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15056041125
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Poeox2aosol INHERITANCE TAX RETURN 2 1 0 6 0 7 9 6
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 8 6 1 2 1 9 8 6 0 6 2 8 2 0 0 6 0 1 3 0 1 9 2 2
Decedent's Last Name
M I T C H E L L
Suffix Decedent's First Name
S R C H A R L E S
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
MI
W
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ^X 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
~I
l~J 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
® 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
H A R O L D S I R W I N I I I 7 1 7 2 4 3 6 0 9 0
Firm Name (If Applicable)
I R W I N L A W O F F I C E
First line of address
6 4 S O U T H P I T T S T R E E T
Second line of address
City or Post Office
C A R L I S L E
State ZIP Code
REGISTE~OF WILLS US~~NLY
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Correspondent's a-mail address: IfWIf118WOffICe~Qf11211.COf11
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, ct and complete. Declaration of prepan;r other than the personal representative is based on all information of which pn;parer has any knowledge.
SIGN A Fj,PERS ~~ n g j1LING RETURN DATE
ADDRESS ~ -
3833 DURHAM ROAD HARRISBURG PA 17110
SIGNAT RE REPARER OTHER Tj~4N REPRFSENTATIVF~ DATE
64 SOUTH PITT ST
CARLISLE
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041125
PA 17013
15056041125
J \
9~'
i
15056042126
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: CHARLES W. MITCHELL, SR 1 8 6 1 2 1 9 8 6
RECAPITULATION
1. Real estate (Schedule A) 1 1 1 7 5 0 0 0 0
........................................
2. Stocks and Bonds (Schedule B) 2. 0 0 0
..................................
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0 0 0
4. Mortgages & Notes Receivable (Schedule D) ........................ 4. 0 0 0
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 1 7 4 4 3 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 0 0
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ....... 7. 0 0 0
8. Total Gross Assets (total Lines 1-7) ........................... 8. 1 1 9 2 4 4 3 0
9. Funeral Expenses 8~ 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/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14.
1 6 6 7 5 4 7
5 5 6 3 5
1 7 2 3 1 8 2
10 2 0 1 2 4 8
1 0 2 0 1 2 4 8
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X.0 _ 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 1 0 2 0 1 2 4 8 16.
17. Amount of Line 14 taxable
0
0
0
at sibling rate X .12 17
18. Amount of Line 14 taxable
0
0
0
at collateral rate X .15 18.
19. Tax Due ................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 15056042126
0 0 0
4 5 9 0 5 6
0 0 0
0 0 0
4 5 9 0 5 6
0
15056042126
REV-1500 EX Page 3
decedent's Complete Address:
File Number
0796
DECEDENTS NAME
CHARLES W. MITCHELL, SR
STREET ADDRESS
5016 EAST TRINDLE ROAD
CITE'
MECHANICSBURG STATE
PA ZIP
17055
Tax Payments and Credits:
~ • Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 4,820.46
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(1) 4,590.56
Total Credits (A + B + C) (2) 4,820.46
Total Interest/Penalty (D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(3) 0.00
(4) 229.90
(5) 0.00
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ................................................................ ...... ^ X^
b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ X^
c. retain a reversionary interest; or .......................................................................................... ...... ^
d. receive the promise for life of either payments, benefits or care? ................................................. ...... ^ X^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................................................. ...... ^ ^X
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ... ...... ^ ^X
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................................................ ...... ^ ^X
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 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. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX + (6-98)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
CHARLES W. MITCHELL, SR 0796
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 pace 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 orooerty which is rointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. HOUSE AND LOT AT 5016 EAST TRINDLE ROAD, MECHANICSBURG, PA 17055 100,000.00
Value based on Sale Price
HUD-1 attached as Exhibit B
2. HOUSE AND LOT ON MAIN STREET, SHADE GAP, PA 17255 17,500.00
Value based on Sale Price
HUD-1 attached as Exhibit C
TOTAL (Also enter on line 1
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
CHARLES W._MITCH_ELL, SR 0796
All property jointty•owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
TOTAL (Also enter on line 2, Recapitulation) ' 3
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
FILE NUMBER
CHARLES W. MITCHELL, SR 0796
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
NONE
0.00
TOTAL (Also enter on line 3, Recapitulation) I s 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1507 EX+,(6-9A)
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES ~ NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CHARLES W. MITCHELL, SR 0796
All property jointly-owned with the right of surv'nrorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
TOTAL (Also enter on line 4, Recapitulation) ~ S 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CHARLES W. MITCHELL, SR 0796
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of surv'nrorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. MISC. PERSONAL PROPERTY 1,500.00
2. TAX PRORATION ON REAL ESTATE SALE 88.31
5016 East Trindle Road, Mechanicsburg, PA 17055
HUD-1 attached as Exhibit "B"
3. TAX PRORATION ON REAL ESTATE SALE 136.71
Main Street, Shade Gap, PA 17255
HUD-1 attached as Exhibit "C"
4. PEBTF 19.28
Final Survivors Benefit from Pension
TOTAL (Also enter on line 5, Recapitulation) I E 1,744.30
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX + (6-98)
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CHARLES W. MITCHELL, SR 0796
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
A.
