ...... c. retain a reversionary Interest ........................................................................................................................ ...... ^ d. receive the promise for life of either payments; benefts 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 "intrust fol" 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 benefciary 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. ,:,,, ,.. ... ;ir ,~ ,;, 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 survNing 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 disGosure 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. §91t6(a)(1.2}}. • The tax rate imposed on the net value of Vansfers to or far the use of the decedent's lineal beneficiades is 4.5 percent, except as noted in [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 [/2 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in comnron with the decedent, whether by blood or adoption. REV-LSU2 EX+ (ll-OB) ~ pennsylvania DEPAgTMENT OF gEVENUE (NHERITANGE TAx RETURN RESIDEM DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Harold O. Jacobs 21.12.0282 All real property owned solely or as a tenant in common must be reported at fair market value. Fair 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet If the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1' 524 North Third Street, Wormleysburg, Cumberland County, Tax Map #47-19-1590-100 and 119,900.00 2. Tax Map #47-19-1590-099A 52,300.00 TOTAL (Also enter on Line 1, Recapitulation.) $ 172,200.00 If more space is needed, insert additional sheets of the same size. ~"ax Mapper Cumberland County, PA PEFtR7 ~: Ul7 rdTY urm r.~~ at.?osY~S! ,~,,1~T~a ~o mi f ; Copyright 2011 Esri. All rights reserved. Thu Nov 8 2012 02:45:15 PM. 47-1.9-1590-100 Site Address: 524 N THIRD STREET Deedbook:201225730 Owner: JACOBS, SHIRLEY ANN Land Use Code: 101 Property Type: R Acreage: 0.11 Square Feet: 1794 Taxable Status: T Clean & Green Status: Land Assessed Value $: 29600 Building Assessed Value $: 90300 Total Assessed Value $: 119900 Sale Price $: 1 Sale Date: Wed Aug 22 2012 08:00:00 PM Year Built: 1933 Municipality: WORMLEYSBURG BORO Height in Stones: Type of Dwelling: DETACH Primary Exterior; Vinyl Basement Percentage: 75 Air Conditioning: AC Total Rooms: 8 Bedrooms: 3 Full E?'~ath: 2 Half E3ath: 1 G S. ;~ s ~1 ~'.~'! fax Mapper Cumberland County, PA P~F'P.'r +; C70.J PJT'/ '': 1B 4n (^~~`w ~t~'s~~ A'av j~li 1tm :' x Copyright 2011 Esn. All rights reserved. Thu Nov 8 2012 02:45:43 PM. 47-]9-1590-099A Site Address: N THIRD STREET Dee~ibook: 201225731 Owner: JACOBS, SHIRLEY ANN Lanc Use Code: 109 Property Type: RO Acre age: 0.18 Squere Feet: Taxable Status: T Cleat & Green Status: Land Assessed Value $: 38000 Builcing Assessed Value $: 14300 Total Assessed Value $: 52300 Sale Price $: 1 Sale Date: Wed Aug 22 2012 08:00:00 PM Year Built: Muni~=ipality: WORMLEYSBURG BORO Height in Stories: Type of Dwelling: Primary Exterior: Basement Percentage: Air Conditioning: Total Rooms: Bedrooms: Full E~ath: Half E3ath: N". 