HomeMy WebLinkAbout09-13-07
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15056051058
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
21 07
0236
Date of Birth
167-14-1176
12/14/2006
09/15/1920
Decedent's Last Name
Suffix
Decedent's First Name
MI
Dunwoody
Betty
H
(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
. 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4. Limited Estate
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
between 12-31-91 and 1-1-95)
8. Total Number of Safe Deposit Boxes
. 6. Decedent Died Testate .
(Attach Copy of Will)
9. Litigation Proceeds Received
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Tricia D. Naylor
Firm Name (If Applicable)
(717) 243-7437 .-
Law Office of John C. 0
REGISTER OF Wlll$ USE ON[Y~
First line of address
104 S. Hanover Street
Second line of address
\_,:~1
( "
-I
City or Post Office
State
ZIP Code
DATE FILED
Carlisle
PA
17013
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,
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.
013
PLEASE USE ORIGINAL FORM ONLY
91101
1tn (b1
L
15056051058
Side 1
15056051058
--.J
--I
15056052059
REV-1500 EX
Decedent's Name:
RECAPITULATION
1. Real estate (Schedule A).
. . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . .
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . 3.
4. Mortgages & Notes Receivable (Schedule D) . . .
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . .
6. Jointly Owned Property (Schedule F) Separate Billing Requested. . . 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). .
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . .
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . .
13. Charitable and Governmental Bequests/Sec 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)
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
16. Amount of Line 14 taxable
at lineal rate X.O 45 187,681.48
17. Amount of Line 14 taxable
at sibling rate X. 12
18. Amount of Line 14 taxable
at collateral rate X. 15
19. TAX DUE.
................................................ 19.
11.
12.
. . 13.
.. 14.
15.
16.
17.
18.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
167-14-1176
Decedent's Social Security Number
2.
4.
5.
8.
9.
15056052059
31,751.19
1,200.00
176,406.50
209,357.69
14,771.20
6,905.01
21,676.21
187,681.48
187,681.48
8,445.67
8,445.67
.
--I
REV-1500 EX Page 3
File Nljmber
Decedent's Complete Address: 0236
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
Betty H Du nwoody 167 -14-1176
- -------- -- .- -~-.,--~------- -_._._---'----_.__._-_.~_._--_..
STREET ADDRESS
16 Green Spring Drive
--- -- ------.----.-----....---,-,.----- --~---~'--_._--_._---_._-
CITY
Mechanicsburg
STATE
PA
ZIP
17050
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
8,445.67
8,600.00
422.28
3. InteresUPenalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C ) (2)
9,02228
TotallnteresUPenalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
576.61
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5B)
A. Enter the interest on the tax due.
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 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 00
c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ
d. receive the promise for life of either payments, benefits or care? ..................................................................... 0 [iJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................................................. ~ 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 0 ~
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 [72 P.S. 99116 (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 PS. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. 99116(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. 99116(1.2) [72 P.S. 99116(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 PS. 99116(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-1503 EX+ (6098*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Betty H. Dunwoody
FILE NUMBER
21-07-0236
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
1137.68 sh Templeton Foreign A - Mutual Fund
('J I<::/P' Ill101 QI':?OQ
443.62 sh Franklin Rising Dividends Fund Class A - Mutual Fund
(,II<::IP. ~qll,)"1()?
VALUE AT DATE
OF DEATH
2.
D
15,745.42
D
16,005.77
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
31,751.19
REV-1'So6 EX+ (6-96) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Betty H. Dunwoody
FILE NUMBER
21-07 -0236
ITEM
t.mMocR
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property iolntly-owned with right of survivorship must be disclosed on Schedule F.