JOINTLY•OWNED PROPERTY:
IP TO DECEDENT
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. NONE 0.00 0.00
TOTAL (Also enter on line 6, Recapitulation) I E 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
CHARLES W. MITCHELL, SR 0796
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIRREUITIONSHIPTODECEDENTAND
THE DATE OF TRANSFER ATfACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
°A°OFDECD'S
INTEREST
EXCLUSION
QFAPPUCABLE)
TAXABLE
VALUE
1. NONE 0.00 0.00
TOTAL (Also enter on line 7 Recapitulation) I S 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES 8~
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
CHARLES W. MITCHELL, SR 0796
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MYERS FUNERAL HOME, INC. -Funeral Expenses 3 980.00
2. JOHNSON FUNERAL HOME -Funeral Expenses 497.38
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2, AttomeyFees IRWIN LAW OFFICE 6,525.00
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4• Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS -Initial filing fee at time of 371.00
probate and filing of inheritance tax return and inventory and supplemntal return
5 Accountants Fees
6. I Tax Retum Preparers Fees
7. NELSON EBERSOLE -Real Estate Appraisal 250.00
8. DON RAPP -Real Estate Appraisal 275.00
9. AAA SELF STORAGE -Storage of Personal Property 315.00
10. STEPHANIE MITCHELL -Reimbursement of Expenses Paid for Estate 101.84
11. MARIE HUBER, TAX COLLECTOR -Real Estate Taxes 1,526.24
12. SUSAN M. HARRY, TAX COLLECTOR -Real Estate Taxes 604.13
13. IRWIN LAW OFFICE -Attorney Fees on Sale of Both Tracts of Real Estate 700.00
14. Closing costs from Sale of Real Estate in Shade Gap, PA 1,335.00
15. Real Estate Taxes on Real Estate in Shade Gap, PA 194.88
TOTAL (Also enter on line 9, Recapitulation) $ 16.675.47
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (9-p0)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CHARLES W. MITCHELL. SR may
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 [nclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2))
1. PHILLIP ALLEN MITCHELL Lineal
3833 Durham Road 1/3 Residue
Harrisburg, PA 17110
2. JAMES D. MITCHELL Lineal
508 L W E 1/3 Residue
Chambersburg, PA 17201
3. CHARLES W. MITCHELL, JR. Lineal
5016 East Trindle Road 1/3 Residue
Mechanicsburg, PA 17055
4. SHIRLEY C. STEBBINS
Deceased -DOD May 3, 2006 N/A
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET s
(If more space is needed, insert additional sheets of the same size)
°03113/2007 14:05 7175415487 THE UPS STDRE 22D4 PAGE 05/07
r~ , - ,
LAST WILL AND TESTAMENT
OF
CHARLES W. MITCHELL
f, CHARLES W. MITCHELL, a resident of Scott County, Commonwealth
of Kentucky, being of full age, sound mind and memory, dv hereby make, publish, and
declare this to be my LAST WILL AND TESTAMENT, hereby revoking any and all Wills
and Codicils heretofore made by me.
