HomeMy WebLinkAbout05-14-07 (3)
~o EX + (6-00)
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
Uzemack Patricia G.
DATE OF DEATH (MM-DD.Year)
DATE OF BIRTH (MM.oo.Year)
OFFICIAL USE ONLY
FILE NUMBER
21 -0 7 0 0 8 2
"COOiiTY"CciiE --vEAR- - - ~- -
SOCIAL SECURITY NUMBER
498-34-2803
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Retum (dale ofdealh prior 10 12.13-82)
D 5. Federal Estate Tax Retum Required
.Q... 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
Gerald J. Shekletski Es . 414 Bridge St.
FIRM NAME (If Applicable)
Stone LaFaver & Shekletski P.O. Box E
TELEPHONE NUMBER
717774-7435 New Cumberland PA 17070
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01/19/2007 11/29/1933
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[RI1. Original Retum
D 4. Limited Estate
[RI 6. Decedent Died Testate (AttachcopyofWlU)
D 9. Litigation Proceeds Received
D 2. Supplemental Retum
D 4a. Future Interest Compromise (dale of death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Attach copy ofTrus!)
D 10. Spousal Poverty Credit (dale of death between 12.31.91 and 1.1.95)
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closaly Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expensas & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Totsl Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental 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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under See. 9116 (a)(1.2)
0.00 X _ (15)
379.954.79 X .045 (16)
0.00 X .12. (17)
35.895.17 X .15 (18)
(19)
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
20. D
CHECK HEf<E IE yo~ ,~R: r~rOIJ[STIf\JG A RE-FUND OF AN OVERPtlYMENT
>>
'.MDRSCH CKMATH < <
238.000.00 I
24,494.15
,j
OFFICIAL USE ONLY
139.980.27
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106.57 .
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75.641.78-~:-~i
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en
478,222.77
(8)
62.372.81
(11)
(12)
(13)
62.372.81
415,849.96
(14)
415,849.96
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ece en s omple e ress:
STREET ADDRESS
928 Shiremant Dr.
~
CITY I STATE I ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
22,482.25
20.000.00
1.052.60
Total Credits (A + 8 + C)
(2)
21,052.60
3. InteresUPenalty if applicable
D. Interest
E. Penalty
0.00
TotallnteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
A. Enter the interest on the tax due. (5A)
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58)
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 IX!
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IX!
c. retain a reversionary interest; or ...................................................................................................... 0 IX!
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?....... ........ ................... ................ ....... .................. ............. ...... 0 IX!
3. Did decedent own an "in trust for" or payable upon death bank account or secur~y at his or her death? ................. 0 IX!
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... IX! 0
0.00
1,429.65
1,429.65
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penatties of perjury, I declare th
Declaration of preparer other than the
SIGNATURE OF PERSON
have examined this return, includi~ accompanying schedules and statements, and to the best of my knowledge and belief, n Is true, correct and complete.
al representative Is based on aU Information of which preparer has any knowledge.
NSIBLE FOR FILING RETURN DATE
NY
ADDRESS
ADDRE
PA 17070
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 3%
[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 0% [72 P .S. ~9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 0% [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%, 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 decedenfs siblings is 12% [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 + (6-98)
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SCHEDULE A
REAL ESTATE
, COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Uzemack. Patricia G. 21 07 0082
All real property owned lolely or II a tenant In common mUlt 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 DrODertv which II lolntlv-owned with rlaht of lurvlvorshlD mUlt be dllclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
ALL THAT CERTAIN piece or parcel of real estate with improvements thereon situate
Hampden Township, Cumberland County, Pennsylvania known as 928
Shiremont Drive, Mechanicsburg, Pennsylvania. Being the same premises conveyed to
Edward Uzemack and Patricia G. Uzemack, husband and wife, by deed dated August
14, 1976, and recorded August 18, 1976, in Cumberland County Record Book T,
Vol. 26, Page 221. Edward Uzemack died July 1, 2004, whereby the aforesaid
property passed to Patricia G. Uzemack, the decedent, by operation of law.
The property was sold April 25, 2007 to Shawn M. Caufield and Lara F. Beer.
Copies of the deed of conveyance and settlement sheetare attached hereto.
VALUE AT DATE
OF DEATH
238,000.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more spece is needed, insert additional sheets of the same size)
238000.00
. REV.150,.X . (tl-.
SCHEDULE B
STOCKS & BONDS
, COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Uzemack. Patricia G.
FILE NUMBER
21 07
All property jolntly-owned with right of survivorship must be disclosed on Schedule F.
0082
ITEM
NUMBER
1.
