HomeMy WebLinkAbout03-19-09-~ REV-1500 1505607120
EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
Po Box.2soso~ 21 0 8 0 0 7 0 5
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
200286874 06172008 09171936
Decedent's last Name Suffix Decedent's First Name MI
DELLINGER DONALD I,
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Retum ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-92)
® 5 Decedent Died Testate ^ ~ Decedent Maintained a Living Trust ~ 8. Total Number of Safe De osit Boxes
(Attach Copy of Will) (Attach Copy of Trust) ---- P
^ 9. Litigation Proceeds Received ^ 1 p. 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 TO:
Name Daytime Telephone Number
DEBRA K. WALLET 7177371300
Firm Name (If Applicable)
LAW OFFICES OF DEBRA R. WALLET
First line of address
24 NORTH 32ND STREET
Second line of address
City or Post Office State ZIP Code
CAMP HILL PA 17011
Correspondent's a-mail address: W a l l e t d e b@ a O I. C O m
REGISTER OF WILLS USE ONLY
C7 rv
f= C7
_
J -__
T
- ~~
r f-- .w'J
t.fl
DATE FtLEQ~ ' :-Y
i
~.~
s
- ::i _
N ~i
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, ~onrect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
~/-(~ ',~,,f ~ , ~b~.~ ~ ,~~ Robert Lichliter G-'~j ~/ ~ oo
ADDRESS ~ "T--
3641 Chestnut Street, Camp Hill, PA 17011
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
~,Q,,,~„~-~~,~. Debra K. Wallet 3~ 14~ v4
ADDRESS
24 North 32nd Street, Camp Hill, PA 17011
Side 1
1505607120 1505607120 J
J
1505607220
REV-1500 EX
Decedent's Social Security Number
~eceaenrsName: DELLINGER, DONALD L 200286874
RECAPITULATION
1. Real Estate (Schedule A) ........................................................................................ .. 1. 2 4 0, 9 9 7 3 3
2. Stocks and Bonds (Schedule B) .............................................................................. . 2. 2 1 6, 2 6 2. 8 2
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... . 3.
4. Mortgages 8 Notes Receivable (Schedule D) ............................:............................ . 4.
5. Cash, Bank De osits & Miscellaneous Personal Pro a
p p rty (Schedule E) ...............
. 5. 13 6 7 5 5 4 3
r
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. 5 9 4, 0 1 5. 5 8
9.
Funeral Expenses & Administrative Costs (Schedule H) ........................................
. 9. ------
6 3 , 7 1 2 . 2 7
10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) ............................... . 10. 5 , 216.6 4
11. Total Deductions (total Lines 9 & 10) ..................................................................... . 11. 6 8 , 9 2 8 . 9 1
12. Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 5 2 5 , 0 8 6 . 6 7
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................................................ . 13. 5 2 2 , 9 8 6 . 6 7
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14. 2 , 1 0 0 0 0
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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 2, 10 0 0 0 16. 9 4 5 0
17. Amount of Line 14 taxable
at sibling rate X ,12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due .................................................................................................................... . 19. 9 4 . 5 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
L, 1505607220 1505607220 J
REV-1500 EX Page 3 File Number 21 - 08 - 00705
Decedent's Complete Address:
Dellinger, Donald L
EET ADDRESS
1269 Hillside Drive
- _ - --
clrr
Mechanicsburg
-- STATE --ZIP -- --- -
PA 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)
3. InteresUPenal if a licable Total Credits (A + B + C) (2)
tY ~ PP
p. Interest
E. Penalty
Total InteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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 the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
94.50
- - 0.00
0.00
94.50
94.50
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 :.................................... J' x
-__
c. retain a reversionary interest; or .................................................................................................................. x
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 "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)]. 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.
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA ~, REAL ESTATE
INHERITANCE TAX RETURN ' ~~,
RESIDENT DECEDENT - 'i
ESTATE OF Dellinger, Donald L I' FILE NUMBER
21 - 08 - 00705
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 wilting 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 OF
NUMBER DEATH
1 1269 Hillside Drive, Mechanicsburg, PA 240,997.33
(based on proceeds from sale -HUD-1 attached)
_ ------
---- __
TOTAL (Also enter on Line 1, Recapitulation) 240,997.33
SCHEDpULE B '
COMMONWEALTH OF PENNSYLVANIA STOCKS ~[ BONDS i
INHERITANCE TAX RETURN
RESIDENT DECEDENT ,
-__ FILE NUMBER
ESTATE OF Dellinger, Donald L~ 21 - 08 - 00705
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
- - -- _ ---. _------- _ ___ -_ - ---- --- __- __ __- i ---
NUM ER DESCRIPTION UNIT VALUE ;VALUE AT DATE OF
DEATH
1 Orrstown Financial Advisors Investment Account 216,262.82
#50000758007 ',
TOTAL (Also enter on line 2, Recapitulation) 216,262.82
I, SCHEDULE E
CASH, BANK DEPOSITS, & MISC. II
COMMONWEALT„OF PENNSYLVANIA
I
,N„ER~TANDE TAXRETURN ~~ PERSONAL PROPERTY
RESIDENT DECEDENT it
ESTATE OF Dellinger, Donald L FILE NUMBER
21 - 08 - 00705
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorsh ip must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF
DEATH
1 -----
Commerce Bank Checking Account #0513226027 -------- ---- - -- - --
311.60
2 Orrstown Bank Checking Account #106004008 2,047.35
3 U.S. Treasury stimulus check 300.00
4 Landis Auction Service (proceeds from auction of personal items and automobiles -see 130,062.42
attached net profit summary)
5 J.P. Sauer & Sohn Revolver (based on proceeds from sale) 100.00
6 Hagerty Insurance refunds 621.00
7 Highmark premium refund 383.00
8 Comcast refund 65.73
9 AT&T refund 16.47
10 Verizon refund 27 39
11 State Auto refunds 494.00
12 Waste Management refund 38.46
13 PayPal account 488.01
14 Personal property not sent to auction (including washer, dryer, refrigerator, television, etc.) 1,800.00
TOTAL (Also enter on Line 5, Recapitulation) 136,755.43
OLE H
FIAVERAL EXPENSES & ''
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN ~, ~~~ ~~
RESIpENT DECEDENT ~.