FiRST~ i wUl and direct that all my dust debts, funeral expenses, and
expenses connected with the administration of my estate be paid as savn as
practicable after my death. 1 further direct the Executrix/Executor hereof tv pay all r~,
f7 ~i -n
inheritance, estate, transfer and succession texas which may be levied or as`~s3ed .:., } ', .,
~-, ~ •I
upon any property which is included as part of my gross estate for the purpose any ~ !`;,•; i '_~;
~...~
SUN I tan. _ I I.J }, ~:. ' i t
';] i fl
SECOND: I will, devise and bequeath all of my prvpeRy. real, personal ~~~ •' I
N
and mixed, and wheresoever situated, tv my children, CHARLES W. MITCHELL, JR.,
SHIRLEY C, STES131NS, ,LAMES D. MITCHELL and PHILIP A. MITCHELL, share and
share alike, to be theirs absolutely and in fee simple.
~D_: I hereby nominate and appoint my daughter. SHIf~L1=Y C,
STEBBINS, as Executrix of this Will 2nd 'rf she shall predecease me, or if for any other
reason she fails to quai'ify, then i nominate and appoint my son, PHILIP A. MITCHELL,
as Executor of this W[II. I direct that my above named Executrix/Executorehall serve
without requirement of surety on the bond as such. 1 hereby grant to my
Executrlx/Executorfuil power and authority to compromise, settle, andlor adjust any
and all claims, charges, debts or demands against or In favor of my estate, as fully as I
could do if living, and further, with full power, without order of court to sell, transfer and
convey any property, real or personal, which I may own at the time of my death at such
price, time, terms and conditions as they may determine, and to perform those
transactlans authorized far personal representatives as set faith in Chapter 395 (as i#
may be emended from time to time) of the Kentucky Revised Statutes, for the purposes
of administration, diviaivn or distribution In carrying out the terms of this Will.
. ~ 1 .
•
03113!2007 14:05 7175415487 THE UPS STORE 2204 PAGE 06107
LAST WILL ANU TESTAMENT
OF
CHARLES W. NIITCHELL
IN TESTIMONY WHEREOF, I have hereunto subscribed my name, by
making my mark, tv this my LAST WILL AND TESTAMENT, consisting of THREE (3)
rypewrltten pages, and for the purpose of identification I have initiated each such page,
alt in the presence of the persons witnessing It at my request on this ~~~ day of April,
2006, at Georgetown, Kentucky. ~
CHARLES CHELL (his mark)
The foregoing instrument, consisting of three (3) typewritten pages, was
signed and dectased by CHARLES W. MITCHELL, the Testator, by making his mark, to
be his LAST WILL AND TESTAMENT, fn our presence, and we, at his request and in
the presence of each other have subscribed our names as witnesses, this ~ day of
April, 2006, at Deorgetown. Kentucky.
~ I
residing in ,Kentucky
r'~' -~ residing in 't^~'~'4 Kentucky
I, CHARLES W. MITCHELL, the Testator, sign my name, by making my
~~
mark, to this instrument this ~ day of April, 2006, and being first duly swam, do
hereby declare to the undersigned authority tha# I sign and execute this instrument as
my LAST WILL AND TESTAMENT, and that 1 sign it willingly, that I execute it as my
free and voluntary act for the purposes therein expressed, and that I am eighteen (18)
years ofi ege yr alder, of sound mind, and under no constrain ue influence.
~ c
TESTATOR (h
~P~
a
63f13f2667 14:65 7175415487 THE UP5 STORE 22[]4 PAGE 67f67
LAST WILL AND 'TESTAMENT
~F
CHARLES W. MITCHELL
We. V1fQl and < 4 . "~~-. the
witnesses, sign our names to this instrument, being first duly swum, and do hereby
declare to the undersigned authority that the Testator signs this instrument as his LAST
WILL AND TESTAMENT and that he signs ik willingly, and that each of us, in the
presence and hearing of the Testator and in the presence of the other subscribing
witness, hereby signs this W[II as witness tv Testator signing, and that #v the best of our
knowledge the Testator is eighteen (1 B) years of age or older, of sound mind, and
under no cnnstra[nt or undue [nftuence.
WI NESS ~ ~
,. ~T"
WITNESS
COMMONWEALTH OF KENTUCKY
COUNTY OF SCOTT
Subscribed, swom to and acknowledged before ma by CHARLES W.
