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REV-1500 EX + (6-00)
*
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
: OFFiCIAL USE ONLY
I
I FILE NUMBER
21 06
I COUN~ODE YEAR
SOCIAL SECURITY NUMBER
0113
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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2 Supplemental Return
Thomas, Mary C.
DATE OF DEATH (MM-DD-YEAR) I' DATE OF BIRTH (MM-DD-YEAR)
01-28-2006 12-24-1914
i (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
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:.: i ~ I 0 4. Limited Estate
lil~g
ij ll: iil [!] 6. Decedent Died Testate (Attach
ll. copy of Will)
c( 0 9. Litigation Proceeds Received
i 264-52-7100
I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
i SOCIAL SECURITY NUMBER
I
4a. Futura Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal Poverty Credit (date of death between
. 12-31-91 and 1-1-95)
LJ 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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NAME
James G. Morgan, Jr.
FIRM NAME (If applicable)
l Tucker Arensberg, P.C.
I TELEPHONE NUMBER
1717/234-4121
I 1. Real Estate (Schedule A)
I 2. Stocks and Bonds (Schedule B)
I
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I 4. Mortgages & Notes Receivable (Schedule D)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
COMPLETE MAILING ADDRESS
111 North Front Street
POB 889
Harrisburg, PA 17108-0889
(1 ) 149,900.00 QFFICIAL J,.t~E ONLY
" . r'1
(2) 99,131.46 ~
(3) None
'-- ")
(4) None
(5) 204,796.54
(6) 4,030.72 .~ , ,o' J
( ., .. 1 ]
(7) 39,049.30 -...
(8) 496,908.02
(9) 27,972.33
(10) 147.75
(11 )
28,120.08
468,787.94
0.00
(12)
(13)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
468,787.94
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
x .00 (15)
0.00
15.Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
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16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
468,787.94
x .045 (16)
21,095.46
0.00
0.00
x .12 (17)
x .15 (18)
(19)
0.00
21,095.46
0.00
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
20. D
,. ! ..' · ,'. .... >>:e/SUReTe>ANswEItALLQUESTlONS"O",iREVERSS'SrOe AND REcHeCK MATH <<
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Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00;
o
Rev-1502 EX+ (6-98)
*'
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Thomas, Mary C.
FILE NUMBER
21-06-0113
ESTATE OF
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, ne~her being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which Is jolntly-owned with right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 2011 Harvard Avenue, Camp Hill, PA 17011
VALUE AT DATE
OF DEATH
149.900.00
i2 :}
TOTAL (Also enter on Line 1, Recapitulation)
149.900.00
(If more space is needed, additional pages ofthe same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule A (Rev. 6-98)
Rev-1503 EX+ (6-98)
*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Thomas, Mary C.
FILE NUMBER
21-06-0113
ESTATE OF
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 140.084 shares of Ameriprise Financial - Acct. No. 20.240 2.835.30
010100732378002
2 3,543.379 shares of Ameriprise Financial - Acct. No. 2.880611 10.207.10
012559283911002
3 596.229 shares of Ameriprise Financial - Acct. No. 5.450 3.249.45
013159283913002
4 014327100 200 shares of Arlen Corporation (ARRD) .001 0.20
5 302520101 771 shares of F N B Corp PA - Com 17.215 13.272.77
6 316773100 402 shares of Fifth Third Bancorp - Com 38.045 15.294.09
7 353496300 5,143.355 shares of Franklin Custodian Funds Inc- 2.46 12.652.65
Income Fund CL A
8 409902780 317.548 shares of Hancock John Cap Series - Classic 25.37 8.056.19
Value A
9 Royal Alliance Associates - Acct. No. 4KM-041010 10.802.75
10 920917101 1,133.233 shares of Van Kampen Merr Municipal 14.66 16.613.20
Income Fund - CL A
11 957904709 623.505 shares of Westcore Trust - Flex Income Fund 9.86 6.147.76
TOTAL (Also enter on Line 2, Recapitulation) 99.131.46
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
Rev.1508 EX+ (6.98)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Thomas, Mary C.
FILE NUMBER
21-06-0113
ESTATE OF
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
NUMBER DESCRIPTION
1 Ameriprise Financial - Client No. 164034290001
VALUE AT DATE
OF DEATH
438.83
2 PNC Bank - Savings Acct. No. 5130063782
2.847.62
Accrued interest on Item 2 through;.ct,Cl'~~f d~ath
U.S. Department of Treasury - refund from 2005 individual income tax return
4.77
3
4,501.00
4
Ameriprise Financial - Acct. No. 930059993558004
32,916.87
5
Ameriprise Financial - Acct. No. 930059993764004
72,028.82
6
Ameriprise Financial- Acct. No. 93006659160004
21,988.39
7
Ameriprise Financial - Acct. No. 930073506030004
70,070.24
TOTAL (Also enter on Line 5, Recapitulation)
204,796.54
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+ (6-98)
*'
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Thomas, Mary C.
