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HomeMy WebLinkAbout03-08-13 (2) 1505610101 REV-1500 Ex t°1-1o, ' OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes OF REVENUE County Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN Harrisburg, PA 17128-o6oi RESIDENT DECEDENT 2 1 1 2 1 3 1 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 1 6 4 6 4 9 2 9 1 2 0 9 2 0 1 2 0 7 0 5 1 9 1 9 Decedent's Last Name Suffix Decedent's First Name MI J,a c !o b y P au l i n e S. (If Applicable) Enter Surviving Spouse's Information Below Spouses Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW jM 1. Original Return p 2. Supplemental Return p 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate p 4a. Future Interest Compromise (date of p 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate p 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 p 10. Spousal Poverty Credit (date of death Q 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 TO: Name Daytime Telephone. Number n ~Ic A n t h o n y L D e L u c a E s q. 7 4 a 2 5- 8 1`18 4 4 fT1 R IFJ-=R O€TW_ ILLSWS"NLY xs P' i f M M r1i First line of address ~ CO o 1 1 3 F r o n t S t r e e t 11 Second line of address J e 3 1 P O B o x 3 5 8 m cn va c7 F-4 'n City or Post Office State ZIP Code DATE FILED B o i l i n g S p r i n g s P A 1 7 0 0 7 Correspondent's e-mail address: 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. ' TURE OF PERSON RE NSIB FOR FILING RETURN DATE a, 1 M ADDRESS SIGNATU E OFPR PARER TIE THAN EPRES TATIVE DATE i ADDRESS /X-3 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: Pauline S. Jacoby 2 1 6 4 6 4 9 2 9 RECAPITULATION 1. Real Estate (Schedule A) 1. 2 5 3, 9 1 8• 8 0 2. Stocks and Bonds (Schedule B) 2. 7 1 0, 9 0 9-8 4 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. 0 • 0 0 4. Mortgages and Notes Receivable (Schedule D) 4. 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 4 5 9,2 9 9 . 6 5 6. Jointly Owned Property (Schedule F) p Separate Billing Requested 6. 1 0 8 , 1 8 0 -4 6 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 5 2,4 3 5' 4 4 8. Total Gross Assets (total Lines 1 through 7) 8. 1 , 5 8 4 , 7 4 4-0 0 9. Funeral Expenses and Administrative Costs (Schedule H) 9. 5 7,2 1 7 • 0 6 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) 10. 2,1 4 5 ' 0 0 11. Total Deductions (total Lines 9 and 10) 11. 5 9,3 6 2- 0 6 12. Net Value of Estate (Line 8 minus Line 11) 12. 1 , 5 2 5,3 8 1 - 9 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 13. 0 • 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 1 , 5 2 5,3 8 1 ' 9 4 TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X o 4 5 1, 5 2 5,3 8 1. 9 4 15. 6 8,6 4 2. 1 8 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 0 00 0 17. Amount of Line 14 taxable at sibling rate X .12 17. 0 00 0 18. Amount of Line 14 taxable at collateral rate X .15 • 18. 0 •0 ` 0 19. TAX DUE .........................................................19. 6 8,6 4 2 •1 8 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21-12-01311 DECEDENT'S NAME Pauline S. Jacoby STREET ADDRESS 4 Moore Circle CITY STATE ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) $68,642.18 2. Credits/Payments A. Prior Payments -0- B. Discount 3, 432_.__11 Total Credits (A+ B) (2) 3,432.11 3. Interest (3) -0- 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, 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) $65, 21 0 . 0 7 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; ❑ ~7 b. retain the right to designate who shall use the property transferred or its income; ❑ Ex c. retain a reversionary interest; or ❑ 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? ❑ ~xl 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ❑ 0 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? FX1 ❑ 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)]. 