HomeMy WebLinkAbout08-28-13 (2) J �5056b01�5
REV-iS00°`i°�-'°„F" t�
OFFICULL USE OWLY
PA Uepartment of Revenue P�^nsY���a�m�a � � Y�, Fi�Num6ef
eureau of indtv�duat raxes �NHERYI'ANCf TAX FtETURN !ry'�� r�, �`�(3
s�ca aoX�so6a� cr�-F �✓ �✓'"1�
Herrisburq,PA nu8o6o� RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW �����—
Social5ecurity Number Date of Death MMDDYYYY Date of BMh MMODYYYY
07Jd5/2013 06123/1919
Decedent's Last Name SufAx DecedeoPs First Name MI
JACqBS MRS MILDRED p
(NApPliceble)Eiker Surviving Spousu'a Intormadon Below
Spouse's Last Name Suflix Spouse's Fiwt Name MI
Spouse's Social Security Number �{IS RET!!RN MUSS BE FIl.EQ 1k OUPIJCATE 4MCTW THE
RE��sTE� a� wr��s
FILL IN APPROpR1ATE OVAL$BELOW
� 1.Onginal Retum p 2.Supplemental Retum p 3, Remainder Retum{Oate of Dealh
Priorto 12-}g•82}
m 4.�imited Estate p 4a.Future Interaffi Compromiss(date of O 5. Federal Estate Tax Retum Required
death after 12�12-82)
O 6. Decedent DieQ Testate p 7.Decetlent Maint2ined a Living Trust _ 9.7ota1 Number of Safe Deposit Boxes
{Aitach Copy of Wi11} {AtfBCIt COp}'Df TNSI.)
O 9.Litigation Proceeds ReceWed p 10.5pousai Pwerty Credit{patb of Death p 1i. Election to Tax under Sea.9113(A)
BeMreen 1231-91 and i-1-95) (Attach Schetlule O)
CORRE$PQNOEMT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDEN71At.TAX INFORM(�i)pN SHOUlO B ECTi,/}
Name Day8m6�7'e a�hone Nu`'m'ber 1'rt n
;'s7
Stevonna A.Coleman 717 c�3�g�� �� �°- -�'r�
( )m T �„ e-�. e.n -
_ f P_'Y
REW �AF�USEQqtYJ
T> L;� `
. C�: c:`;
� Y
FirstLineofAddress �''" � _-� -,��
t� ,: .
1$F8nY1 HOUSe l9ne :�' � r-� - r�
SecondLineofAddress '':y �� ' � +,, �>
L r 'rt
Ciry a Post OffiCe state ZiP Code OATE FlLEo
Camp Hill PA 17011
corresponaent�s e•maii address:lynstecol@comcast.net
under penalties of per)ury,f aalare thet 1 heve e�caminsd tnis retum.incluaing aocompanying sclreGules arM stalements,and to ihe Deat of my knowNrdge and belief,
it is we,cwrect ane compiete.pedaration of preparer aM1er man the personni rex�resenmtive iy basetl on ak infamation W w!�prep8rar n�any knowiedge
SlGNATURE OF� �94M#2ESPLINSIBlE�FlLING,qEFUR,y� � DATE
/t/6"'":�. �� �f�..o'r,�',a�i
AD SS
/ 9' f/,�TZNf L��t�S� i ,rt G'i¢1YJ{� }t`lLL ,ai¢ 17dlI
SIGNATVRE OF QREPARER OTHER THAN REPRE3ENTATIVE DATE
ADDRESS
PLEASE USE ORI6INAL FORM BNI.Y
Side 1
�, 1505610y05 150561C11�5 J
1�!/"
J 150561�2�5
REV-1500 EX(FI)
DecedenPs Sadel Saaeity Number
o�aaors w�e: MILDRED A JACOBS
RECAPRULATpN
1. Real Estate(ScF�edule A). ............................................ 1.
2. Stocks and BorMs(SchedWe 6) ....................................... 2.
3. Closey Held Corporation.PaNieiship or SotaProprietorship(Schedule C) ..... 3.
4. Morlgages and Notes Reoeivade(Schedule D)........................... 4.
5. Cash�BaMC Deposits and MiaceNaneous Personai Property(ScFretlWe E)....... 5.
s. �d�r an+ed P�,e�Ar(sd,eawe F� o se�»ram e�ixeyues�ea ....... s. 5.840.63
7. IMer-Vivoa TransRars&M�Nan-Probefe Proparty
(Scheclule G) O Seperale B�ing Requesfed........ 7.