DESCRIPTION
184.980367shares General Motors Corporation (GM) common stock
Date of death value - $31.55 per share x 184.980367 shares = $ 5,836.13
VALUE AT DATE
OF DEATH
5,863.13
2.
554 shares Manulife Financial Corporation common stock.
Date of eath value - $33.63 per share x 554 = $ 18631.02
18,631.02
TOTAL (Also enter on line 2. Recapitulation) $
(If more space is needed. insert additional sheets of the same.size)
24.494.15
REV-1508 EX + (6-98)
.
Ii
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Uzemack. Patricia G.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 07
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntly-ownecl with right of survivorship must be disclosed on Schedule F.
0082
ITEM
NUMBER
1.
DESCRIPTION
Sovereign Bank Checking Account #2331049408
VALUE AT DATE
OF DEATH
114,186.55
2.
Sovereign Bank Checking Account #2561006867
8,511.81
3.
2005 Pontiac Montana Extended Minivan 40
PA Title Number 62008314501 UZ, VIN 1GMOV33E350147680
14,005.00
4.
Pastel Mink and Leather Stroller ($65.00), Muskrat Coat w/Raccoon Collar/Border and
Leather Trim ($45.00) and Sheared Beaver Paw Jacket ($85.00).
195.00
5.
Lady's 14K yellow gold wide band style ring ($159.00), Lady's 14K white gold diamond
cultured pearl pendant ($100.70), Lady's 14K yellow gold diamond and pearl ring
($132.50), Lady's 10K yellow gold opal ring ($100.70) and Lady's 14K yellow gold opal
pendant ($100.70).
593.60
6. Hartford - auto insurance refund check 512.00
7. Blue Cross refund check 268.25
8. Patriot-News refund check 229.90
9. Sevice Oil refund check 794.96
10. Auction sale proceeds - personal property 418.20
11. Hartford Insurance - homeowner's insurance refund 230.00
12. AAA membership refund check 35.00
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
139.980.27
REV-1509 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
,
ESTATE OF
Uzemack. Patricia G.
FILE NUMBER
21 07
If an asset was mad. Joint within one year of the deced.nr. date of d.ath, it must be reported on Schedule G.
0082
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Scot Christiansen
2070 Yellow Breeches Drive
New Cumberland, PA 17070
Grandson
B
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JOINTL Y.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 DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTL Y-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENrSINTEREST
1. A. 8-30-90 Sovereign Bank Account #0575170618 - Certificate of 213.13 50. 106.57
Deposit
TOTAL (Also enter on line 6. Recapitulation) $ 106.57
(If more space is needed. insert additional sheets of the same size)
REV-1510 EX + (6-98)
.
,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Uzemack Patricia G.
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBATE PROPERTY
FILE NUMBER
21 07
0082
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.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME ~ THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE ~ TRANSFER. ATTACH A COf1'( ~ THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICA8l.E) VALUE
1. Sovereign Bank Account #057816957 (IRA) Transferees - 75,641.78 100. 75,641.78
Noel E. Uzemack, Edward Uzumeckis alkJa Edward
M. Uzemack and Bonnie Uzemack Bakaric (Children)
TOTAL (Also enter on line 7 RecaDitulation) $ 75641.78
(If more space is needed, insert additional sheets of the seme size)
"REV-1511 EX + (12-99)
.
t
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF
Uzemack. Patricia G.
ITEM
NUMBER
A.
1.
2.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9
10.
11.
12.
13.
14.
15.
16.
17.
21
07
0082
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Myers-Harner Funeral Home, Inc., 1903 Market St., Camp Hill, PA 17011
Haben Funeral Home & Crematory, 8057 Niles Center Road, Skokie, Illinois 60077
7,266.88
6,070.73
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) Noel E. Uzemack
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 820 Soith Main St.
City Geneva
Year(s) Commission Paid: 2007
5,000.00
322-36-8087
State NY
Zip 14456
Attomey Fees Gerald J. Shekletski, Esq.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
21,500.00
Street Address
City
State
Zip
Relationship of Claimant to Decedent
Probate Fees Letters Testamentary
360.00
Accountant's Fees
Tax Return Prepare~s Fees
Legal Advertising - Cumberland Law Journal
Legal Advertising - Patriot- News
T -Mobile
Settlement Closing Costs of $ 19,430.54 less reimbursement for sewer/trash
of $ 21.13 = $19,409.41
Stephenson Florist
PPL - electric bill
Pennsylvania American Water Company
Hampden Township - Quarterly water/sewer bill (January, February, March 2007)
Pennsylvania American Water Company
Pennsylvania American Water Company
AT&T
75.00
134.46
110.49
19,409.41
88.60
532.09
22.23
141.30
43.58
1.51
67.42
TOTAL (Also enter on line 9, Recapitulation) $
62 372.81
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
.uzemack, Patricia G.
