HomeMy WebLinkAbout03-06-08 (2)
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15056041147
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes ~
PO BOX.280601 ~
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 0 7
0645
Date of Birth
199322620
06162007
07151905
Decedent's Last Name
Suffix
Decedent's First Name
HAZEN
GRACE
MI
B
(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
[X] 1. Original Return
2. Supplemental Return
L
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4. Limited Estate
[J
4a. Future Interest Compromise
(date of death after 12-12-82)
xl
6. Decedent Died Testate
(Attach Copy of Will)
c
[]
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received
1 O. ~~t~:~~ ~3~jf!9?~e~dt ~~f_t~5}f death
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
ame Daytime Telephone Number
WM. D. SCHRACK III 7174329733
Firm Name (If Applicable)
SCHRACK & LINSNENBACH
REGISTER OF \('IILLS USE: ONLY
. lj _.
~.. ~.n
. ~-1
First line of address
-)
124 WEST HARRISBURG STREET
I
C',
Second line of address
) Ii
P.O. BOX 310
DILLSBURG
State
PA
ZIP Code
17019-0310
..",
D~TE FILED
City or Post Office
c.'
Correspondent's e-mail address:Schracklaw@comcast.net
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
James B. Hazen
17112
William D. Schrack III
DATE
..;;" g..'--'
124 W. Harrisburg St., Dillsburg,
019-0310
Side 1
L
15[]56[]41147
15[)56[)41147
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15056042148
REV.1500 EX
Decedent's Name: Grace B. Hazen
Decedent's Social Security Number
199322620
RECAPITULATION
1. Real Estate (Schedule A)...................................................................................... 1.
2. Stocks and Bonds (Schedule B)........................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D)............................._....................... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E)................ 5.
6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) 0 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 Subject to 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, of
transfers under Sec. 9116
(a)(1.2) X .00
16. Amount of Line 14 taxable
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
o .00
15.
159,670.69
16.
o . 0 0
17.
o .00
18.
19. Tax Due............................................................................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L
15056042148
165,000.00
32,057.26
39,468.40
236,525.66
76,854.97
76,854.97
159,670.69
159,670.69
0.00
7,185.18
o . 00
o .00
7,185.18
o
15056042148
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REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
Grace B. Hazen
STREET ADDRESS
2828 Rosegarden Boulevard West
File Number 21 -07 -0 645
CITY
Mechanicsburg
1ST A TE
PA
[ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
7,185.18
8,500.00
359.26
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
8,859.26
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thEOVERPAYMENT.
Check box 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 theTAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
1,674.08
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;...........................................................no............... 0 ~
b. retain the right to designate who shall use the property transferred or its income;................................ 0 ~
c. retain a reversionary interest; or.............................__........................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care?.......................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.......... ...................... ...... .................... ........... ................... .no...... .............. 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 P.S. 99116 (a) (1.1) (ii)]. The statutedoes not exemota 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 P.S. 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 P .5. 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.
c: \mytlles\wills\GraceHazen(j sg)
ruast ~ill atW cm.estament
OF
GRACE B. HAZEN
BE IT REMEMBERED, that I, GRACE B. HAZEN, presently of 2828 Rosegarden
Boulevard, Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania, being of
sound mind, memory, and understanding, do make, publish, and declare this as and for my Last Will
and Testament, hereby revoking and making null and void any and all Wills and Testaments and
writings in the nature thereof by me at any time heretofore made.
ITEM 1: I direct that my hereinafter named Executor pay all my just debts, my funeral
expenses, and the expenses of the administration of my estate. With this direction, I authorize and
empower my Executor to expend for my funeral expenses and interment such amounts as may be
considered necessary and proper, without regard to any limit that may be prescribed by a court of
law.
ITEM 2: I direct my Executor to pay all inheritance, estate, succession, and legacy taxes
of whatsoever nature and kind, to which my estate or the transfer of any property passing hereunder
or otherwise passing by reason of my demise, may be subject and to charge such taxes against my
residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any
property required to be included in my gross estate, under the provisions of any state or federal law
now in force or hereafter enacted, shall be prorated among the persons interested in my estate to
whom such property is or may be transferred or to whom any benefit accrues.
ITEM 3: I give to my former neighbor, TERRY BORDLEMA Y, the sum of FIVE
HUNDRED DOLLARS ($500.00) as a token of my appreciation for all that he has done for me in
making it possible for me to continue to live independently at my home.
