HomeMy WebLinkAbout09-12-07 (2)
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue '*
Bureau of Individual Taxes. INHERITANCE TAX RETURN
PO BOX 280601
Harrisbur , PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
~
Suffix
11m]
OFFICIAL USE ONLY
County Code Year
File Number
Decedent's Last Name
~
Decedent's First Name
MI
IZ1
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
o
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return
C)
2. Supplemental Return
C)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
C)
C) 4a. Future Interest Compromise (date of
death after 12-12-82)
C) 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
C) 10. Spousal Poverty Credit (date of death C) 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:
Na e Da ime Tele hone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
L2
8. Total Number of Safe Deposit Boxes
4. Limited Estate
C)
C)
C)
I"
gi? rv
C) :'""'"
.Tl
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Correspondent's e-mail address:
Under penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief,
i . t e, correct and co let eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
7
Side 1
L
15056051047
15056051047
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--.J
REV-1500 EX
Decedent's Name:
RECAPITULATION
15056052048
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) c::) Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c::) 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 LiRe 14 taxable
at lineal rate X.O_
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15.
16.
17.
18.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
c::J
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15056052048
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Side 2
15056052048
....J
REV-HiDO EX Pat/a 3
Decedent's Complete Address:
DECE~~ NAME -r1_
~ ~~ &'_1 r/tJ/fla5 of--
STREE DDRESS ~ ~ ~
30 C/lta-?laL I/L___~_____~_
File Number
CITY
S E
~
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + 8 + C ) (2)
3.
Interest/Penalty if applicable
D. Interest
E. Penalty
4.
------------~-- ------- TotallnteresUPenalty ( D + E )
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.
(3)
(4)
(5)
(5A)
(58)
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.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
z~~/~
(1 )
/70,oL/
o
o
D
/10.0c{
()
/10.ocf
.. ,-.-.....~_f.1J_..:'11
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did ~ent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... D D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D D
c. retain a reversionary interest; or...........................................~:............................................................................. D D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D D
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 be~eficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed onthe 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 PS. ~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 deceqent'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.
~EV-1502 ~X+ (6-9.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
etJrl6F G7h~5' JfZ-
FILE NUMBER
All real property owned solely or as a tenant in common must be reported at fair market vaiue. 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 property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
3~ {3wj({i j)C- 0 Itii/-c.-
&()/~ /4- l?tJZS-
(Plll///J-M/ ,g?,#
j#l77c/; C'LJ ')
! I J;Plc1, cO
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-l!503 Ex + (1-97)
ESTATE OF
'.
SCHEDULE B
STOCKS & BONDS
~
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
NM-Jv
VALUE AT DATE
OF DEATH
o
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
o
REV-1504 EX+ (1-97)
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF 6~e r; ~5 ,~p
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ITEM NUMBER
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
I\lDNL-
o
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
o
REV-1501EX+(6-98. .
COMMONlM:Al.1'M OF P9lNSVl...VANlA
~ TAX RETtJRfIl
DEC8)ENT
'~T~TE OF
SGIEDULE D
MORTGAGES & NOTES
RECEIVABlE
FILE NUMBER
ITEM
NUMBER
e
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
DESCRiPTION
VALUE AT DATE
OF DEATH
N60L
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
r.-
6)
~
0.00
REV-1508 EX+ (6-98) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSlfS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
-s- Dod#-:fOrn /S-a::> -/ iUGfi ItJf:J.Jtul.7 / 7~1
~C loIv ChflrY6)~L- l/tJlt.lt1l-t;o/ (l~fJO~t'5)(?N
(lhuN lUo uJe.rL-
/lnI '!.cUt:- f!Jef/2rJ!CA,
tftl/t ?
CP517 il-(c~, v~d
.5Oi))
15() ,dJ
021 Sf LJ()
5101. ?B
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
c25~5g ,rfI~
-'~..,,'" '.
COMMONWEALTH OF PENNS' LVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
CO~ C 7lvJJl4- S 171 _
FILE NUMBER
If an asset was made joint within one year of the decedenfs date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
8.
v
No0
c.
