HomeMy WebLinkAbout11-24-08 (2)15056041103
REV-1500 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po Box 2sosol INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ` ~~ U~L'j1~
ENTER DECEDENT INFORMATION BELOW
Social
~8(]52~~8 0471924
Decedent's Last Name
CARR
Suffix Decedent's First Name
HELEN
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE BOXES BELOW
MI
M1
1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
^ 4
Limited Estat
^ 4
t
F
I
C prior to 12-13-82)
^
. e a. ure
u
nterest
ompromise {date of 5. Federal Estate Tax Return Required
6.
Decedent Died Testate
^ 7. death after 12-12-82)
Decedent Maintained a Living Trust
1 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 ^ 1 1. 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 70:
Name Daytime Telephone Number
MAY NARD D CARR 814-342-640
Firm Name (If Applicable)
First line of address
465 BLUE SPRUCE ROAD
Second line of address
City or Post Office
PHILIPSBURG
State ZIP Code
PA 16866
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address:
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 represe rmation of which preparer has any knowledge.
SI TUR/i~-o l ON RESP SIB OR F,Neftd~ RETURN ~~ DAB J - d .~
SIGNATURE PAR HE ENT~~ A DATE
/j /1 oZ60~;
ADDRESS
P 0 BOX 684, PHILIPSBURG, PA 16866
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041,103 ,wvsa7,.oo0 15056041103
15056042104
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: HELEN CAR R
RECAPITULATION
1. Real estate (Schedule A) 1. 17 8 6 7 4 - ^ 0
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. 4 4 2 3 8 • ~ D
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested 7.
8. Total Gross Assets (total Lines 1-7). 8. 2 2 2 912 • ^ ~
9. Funeral Expenses & Administrative Costs (Schedule H) . g. 14 2 2 ~ • ~ ~
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). 10. 7 ~ 9 ' 0 ~
1 1. Total Deductions (total Lines 9 & 10) . 11. ~' 4 9 2 9 ' ~ ~
12. Net Value of Estate (Line 8 minus Line 11) 12. 2 ~ 7 9 8 3 • ~ ~
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. 2 ~ 7 9 8 3 • ~ ~
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- 15.
16. Amount of Line 144~axable 2p7983.00 9359.24
at lineal rate X .0- 16.
17. Amount of Line 14 taxable
at sibling rateX .12 17. ~
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE 19. 9359 • 24
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1525604214 ~wasaai.ooo 150562427,04
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENTS NAME
HELEN CARR ESTATE
STREET ADDRESS
C/0 MAYNARD D• CARR
465 BLUE SPRUCE ROAD
CITY STATE ZIP
PHILIPSBURG PA ],6866
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 9 3 5 9.2 4
2. Credits/Payments
A. Spousal Poverty Credit.
13. Prior Payments
C. Discount
Total Credits (A + g + C) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D + E) (3)
4. ff Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in box on Page 2, Line 20 to request a refund. (4) ~ . ~ ~
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAx DUE. (5) 9359.2 4
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 9 359.2 4
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;
d
i
l
use the property transferre
ts income;
b. retain the right to designate who shal
or
i
i
t
t X
n
eres
; or .
c. retain a revers
onary ^ 0
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? .
"
"
or payable upon death bank account or security at his or her death?
3. Did decedent own an
in trust for
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
^
contains a beneficiary designation?
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. X9116 (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 10 or for use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~116(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.116(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. SJ9116(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.