ITEM 4:
All the rest, residue, and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which I have a
power of appointment, I direct my Executor divide into two (2) shares that are as nearly equal as is
practical, which shares shall be distributed as follows:
A. One (1) share to my son, JAMES B. HAZEN. Ifmy son should predecease me, I
direct that this share be divided between his children in as nearly equal shares as is
practical.
B. One (1) share to be divided between the children of my daughter, Margery, KAREN
BETH CURRY and DAVID HAZEN LOWDERMILK, is as nearly equal shares
as is practical. If either Karen or David should predecease me, I direct that the share
of such deceased grandchild pass to his or her issue, in equal shares.
ITEM 5:
I nominate, constitute, and appoint my son, JAMES B. HAZEN, to serve as
Executor of this my Last Will and Testament, directing that he not be required to post bond to assure
the faithful performance of his duties in this, or any other jurisdiction.
IN~ITNE WHEREOF, I have hereunto set my hand and seal this Jfa day of
~~d 20m.
fj/T4~"() '-8 ;;i A .Q~
GRACE B. HAZEN 0
The preceding instrument, consisting of this and one (1) other typewritten page, was on the
day and date thereof signed, sealed, published, and declared by the Testatrix herein named, as and for
her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses hereto.
~ ~r2P OF 11 12 Jl?J-4?- "? I f /11
~ C.- -R~ OF \.u ..1.\'",,,", II.... 'V A
Page 2
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF YORK
. ..--
/l;} /~/./ 4 --' -r;;
Jh'Y) A /j (-hVL ~~ ~
.... the Testatrix and the witnesses,
and
respectively, whose names are signed to t e attached or foregoing instrument, being first duly sworn,
do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument
as her Last Will and Testament, and that she signed willingly, and that she executed it as her free and
voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and
hearing of the Testatrix signed the Will as witnesses, and that to the best of their knowledge, the
Testatrix was at the time eighteen (18) years of age or older, of sound mind, and under no constraint
or undue influence.
,!",-,,-,/ 11, fb1f4r-'
GRA~ -
& j:{-
0~~~
SWORN TO AND SUBSCRIBED
BEFORE ME THIS #DAY
OF ~/ltdty-- , 2003.
/;----- tf /
( / -}
NotarlaJ Seal
Janet s. Glore, NaBry PtbIIc
Dillsburg Boro, YOlk County
My COmrnissIon Expires Oct. 25, 2006
Member, PeonsyIvanIa AMoclalion Of ~
Rev.1502 EX+ (6-98)
.
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hazen, Grace B.
FILE NUMBER
21-07 -0645
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 compelled to buy or sell, both having reasonabie knowledge of the relevant facts.
Real property which Is Jolntly-owned with rtght of survivorship must be disclosed on schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1
Sale of single-family residence at 2828 Rosegarden Blvd. West, Mechanicsburg,
Upper Allen Township, Cumberland County, Pennsylvania (see HUD1)
165.000.00
TOTAL (Also enter on Line 1, Recapitulation)
165.000.00
<If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule A (Rev. 6-98)
A. U.S. Department of Housing
and Urban Development
10/26/074:42 PM
OMS No. 2502-0265
B. T e of Loan
FINAL
1. [X] FHA
4. [ )VA
6. File Number
20071367
2. [ ) FMHA
5. [ ] Conv. Ins.
7. Loan Number
124007308/1860442128
3. [ ] Conv. Un ins.
C. Note:
Settlement Statement 8. Mortgage Ins. Case No. 441-8068869
This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement
agen(are shown. Items marked C'POC") were paid outside the closing: they ere shown here for information
u oses and are not included In the totals.