JOINTLY-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 identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for joinUy-held real estate. V AWE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 0
TOTAL (Also enteron line 6, Recapitulation) $ n
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX. (1-97)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
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 %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACH A COPY OF THE DEED FOR REAL ESTATE , VALUE OF ASSET INTEREST IF APPLICABLEl
NUMBER
1.
;J{JIJ-&-
" "
TOTAL (Also enter on line 7, Recapitulation) $ 0
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
--'/ Thmac;; ~ ~
FILE NUMBER
Debts of decedent must be reported on Schedule L
ITEM
NUMBER
A.
1.
DESCRIPTION
FUNi77~~1;2ZZ- ;::;~&.f) ;4 In -C
Ptl~IZ.-.Cr~/na/;oN 6er't/IL~3
AMOUNT
e'~c9:f~O
o1~dJ
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Whvd
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
. Stale
Zip
Year(s) Commission Paid:
2. Attomey Fees
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
ProbateFees /J-eg/Sk/Z--O-t WI//S
5. Accountant's Fees
d S-e?/- Q?
4.
6.
Tax Retum Preparer's Fees
/flfJ-ef/AJ I MI7'?!'1!A: /h51J~
'/30/Jwo1a !)fZ. &rifld jJ/l-/70 d)
1.5(J 'C:V
7.
Pule'O-/- A!tuJS 1~6,l)d
TOTAL (Also enter on line 9, Recapitulation) $ ,q~
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-o3) .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF C:;1I7 /' ~::-: ,. -I1/J ~ FILE NUMBER
~ ~ / r /O/1D-S ?If....
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. IItlZtJIlpL- j)1C;tff)~;K.-' C~f}HIL IS-,/}~-
M/~u)5 tf Pik / /l-?50L dIJ~
~~jct~~~e~(~:;%;:~~ I;~~
(412/7~I!:--;Zch /h~()C- 35a"Qrj
'(alZfG;:~/tf7 1m 7f? fj~:if
~;;-ft~mfy~~t~ t1~ Jil;~,u 7
PilI L d?,qtj
f)fc L 3/).'/3
pp rL ~u,~3
11I5f- hfJn5PoW. IPtd/J5/l)7 lIs: tJo
W ;2ttJ/J~etJhtv/lJ5h~jJ dA,OO
VtR-r20AJ t/-7,u .9
L/{),qcf
5/# q)
cJ&-~1
. ~/1(7k!Z C/JI2Y5kiL~f)C,il.x'/ 1~.7~"b3
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
RELATIONSHIP TO DECEDENT
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under
/ktfdtJc r;;;;;'W -~MlnutL-StcJitL--
tnangf." D" l~bu~Jf' A.-/70/1
jJd~t---I-I;~/J /~~~"(/~ /5U
Ju//~/Jtl11 flJ-- / JO/?
sMnoof) llwfTViS (Q.f.t fJflmllltoJ rl-J)~W!-.t;iArlli-(;fl.ak/L
Inl.chtinIt4U fJJ {J1I-17()c;5" .,l!f'
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)
..
LAST WILL AND TESTAMENT
OF
GEORGE E. THOMAS.. JR.
"".
I, George E. Thomas, Jr. of 30 Creekside Drive, Enola, Cumberland County,
Permsylvania 17025, being of sound mind and body declare this to be my Last Will
and Testament, and revoke any and all Wills and Codicils previously made by me.
ITEM I: I hereby direct that all of my just debts, funeral expenses,
aU administration expenses, including inheritance tax shall be paid from the assets
of my estate as soon as practicable after my decease.
ITEM II: I hereby give, devise and bequeath my Dodge pick-up
truck to my father, George E. Thomas, Sr.
ITEM Ill:
I hereby give, devise and bequeath my antique Victrola to
my sister, Angela L. Thomas.
ITEM IV:
K.eltie A. Hoffman.
I hereby give, devise and bequeath my guns to my sister,
-.