~was~1 1.000
REV-1502 EX+(6-98) SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HELEN CARR
FILE NUMBER
A11 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 DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1. PERSONAL RESIDENCE, 40 LIMEKILN ROAD, WEST PENNSBORO TWP, 178,674
CARLISLE, PA 17013
PROPERTY WAS SOLD ON 11-05-2008
NET PROCEEDS WERE $180,000 + $1,209 - $2,535
HUD SETTLEMENT IS ATTACHED
7W4695 1.000
TOTAL (Also enter on line 1, Recapitulation) I $ 178, 674
(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
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
HELEN CARR
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 1987 OLDSMOBILE GUTLESS 500
2 SAVINGS ACCOUNT, MEMBERS 1ST FCU, 1166 WALNUT BOTTOM ROAD, 38,254
CARLISLE, PA, ACCOUNT #339060
3 MISCELLANEOUS REFUNDS 86
4 PERSONAL PROPERTY, SOLD AT AUCTION, STATEMENT ATTACHED 1,412
5 DIAMOND RING, APPRAISAL ATTACHED 3,877
6 SILVER FIREMEN'S PIN 15
7 SILVER TIE TAC 15
8 TOY TRUCK SET 7g
TOTAL (Also enter on line 5 Recapitulation) $ ~ 44, 238
7VJasAD 1.OO0 (If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
HELEN CARR
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AM 0 UNT
A. FUNERAL EXPENSES:
~. NICKEL FUNERAL HOME, LOYSBURG, PA 8,081
2 RICE MEMORIAL WORKS, GRAVESTONE 865
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
Citv
Year(s) Commission Paid:
State
Zip
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
8. Tax Return Preparer's Fees
7. COURT FEES & COSTS
8 ATTORNEY COSTS
9 APPRAISAL FEES
7.0 ADVERTISING COSTS
11 FUNERAL LUNCH
12 AUCTION EXPENSES
13 POSTAGE
14 EXECUTORS' MILEAGE & TRAVEL COSTS
1,050
306
100
307
258
275
750
69
2,159
TOTAL (Also enter on line 9, Recapitulation) ~ $ 14 , 220
7W46AG 1.000 (If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12.03)
SCHEDULEI
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHRESIIDENTDECEDENTRN MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
HELEN CAF2R
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 FINAL UTILITY BILLS & DISCONNECT FEES 709
TOTAL (Also enter on line 10, Recapitulation) $ ~ 709
7W46AH 1.000 (If more space is needed, insert additional sheets of the same size)
REV-1513 EX+(9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
HELEN CARR
1MBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers
under Sec. 9116 (a) (1.2)]
1 RONALD E CARR, CARLISLE, PA 17013
2 SHIRLEY C MAZURAK, ELMORA, PA 15737
3 MAYNARD D CARR, PHILIPSBURG, PA 16866
4 TERRY W SWARTZ, BLAIN, PA 17006
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
SON
DAUGHTER
SON
SON
AMOUNT OR SHARE
OF ESTATE
25$
25~
25~
25~
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
ii ~ NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART Il -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)
7W46AI 1.000
ij~
~y
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LAST' WILL
I, HELEN CARR, of Carlisle, West Pennsboro Township, Cumberland County,
Pennsylvaiua, declare this to be my Last Will and revoke any Wills previously made by
me.
I. I direct that any and all inheritance, estate and transfer taxes imposed upon
my estate passing under my V~Till or otherwise, shall be paid out of the principal of my
residuai-x estate.
II. I bequeath any monies in the Credit Union at Member's First to TERRY
WAYNE SWARTZ.
-__
III. I bequeath the set of Hess trucks to TERRY WAYNE SWARTZ.
N. I bequeath my one_ca~rat diamond ring to SHIRLEY MA,ZURAI~. ~~.~ ~~ ~. ~~ ~~ ;,~
V. I devise and .bequeath the residue of my estate of whatever nature or
wherever situated to my four surviving children, RONALD EUGENE CARR, SHIRLEY
CARR MAZURAK, MAYNARD DEAN CARR, and TERRY WAYNE SWARTZ.
VI. I appoint SHIRLEY CARR MA,LURAK, MAYNARD DEAN CARR, and
TERRY WA'~'NE SVVARTZ, to be Executors of this my Last Will.
VII. I direct that my Executors need not.fileband in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last
Will this .` ~'1~day of QL~~.,~ 2000.
_.~..~2-~.~_ ,~' ~ (SEAL)
/"'~
.~
The preceding instrument consisting of one (1) page(s) was on the date thereof
signed, published and declared by HELEN CARR, the testator herein, as and for her Last
Will, 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
~' -
~--- . c~.LC~..Q_
1~c~2c~ ~
STATE OF PENNSYLVANIA ::
SS
COUNTY OF CUMBERLAND ::
We, HELEN CAIZR, Frances H. Del Duca and Carol A. Morrow, the testator and
witnesses, respectively, whose names are signed to the attached or foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the testator
signed and executed the instrument as her Last Will and that she had 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 testator, signed the will
as witness and that to the best of her knowledge the testator was at that time eighteen
years of age or older, of sound mind au2d under no constraint or undue influence.
