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HomeMy WebLinkAbout09-29-08J REV-1500 EX (06-05) PA Departrnent of Revenue Bureau of Individual Taxes PO BOX 280601 Hanisburg, PA 17128-0601 15056051058 OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT ' 21 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death __ __ _ ___ 203-24-5091 03/02/2008 __ _ _. Decedent's Last Name :BETZ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number 08 0402 Date of Birth _. 11/07/1931 __ _ Suffix Decedent's First Name ... 'DONALD Suffix Spouse's First Name __ __ MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE __ ___ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O)b 1. Original Retum C 2. Supplemental Retum 3. Remainder Return (date of death prior to 12-13-82) C„~3 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) C!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) C3 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death C 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number __ __ 'THOMAS E. FLOWER ' (717;1737-3405 c...., ~i~me ns e....n,..,tii,.~ __ __ -;. ~ e r'i-i ' a ,:~'_i - - ~..~ ~.~, ."] --; ~ _.. CAMP HILL Correspondent's a-mail address: ~IOW2r@Sfl-IaW.COm PA ':17011 ,_ _~ . r~it ~- U~ c:~:3 -. rl` Under Wallies of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, it is tru co t and complete DeGaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA E F PER O E PONSIBLE FOR FILING RETURN ~s 4 ~~i uo~ ADDRESS ~ DOUGLAS .BETZ, 1342 SCONSETT WAY, NEW CUMBERLAND, PA 17070 SAIDIS, FLOWER & LINDSAY, 2109 MARKET STREET, CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 :15056051058 MI ',F', ~/ 15056052059 REV-1500 EX Decedent's Social Security Number __ Decedent's Name: DONALD F BETZ ~ 203-24-5091 ', RECAPITULATION 1. Real estate (Schedule A) ............................................. L 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) t~5 Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property '_..__.._.__. (Schedule G) t~ 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. i 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. 8,184.27 '' 34,497.87 '. 504,475.14 0.00 504,475.14 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X .0 45 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 185,000.00 15,529.40 38,897.15 299,546.46 538,973.01 26,313.60 15. 16. '. 17.' 18. 19. TAX DUE .........................................................19., ._.. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 22,701.38 22,701.38 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: __ FIIe Number, , ~21 08 ~~'0402 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER DONALD F BETZ 203-24-5091 STREET ADDRESS 308 ERFORD ROAD CIN CAMP HILL STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty 10,000.00 526.30 (1) Total Credits (A + B + C) (2) (3) (4) (5) (5A) (5B) Total InteresUPenalty (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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 22,701.38 10,526.30 0.00 12,175.08 0.00 12,175.08 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? ...................................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................... ....................................... ^ 3. Did decedent own an "in trust 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 exemot 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 DONALD F. BETZ 21-08-0402 Ail 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 reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. Dwelling house and lot, 803 Erford Road, East Pennsboro Twp., Cumberland County, Pa gross sale proceeds, see HUD-1 settlement sheet attached behind Schedule H 185,000.00 TOTAL (Also enter on line 1, Recapitulation) I i 185,000.00 (If more space is needed, insert additional sheets of tfie same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCiIIEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER DONALD F. BETZ 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 ADDRESS RELATIONSHIP TO DECEDENT A• Douglas J. Betz 1342 Sconsett Way `son New Cumberland, PA 17070 B. i JOINTLY-OWNED