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Home My WebLink About06-29-07 (3) ---I 15056041125 REV -1500 EX (06-05) PA Department of Revenue. ~~~~:~~g:o~uaITaxes INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 7 File Number o 3 1 4 Date of Birth 184050269 o 3 042 007 01291915 Decedent's Last Name Suffix Decedent's First Name B ALL KATHRYN MI E (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 [2g 1. Original Return o 4. Limited Estate [2g o 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 0 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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o o o o 8. Total Number of Safe Deposit Boxes 2. Supplemental Return o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required JAN L BROWN 71754 1 555 0 Firm Name (If Applicable) 845 SIR THOMAS C T S T E 1 2 REGISTER OF WILLS USE ONLY ~ :t: ~ ~~I~'~ .j r') 0 ( -) "~~ ~~@laD ~__J! ,~:.~ N-fT'1 n c;O , ~~. ;~~ -T'-c") '-;:r- ,.c_ r'l ~~~Lt3~ JAN L BROWN & ASS 0 C First line of address Second line of address City or Post Office State ZIP Code H A R R I S BUR G PA 17109 :'0::"" .P w CD , \..../-:) 1:-) ""::;:"t Correspondent's e-mail address:brendailb@verizon.net Under penalties of pe~ury, 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. NAT E P RE PONSIBLE FOR FILING RETURN DA PA 17055 DATE MECHANICSBURG THOMAS CT STE 12 HARRISBURG PLEASE USE ORIGINAL FORM ONLY PA 17109 Side 1 L 15056041125 15056041125 ...J~ 15056042126 REV-1500 EX Decedent's Social Security Number decedent's Name: KATHRYN E. BALL 1 8 4 0 5 0 2 6 9 RECAPITULATION 1. Real estate (Schedule A) ........................................ 1. 6 2 5 0 0. 0 0 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. 3 9 9 3 • 2 2 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 6 3 5 • 2 9 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 1 6 5 2 8 0 0 (Schedule G) ~ Separate Billing Requested ....... 7. • 8. Total Gross Assets (total Lines 1-7) ........................... 8. 8 3 6 5 6• 5 1 9. Funeral Ex enses & Administrative Costs Schedule H p ( ) ................ 9. 6 2 1 5 • 5 4 10. Debts of Decedent, Mort age Liabilities, & Liens (Schedule I) g ............ 10. 1 0 5 9 5 • 6 2 11. Total Deductions (total Lines 9 & 10) ........................... 11. 1 6 8 1 1 • 1 6 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12. 6 6 8 4 5 • 3 5 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. 6 6 8 4 5 • 3 5 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 0 0 0 15. 16. Amount of Line 14 taxable 0 0 0 at lineal rate X .0 _ . 16 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 . 17. 18. Amount of Line 14 taxable 6 6 8 4 5 3 5 at collateral rate X .15 . 18 19. Tax Due ................................................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0. 0 0 0. 0 0 0. 0 0 1 0 0 2 6. 8 0 1 0 0 2 6. 8 0 Side 2 15056042126 15056042126 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 07 0314 DECEDENTS NAME KATHRYN E. BALL STREET ADDRESS -- 1700 Market St ManorCare Health Services CITY Camp Hill, PA 17011 STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 10, 026.80 Total Credits (A + g + C) (2) 0.00 Total Interest/Penalty (D +E ) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (3) 0.00 (4) 0.00 (5) 10,026.80 (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 10, 026.80 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 : ...................................................................... ^ X^ b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ 0 d. receive the promise for life of either payments, benefits or care? ....................