'L ;~ ~® REVa5a3 Ext (J-v) ~ Pennsylvania ~EP~NTMENi pF PEVENOE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Harold O. Jacobs FILE NUMBER 21-12-0292 All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size REV-1507 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Harold O. Jacobs SCHEDULE D MORTGAGES & NOTES RECEIVABLE 21-12-0292 (If more space is neede4 insetl atlartronai sneers or me same srze/ REV-i5o8 EX+ {o8-u) Pennsylvania Y7 DEPARTMENT OF REVENUE [NNEARANCE TA% RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER; 21-12-0292 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1999 Kawasaki Ninja Motorcycle, Fair Condition 1,000.00 2. 2009 Belmont U[ility Trailer 2,100.D0 3. Personal items, clothing 500.00 TOTAL (Also enter on Line S, Recapitulation) $ 3,600.00 If more space is needed, use additional sheets of paper of the same size . . A TRLE NUMBER (A95HOlNN ONATTACHEO TITLE) MAKE OFVEHICLE MODEL YEAR w w - ~' ~ !~ ~/ ~ ~ ~ PURCHASE PRICE (Sce Nola on Reverse.) w ~ YEHIG_E IDENTIFICATION NI)MBER CONDITION ~ n i f i ,_; ~, k ~ ( ~ ~ ~^ ~._, p GOOD O iR O POOR LE59 TBADE-IN ~ A B LAST NAME (OP FULL flUSiNE55 NAME} FIRST NAME MIDDLE NAME " ~ ~) C,~ ~ ( f; t_r n TAJ(gBLE AMOUNT . z C0.SELLER -' _ v ~ 1. SALES TAX DUE / X6%(.06J X9%(.DII DR (` LAST NAMFIOR FULL BUSINESS NAME) FIRST NAME MIDDLE NAME Pq pLfPH0T0IDp GATE OF BIRTH . X916 (.6a) j f OR BUS. IDp * (9x Nme on Rmnn.) j t'y{} ~ 4 , ~ ~ ~ 6' E ' ti ~ 's ( ~ p° !' Y ~. ~ ~ .-a. f ~'~ ~ a ~. I ~ ~ 'REASON CODE (munL~' rc C6PURCHASER LAST NAME ~ FIRST NAME) MIDO NAME DLIPHOTO I OA E OF BI be a wmbwhwa 1 la. w / 23 w0 s ~ iB. FIRST - ffi SECON D O 5 EET COUNTY CODE ASSIGNMENT /S9IGNNE ~lT n ~ EXEMPTION NO. EXEMI'TKR i NO. r-' f r l ~'' 7 ~J t,.f I I r- ('. e Y 1 1/ f 1~ _ i ~ r 2. TITLE FEE ~~ C STATE ZIP CODE DATE ACQUIRED/ 'O' '~ ' '1 PUR HA E D REFER TO COUNTY CODES - C S( ^ y { ~ ~ Y ~ ~ ' F L16TlNG ON REVERSE SIDE { ( IC'.( (1 t ~ 'i ~ 7 ] OF YELLOW COPY 3. LIEN FEE D LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDpLE NAME PADVPHOTO IDp DATE OF BIRTH OR BUS. ID# 4. REGISTRAT1pN OR - . PROCESSING FEE L ~ „~.. F OfURCHAS R LAST NAME FI ST NAME MIDpLE NAME pA DVPHOTO IDp DATE OF BIRTH f w G ~ - FEE E%EMPT NUMBER i a AS A591GNE0 BY THE ~ n ~ rc STREET ~ DEPARTMENT COUNTY CODE 4 n ~ H S. 'DUPLICATE REG. p o FEE NO. OF n ~ CARDS CITY STATE ~ 21P CODE pgTE pCOUiREDI PURCHA9E0 REFER t0 COUNTY CODES ®. TRANSFER FEE LISTING ON REVERSE SIDE OF YELLOW COPY E MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER ]. INCREASE FEE ~~ Up ~i, ~ MODEL YEAR BOGY TYPE (GP, TK. ETC.) CONDITION REPLACEMENT FEE 9 ~ F . O GOOD O FAIR O POOR rprAL PAID s. yD. F. O PLATE TO BE ISSUED BY O TRANSFER OF PREVIOUSLY ISSVED PLATE (ADD 1 THRV e) DEPARTMENT (PROOF OF RA SF OF L E O INSURANCE MllBT BE P AT T N ER BRENEWAL Q TRANSFER 8 REPLACEMENT OF PLATE Ttl' GRAND TOTAL SEND ONE CHECK IN Cy (J ATTACHED.) O EXCHANGE PLATE TO BE O TRANSFER OF PLATEBREPLACEMENT