Testator - fitness
Witness
./
3~
SUBSCRIBED, sworn to and acknowledged before me by HELEN CARR, the.
testator, and subscribed and sworn to before me by Carol A. Morrow and Frances H. Del
Duca this~day of ~,~~ , 2000.
Notary Pubi' ~ _ = ~ ' __
_ -:.
~ v+'i!i'i«.~ ~. C4,.C'~. ~~~7.F~~~ct. +e~~FI.AI!' ~i3~~~r .~ ~ -~ j~
iw°J~~~~9 ~,,Cr1 fi{f~'1, rilEq'!SotY~iT+$ ~',RSUI~ - _ ..... .
~t~fsrri~n ~ ~
P!e'AOlls etllllons are obsolete
loon ttUD~1 (318fiJ ref HandbOOk 43052
A. Se~a1e111eT1t StdtelTleTlt U.S. Deparlmentof Housing and Urban Development
F,. Tvne of I nan
1. ^FHA 2. ^FmHA 3. OConv. Unins. 6. Fife Number 7. Loan Number ~ 8. Mortgage Insurance Case Number
4. VA 5. ^Conv.lns. 082017BRANT
o gore you a s a amen o ac va se amen cos s. maun s Dal o en a e sa amen gen are s own.
C. Note: Items marked "(p.o c.)' were paid outside the clasing; Ihen are sho n here for inrormallon pure see end are not Included In the totals. TItleExpfesS Settlement System
WARNING: it is a crime to knowln9ly make false slaleme Is to the Unlled Slates on Ihls or an Iher similar form. Penellles upon
conviction can Include a Ilne end Im daonment. For datalls see: Title 18 U. S. Code Section trot and Section 1010. Pfinled 11105/2008 at 13;06 ASF
D. NAME OF BORROWER: Henry K. Brant and Judy E. Brant and Bethany J. Adamski
ADDRESS: 15 Woodcrest Drive Carlisle PA 17015
E. NAME OF SELLER: Estate of Helen Carr and Shirley Mazurak - ' ~_; j \\/J
ADDRESS: 40 Limekiln Road Carlisle PA 17013 ((" ~~' ~ ~Il
F. NAME OFLENDER: --- ~- -
ADDRESS:
G. PROPERTY ADDRESS: 40 Limek(In Road, Carlisle, PA 17013
West Pennsbaro Townsht
H. SETTLEMENT AGENT: South Central Home Settlements, Inc., Telephone: 717-532.7387 Fax: 717-532.6552
PLACE OF SETTLEMENT: 126 East Kin Street Shi ensbur PA 17257
I. SETTLEMENT DATE: 1110512008
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
100. GROSS AMOUNT DUE FROM BORROWER 4D0. GROSS AMOUNT DUE TO SELLER
101. Contract sales rice 180 000.00 401. Contract sales rice 160 000.00
102. Personal Pro art 402. Personal Pro erl
103. Settlement char es to borrower line 1400 3 000.38 403,
104. 404. ,
105. 405.
Ad"ustments for items aid b seller in advance Ad ustments for Items aid b seller in advance
107. Count faxes 111051081012131108 54.05 407. Count taxes 171051081012131108 54.05
108. School Taxes 11105108 1006130109 1 154.74 408. School Taxes 11105/08 to 061301D9 1 154.74
109. 409,
110. 410.
111. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 184 209.17 420. GROSS AMOUNT DUE TO SELLER 181 208.79
200. AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500. REDUCTIONS 1N AMOUNT DUE TO SELLER
201. De osi(or earnest mone 20 000.00 501. Excess De osil see Instructions 20 000.00
202. Princi al amount of new {oans 502. Settlement char es to seller line 1400 2 535.00
203. Exlstln loan s taken sub'ect to 503. Exislln loans taken sub ecl to
204. 504. Pa off of First Mort a e Loan
205. 505.
206. 506.
207. 507. ;
206, 508.
209. 509.
Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller
213. 513.
214• 514.
215. 515.
216. 516.
217• 517.
218. 518.
219• 519.
220. TOTAL PAID BYIFOR 80RROWER 20 000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 22 535.00
300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLE R
301. Gross amount due from borrower line 120 184 209.17 601. Gross amou l due to seller Ilne 420 181 208.79
302, Less amounts afd b llor borrower line 220 20 000.00 602. Less reduction amount due seller line 520 22 535.00
303, CASH FROM BORROWER 164 209.17 603. CASH TO SELLER 158,673,79
SUBSTITUTE FORM 1099 SELLER STATEMENT: The Informallon conlelned herein is Imponanl lax Inronnallon end Is haing fuMshed to lha Infernal Revenue earvlca. 11 you ere required to file a velum,
e tieggllggence penally or other sanction will ve Imposed on you if Ihls Nam is required to he reported and the IRS delerminee that II has not been reported. The Contract Sales Price described an
line d01 ebo~a consillulae the Gross Proceeds of lhls lrensecllon.
You are required by taw to provide Iha selllemenl agent (Fed. Tax ID No: ) vhth your correct taxpayer Idenlllicallon number. II you do not provide your correct lax~ayer Idenligcallon
number, you maybe subf eci to clvll or crlminal penellles Imposed by few. n er pal tuna I e~0 rJury, I cerUly Ihel the number shown on Ihls slalemenl la my conecl taxpayer Idemlflcalion number.
TIN: -_- / -V- BELLER(S)SIGNATURE(B): /
SELLER(S) NEW MAILING ADDRESS:
BELLER(B)PHONE NUMBERS: (H) _ _ IWI
PreNOUS ed'dions are obsolete
form HII D-1 (3/B6! rel Handbook 4305.2
U.~. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT File Number: 082017BRANT PAGE 2
DCTTI CIIAC~IT CTATCMGAIT TiIleGvnroec SAttlamant Cvclr?m Prinfer1111(151700A ai 13'Dfi ASF
L. SETTLEMENT CHARGES PAID FROM PAID FROM
700. TOTAL SALES/9ROKER'S COMMISSION based on rice $180 000.00 0.000 = BORROWER'S SELLER'S
Division of commission line 700 as follows: FUNDS AT FUNDS AT
701 (o SETTLEMENT SETTLEMENT
702. io
703. Commission aid al Settlement
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Ori ination Fee °!
802. Loan Discount °/°
803. A ralsal Fee
804. Credit Re ort
805. Lender's Ins ecfion Fee I
806. Mort a e A licallon Fee
807. Assum lion Fee
808.
809..
010.
811.
,
900. ITEMS REQUIRED 8Y LENDERTO BE PAID IN ADVANCE
901. Interest From to /da
902. Mort a e Insurance Premium for to
903. Hazard Insurance Premium for to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER FOR
1001. Nazardlnsurance mo. /mo
1002. Mort a e Insurance mo. Imo
1003. Cit Pro erl Tax mo. /mo
1004. Count Pro erl Tax mo. /mo
1005. School Taxes mo. Imo
1009. A re ale Anal sis Ad'uslment
1100. TITLE CHARGES
1101. Selliemenlorclosin fee
1102. Abstract or title search
1103. Title examination
1104. Title Insurance binder
1105. Document Pre aralion
1106. Notar Fees
1107. Attorne 's fees to Wel le & Associates P.C. 735.00
includes above items No:
1108. Title insurance to SCHS A ant for Conesto a Title Ins. Co. 1 132.88
includes above items No;
1109. Lender's Polic
1110. Owner's Pollc 180 000.00 -1 132.88
1111
.
1112.
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordin Fees Deed 52.50 • Mort a e 'Release 52.50
1202. Cil /Count (ax/stam s Deed 1 800.00 • Mort a e 1 800.00
1203. Stale Taxlslam s Deed 1 600,00 Mori a e 1 800.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Surve
1302. Pest Ins ecfion
1303. Overni ht Fee to South Central Home Settlements Inc. 15.00
1304,
1305.
1306,
1307.
1308.