. Benjamin J. Koppenhaver, 1044 Walnut Street, Lemoyne, PA 17043
Jamie L. Kopp~nhaver, 1044 Walnut Street, Lemoyne, PA 17043
Grace B. Hazen Estate TIN:
Philadelphia Financial Mortgage, a division of Leesport Bank, ISAOA, 1044
MacArthur Road, Reading, PA 19605
Upper Allen Township
D. Nama of Borrower:
E. Name of Seller:
F. Name of Lender:
G. Property Location:
H. Settlement Agent:
Place of Settlement:
I. Settlement Date:
2828 West Rosegarden Boulevard, Mechanicsburg. PA 17055
Great Road Settlement Services, LLC (866) 440-6400
350 North 21st Street, Camp Hill, PA 17011
10/3112007 Proration Date:
10/3112007
10/3.112007 to 7/1/2008
10/3112007 to 1/112008
1,186.72
67.95
Gross amount due to seller:
Total reduction In amount due seller:
16.513.30
Gross amount due to seller (line 420) 166,341.13
602. Less total reduction in amount due seller(line 520 16,513.30
CASH (X)FROM OTO BORROWER 9,908.40 603. CASH OFROM (X)TO SELLER 149.827.83
SUBSTITUTE FORM 1099 SELLER STATEMENT. The information oontained In Blocks E, G, H and I and on IIna 401 (or, if line 401 is asterlskad, lines 403 and 404). 406,407 and
406-412 (applicable part of buye~s real estate tax reportable 10 the I.RS) Is Important tax Information and IS being furnished to the intemai Revenue Service. If you are required to file a
retum, 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.
SELLER INSTRUCTION -If this real estate was your principle residence, file form 2119, Sale or Exchange of Principal Residence, for any gain, wi1h your Income tax return; for other
transactions, complete the applicable parts of form 4797, Form 6252 and/or Schedule 0 (Form 1040).
You are requlreo oy law to previae ureat Koad ~emement ~ervlces, LLL; ll:U:U:5J 44U-t;S4UU W1Ul your correct taxpayer loennncatlon numOer.
u do not provide Great Settlement Services, LLC (666) 440-6400 with your correct taxpayer IdentificaUon number, you may be subject to civil or criminal penalties.
~ t3 E:. 'iTOrt-
<,--- "~""'___"""",""H""'''_''_'','''<'''' _,"'"_.."....".,..;. .,!'Jl ~4:l.~,!:!; ^."'~"".JIl,'=.;['.~:i<~-""~;<!!,."'!:>l:':.JiB!m'f;>~.I.M~1;~~~..\,!j.,;~~~OW~~~!I;<V'.!~:lJ\i\inlilf.HV'!i'I~~'''''.~~$~'''"~dl~iJ'f
700, Total saleslbroker commission based on: .. $9,803.00 Paid From Paid f=rom
Di....islon of commission line 700 8S follows: Borrower'!l S!~lIer's
701. . $4,826.50 to RElMAX A 1 RealN, Inc. Funds at Funds at
702. $4,776.50 to Straub & Associates Real Estate Group, Inc. Settlemert SetIJement
703. CommIssion paid at settlement $9,603.00 9,603.00
704,
705, Transaction Fee-Buver to Straub & Associates Real E9tate Group. Inc. --
295.00
706. TIliIn98ctlon Fee-SeUer 10 RElMAX A1 Reelly, Inc. 195.('0
801. Loan orioineUon fee to Phlladel hie Financial Morto 1,567.50
802. Loan discount
803. Aporaisal fee 10 Koppenha....er Aonraisals 325.00
804. Credit report to Eouffax mortaage Solutions 24.06
806. Lender's tnsoectlon fee
806. Mortoaae Insurance aoollcatlon fee
807. Assumption fee
808. Processing Fee
809. Document Preoeration Fee
810. Flood Certification Fee to First American Flood 16.00
811.
612.
813. Deferred Premium bv Lender
814. Yield Spread Premium
901. Interest from 1013112007 10 11/112007 at $30.51250/dav for 1 days. 30.51
902. Mortaaoe Insurance premium' for financed to HUD 2,351.25
903. Hazard Insurance ~remlum for 1yr.. to Nationwide Insurance poce 390.00
904.
90S.
1001. Hazard Insurance 4 mo.all $32.5000 nAr mo. 130.00
1002. Mortoaoe insurtlnce eS.31oer month
1003. Cllv orooertv taxes
1004. Coun I nronertv -taxes 10 mo.a!> $42.4200 PBr mo. 424.20
1005. Annual assess menta melnt. \
1006. School Proaertv Taxes 6 mo.la) $147.9400 oar mo. 887.84-
1007.
1008.