PROPERTY: 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 ~' A' O6/06/O6 Commerce Bank checking acct. #512038027 69,865.53 ' .5 34,932.77 - 2• A 0629106 Commerce Bank savings acct. # 410115542 2,429.98: .5 1,214.49 3• A 03/14/06 Americhoice FCU savings acct. #229 3,988.31 .5 1,994.16 4• A 03/14/06 Amelichoice FCU checking acct. #229 1,511.46 ' .5 755.73 TOTAL (Also enter on line 6, Recapitulation) 13 38,897.15 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RFSIr1FNT I'1FCF{~FNT SCHEDULE 6 INTER-YIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER DONALD F. BETZ 21-08-0402 rnl~ sd,adula mutt be rnmDleted and filed if the answer to anv of Duestlons 1 through 4 on the reverse side of the REV-15110 COVER SHEET is yes. ITEM NUMBE DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A CCPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET °b OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE ~ ~ CUNA Mutual Annuity contract #000060130049, lump sum death benefit 78,516.79 100 78,516.79 2. 4,697.385 SHARES DELAWARE TAX FREE PA FND CL A @ 7.625 35,817.56 100 35,817.56' 3. 1,056 SHARES IBM COMMON STOCK @ 114.195 120,589.92 100 120,589.92 4. 4,811.779 SHARES PHOENIX BALANCED FUND CL A @ 13.43 64,622.19 100 64,622.19 All assets paid to David Betz (son) and Douglas Betz (son) in equal shares TOTAL (Also enter on line 7 Recapitulation) S I 299,546.46 (If more space is needed, insert additional sheets of the Same size) PHBLX: Historical Prices for PHOENIX CAPITAL GROWTH FUND CL.A Yahoo! My Yahoo! Mail More ,~H~® FINANCE Dow ~ 0.12% Nasdaq 'f' 0.77% Search WEB SEARCF Wed, Sep 24, 2008, 10:48AM ET - U.S. Markets clod Q~T ~DiufS°rfs<S Finance Search ~_ _. Phole~npi~x 1YBalpaYY nced A (PHBLX) /~' -,Y On Sep 23: '12.13 ~i ~WfA~W~~ ~~II4l I Mi ~IIA !~ f W ~~E ~ $9.9~ tt'c'1E~@$. ,; 1rlO~ surprises- E~IF.H4E SCCU~tt IC! LPL Historical Prices Get Historical Prices for: r~ GO SET DATE RANGE r- Daily Start Date: Feb t 29 2008 ~ Eg. Jan i, ~ .. _ 2003 ~ Weekly End Date: Mar ~ 03 2008 r Monthly ~~~ C- Dividends Only Gi3# Prices First ~ Prev ~ Next ~ Last PRICES Date Open High Low Close Volume Adj Close" 3-Mar-08 13.43 13.43 13.43 13.43 0 13.20 29-Feb-08 13.43 13.43 13.43 13.43 0 13.20 "Close price adjusted for dividends and splits. First ~ Prev ~ Next ~ Last 1 Download To Spreadsheet ADVERTISEMENT ! Fi... Page 1 of 3 User? Sign Up Sign In http://finance.yahoo.com/q/hp?s=PHBLX&a=01 &b=29&c=2008&d=02&e=03&f=2008&... 9/24/2008 IBM: Historical Prices for INTL BUSINESS MACH -Yahoo! Finance Yahoo! My Yahoo! Mail More Page 1 of 3 New User? Sign Up Sign In __ Search ~~ ~ WEB SEARCF Dow '~' 0.15% Nasdaq 'f' 0.18% Wed, Sep 24, 2008, 9:56AM ET - U.S. Markets clo ~titWT'E3 Finance Search s,,~.~.. International Business Machines Corp. (IBM) At 9:38AM ET: ~ 17.02 t ,.~ .~„ r~"' ,. + ~ bws'~~i~~al Ai'~~ ~ . ~P~ I ~ ArirlNtl'rl~i~~6 ~ ~~'"~~~~ EVo ma+ntonanoa . '' E~ISA~'E 5¢[Jfli{7t LLG -- - Historical Prices SET DATE RANGE Start Date: Feb - 29 2008 Eg. ]an 1, 2003 End Date: Mar „- ~~ 2008 Get Prices Get Historical Prices for: DELIx GO r Daily C Weekly C', Monthly C Dividends Only First ~ Prev ~ Next ~ Last PRICES Adj Date Open High Low Close Volume Close" 3-Mar-08 113.86 114.81 113.48 114.23 6,335,700 113.32 29-Feb-08 114.04 115.14 113.35 113.86 8,475,100 112.96 Close price adjusted for dividends and splits. First ~ Prev ~ N ext ~ Last `i Download To ~readsheet ADVEr~TISEMENT http://finance.yahoo.com/q/hp?s=IBM&a=01&b=29&c=2008&d=02&e=3&f=2008&g=d 9/24/2008 DELIX: Historical Prices for DMC TAX-FREE INCOME TRUST -PEN -Yahoo! Finance Page 1 of 3 Yahoo! My Yahoo! M il a More New User? Sign Up Sign In ~ ' ._.~ ___ _ _. _ __ ~;~ F~~A~~E Searc h I _.......... .... _._. __ .. ~ .WEB SEARCF DOW ~ 0.08% Nasdaq '~' 0.19% Wed, Sep 24, 2008, 9:58AM ET - U.S. Markets clo +It<8t tItJCTr1~ Finance Search Delaware Tax-Free PA A (DELIX) On Sep 23: 7.57 # ! ~ wa~i~Nirrwwo^ f~~i ~, r+ +~~ ~ ~ ~ air a ill i , TRA1~3Ea FREE i=C]H ~ ~~ .