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Home My WebLink About01-05-15 ' � '�pennsytvania 15 0 5 61410 5 °�"p'.'B`�°`"�'"'E EX(03-14)(FI) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes Counry Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT � �y 0�/� ENTER DECEDENT INFORMATION BEIOW Social Secunty Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10272012 11081917 DecedenYs Last Name Suffix DecedenYs First Name M� Jacobs Hannah E (If Appiicable)Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name M� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Retum p 2.Supplemental Retum p 3. Remainder Retum(date of death priorto 12-13-82) p 4.Agriculture Exemp6on(date of p 5. Future Interest Compromise(date of p 6. Federal Estate Tax Retum Required death on or after 7-1-2b12) death afte�12-12-82) p 7. Decedent Died Testate p 8.Decedent Maintained a Living Trust _ 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) p 10. Litigation Proceeds Received p 11.Non-Probate Transferee Retum Q 12. DeferraUElection of Spousal Trusts (Schedule F and G Assets Only) O 13. Business Assets O 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Joel R. Jacobs (717)241-5635 First Line of Address 2 Locust HOLW Second Line of Address City or Post Office State ZIP Code Carlisle PA 17015 CorrespondenYs email address: � �a y-�r� 1 REG E F WIIL�E OI�N Q � � '�� -� ti.;'s %c� REGISTER OF WILLS USE ONLY 1 - �? "'"� �"� DATE R'lIED MM�YYYY ;� �-" ;",-1 C�1 � �''. ��'1 f.1'1 ;:3 a �'_a C3 - . - ..� .:,�..i '.�.1 X� �-;, � -rt . �t� . � D/(T�BILED STA101� �� C%'1 � 't1 , - CD P4EASE USE ORIGINAL FORM ONLY Side 1 �(II��N��Iq��5 0'I�61I��H��II��N�� 15 0 5 61410 5 J (� � , � 15056142�5 REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: Hannah E. Jacobs RECAPITULATION 0.00 1. RealEstate(Schedule A). ..................... ... .................... L _ 2. Stocks and Bonds(Schedule B) 2. 0.00 ... ..... ......................... . ..... 3. Closel Held Co ration,Partnershi or Sole-Pro netorshi Schedule C 3. 0.00 Y � P P P( ) ..... _ _ 4. Mort a es and Notes Receivabie Schedule D 4. 0.00 9 9 ( )...................••---... _ _ 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. 0.00 6. Jointly Owned Property(Schedule F} O Separate Billing Requested ....... 6. 1,516.00 7. Inter-�vos Transfers 8�Miscellaneous Non-Probate Property 0.00 (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets total Lines 1 throu h 7 ............. 8. 1,516.00 ( 9 ).. ... ........... 9. Funeral F�cpenses and Administrative Costs(Schedule H)................... 9. 495.52 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. 1,748.99 11. Total Deductions(total Lines 9 and 10)................................. 11. 2,244.51 12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 0.00 13. Chantable and Govemmental Bequests/Sec.9113 Trusts for which an elec6on to tax has not been made(Schedule J) .......... .............. 13. 0.00 14. Net Value Sub"ect to Tax Line 12 minus Line 13 ............. 14. 0.00 , 1 � � ) ........... TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (axL2)X.0- 15. 16. Amount of Line 14 tazable . __ _ . _ at lineal rate X.0_ �6- 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE ........ ... .... 0.00 ....................... ................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Under penalties of perjury,I declare 1 have examined this retum,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 person responsible for filing the retum is based on all information of which preparer has any knowledge. SIGNATU P SON�S IBLE FOR FILING RETURN DATE ` � /� �C ADDRE � �U � a/.