1009. Aggregate Adjustment to Phl1Bdelphla Financlal Mortgage, 8 divlsion of Lees (717,84)
1101. Settlement or closlno fee
1102. Abstract or title search 10 ACE Abstracters POCS 150.00
1103. Title examination
1104. TiUe Insurance binder
1106. Document oreaaration to Great Road Settlement Services, LLC 125.00
1106. Notarv fees 10 Cash 25,00 10.30
1107. AttomfW's fees to
Includes above Items no.:
1108. TItle In9urance to Great Road Settlement Services. LLC 1,183.75
includes above Items no.:
1109. Lender's coveraoe $159,101.00
1110. Owner's coverane $165,000.00 $1,163,75
1111. Endorsements-100,3oo,9OO to Great Road Settlement Servk:es, LlC 150.00
1112. Closing Protection Letter 10 Great Road Settlement Services, LLC 35.00
1113. Real Estate Tax Certification 10 Great Road SeWement Services, LLC 5.00
1114. Oveminht out 10 Greet Road Settlement Services, LLC 25.00
1116. Deed Preparatlon
1201. Recordlna fees: Deed $38,50 Morto8ae $52.50 81.00
1202. City/county tax/stamps: Deed $1850.00 1,850.00
1203. State taxlstamns: Deed $1650.00 1,650,00
1204.
1205.
1206.
:1Ji@~ - \'!k10;;11 "11~ r~";'!~_- '~Lf; - - ~~ -, ""< r- -.. -,-,~"". - - - ~ ~ , - ~ , -, . ~ - --
;';-->_~~<d"-~ _ .;1.' ~ , - _~_L --- - . -, .~ .. ~ _, {.L"..
Surve
Pest ins ctlon
Home Ins ection
2001-08 School Tax
2007 Coun Tax
Assessment. Water
Sewer-4th Qtr.
Assessment. Trash
to M8l1In A. Yohn, Tax Collector
to Mar1ln A. YOOn, Tax Collector
poes 1775.22
POCS 509.00
to U er Allen Townshl Sewer Aulhorl
100.00
G?\..rzCo.:,f;:,<1-
jvltd IIfld have been or ~[ be
ettlement Berv ., LLC 0.1.
'I ANDlOR PU IER'B 8TA TCMENT Seller's and Purch.....s .Ilgnature h"..-on .cknowledge. hlallheir appronl of tax prorIIUona and slgnlfles their
.~tandlng Iha Uons we... ba..d on taHa for the pracedlng year, or estim.t.s for tha CUITCInl year, III1d In !he avent of any change for \he current year, all necessary
adjustments b4I made between Saler and Purcha.er; likewise IIny def.ult In delinquent taxes w1M be relmburM[d 10 TItle Comp.ny by the Saller.
. Company, In Itl apaclty.. Escrow Agent, Is and h.. bun aulhoriHd to dapo.it all fundi it recer..... In this translldlon In any fiflllnclallnsUluUon, whether
ted or nol. Such financial mtltutlon mey provide Tille Company computer eceountlng and audO servlcal dI...ctly or through a ..p....!. entity whlcl1, If ambl.d with T1tIIIl
Company, may chllllle the financlallnathullon ruaonable and propar compensallon lh....fo~ and ~lain any prgmSlherefrorn. A.ny elcrow feel paid by any party Involved In
lhIs tren.acllon shllM only be for chacXwrttlng and Input 10 tha computen, but nol for afo,...&id accounUng and audit Hl'VIceI. TlU" Company shan not be lieble for any Interest
or other charges on the eamesl money .nd shalr be under no duty to Invest or ...lnvesllunds held by It .t any Ume. Sell~. IInd Pun:hllsws hereby acknowledge and consenl
to th. deposlt or the e.crow money In flnancl8lln.UluUon. with whlct'l 11Ua Company hall or may have other banking relatlonlhlp. and fur'ttIM consent 10 th. ...tentlon by 110.
Company ana/or it. .!fillata. of any an aSl baneflts (Including actvanlageoua interest rate. on loans) 11Ua Company and/or Itl aHlIl.tas may r.ceiva from IUch flnanclal
JnsUluUona by ....lOn of their malnt of said e.crow accounts.
Th. ........ .. .....,,,_
;;; Xl: (....'1 ~
ie L. Koppenha....er
RNING: It I. a crime to knoWtngly make f.l.a statements to the United State. on thla or any other .Imlla,. form. P_nalti.. upon oonviatlon can Include I nna and
Imprisonment For delalrs see: Titla 18: U.S. Code SeclIon 1001 and SecUon 1010.
Rev-1503 EX+ (6-98)
---.
.
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Hazen, Grace B.