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-1502 EX+ (11-08) IN pennsylvania SCHEDULE A. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 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 i' Refund amount on cottage at 4 Moore Circle, $253,918.80 Carlisle, PA whihc is a retirement community known as Cumberland Crossings Retirement Community. See attached email reflecting refund value. TOTAL (Also enter on Line 1, Recapitulation.) $ 2 5 3 , 918 . 8 0 If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) 4AW SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 839.1780 shares of Columbia Balanced Fund-A at $23,966.92 $28.56 per share 2. 3,654.522 shares of DWS Technology Fund-A at 52,625.12 $14.40 per share. 3. 2,998.5000 shares of Federated Clover Value Fund_ 49,445.26 at $16.49 per share. 4. 50 shares of Coeur D Alene Mines Corp. Idaho 1,130.00 Common Stock at $22.60 per share. 5. 29 shares of Samaritan Pharmaceuticals Common 250.00 Stock at $8.62070 per share 6. 759.6650 shares of Alliance Bernstein Growth 31,670.43 Fund -A at $41.69 per share. 7. 400.2630 shares of Federated Equity Funds 1,348.88 Prudent Bear Fund Class C shares at $3.37 per share 8. 1,384.1780 shares of Emerald Banking and Financial. 25,371.98 Fund Class A at $18.33000 per share 9. 102.4740 shares of Rydex Series Energy Fund C 2,098.66 at $20.48 per share. 10. 35,513.25 shares of Blackrock Funds Municipal 35,513.25 Money Market at $1.00 per share. 11. 150 shares of Barclays Trust US TIP at $123.16 18,474.00 per share. 12. 7,105.459 shares of Blackrock Funds Muni Bonds Institutional Class at $12.01 per share 85,336.56 13. 7,439.866 shares of Blackrock National Muni Fund 84,293.68 Institutional at $11.33 per share. 14. 13,883.356 shares of DWS Short term Municipal 143,831.56 Bond Fund at $10.36 per share. 15. 12,823.870 shares of T Rowe Price Summit Muni 155,553.54 Intermediate Fund at $12.13 per share. TOTAL (Also enter on line 2, Recapitulation) $ 71 0 , 9 0 9 . 8 4 (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (1-97) SCHEDULE D AA COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH NONE -0- TOTAL (Also enter on line 4, Recapitulation) $ -0 (If more space is needed, insert additional sheets of the same size) REV-1508 EX -(1-97) 4Z SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE RN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Miscellaneous items of personal property. See $7,940.00 attached appraisal 2. Savings account, #015004218033261,at M&T Bank 108,099.95 3. Interest checking account, #51-4042-7797, at PNC Bank 18,098.97 4. Performance money market account, #50-0390-4315 at 206,691.78 PNC Bank 5. Two (2) Certificates of Deposit at PNC Bank 25,565.57 6. Checking account, #2891033221, at Sovereign Bank 13,662.01 7. Money Market account, #2891100085, at Sovereign Bank 22,870.35 8. Certificate of Deposit, #2895555387, at Sovereign Bank 5,127.91 9. Certificate of Deposit, #2895555395, at Sovereign Bank 5,127.91 10. Certificate of Deposit, #2895555403, at Sovereign Bank 5,127.91 11. Certificate of Deposit, #2895539787, at Sovereign Bank 6,027.03 12. Certificate of Deposit, #2895548812, at Sovereign Bank 10,839.96 13. Miscellaneous coins. See attached appraisal. 