OF STICKER (ADD 98101 THIS AMOUNT "> q~/} ~ r FA (f' I$BtlED BY DEPARTMENT pLATE NO. ~ REASON FOR REPLACEMENT ' TEMPORARY PLATE 195UEp O LOST ~ DEFACED O STOLEN O NEVER RECEI VED (Lost in Maip BY FULLAGENT (NMe: This o plate will explra 90 tlays fiom tlam of Issuance ) EXPIRES Momh Vaer NOTE: IPNEVER RECEIVED' bWCk is cNeckaE, spp3wnl must complete Porm MV-04. z LL O TRANSFERRED FROM TITLE N0. VIN p~ ~ ~ ~ ra-. ~ 51 NA RF OF P RS N ROM WHOM SIGN HERE RELATIONSHIP TO A PPLICANT y w TEMP PLATE NO , PLATE IS BEING TRANSFERRED (IF <c . . OTHER THAN APPLICANT) GVWR EI G T EG GR UNLADEN WEIGHT IFA N DIN LOADS ~~ 0 S C B. WC ~ LE INFORMA ION (IF APPLIC ~ PP ( I 111 G C E INSURANCE COMPANY NAME POLICY NO. (OR POLICY EFFECTIVE POLICY EXPIRATION ATTACH BINDER .DATE OATS 1 CERTIFY THAT ON MONTH OAY _ YEAR_ ISSUING AGENT (PRINT NAME) ~ 1 AGENT NO. ~ '" ISSUING AGENT WAVE CHECKED TO DETERMINE THAT THE VEHICLE 191NSURED AND ISSUED TEMPORARY REGISTRATION TD THE ABOVE APPLICAM IN j -~ ~~ ~ ~~{S "'^ ~ ^ ~~ ~ / INFORMATION , COMPLIANCE WITH ALL APPLICABLE PROVIBIONSOFTHE VEHICLE LNG AGE ySl~gpp/TARE- TELEPH NE NO. CODE ANp DEPARTMENT REGUTATION9 - '^r ~rl ~~ ~ ~/JC . ,,,` (~`, LANE CERTIFY THAT LAVE HAVE EXAMINED AND SIGNED THIS APPLICATION AFTER ITS COMP TION.I EFURTHER CER IFY~M1IATALL STATEMENTS HEREIN ARE TRUE AND CORRECTAND MAKE APPLICATION FOR CERTIFICATE OF TITLE FOR THE VEHICLE DESCRIBED IN SECTIDP{A. IF ANV E%EMPTION IS CLAIMED, THE PURCHASER FURTHER CERTIFlES THAT HESHE 18 AUTHORIZED TO CLAIM'ITftS EXEMPTION. LANE ACKNOWLEDGE THAT IM'E MAY LOSE MYlOUR OPERATING PRMLEGE(9) OR VEHICLE REGISTRATION FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON TIE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. NNE ACKNOWLEDGE THAT INVE MAY BE SUBJECT TO A FINE NOT EXCEEDING 55,000 AND x Q IMPRISONMENT OF NOT MORE TH TWO R9 FOR ANY FALSE STATEMENTTHAT IhYE MAKE ON THIS APPLICATION. Sieneture first Purdiasa Signer ~ Telephone No. 1ST 6~'i 7 ~ Y ASSIGN- MFNT ur ~§- ulhorize09igner S' t t ( /° (T l~~a)-Cl~fir©]~~ ^ w ~ 0 V 2ND Signature o(9awn0 PUmheser or AUthwiietl Signer Telephone NO. ASSIGN- MENT igrlaWrao o-vro sar ileo AU r¢ ar ( 1 H.~ z NOTE IFAC0.PUROHA9EROTHERTHANYOURSPOUSEISLISTEpANDYOIIWANTTHETITLETOBELI9TE-AS'JOINTTENANTSWITHRIGHTOF9DRVIVORSHIP"(ONDEATHOFONE i w ~ OWNER, TITLE GOES T09URVIVING OWNER.) CHECK HERE O. OTHERWISE THE TITLE WILL BE ISSUED AG'TENANTS IN COMMON' (ON pEATH OF ONE OWNER, INTEREST OF DECEASED t ~ E OWNER GOES TO HISIHER HEIRS OR ESTATE.) ~~ O ~ C COMPLETE AN- ATTACH FORM MV-1 L CHECK THIS BLOCK O IF BLOCK IS CHECKED IF THE VEHICLE IS TD BE USED AS A DAILY RENTAL OR LEASE- VEHICLE ~ NGTE' a . , . , . z MESSENGER N0. 