FILE NUMBER
21-06-0113
ESTATE OF
If an aaaet waa mede joint within one year of the decedenfa date of death, it muat be reported on achedule G.
SURVIVING JOINT TENANT(S) NAME
A. Keith L. Thomas
ADDRESS
RELATIONSHIP TO DECEDENT
423 S. Frederick Street
Mechanicsburg, PA 17055
Son
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER DATE
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENT'S INTEREST
JOINTLY-HELD REAL ESTATE.
1 A 10/4/2004 PNC Bank - Checking Acct. No. 8.060.47 50.000% 4.030.24
5140064068
2 A 10/4/2004 PNC Bank - Checking Acct. No. 0.95 50.000% 0.48
5140064068- accrued interest
TOTAL (Also enter on Line 6, Recapitulation) 4.030.72
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 ScheduleF (Rev. 6-98)
Rev-1510 EX+ (6-98)
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM IIUN -oF .vr..." , Y DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE.
1 MetLife - Contract No. 9200600935, CUSIP 16.694.13 16.694.13
#59156T708
2 New York Life Insurance Company - Policy 22.355.17 22.355.17
No.N#170549
,
,
TOTAL (Also enter on Line 7, Recapitulation) 39.049.30
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleG (Rev. 6-98)
REV-1151 EX+ (12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRA TIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-06-0113
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 5,058.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees 7,000.00
See continuation schedule(s) attached
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 398.00
See continuation schedule(s) attached
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 15,516.33
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 27,972.33
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H.A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Myers Harner Funeral Home, Inc.- funeral
5.007.00
2
Myers Harner Funeral Home, Inc. - funeral
51.00
Subtotal
5.058.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H.82
ATTORNEY'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Tucker Arensberg, P.C. - attorney fees
7.000.00
Subtotal
7.000.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleH-B2 (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-84
PROBATE FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Register of Wills - probate will
398.00
Subtotal
398.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B4 (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H-B7
OTHER
ADMINISTRA TIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
ITEM
NUMBER DESCRIPTION AMOUNT
1 2011 Harvard Ave., Camp Hill, PA - Settlment charges paid by seller 12.758.97
2 Cumberland Law Journal - legal advertisement 75.00
3 Dorado Restaurant - funeral dinner 409.84
4 Home-Aide Center - private duty aide 77.50
5 Penn Waste - curbside trash & recycling for 2011 Harvard Ave. 42.63
6 Pennsylvania American Water - water to 2011 Harvard Ave. 12.47
7 Pennsylvania American Water - water to 2011 Harvard Ave. 13.64
8 Pennsylvania American Water - water to 2011 Harvard Ave. 36.15
9 Pennsylvania American Water - water to 2011 Harvard Ave. 8.12
10 PPL Electric Utilities, Inc. - electric for Harvard Ave. 12.91
11 PPL Electric Utilities, Inc. - electric for Harvard Ave. 13.01
12 PPL Electric Utilities, Inc. - electric for Harvard Ave. 20.56
13 PPL Electric Utilities, Inc. - electric for Harvard Ave. 31.00
14 R. WM. Wire Associates - income tax preparation 385.00
15 Register of Wills - short certificates 28.00
16 The Sentinel - legal advertisement 130.68
17 Tucker Arensberg, P.C. - expenses 190.41
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
ITEM
NUMBER DESCRIPTION AMOUNT
18 UGI Gas Services - gas service to 2011 Harvard Ave. 313.95
19 UGI Gas Services - gas service to 2011 Harvard Ave. 110.00
20 UGI Gas Services - gas service to 2011 Harvard Ave. 214.90
21 Verizon - telephone to 2011 Harvard Ave. 16.99
22 West Shore EMS - Paramedic service 614.60
Subtotal
15.516.33
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleH-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Thomas, Mary C.
FILE NUMBER
21-06-0113
Include unreimbulSed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Heritage Cardiology Assoc.
VALUE AT DATE
OF DEATH
33.38
2 Holy Spirit Hospital
18.85
3 Janet Miller, Tax Collector
4.90
4 Neurology Center, PC - hospital consult
90.62
TOTAL (Also enter on Line 10, Recapitulation)
147.75
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV.1513 EX+ (9-00)
.