Decedent's Name
Page 1
21 07 0082
File Number
Schedule H - Funeral Expenses & Administrative Costs - 87.
ITEM
NUMBER
DESCRIPTION
AMOUNT
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
AT&T
Verizon
Verizon
T -Mobile
Com cast
UPS - cost to ship personal property
Executor travel expenses
Chern Clean - carpet cleaning
Additional Probate Fee
Filing Fees - PA Inheritance Tax Return ($15.00) and Inventory ($15.00)
Reserve for Closing Expenses
39.48
30.72
31.30
110.49
57.82
206.30
293.00
150.00
100.00
30.00
500.00
SUBTOTAL SCHEDULE H.B7
1,549.11
..""."""'.''*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
I - .. G ?1 07 OOR2
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 pnclude outright spousal distributions. and transfers under
Sec. 9116 (a) (1.2)]
1. Noel E. Uzemack Lineal 126,651.60
820 South Main St.
Geneva, NY 14456
2. Edward Uzumeckis alkJa Edward M. Uzemack Lineal 126,651.60
430 Saddle Circle
Sedona,AZ. 86336
3. Bonnie Uzemack Bakaric Lineal 126.651.59
214 Wyoming St.
Royalton, PA 17057
4. Larry O. Hughes Collateral 35,000.00
P.O. Box 293
Clarkton, MO 63837
5. Patricia Ann Hughes Allison Collateral 788.60
16851 North Crownview Drive
Centralia, MO 65240
6. Scot Christiansen Collateral 106.57
2070 Yellow Breaches Drive
New Cumberland, PA 17070
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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - 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)
ESTATE OF PATRICIA G. UZEMACK
NOEL E. UZEMACK EXEC.
OATE'tllo 10"1
~~~;~ ~~E ee11~r~It<,;;' u..)1l_1..::5 I A~i!^,r- . J $20 000 ~
~ ~ ~XQt) DOLL':' Gl
. I ' CHECKING
.,,~~~Z1~
-: 2 ~ ~ ~ ? 2 b q ~I:
60-7269/2313
233111 1499
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110 ~ 2 ~f.lot;l.- ~. tA.l:.eM4c..~
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LAST WILL AND TESTAMENT
OF
PATRICIA G. UZEMACK
I, PATRICIA G. UZEMACK, of Hampden Township, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will
previously made by me.
ITEM I: I bequeath $35,000.00 to my nephew, LARRY O. HUGHES, if
he survives me.
ITEM II: I bequeath my jewelry, armoire, and everything in it,
including jewelry, and my clothes, including furs, to my niece,
PATRICIA ANN HUGHES ALLISON, if she survives me.
ITEM III: Provided that I have been buried in the proper grave
with birth and death dates recorded on my tombstone, I devise and
bequeath all the rest, residue and remainder of my estate, of every
nature and wherever situate, in equal shares to such of my step-
children, NOEL E. UZEMACK, EDWARD M. UZEMACK, and BONNIE UZEMACK
BAKARIC, as survive me. Should any of my step-children predecease me,
I devise and bequeath the share of such step-child to his or her
issue, per stirpes; and should any such step-child of mine leave no
such issue living following my death, I devise and bequeath the share
Page 1 of 4
of such step-child in equal shares to those step-children mentioned
above'in this Item III who survive me.
ITEM IV: I appoint my step-son, NOEL E. UZEMACK, Executor of
this my last will. Should my step-son, NOEL E. UZEMACK, fail to
qualify or cease to act as Executor, I appoint my niece, PATRICIA ANN
HUGHES ALLISON, Executrix of this my last will.
ITEM V: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his/her duties
in any jurisdiction.
IN WITNESS WHEREOF, I, PATRICIA G. UZEMACK, have hereunto set my
,p
hand and seal this ~ day of
~
()~ )1 ~~~
PATRICIA G. UZEMACK
, 2005.
SIGNED, SEALED, PUBLISHED and DECLARED by PATRICIA G. UZEMACK,
the Testatrix above named, as and for her Last Will and Testament, and
in the presence of us, who at her request, in her presence and in the
~:~~SUbsc;~:~a;~e~/!I
Wi tne Address / . /2/70
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Witness Address
Page 2 of 4
COMMONWEALTH OF PENNSYLVANIA:
SS:
COUNTY OF CUMBERLAND
I, PATRICIA G. UZEMACK, the Testatrix 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 this instru-
ment as my last will; that I signed it willingly and that I signed it
as my free and voluntary act for the purposes therein contained.
<yJv~)J. +-~
PATRICIA G. UZEMACK
Sworn to or affirmed to and acknowledged before me by PATRICIA G.