s. rom cross nsa.�s(easi unes�a�rou9n�).................___.--.. a. 5,810.63
9. Fune�al Expenses antl Administrative Costs(ScI�eAWe H)................... 9. 1,205.15
io. �ems a oeceden�,x�a�uacines ana�ens(scnedwe p............... �o. 321.48
��. roa�osdu�ao�a(m���es s ma�o)................................. n. 1,526.63
i2. Net Va1ue ot Esma(une 8 rrenus L'me'11).............................. t2. 4,314.00
13. CharRable and Govemmen�l B9questalSec 9173 Tnrs�for which
an eledion to tax has rat been made(Schedule J) ................ ........ 13.
14. Nat VaWe Subjatt to Tm[(Line 72 mi�ws L'me 13) ........................ 14. 4,314.00
TAX CALCULATION-SEE MSTRUCT1pNS FOR APPLICABLE RATES
15. Amount d Line 14�ceble
at Me spousal taz 2te.ar
Vansfers under Sec.9116
cex�.z�x.o_ �s.
16. Amount of Line 14 tax�le
at Iuieai rate X.0_ �g,
17. Mqunt of Line 14 t��le
at s�g rate X.12 17.
18. AmouM of line 14 taxable
at collateral rate X.15 �7.1� 78. 647.10
19. TAX DUE......................................................... 19. B14.7�
20. RLL MI THE OVAL IF YW ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
L 1505610205 1505610205 J
REY-150U EX(FI) Pepe 3 Fie NunOw
�6C�@11t'S CrOf1��@t@ Adl�IE3$: �
DEC�B(f5 NAI�
MILDRED A JACOBS
srn�rnom�ss
Emeritus at Creeicviaw,Senior Liring
1100 Grendon Way Room 424
CRY 5TATE ZP
�a��r9 PA 17050
Tax Payments and Credits:
t. raz we(Page 2.�ine�s) (i) 6as.45
2. CrediLSlPayments
A.Prior Paymenis
B.DiscaM 32.42
Toial CBdiS(A+B) (2) 32.42
3. Interest
(3}
4. If L'me 2 is greatar than Line 1+�3,e�the diBerence. This�tlie OVERPAVMENT.
FiII in ovai on Page 2,Line ZO to raq�t a r�und. (4)
5. If Line 1+�3 is greater tlian Lq�e 2.eM�,v tlie diflerence.This is the TI1X DUE. (5) 616.03
Make check payable to: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLIOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
i. Did dacedent malce a transfer and: Y� No
a. ietain tlre use w income oi the prapeM1y iransterred.......................................................................................... ❑ �
b. retein Ure rigM to designate who shaq use ihe propeAy transferted ar its income ............................................ ❑ ■
c. retain a�ever�onary a�eresl.............................................................................................................................. ❑ �
a. rec�u��ra�m��y��,c��as o�m�a...................................................................... ❑ ■
z. n aeaa�ocaxrea af�r oec.�2.�sez.ad aec�em aansker qoperry wi�in«�e year ot�an,
'xiUwut receivio9 adeyi�sb considera�bn?.............................................................................................................. ❑ �
3. Did decedent own an�n Wsl for or�death baNc account w sewriry at his a her death?.............. ❑ �
4. Did decedeM own an ndiui��ie6remeM a�amt�annuiy or dher noo-probale proPertY,wl�ich
containsa be�oe�y designe6on? ................................................................................................._.._................. ❑ �
IF THE ANSMIER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FlLE R AS PART�THE RETURN.
For dates a aealh a�w aBer Jury�,tssa.and net«e dsn.1,1s95,u�e tax rate imposed an uie r�t v�ue of vansters w a rar uie use of nre�rviviny s�ouse
is 3 percenc�rz P.s.§s»s�a>��.����.
For dates M deatli an a aPoar Jan. 1, 1�, the lax rffie i�ed on the r�et va�e of transfeis io a for the use of the swviving spouse is 0 pe�ceni
(72 P.S.§9N6(a)(1.1)(Y�1.Tha smWOe does not exempt a Uansfer to a surviving spouse fran tax,and 1he stahtBory requiremenis far�isdosure of assefs and
filirg a hax reiwn a�e�app6cade even if tice swviving spa�se i�tice oMy beneficiary.