ITEM V: I hereby give, devise and bequeath all the rest, residue
and remainder of my estate, wheresoever situate and of whatsoever nature, to my
dau~,8Jt.aQnon Rae Thomas, IN TRUST; however, naming my sisters, Angela
L. Thomas and Kellie A. Hoffinan, as Trustees under the following terms and
conditions:
(a.) To pay the income and so much of the principal and
accumulated interest in such equal or unequal amounts as
may, in the sole discretion of my Trustee, be necessary
for the post high school educational expenses only of my
daughter, Shannon Rae Thomas;
{b.)Payments may be made only directly to any institution
entitled to such payments by reason of services renderede
or to be rendered;
2
(c.) Any and all payment of any sum or sums whether in cash
or in kind and whether for principal or income payment
to such PerSOn shall be made free from anticipation,
alienation, attachment and pledge or control by any
creditor of any of them and shall not be subject to
execution or attachment;
..
(d.) I hereby direct my Trustees above named to disburse all of
the assets of the trust, both principal and interest to my
daughter, Shannon Rae Thomas, upon my daughter
attaining the age of twenty-one (21) years.
ITEM VI:
I hereby nominate, constitute and appoint my sisters,
Angela L. Thomas and KeUie A. Hoffman, as Co-executrixes of my estate.
ITEM VI: I hereby direct that my Executrixes shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
3
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
5!J, day of September, 2006.
A2 { f~tJ
Geor~ E. Tho~r.
.
4
(SEAL)
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
Before me, the undersigned authority, this day personally appeared before
me, George E. Thomas, Jr. Testator, L P1da A '#tPnt~.5 and
l'M!l;Iti.. I Jtf)f/'j , known to me to be the Testator and Witnesses respectively,
whose names are signed to the foregoing instrument and all of these persons being
by me first duly sworn, George E. Thomas, Jr., the Testator, declared to me and to
the Witnesses in my presence that the instrument is his Last Will And Testament
and that he willingly signed the same and executed it in the presence of the
Witnesses as his free and voluntary act for the purposes therein expressed; that the
Witoesses stated before me that the foregoing Will was executed and
acknowledged. by the Testator as his Last Will And Testament in the presence of
said Witnesses who, in his presence and at his request, and in the presence of each
· otber,did subscribe their names, thereto as attesting Witnesses on the day of the
date of the Will, and that the Testator was over the age of eighteen (18) years, of
sound mind and under no constraint or undue influence.
-4?~ (SEAL)
, rge E. ' , Jr., Testator
# !l~
I Witness
~:J~@
Witness
Subscribed, sworn and acknowledged before me by George E. Thomas, Jrw'
the Testator, and Linda A 'fh1mll5 and Ktl'ldflc1 r JtIifIS "--'1 ",_
Witnesses, on the 6Lh day of 5~j)ffl?1bt,r , 2006. ~ ,-~.\- -. :"
-' ~ ' .
~ . .
- .
. -
;- -.. '":.. - ~-
Notary Public \..' ~,:"':: " '- '" :
cOMllOHWEAlJ:H OF PENNSYlw.HlA '-' \. "-
NOTARIAL SEAl "--
KAREN L. HOWARD. Notary Public
Hampden Twp.. Cumberland County
My Comnission EJplm AprI 22. 2010
6
,.
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: Tide 18 U.S. Code Section 1001 & 1010.