~
UZEMACK, the Testatrix, this ~ day of , 2005.
Page 3 of 4
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
We,
, ~
~-k tV 7' ~/t:V~ and ~,,-,,- \.. ~~\\
1
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign and execute the instrument as
her last will; that Testatrix signed willingly and that she executed
it as her free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testatrix signed the
will as witnesses; that to the best of our knowledge, the Testatrix
was at that time eighteen or more years of age, of sound mind and
under no constraint or undue influence.
.~\
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Witness
Sworn to or affirmed to and
t4~td~ 6h~IL/f/k'
wi tnesses, this ~ day of
aCknO~ged before me by
and ~\...-L \..-;\~ ~"'-t ~
~ ,2'005.
(~
Notar b'c
,
Page 4 of 4
ESTATE OF PATRICIA G. UZEMACK
NOEL E. UZEMACK EXEC.
uu- , 4.VfW ... ....
23311114811
OATE!t/~-J~J_-
~~:~ ~~:--~t.7 '~TI.~_,~J!d/~_+-~~~f:!!_~__,____ $ ~,000 .0
1:r7~_~_~~~________ .... .DOLLARS ~,=-~::"
'~ ~
_16:~m1lf_ _
.: 2 ~ I. ;} ? 2 &. q 1.1: 2 3J :1 II II Ii II" q 0 I. 2 ;}llIoc./" ~. UU'M:~
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A. U.S. DEPA!molENTOF HOUSING AND URBAN DEVELOPMENT
SETTLEMENT STATEMENT
Express Financial Services, Inc.
275 Grandview Avenue
Suite 103
Camp Hill, PA 17011
(800) 422-4169
FINAL
Form An~ovedOMB No. 2502.Q265
B. TYPE OF LOAN
1. D FHA 2. D FMHA 3. 0 CONY. UNINS.
4. 0 VA 5. IX] CONY. INS.
6. ESCROW FILE NUMBER: 7. LOAN NUMBER:
01400680-003 AN 12153326
8. MORTGAGE INSURANCE CASE NUMBER:
C. NOTE: This fonn Is furnished to give you e stetement of actuel settlement costs. Amounts paid to end by the settlement agent are shown.
Items marked "(P. O. C.) " were paid outside the closing; they are shown here for infonnational purposes and a/& not included in the totals.
D. NAME OF BORROWER: Shawn M. Caulfield and Lara F. Beer
ADDRESS OF BORROWER:
928 Shiremont Drive
Mechanicsburg, PA 17050
Estate of Patricia G. Uzemack
E. NAME OF SELLER:
ADDRESS OF SELLER:
F. NAME OF LENDER:
ADDRESS OF LENDER:
M& T MortaQe Corporation
One Fountain Plaza, 6th FIr.
Buffalo, NY 14203
928 Shiremont Drive
Mechanicsburg, PA 17050
CUMBERLAND County
G. PROPERTY LOCATION:
H. SETTLEMENT AGENT:
PLACE OF SETTLEMENT:
I. SETTLEMENT DATE:
Express Financial Services, Inc.
WILLIAM R. LINDSLEY, 275 GRANDVIEW AVENUE, SUITE 103, CAMP HILL, PA 17011
4/2512007 PRORATION DATE: 4/25/2007 DISBURSEMENT DATE: 4/25/2007
J. SUMMARY OF BORROWER'S TRANSACTION IK SUMMARY OF SELLER'S TRANSACTION
f.."". : . --~ . '.400; . GROSS 'AMOUNt DUE1'OSELLER: , I
101. Contract Sales Price 238,000.00 401. Contract Sales Price 23B,OOO.00
102. Personal Property 402. Personal Property
103. Settlement charges to Borrower (line 1400) 6,956.95 403.
104. 404.
105. 405.
ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE'
ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE'
106. CltvlTown Taxes 406. CilvlTown Taxes
107. Caunlv Taxes 407. Counlv Taxes
108. Assessments 04/25/07 to 04130/07 21.13 408. Assessments 04/25/07 to 04/30107 21.13
109. 409.
110. 410.
111. 411.
112. 412.
113. 413.
114. 414.
115. 415.
120. GROSS AMOUNT DUE FROM BORROWER: 244,978.08 420. GROSS AMOUNT DUE TO SELLER: 238,021.13
I 2oooAMOUNTS,~AID'BVpR:IN8ew.I'OF'EiORROWER: ...... ',' ..... '" ...... . .:;~ &GOo.REDUct,ONS'IN AMOuNt:tiue'TO seLi:;ER: -C;-,., '<..' I
201. Deposit or eamest money 5,000.00 501. Excess deDostt (see instructions)
202. Principal amount of new Ioan(s) 190,400.00 502. Selllement charges to Seller (line 1400) 19,430.54
203. Existing loan(s) taken subject to 503. Existino loan(s) taken subject to
204. 504. Payoff of first mortgage loan
205. LENDER CREDIT/CCAL 156.13 505. Payoff of second mortgage loan
206. INTEREST CREDIT 78.25 506.
207. 507.