DESCRIPTION
VAlUE AT DATE
OF DEATH
1. 1989 Toyota Corolla
1,200.00
TOTAL (Nso enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,200.00
.<
REV-1510 EX+ (6-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Betty H. Dunwoody
FILE NUMBER
21-07-0236
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 DATE OF DEATH % OF DECD'S EXCLUSION TAMBLE
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND
NUMBE THE DATE OF TRANSFER. ATTACH A copy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. Betty H. Dunwoody Trust dated September 5, 1996
Comprised of the following: C
58.83 sh AIM Basic Value Fund - Class B 2,12064 100 2,12064
CUSIP: 00141M739 0
534.79 sh AIM Basic Value Fund - Class B 20,70715 100 20,70715
CUSIP: 00141M747
16 Greenspring Drive, Silver Spring Twp, Cumberland County, PA 150,000.00 100 150,000.00
#38-23-0571-140 (see attached IElgaldElscdption)
Sovereign Bank Checking Account #1681729288 1,992.25 100 1,99225
Sovereign Bank Checking Account #1681723624 13666 100 136.66
Penn State Prescription Plan reimbursement 38.39 100 38.39
General Board of Pension & Health Benefits of the United Methodist 173.46 100 173.46
Church Pension
State Employees Retirement System Pension #061229 286.15 100 28615
AAA refund 19.98 100 1998
Refuse refund 24.00 100 2400
Homeowners insurance refund 173.00 100 17300
Car insurance refund 57.42 100 57.42
2006-07 School (Real Estate) Tax refund 562.04 100 56204
Refund of Escrow on HUD-1 Settlement Sheet 115.36 100 11536
2. Monthly gift to Compassion International 64.00 100 6400 0.00
3. Christmas gift to Pastor Terry and Ruth Smith 50.00 100 50.00 0.00
4. Birthday gift to Scott Dunwoody 35.00 100 35.00 0.00
5. Christmas gift to Scott and Rachel Dunwoody 50.00 100 50.00 000
TOTAL (Also enter on line 7 Recapitulation) $ 176,406.50
(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
Betty H. Dunwoody
FILE NUMBER
21-07 -0236
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
AMOUNT
DESCRIPTION
1.
FUNERAL EXPENSES:
Neill Funeral Home Inc. - funeral
Brachendorf Memorials Inc. - gravemarker
Immanuel Church - funeral
567.00
395.00
50.00
2.
3.
B. ADMINISTRATIVE COSTS:
4.
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Represenlative(s)
Street Address
City
. State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
3,350.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
Probate Fees
129.00
5. Accountant's Fees
7.
6. Tax Return Preparer's Fees
8.
9.
10.
11.
12.
Legal Advertising - Cumberland Law Journal
Dan White - plumbing repair to house
H.A. Bixler & Son - repair to house
United Water - water bill
PPL Electric Utilities - electric bill
HUD-1 Settlement Expenses - see attached continuation schedule and HUD-1
75.00
82.00
315.00
28.16
151.87
9,628.17
14,771.20
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1612 EX' (12-03)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOEIHOECEOENT
SCHEDULE I
DEBTS' OF DECEDENT,
MORTGAGE UABIUTIES, & UENS
ESTATE OF
Betty H, Dunwoody
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 DArE
NUMBER DESCRIPTION OF DEATH!
1.
FILE NUMBER
21-07-0236
2.
3,
4.
5.
6.
7.
8.
i
I
\. .
TOTAL (Also enter on line to, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
6,905.01
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Betty H. Dunwoody
SCHEDULE J
BENEFICIARIES
FILE NUMBER
21-07 -0236
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)]
A. Donald R. Dunwoody 7314 S. 174th St., Omaha, NE 68136 son 62560.50
B. Dwight L. Dunwoody 915 Siddonsburg Rd., Lewisberry, PA 17339 son 6256049
C. Scott T. Dunwoody 2500 Glime Dr., Mechanicsburg, PA 17055 son 6256049
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)
01/11/2007 13:16
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THE UPS STORE
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'rHIS DEED
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MADE this 3,:) Y-d'day of /';?7c%<r'~ , in the yeaL of OIC Lord,
one Thousand Nine Hundred Eighty-nine (~989).
BETWEEN
MAX D. MARBAIN and fRAYDON F. LOMBARD, Co-partn -cs,
having their partnership office in the Borough )f
MechanicsburS, Cumberland County, ~ennsylvania, parties
of the first part, hereinafter called the "Gran":o!:"s",
AND
BETTY H. DUNWOODY, Trustee of the BETTY H. DUNWIIODY
TRUST, party of the second part, hereinafter ca..led
the "Grantee":
WITNESSETH, that in consideration of the sum of Ninet.r Thousand
Five HUndred seventY-five and No/IOO ($90,575.00) DOlLars, in
hand paid, the receipt whereof is hereby acknowledged. the said
Grantors do hereby grant and convey to the said Grant'le, her
heirs and aSSigns,
ALL that certain piece or parcel of land situat'!d in the
Township of Silver Spring, County of Cumberland and C,'mmonwealth
of Pennsylvania,. more particularly bounded and descri:'ed as
fol,lows:
BEGINNING at a point on the southern side of Gr-<.enspring
DriVe North at the diViding line between Lots Nos. 76 and 75 as
shown on the hereinafter mentioned plan of lots: then<:e along
said dividing line between Lots Nos. 76 and 75, South 6 degrees
55 minutes 49 seconds East, a distance of 127.23 feet to a point
at other lands being deve~oped as Westfields; thence 010ng the
latter, the following two (2) courses and distances:~ (1) Sou~h
70 degrees a minutes 15 seconds West, a distance of 1.50 feet
to a point, and (2) North 19 degrees 51 mi.nutes 45 s ,:onds We,st,
a distance of 124 feet to a point on the southern 'sid,' of .