SETTLEMENT STATEMENT
PAGE 2
L. SETILEMENT CHARGES ..........:: .... PAID FROM PAID PROM
700. TOTAL SALES/BROKER'S COMMISSION based on price S 118.000.00 @ % = $ BORROWER'S SELLER'S
Division of commission (line 700) as follows: FUNDS AT FUNDS AT
701. S 2.925.00 to Straub & Associates SETILEMENT SETILEMENT
702. S to Remax A-I ($3004.56)
703. Commission paid at Settlement 2.925.00
704. Transaction Fee - Remax A1 195.00
800. ITEMS PAYABLE IN CONNECTION WITH LOAN .. ... .... ... ... . :... e. ....c-.../H .. .: .e .. ...:....
801. Loan Origination Fee %
802. Loan Discount st
803. Appraisal Fee 10 ($300 POC) Fairway
804. Credit Report to
805. Lender's Inspection Fee Yield Sprd Prem to APC - $944
806. Mortgage Insurance Application Fee to broker fee to: American Property Capital 2.300.00
807. Assumption Fee processing to: American Property Capital 1.000.00
808. flood cert fee to Nationwide to Novastar Mortgage Inc 7.00
809. MERS fee payable to MERS to : Novastar Mortgage Inc 4.95
810. tax service payable to First American to: Novastar Mortgage Inc 60.00
811. underwriting to: Novastar Mortgage Inc 995.00
900. ITEMS REQUIRED BY LENDER TO BE PAID IN AnV ANCE ...... ....: ...:...:..:i...: ::::.... ........ >< :......... ..... ...:..:::
901. Interest from 01/31/2007to 02/01/2007 @S 20.300000 /day 20.30
902. Mortgage Insurance Premium for months to
903. Hazard Insurance Premium for 1 years to ERIE (POC $337)
904.
905.
1000. RESERVES DEPOSITED WITH LENDER ::... ...:. ....: .: .......... ...........: <<H ........: :...:.><.
1001. Hazard insurance months @ S 16.92 per month
1002. Mortgage insurance months @ S per month
1003. City property taxes months @ S . .. per month
1004. County property taxes months @ S 21.31 per month
1005. Annual assessments months @ S 79.24 per month
1006. months @ S per month
1007. months @ S per month
1008. aggregate adjustment
1100. TITLE CHARGES ......... ...:: .....::. . ......:.:...)..:.:......::.. .::.........:
1101. Settlement or closing fee to Great Road Settlement Services. LLC
1102. Abstract or title search to ACE Abstracting POC $150.00
1103. Title examination to Great Road Settlement Services. LLC
1104. Title insurance binder to
1105. Document preparation to MLLLC - deed 125.00
1106. Notary fees to cash v 25.00
1107. Attorney's fees to Great Road Settlement Services. LLC
(includes above items Numbers: )
1108. Title insurance to GRSS (Stewart Title Guaranty) 745.88
(includes above items Numbers: )
1109. Lender's coverage S 94.400.00 Novastar
1110. Owner's coverage S 94.400.00 Wi 11 i ams
1111. endorsements 100. 300. 900. ARM 200.00
1112. closing service letter. Stewart Title Guaranty 35.00
1113. Debbie Lupold . tax cert (adv by GRSS) 10.00
1200. . GOVERNMENT RECORDING AND TRANSFER CHARGES .. .. .. :.:..:....... ...:.........<-c-- ..-c--T....:..........:... ..:..:..
1201. Recording fees: Deed S 38.50 ;Mortgage S 80.50 ;Releases $ 119.00
1202. City/county tax/stamps: Deed S 1.180.00 ;Mortgage S 1.180.00
1203. State tax/stamps: Deed S 1.180.00 ;Mortgage S 1.180 . 00
1204. assignment of rents 17.00
1205.
1300. ADDITIONAL SETTLEMENT CHARGES ....... .. ... i::: .:i.> ~ .. . ....
,.,:,/,.....:,
1301. Survey to
1302. Pest inspection to
1303. East Pennsboro Twp - final sewer 22.00
1304.
1305. Deborah Lupold treasurer (POC $255.61 07 county tax)
1400. TOTAL SETILEMENT CHARGES (enter on line 103, Section J and line 502, SectionK) . :,.:.:.. :.:: ...:...:.:.. 6.709.13 4.457.00
CERTIPICA TION
! have carefully review~d the-!:IUD.l Set~em:m:s'tatement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and
dlsbursc;~n,.made 0 /m~~unt or b~ this transaction. I further certify th I have received a copy of the HUD-I Settlement Statement.
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Borrowers - Mia Wi 11 iams
The HUD-I Settlement Statement which I have prep
in accordance with this statement. _
January 31, 2007
Date
A. Settlement Statement
U.S. Department of Housing
and Urban Development
OMB No. 2502-0265
B. Type of Loan
1. 0 FHA 2.DFmHA 3.0Conv. Unins.
4. OVA 5.0Conv. Ins.
6. File Number
7. Loan Number
8. Mortgage Ins. Case Number
GR07-1106REP
06-U9070
C. This form is furnished as 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 for informational purposes and are not included in totals.