MITCHELL, the Testator, by making his mark subscribed and swom to be#ore me by
and 1~?_~~~ a_~Q- ,witnesses, this +~ day of
April, 2006.
~~
NOTARY P LIC
My cnmmisston expires: ~ ~' S " ~O
PREPARED BY:
RAND L. MARSHALL
ATTORNEY AT LAW
198 East Washington Street
Georgetown, Kentucky 40324
[ml-Willa-m1K11ollchas]
.~e~ ~ 3
~~~~~
1a, vG~1,lGtlltlll~ .71L'dlE'lll6lli U.S. Department of Housing
and Urban Development ~
~~
OM8 Approval No. 2502-0265
Ts'. T e of Loan
1. ^ FHA 2. ^ FmHA 3. ^Conv. Unins. a. Fue Number 7. Loan Number 8. Mortgage insurance Case Number
4. ^ VA 5. ^Conv. Ins. 1320552
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are
shown. Items marked '(p.o.c.)' were paid outside closing; they are shown here for informational purposes and not
included in the totals.
D. Name end Atldress of aorrower E. Name and Address of Seller F. Name end Address of Lender
LISA D. MITCHELL ESTATE OF CHARLES W. MITCHELL GRAYSTONE MORTGAGE, LLC
G. Property Location H. Settlement Agent
5016 EAST TRINDLE ROAD HAROLD S. IRWIN 111
PAECHANICSBURG PA 17050 Piece of Settlement I. Settlement Date
IRWIN LAW OFFICE 5/412007
CARLISLE PA 17013 Disbursement Dete
Lat: slack: 5/4/2007
J. Summary of Borrowers Transaction K. Summary of Seller's Transaction
__ ....,.,... n.,e o....., ra.........e. enn. r,.,, . nm r„r nno 7r, sour,.
tot. Contract sales ice 100 000.00 4ot. Contract sales dce 100 000.00
102. Personal r e 402. Personal ro e
103. Settlement char es to bonower line 1400) 3 567.61 403.
104. 404.
105. 405.
Ad ustments for items aid b seller in advance Ad ustments for Items aid b seller in advance
106. Ci /town taxes to 406. Cit /town taxes to
107. Coun taxes to 407. Coun taxes to
708. Assessments to 408. Assessments to
tos. School Taxes 5/4/2007 to 6/3012007 216.03 aos. School Taxes 5/4/2007 to 6/30/2007 216.03
7 to. to ato. to
111, to 471. to
112. to 412. to
113. to 413. to
114. to 414. to
115. to 415. to
i20. Gross Amount Due From Borrower 103,783.64 420. Gross Amount Due 7o Seller 100,216.03
_ _ .. .. a mn RaAr,~Hnnn In Amn„M fh,n Tn Collar
201. De sit or earnest mono 501. Excess de osit see instructions
202. Princi al amount of new loans 77 300.00 502. Settlement char es to seller Tine 7400 205.00
203. Existin leans taken sub ect to 503. Existin loan s taken subject to
P0q_ 504. Pa ff of first mart a e loan
205. 505. Pa ff of second mart a e loan
206. 506.
207 507.
P08. 508.
209, 509.
Ad'ustments Tor Items un aid b seller Ad ustments for Items un aid b seller
210. City/town taxes 1/1/2007 to 5/4/2007 127.72 510. Cit /town taxes 1/1/2007 to 514!2007 127.72
to
271. Coun taxes
511. Coun taxes to
to
212. Assessments
512. Assessments to
to
213.
573. to
to
214.
514. 1O
to
215.
915. to
to
276.
516. tO
to
217.
517. to
to
218.
518. to
to
279.