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ~ ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ^ 0 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 p2 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 childtwenty-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 of transfers to or for the use of the decedent's siblings is twelve (12) percent (72 P.S. §9116(a)(1.3)]. Asibling 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) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER KATHRYN E. BALL 21 07 0314 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, neither being compelk~d to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is ~inW-owned wkh ri~tht of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1/2 interest in 518 Eutaw Avenue, New Cumberland Borough, Cumberland County 62,500.00 See HUD Settlement Statement dated 6/22/2006 TOTAL (Also enter on line 1 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN R S DENT DECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER KATHRYN E. BALL 21 07 0314 Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly jointy-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sovereign Bank; Account 771101376 170.99 2 Social Security; February 2007 benefit 866.00 3 PSERS; prorated pension 131.69 4 Conseco; long-term care final reimbursement 240.00 5 HCR Manor Care; patient refund 1,834.54 6 United States Treasury; 2006 1040 refund 750.00 TOTAL (Also enter on line 5, Recapitulation) ~ S 3, 993.22 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (8-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN FILE KATHRYN E. BALL 21 07 0314 Han asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. ADDRESS SURVIVING JOINT TENANT(S) NAME A. John R Ward1457 Main Street Mechanicsburg PA 17055 C JOINTLY•OWNED PROPERTY: JIONSHIP TO DECEDENT nephew ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 1995 Sovereign Bank 138.20 50. 69.10 Account 771036175 2 A 1995 Sovereign Bank 1,132.38 50. 566.19 Account 774038871 TOTAL (Also enter on line 6, Recapitulation) I E 635.29 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS 8r, MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER KATHRYN E. BALL 21 07 0314 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 NUMBER DESCRIPTION OF PROPERTY INCLUDE 711ENANEOFTHETRANSFEREE,THEIRRELA710NSHIPTODECEDENTAND THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET °k OFDECD'S INTEREST EXCLUSION QF APPLICABLE) TAXABLE VALUE 1. Gift on 6/26/06 to John R Ward (nephew) and 22,528.00 100. 6,000.00 16,528.00 Karyn S. Ward (nephew's spouse) TOTAL (Also enter on line 7 Recapitulation) ~ S 16,528.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER KATHRYN E. BALL 21 07 0314 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: 1. Gingrich Memorials 120.00 B. ADMINISTRATIVE COSTS: ~, Personal Representative's Commissions Name of Personal Representative (s) Sodal Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees Jan L Brown & Associates 4,183.00 3, Family Exemption: (If decedents address is not the same as daimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills, Cumberland County 235.00 5 Accountant's Fees Parks & Company; 2007 1040 and 1041 tax preparation 450.00 6. Tax Return Preparer's Fees Richard S Simpson I I CPA; 2006 1040 preparation 95.00 7. Cumberland Law Journal; legal advertising 75.00 8 The Patriot-News; legal advertising 302.54 9 Real estate settlement charges (Estate's share) 755.00 TOTAL (Also enter on line 9, Recapitulation) 13 15.54 (If more space is needed, insert additional sheets of the same size) REV-1512 EX; (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER itATHRYN E. BALL 21 07 0314 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. Department of Public Welfare, Commonwealth of Pennsylvania 10,418.62 Estate recovery claim; see DPW's letter dated 4/4/07 and HUD Settlement Sheet 2 ~ Heartland Pharmacy Of Pennsylvania LLC 3 ~ Pulmonary And Critical Care Medicine Associates PC; date of service 2/5/07 4 Robin Gasperetti Tax Collector; 2007 personal tax 5 