FILE NUMBER
21-07 -0645
ESTATE OF
All property jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 3,158.351 PNC Investments - Account #41418404 10.150 32,057.26
(proceeds of sale)
TOTAL (Also enter on Line 2, Recapitulation) 32.057.26
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
~PNC
lNVESTMENTS
M......IoIOUO'"""SIK
""'-1'NC..uo,UII..................PI...h.rll,....IUn
TRADE
CONFIRMA TION
ACCOUNT NUMBER: 41418404
FINANCIAL CONSULTANT: J2DC
355526 FOO2 19S lQZ 1'1 ------ )93
GRACE B HAZEN
JAMES B HAZEN POA
7706 FARMDALE AVE
HARRISBURG PA 17112-3822
ALEXANDRA ASCIONE/RICHARD ZELLERS
4999 JONESTOWN ROAD
HARRISBURG, PA 17109
717.540.8050
Customer Service Desk: 1-800-762-6111
1IIIIIIIIaI".IIIIIIIIII,IIIII.IIIIIIII,IIII.IIIII,1
PNC Investments appreciates your patronage. We hope that you found the experience surrounding this
transaction to be satisfying. Should you have any questions at all regarding this transaction, or the
security purchased or sold, do not fail to contact your Financial Consultant. Your Financial Consultant
will be happy to answer any questions or provide further information regarding this transaction.
TRADE DATE
07127/07
PNC Investments is pleased to confirm the following SALE transaction.
SECURITY DESCRIPTION SYMBOL SOLD PRICE
BLACKROCK FDS CIGAX 3,158.3510 10.1500
INTERMEDIATE GOVT
PORTFOLIO A
PRINCIPAL
$32,057.26
SETTLEMENT DATE:
ACCOUNT TYPE:
CUSIP / SECURITY NUMBER:
TRANSACTION AMOUNT
$32057.26
08/01/07
CASH ACCOUNT
091928549
Capacity:
AS AGENT FOR YOU ON THE OVER-THE-COUNTER MARKET.
WE WILL. FURNISH THE NAME OF THE OTHER PARTY AND THE TIME OF EXECUTION ON REQUEST.
Special remarks for this transaction:
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Processing Date: 07/27107
PNC Inves1ments may recommend secunties wI1ch are underwritten or sold by PNC Inves1ments or its afflUales or may recommend rrutual funds which are ad\lised or admirlsterad by PNC Investments or i1s affiUal.s.
III I Important Investor Information:
I . May Lose Value S<curlti<s and brok<rag< s<rvic<s
I., . No Bank Guarantee at< provided by PNC Inv<stm<nts
LLC, memb<r NASD and SIPC.
Annuiti~s and othe:r insurance: products arc offe:re:d by PNC Insurance:
Se:rvitcs LLC a lic~nsed insurance agency.
Your Account is carried with J.J.B. Hilliard, W.L. Lyons, Inc.
Member New York, American, and Midwest Stock Exchanges; CBOE; NASD; and SIPC.
Page 1 of 2
~
Rev-150B EX+ (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Hazen, Grace B.
FILE NUMBER
21-07-0645
ESTATE OF
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 PNC Certificate of Deposit #21001021136
VALUE AT DATE
OF DEATH
20.036.66
2 PNC checking account #5140027523
19.431.74
3 Household contents liquidated upon decedent's move into nursing home in
October 2005
0.00
TOTAL (Also enter on Line 5, Recapitulation)
39.468.40
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleE (Rev. 6-98)
.
.
JUL-19-2007 21:43
PNCBANK
412 768 3458
FJ.01/01
a
G PNCBAN<
July 19, 2007
Wm. D. Schrack, ill
124 W. Harrisburg Street
P.O. Box310
nillsburg, PA 17019-0310
RE: Estate of Grace B. Hazen, deceased
SSN: 199-32-2620
DOD: 6/16/2007
Dear Mr. Schrack:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Certificate of Deposit
Account #21001021136
Established 03/22/1993
GRACE B HAZEN
000 balance: $20,000.00 + $36.66 accrued interest
Checking Account
Account #5140027523
Established 09/0 II 1961
GRACE HAZEN
DOD balance: $19,428.81 + $2.93 accrued interest
The decedent maintained Investment Account (INV #41418404). For further information,
you may contact the Brokerage Department at 1-800-762-6111.
Please note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do Dot process any financial
transactions or provide statements. If you need assistance with any of these items,
please call1-888-PNC-BANK (I -888-762-2265) or stop by your local PNe Bank branch
office.