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Thomas, Mary C.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
aistributions.l. and transfers
under Sec. l::f116(a)(1.2)]
RELATIONSHIP TO
DECEDENT
Do Not List Trusteelsl
FILE NUMBER
21-06-0113
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
Sandra J. Miller
708 South Broad St.
Mechanicsburg, PA 17055
John B. Thomas
19 Hillymede Road
Hummelstown, PA 17036
Daughter
one-third
residue of
estate
Son
one-third
residue of
estate
Keith L. Thomas
423 South Frederick Street
Mechanicsburg, PA 17055
Son
one-third
residue of
estate
Total
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleJ (Rev. 6-98)
LAST WILL AND TESTAMENT
BE IT REMEMBERED THAT
I, MARY C. THOMAS, 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 Wills and Codicils previously made by me.
I declare that I am not married. My beloved husband, PAUL C. THOMAS,
having predeceased me and that I have three (3) children, SANDRA J. MILLER,
JOHN B. THOMAS, and KEITH L. THOMAS.
II
I direct that all my just debts and funeral expenses shall be paid from my
residuary estate as soon as practicable after my decease.
III
I 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.
IV
I give and bequeath to my daughter, SANDRA, my personal items including
jewelry (but excluding Aunt Beth's diamond ring). I direct that she divide these
items among th~ fell.1ale members of my family utilizing her di~cretion. . .' .' _ .'
[1-l..<-;'v( /~-dlJ-/l,u1 Jto h ~<. tL,yf eU.~~<- ~ /l "if4d'7" I1Y'L,)k..c~. ....,"':.4J~'<'
V .,[.A.'1z...J:<.e.J!;.'flJ{.."",) "'U''t fU'~l (~.4r.L.t!~ t,,-z;;z;.
All the rest, residue, and remainder of my property whether real or personal
wherever situate, including any property over which I may have a power of
appointment, I give, devise and bequeath to my daughter, SANDRA, my son,
JOHN, and my son, KEITH, in equal shares, per stirpes.
VI
I nominate, constitute and appoint my son, JOHN B. THOMAS, as
Executor of this LAST WILL, to serve without bond. If my son is unable or
unwilling to act in that capacity, then I nominate, constitute and appoint my
daughter, SANDRA J. MILLER, as Executrix of this LAST WILL, to serve without
bond.
IN WITNESS WHEREOF, I, MARY C. THOMAS, have set my hand to this
LAST WILL this ~ to day of ~iJ ' 2001.
It; ~~ .1~J1/w/
MARY C. TffibMAS
Signed, sealed, published and declared by the above-name MARY C.
THOMAS, as and ~or her Last Will and Te~tament, in, th~" e pes ence I us, who, at
her request and ill her presence, and ill Ihzr~se ,t fof ~ ' other, have
hoceunto ,ub","bed our name, ., witnme'"fItt{ l' t/
~/I r
94Yt~
2
ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
I, MARY C. THOMAS, Testatrix, whose name is signed to the attached or
foregoing instIUment, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instIUment as my LAST WILL; that I
signed it as my free and voluntary act for the purposes therein expressed.
m~(V\~~~/
MARY C. T MAS
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Sworn or affirmed to and acknowledged before me by MARY C. THOMAS,
Testatrix, this 0l{,W-.. day of ~r(^(J-<d-_ ,200l.
V~ h1.~
Notary Public
Notarial S8aI
Diane M. Smnh, Notary Public
Mechanlcsbu~ Bom, Cumberiand County
My Commission Expires June 22, 2004
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, (hurt"! R. lth.If-tri, iiT and ~ u D't }14\tF~
the witnesses whose names are signed to the attached or foregoing instrument,
being duly qualified according to law, do depose and say that we were present
and saw Testatrix sign and execute the instIUment as her LAST WILL that MARY
C. THOMAS signed willingly and that she executed it as her free d voluntary
act for the purposes therein expressed; that each of us in the he . g and sight of
the Testatrix signed the Will as witnesses; an~th t. to~ be st 0,' our knowledge,
the Testatrix was at the time 18 years of age or ore, 0 soun vmind and under
no constraint 0' undue influence. .1(f: , .
ss.
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Sworn or affIrmed to and acknowledged before
me this ~('/1.. day of f::-e..brl.<.a./l 'J-. ,200l.
O~1,~
Notary Public
Nolarial Seal
Diane M, Smnh, Notary Public I
Mechanlcsbu~ Boro, Cumberiand County
My Commission EXpires ,lune 22, 2004
MAY-01-2006 MON 08:26 AM CAIU
FAX NO. 7177328425
P. 02
A. u.s. DEPARTMENT OF HOUSING .nd URBAN DEVELOPMENT OMS No, l502.0265
SETTLEMENT STATEMENT TIlLEPRO
SELECT LAND L"Hrpl'inl
."