2. DEALERASSIttMG AGEMT REV-a5og EX+(oi-io) petRtsytvania SCHEDULE F DEPAflTMENT OF pEVENUE WHERirANCE TAX REruRN 70INTLY-OWNED PROPERTY RESIDEM DECEDERT ESTATE OF: FILE NUMBER: Harold O. Jacobs 21-12-0292 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS REIATIONSHIP TO DECEDENT A. Shirley A. Jacobs 524 North 3rd Street, Wormleysburg, PA 17043 Spouse B. C. JOINTLY OWNED PROPERTY: REM NUMBER LETTER FOR JOWT TENANT DATE MODE lOIM DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSRRIrfON AND BANK ACCOUM NUMBER OR SIMILAR IDENTIFYING NUMBER. ATFACH DEED FOR ]OINRY HELD REAL ESTATE. DATE OF DEATH VPLUE OF ASSET % OF DECEDENTe !MEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. ' 1998 Chevrolet Corvette Coupe 15,000.00 50%. 7,500.00 2. A 08/23/97 Susquehanna Valley Federal Credi[ Union, Savings Account #10808-00 120.29 50% 60.15 ' 3. A 08/21/07 Susquehanna Valley Federal Credit Union, Money Market Acct #1080-35 48,876.19 50% 24,438.10 4. A 08/23/97 Susquehanna Valley Federal Credit Union, Checking Account #10808-40 2,087.60 50°1° 1,043.80 TOTAL (Also enter on Line 6, Recapitulation) I $ 33 042.05 If more space is needed, use additional sheetr of paper of the same size. 01-15-~ 1;3 15:09 FRC1M-:L~~ VA.,~EY FGU SUSQUEHANNA ALLEY FpDERAL CREDIT UN-ON Michael Cherewka 62f North Front Street Wormleysburg, Pa 17043 Re: Estate of Harold O Jacobs Accounck 10808 Fife k 4168.01 71'-i?-05c""" T-615 PGa0~!1!0001 F-32^- ~o.~v ~rur~uaaic ur. ~..anrP raui, i.-s ai~ai-iav~ 339 East Park Dz. Harrisburg, P.~ 17111-2730 Loc~1: 717-737-4]52 Toll Free; 8110-94$-1454 Fax:717-737-0589 Mr. Harold O Jacobs account 10808 was Joint with Shirley Jacobs. Balance in his share saving account k10808-00 was $120.26, dividend was $.03 opened 08/23/1997 Balance in share draft account k 10808-35 was $48866.15; dividend was $10.04 opened 08/21/2007 Balance in share draft account k1080&40 was $2087.60, no div. opened 08/29/1997 If you have any other questions, please feel free to contact the credit unbn. Sincerely, 1~/~'7°'8ar Fisher VP Member Services www.SVF~U.org "rr~~r !ice ww~~~~~ r~r~ VEHICLE CASH PURGNASE CONTRACT YYVtSLCT IYIV 1 VI'S1 IIYI.. s1~D.n.m. aY.. a Erwk Road • Enok, Pa t7025 ~ ~ ~ 3 ~ i Z ' (!17) 732-2051 F"A`"A'i""~` ~ J~ ~o~S r IbWiY i\Y[T ApMl4 ~ Y~ 5J P{f-AfE ENFOIYY ORpE11FM THE IOLLOWNG C~ n J // 4RdI 1DreA.P~FIR A~CYi DTwiY O itlTE'l LF COOF. fIT7 L-~ar~~ 5~~ (J'/C_ 1-~oY3 YEAR IMIR ImE1 LYrE AEPWAO[HIOIR IARNfY PHOrR Iq~g Gheu~c~c-~ C.or CpLOR YILFAGE TORE DELIVERED ON ORAEOUt 3 3 5 I / 8 TT~Fri .YCwaY-~Ou F.i FwrV/i~. E iY S, ~ Yi ` ' - r G~VV 5%~-3r'7~ ` Y,R // YEMC 10 HD ADE COaOR PRICE OF VEHICLE : (''DO(> LD ADO R[Y TRADE IN AL WANCE i •AUNCE OWED T11ADE N1 NET TRADE IN All i ClFMe raw rA. F[ R[Anwr NIT HAi WFNIKD oAYAIN OA T A i AOY[ p M i MwaAi IEaIANCU SENwpAA w wrCt rrr T[ a TIY OwwNLL ru1MtH1N ARD rwpA TO ILi D[W[M TO \HF DE , DR N M ADDlMDNEi OA FDM IIICUIDIMI \RYi wrE YFN A[YOYEO a A[ FM\i [IO ACEMORIi OF A1Ii1FW yrYn wnn+uu~tr +nF ,°FI. Ai.I..11.ii.E..Yi[q ~ DISauIMER w wMRMTI I 7ANp TNA7 You 17HE DEALERI Ell- FwEULYaxLAwww ts. EITHEII OR I[llirO. INGLIIDIFq ANT RYLEDWARMNTYOf YE AMLITT ORF Fp1APAR710UIMF[IIIVO/E. AND TINT TDtl11EITIEII NDR AUT OTTER PEIISOII TO ASSlP1E INIL w COIRECTION WITH a THE VbYf1E FJCCER n ou ANT I ro T L - Aa oTNEREaE w TIMTIIq ST roU w nADIwIENr i0 