Greenspring Drive North; thence along said side of Gr<enspring
Drive North, North 70 degrees a minutes 15 seconds Ea::t, a
distance of 69.97 feet to a point on the same at the I'ividing
line between Lots Nos. 76 and 75 as shown on the herenafter
mentioned p~an of lots, the place of BEGINNING.
BEING Lot No. 76 as shown on a certain subdivis:: On plan of
lots entitled "Final SUbdiViSion/Limited Plan for West fields
Phase 2- as recorded 1n the Office of the Recorder Of Deeds i~
and for Cumberland County, pennsylvania, in Plan Book 56, Page
137.
"-'---"',.- -....--.--.
h __. ~ .___.'. .' ._._____.... _.._
HAVING erected thereon a townhOUSe style dwellir'g unit>:~~?, <;;'0.......
known anCl numbered as 16 Greenspring Drive North. ;'(;"'~ ;t~~~
BEING a portion of that certain larger premises which
OscaJ;' P. Shafer and Pau~ine M. Shafer, husband and wife, by 11'''01'1 :..:_~t,~..-.
their deed dated November 30, 1988, and recorded in t~,e ~; !I ci~
Recorder · S Qff ice afo resaid in Deed Book "R", Vol ume ,3, Page ._"__ := '=i
757, granted and conv(ilyed unto Max D. Marbain and Graj.don F. ~[/t~)Y,"\~:'J;
Lombard, Co-partners, the Grantors herein. K;\~~>?~Q
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THE UPS STORE
PAGE 04/04
SArD premises are conveyed under. and SUbject, n'vertheless,
to all those certain covenants, conditions and restr-i, tions as
more fully con~ained in a document entitled nDeclarat~ons of
Covenants, Conditions and Restrictions Applicable to 'Westfields'
Phases 2 and 3, in SilVer Spring TownShip, Cumberland County,
Pennsylvania-, as recorded in the Recorder"s Office aforesaid in
Miscellaneous Record Book Volume 362, Page 897, and ircorporated
herein by reference thereto.
ANP.the ~aid Grantors hereby COV~nant and agree that they
will warrant specially the premises hereby COnveyed.
IN WITNESS WHEREOF, the said Grantors haVe hereu~to set
their hands and Seals the day and year first abOVe written.
WITNESSED BY;
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rd>'d_~J_:' D
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.... ~ A. I-<j~.7.L1_
(" .c.... .-Zf; -/~/
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Max D. Mar BJ.n Co-pa '~tne r)
<~~~~~.~ (SEAL)
Gray n F. Lorn ard (C -partne,r)
COMMONWEALT5 OF PENNSYLVANIA
COUNTY OF CUMBERLAND
On this, the ."'30 1'-4 day of '----??t"~--- , 1989, bef<re me, a
Notary Public in and for the Commonwealth and County ajoresaid,
personally appeared MAX D - MARBAIN and GRAYDON F. LOl'1Bl' RD,
Co-partners, known to me (or satisfactori~y proven) to be the
persons whOse names are subscribed to the within Deed, and
acknowledged that they eXecuted the same for the pu rpo~es':'
therein contained. ,,;....r.!l'"''''
,.'.' ~ n d ...{ t''''
IN WITNESS WHEREOF, I her.eunto set my hand and 01 f.:1..ih.;f~''Js~:~Z!::ra_
seal. ....~:.~ ...~...~:..
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(_.~-#f~.J7_ ';:;:;-.- - Y-<}h'~,~\':!:."-~$EA:.)j"bi:L""j
Notary Pub J.C . <~..:.-_ ':-~'.....<~~..~X'.:
My commi ss ion expi res: F.. :y:<.;< ;;:.J.-9.:.!::q.",,'I./'
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c.~,~"'~.!,,'" r:., ,,(mum.,tl,"lu;Y~ulrty
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7A-;- Ldlon of Natal1GS
tll'Oml~r. il"!mil"'b'l\' "... "
ss-....
CERTIFICATE OF RESIDENCE
I hereby certify
post office address of
5- hrJ
,
that the precise residence and e'>mplete
the within nam~d Grantee, i~-l. . h L
/t:. .l!sf/l.-Jl..J:J."'''-<J1'''-:''~'''CJ &/'-~?-"<_..' /""~
' 1989 /4~u.",A J'd' 0'",- / ",7.:53
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693
Continuation of Schedule H
Estate of
Betty H. Dunwoody
ITEM
NUMBER
1.