TRANSFERS,LLC 8. TYPE OF LOAN
801 East Park Drive, SuIte 106A 1.[ ) FHA 2. r ] FMHA 3. I I CONV. UNINS
Harrisburg, PA 17111 4. [ JVA 5. l J CONV. INS.
6. FILE NUMBER: 17. LOAN NUMBER:
Phone: (717) 441-2802 FAX: (717) 730-9665 801359 134614237
B. MORT. INS. CASE NO.:
C. NOTE; This form is furnished 10 give you e Slalemenl 01 aCluel selllemenl CoslS. Amounls paid 10 and by lhe selllement age'll are shown. lIems marked
'(P.o.c.)' were paid oUlslde Ihe Closing; Ihey are shown here for informational PUrposes IIlld are nol included in tho 101a/s.
D. NAME AND ADDRESS OF BORROweR: E. NAME AND ADDRESS OF SelLER: F. NAME AND ADDRess OF LENDER:
David B. Jones John B. Thomas Countrywide Home Loans,
Gail L. Brown Estate of Mary C. Thomas Inc.
G. PRopeRTY LOCATION: H SETTLEMENT AGENT: I. SETTLEMENT DATE:
2011 Harvard Ave. Select Land Transfers,LLC 04/28/06
Camp Hill Borough f'LACe OF smLEMENT:
Cumberland County Re/Max Realty Select, Harrisburg, FA
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMIIlARY OF SELLER'S TRANSACTION:
100. GROSS AMOUNT DUE FROM BORFlOWEFI '00. GROSS AMOUNT OUE TO SELLER
101. Contract sales price 149900.00 ..Ol.Contract sa/.a: oriC8 149900.00
102. PerGOnal-';;openv .02PorSonal prol);,nv
103. SeUlemenl char';;. 10 borrower (line 1400) 7944.03 .o:t
104. 404,
' 10S. 40S.
AdlUslmenls for items oald bv soller in advance AdlUslment. for items paid bY seller in adyenco
106. Citylfown tlx 10 40ti.CityfTcwn lax to
: 107. Counlv lax 047287061012/31/06 326.16 407. Counry tax 04 f28 106to 12731106 326.16
t08. Ass.51monts '0 "OlI.Aneumanl! 10
lOll. SCHOOl.. 047287061006730706 235.03 40;. SCHOOL 047287061006130706 235.03
"D. Sewer 4728-6130.0 29.61 "0. Sewer 4728-673010 29.61
111. ."
t12. 4'2.
I 120. DROSS AMOUNT DUE FROM BOFlFlOWER 158434.83 .20.0FlOS5 AMOUNT DUE TO SELLER 150490.80
200. AMOUNTS PAID BY OR IN BEHALF OF BOFlROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER
20 I. Decosit or earnest moneLl 1000.00 501.&co$& depoGll'iSeo instruCtions'
2o~. PrinCipal emounl of new 'oan(5) 88500.00 502.Sall/emenl cha",.s to solle~ine , 400\ . 12758.97
203, Exlslinn ',oan(s) laken subjecllo 50s.Existino Ioan(s) laken subject 10
20.. 50'.Payoff at First Mongags Loan
HELOC - draw 20000.00
205. sos.Payoff at Second Morlgage Loan
206. 506.
207. 507,
200. G08.
2011. SOS!
Adjustments for iloms unpaid bv soller Adiu,'monls for 110m. unpaid by sello(
210. CiWlTown I.. 10 610.cI;;;;,-0",n lax 10
211. COunly lax to 511.COunry lax 10
212, Asseumen!$ 10 612.ASS&lImQntl 10
2t:l. SCHOOL 10 513. SC'HOOL 10
21' 514,
2t5. 515.
216, SUi.
:!P. 6t1.
218. 51..
219. S19.
2<0. TOTAL PA'O BYIFOfl BORFlOWER 109500.00 620. TOTAL REDUCTION AMOUNT DUE SELLEFI 12758.97
300, CASH AT SETTLEMENT FFlOM OR TO BORFlOWER 600. CASH AT SCTTLEIlENT TO OFl FAOM SELLER
301. Gross amount due Irom borrowercline 1201 158434.83 601.Gro.. omoun' due 10 seller (line 420) 150490.80
302. Les. amount naid ;;;;;'or borrowetilino 220\ 109500.00 60..Less rodUClion amounl due seller (line 520) 12758.97
103. CAS~[X FROM) ([ ] ~ BORROWER 48934.83 $03. CASH ([ XTO) ([ J FROM) SeLl.ER 137731.83
riAL - /J /<{ .J...... ^ C,__ ~-. ~--oL.