THIS coN- 7MCT OII N A OEL[VNIFa TO MEYAEN T YNIICLE B OBIVi11E0. C7 'AS 6' T Tdl VEHICLE IS 50L0'AS 15' YEIT Y WMRMn EITHEII EEPRES6 MMl1E0 7ME AlRCHASEP WAL .EAR THE 111E ElPENSE OF RE~ MUIT'V PAMI COARECTwG ANY DETECTS THAT FIIESEMLY T OA TINT WY W T!E VEMCEE. pOCYYENTARY FR 1RAClUAI DISCLOSURE STATEMENT IUSFD VEHICLES ONLYI TRtF AYp gEOETMTgF FEES UCFWE T YEORYATION YOU SEE ON TILE WIADOW fO1W FT1R THIS VEWCL PMT OF , rHls CONTMCT wFORIMTgN OY THE wx+DOw NtRM oYEANDES ANT CONTRMY - FRWISION6 w THE COr1TRACT Or SALE. \OTAI COMYIIACT FNCE i !f 1 CANCEL THIS -URCNASE CONTRACT OR REFUGE TO ~~OF~" _ - ~ ACCEPT DELIVERY OF THE VEHICLE ORDERED, EECEPT. IlEt uaawARDE FaP LAAAEp/ AS PERMITTED BY LAW, ~1 Wlll. AT YOUR OPTION, FORFE{T AS DAMAGES i IIYARCE DIIE OA c/ ~~y J J I /U I ACCEPT THE A9pYE CONDITIpN51Gus1. IniuFk) X T BE INCREASED AFTER THIS CONTMCT NAS 6EEN ACCEPTED 8Y THE DEALER NNO THE CONT CT PRICE OF THE MOTOR VEHICLE ~CA OR THE AU NOR12E0 DEALER REPRESENTATIVE WKESS THE INCREASE IS DUE 70 THE PASSAGE OF A uw OR REGULATION OF THE UNTED STA 5 OR THE COMMONWEALTH WIYCN. REQUIRES ADpT1ON OF NEW EQUIPMENT TO CERTAIN VEHICLES: CHANGES IN TRANSPORTA71 R~E1f15TING TAX RATES: OR. IN THE CASE OF FOREIGN MADE YEWCLES. t5 DUE TO A RE-EYALWTION Of THE UNITED STATES DOLLAp rN~i•rq THE CURRENCY OF THE COUNTRY OF MANUfACTURE. THIS CONTRACT t5 NOT BINgNO UPON EITHER THE DEALER OR THE PURCHASER UNTIL SIGNED BY AN AUTNOF52ED DEALER REPRE SENTAf1YE. YOU. THE 9UYER MAY CANCEL THIS CONTRACT AND RECEIVE A FULL REFUND ANY TIME BEFORE RECEIPT OF A COPY DF THIS CONTRACT 61EWED BY AN A{/TNORI2ED DEALER REPRESENTATIVE BY GIVING WRITTEN NOTICE OF CANCELLATION TO THE DEALER. I CERTIFY THAT 1 AM OF LEGAL AGE OR OLDER AND ACKNOVA.EDGE IPT OF A COPY OF THIS CONTRACT e -13 - /Z ~~ at - $ipTISiIXA OI WMCM EIYWMM(x Slprutun Ot AutROrit.o pSa1S[ PTSSen au REV-1511 EX+ (10-09) ~ . Pennsylvania SCHEDULE H DERARrMENT OF REVENDE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Harold O. Jacobs 21-12-0292 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Hetrick Crematin Services of Centeral Pennsylvania 2,435.62 2. Gingrich Memorials 8,120.00 3. Restland Cemetery Association 175.00 a. Reception at Church 100.00 B, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address - Gty ----... __--`---------- State _._-__. ZIP --- Year(s) Commission Paid: 2,750.00 2. Attorney Fees: 0.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address Gty State _ ZIP Relationship of Claimant to Decedent 103.50 4. Probate Fees: 0.00 5. Accountant Fees: 6. Tax Re[um Preparer Fees: 0.00 z Legal Advertising -Sentinel 182.00 a. Legal Advertising Cumberland Law Journal 75.00 TOTAL (Also enter on Line 9, Recapitulation) ~ 13,941.12 If more space is needed, use additional sheets of paper of the same size. Ii ,, N N i!~ tD 'd ~ ~ ~ d A d^~N .~ ~ ~ °' u,+ y ~ a ~n 9 s c~~ t E ._ *+ *'+ 41~ A~ ~ d -~fl '~ n y (!Y U 'O R ~ N N ~ GI .