~~
Rachelle Wells
1-800-762-1775
P7-PFSC-04-F
500 first Ave.
Pinsburgh P A 15219
Member FDIC
TOTAL P.01
REV.1151 EX+ (12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hazen, Grace B.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-07-0645
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
10,268.23
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
James B. Hazen
Social Security Number(s) I EIN Number of Personal Representative(s):
173-38-7498
Street Address 7706 Farmdale Avenue
City Harrisburg State
Year(s) Commission paid 2008
PA
Zip 17112
10,700.00
2.
Attomey's Fees
Wm. D. Schrack III
6,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
32,057.26
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
17,329.48
TOTAL (Also enter on line 9, Recapitulation)
76,854.97
Copyright (c) 2002 form software only The Lackner Group, Inc.
Fonm PA.1500 ScheduleH (Rev. 6-98)
Rev-1502 EX+ (6-981
*'
SCHEDULE H.A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hazen, Grace B.
FILE NUMBER
21-07-0645
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Funeral luncheon following Memorial Service
117.00
2
Hoover Funeral Homes & Crematory, Inc.
9.366.23
3
Marshall's Memorials, Uniontown - gravemarker
785.00
Subtotal
10.268.23
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev.1502 EX+ (6-98)
*'
SCHEDULE H-87
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hazen, Grace B.
FILE NUMBER
21-07 -0645
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Costs on sale of 2828 West Rosegarden Blvd., Mechanicsburg property (see HUD1)
16.513.30
2
CRE Appraisal Services
325.00
3
Cumberland Law Journal - estate advertisement
75.00
4
Miscellaneous expenses during administration (postage, copying, etc.)
25.00
5
Reserve for future administrative expenses
250.00
6
The Patriot News - estate advertisement
141.18
Subtotal
17.329.48
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
A. U.S. Department of Housing
and Urban Development
10/26/074:42 PM
OMB No. 2502-0265
D. Name of Borrower:
B. T pe of Loan
1. [XJ FHA 2. [ J FMHA
4. [ J VA 5. [ J Conv. Ins.
6. File Number 7. Loan Number
20071367 124007308/1860442128
Settlement Statement 8. Mortgage Ins. Case No. 441-8068869
This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement
agent' ane shown. Items marked ("POC") were paid outside the closing: they ane shown here for Information
u oses and are not Included In the totalo.
. Benjamin J. Koppenhaver. 1044 Walnut Street, Lemoyne, PA 17043
Jamie L. Kopp~nhaver, 1044 Walnut Street, Lemoyne, PA 17043
Grace B. Hazen Estate
3. [ J Conv. Unins.
FINAL
C. Note:
E. Name of Seiler:
F. Name of Lender:
Philadelphia Financial Mortgage, a division of Leesport Bank, ISAOA, 1044
MacArthur Road, Reading, PA 19605
Upper Allen Township
TIN:
G. Property Location:
H. Settlement Agent:
Place of Settlement:
I. Settlement Date:
2828 West Rosegarden Boulevard, Mechanlcsburg, PA 17055
Gneat Road Settlement Services. LLC (866) 440-6400
350 North 21stStneet, Camp Hili, PA 17011
10/3112007 Proration Date:
10/3112007
Gross amount due to seller:
Contract sales rice
Personai pro e
165,000.00
10/3.112007 to 7/112008
10/3112007 to 1/112008
1,186.72
67.95
Gross amount due to seiler:
166,341.13
Total reduction In amount due seller:
16,513.30
Gross amount due to seller (line 420) 166,341.13
302. 602. Less total neductlon in amount due seller line 520) 16,513.30
303.. CASH (X)FROM {)TO BORROWER 9,908.40 603. CASH (}FROM (X)TO SELLER 149,827.63
SUBSTITUTE FORM 1099 SEUER STATEMENT - Thalnlormation contained In Blocks E, G, Hand 1 and on line 401 (or, If line 401 Is asterisked, lines 403 and 404), 406. 407 and
408-412 (applicable part of buye~s real estate tax reportable to the I.RS) Is Important lax InformaUon and Is being furnished to the Internal Revenue Service. If you are required to file .
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.
SELLER INSTRUCTION -If thlo real a.tate wes your principle residence, file form 2119, Sale or Exchange of Prlnclpel Residence, lor any gain, with your Income lax relurn; for other
transactions, complete the applicable parts of form 4797, Form 6252 and/or Schedule D (Form 1040).