208. 508.
209. 509.
ADJUSTMENTS FOR ITEMS UNPAID BY SELLER'
ADJUSTMENTS FOR ITEMS UNPAID BY SELLER
210. CttylTown Taxes 510. CitvlTown Taxes
211. County Taxes 511. Countv Taxes
212 Assessments 512. Assessments
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518
219. 519.
220. TOTAL PAID BYIFOR BORROWER: 195,634.38 520. TOTAL REDUCTIONS IN AMOUNT DUE SELLER: 1 9,430.54
r 3000 . CASH AT SETtL.EMI;N:t;f'ROMITO'B()R~oweR: '. ..,:.:i:....' ." '. ." 600.'. CA$HATSETTLEMEN1'tO/FR()1III SEu.ER:: ". ,. ' I
301. Gross amount due from Borrower ( line 120) 244,978.08 601. Gross amount due to Seller (line 420) 238.021.13
302. Less amount paid bylfor Borrower ( line 220) 195,634.38 602. Less reduction in amount due Seller (line 520) 19,430.54
303. CASH ( lID FROM) ( 0 TO) BORROWER: 49,343.70 603. CASH (0 FROM) (Iii! TO) SELLER: 218,590.59
/'__ _c--
Lf/J
All.\.
I I NII"R~R: nunMAn.nn. ...
f, 700. TOTALSALESlBROKER'S COMMISSION: "". ., '., .' . .' :- ~.' .P.O.C.'.:':' "'':'''>';''.'' "".', I
BASED ON PRICES 238,000.00 @ 7.000%= $16,660.00 PAID FROM PAID FROM
DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: BORROWER'S FUNDS SELLER'S
AT SETTLEMENT FUNDS AT
701. S 9 545.01 to REIMAX REALTY ASSOCIATES INC. SETTLEMENT
702. S 7114.99 to CENTURY 21 PISCIONERI REALTY INC.
703. Commission paid at settlement 16,660,00
704. TRANSACTION & TAX CERT FEE to REIMAX REALTY ASSOCIATES I 257.00
I 800;, 'ITEMS PA YABLE1NCONNECTION'WITHI..OAN:" . . ,),'C' . '.. .. ,.... '<....... ":P.q.C;;'\, ....,.., ".,. ;.., ., '" I
801. Loan Oriaination Fee
802. Loan Discount Fee
803. Appraisal Fee to APPRAlSALCOM 370.00
804. Credn Report to CBC (POCL) (14.00)
805. Lenders Insoection Fee
806. Mortaaae Insurance Application Fee
807. Assumption Fee
808. PROCESSING FEE 195.00
809. TAX SERVICE FEE to FARETS 72.00
810. FLOOD CERT FEE to FAFDS 8.00
811. "See attached for breakdown 400.00
r 900. 'ITEMSREQUIRED:BY lENDER TO BE PAID,IN ADVANCE.: . 7 ". P.O.C. " , '. " I
901. Interest From 04/25/07 to 05/01/07 @ $33.2547/day % (6 days) 199.53
902 Mortgage Insurance Premium for Month(s) to
903. Hazard Insurance Premium for Years(s) to
904.
905.
I 1000. RESERVES DE~Ol'lITEDWlTHLENDER: ",' ,. , "., ,.',c ",~~ '.<.. " ",>,'. ,;,.i".\' , ,', I
1001. Hazard Insurance months @ S per month
1002 Mortgage Insurance months @ S per month
1003. City Property Taxes months @ $ per month
1004. County Property Taxes 3 months @ $ 71.13 permonth 213.39
1005. Annual Assessments months @ $ per month
1006. Aggregate Adjustment months @ $ per month -355.62
1007. School Taxes 10 months @ $ 106.69 per month 1,066.90
1008. Aggregate Adjustment 0.00
I 1100; TlTLECHARGESt ':.,. , '" """ "..'. c.. ',' '., 'P;O.C. .,' i.. , '.':. '" I
1101. Settlement or closing fee to Express Financial Services, Inc. 300.00
1102. Abstract or title search
1103. Title examination
1104. Title insurance binder
1105. Document preparation
1106, NotBrV fees
1107. Attarnev's Fees
(includes lbeve items numbelll: )
1108, Title Insurance to Express Financial Services, Inc. 1,733.75
(includes lbeve Itlms numbelll: Total Premium )
1109. Lenders coverage $ 190,400.00 LOIn Policy
1110. Owne(s coverage $ 238,000.00 Owne(s Policy
1111. Tax CertiflC8tion Fee to Express Financial Services, Inc. 5.00
1112. Patriot Search to Exoress Financial Services, Inc. 5.00
1113.