D. Name and Address of Borrower E. Name and Address of Seller F. Name and Address of Lender
Alfred L. Williams The Estate of George E. Thomas. Jr. Novastar Mortgage. Inc.
Hia Williams 6200 Oak Tree Boulevard
811 S Front St Third Floor
Harrisburg, PA 17104 Independence Ohio 44131
G. Property Locatlon H. Settlement Agent Great Road
Sett 1 ernent Services, LLC
30 Creekside Drive Place of Settlement I. Settlement Date
Enola, Pennsylvania 17025
East Pennsboro Township, Cumberland County 2157 Market Street 01/31/2007
Camp Hi 11 PA 17011
J.SUMMARY OF BORROWER'S TRANSACTION: K.SUMMARYOFSELLER'S TRANSACTION: ., , . "
100, GROSS AMOUNT DUE FROM BORROWER .. .400. GROSS AMOUNT DUE TO SELLER ..< .i"
101. Contract sales price 118.000.00 401. Contract sales price 118.000.00
102. Personal property 402. Personal property
103. Settlement charges to borrower(line 1400) 6,709.13 403.
104. overnight 25.00 404.
105. wire 25.00 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. City/town taxes to 406. City/town taxes to
107. County taxes to 407. County taxes to
108. Assessments 01/31/200R> 06/30/2007 389.67 408. Assessments 01/31/200R> 06/30/2007 389.67
109. 409.
110. 410.
111. 411. .
112 412
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.120. GROSS AMOUNT DUE FROM BORROWER 125.148.80 420. GROSS AMOUNT DUE TO SELLER . 118.389.67
100... AMOUNTS PAID BY OR IN BEHALF OF BORROWER ..500. REDUCTIONS IN AMOUNJ' DUB 'r-PSELLER ,..,..... .'. .........'..
201. Deposit or earnest money 300.00 501. Excess deposit(see Instructions)
202. Principal amount of new loan(s) 94.4..:J.00 502. Settlement charges to seller(line 1400) 4,457.00
203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
204. 504. Payoff of first mortgage loan 65.022.84
205. 505. Payoff of second mortgage loan 38.749.32
206. 506. ire out payoff to Countrywide 30.00
207. seller assist 7,080.00 507. overnight payoff to PNC 25.00
208. 508. ESCROW REMAX FUNDS PENDING REPAIR & INTRST 3.004.56
209. 2nd mortgage proceeds 22.497.13 509. seller assist 7,080.00
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. City/town taxes to 510. City/town taxes to
211. County taxes 01/01/20Oib 01/31/2007 20.95 511. County taxes 01/01/20000 01/31/2007 20.95
212. Assessments to 512. Assessments to
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
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'- ...-.....'.',..-......,.' .-- .".... ..",.. .-."......-.-. ...-- ",..... ....
220. TOTAL PArD BY/FOR BORROWER 124.298.08 .520. TOTAL.REDUCTION..AMOlJN'I'I)UESEli,ER 118.389.67
300. CASH AT SETTLEMENT FROM/TO BORROWER 600. CASH AT SETTLEMENT TO/FROM SELLER . ......... ,.,
301. Gross amount due from borrower(line 120) 125.148.80 601. Gross amount due to seller(line 420) 118.389.67
302. Less amount paid by/for borrower(line 220) 124,298.08) 602. Less reduction amount due seller(line 520) ( 118.389.67 )
... ..< ... ..
303. · CASH([!}FROM)(O TO) BORROWER 850.72 603. .CASH(DTO)( [1]FROM)SELLER 0.00
SUBSTITUTE FORM 1099 SELLER STATEMENT: The information contained in Blocks E, G, H and I and on line 401 or, ifline 401 is asterisked,
lines 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 negligence
penalty or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported.
You are required by law to provide [see box II] with your correct taxpayer identification number. If you do not provide [see box II] with your correct taxpayer
identification number. you may be subject to civil or criminal penalties imposed by law, and under penalties of perjury, I certify that the number shown on
this statement is my correct taxpayer identification number. Seller's Signature
HUD-l SETTLEMENT STATEMENT
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