579. to
220. Total Pald By/For Borrower 77,427.72 520. Total Reduction Amount Due Seiler 332.72
--- _... .. .. _...----•'-_-.~.- ~----...__ ann ran er sonln,.,onr rr,rFrnm souor
301. Gross Amount due from borrower line 120 103 783.64 601. Gross amount due to seller line 420 100,216.03
302. Less amaunt id b /tar bonower line 220 77 427.72 602. Less reductions in amt. due seller line 520 332.72
303. Cash ~ From ^ To Borrower 26,355.92 603. Cash ®To ^ From Seller 99,883.31
SUBSTITUTE FORM 1099 SELLER STATEMENT
The information contained in Blocks E, G, H, and I and on line 407 (or, line 403 and 404) is important tax information end 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 end the IRS determines
that it has not been reported. If this real estate is your pdncipal residence, file Form 2719, Sale or Exchange of Principal Residence, for any gain, with your income tax
return; for other transactions, complete the applicable parts of Form 4797, Fonn 6232 and/or Schedule D, Form 7040). You are required to provide the Settlement Agent
(named above) with your correct taxpayer identification number. If you do not provide the Settlement Agent with your correct taxpayer identification number, you may be
subject to civil or cdminal penalties Imposed by law. Under penalties of perjury, I certify that the number shown on this statement is my coned taxpayer identification number.
Signature)
700. Total Sales/Broker's Commission based on rice $ % ` Paid From Paid From
Division of Commission line 700 as follows: Borrower's Seller's
Funds At Funds At
701!$ to
Settlement Settlement
A00. Item.¢ Pavahle In Connection With Loan
801. Loan Ori ina0on Fee
802. Loan Disccunt
803. A rafsal Fee to
804. Credit fle ort to
805. Lenders fns action Fee
806. Mort e e Insurance A lication Fee to
807. Assum lion Fee
aofi. Document Pre aration Fee to GRAYSTONE MORTGAGE 375.00
Bog. Processin Fee to GRAYSTONE MORTGAGE 125.00
ato. Tax Realted Service Fee to GRAYSTONE MORTGAGE 75.00
817. Underwritin Fee to GRAYSTONE MORTGAGE 150.00
e72. A lication Fee to GRAYSTONE MORTGAGE 395.00
873. FAFDS Flood Certification Fee to FAFDS /FLOOD CERT 18.50
ono Ifnme Rannlroef Rv I nnrler Tn An Pair) In Arlvanra X Frrh vie lacf riav In ralr¢ _ line Ont
907. InterasUrom 5lM2007 to 6/1/2007 ®$12.97 /da 28 Da s 363.16
902. Mon e e Insurance Premium for months to
903. Hazard Insurance Premium for One ears to ALLSTATE 561.20
soa. ars to
sos.
Dnnen•ne nnnnrtilnrl Wiflr I on Aar
1001. Hazard insurance months~$ per month
1002. Mort a e insurance months~$ er month
7003. Ci roe texas months®$ er month
1004. County roe taxes months®$ er month
7005. Annual assessments months®$ ar month
1006. months®$ er month
7007. months ®+$ er month
1006. Arc gre to Accountin Ad'ustment
1107. Settlement or closin fee to IRWIN LAW OFFICE 200.00
1102. Absnect or title search to
1103. Title examination to NIVEN BAIRD 105.00
1104. Title Insurance binder to
1105. Document r aration to
7106. Notary fees to
7 707. Anomey's fees to IRWIN LAW OFFICE 200.00
(Includes above items numbers:
1108. Title Insurance to PENN ATTORNEYS TITLE INSURANCE COMPANY 958.75
(Includes above items numbers: 1107 1108
1109. Lender's covera a 77 300.00 $
1110. owners covera a 100,000.00 $
77 t t. Endorsements 8.1 100 and 300 to PENN ATTORNEYS TITLE INSURANCE COMPANY 75.00
t t t2. Closing Protection Letter to PENN ATTORNEYS TITLE INSURANCE COMPANY 35.00
7773. Overnight Mail Exgenses to IRWIN LAW OFFICE 30.00
1201. Recordin fees: Deed $ 38.50 Mort a e $ 62.50 ; fleleases $ 101.00
1202. Citylcoun taxlstam s: Deed $ ; Mon a e $
7203. State taxfstam s: Deed $ ; Mort a e $
1204.
1205.
1301. Survey to
1302. Pest inspection to
1303. Tax Certification to MARIE HUBER TREASURER 5.00
1304.
1305.
7306.
1307.
7308.
1400. Total Setdement Charges (enter on lines 103, Secitan J and 502, Section K) 3 567.61 205.00
CERTIFICATION
1 have carefully reviewed the HUD•1 Settlement Statement end to the best of my knowledge and ballet, it is a true and accurate statement of all receipts and disbursements
on my account or by me In this transaction. I further certity that I have received a copy of the HUD-7 Settlement Statement.