11200: GOVERNMENl'RECORDINGAND TRANSf'ER cHARGES: ,', 7 = P.O.C. '.., . '." ,.', I
1201. Recordina Fees: Deed $ 38.50 Mortgage $ 90.50 Release $ 129.00
1202. City/County tax/stamos Deed $ 2,360.00 Mortgage $ 2,380.00
1203. State tax/stamos Deed $ 2,360.00 Mortaaae $ 2,380.00
1204.
1205.
I 1300; ADDITIONAL-SETTLEMENT CHARGES:' .' .'.: ",. J.....-.;' ,,<,,"7 ~y .....,'. ,...::.'i..:, ')"" I
1301. Survey
1302. Pest Inspection CNB PROPERTY EVALUATION
1303. Courier Fee to Express Financial Services, Inc. 20.00
1304. TRANSACTION FEE to CENTURY 21 PISCIONERI REALTY INC. 195.00
1305. E-Mail Docs to Express Financial Services, Inc. 25.00
1306. FINAL SEWERlTRASH TO 04 to HAMPDEN TWP 128.54
1307.
1400. TOTAL SETTLEMENT CHARGES (Entlron line 103,SectlonJ - and -line 502, Section K) 6,956.95 19.430.54
Ind Iccuretl stl18mant of III racelpts Ind disbulllements made
tatlmlnt.
Borrowelll Slllers
pored is I trul Ind Iccurete lCCOunt of this lIlInsection. I have ceuse<f or will ceuse thl funds to be disbullle<f in Iccordance
Settlement Agent
t-f-.J5-o7
Oltl
WARNING: It is I crimI to knowingly mIke felse stetlments to thl United StetlS on this or Iny simillr form. Plnlnies upon conviction cen Include I fine Irn imprisonment. For
deteila see: Trtll 18 U.S. Code Section 1001 Ind Section 1010.
Escrow Number: 01400680-003 AN
HUD 811 DETAILED BREAKDOWN OF ITEMS PAYABLE IN CONNECTION WITH LOAN
Description
812. DOC/PREP FEE to M&T Mortage Corporation
Total as shown on HUe page 2 LIne #811
Buyer
Amount
400.00
400.00
HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSFER FEES
Buyer Seller
Amount Amount
1202. City & County Tax/Stamps
City Tax/Stamps: Deed $2,380.00
Total as shown on HUe page 2 LIne #1202
1203. State Tax/Stamps
State Tax/Stamps: Deed $2,380.00
Total as shown on HUD page 2 LIne #1203
2,380.00
Buyer
Amount
'--"
/-;-
.F/!J
L..-
Seller
Amount
2,380.00
IV"'.
...eldedIUZEMACKEST A TEcaultield&beer
PARCEL # 1 0-17 -1 035-061.-EX
DEED
/
THIS INDENTURE made the .J.~ A day of ~
, in the year 2007, between
NOEL E. UZEMACK, Executor of the Last Will and Testament of Patricia G. Uzemack, late of
Hampden Township, County of Cumberland, and Commonwealth of Pennsylvania, of the first part,
hereinafter called the Grantor,
-AND-
SHAWN M. CAULFIELD, a single man, an undivided 60% ownership interest, and LARA F.