For�6es of deafh on w aRer July 1,200D:
. The tax ra�imposed on the net value W Vansfers Gom a deceased dtild 21 years af age a yrounger at dealh to or for the use of a maWral parem,an
adoptive pareM a a steppa�ert d the child's 0 percent[/2 P.S.§9116(a)(1.2)].
• The ta�c rate imposed on tlie nd v�e oitrarafers fo or for Ihe use of the decedenfs lirreal b�is 4.5 perceM,except as ra6ed in[!2 P.S.§9116(a)11)].
. The tax rate imposed a�itce nel v�ue of Ua�fers b a far ihe use of the decadeM's sblig.a is 12 parcent(72 P.S.§9116(ax7.3)].A sibiing is defined,
wMer SecUon 9102,as an indnridu�wfw has at least one parent in cartman w�h the dec�ent,wF�e9her by bbod a adoption.
REV-�SOg IX+(oi-io)
� pennsylvarria SCNEPIILE F
DEPAPTMENT OF PEVENUE
INHFMNKETAXRE7VRN 70INTLY-OWNED PROPERTY
Rf3mlM DECE�flIT
ESTATE OF: FILE NUMBER:
MILDRED A.JACOBS 195-07-0270
If an asset became jdntty ownM within one year of the decedeM's date ot death,k muat be raportM on Schadule G.
SURVNING 70[M THiANf(5)NAME(S) ADDRE55 RQATIONSHIP TO DECEDENT
a Stevonna A. Coleman 19 Fartn House Lane,Camp Hill, PA 77011 nieoe
e.
C.
lOI1fiLY OWNED PROPERTY:
tertEn o� DESrnIVrtoN oF p�tOVe�Y w oF nate oF oenni
� raa�r w�oE �xame rur�oF Amwaa vrsrtnman u/o e�/a�xaert M�oa stMnna o�a o�x o�erts v�ue ar
rwr� �xr wnrr �oeasrurc M�.�miai o�ran wmn.r xun nr�,u ar�re v�vuE a�r �xre�sr �5�riraeesr
1. A. 071D&11 PNC BMII(GA 5140031733 11,681.27 50 5,840.63
TOTAL(Nso enter an Line 6,Recapituladon) ; 5,840.63
If more space i�needed,use addidaial sheetr of paper of the same size.
� P��� SCHEt}U1.E H
��� Fur���u.���u
�*,�T��, auMiNisr�►rnE cosrs
0.610fi1f bfd,'EI1BIf
���� ����
MILDRED A JACOBS 795-Q7-0270
oecMmt's+�s�st 4e reported an S�e�t L
R@!
NUMB6t DESCRIp17411 AROIMff
n• FUNERAI.EXPENSES;
1. �8��Y 335.IX3
2 � F��� 122.41
3 hbss's Slaek and See -Funera!Undienn T23.74
e. I�IM157RAT2VE{Y}$TS:
1. Personat R�t�e tnnr�i�s:
Name(s)af Pkasonal Repr�s}
5heet�5,°— . .
�V--.. _.. _ �StatE_.._IIP__ _
YeBr{a}Cm�e�FaW:_._ - -
2. Atfm�cy fiea:
?. FanaM Exemptiorr{ff aeaded4 addres is not n�e�mme as ctaim�t�s,adazh e�anztian.)
!]aimaM
Strt�et Ad�ess
_--` -
�' - - --�__Tnv_. _
adm�ar c�cm nec�,c
a. aroaate iees:
5. Aatxmtixft it�
6. Taz Rehtrn Preparpr Fees�
7. R9�fQf�B�iBE
15.D0
TOTAL(Also enter on line 9.Recapitul�at) ; �,1$6.15
If more spate is needed,use�ditional sheNs af paper of tMe sa�ne s¢e.
_ _ i���
.._.. ... .. . . ..
� �,�y�,�,,,� SCHEDUl.E I
� o�vnxn,wraFaEVe«� DEB7'S Q�DECELtENT,
uu�wr,w�ux nEnaw MORT6A6E LIABILI7IES&LIENS
nESOe�r a�r
ESfA7f# FftE NpNBfR
MILDRECI A.JACCIBS 195-G7-0270
Napxt de6ts Inwna�d 6�r tl�e Aeudak peior to d�A thtt�unpak a#tlm hh ot deMhr MMU���ed mMicai a�maes.