~ ~~Q ~ CST StOe C*THHOE fEi~VRiT~f lLC Historical Prices Get Historical Prices for: ~- GO SET DATE RANGE r Daily Start Date: Feb - an 1, ~. Weekl 29 2008 j zo ___ , y o3 End Date: Mar - ~3 ~ 2008 C Monthly C' Dividends Only Get Prices First ~ Prev ~ Next ~ Last PRICES Date Open High Low Close Volume Adj Close* 3-Mar-08 7.64 7.64 7.64 7.64 0 7.48 29-Feb-08 7.61 7.61 7.61 7.61 0 7.45 * Close price adjusted for dividends and splits. 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BETZ 21-08-0402 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES:... ~~ Myers-Hamer Funeral Home, professional services and products 2,971.00 2. St. John's Cemetery, burial 250.00 3. Gingrich Memorials, engraving 130.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Soaal Security Number(s)IEIN Number of Personal Representative(s) ', Street Address City State'. Zip Year(s) Commission Paid: 2. Attorney Fees 5,000.00 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 4. Probate Fees 302.00 5. Accountant's Fees 3,500.00 6. Tax Return Preparer's Fees ~. .publish executor's notices; Sentinel, $182.56, Cumbeliand Law Journal, $75 257.56 B. Net Settlement Costs on sale of 308 Erford Road, see attached HUD-1 settlement sheet 13,903.04 TOTAL (Also enter on line 9, Recapitulation) $ 26,313.60 (If more space is needed, insert additional sheets of the same size) Previous editions are obsolete A. Settlement Statement forth HUD-1 (3186) ref Handbook 4305.2 U.S. Department of Housing and Urban Development OMB A roust No. 2502-0265 ex fires 11/30/2009 FINAL ts. t e of Loan 1. ^FHA 2. pFmHA 3. pConv. Unins. 6, File Number 7. Loan Number 8. Mortgage Insurance Case Number 4. ^VA 5. Conv.lns. HS08039 0055228795 Is orm is umi e o give you a s a amen o a ua se amen cos s. moun s psi o an y e se amen agan are own. TitleExpress Settlement System C. Note: Items marked "(p.o.c.)" were paid outside the Dosing; they are shown here for information purposes and are not inducted in the totals. WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon convia;on can include a tine and im nsonment. For details see: Title tli U. 5. Code Section 1001 and Section 1oto. Printed 08/01/2008 at 13:34 JG D. NAME OF BORROWER: Justin Kasprzak and Kristin McCabe ADDRESS: E. NAME OF SELLER: The Estate of Donald F. Betz, and Douglas J. Betz ADDRESS: F. NAME OF LENDER: ERA Home Loans ADDRESS: 3000 Leadenhall Rd. Mt. Laurel NJ 08054 G. PROPERTY ADDRESS: 308 Erford Road, Camp Hill, PA 17011 East Pennsboro Townshi H. SETTLEMENT AGENT: Heritage Settlement Services, LLC, Phone: 717-975-2117 Fax: 717-730.9665 PLACE OF SETTLEMENT: 4705 E. Trindle Road Mechanicsbur PA 17050 I. SETTLEMENT DATE: 0810412008 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM 80RROWER 400. GROSS AMOUNT DUE TO SELLER 101. Contract sales rice 185 000.00 401. Contract sales rice 185 000.00 102. Personal Pro a 402. Personal Pro art 103. Settlement cha es to borrower line .1400 5 602.65 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad'ustments for items paid b)/ seller in advance 106. Ci Itown taxes 406. Git /town taxes 107. Count taxes 08104108 to 12131108 205:98. 407: Coun axes 08104108 to 12131108 205.98 108. School taxes 08104108 to 06(30109 1537.31 408. School taxes 08104108 to 06130109 1 537.31 109. Sewer JIA/S 08104108 to 09130108 72:50 409. Sewer J1AIS 08104108 to 09130!08 72.50 110. 410. . 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM 80RROWER 200. AMOUNTS PAID' BY OR ON BEHALF OF BOR 192418.44 ROWER 420. GROS5'AMOUNT DUE TO SELLER 186 815.79 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. De osit or earnest mone 2 000.00 501. Excess De sit see'instructions ' 202. Princi al amount of new loans 166 500.00 502. Settlement char es to seller line 1400 15 718.83 203. Existin loan s taken sub'ect to 503. Existin loans taken sut~'eci t to 204. 504. Pa off of First Mort a e Loan 205. 505. 206. 506. 207. 507. 208 508. 209. 509. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. Cit !town taxes 510. Cit !town taxes 211. Count taxes 511. Count taxes 212. School taxes 512. School taxes 213. 513. 214. 514. 215 515. 216. 516. 217. 517. 218, 518. 219. 519. 220. TOTAL PAID BYIFOR BORROWER 168 500.