Seller
ESTATE OF GHARLES W. MITCHELL
Borrower
LISA D. MITCHELL
Seller
Borrower
To the best of my knowledge the HUD•1 Settlement Statement which 1 have prepared is a true and accurate account of the funds which were received and have been or will
be disbursed by the undersigned as part of the settlement of this transaction.
_ Settlement Agent 5/4/2007 Date
HAROLD S. IRWIN, 111
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 floe and
imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 7010.
US GGYERNGENT PRINTING OFFICE: t%90944-145
OMB N0.2502-0265 ~r
A B. -TYPE OF LOAN:
1'Q FHA 2.QFmHA 3.QCONV. UNINS. 4.QVA 5.QCONV. INS.
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT
ENT STATEMENT 6. FILE NUMBER:
08REVERCOMBR 7. LOAN NUMBER:
SETTLEM 8. MORTGAGE INS CASE NUMBER:
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "(POCJ" were paid outside the closing; they are shown here for in/ormational purposes and are not included in the totals.
1.0 398 (OBREVERCOMBR.PFD/OeREVERCOMBRli 4)
D. NAME AND ADDRESS OF BORROWER:
Robert O. Revercomb III and
Maria L. Revercomb
P.O. Box 54
Shade Gap, PA 17255 E. NAME AND ADDRESS OF SELLER:
Charles W. Mitchell Estate
64 S. Pitt Street
Carlisle, PA 17013 F. NAME AND ADDRESS OF LENDER:
Community State Bank
P.O. Box 8
Orbisonia, PA 17243
G. PROPERTY LOCATION:
Main Street
PA 17255
Shade Ga H. SETTLEMENT AGENT: 25-1741454
Central Penn Settlement Co. I. SETTLEMENT DATE:
May 30, 2008
p,
Huntingdon County, Pennsylvania
Tax Parcel No. 41-Ot-48 PLACE OF SETTLEMENT
225 VJashington St.
Huntingdon, PA 16652
Disburse:06/04!08
J. SUMMARY OF BORROW ER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 17,500.00 401. Contract Sales Price 17,500.00
102. Personal Pro a 402. Personal Pro e
103. Settlement Char es to Borrower Line 1400 1,420.50 403.
104. 404.
105. 405.
AdLstments For Items Paid B Seller in advance Ad'ustments For Items Paid B Seller in advance
106. School O6/OS/OS to 07/01/08 27.13 406. School 06/05/08 to 07/01/08 27.13
107. Count /Boro 06/05/08 to 01/01/09 109.58 407. Count /Boro 06/05/08 to 01/01/09 109.58
108. Assessments to 408. Assessments to
109. 409.
110. 410.
111. ~ 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 19,057.21 420. GROSS AMOUNT DUE TO SELLER 17,636.71
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. De osit or earnest mone 500.00 501. Excess De osit See Instructions
202. Princi al Amount of New Loans 26,500.00 502. Settlement Char es to Seller Line 1400 1,835.00
203. Existin loans taken sub~ect to 503. Existin loans taken sub'ect to
204. 504. Payoff of first Mortgage
205 505. Pa off of second Mort a e
206. 506.
207 507. De osit disb. as roceeds
208. 508.
209. 509.
Ad'ustments For Items Un aid B Seller Ad'ustments For Items Un aid B Seller
210. School to 510. Schocl to
211. Coun /Boro to 511. Coun /Boro to
212. Assessments to 512. Assessments to
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218 518. 2008 Co/Boro Tax to Shade Ga Boro T/C/#41-01-48 194.88
219. 519.
220. TOTAL PAID BY/FOR BORROWER
300. CASH AT SETTLEMENT FROM/TO BORROWER: 27,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER
600. CASH AT SETTLEMENT TO/FROM SELLER: 2,029.88
301. Gross Amount Due From Borrower Line 120 19,057.21 601. Gross Amount Due To Seller Line 420 17,636.71
302. Less Amount Paid By/For Borrower (Line 220) ( 27,000.00) 602. Less Reductions Due Seller (Line 520) ( 2,029.88
303. CASH ( FROM) (X TO) BORROWER 7,942.79 603. CASH (X TO) ( FROM) SELLER 15,606.83
The undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein.