2.
3.
3.
4.
5.
6.
DESCRIPTION
Sovereign Bank - mortgage payoff escrowed
Window repair - escrowed
County Real Estate Taxes - pro rata
Attorney fee - John C. Oszustowicz
PA Realty Transfer Tax
Silver Spring Twp - final sewer
Notary fee - Murrel R. Walters, III
Total
File Number
21-07-0236
AMOUNT
7250.00
500.00
16.99
250.00
1500.00
101.18
10.00
$
9628. I 7
.J
A. Settlement Statement
U.S. Department of Housing
and Urban Development
..;a~
~
,r
H
B. Type of Loan
1.0 FHA 2.0 FmHA 3.0 Conv. Unins. 6.AllNumbIt
4. 0 VA 5. 0 Conv. Ins.
OMS Approval No. 2502-0265
7. Loan Number
8. Mortgage Insurance Case Number
C. Note: This form is furnished to give you a statement of actual setUement costs. Amounts paid to and by the setUement agent are
shown. Items marked "(p.o.c.)" were paid outside closing; they are shown here for Informational purposes and not
included In the totals.
D. Name and Addrs.. of Borrower E. Name end Addrea or Seller F. Name and Address of Lender
STANLEY W. STAMBAUGH
PATRICIA A. STAMBAUGH
32 GREENSPRING DR.
MECHANICSBURG PA 17050
BETTY H. DUNWOODY TRUST
SCOTT T. DUNWOODY, TRUSTEE
2500 GUME DR.
MECHANICSBURG PA 17055
G. Property Loc.Uon
TAX PARCEL # 3B-23-0571-140
16 GREENSPRING DRIVE, SnoVER SPRtNG TWP.
MECHANICSBURG PA 17050
H. Setu.m.....l Agenl
MURREL R. WALTERS, III, ESQUIRE
Place of-Settlement
54 EAST MAIN STREET
MECHANICSBURG
PA 17055
-1.~~;:~I'---
I ~iSburS6ment Date
Lot: - Block;
J. Summary of Borrower's Tran..ctlon
100. Gross Amount Due From Borrower
K. Summ~ry of Seller's Transaction
400 GrO&I Amount Due To SIUer
101. Contract sales crlee 150 000.00 401. Contract sales Drlce 150,000.00
102. Personal Drooertv 402. Personal DrODertv
103. Settlement charoes 10 borrower (line 1400\ 2.39B.50 403.
104. 404.
105. 405.
Ad]ultmlnta for Itlml olld bv ooUer In advanca AdJultrnenta lor Itlml oald bv ooUer In advance
106. Cltyltown taxes 10 406. Cllvltown taxes 10
107. Countv taxiS to 407. County taxes to
108. Asses$I1lenta 10 408. Assessments to
109. School T8X 1/17/2001108/30/2007 582.04 409. School T8X 1/17/2007\0 8/30/2007 562.04
110. 10 410. to
111. to 411. to
112. to 412. 10
113. to 413. to
114. to 414. to
115. 10 415. to
120. Grol. Amount Due From Borrower 152,960.54 420. GrolS Amount Due To SeUer 150,562.04
20 . Amounta Paid Bv Or In Blhall 01 Borrower 500~ Reductions In Amount Due To Seller
201. Ooooslt or lamest monlv 001. Excess dlDOslt rseelnstructions) 0.00
202. PMncleelamount of new Ioanls) 002. Settlement charoes to seller (line 1400) 9,611.1B
203. ExI.tine loonls) takln subiactlo 003. Exlstina Ioanls\ taken sublect to
204. 004. Pavoff of first morteaae loan
205. 005. Pavoff of slcond mortaaae loan
206. 506.
207. 507.
208. 508.
209. 509.