Sovereign Bank; service fee TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) S 10 39.65 102.35 10.00 25.00 REV-1513 EX + (9-0O) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE SCHEDULE J BENEFICIARIES FILE KATHRY N E. BALL 21 07 0314 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. John R Ward & Karen S Ward, nephew and spouse Collateral 1457 Main St, Mechanicsburg, PA 17055 Real estate proceeds 2 John R Ward, nephew Collateral 1457 Main St, Mechanicsburg, PA 17055 1/3 residue 3 Patricia J Dayton, niece Collateral 1128 Highland Dr, Mechanicsburg, PA 17055 1/3 residue 4 Irene E Simpson, niece Collateral 2118 Princeton Ave, Camp Hill, PA 17011 1/3 residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET E (If more space is needed, insert additional sheets of the same size) Jf~7~,1~,-; ., T r ~y `i r,ffi t~ 57 CF~,~~..~:. HATHRYN ELIZABBTH BALL BE IT IIaiOWN HEREBY, That I, Kathryn E. Ball, of the Borough of New Cumberland, County of Cumberland, and Commonwealth of Pennsylvania; being a widow, my husband, George E. Ball having died on December 19, 1994; being of eighteen (18) years of age or older; and being of sound and disposing mind, memory and understanding and not acting under duress, menace, fraud, restraint or undue influence of any person whomsoever; do hereby make, publish and declare this instrument to be my Last Will And Testament, hereby revoking and making null and void any and all other last wills and testaments and codicils thereto by me at any time heretofore made. ITEM I: This Last Will And Testament is not made as a result of any contract or agreement, either expressed or implied, which would in any way restrict my right and power to revoke any or all of the provisions of this, my Last Will And Testament. If any provision of this Last Will And Testament shall be declared inoperative or in violation of any rule of law, such invalidity shall not affect the remaining provisions of this, my Last Will And Testament and they shall remain in full force and effect. ITEM II: I hereby order and direct that, following a private memorial and/or funeral service in the presence of my family and friends, my Executor, named hereinafter, shall cause my remains to be interred in my cemetery lot in the Mechanicsburg Cemetery, situated at 13? West Marble Street, Mechanicsburg, Pennsylvania. I hereby authorize and direct my aforesaid Executor to enter into such agreements and. contracts as may be necessary for the interment of my remains, such agreements and contracts to be in accordance with such provisions, terms and conditions as he may deem to be appropriate within the provisions of this, my Last Will And Testament. ITEM III (A): I hereby order and direct that my Executor, named hereinafter, shall pay out of the residue of my estate the costs of the administration thereof, my funeral expenses, any expenses which may have resulted from my last illness, and those of my other just debts which are legally collectable on the date of my death, as soon after my death as it is practicable to do so; excepting therefrom only encumbrances on real or personal property, it being my intention that such encumbered property which passes under the terms and conditions of this Last Will And Testament or otherwise shall pass subject to such encumbrances, provided, however, that any arrearage or past due installments on account of principal or interest with respect to such encumbrances may be paid by my Executor in his discretion. ITEM III(B): I hereby order and direct that my Executor shall pay out of the ~~ ; ~ ~ `~ KATHRYN E. BAL (b) Patricia Jean Dayton, my niece, of 1128 Highland Drive, Mechanicsburg, Pennsylvania 17055; and (c) Irene Elizabeth Simpson, my niece, of 2118 Princeton Avenue, Camp Hill, Pennsylvania 17011. ITEM V (B): In the event that either of the legatees named in Item IV (B) (b) or (c) or any of the residuary legatees named in Item V (A) predeceases me, dies simultaneouly with me, or dies under circumstances which render it impossible to determine such survival, then I hereby give, devise and bequeath the distributfve share of my estate which would have been received by such deceased legatee or by such deceased residuary legatee unto the Shepherdstown United Methodist Church of 1934 South York Street, Mechanicsburg, Pennsylvania 17055, its successors and assigns. ITEM VI(A): I hereby nominate, constitute and appoint the aforesaid John R. Ward, my nephew, to be the executor of this, my Last Will And Testament. 'In the event that the said John R. Ward, my nephew, predeceases me or otherwise is unable or unwilling to serve in this capacity or, once qualified, is unable or unwilling to continue to serve in this capacity, then I hereby nominate, constitute and appoint the aforesaid Patricia Jean Dayton, my niece, and the aforesaid Irene Elizabeth Simpson, my niece, to be the co-executrices of this, my Last Will And Testament. ITEM VI (B): I hereby order and direct that any executor or executrix appointed under this, my Last Will And Testament, in extension of the powers and responsibilities conferred by law and not in limitation thereof, shall have the fullest discretionary power and authority necessary for the complete administration of my estate in all matters and questions and to do all acts which I might or could do, if living, limited only by such specific provisions set forth herein as may be contrary to such complete discretionary power and authority, including but not limited to, complete power and authority to accept and retain in specie, to invest and reinvest in any form of property without restriction to investments permitted. by law, to sell at public or private sale for cash or credit with or without security and without order of court, to mortgage, to lease, to exchange, to alienate, to dispose of, or to distribute in cash or in specie all or any part of such property, whether real, personal or mixed, which I may own or in which I may have an interest at my death as aforesaid at such times and upon such terms and conditions as he or she may deem to be advisable, to postpone distribution by agreement with any beneficiary, to make distribution directly to a minor child or to any person or trustee fora minor child and to settle or adjust any and all claims or debts against or in favor of my estate. ITEM VI (C)d Any and all executors and executrices appointed under this, my Last Will And Testament, shall be and hereby are released from any and all requirements, whether of the law or otherwise, to enter security in any jurisdiction in which he or she may act and if, nevertheless, security is required, then it shall be without corporate or other surety. IN WITNESS WHEREOF, I, the undersigned Kathryn E. Ball, have hereunto set my -~ KATHRYN E. BALL . -[3]- COMMONWEALTI3 OF PBNNSYLVANIAs COUNTY OF DAIIPffiN I, Kathryn E. Ball, 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 .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. SWORN TO OR AFFIRM. and acknowledged before me by Kathryn E. Ball, the Testarix, this ,~t?~+'`~'~ day of ~ -•,,.. -', , A.D. 1997. y ~ ~~i~~r.~-P wc~~ ~ ~ KATHRYN E. ALL NOTARY PUBLIC (`,/ My Commission Expires: ~` ~ •=="~'' COMMONWEALTH OF PENNSYLVANIA: Notarial Seal I Debra A. Evanggelista, Notary Public 1 Sus:~uehanna T . Dauphin t;ounty :33: Commission Expires May 7, 2000 COUNTY OF DAUPffiN BEFORE ME, a Notary Public in and for the aforesaid Commonwealth and County, the undersigned officer, personally appeared Clarence B. Turns, Jr., Esquire, known to me or satisfactorily proven to be a member of the bar of the highest court of this Commonwealth and a subscribing witness to the within instrument, and certified that he was personally present when Kathryn E. Ball, whose name is subscribed to the within instrument, executed the same and that said person acknowledged that she executed the same for the purposes therein contained to the end that the same might be recorded as such. IN yVITNES3 W~H7EBEOF, I have hereunto set my hand and official eal thls i~~t ~""/ day Of i rC r . ~~ , A.D. 1997. ~.