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 15 718.83 300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLER 301. Gross amount due from borrower line 120 192 418.44 601. Gross amount due to seller line 420 186 815.79 302. Less amounts aid b/for borrower line 220 168 500.00 602. Less reduction amount due seller line 520 15 718.83 303. CASH FROM 80RROWER 23 918.44 603. CASH TO SELLER 171 096.96 SUBSTITUTE FORM 1099 SELLER STATEMENT: The information contained herein is importani tax information and is being furnished to the Internal Revenue Service. It you ere requ(red to file a return, a negligence penalty or other sanction will be Imposed on you if this item is required to be reported and the IRS determines that it has not been reported. The Contract Sales Price described on line 401 above constitutes the Gross Proceeds of this transaction. You are required by law to provide the aetttement agent (Fed. Tax ID No: 251751621 } wllh your wrred Taxpayer ioentlficatton number. If you do not provide your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed bylaw. Under penalties of perjury, I certity that the number shown on this statement is my correct taxpayer identificaton number. TIN: / SELLER(S) NEW MAILING ADDRESS: _ SELLER(S) PHONE NUMBERS: _ SELLER(S) SIGNATURE(S): (H) _(W) Previous editions are obsolete U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ' SET`fLEMENT STATEMENT File Number: HS08039 re.,e,.....,.,,, e,.ui,.__.,. ~ form HUD-1 (3/88) rei Handbook 4305.2 FINAL PAGE 2 - ~ nic~n ~caa vcuicinGin J stem L. SETTLEMENT CHARGES nuIIeV V6/U-I/LVUtS aI PAID FROM 15:34 Jli PAID FROM 700. TOTAL SALES/BROKER'S COMMISSION based on rice $185 000.00 =11 100.00 BORROWER'S SELLER'S Division of commission line 700 as follows: FUNDS AT FUNDS AT 701. to ERA-NRT Inc. SETTLEMENT SETTLEMENT 702. 11 100.00 to ERA-NRT Inc. 703. Commission aid at Settlement 11 100.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee 802. Loan Discount 803. A raisal Fee 804. Credit Re ort to FNMA CBC Innovis Inc $22.50 POC b Lender 805. Lender's Ins action Fee 806. Mort a e A lication Fee to ERA Home Loans $500.00 POC b Lender 807. Assum tion Fee 808. Flood Certification to STARS 19.50 POC b Lender 809. Document Pre aration Fee to ERA Home Loans 85.00 POC b Lender 810. 811. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From ©810412008 'to 09/0112008 30.9800 Ida 28 Da s 867.44 902. Mort a e Insurance Premium'"for to 903. Hazard Insurance Premium for to 904. 905. 1000. RESERVES DEPOSITED WITH LENDER FOR: 1001. Hazard Insurance 3 mo; 42.17 Imo 126.51 1002. Mort a e Insurance mo. /mo 1003. Ci Pro art Tax mo. /mo 1004. Count Pro art Tax 8 mo. 41.88 Imo 335.04 1005. School taxes 3 ma' ~ 141.27 Imo 423;81 1009. A re ate Anal sis Ad'ustment to ERA Home-Loans -209:40 0.00 1100. TITLE CHARGES 1101. Settlement or closin fee 1102. Abstract or title search 1103. Title examination 1104. Title insurance binder 1105. Document Pre aration 1106. Note Fees to Nota Public 25.00 20.00 1107. Attome 's fees includes above items No: 1108. Title Insurance to Herita a Settlement Services LLC 1283.75 includes above items No: 1109. Lender's Polic 166 500.00 - 1110. Owner's Polic 185 000.00 -1283.75 1111. 100 No Viol 300 Surve 900E to Herita a Settlement Services LLC 150.00 1112. 1113. Closin Svcltr to Old Re ublic National Title Insurance Co. 35.00 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recordin Fees Deed 38.50 • Mort a e 64.50 • Release 103.00 1202. Cit (Count tax/stam s Deed 1 850.00 • Mort a e $ 1 850.00 1203. State Taxlstam s Deed 1 850.00 • Mort a e 1 850.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Radon Treatment to Enviro uest _ 407.50 407.50 1302. Transaction Fee to ERA-NRT Inc. 165.00 165.00 1303. Courier Fee to Herita a Settlement Services LLC 15.00 15.00 1304. Electronic Document to Herita a Settlement Services LLC 25.00 1305. 