> O ~U c sI U N d v` o~ m a O N Q a o~ n T d O p O N N a v+ ~ ~ ~ ~ I ui 0 obi ~ r ~ ~ .6 a ~ ~ ~ ~-- O m ~~~~ ~', q 1 N N N ~..a ~'C; g ~, ~ c O ~ U d 4 ~ ~ r N ~ o ~ ~ ~ o ~ ~1 ~ U ~`' ~ ~ N ~ `' ~ Hetrick Cremation Services of Central Pennsylvania, Inc. 3125 Walnut Street Harrisburg, PA 17109 Bill To Shirley Jacobs 524 N. }rd St. Wormleysburg, PA 17043 Invoice Date Invoice # 11/29/2011 673 Client Terms Due Date Harold O. Jacobs COD 11/29/2011 Qty Description Rate Amount 0 Direct Cremation Rose Um with engraving Garden of Promise Memorial Package Death Certificates Newspaper Notice 1,550.00 430.D0 130.00 6.00 265.62 ],550.00 430.00 130.00 60.00 265.62 TOtai $2,435.62 Payments/Credits $-2,435.62 It's been a pleasure working with you! Balance Due $o.oo RESTLAND CEMETERY ASSOC., INC. CIO Rosalie Heisey, Secretary 5966 Waggoners Gap Road 0 2 8 5 719 landisburg,PA 17040-9703 Customers Date ~ ~ ~J 201/ Order No Name S~ I f ' _t ~ ~UbS OltltlPSC SOLO BY CASH C.O.O. CHARGE ONACQ MO6E. REID~ PAIOOUT DUAN, DESCRIPTION PRICE AMUUN T rtLJL~ eilt UV -Fv~ Tlitr°Lt~ o J gabs j ~~rz /BPS /c2r]r,'1L. Fee ~s o0 7s Ov ALL claims antl returned goods MUST be accompanied M this biA. Recd by CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3168 Fax: (717) 249-2663 September 21, 2012 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Michael Cherewka, Esquire RE: Harold O. Jacobs Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: September 7, September 14, and September 21, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by REV-1512 EX+ (12-OS) pennsylvania SCHEDULE I DEaanTnENT oc aEVENUE DEBTS OF DECEDENT, `""eu'T""cET"'c"ETUR" MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Harold O. Jacobs 21-12-292 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATN 1' Milton S. Hershey Medical Center 246.98 2. Mil[on S. Hershey Medical Center 14.27 3. Eastern Regional Medical Center 32,572.35 4. Susquehanna Valley Credit Union, Loan Accoun[ 4,928.17 5. Rominger & Associates, Attorneys at Law 2,000.00 s. Milton S. Hershey Physicians Group 136.53 7. Alma Berresford, Tax Collector, Real Estate Taxes 872.14 8. Milton S. Hershey Physicians Group 111.53 9. Engle Printing-Auto Locator, Advertlsing to Sell Motorcycle 112.00 Milton S. Hershey Physicians Group 147.99 11. Alma Berresford, Tax Collector, SchoollCounty Taxes 1,500.00 TOTAL (Also enter on Line 10, Recapitulation) $ 42,641.96 If more space is needed, insert additional sheets of the same size. _ - _- W d ,ry~ ` V , N ~~ T d ~r ~ ~ E d oao~ 7` T N y E C W U j 7 ~' 'O NE C r y C d C ~ _ , R a ° o N N ~ ~' V z+ N D ~ »~- L N oaL~Q i(1 y 'G .Li '~ ~ U ~N ~ G d 0 U 4 E ° ~ 6 V 4.09 N N 3 4 N O ~ N n ~ ~ 6 U T O ~ G N N R r H N x~ O ;^~ ~~ tia-' Z a N N+ n`4 rn °m~ N °, a S 8 N J 0] i Z `L N ~ ~ W ~ w~i~zd~W z w o s° a N ~ a w ~ ~ 3 Y z~g~ G ~ j 4~ W O K Q" J a N I r O c ~ ~ ~ N N N B p p o 4 N '. W S'. N K' ~ G d Z V O y M ~ ~ U d ~ O~ i ~ ~Fo O GO is ~ U~' U d 70 m 7 'Oy Or v N U~A ~.0 ~° O ~ N A N'~ >` ~ O'~N ~•O v ~O ~ ~.~~bW .y+.~@p u~y+ ~ Q N ~..~moyo~ai ev'Vo s+ "" 6 0 T NT V~ V~ r ~' N~'db e~c~yed O ~~ o ° ~ C w 5ovo P~ Cp ~. 