(f
f. ,&:d.1' fL.:'
"
3uyer or 8orrow.r'~ Signature
SQller'a; Signature
HUD., Rov. 51BG
L. SE'TTlEMENT CHARt; s 8013 5 9
700. TOTAL SALESIIROKER'S COMMISSION blOOd on price $
Division of Commission (line 700) as follows:
701. $ 4522.00 to
70.$ 4472.00 10
703. Commission paId al Selllemenl
704. Trans fee
soo. ITEMS PAYA8LE IN CONNECTION WITH LOAN
SO t, Loan Ori ination Fee %
e02. Loan Discount 3 . 00 0 %
e03. Ap raisal Fee to
804. Credil Repon 10
80S. Lender. InsPeclion Fee
S05 1101011 age Insurance Application Fee to
807. Assumption Fee
80S. Tax servic
809. Flood chec
S10. Doc re
811,
GOo. ITEMS REQUIRED IY LENDER TO BE PAID IN ADVA"ICE
901.lnteresllrom 04 28 06 1004 30 06 0$
902. MOrl a e Insurence Premium for mo. 10
903. Hazard Insurence Premium lor yrs. 10
g04. rs. 10
90S.
000. RESERVES DEPOSITED WITH LENDER FOR
001. Hazard Insurance 3 mo. 0 $
002. Morlgage Insurence mo. 0 $
1003. Cil rrown lax mc. (I $
1004, County I"" 3 mo. 0 Ii
100S. Assessments mo. C $
1006. School 10 mo.@S
1007. mo. @ $
1008. A Ad mo. @ S
1100. nTLE CHARGES
1101. Selliemenlorelosin leeto
110Z. Abslracl or tille Search 10
1103. Title examination fo
"04. Tille insurance binder 10
1105. Document prepararion 10
lTOE, NOla fees 10
1107, AlIorney's fees 10
(includes ebove ilems No.:)
IIOS. Tille insurance 10
(inoludes above items No.:)
1109. Lender', COverage S
1110. Owner's covera e $
111. Endts.
112. CSL
113. Courier
200. GOVERNMI!NT RECORDING '1"10 TRANSFER CHARGES
ZO 1. Recording fees: Deed Ii 38 . 50 Morlga e $
202. Cil Icounry 1"lC/&Iemps: Deed $ 1499 . 00 Mort
203. Slele taX/slamps: Deed $ 1499.00 Morl e e $
204. Sewer Cam Hill Borou h
z05.e-doc Select Land Transfers
300. ADOrTIONAL SETTLEMENT CHARGES
30'. Surve 10
302, POSI Inspection 10 Terminix
303. Electrical W. J. Care
304.06 Ct Bor Janet L. Miller
305 Trans fee ReMax Realt select
100. TOTAL SETTLEMENT CHARGES (onlo, on Iino. 103 and 502. SeClion, J and K)
MAY-01-2006 MON 08:26 AM CAIU
1102
88
149
FAX NO. 7177328425
P. 03
SETTLEMENT STATEMENT
149900.00 6.0
Total: 8 994.00
ERA-NRT Inc.
ReMax Realt Select
ERA-NRT
Inc.
Home Loans
raisal
Home Loans
2655.00
320.00
35.00
Count ide Tax Service
Landsafe Flood
Countr ide Home Loans
90.00
26.00
450.00
Ida
42.72
39.17
40.16
Imo.
/mo.
Imo.
Imo.
Imo.
Imo.
Imo.
Imo.
1134.70
117.51
120.48
113.47
-396.63
Tucker
Notar
95.00
10.00
25.00
Select Land Transfers LL
1103 1104
500
900
Select Land Transfers LL
Fidelit National Title
Select Land Transfers LL
Misc. $
167.50
1499.00
1499.00
85.00
20.00
212.00
189.00 1257.00
481.97
145.00
7944.03 12758.97
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)mpen,;aUon lOt iI. Htvic;esln Ihi:lI'lna.clio.,.
I-iUD CERTIFICATION 0' BUYERS AND SELLERS
I ha.e .arQ(ully ro.iawed Iho HUO.l SOUlo"'onl Slole"'onl and I. Iho bo" of ",y knowlodge ond bollo'. il i. a 'rvo and aeev"'I.-rn""mon' 0' ell ,oe.iol. and ';iaburso",onll
.do on my ounl by mo In Ih' o.llon. llurrh., ..rrlly thai I h..e '''''oiued . .opy 01 'he HUe-, Se'lIemon, S,a'omont.
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