I HAVE CAREFULLY REVIEWED THE HU -1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOW LEDGE AND BELIEF, IT IS A TRUE AND
ACCURATE STATEMENT OF ALL R TS AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY ME IN THIS TRANSACTION. I FURTHER CERTIFY
THAT I HAVE RECEIVED A C E U -1 SETTLEMENT STATEMENT.
Borrower Seller Ch W Mitc II Es e
Robe O. comb III I
BY:
M ria L. R rc m
TO THE BEST OF MY KNO EDG ,THE HUD-1 S EMENT STATEMENT WHICH I HAVE PREPARED IS A TRUE AND ACCURATE ACCOUNT OF THE
FUNDS WHICH WERE C A E E WILL BE DISBURSED BY THE UNDERSIGNED AS PART OF THE SETTLEMENT OF THIS
TRANSACTION.
Central Penn eaement Co.
Settlement Agent
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE: TITLE 18 U.S. CODE SECTION 1001 & SECTION 1010.
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION Based on Price $ 17,500.00 ~ 6.0000 % 1,050.00 PALO FROM PA{O FROM
Division of Commission line 700 aS FO/TOWS: BORROWER'S SELLER'S
701. $ 1,050.00 to Country Heritage Real Estate FUNDS AT FUNDS AT
7D2. $ t0 SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement 1,050.00
704. to
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Ori ination Fee % to
802. Loan Discount % to
803. Appraisal Fee to
804. Credit Report to
805. Lender's Inspection Fee to
806. Mort a e Ins. A .Fee to
807. Assumption Fee to
808. Application Fee to Community State Bank 150.00
809. Document Preparation Fee to Community State Bank 200.00
810. Flood Determination Fee to CBC Innovis 28.00
81 t. Pre aid Satistaction Fee to Communi State Bank POC:B107.00
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to ~ $ /day ( days %)
902. Mort a e Insurance Premiumfor months to
903. Hazard Insurance Premium for 1.0 ears to Everett Cash Mutual POC:685.00 I
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance months ~ $ er month
1002. Mort a e Insurance months ® $ er month
1003. School months ~ $ er month
1004. Coun /eoro months @ $ er month
1005. Assessments months ® $ per month
1006. months ~ $ er month
1007. months ~ $ per month
1008. A re ate Ad'ustment Cr. months ® $ er month
1100. TITLE CHARGES
1101. Settlement or Closin Fee to Central Penn Settlement Co. 95.00
1102. Abstractor Title Search to Central Penn Settlement Co. residence 135.00
1103. Title Examination to Central Penn Settlement Co. 395.00
1104. Tite Insurance Binder to
1105. Document Pre oration to Central Penn Settlement Co. 95.D0
1106. Nota Fees to Nota 10.00
1107. Attorney's Fees to Irwin Law Office 500.00
includes above item numbers:
1108. Title insurance to
includes above item numbers:
1109. Lender's Coverage $
1110. Owner's Coverage $
1 t 11. Overnight Delivery to Irwin Law Office 30.00
1112.
1113. Wire-In Fee Omega Bank
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 28.50; Mortgage $ 109.00; Releases $ 137.50
1202. Cit /Count Tax/Stam s: Revenue Stam s 175.00 ~ Mort a e 175.00
1203. State Tax/Stam s: Revenue Stam s 175.00; Mon a e 175.00
1204. Exem lified Estate Records to Irwin Law Office 50.00
1205. Record Estate Records to Huntingdon County Recorder of Deeds 30.00
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Surve to
1302. Pest Ins ection to
1303.
1304.
1305.
1400. TOTAL SETTLEMENT CHARGES Enter on Lines 103, Section J and 502, Section K 1,420.50 1,835.00
ey signing page ~ o/ this statamerti, tha signaroAes acknowtetlge receipt of a completeo copy of page 2 of Nis two page sra~em~ ,,¢¢//~ i (i IL~-
Central~Settlement Co
Settlement Agent
Certified to be a true copy.
(OBREVERCOMBR /OBREVERCOMBR/t4)