AdJultrnlnta lor llaml unoald bv leUer Adlultmenta lor Itlm. unoald bv .eller
210. Cilvltown taXI' ta 510. Clty/tawn taxes to
211. Counlv taXIS 1/1/2007 10 1/17/2007 16.99 511. Countvtaxes 1/1/2007 to 1/17/2007 16.99
212, Assessments to 512. Assessments 10
213. to 513. to
214. 10 514. to
215. 10 515. to
218. to 516. to
217. to 517. to
218. 10 518. 10
219. to 519. to
220. Total Paid By/For Borrower 16.99 520. Total Rlductlon Amount Due SeUer 9,628.17
300 Cash At Settlement FromlTo Borrower
301. Gross Amount due from borrower fllne 120\ 152,960.54 601. Gross amount due to ..lIer (line 420) 150,562.04
302. Less amount Dald bvlfor borrower (line 220) 16.99 602. Less reductions in amt due seller lline 520 1 9,628.17}
303. Cuh l&J From o To Borrower 152,943.55 603. C..h l&J To o From SeUer 140,933.B7
600 Cuh At S.ttlement To/From Seller
SUBSTITUTE FORM 1099 SELLER STATEMENT
The Information contained In Blocks E. G. H. and I and on line 401 (or. line 403 and 404) Illmporlant tax Information and II being furnished to the Internal Revenue
Service. If you are required 10 file a return. a negligence penally or o!her sanction wUl be Imposed on you If this Itlm Is required to be reported and the IRS determines
that II has not been reported. If this real estate '" your prInclpat reaidence, file Form 2119, Sale or Exchange of Principal Residence, for any gain. with your income tax
retum; for o!her transactions, complete !he applicable parts of Form 4797, Form 6232 and/or Schedule D, Form 1040). You are required to provide the Settlement Agent
(named above) with your correct taxpayer Identification number. If you do not provide !he Settlement Agent with your correct taxpayer Identification number, you may be
subject to civil or criminal penaltlellmposed by law. Under penaltlel of perjury, I certlly!het the number shown on this statemenlls my correct Iaxpayer Identification number.
(Selle~1 Slgnlturo)
.
l. Selllement Charo..
700. Total Sales/Broker'a Commlaalon based on Drlca $ 150.000.00 Illl 'I.- 0.00 Paid From PaId From
Division of Commission (line 700) as follows: Borrower's Seller's
701. $ to Funds At Funds At
Settlement Settlement
702. $ to
703. Commission paid at Settlement
704.
00 I P bl
8 tern. ova e In Connection With Loan
801. Loan OrlalnaUon Fee %
802. Loan Discount %
803. Appraisal Fee to
804. Credit R.oort to
805. Lende~s Inspection Fee
806. Mortoao. Insurance Aoollcation F.e to
807. Assumption Fee
808.
809.
810.
8". cc-
812.
813.
900. Items Reoulred Bv Lender To Be Paid In Advance Exclud. last dav In cales -lIn. 901
901, Interest from to @$ I day
902. Mortaaae Insurance Premium for months to
903. Hazard Insurance Premium for VAars to
904. VAsrs to
905.
1 rmonth
1 er month
1 per month
1 r month
Annual assessments 1 r month
1 month
1 er month
re ate Accountl" Ad ustm.nt
11 00. TItle Charge.
1101. S.Wement or c1oslno f.e to
1102. Abstract or tiUe search to
1103. ntle examination to
1104. Tltlelnsuranc. binder to
1105. Document DreoaraUon to .JOHN C. OSZUSTOWICZ. ESQOIrnr 250.00
1106. Notand.e. to 10.00 10.00
1107. Attorney's f..s to MURREL R. WALTERS, III, ESQUlltE 850.00
lJncludes above Items numbers: 1101-1103 \
1108. Titi. Insuranc. to
{Includes above It.ms numbers: 1
1109. L.ndo(. coverao. $
1110. Owno(s coveraae $
1111.
1112.
1113.
1200. Government Recordlna and Transfer Charaes
1201. Recordlnc fees: Deed $ 38.50 ; Mortnaao $ ; Releases $ 38.50
1202. Cltv/counlv taxistamas: Deed $ 1 500.00 ; Mortaaa. $ 1,500.00
1203. Stale tax/stamps: O.ad $ 1,500.00 ; Mortgage $ 1,500.00
1204.
1205.
1300. Additional Settlement Chara..
1301. Surv.v to
1302. Pest Inspection to
1303. -----
1304. FINAL SEWER BILL SILVER SPRING TOWNSHIP 101.18
t305.
1308. ESCROW SOVEREIGN MORTGAGE $7 250.00
1307. WINDOWS 500.00 7,750.00
1308.
1400, Total Salllament Charge. (entar on line. 103, SacUon J and 502, Section K) 2.398.50 9,611.1 B
CERTIFICATION
I haye carefully reylewoa lI1e HUD-l Settlement Stalement an<! to lI1e best of my knowledge and bellef,Jlls ue a
on my accounl or by m. In this transaction. J further certify that I have rocelvad a copy of tha HUD-l 'enl Stat
S.u.r
I , ESQUIRE
WARNI Is a crlm to knowtngly make false statements to the United States on thl, or any other similar form. PenaltIes upon convict/on can include a fine and
Imprisonment. Ford.tau.....; Title 18 U.S. Code Section lDOland Sectlon 1010.
S.tt1em.nt Agont
DOl.
U.I, GOVl:~NMENT PRINTING OffiCE: lNt O-'40UU