~ ~,,...~. ~ I .hn~n f~ CLARENCE B. TURNS, JR. i r t /~ F ~ ~ l ~n~~r% ~ ~ ~ ~~ ~.' / NOTARY PUBLIC My Commission Expires: - 7 -„> ~:. ~:~ Notarial Seal Debra A. Evangelista, Notary VubBc Susquehanna Twp Dauphin county My Commission Expires May 7, 2000 HUD - 1 UNIFORM SETTLEMENT STATEMENT OMB Approval No. 2502-0265 A. U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SETTLEMENT STATEMENT B. TYPE OF LOAN 6. File Number: 7. Loan Number. 1. FHA 2. FmHA 07-25 0096200846 3. Conv. Unins. 4. VA 5. X Conv. Ins. 8. Mortgage Insurance Case Number N/A C. NOTE: This form is famished to give you a statement of actual 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 here for informational purposes and are not included in the totals. NOTE: TIN = Tax a er's Identification Number D. NAME AND ADDRESS OF BORROWER: E. NAME, ADDRESS AND TIN OF SELLER: F. NAME AND ADDRESS OF LENDER: Lisa Nicole Simpson John R.Ward, Karyn S. Ward Sovereign Bank Estate of Kathryn E. Ball 101 South George Streeet 409 West Main Street, Apt 2 York, PA 17401 Mechanicsburg, PA 17055 G. PROPERTY LOCATION: H. SETTLEMENT AGENT NAME, ADDRESS AND TIN 518 Eutaw Avenue Karl M. Ledebohm, Esq. New Cumberland, PA 17070 P.O. Box 173 New Cumberland PA 17070-0173 PLACE OF SETTLEMENT I. SETTLEMENT DATE 845 Sir Thomas Court, Suite 12 06/22/2006 Harrisbur PA 17109 J. StTMMARY OF BORROWER'S TRANSACTION li;. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DLIE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract sales rice 12 5 0 0 0. 0 0 401. Contract sates rice 12 5 0 0 0. 0 0 102. Personal ro 402. Personal ro 103. Settlement char es to borrower Line 1400 4 4 6 3 . 5 9 403. 104. 404. 105. 405. Ad'ustmenU for items aid b • seller in advance Ad"ustments for items aid trv seller in advance 106. Ci /town taxes 406. Ci /town taxes 107. Coun taxes 06/22/2007-12 31/2007 306.58 407. Coun taxes 06/22/2007-12/31/2007 306.58 108. Assessments 408. Assessments 109. School Tax 6/22 -6/30/2007 25.73 409. School Tax 6/22 -6/30/2007 25.73 IlO.Sewer 6/22 - 6/30/2007 2.28 410. Sewer 6/22 - 6/30/2007 2.28 111. 411. 112. 412. 120: GROSS AMOUNT DUE FROM BORROWER 12 9 7 98.18 420. GROSS AMOUNT DUE TO SELLER 125 334 .59 200. AMOLINTS PAID BY OR IN BEHALF OF BORROW ER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De sit or earnest mon 2 5 0. 0 0 501. Excess de sit 2 50.00 202. Princi al amount of new loans 110 6 0 0 . 0 0 502. Settlement char es to seller Line 1400 11 92 B . 62 203. Existin loans taken subject to 503. Existin loans taken subject to 204. FHLB Grant 5 000.00 504. Pa off of firstmort a eloan 205. 505. Pa off of second mort a e loan 206. 506. 207. 507. 208. 508. 209. 509. Ad~ustments for items un id seller Ad'ustments for items un id b seller 210. Ci /town taxes 510. Ci hown taxes 211. Coun taxes 511. Coun taxes 212. Assessments 512. Assessments 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 115 8 5 0. 0 0 520. TOTAL REDUCTION AMOUNT DUE SELLER 12 17 8.62 300. CASH AT SETTLEMENT FROM/TO BORROWER 600. CASH AT SETTLEMENT FROM/TO SELLER 301. Gross amount due from borrower Line 120 12 9 7 9 8.18 601. Gross amount due to seller Line 420 12 5 3 3 4 . 5 9 302. Less amount aid b /for borrower Line 220 115 8 5 0 . 