� /_ �aL Gj� C�Ol�I�r/�� / / / � /J SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE ADDRESS � I Il�u IIIN nNl I�l��ll�l�l�i��i�ii i�iui iiii Side 2 J 1505614205 REV-1500 EX (FI) Page 3 Ffle Number Decedent's Complete Address: DECEDENTS NAME Hannah E. Jacobs STREETADDRESS 2 Locust HOLW ��Jy STATE ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount (See instructions.) Total Credits(A+g) (2) 0.00 3. interest (3) 0.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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 Vansferred.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest.............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec.12,1982,did decedent transfer properry within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa 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 sunriving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax�etum are s611 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 ftom 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 step-parent 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 decedenYs lineal beneficiaries 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[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. �� . . HANNAH JAC08S � pccoum�2�pg633g JOEL R JACOBS Balances De 'ts/Gediis +$122.52 Aver pail Balance $2 452.64 Interest �Eamed ihis Pe�d �0.01 Paid Last Year gp,3p • 'The interest eamed and the interest paid may difter depending on arhen interest is credited to yrwr acxount Checks Posted Check# Date Paid AmouM Reference Check# Date Paid Amour�t Reference 2544 Ot/08 575.00 990453745 0 3 Check(s)Posted=52,244.51 o An asterisk(')indicates a skip in sequen6al chedc numbers. An(E)i�dicates chedc was oonverted to an electronic item. g Account Activil7/ � ob Date Description Add"itions Subtractions Balance �0 12-25 Beginning Balance $5,186.08 0 N 0 01-02 DEPOSIT 3122.50 53,154.58 0 �' 01-08 CHECF(000000002544 :75.00 52,584.06 0 0 0 A � Ot-22 INTEREST CREDIT FROM 12/21/2012 TO $0.02 $910.09 W � 1/20/2013 � w v V � N b r'- � D � ��2°l4 21Of6338 ' -�, y--� �� t� 2663 �R� �,ain. 2546 '��s�rm. d!'�iw./�-2N1 �'..w.�aw�w�.°Ra�w ��ZOfI w�wesm ew.r,e �,/ � � J �o�+.�w�i 8:.�:.�'�.�.�..�'J�+l_ ^�J S �l9Sc"32 ,;,u w �d � "��`�"�Jc /.�'1T.'!! ��/�=: --�� s1 I aa�ws�°.� � �f�Ef�s�lNe�C��/./�u�t 8 . �OYEl��I�iL� / ,�j � �� M�� j�� lj- 'C w �r �•a�an[! rH �� !:23i34264M: OOZL08b 8M254 �Z�i34t69U: OOZi086� t545 21086338 #2543 01/03/13 $495.52 � 21086338 #2545 01/7 6h 3 $1,673.99+^ �� ..,�,., 2saa �,w mw � i�;;` � wr['' T �� S 7t ab 1 �5��:'��^-7� �..�I...�./ os .w....�� kc Y �� _ � � �i�ii?2G9i�. 002�OB63 r254 21086338 #2544 01/08l13 $75.00 0 0 0 0 V O � �f O O O � N N O _.._. . " _._.. .. O O A b 0 0 A � � � � CJ V V � O N O r � � � page 4 oj4 210d6338 REV-15o9 EX+(01-io) ii�J' pennsylvania SCNEDULE F r�� DEPARTMENTOFREVENUE �OINTLY-OWNED PROPERn INFiERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Hannah E.Jacobs 2114-0512 If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVNING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A•Joel R.Jacobs 2 Locust HOLW,Carlisle, PA 17015 Son B. C. ]OINTLY OWNED PROPERTY: �rreR �n� DESCRIRTTON OF PROPERTY %oF DATE Of DEATH ITEM FOR IOiNT MADE INCLUDE NAME OF FINANC7AL INSTITUTION AND BANK AOCOUNT NUMBER OR SIMILAR DATE OF DEAiH DECFDENTS VALUE OF NUMBER 7ENANT JOINT IDEMTIFYING NUMBER.ATTAqi DEED FOR]OINTLY HEID RFAI ESTATE. VALUE OF ASSEf INiEREST DECEDENT'S INTEREST 1. A. 01/01/00 Sovereign Santander Interest Checking Acct#21086338 3,032.00 50 1,516.00 TOTAL(Also enter on Line 6, Recapitulation) $ 1,516.00 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(OS-13) � � pennsylvania SCHEDULE H � DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RE?URN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Hannah E. Jacobs 2114-0512 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hetrick-Bitner Funeral Home,Inc.