HomeMy WebLinkAbout05-03-07 (3)
.-J
15056051058
REV-1500 EX (06-05)
PA Department of Revenue *
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
21 06
00896
Date of Birth
159-26-1207
10/04/2006
04/01/1933
Decedent's Last Name
Suffix
Decedent's First Name
MI
Kiritsis
Nicholas
C
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's 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
e: 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4a. Future 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 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT _ THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
4. Limited Estate
.
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
William C. Kollas
(717) 731-1600
\-")
Firm Name (If Applicable)
Kollas and Kennedy
S~2. -." --- ,~~
REGISTER ~S USE o~
" -
1104 Fernwood Avenue
f'\..)
~..~~
First line of address
0,)
Second line of address
Suite 104
City or Post Office
State
ZIP Code
DATE FILED
f'.)
.--
.....
Camp Hill
PA
17011
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.
S:-Z~~~ORFILlNGRETURN DATE 5/3{07
ADDRESS .
-JI~~UR~~~~R ~~R~~Z;RE~~;~T~IV!k 11. Pit 110 II
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058
-.J
L
15056051058
-f
~
15056052059
REV-1500 EX
Decedent's Name:
Nicholas
C Kiritsis
RECAPITULATION
1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .., .. 3.
4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION. 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 .0_
16. Amount of Line 14 taxable
at lineal rate X.O 45
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X. 15
15.
10,000.00
103,823.00
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059
Side 2
L
Decedent's Social Security Number
159-26-1207
94,592.63
40,537.15
135,129.78
10,082.00
11,225.15
21,307.00
113,822.78
113,822.78
16.
450.00
17.
18.
15,573.00
16,023.00
15056052059
......J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21
06 00896
DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER
Nicholas C Kiritsis 159-26-1207
STREET ADDRESS
100 Howard Street
CITY I STATE 1ZIP
Enola PA 17025
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
16,023.00
Total Credits (A + B + C ) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( 0 + E ) (3)
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)
16,023.00
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(SA)
(5B)
A. Enter the interest on the tax due.
16,023.00
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 transferred;.......................................................................................... 0 [iI
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [iI
c. retain a reversionary interest; or.......................................................................................................................... 0 [i]
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [iI
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [iI
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [iI
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 [iI
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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (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 twenty-one 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 zero (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 four and one-half (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 oftransfers to or for the use of the decedent's siblings is twelve (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+ (6-9W
COMMONV\lEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
Nicholas C. Kiritsis
FILE NUMBER
00896
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. neRher being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which Is Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
100 Howard Street, Enola, PA 17025
94,592.63
Sold January 31,2007
HUD Attached
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
94,592.63
REV-'S08 EX+ (6-98) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Nicholas C. Kiritsis
FILE NUMBER
00896
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.
ITEM
NUMBER DESCRIPTION
1. M&T Bank Checking and Savings Account
2. Refunds PP&L and Verizon
3. Refund Insurance State Farm
4. Cash
5. Sale of 2003 Hyundai Sonata LX
6. Refund of Westfield Insurance
7. Interest
8. Misc. Settlement Fund
9. Retirement Fund
10. IRS 2006 Reimbursement (Anticipated)
11. Refund UGI Utilities
VALUE AT DATE
OF DEATH
32,598.38
219.27
139.17
1,080.00
5,500.00
162.25
102.31
8.01
47.95
30.00
649.81
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
40,537.15
REV:1511 EX+ (12-99)*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Nicholas C. Kiritsis
FILE NUMBER
000896
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
St. Catherine Philoptochos Society
Funeral Repast
648.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) William C. Kollas
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
0.00
City
State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
9,396.00
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
35.00
5.
Accountant's Fees
0.00
6. Tax Return Preparer's Fees
7. Miscellaneous
a.
Pennsylvania Department of Revenue 2006 Taxes
3.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
10,082.00
REV-1512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE UABILmES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
000896
ESTATE OF
Nicholas C. Kiritsis
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
2.
10.
11.
12.
13.
14.
15.
16.
3.
PPL Electric Utilities 1,223.75
Pennsylvania American Water 331.44
UGI Utilities. Inc. 1,749.53
Cingular Wireless 62.60
MCI 148.78
Comcast Cable 142.25
Chase Card Services 172.05
Westfield Insurance 293.25
Clayton Miller Expenses 355.00
Citizen Automobile Finance 4,399.41
Debbie Lupoid, Treasurer 1,389.60
The Water Guy 14.99
East Pennsboro Township 253.00
Medco 55.00
The National Motor Museum Mint 34.98
Kollas and Kennedy - Probate Fees 599.52
4.