~ enn TnTel SFTTi FMFNT CHARGES /enter nn lines 103. Secllon J andb02, Secllon K1 _ - 3 000.38 2 535.00
HUD CERTIFiCA710N OF BUYER AND SELLER '
I have careful)yy reviewed the HUD-1 SelOemenl 5lalemenl end to the best of my knowledge and belle( II Is e W e and accurate statement of all receipts and dlsbursemenls made on my account or by me
in Ihls Iransacllon. i lmlher certify Thal I have recalved a copy or the HUD-1 Selllemenl 5lalemenl.
e any ems
Eslale of Helen Cerr //,}n p '
`i y,." ry ~ .fir-'~L S~rTey azur ~ lJ '
WARNING: IT IS A CRIME 70 KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Selllemen( 5lalemenl which I },eve repered iggqqq rue and accurate account of this Iransacllon.
UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION l hav aused or will cause the funds ebe dls ulse n ra0c rdance wllh Ihls statement
CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: l f
U.S. CODE SECTION 1001 AND SECTION 1010. ~/~~J~ ~ // ~--C ~~/'~
aY' .-S_--__~. F J (/ GOO
~~~
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- a~~d
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~~r~isai
WOJCII( JEWELERS
3rd Generation Jewelers Since 1905
4106 Crawford Avenue
NORTHERN CAMBRIA, PA 15714
(814) 948-9355
TO WHOM IT MAY CONCERN:
This is to certify that we are engaged in the jewelry business, appraising diamonds, watches, jewelry and `~
precious stones of all descriptions.
We herewith certify that we have. this day carefully examined the following listed and described
articles, the property of:
`~ i~ NAME `~
1~~ r I Pv 1~1~~llrais
~
~ .
ADDRESS liOX 7 1 ~ LlmOra ~ lea. i ~3~
~
We estimate the value as listed for insurance or other purposes at the current retail value, excluding
Federal and other taxes. In making this Appraisal, we DO NOT agree to purchase or replace the
articles.
DESCRIPTION... APPRAISED VALUE
.~
~ A a yKt, Yellotit~ Gold. 6 Prong Solitare Diamond.
~,
Q"+ _
Engagement Ring. The Diamond is a Rouncl Cut
:\` - -
Appro:~imate GVeight of ' .OOCT, II to I2
Clarity and. K to L Color. finger Size 61/2 ~
,~
.
-
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The foregoing Appraisal is made with the understanding that the Appraiser assumes no liability with
~
ction th t m be taken on the basis of this Appraisal.
respect to a
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~~~
.> ` ~ .Sept. ~ 8, X008 `,
APP I R DATE
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~]O, if~,1~~~~C MEMORI 5
1-!/ Since 19:
L,y31ne TPaCe Brnrtch rVlanager
417 West Main Street
New Bloomfield, Pennsylvania 17068
Office (717) 582-2~ 12
Fax (717) 582-404
~~ ~ ®Y~HL Lynne@Qin,richmemorials.com
j ~---
Heirloom Full
Perpetual Warranty
ag~division of
James R. ~~~® ~~~
~~ MEMORIALS
Bey-6~9?West Main Street, New Bloomfield, PA 17068 • (717) 582-2512
(3/4 mile urest of the square)
to:
r~ v~ ~ / r~c_~? .
on
` - l~
ame of cemetery: (7--
tart
We hereby submit specifications for:
eir /l; a u~ ~
/r~~~ 6l P ~ P - CR r~ 2-F'.~ r° ~ ~ - - ``~ T / ~, ~~J ~ • _- '~-~z ~{~ '~n ~~lr•~e~~e'~ow,a
~~###~k~k#~~krh~##*#,~c~k###~~k~k#~#~h###***#~k~#~k+k~#~k#*#>kk~k*~krk#*#~k#~k##**#*~~k*~k#%~~k#~k#*
The above memorial is of the finest workmanship. The cost includes memorial, lettering and cemetery
foundation. Future lettering is extra.
Our price of is guarantee for 30 days from this date.
Authorized signature: -~
yr ~->-~-c~~~ .~.~ ~ C ~~
Customer signature: ~'??
%"' ~~
MEw•.~~«,E,~ 6ARRE
~`
te:
~%n ~~~
Gi11LD
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~~~