� Yl�AF 6A7E
x�sa�R oESCwvnao c��nTn
1. ��N S 34.48
2 �g�`+� 191.40
TOTAL(Also entcv on L'me 10,R�) � 321.48
If more space is tmeded,insert ad�sheMs af the same srze.
STATEMENT OF ACCOUNT
wr,,,,..��r�� OIAINCARE RiARMACY SERVICES OF EAS18W PA
eaeo e sNOwoR�Fr Raw.7 ST�ooa PAGE: 1 ot 2
� ALLENiDYVN.PA 78108
ACCOUNT NO: 10�.483
� RETURN SERVICE REWESlED �5_� INVOICE NO: PM1017783
DX NO: KOPDX
INVOICE DA7E: 06I3W13
�oe ozoz p�e: g77�70-6323 FACILtIY: 7039 EMERITUS OF CREEKVIEW
PATIENT NO: 483
You may also view/pey your bAls et: PATIENT NAMf: JACOBS.MILORED
MtpsJ/myomniview.omnicare.can AMOUNT DUE: 125.oe
TAX: 0.00
����d�w9�I�Id�hi�hnulP4�lh�p��p�•�lu��n������nu
JACOBS, MILDRED
GO STEVONNA COLEMAN oue uAre: 07/30/2013
19 FARM HOUSE LANE
CAMP HILL, PA 17071-8303 awaw+rouE: 1z5.oe
30906-UB�B•TT009TIIC003193
31U09Y6PC:7.2
KEEP TOP PORTION FOR YOUR RECOHOS-RETURN BOTTQM STUB WITH PAYYENT . ���
JACOBS.MILDRED 10�EMERITUS OF CREEKVIEVY
1039.483 06/30/13
LATE �� RII�MO. TWIIIS . RE�ItIM19M�. . � PMT81C[MF �� ��� IOt� lp.. WANF .�� NM111T ��� TYPE�. .
. @IS/24/73 8597 ld'X Poh7EMT - TIWIK�Yd! - Loekl�wc.�2073062407S59i � -150.55
000'�95045� � � .
06/83l73 R21 CNM6E CALCIUI�M[TN YtilfllCN�.D 600l16' BiIDER 0090L-3233-92 60 �. 3.69 OiC
(1�-fJLLf.IU� G00 V1YtT D) . . .
OE/03/73. R21 � �CMAR6E IItM.FIVITAMiM <t11B'R'YtTE BIIIQER 009D4-0530-80 3(i � 2.69 �OTC
06/06/13 R21 tiN��� UtTNItlPWDST 0.805���:� ..... . IIDER� 26206'0463�-25 2.5 5.00 �R7I
LLAfAAGPI�Sf)) (OdMY)
06/07/13 R21 CIWt6E� &tIMOM10Ii� TARTRAt£�tlf�ll'Fq:�. tlDpt 6137�-0743-OS 5 5.00 �RX
06/OB/13 R21� .. �� GIMR6E JYSPtRIN��6 TA9lET B11DER 00536-331MS-70 30 2.75 OTC
�Q6l11/73� R27 CH�1R� AIyRlNItM 111CiA�E S2[LCt2 (� i BIIDER 45802'0525-55 22T 18.23 OTC
Ob/12/13 �R21i97 �CNIIRI��. KLOR-fGM 112@ Z�tI�LET' BIMDER 00245'0056"10 60 �S.00� RX
06/32J13 R21 CW1Rr#�� O�Rit1llYl[6E�1. 2�-BWtlPS i �. BIIDER 2<20E'0�-70 10 S.OfI RX
�
� . FtviceGs9��Ybawspsdat�MONiNLYPHilOD�RAYEOF
.. . 1.50%(AlMAW.RA7E OF 18.00%)hrd upon a�uiVeid helrna .
.. . ou�g 30 dey+a moie.
ppEytplS�B�LAMCE .CR�Eg ..�.. FjMIMEE i�IR� � FOTAL CIWlGES P1IYIEMTS i CREDITS � MlQlllT DIIE
150.55 125.9R � � ����0.00 275.63 -150.55 725.06
JACOBS, MILDRED 1039 EMERI'TUS OF CREEKVIEW
1039.483 07/31l13
� �.DATE RX�NO.. �TRAMS ���DE9CRl7TIp1 . �VNTSIC[AM ��� !DC Iq. qJµT . . . . . .