5.
6.
7.
8.
9.
11,225.15
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REVL1513 EX+ (9-00) '*
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Nicholas C. Kiritsis
FILE NUMBER
000896
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. Christopher Kiritsis Nephew 16.6% Remainder
2. Paul Kiritsis Nephew 16.6% Remainder
3. Constantine Wood Nephew 16.6% Remainder
4. Peter Wood Nephew 16.6% Remainder
5. Jonathan Wood Nephew 16.6% Remainder
6. Christopher Chekouras Nephew 16.6% Remainder
7. Tina Beam Child $10,000.00 Outright
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 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 $
(If more space is needed, insert additional sheets of the same size)
d( I ~ lAP ~-
u 0
I'f"
~")
.......,
~')
LAST WILL AND TESTAMENT
r-)
':-1
::.- .
C:.'\
^:J
OF
1'-',)
NICHOLAS C. KIRITSIS
~-~.- )
. ",
..::!
)
=) )
(...:J
I, NICHOLAS C. KIRITSIS, of Enola, cumberland County,
Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare the following as
and for my Last Will and Testament, hereby revoking and making null
and void any and all Wills and Testaments or Writings in the nature
thereof by me, at any time heretofore made.
FIRST:
I direct that all my legal debts and funeral expenses
shall be paid from the assets of my estate as soon as practicable
after my decease.
I further direct that my funeral be arranged
through the Sullivan Funeral Home, 51 North Enola Drive, Enola,
Pennsylvania. And I ask that my pallbearers be: Tony Mastrine of
Marysville,
Pennsylvania;
Rick
Brewbaker
of
Marysville,
Pennsylvania; Steve Myer of Enola, Pennsylvania; Christopher
Chekouras of columbia, Maryland; Constantine Wood of Hollidaysburg,
Pennsylvania; and either Christopher Kiritsis of Manchester, New
Hampshire or Paul Kiritsis of Richmond, Virginia.
SECOND: I give, devise, and bequeath all the rest, residue and
1
remainder of my Estate to my beloved mother, KATINA KIRITSIS of
Enola, Pennsylvania, including but not limited to, the real
property located at 100 Howard Street, Enola, Cumberland County,
Pennsylvania, my automobile, my personal belongings and worldly
possessions, and any monies in checking, savings and trust accounts
or in certificates of deposit. In the event that my mother fails
to survive me by thirty days, then I direct that my estate shall be
divided equally between the following six persons: Christopher
Kiritsis of Manchester, New Hampshire; Paul Kiritsis of Richmond,
Virginia; Constantine Wood of Hollidaysburg, Pennsylvania; Peter
Wood of New Jersey; Jonathan Wood of New Jersey; and Christopher
Chekouras of Columbia, Maryland.
THIRD: I nominate, constitute and appoint WILLIAM C. KOLLAS,
ESQUIRE, of Camp Hill, Pennsylvania, Executor of this, my Last Will
and Testament, and he shall so serve without the necessity of
posting any bond whatsoever. In the event that he is unable to
serve as Executor for any reason, I nominate, constitute and
appoint WILLIAM C. COSTOPOULOS, ESQUIRE, of Lemoyne, Pennsylvania,
as substitute Executor of this, my Last Will and Testament, and he
shall so serve without the necessity of posting any bond
whatsoever.
2
IN WITNESS WHEREOF, I have hereunto set my hand and
seal and caused this my Last Will and Testament, consisting of five
(5) typewritten pages, including this attestation clause, to be
executed, declared and published this 1/1-;1 day of February 2002,
at Lemoyne, Pennsylvania.
, --------
cJ~ iJ#>
NICHOLAS C. KIRITSIS
3
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
I, NICHOLAS C. KIRITSIS, the 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
the instrument as my Last Will and Testament; that I signed it
willingly and that I signed it as my free and voluntary act for the
purposes therein expressed.
or affirmed to and acknowledged before me by NICHOLAS
the Testator. this ~da~rY 2002.
~ 6' t) --..-
-
"d{ -
N HOLAS C. KIRITSIS
Sworn to
C. KIRITSIS,
~/71.P. ~/l! ~~
INotary Public
(
. Notarial Seal I"
Tina M. Rob~rtson, Nota;y Public
East PennS~Oi? l'~., Cumberland Count"
My Comr:usslon 'expires 1-10'''. 15, 2003'.