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I ~ Pnnt Close r'hec'{ Image Fage 1 of i Check # 5481 $,~~ ~ ~ ~»trb rs a~i3»s~~ a~ irsu-iaca ~'1~~-...- ~----... ~, ~R.~,,.,,,,J ~~ a•~e~t cwt utol~ $~~ v~ C Hil Pw 171111 ~$, m~srrrla ILIn ~ $ lSoo ~jc ~ e ~.~:_ sr... rrN w Iw.oa -eOP > ~'IR / ..K l.~~JSa.~i~rJ~ ,r 1:23 L38 2568: 0003 53407u' 5~8 i So c'} 1O n- 'J ' '1 1 . ;$ a €a'z `-'.::~: 1 !f ~ d~ F f'~a'._II ~ " n ggr • ~ ~ . ;te '` a ~ !*•a~5 .~ j ~i r ,i r~l ~' : ~~ j . t .~ ]D313D1846C ~p ~ •~ Metro Bank H~ zDlz-o7-17 #Ol • ' '~ ~' 71 ~ ~ y ~ O1D375387 •~ ~ r ~ 001 8375387 ~ ~;+ ~ }n;( m ~ r r ~ V m~ N 3 1 1 I~ I_r• mGy Cs~m=+ ~D r NQ o ~,,, ~ •. _ , _ F . •_ ~° i P~nnt. ,Close;„ f EASTERN REGIONAL MEDICAL CENTER 2610 SHERIDAN RD ZION IL 60099 32387 RETURN SERVICE REQUESTED ~oasoi o202 Statement Date Due Date 09/12/2012 10/12/2012 Combined Patient Guarantor Responafbllity Number $32,572.35 281829 Patient Responsibility $32,572.35 PAGE: 1 ~~ REMIT TO: ~~ II'll'I"~Ilul°u~~~hl~'~I~III'~~II~III~'ll~l~ll~llll'I~I~JJ ilh~I~~ILlllll~pLh1~IL"I'~~I'IJIIII""I""I~~IIIII'll9 HAROLD O JACOBS EASTERN REGIONAL MEDICAL CENTER EST. OF HAROLD JACOBS DEPT. 3677 PAYSPHERE CIRCLE 524 N. 3RD STREET CHICAGO, IL 60674-0001 WORMLEYSBURG, PA 17043-1007 32387•TLGOP8VN9003052 STATEMENT OF HOSPITAL SERVICES iioos7 (aaa21 O For yourconvenience, we now offer online bill payment at: myCTCA.com Pending Patient &xpl Account Number DateoP Serviea Total CSargea Paymeata. Adjustments Insurance Reaponeibility Coda Patient Name: HAROLD OJACOB3 Provider: &A$TERN RNG !® CTA. 550903560 - 08)15/11-08/20111 8; 70T. 00 0.00 0.00 8, 707. 00 0.00 550909229 08/21/11-08/29/11 32,572.35 0.00 0.00 0.00 32,572.35 ' Balaaca pending irithimUrance: $8,707:00 Patient raaponslbility: $32,572 .35 CTCA Office Hours: Monday -Friday 7:30am through 6:OOpm (Central) See back bf this page for Questions, please Call - 800=677-5545 (Se Habra Espanol) . Explanation of Statement Codes Change of address or insurance information, please see last page. i~ll~e~®r~~~w~srl~~Nlll 32387*TLGO P8VN8003052 3LGOPD030:1.2 W ~, ~~ sa ~ ~ rn ~ N z M ~ ~ ~ ~ O ~ ~ N M1 ~ ~ M ~ J O HO m G WP 8 ° w.. a m ~ O N a Vi 4 ,~ ~ o m a 0 ~w ° aM o ~ soa v ~ o~vi o ~> M1 qOW S O J2J ~ 00 S F O R' ~t6.' C O QNO ~ a ~ o =~3 m W ~„~ a ~$ N C O O O M '+ M a a i+r :» i coo .r o mm ~ f.9 CD N LL~ N N '+ p, Z 2 G ~iaiHMQ ~ + _ ~u-.a ~0 uS ^ ~ _ a.a o ~~ ~ _ x~ = ~d _ ~=mom __ gssda _ y m md~ ~ +~ ~ = au ~I'I~I J ° $ ~ LL v W C.! O = REV-1513 EX+ (OS-10) ~ : Pennsylvania SCHEDULE J DEPFRTM ENT OF REVENUE mNERrrnrvcE Tnx RETURN BENEFICIARIES RESIDENT DECEDEM ESTATE OF: FILE NUMBER: Harold O. Jacobs 21-12-0292 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 distributions and transfers under Sec. 9116 (a) (1.2).] 1. Shirley Ann Jacobs Spouse 100°/a ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN A80VE ON LINES IS THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. None 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1, None 0.