-balance due for funeral e�enses 495.52 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 3. family Exemption: (If decedent's address is not the same as claimant's,attach expianation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) # 495.52 If more space is needed,use additional sheets of paper of the same size. . ✓ Invoice . Hetrick-Bitner Funeral Home, Inc. 3125 Walnut Street Harrisburg PA 17109 Date Invoice# �� _ 10/29/2012 3453 Phone# 717-545 3774 BIII TO JoelJacobs 2 Locust Hollow Carlisle,PA 17015 . Terms Due Date Client COD 10/29/2012 Hannah Jacobs Quantity Description Rate Amount Opening and Closing of Grave 850.00 850.00 Equipment Rental 395.00 395.00 Rabbi offering 300.00 300.00 $ Death Certificates 6.00 48.00 Obituary in Patriot News 613.80 613.80 Perpetual Care 800.00 800.DO Chevra Kadisha 300.00 300.00 `9tn t�een a p�ea°uxe u'`v�tit�u��/ Total $3,306.80 Payments/Credits $-2,811.28 BITNER FAMILY FONERAL HOMES �� Balance Due �195.52 G� � Z 26l�� , � REV-1512 EX+ (12-12) �� pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Hannah E. Jacobs 2114-0512 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• Debt owed to Joel R.Jacobs for Ambulance fees paid on behalf of decedent on 8-9-12 prior to death 75.00 The Jewish Home of Greater Harrisburg-balance due for nursing home services 1,673.99 TOTAL(Also enter on Line 10, Recapitulation) � 1,748.99 If more space is needed,insert addidonal sheets of the same size. . ETRo BANK - __ . i :."�..�� --� sas. � � �� 5.:: 5�..?i� �,��J s=' ?sarv_ � 5�..�-.,�.-r.�..-rl-.--'-"�� — ,..�.�......�.. . '�. f �r.m1�tzo��o7 �i-� .�v _ �-eaai3nza�.�e oe 3osaas 6�3i � S�rees� Da.a��c s or �f.��t�r[ #6434 20121017 $75.00 � � a � � � � � � � m � • N m � O � � w n � �0230R3R1A Da.r S e.f R ��o riou.mm �- . `.-�''� � STATEMENT Jewish Home of Greater Harrisburg Resident: Jacobs, Hannah Edith (1475) 4000 Linglestown Rd Location: - Harrisburg, PA 1 71 1 2-1 01 7 Statement Date: 12/1/2012 (717)657-0700 ALL TRANSACTIONS PROCESSED AFTER Nov 30, 2012 WILL APPEAR ON YOUR NEXT STATEMENT JoelJacobs 2 Locuet Hollow Carlisle, PA 17015 _ _ .____ .___ Amount Due_$1,673.99 _ _ PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed$ Jewish Home of Greater Harrisburg Resident: Jacobs, Hannah Edith(1475) 4000 Linglestown Rd Location: - Harrisburg, PA 17112-1017 5tatement Date: 12/1/2012 (717)657-0700 Effective Date Description Units Unit Amount Amount BALANCE FORWARD $3,980.55 10/1/2012 Resident Liability Due Oct 1-2 2012 ($111.56) 7/31/2012 Other Medical F�cpense Resident Pd Deductible ($208.50) $/31/2012 Other Medical Expense Resident Pd Deductib�e ($1,986.50) BALANCE DUE $1,673.99 PAYMENT DUE UPON RECEIPT If you have any questions Contact Business Office 717-657-0700 Wanda Nearhood , Jewish H�►ne of Greater Harrisburg Resident: Jacobs, Hannah Edith(1475) � 4000 Linglestown Rd Location: - Ha��isburg,-PA 17112-1017 Statement Date: 111/2013 ' (717)657-0700 Effective Date Description Units Unit Amount Amount BALANCE FORWARD $1,673.99 BALANCE DUE $1,673.99 Payment Due Upon Receipt If you have any questions Contact Business Office 717-657-0700 Wanda Nearhood Q� �� 3 � , a r � _ _ _ _ _ ___ __ .__