You are reqUlrea Dy law 10 previae Ureal Koaa ~emement t:iecvlces, LLL,; (tU:StI) 44U-t:l4UU Wltn your correct taxpayer IOentlTlcatJon numoer.
u do not provide Great SaWement Services, LLC (886) 440-6400 with your correct laxpayer IdenUficaUon number, you may be subject to civil or criminal penalUes.
CJ-n.v..-<V t3 E:. )TOn...-
700. Total salesJbroker commissioM based on . $9,603.00 Paid From Paid From
Division of commission nine 700 as follows: Borrower's Seller's
701. $4.826.50 to RElMAX A1 Roaltv.lnc. Funds at Funds at
702. $4.778.50 to Straub & Associates Real Estate Grouo, Inc. Settlement Settlement
703. Commlsllon oskt at settlement $9,603.00 9.803.00
704.
705. Traneactton Fee-Bwer to Straub & Associates Real Estate Grooo, Inc. 295.00
706, Transaction Fee-Sener lc REIMAX A1 Realty,lnc. 195.00
801. Loan or1olnaUon fee lc Phnadel hla Financial Morto 1,567.50
802. Loen discount
803. Appraisal fee to KODDfIlnhe"8r.A~-;;;;j88ls 325.00
804. ered~ re_ to Eaulfax mortoBae Solutions 24.06
805. Lender's Insaectlon fee
B06. MortNlnA Insurance eDDllcaUon fee
B07. ASIliumptlon fee
80B. Proce811lno Fee
809. Document Prepe~t1on Fee
810. Flood Certification Fee to First American Flood 18.00
811.
812.
813. Deferred Premium bv Lender
814. Yield Spread Premium
901. Interest from 1013112007 to 111112007 at $30.51250/dav for 1 dsvs. 30.51
902. MortoaDe Insurance Df8m1um' for financed to HUD 2,351.25
903. Hazartllnsurance oremlum far 1 \'1'0, to Nationwide Insurance POCB 390.00
904.
905.
1001. Hazard Insur1lnce -4 mo.~ $32.5000 08l" mo. 130.00
1002. Mortoo.olnauronce 85.31oer month
1003. City .ron."" tax..
1004. County proDlWtv taxes 10 mo.11JI $42.4200 n.oormo. 424.20
1005. Annual a.s.ssmenle lmalnt.
1006. School Prooen;- Taxes 6 mo.tm $147.9400 oer mo. 8B7.84
1007.
1008.
1009. Aggregete Adjustment to PhiladelphIa Financial Mortgage, a division of Lee.s (717.84)
1101. Settlement or cIoslna fee
1102. Abstract or lIt1e search 10 ACE Abstracters POCS 150.00
1103. T1Ue examlna60n
1104. T1Ue Insurance binder
1106. Document p~Daratjon to Gl'1!8t Road Settlement Services, LLC 125.00
1106. Notary fees to Cash 25.00 10.30
1107. Attorney's fees 10
Includes abDve It8ms no.:
1108. T1Ue Insurance to Great Road Settlement Services, LLC 1,183.75
Includes above Items no.:
1109, Lender's coveraoe $1~9,101.oo
1110. Owner's COVArRne $165,000.00 $1.183,75
1111, Endorsements-1oo,3OO,900 to Great Road Settlement Services, LLC 150.00
1112. Closlna Protection Letter 10 Greet Road Settlement Services, LLC 35.00
1113. Reel Estate Tax CertlflcaUon lc Great Road Settlement Services, LLC 5.00
1114. Ovemloht out to Great Road Settlement Services, lLC 25.00
1116. Deed Preparation
::";l:t - - ' ::~.. ;," , ",~I' - -. 1: . - . ., _-- -' \.. -.1"
11,' ILl'_I'I." 'J " - -"",,", , ~ ,. - ~ -;w .:J ..~ ...."j
1201. Recordl fees:
1202. CI lcoun taxlstem s:
1203. State tax/starn 8:
1204.
1205.
1206
Oeed $38.50 M
Oeed $1650.00
Oood $1850.00
e $52.50
91.00
1,650.00
1.550.00
t~lT:t"'.-\.~l:r<!':<lm:~:;-'1 ':i.~rL'_" 1 i-L~. ":,,"'L~""P, :L_~' ._ ,.-.:..~. :~-~.I'':.- ~ ):::~__~-:'..~:'",~j~
Su
Pest Ins ectton
Home Ins ectIon
2007-08 School Tax
2007 Coun Tax
Assellment . Water
Sewer~ Qtr.