23,857.30 14. One (1) $10.00 gold certificate, One (1) $5.00 US Note and 25(P fractional currency, five (5) two dollar bill 263.00 see attached appraisal. TOTAL (Also enter on line 5, Recapitulation) $459,299-65 (If more space is needed, insert additional sheets of the same size) REV-1509 EX . (1-97) 4& SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A, Lowell E. Jacoby 815 N. Alfred Street Son Alexandria, Virginia 22314 B.Wanda J. Lord-Steele 6707 White Post Road Daughter Centreville, Virginia 20121 C-Sophie J. Kowzun 11707 Pindell Chase Drive Daughter Fulton, Maryland 20759 JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. /7/8 Brokerage Account #A25-0160007, $46,296.72 50% $23,148.36 at Oppenheimer & Co. Inc. 2. B. 5/7/8 Brokerage account,#A25-0160106, $46,278.30 50% $23,139.15 at Oppenheimer & Co. Inc. 3. C. 5/7/8 Brokerage account, #A25-0160205, $46,273.65 50% $23,136.83 at Oppenheimer & Co. Inc. 4. A. 8/3/9 Certificate of Deposit, #289517332.!, at Sovereign Bank $21,360.72 0% $10,680.36 5. A. 8/26/97 Certificate of Deposit,#289539354 , at Sovereign Bank $4,476.53 0% $ 2,238.26 6. B. 8/3/9 Certificate of Deposit,#2895173330 at Sovereign Bank. $21,360.99 50% $10,680.49 7. B. 8/26/97 Certificate of deposit,#289539353 , at Sovereign Bank $ 4,476.53 50% $ 2,238.26 8. C. /3/9 Certificate of Deposit,#2895173348 at Sovereign Bank $21,360.98 50% $10,680.49 10. C. /26/ 7Certificate of Deposit,#2895393557 at Sovereign Bank $ 4,476.53 50% $ 2,238.26 TOTAL (Also enter on line 6, Recapitulation) $ 1 0 8 , 1 8 0.4 6 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. 1,411.538 shares of Putnam US Goverment Income Trust-A at $13.54 per share. 19,112.2 100% -0- $ 9,112.22 2. Jackson National Life Insurance Co., Annuity #0059296040 11,107.7 100% -0- 1,107.74 3. Jackson National Life Insurance Co., Annurity #0059296050 11,107.7 100% -0- 11107.74 4. Jackson National Life Insurance Co., Annuity #0059296060 11,107.7 100% -0- 1,107.74 TOTAL (Also enter on Line 7, Recapitulation) $ 5 2_, 4 3 5 . 4 4 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-06) 4b SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Hoffman Roth Funeral Home $10,952.28 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees Anthony L. DeLuca, Esquire 45,000.00 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 585.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Legal Advertising - Cumberland Law Journal 75.00 8. Legal Advertising - The Sentinel. 210.78 9. Filing fee for Inheritance Tax/Inventory 30.00 10. Roy D. Gottshall, Auctioneer-Appraisal 75.00 11. Wanda Steele - Funeral Luncheon 250.00 12. Gold Mine Coin Appraisal 38.50 TOTAL (Also enter on line 9, Recapitulation) $ 5 7 , 21 7 . 0 6 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 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 DEATH 1 CenturyLink - Telephone $74.65 2. Met-Ed - Electric 40.30 3. Cumberland Goodwill 83.25 Fire Rescue EMS - Ambulance 4. UGI Utilities, Inc. - Heating 84.08 5. AAA Financial Services - Credit Card 92.52 6. Diakon Lutheran Social - Monthly fee at 1,734.36 Retirement Community 7. Guideposts - Christmas Books 35.84 TOTAL (Also enter on Line 10, Recapitulation) $ 2 , 14 5 . 0 0 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Pauline S. Jacoby 21-12-1311 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. 2116 (a) (1.2).] 1. Lowell E. Jacoby Son 1/3 share 815 N. Alfred Street Alexandria, Virginia 22314 2 Wanda J. Lord-Steele Daughter 1/3.share 6707 White Post Road Centreville, Virginia 20121 3. Sophie J. Kowzun Daughter 1/3 share 11707 Pindell Chase Drive Fulton, Maryland 20759 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1 NONE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ -0- If more space is needed, insert additional sheets of the same size. LAST WILL AND TESTAIAENT rn C> r1l Co a*> OF m r, c (p ;xs r M " ~M - J r~s PAULINE S. JACOBY J t:-3 'wa 'r a': 3 C) t'i ~r7 C- I, PAULINE S. JACOBY, a resident of 246 East old Yorke Reap) " rv `1 Carlisle, Cumberland County, Pennsylvania being of sound mind, memory and understanding, do hereby make, publish and declare this to L)e my Last W11Y aric T= ee e:"~' =r _ © yid Codicils heretofore made by me. ITEM 1: I direct that all my just debts, the expenses of my last illness and funeral expenses be paid as soon after my decease as the same can conveniently be done. ITEM 2: I direct that there shall be paid out of my residuary estate all estate, inheritance and like taxes together with any interest or penalty thereon imposed by the government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate z ,e ments, whether the property passes under this Wi11 or of erwse,A excluding, however, any property over which I have a taxable power of appointment, provided, however, that no residuary beneficiary shall by reason of this provision be denied the benefit of any deduction, credit, favorable rate of tax or other benefit which by law enures to such beneficiary. PAULINE S. JACOFVT -1- S Y yy r~ N~ n r P ,r X73 , '3 kH 5 '..z. h"... «;,.a. .Y, "y~ Yom' - LAST WILL AND TESTAMENT i OF PAULINE S. JACOBY ~i ITEM 3: I give, devise and bequeath all of the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever kind and nature, and wheresoever situate at the time of WANDA J. LORD, and SOPHIE J . KOWZ~JIV , p~ov~'ed; Yioweve"r', 'heY F survive me and are living sixty (60) days after the date of my death. ITEM 4: If and in the event that a child of mine does not survive me and is not living sixty (60) days after the date of my death, then and in such event, I give, devise and bequeath the interest in my estate, which such deceased child would have received, if living, to the issue of said deceased child, per stirpes. ITEM 5: If and in the event that my son, LOWELL E. JACOBY, dies without issue, then and in such event, I give, devise, and bequeath if living, in equal shares, unto my other children, then living. ITEM 6: I hereby nominate, constitute and appoint my son, LOWELL E. JACOBY, Executor of this my Last Will and Testament, with full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of him in this or any other jurisdiction for his performance of this office. PAULINE S. JAC BY -2- .9 Y .s LAST WILL AND TESTAMENT OF PAULINE S. JACOBY If and in the event that my son, LOWELL E. JACOBY, does not survive me and is not living sixty (60) days after the date of my death, or does not complete his duties as Executor, then and in such event, I hereby nominate, constitute acid ap 0ant m, dau hter, WANDA J. LORD, Executri x°" o zsrct, 4 full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of her in this or any other jurisdiction for her performance of this office. ITEM 7: If any provision of this Will or of any Codicil hereto is held to be inoperative, invalid or illegal, it is my intention that all the remaining provisions thereof shall continue to be fully operative and effective, so far as is possible and reasonable. IN WITNESS WHEREOF, I, PAULINE S. JACOBY, the Testatrix, have to thi.-$,. my° - ast ,;W~ consecutively numbered pages, subscribed'' mp `'narPie``°a a e seal this 7- day of February, 1991. (SEAL) P fULINE S. JACO -3- 07-0~0"" .ti. 8 ~yF,~•Ai _ o- PAULINE S. JACOBY Signed, sealed, published and declared by the above named Testatrix, as and for her Last Will and Testament, in the presence of us, who have hereunto subscribed our names at her request, as witnesses hereto, in the presence of the said Testatrix, and of each other. e s .,diYzg: a.