0 0 602. Less reduction in amount due seller Line 520 12 17 8.62 303. CASH FROM BORROWER 13 948.18 603. CASH TO SELLER 113 155.97 SELLER'S STATEMENT The information contained in Blocks E, G, H, and I and on line 401 (or, if line 401 is asterisked, line 403 and 404) is important tax information and is being famished to the Internal Revenue Service (see Seller Certification). If you are required to file a return, a negligence penalty or other sanction will be imposed on you if this item is inquired to be reported and the IRS determines that it has not been reported. You are required to provide the Settlement Agent with your correct taxpayer identification number. If you do not provide the Settlement Agent with your cotrect 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. (Sell s ignature) John R. Ward, Karyn S. Ward (Sell s ignature) Estate of Kathryn E. Ball ®EASY SOFT, Inc. 2001 Previous editions are obsolete Page 1 form HUD-1 (3/86) ref Handbook 4305.2 Summary of Sellers' Net Proceeds Estate John R 8 Karyn S Ward Contract Sales Price (Line 401) $62,500.00 $62,500.00 Adjustments (Lines 407, 409, 410) $334.59 Buyer's deposit (Line 501) ($250.00) Attorney's fees (Line 1107) ($130.00) ($130.00) Realty transfer tax (Line 1203} ($625.00) ($625.00) DPW estate recovery claim (Line 1306) ($10,418.62) Cash to Sellers $51,076.38 $62,079.59 Decedent, Kathryn E. Ball, was a resident of Manor Care in Camp Hill, Pennsylvania since 2005. Since that time, John R. Ward and Karyn S. Ward have paid all bills in connection with the maintenance and upkeep of the real property at 518 Eutaw Avenue, New Cumberland. Therefore, they are entitled to 100% of the adjustment shown on Lines 407, 409 and 410 of the HUD Settlement Statement dated 6/22/2006. 6!22/2006 R COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 ' _ HARRISBURG, PA 17105-8488 f~ 3~ ~p~ ~ ~ ~ April 4, 2007 ~ e ~ U JAN L BROWN & ASSOCIATES JAN L BROWN ESQUIRE STE 12 OLDE ENGLISH GAP 845 SIR THOMAS CT HARRISBURG PA 17109 Re: KATHRYN BALL CIS #: 340184907 SSN: 184-05-0269 Date of Death: 3/4/2007 Dear Attorney Brown: Please be advised that the Department of Public Welfare maintains a claim in the amount of $10,418.62 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $10,418.62, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, .a ,. Barbara I. Aschenbrenner TPL Program Investigator 717-772-6617 717-772-6553 FAX Enclosure JAN L. BROWN 8z ASSOCIATES ATTORNEYS AND COUNSELORS AT LAW OLDE ENGLISH GAP 845 SIR THOMAS CQURT SUITE 12 HARRISBURG, PA 17109 EMAIL: jlbassoc@verizon.net www.janbrownlaw.com JAN L. BROWN, ESQUIRE' JACQUELINE A. KELLY, ESQUIRE 'ADMITTED IN PA AND DISTRICT OF COLUMBIA TELEPHONE (717) 541-5550 FACSIMILE (717) 541-9223 BRENDA F KEPHART, LEGAL ASSISTANT PAULA K. WHITE, LEGAL ASSISTANT .JUDITH A. EBERSOLE, ADMINISTRATIVE ASSISTANT June 27, 2007 Register of Wills „.., Cumberland County Courthouse ~? ;- One Courthouse Square = ~ , _ ~ Carlisle PA 17013 , ~; ~ °°= , --,.rn tv ~ ~_ f w ..=~ Re: Estate of Kathryn E. Ball -~ ~ ~--~ File No. 2007-00314 5 ~ " ~ t T Gentlemen or Ladies: j' -`'.,i Enclosed please find the following items for filing with the Register of Wills: 1. Inventory. 2. An original and one copy of the Inheritance Tax Return. 3. Estate Check 998 payable to the Register of Wills in the amount of $30 to cover the filing fee for the Inventory and Inheritance Tax Return. 4. Estate Check 999 payable to the Register of Wills Agent in the amount of $10,026.80 to cover the tax shown to be due. Please time stamp and return our file copies of the Inventory and Inheritance Tax Return. If you have any questions, feel free to contact this office. Sincerely, ~~j~ ,,/ GZ~ Brenda F. Kephart Legal Assistant bfk Enclosure /p~1~ n o~ I W /~ O m Wt..Na I O V • N en- 1~6~Zo .o~~ ~ N ~~ ~~~ ~i a c~i "` • °- ``~ w 'h- ~ J ~~so3~-+~ a a ~ '~ i' SRS T. GVP s ^~ ®^ ^~ ~^ ,1r., p,, ~~~.~-~ ~~.~; ~. q ~ J ~u~ 29 ~; ~_ ~s CLERK C= ~Ff-i.tiN'S L W ~ U CV O ~ C ~ a O J Q A ; ~ W C7 f. ~ o`~ o ~ Ua U Z W ~ ~ ~ Z o ~ = ~ O N ~ ~ ~ p~ W cn = 1~ a h N O U A ~ ~ ti ~ O ~ U ~ ~ '" C .-~ o ~~a ~~ a ~ o a; v ~ U N •~ ~ ~ ~U~U