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size THE LAST WILL AND TESTAMENT OF HAROLD OTTO JACOBS I, HAROLD OTTO JACOBS, a resident of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my LAST WILL and TESTAMENT, hereby revoking any and all other Wills and Codicils previously made by me. 1 direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable after my decease. I further direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. I give, devise and bequeath all of my property, whether real or personal, including the marital residence located at 524 North Third Street, Wormleysburg, Cumberland County, Pennsylvania, 17043, and all of my financial assets, wherever situate, including any property over which I may have a power of appointment to my dear wife SHIRLEYANNJACOBS. Should my wife not survive me, then her shares to be divide equally to: CHRISTOPHER ALAN JACOBS MELISSA ANN SPIDEL ROBERT WILLIAMSPIDLE Page I or 4 I nominate, constitute and appoint my wife SHIRLEYANNJACOBS, as Executrix of this LAST WILL and TESTAMENT, to serve without bond. If my wife is unable or unwilling to act in that capacity, then I nominate, constitute and appoint, my son CHRISTOPHER ALAN JACOBS as Executor of this LAST WILL and TESTAMENT, to serve without bond. If both my wife and my son are unable or unwilling to act in that capacity, then I nominate, constitute and appoint MELISSA ANN SPIDEL as Executrix to serve without bond. IN WITNESS WHEREOF, I, HAROLD OTTO JACOBS, have set my hand to this LAST WILL and TESTAMENT, this -~- day of , 2011. ~, t,! Oy'To AROLD OTTO JACO Signed, sealed, published and declazed by the above-named HAROLD OTTO JACOBS, as and for his LAST WILL and TESTAMENT, in the presence of us, who, at his request and in his presence, and in the presence of each other, have hereunto, subscribed our names as witnesses. SAN DZ R~ Cf.~~""yyyY{oQ14e Name L( /~"~-- Address ~i` ] - ly ayt,~ l'tOW0.J~ 1\ 1"~00~,~Vd~ Name /Yt~*-~/~~/'"Ldp-z-~ ~ 7 (~ ~ Address ~-(2 7 N ~~q' ~ree~ ltldr wt l~eysb+,~ara . ~a, t 70 ~ 3 Page 2 or 4 ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND We,~ ~ (, and t~-rULtJ6QV~, /'iQbTB.7lLthe witnesses whose names aze signed to the attached or foregoing instrument being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as his LAST WILL and TESTAMENT; that HAROLD OTTO JACOBS signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the heazing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge, the Testator was at the time 18 yeazs of age or more, of sound mind and under no constraint or undue influence. t-~ow~,. fZ wt~~e--~~~ Name ~' Address ~ ~ ~ ~ ~ kd' $(~r~ e~ ~awwt~ blxr ~ I7o Page 4 of 4 S~4Nba~ J; n?a~r~ ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND I, HAROLD OTTO 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 this instrument as my LAST WILL and TESTAMENT; that I signed it as my free and voluntary act for the purposes therein expressed. U'T'7"d ~ e~~ ROLD OTTO JACOB~~~ Page 3 of 4