.NIOlMT. �TYPE
07/18/73�� E60i � LOCK PA7IENT� �- �TtI11NK�. YW '�Lockbmc 20t30718076505
00010�71 -18.08
U7/03/73 R27 � CIURGE BqI1qN1DI11E TARTRATE �IITN�O. . .
BFIDER 5137<-01<3-OS 5 S.W �.RX
� ��
� �
��, , I ,,/j
�� �� , � ,,q. ,� A �amily �'r�cii�ion c�f Ca�ring°
PARTHEMORE Funera.l Home & Cremation Services, Inc.
July 22,2013
1303 Bridge Street
PO.Box a3t Ms. Sbevonna A.Coleman
New Cumberland,PA 77070 19 FSrMhOUSe Lane
PH:(717)774-7721 �mp Hill,PA 17011
FX:(717)7745546
www.parthemore.com ��'Ms• C°leman;
The following items were either not fiznded ar not guaranteed in the pre-
arrangements for Mildred A.Jacobs:
Actual Co� As Fandad
Gilbert W.Parthemore �����H�,y�burg Patriot $ 133.46 $ 254.U0
Founder ��������� 36.00 36.00
Gilbert J.Parthemore Hairdresser 45.00 40.00
Supervisor Clergy Honorarium 150.00 150.00
Organist Honorarium 125.00 I25.00
Stephen K.Parthemore ���'e� 237.95 �0^�
President,CFSP
Subtotals: $ 727.41 S 605.00
Btuce R.Parthemore
Pre-Need Coordinator,CPC Diffet'enCe: $ 122.41
_ . _ _ Tofai Due: 5122.41
Professional Memberships: Ptease call if you have any questions. Thank you.
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- - _ PRENEED COUNSELOR SALES RECEIPT �
RQLLING GREEN CEMETERY COMppNY
?891 CAftLiSLERD �24 (V0.0009'13Q'
CAMP HiLL, PA 17011
717-761-4055
RECEIVED FFpy S�p O�TE `�' l 3
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Design/Siu � . p��y a . .
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• Memorial Iwfalhtloo Aee " � � �
• Memorial Inapecdao Fee '- pp�y� . n� /���
• PIa�&/SCro11 �G�� c�',p�P Ccrnfl �-'Ot$.ttc�c4 rZ.�S�Q � S�b'(blal 5�.�3��.�W
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i43 plertzville Road
Errola, PA 17025
(717)732-5444
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� 's 7/10J2013 2:�i:34 PM
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! ����� � � Y � pePSi 2.29
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! � � '' D1et Pepsi 2.29
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� � LL � i
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Seat 9
1 Stuffed Chidcen 12.49
p�; 2.29
Seat 10
1 Butcher Pride 8 oz 14.99
RaspberrY Tea 2.29
Seat 11
1 Butdter Pride 8 oz 14.99
Raspberry Tea 2.29
. •
Sest 29 Seat 12
1 Butcher Pride 8 oz 14.99 1 Kid's Chicken Bites 4,49
Coffee 1.89 Chocolate Milk 1.19
Seat 30 Seat 13
1 Butdier Pride 8 oz 14.99 1 Stuffed Chidcai 12.49
�{ p� 2,Zg Water
Seat 31 Seat 14
t Kid's Burger Buddie� 4.49 1 8utcher Pride 8 oz 14.99
Dr. Pepper 1.19 L�onade 2.29
Seat 32 Seat 15
1 Adult Salad Bar 6.99 1 Butcher Pride 8 oz 14.99
Water P�i Z'29
Seat 33 Seat 16
i Adult Salad 8ar 6.99 1 Adu1t Salad Bar 6.99
Chocolate �liik 2.29 Unsweetened Iced Tea 2.29
Seat 34 Seat 17
t Kid's Chidc� Bites 4.49 1 Stuffed Chtcken 12.49
Chocolate Mitk 1.19 Uns�et�ied Iced Tea 2.29
Seat 35 ' Seat 18
1 Adult Salad Bar 6.99 1 Butcher Pr1de 8 oz 14.99
Diet Pepsi 2.29 Pepsi 2.29
Seat 36 Seat 19
1 Butdier Pride 8 oz 14.99 1 Butcher Pride 8 oz 14.99
pepsi 2.29 PePSi 2.29
Seat 37 Seat 20
1 Crob Cake 14.49 1 Stuffed Chldcen 12.49
Coffee 1•89 P�j Z.29
Seat 38 Seat 21
1 Stuffed Chidcen 12.49 1 Stuffed Chidcen 12.49
PePSi 2.29 P�i 2.29
Seat 39 Seat 22
t Crab Cake � 14.49 1 Stuffed Chidcen 12.49
PePsi 2.29 Pepsi 2.29
Seat 40 �t �
1 Butcher Pride B oz 14.99 1 Stuffed Chidcen 12.49
Sweetened Iced Tea 2.29 Unsweete�d Iced Tea 2.29
Seat 41 Seat 24
1 Butcher Pride 8 oz 14,99 1 Adu1t Salad Bar 6.99
Unsaeeter�ed Iced Tea 2.29 P�PSi 2•Z9
SubTotal 578.62 Seat 25