2008 School Taxes to Debbie Lu old 1 661.33 1306. Tax Cert Fee to Herita a Settlement Services LLC t 5.00 1307. Home Warrant to American Home Shield 495.00 11400. TOTAL SETTLEMENT CHARGES tenter on lines 103 Section J and 502 Section IQ 5 602.65 15 718.83 HUD CERTIFICATION OF BUYER AND SELLER 1 have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belles, it Is a true and accurst statement of atl receipts and disbursements made on my account or by me in 's transaction. I further certiry that I hav received a copy of the HUD-1 Settlement Statement. us in as s m c e sa o na e , oug as e WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-7 UNITED STA7ES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION transaction. CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION'10~0. SETTLEME :cunt of this vith this statement. DATE: U ~ -U REV-1512 EX+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MnRTGAGE LIABILITIES. & LIENS ESTATE OF FILE NUMBER DONALD F. BETZ 21-08-0402 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ US Treasury, 2007 federal income tax paid with return 6,624.87 2. Dr. Michael Sams, physician's bill 87.97 3. Holy Spirit Hospital 1,061.69 4. Medco, pharmacy bill 113.14 5. Central PA Pulmonary Assn. 90.83 6. OSL DBA Orthopedic Institute of PA 99.62 7. Spirit Physician Services 106.15 TOTAL (Also enter on line 10, Recapitulation) S 8,184.27 (If more space is needed, insert additional sheets of the same size) ` REV-1513 EX+ (g-p0) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER DONALD F. BETZ 21-08-0402 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) (12)1 1 DAVID D. BETZ, 889 MANDY LANE, CAMP HILL, PA 17011 SON •5 2 DOUGLAS J. BETZ, 1342 SCONSETT WAY, NEW CUMBERLAND, PA SON •5 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET lI NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MIADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $, (If more space is needed, insert additional sheets of the same size) LAST WILL ` ~ ~' OF ~: DONALD F. BETZ ,• ' I, DONALD F. BETZ, of the Township of East Pennsboro, ,! jCumberland County, PennsylvaniG, declare this to be my Last Will i 'j and revoke any Will previously made by me. ~: Item 1: I devise and bequeath all of my estate of every ;:nature and wheresoever situate, together with insurance thereon, Ito my wife, JANE M. BETZ, providing she shall survive me by ~: ~~ ;thirty (30) days. ~' Item 2: Should my wife, JANE M. i,ETZ, predecease me or die ii 1. on or before the thirtieth (30th) day following my death, I devise !:and bequeath all of my estate of every nature and wheresoever :situate, together with insurance thereon, to my sons, DAVID D. :BETZ and DOUGLAS J. BETZ, share and share alike. I direct that ;; jdistribution be a per stirpes basis and not a per capita basis. ~ Item 3: I direct that all taxes that may be assessed in ~: ~jconsequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as ~a part of the expense of the administration of my estate. Item 4: I appoint my wife, JANE M. BETZ, Executrix of this jmy Last Wi11. Should my wife, JANE M. BETZ, fail to qualify or !:cease to act as Executrix, I appoint my son, DOUGLAS J, BETZ, ~~ ~:xecutor oz this my Last w11.L. In the event my wl=e, JA1V~; M. I. 3 1. .~,~ ~ i~`BETZ, and my son, DOUGLAS J. BETZ, both fail to qualify or cease `,,'- ~ } ; ~`%- ~;~';ta act as Execut©rs, I appoint my son, DAVID D. BETZ, as Executor. ~' ~ `~ `a;;_ -';~ Item ~: I direct that my personal representative or their '~ ~:" ' ~_~~~'~ ~ ~ ~ successors shall not be required to give bond for the faa.thful ~ ~= ~ j~ performance of their duties in any jurisdi.ct,ion. ~: t ~. ,.;{ s is rI t i ~,.: I ~--` i a~ ~, Item 6: I direct that all my just debts and funeral expenses shall be paid from my residuary estate as a part of the expense of the administration of my estate. IN WITNESS WHEREOF, I have hereunto set my hand this %~~ If1r day of ~! i?t'/ t 19 ~~ . ~. .. Donald F. Betz ~~ The preceding instrument consisting of this and one {1) ?. other typewritten page, each identified by the signature of the .~ Testator, DONALD F. BETZ, was on the day and date thereof signed, ~~ ~; published and declared by DONALD F. BETZ, th.e Testator therein named, as and for his Last Will, in the presence of us, who, at his request,- in his presence, and in the presence of each '4t her, `" have subscribed our-names as witnesses hereto. ~ l i ~~~ residing at j I 1' 1' ~c~ residing at ~~O~i if ~' +' i i l a 1 << .... ~ 1 r: .~ ___ _ . _ _ ~ i