MemrJO;, Pennsv';'va ~;"::~':;:;;;j;';f or Notari,~s '
4
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
We, J 0 \t n \3 'be I:- kc n s ~~_/1nd c he... don; (VI We.. J <;; we tC. <fI....., the
witnesses whose names are signed to the attached instrument, being
duly qualified according to law, do depose and say that we were
present and saw the Testator, NICHOLAS C. KIRITSIS, sign and
execute the instrument of his Last Will and Testament; that he
signed it willingly and that he executed it as his free and
voluntary act for the purposes therein expressed; that each of us
in the hearing and sight of the Testator signed the Will as
witnesses; and that to the best of our knowledge the Testator was
at that time 18 or more years of age, of sound mind and under no
constraint and undue influence.
Sworn to and subscribed before me this
2002.
/ / 7ft day of February
~fhes~ ~~
,,~"~::;?' ,,""----.;::;? ~~'''?<:::'.
./ C7" ___.-=-~~'
(_~-,:::::::,"-.- . :--,:C==--- .7 t5Z.. (. --"
Witness
'"
J //Jt~'z:7)
/~7 e,/h./J> //?:L 'Lf_
)(otary Public .
(
T' ~ Notarial Seal !
,in3 M. :-;::>~F",,:>n, ;,IOIE'''\' PUblic I
East Pennst>()r~. "'"';')'Tlb(de,nd C "
M\! C-'m.r'.c...... '. Gun"J
J \,.. ,I ,,~:)"'~_.', "., '" 1-,1(11'" C. "'O!\";;t'"
~....,,_ ._~__, '. ,".-, .....', c.. i".I"",
r..~:?;:';~_,~_J~ {'\:/:;; .~,. ~ti "...~.~I~f\1;,JtC!~<~3
5
.
".).1.5. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
A... HUD-1 UNIFORM SETTLEMENT STATEMENT
B. T e of Loan
1.[] FHA 2.[] FmHA 3.[] Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number:
4.[] VA 5.[] Conv. Ins.
C. NOTE: This form furnishes a statement of settlement costs. Amounts paid to and by the settlement agent are shown. Items marked
"(p.o.c.)" were paid outside the closing; they are shown for informational purposes and are not included in the totals.
D: Name & Address of Borrower: E. Name, Address & TIN of Seller: F. Name & Address of Lender:
Konstantinos and Tina Giannaris William C. Kollas, Executor for the Estate
5 Spartan Circle of Nicholas C. Kiritsis
Camp Hill , PA 17011 , ,
G. Property Location: TIN of Seller: I H. Settlement Agent:
100 Howard Street Place of Settlement William C. Kollas
Enola, PA 17025 1104 Fernwood Avenue
Camp Hill, PA 17011 I. Settlement Date: Jan 31, 2007
J. Summary of Borrower's Transaction
100 Gross Amount Due from Borrower:
K. Summary of Seller's Transaction
400. Gross Amount Due to Seller:
101. Contract sales price 95,000.00 401. Contract sales price 95,000.00
102. Personal Property 402. Personal Property
103. Borrower's settlement charaes (line 140m 1,121.50 403.
104. 404.
105. 405.
Adjustments for items oaid by seller in advance Adiustments for items oaid by seller in advance
106. Citv/town taxes to 0.00 406.Ciwnowntaxes to 0.00
107. Countv taxes to 0.00 407. Counw taxes to 0.00
108. Assessments to 0.00 408. Assessments to 0.00
109. School 1/31/07 to 6/30/07 570.32 409. School 1/31/07 to 6/30/07 570.32
110. 410.
111. 411.
112. 412.
113. 413.
120. Gross Amount Due from Borrower 96,691.82 420. Gross Amount Due to Seller 95,570.32
200. Amounts Paid by or in Behalf of Borrower: 500. Reductions in Amount Due to Seller:
201. Deposits or earnest money 501. Excess deposit (see instructions)
202. Principal amount of new loan(s) 502. Settlement charaes to seller (line 140m 950.00
203. Existina loan(s) taken subiect to 503. Existina loan(s) taken subiect to
204. 504. Payoff of first mortaaae
205. 505. Pavoff of second mortaaae
206. 506.
207. 507.
208. 508.
209. 509.
Adiustments for items unoaid by seller Adiustments for items unoaid by seller
210.Ciwnowntaxes to 510. Ciwnown taxes to
211. Countv taxes 1/1/07 to 1/31/07 27.69 511. Counw taxes 1/1/07 to 1/31/07 27.69
212. Assessments to 512. Assessments to
213. to 513. to
214. 514.
215. 515.
216. 516.
217. 517.
-
218. 518.
219. 519.