BEER, a single woman, an undivided 40% ownership interest, as joint tenants with the right of
survivorship, of the second part, hereinafter called the Grantees;
WHEREAS, the said Patricia G. Uzemack became in her lifetime seised, as of fee, of and in to a
certain tract of land, together with the improvements thereon erected, situate in the Township of
Hampden, County of Cumberland, and Commonwealth of Pennsylvania, and more particularly
described hereinafter; and being so thereof seised, died on January 19, 2007, having first made her Last
Will and Testament in writing dated May 17,2005, duly probated and registered in the Office of the
Register of Wills of Cumberland County on January 24, 2007, wherein and whereby she appointed as
Executor, the said Noel E. Uzemack, to whom Letters Testamentary were duly issued by said Register
of Wills on January 24, 2007, wherein and whereby said premises hereinafter described were not
specifically devised, all as in and by said Will and the records of said Register of Wills more fully
appears;
-1-
NOW THIS INDENTURE WITNESSETH, that the said Grantor, for and in consideration of
the sum of Two Hundred Thirty-Eight Thousand and NO/100 ($238,000.00) Dollars, which has been
paid to him by the said Grantees at or before the sealing and delivery hereof, receipt whereof is hereby
acknowledged, has granted, bargained, sold, aliened, released and confirmed, and by these presents does
grant, bargain, sell, alien, release and confirm unto the said Grantees,
ALL THAT CERTAIN tract or parcel of land situate to Hampden Township, Cumberland County,
Pennsylvania, more particularly bounded and described as follows to wit:
BEGINNING at a point on the easterly line ofShiremont Drive, (50 feet wide) which point is located
458.24 feet measured southwardly along said line ofShiremont Drive from the southern line of Will cliff
Drive, and which point is on the line dividing Lots Nos. 46 and 63 on the hereinafter mentioned Plan of
Lots; thence North 07 degrees 00 West 105 feet to a point in the line dividing Lots Nos. 62 and 63 on
said Plan; thence North 83 degrees 00 minutes East along the last said dividing line 140 feet to a point in
the line dividing Lots Nos. 37 and 63 on said Plan; thence South 07 degrees 00 minutes East along the
last said dividing line and beyond 105 feet to a point in the line dividing Lots 46 and 63 aforesaid;
thence South 83 degrees 00 minutes West along said dividing line 140 feet to a point in the easterly line
ofShiremont Drive, the Place of BEGINNING.
BEING Lot No. 63 on Plan No.5 of Ridgeland which plan is recorded in the Office for the Recording
of Deeds in and for Cumberland County, Pennsylvania in Plan Book 20, Page 5.
BEING THE SAME PREMISES WHICH Allen G. Zanetti and Janet J. Zanetti, his wife, by their
deed dated August 14, 1976, and recorded August 18, 1976, in the Office of the Recorder of Deeds in
and for Cumberland County, Pennsylvania, in Record Book T, Volume 26, Page 221, granted and
conveyed unto Edward A. Uzemack and Patricia G. Uzemack, his wife. Edward A. Uzemack died July
1,2004, thus by operation oflaw vesting title in Patricia G. Uzemack, an unremarried widow, deceased.
UNDER AND SUBJECT to restrictions and rights of way of record.
HAVING thereon erected a dwelling known as 928 Shiremont Drive.
TOGETHER with all and singular the buildings, improvements, ways, streets, alleys, passages,
waters, water-courses, rights, liberties, privileges, hereditaments and appurtenances whatsoever,
-2-
thereunto belonging or in any wise appertaining and the reversions and remainders, rents, issues and
profits thereof, and all the estate, right, title, interest, property, claim and demand whatsoever of her, the
said Patricia G. Uzemack, at and immediately before the time of her decease, in law, equity, or
otherwise howsoever, of, in, to or out of the same.
TO HAVE AND TO HOLD the said lot or piece of ground above described, with the buildings
and improvements thereon erected, hereditaments and premises hereby granted or mentioned, and
intended so to be, with the appurtenances unto the said Grantees, to and for the only proper use and
behoof of the said Grantees, forever.
And the said Grantor, for himself and his respective heirs, executors and administrators, does
covenant, promise and agree to and with the said Grantees, their heirs and assigns, that he, the said
Grantor, has not heretofore done or committed any act, matter or thing whatsoever whereby the premises
hereby granted, or any part thereof, is, are, shall or may be impeached, charged, or encumbered in title,
charge, estate or otherwise howsoever.
IN WITNESS WHEREOF, the said Grantor has hereunto s his hand and seal the day and year
first above written.
~...
"""Witness
/ (SEAL)
NOEL E. \ ZEMACK" Executor of the Last Will
and Testament of Patricia G. Uzemack
-3-
COMMON~ TH OF, PENNSYL VANIA :
COUNTY OF ~\:..\...-~\., ~ SS:
~ '\'
On this, the ,>> day of ~~
, 2007, before me a Notary Public, the
undersigned officer, personally appeared NOEL E. UZEMACK, Executor of the Last Will and
Testament of Patricia G. Uzemack, known to me or satisfactorily proven to be the person whose name is
subscribed to the within instrument, and acknowledged that he executed the same for the purposes
therein contained.
IN WITNESS WHEREOF, I have hereto set my hand and notarial seal.
-.... ,
COMMONWEAlTH OF PENNSYlVANIA
NOTARIAL SEAL
CAROL L. TROXELL, Notaty_PuIa ~I~o
New Cumberland Boro. CumUVI n .