ASaessmenf- Trash
to Martin A Yohn Tax Collector
to Mar11n A Yohn, Tax CoMectar
poes 1775.22
poes 509.00
to U r Allen Townshl Sewer Auth
100.00
Gx.rz.c.0To~
J mJe L. Koppenhaver
lhe besl of myknowt.dge, the HUD-l Sam.menlStatementwhlch I h.va prepared Is alRle and accu...te sccounl Q(tha funds which2;wet'8 Ive<:land have been or WIll be
dwOO".d by "'. "nd."~nad .. or "'" Hlllemeot of Ihl. 1<en..dIon. ~ _
c. 6/ I(
a, uc o.ta I'
B ANDIOR PU ER'S STATEMENT Sel...... and Purt:haHr'. aigNllure henton acKnowleOgtis hlslthlllr approval of tax prv...Uons end slgn/lies their
landing thII liona were beMd on taxes for tho pnK:Odlng year, or eslkMtaa for the current )'Hr, and In tho event of any change for Ihe current year, an necenary
.-dJustments be made betwnn Bel.... end Pun:t\aaer; llUwlu rry default In delinquent luas will be relmburH:d \0 nu. Company by the Sellef.
Company, In n. CIIpeclly u Eaaow Agent, Is and has ba.., authorized 10 dapoallan funda It recelv..1n IhIs trar\sllCllon In any flnanciallnsUluUon, whether
.ted 01" not. Such flnancI.. Instltutlon may pnMda TItle ComplW1Y computer IlCaNntIrtg aod aucll Hrvlces dlnicUy or through . separat. enUty which, If affiliated with TlUe
Company, may charga tha financIeJ InsUlutlon l1laaonaIH and ptaper compensation therefore and relaln any prvftts IMrefrom. AIry .saow fees pilld by any party Involved In
this lnmNctIon ah.11 only be for ch.acwrtllng and Input 10 the computers, but not 101" .foresald accoW1tlng and .uelll S.fVk;eI. T1tI. Comp.-.y shal not be lable rot any Intereat
01" other" charges on the eam...t money and shill be under no duty to InvefC or relnvesllunds hakl by It al any Uma. Sal.. and Purchasa,.. hereby acknowledge and con.enl
10 the aaposh of tha UCfOW money In rInenQallnsUlutiona with whk:h TWII Compllny he. or may have olhw banking relallonshlm ancI funher con..". 10 tha relenUon by TlUe
Company Md/or I~ aflEelas of any .a benefits (lndudlng .dvanlllg~slnl.....1 ral.. on loans) TlUa Comp.ny .ncUor h. Smll.las mIIy r.celva rrom auch flo.ncIal
InsUtuUona by ruson of their mai1t nee of lakl NCl"OW accounts.
""- ..-.... -..l...... . .....,_. ............... .....1'.... ~.IIn... "'_1.._
6)<<i: c..-.J/ Dc'1....-
a ie L, Koppenhaver
ING: tt Ie . crime to knoWIngly msg f.... statements to the United SlIIte. on this or any other similar fonn, Panaltles upon oonvlotlon can Include a nne Ind
imprisonment. For details se.: T1tIe 18: U.S. Coda SectIon 1001 and Sedion 1010.
. .
REV.1513 EX- (9.00)
*'
SCHEDULE J
BEN EFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Hazen, Grace B.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
ClistributionsA and transfers
under Sec. l::1116(a)(1.2)]
RELATIONSHIP TO
DECEDENT
Do Not LlstTrusteelsl
FILE NUMBER
21-07 -0645
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
Terry Bordlemay
188 Crooked Gulley Circle
Sunset Beach, NC 28468-4438
Friend
500.00
Karin Beth Curry
24A West Main Street
Mendham, NJ 07945
Grandchild
25% of residue
James B. Hazen
7706 Farmdale Avenue
Harrisburg, PA 17112
Son
50% of residue
David Hazen Lowdermilk
23821 Pepperleaf Street
Murrieta, CA 92562-3295
Grandchild
25% of residue
Total
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropriate, on Rev 1500 cover sheet
500.00
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
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 ScheduleJ (Rev. 6-98)