~ r _ residing at i -4- iI now low CUMBERLAND CROSSINGS A DIAKON LUTHERAN SENIOR LIVING COMMUNITY March 1, 2013 Attorney Anthony L. Deluca esq. 113 Front St Soiling Springs, PA 17007 To whom it may concern, Diakon Lutheran Social Ministries is committed to living out its mission to "demonstrate God's command to love the neighbor through acts of service," and with that in mind, we are privileged to serve you in our community. According to our Corporate Capitol Analyst, Kendyl Rice, the refund amount due on the cottage belonging to the Estate of Pauline Jacoby would be $253,918.80. Thank you, Jason Lindemuth Financial Services Coordinator Cumberland Crossings Retirement Community Toll Free: (800) 722-0267 Phone: (717) 240-6040 Fax: (717) 240-6042 Email: LindemuthJ@diakon.org 1 Longsdorf Way Carlisle, PA 17015 Phone 717.245.9941 Fax 717.240.6017 F!l / f r r . 00 10( Or ~r N . 7 42 A. } < r t Y r 1:007 4 -Ale .E D a f r r w~n r _ ~~~,-CeR!_'4""~•.~ ~{sec-.,~-+G~ ~ _ r ; VI-.4 i -41~ 14 Gam/' auil - CUSTOMER'S ORDER NO. DEPARTMENT DATE NAME t ADDRESS CITY, STATE, ZIP VQUANTIT LD BY CASH C.O.D. CHARGE ON. ACCT. MDSE. RETD. PAID OUT Y D ESCRIPTION PRICE AMOUNT 711. 2 't e 3 t ti 1 k 4 E 5 V f 6 f,.Ik 6 9 10 3 a 11 4., 12 1 13 s 14 15 i S [ 16 17 s' 18 4 RECEIVED BY 3 632 ns35o 01-11 G A- 5805 KEEP THIS SLIP FOR REFERENCE a ~ 9 'A In consideration do hereby sell 425734 and ass;`;!; all properties lasted or) 01i" hii; c?s sae to Gold Mi a`., . nd ',varram that I have ,tal - t:;r,rily to deposc of sarnc. ` furiher Nxarram i shah ri'aht and title to disro+ ie nroperty x NAME SHIP TO Lu c. ADDRESS ADDRESS Psi✓~,°~. e Sc CITY, STATE, ZIP CITY, STATE, ZIP ORDER NUMBER DEPARTMENT SALESPERSON WHEN SHIP TERMS HOW SHIP DATE I E -1-Av-liz QUANTITY DESCRIPTION PRICE AMOUNT d \~Wt ✓ O `J S i~ L~ C~ w~ VY~J ` ~p o ~.@ Cr Lj A,- -tCl~t(f I .tlr Z, ^J 1 -D CIA{Z i0o i0o 33 00 34 ©o r I n ` V t= 3(. 00 1 \$S° 1 o f~U rt~1#5L , Ct~r~cr ~IQt 3 r,a VN x,, 1 1 A c.- ~111I►~ S^ ~'3 oa 1 1ti ~/1 C0.0 36 o~ r~~S -Lo 10a 133y \ I la ov IN' 500 100 BUYER: L LA go 8 KEEP THIS SLIP FOR REFERENCE In wnsideration of value. received, do hereb° 425736 , sell and assign all ro ort.es bi P P this :1 of sale, to Cold Mirc. and warrant tni.fll authority to depot o t>t carne. i further warraw t rend my right and title to dispose of said property. NAME SHIP TO ADDRESS ADDRESS f , STATE, ZIP CITY, E, ZIP ORDER NUMBER DEPARTMENT SALESPERSON WHEN SHIP TERMS HOW SHIP DATE A ANTITY DESCRIPTION PRICE AMOUNT l u`~3 ti Il 0 i ov `3 S`1 x= Ito o(a' [ $ F r Sf r,, , 1 ~I o u 3 S ^0J : 1 5" f= la e o v ~ S~fr t" V P, 3 .z 0J 100 1 k VGA ^0Q 0 ,1 4 S'" o 0 t n~~1ti Z~ QJ VV, 1 1< ✓ ~~l S u O; O e Z6 br„ SY o~ oL IL '~v o0 1 ~o V °o c l Z )C F `11 y` o BUYER: ~arra,-sar ~ ~ ~ 1 i~ty 8100 KEEP THIS SLIP FOR REFERENCE " In consideration do hereby sei? 4 2 5 1 3 7 anci assign all properties ±i.. , fl of sale to Gold Mine, and warrant that I fr),,,jthority tt; depose oI sang:. I further warrant I sh~J, Sri my right and title to dispose of said property. x qo~ NAME SHIP TO ADDRESS ADDRESS CITY STATE, ZIP CITY, STATE, ZIP ORDER NUMBER DEPARTMENT SALESPERSON WHEN SHIP TERMS HOW SHIP DATE QUANTITY DESCRIPTION PRICE AMOUNT Zv C iZ \J ©z. J ~~lo 00 1 `351-5 ~o colt ~/,F r I S'~yu 0 0 g o o Z a C~a 1 L ~,t ) a~ y LS'V` o') © 4L_ o VLF ~ 1 1 CO . BUYER: KEEP THIS SLIP FOR REFERENCE " . In consideration oi vat~.ic: received, do hereb'v sell 4 2 5 " 5 7 and assign all properti c)t ,case Gulc's. line, and warraim tlix SITll£4. l :l`UrtillBt '1arill. - `iota '1 s post of s-d !(1 a NAME SHIP TO ADDRESS ADDRESS CITY, STATE, ZIP CITY, STATE, ZIP ORDER NUMBER DEPARTMENT SALESPERSON WHEN SHIP TERMS HOW SHIP DATE JM 3 /y AT QUANTITY DESCRIPTION PRICE AMOUNT \ n [ 1 ~ ~ ~ ~ ~ t.T~~ \ ~lY"trG a t~ Yls Tom-- ~ 1 0d 5' n J I P1~ d^ O o 0 i~'zz. r 1 I- V G a BUYER: 01-11 KEEP THIS SLIP FOR REFERENCE