My Commission expires Dec. 27,2009
.J:J-~~\
Notary Public \
I hereby certify that the precise address of the Grantee is:
Attorney for
I
I
I
II
II
-4-
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MAl MB3 02-10 Court OrdC:red Processing
P.O. Box 841oQ5
Boston, MA 02Z84
lanuary 29, 2007
Stone LaFaver & Shekletski
Attn: Gerald 1. Shekletski
414 Bridge Street
P.o. Box E
New Cumberland, PA 17070
RE: Estate of Patricia G. Uzemack
Date of Death: 01/19/07
Dear Mr. Shekletski:
Per your request, enclosed please find the account information as of the date of death for
the above-named decedent. For your information, accrued interest is not included in the
date of death balance.
Please feel free to contact me if I can be of any further assistance.
Very,truly yours,
M,Ot ~
Nicole lob
cOP Specialist ITI
Decedent Department
(617) 533-1364
.: Sovereign Ba~k
:Patricia G. uzemack~1
. 498-34-2803 _.
January 19,200
,
Account #: 2331049408 Type: Ch~king
In the name of: Patricia G Uzemack oel E Uzemack POA
Date of Death Balance: $114,0 6.62
Int.(YTD) from 1/1/2007 . . to 1/!9/2oo7
Aeerued Interest to date of death: $ll9.93
~herlnfo: i
I
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Open date: 11/22/2002
$0.00
,
Account #: 2561006867 Type: Ch~king
In the name of: Patricia G Uzemack oel E Uzemack,POA
Date of Death Balance: $8,5 .69
Int.(YTD) from 1/1/2007 to 1/~9/2oo7
Accrued interest to date of death: $111.12
~her Info:
Open date: 8/9/2004
$0.00
I
Account #: 0575170618 Type: go
In the name of: Scot Christiansen or Patricia G Uzema4k
Date of Death Balance: $212.79
Int.(YTD) from 1/1/2007 to 1/19/2007
Accrued interest to date of death: $~.34
~her Info:
Open date: 8/30/1990
$0.00
Account #: 0578168957 Type:
In the name of: Patricia G Uzemack
Date of Death Balance:
Int.(YTD) from 1/1/2007 to
Accrued interest to date of death:
~her Info:
utA
Open date: 10/13/2000
I
$76,465.26
I
1/119/2007
$176.52
:
$0.00
Page 1 of 1
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2005 Pontiac Montana Extended Minivan 40
BLUE BOOK PRIVATE PARTY VALUE
Condition
Value
$14,920
Excellent
..t Good
$14,005
(Selected)
Fair
$12,805
Vehicle Details
Mileage: 26,073
Engine: V6 3.4 Liter
Transmission: Automatic
Drivetrain: FWD
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Blue Book Private Party Value
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Vehicle Condition Ratings
Excellent
$14,920
"Lx((:IIf'llI" ('"lclilicl!" means that the vehicle looks new, IS in excellent
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1,.;!u,V c!l',C w!ll p,1So. a smog and safety inspection. Thl: en.Jine compartment
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. ~IV t\IQw ..J
../ Good (Selected)
$14,005
"Good" condition means that the vehicle is free of any major defects. This
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should be little or no rust on this vehicle. The tires match and hav~
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be sold at retail. Most consumer owned vehicles fall into this category.
Fair
$12,805
'i""-:dil '(Hi ITei_iil:'; th,:1t U'IC vehicle hdS son1f.' rlll:(~hdn!(dl 01 cosmetic
':,\I.".ilclnl) !)l1t is stili in rCdS;jna!Jit.' r (llnditjOll, Ttiic,
t ,l_it_~' hi'stc~y, the paint., bodY' l..1ncl/u: \(Vi.~;r;or \")Qe.c1 wor~
r.d(:,ssif.lna! 1'hf: tires rnaY' l"ieecJ to bi,: if~plll(ecJ There rl'dY
r u~.,I- ;j~H)iage,
Poor
NjA
i(\i)d~.ti'"):l \n~~dn<.:, thdt the vehiclf' has St:~vere lTH:~chdnlca\ anO/Ot
Iii..' d('(c ts ClncJ is Iii POOl I unning condltlo'l. TI"I(' vehicle may have
pi oi)lenlS tJ;zit ('(jr':f",ot be readily fixed such (1~-~ (Janlc}~!ed fr aine or: a r-usted-
IlIruul," Unci i i\it'hicle with a b, arlded (,tie (sai'vc1(jc, !Io"ci, etC) tiJr
\11 ".uI)stanti,i1ec1 rnilt'dqe is considered "poo:." ^ vehicle in poo" condition
Illd)! ,,'qUilt' dfi indep(:lldent appraisal to det"imine its vaiue. Kelley Blur,
r30Clk docs net ;:;~tten\pt to report a value \)11 a "pool'" v(.:h:(je bi;:c2u5e the
\falue of Cdr ,. tI,is ccltegory var ie'S grea; II'.
* Pennsylvania 2/28/2007
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