Tax 34.72 1 Adu1t Salad Bar 6.99
Gretuity 110.40 PePSS 2.29
lotal 123,14 �t 26
i Crab Cake 14.49
(����6���� Seat 27ter
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Pepsi 2.29
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Transport Van Mileage S0209 5.5 4.68 25.74
OXYGEN ADMINSTRA110N A0422 1.0 65.01 65.01
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IMPORTANT MESSAGES: TH�s ACCOUNT IS PAST DUEI Send your paymeM now or contact
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WEST SHORE EMS-BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNlNG: It is iUegat to dupiicate this capy by photastat or photograph.
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LAST WILL AND TFSTAMENT
OF
MILDRED A.JACOBS
I, MILDRED A. JACOBS, a resident of the Commonwealth of Pennsylvania, make,
pubGsh and declare this to be my Iast VJill and Testatnent, revoking all wills and codicils at any time
heretofore made by me. I live with my husband who reared from the military service of the United
States.
FIRST: I direct that the expenses of my last illness and funeral, the expenses of the
administration of my estate, and all estate, inheritance and similaz Gvices payable with respect to property
included in my estate, whether or not passing under this will, and any interest or penalties thereon, shall
be paid out of my residuary estate, without apportionment and with no right of reimburse�nt from any
recipient of any such property.
SECOND: It is my desire that,upon my death,I be buried at the Roiling Green cemetery
in Camp Hill,Pennsylvania.
THIRD: I give all real estate owned by me at the time of my death, and all rights that I
have under any related insurance policies, to my husband SYLVIA THOMAS JACOBS, if he survives
me.
FOURTH: I give all tangible personal property owned by a� at the time of my death,
including without limitation personal effects, clothing,jewelry, fumiture, fumishings, household goods,
automobiles and other vehicles, together with all insurance policies reladng thereto, to my husband
SYLVIA THOMAS JACOBS, if he survives me. If my husband shall not survive me, I give specific
items of tangible personal property,if owned by me at t6e time of my death,in accordance with a written
memorandum wluch I intend to pTepare and sign, disposing of such property, or any part thereof as
pemutted by Pennsylvania law. If I sign more than one such memorandum, the memonndum which
bears a date later than that of any other such memorandum shall govem. In the absence of such a
memorandum,or to the extent thaz such memorandum fails to eff�6vely dispose of any such property for
any reason, including the death of any beneficiary, I give such property or the portion not effectively
disposed of as hereafter provided with respect to my residuary estate. All other tangible personal property
not referenced in a memorandum is given as hereafter provided with respect to my residuary estate.
FIFTH: I give all the rest, residue and remainder of my property and estate, both real
and personal, of whatever kind and wherever located, that I own or to which I shall be in any manner
entitled at the time of my death(collectively referred to as my "residuary estate"),as follows:
(a) If my husband SYLVIA THOMAS JACOBS survives me,to my husband outright.
(b) If my husband dces not survive me, my residuary estate shall be paid and distributed
to the ROCKVII,LE iJNITED METHODIST CHURCH, 6th and Linglestown Road,
Harrisburg,Pennsylvania.