220. Total Paid Bylfor Borrower 27.69 520. Total Reduction Amount Due Seller 977.69
300. Cash at Settlement From/to Borrower 600. Cash at Settlement To/from Seller
301. Gross amount due from borrower (line 120) 96,691.82 601. Gross amount due to seller (line 420) 95,570.32
302. Less amounts paid by/for borrower (line 22m 27.69 602. Less reductions in amount due seller (line 52m 977.69
303. Cash r~ from r[]\ to Borrower 96,664.13 603. Cash rDm to It11 from Seller 94,592.63
Substitute Form 1099 Seller Statement
The information in Blocks E, G, H, I & line 401 (or, if line 401 is asterisked, line 403 and 404) is important tax information and is being furnished
to the Internal Revenue Service. If you are required to file a return, a sanction will be imposed on you if this item is required to be reported and
the IRS determines that it has not been reported. If this real estate is your principal residence, file Form 2119, Sale or Exchange of Principal
Residence, for any gain, with your income tax return; for other transactions, complete the applicable parts of Form 4797, Form 6252 and/or
Schedule D (Form 1040). You are required to provide the Settlement Agent (named above) with your correct taxpayer identification number. If
you do not provide the Settlement Agent with your taxpayer identification number, you may be subject to civil or criminal penalties imposed by law.
Under penalties of perjury, I certify that the number shown on this statement is my correct taxpayer identification number.
It/l/' ffi4L
William C. Kollas, Executor for the Estate
(Seller)
aM/l/ddL
William C. Kollas, Executor for the Estate
(Seller)
C ThorpeFormscom
" -
700. Total Sales/Broker's Commission: (based on price\ 95 000.00 /6) % Paid from Paid From
Division of Commission -(line 70m as follows: Borrower's Seller's
701. Funds at Funds at
702. Settlement Settlement
703. Commission oaid at Settlement
704.
800. Items Pavable in Connection with Loan
801. Loan Oriaination Fee
802. Loan Discount
803. Aooraisal Fee
804. Credit Reoort
805. Lender's Insoection Fee
806. Mortaaae Insurance Annlication Fee
807.
808.
809.
810.
811.
812.
813.
814.
900. Items Reauired bv Lender to Be Paid in Advance
901. Interest from to {(j) oerdav
902. Mortaaae Insurance Premium for
903. Hazard Insurance Premium for
904.
905.
1000. Reserves Deoosited with Lender
1001. Hazard insurance months ~ ~ & Der month
1002. Mortaaae insurance months ( 1\ t oer month
1003.CiNorooertvtaxes months / oer month
1004. County orooertv taxes months I Der month
1005. Annual assessments months (, ;) oer month
1006. months ~'i) oer month
1007.
1008.
1009. Aaareaate Accountina Adiustment
1100. Title Charaes
1101. Settlementlclosina fee
1102. Abstract/title search to Abstract Settlement and Prooertv Services Inc. 130.00
1103. Title examination
1104. Title insurance binder
1105. Document oreoaration
1106. Notarv fees
1107. Attomev's fees
. (includes above item numbers
1108. Title insurance
(includes above item numbers
1109. Lender's coveraae
1110. Owner's coverage
1111.
1112.
1113.
1200. Government Recordina and Transfer Charaes
1201. Recordina fees: Deed 41.50 Mortaaae Release 41.50
1202. CiN/countv tax/stamns: Deed 1% Transfer Tax Mortaaae 950.00
1203. State tax/stamos: Deed 1% Transfer Tax Mortaaae 950.00
1204.
1205.
1206.
1300. Additional Settlement Charaes
1301. Survev
1302. Pest Insnection
1303.
1304.
1305.
1306.
1307.
1308.
1400. Total Settlement Charaes {This Number Transfers to Lines 103 & 502 Abov8\ 1 121.50 950.00
CERTIFICATION
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of
all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1
Settlement Staten;e~ / ,,/ /)
~t1/[-I?--fJ-- Seller \~'V, J A ~'-" '-- ,-. '\.... LBorrower
Wi 'am C. Kollas, x tor for the Estate Konstantinos a~ Tina Giannaris .......
Seller ~( I /f I :1 ......,//. .~v\.. '" oc.:>... LA Borrower
illiam C. Kollas, Executor for the Estate Konstantinos and Tina Giannaris
To the best of my knowledge the HUD-1 Settlement Statement which I have prepared is true and accurate account of the funds which were
received and ve bee or il e' rsed by the undersigned as part of the settlement of his tr saction.
~ Settlement Agent -z.. (;)1 0 Date
WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For
details see: Title 18 U.S. Code Section 1001 and Section 1010.
o ThorpeForms.com