�'/ ..1.C,/;(X1��� ��O�l?/
SIXTH: If any property of my estate vests in absolute ownership in a minor or
incompetent, my Executor,at any time and without court authorization, may: distribute the whole or any
part of such property to the beneficiary; or use the whole or any part for the health, education,
maintenance and support of the beneficiary; or distribute the whole or any part to a guardian, committee
or other legal representative of the beneficiary, or to a custodian for the beneficiary under any gifts to
minors or transfers to minors act, or to the person or persons with whom [he beneficiary resides.
Evidence of any such distribudon or the receipt therefor executed by the person to whom the distribution
is made shall be a full dischazge of my Executor from any liability with respect thereto, even though my
Executor may be such person. If such beneficiary is a minor, my Executor may defer the distribution of
the whole or any part of such property until the beneficiary at[ains the age of eighteen(18)years,and may
hold the same as a separa[e fund for the beneficiary with all of the powers described in Article EIGHTH
hereof. If the beneficiary dies before attaining said age, any balance shatl be paid and distributed to the
estate of the beneficiary.
SEVENTH: I appoint my husband SYLVIA THOMAS JACOBS to be my Executoc If
my husband does not survive me, or shali fail to qualify for any reason as my Facecutor, or having
qualified shall die, resign or cease to act for any reason as my Executor, I appoint my niece S1'EVONNA
COLEMAN as my Executor. I direct that no Executor shall be required to file or fumish any bond, surety
or other security in any jurisdiction.
EIGHTH: I grant to my F�cecutor all powers conferred on executors under the
Pennsylvania Probate,Estates and Fiduciaries Code,as amended, or any successor thereto, and all powers
conferred upon executors wherever my Executor may act. I also grant to my Executor power to retain,
sell at public or private sale, exchange, grant options on, invest and reinvest, and otherwise deal with a�y
kind of property, real or personal, for cash or on credit; to bo�row money and encumber or pledge any
property to secuce loans; to exercise all powers of an absolute owner of property; to compromise and
release claims with or without consideration; and to employ attomeys, accountants and other persons for
services or advice. The term "Executor" wherever used herein shall mean the executors, executor,
executrix or administrator in office from time to time.
NINPH: I direct that for putposes of this will a beneficiary shalt be deemed to
predecease me unless such beneficiary survives me by more than thirty days.
This document was prepared under the authority of 10 U.S.C. §1044 and implementing
military regulaGOns and instructions,by Captain Joseph Krill,United States Army,who is licensed to
practice law in the State of Pennsylvania.
IN WITNESS WHEREOF, I, MILDRED�. JACO sigm m �ame and publish and
declaze this instsument as my last will and testament this�day of 2006.
�� D� � �- �-e-
�MII.IZRED A. JACOBS
The foregoing instrument was signed, published and declared by MIIJDRED A.
JACOBS, [he above-named Testatrix,to be her last will and testament in our presence,all being present at
2
the same time, and we, at her request and in her presence and in the presence of each other, have
subscribed our names as witnesses on the date above written.
, c
having an address at
��,!!e�/��k�'4/ J
T—
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having an address at
�r�s����H lZ� l�
3
ACKNOWLEDGMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA,COUNTY OF CUMBERLAND,ss.
We, the Testatr'uc and the wimesses, whose names are signed to the attached or foregoing
instrument, being first duly swom, do hereby declare to the undersigned authoriry that the Testatrix,
MII..DRED A. JACOBS, signed and executed said instrument as her last will and testa�nt in the
presence and hearing of the witnesses, and that she had signed willingly, and that she executed it as her
free and voluntary act and deed for the purposes therein expressed, and that each of the witnesses at the
request of the Testatrix, in the presence and hearing of the Testaaix and each other, signed the wIll as
wimess, and that to the best of his or her Imowledge the Testatrix was at tbe time at least eighteen years of
age or emancipated,of sound mind and under no constraint,duress,fraud or undue influence.
� ,
�a..I'�d
DRED A.JACOBS
Testatri�c
Q Q.
print: l�j� I� D /Z
WiMes
La
print �•ol G�i•1�.-'
Witness
Subscribed, sworn to and aclmowledged before � by the said MII.DRED A/'.]�COBS,
T �taVix, and subscribed and sworn to before me by the above-named wimesses, this [� day of
���C��,2006.
Public /y,�
My commission expires on/�A"!i, �y Z��
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naw�ser
eears asaer,raay r„u�
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