ESTATE OF Dellinger, Donald L '~
Debts of decedent must be reported on Schedule 1,
-ITEM -- ----- - ----
NUMBER', FUNERAL EXPENSES: DESCRIPTION
--- -- - __
A. 1 ~ Myers Funeral Home
2 'The Patriot-News (memorium)
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
ecurity Number(s) ! EIN Number of Personal Representative(s):
' street address 3641 Chestnut Street
City Camp Hill State PA Zip 17011
Year(s) Commission paid 2009
2. ' attorney's Fees Debra K. Wallet, Esq.
3, ' Family Exemption: (lf decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip r
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees Charles D. Kokoski, CPA (2008 lifetime tax returns)
6. Tax Return Preparer's Fees
7, Other Administrative Costs
1 'Postage, photocopies, mileage, etc.
FILE NUMBER
21 - 08 - 00705
!,y -AMOUNT
810.00
464.10
30, 000.00
15, 000.00
676.00
350.00
50.00
TOTAL (Also enter on line 9, Recapitulation) 63,712.27
'~ Schedule H
Furier~l E~enses &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN i, ~ C~
RESIDENT DECEDENT _
--
ESTATE OF Dellinger, Donald L FILE NUMBER
21 - 08 - 00705
2 Landis Auction Service (commission on real estate sale)
3 Met-Ed
4 ~~ Debbie Rhoades (lawncare) ~~~~
5 ;Pau{ Glantz (labor and equipment to clean out house)
6 ', RSR Appraisers (property appraisa{}
I
7 Battery Warehouse (batteries for autos and vans before sale) !I
I
8 I Brad Nauss Automotive (sorting and evaluation of auto parts & memorabilia)
9 'Waste Management
10 i Got Junk (trash removal - 1.5 truckloads)
11 Peggy Long (final cleaning of house and motor home)
12 ', Safe Kleen S stems (hazardous waste removal)
tY Y
13 '~ Duty's Lock & Key (change locks)
14 Hess (gas for vehicles)
15 ,The UPS Store (shipping to France)
16 ', Harbor Freight Tools (auto cover tarp)
17 Home Depot (driveway markers for parking limits for auction)
18 'Office supplies purchased by Executor for administration of Estate
19 ' U-Line (boxes)
20 FedEX International (to send documents to Fortis Bank)
7, 350.00
234.38
565.00
1,575.00
350.00
328.56
1,605.90
76.92
774.00
150.00
1, 808.00
128.62
20.07
191.22
12.07
16.79
149.55
268.80
42.25
Page 2 of Schedule H
', Sdiec~de H
Ftx~eral E~enses &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Dellinger, Donald L
21 Reimbursement to Executor for postage, auto titles, etc.
22 I Mileage of Executor (1,119.5 miles at $0.585/mile)
23 ,Certified mail charges for final income tax returns
FILE NUMBER
21 - 08 - 00705
48.00
654.90
12.14
Page 3 of Schedule H
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Dellinger, Donald L
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS II
L NUMBER
li 21 - 08 - 00705
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1 Hagerty Insurance (insurance on classic cars) 604.00
2 Chase Card Services 582.47
3 Comcast Cable 110.44
4 Shillite Oil, Inc. 500.00
5 Met-Ed (May-June bills) 96.93
6 State Auto (insurance on vans and rollback) 534.75
7 State Auto (homeowner's insurance) 397.50
8 PA Department of Revenue (personal income taxes) 11.54
9 Waste Management 76 92
10 VA Affairs, Lebanon VA Med. Center 63.00
11 Mary Murray, Tax Collector (school taxes) 2,100.11
12 Verizon 138.98
TOTAL (Also enter on Line 10, Recapitulation) ~ 5,216.64
REV-1513 EX+ (9-00)
II SCHED~wU/LpE J
COMMONWEALTH OF PENNSYLVANIA ' BENEF~C~AR~ES
INHERITANCE TAX RETURN ',
RESIDENT DECEDENT _~
ESTATE OF Dellinger, Donald L
NUMBER NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY _---
I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2))
1 ,Cathleen A. Olinick
15 Ashley Drive
~~ Dillsburg, PA 17019
2 Shirley G. Theofiles
202 South Main Street
Shrewsbury, PA 17361
FILE NUMBER
'~ 21 - 08 - 00705
RELATIONSHIP TO S ARE OF ESTATE ~AMOUN~T OF ESTATE
DECEDENT (Words) ($$S)
Do Not List Trustee(s) i
', Daughter
', Daughter
3 Donna Leigh Spoonhour
137 West Middlesex Drive
Carlisle, PA 17319
Daughter
~, $100 + personal
~' property with est.
value of $1,400
$100 + personal
property with est.
value of $400
1, 500.00
500.00
100.00
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 DISTRIBU710NS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS
'NOT BEING MADE I,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 ' ALS Association, Greater Philadelphia Chapter
321 Norristown Rd., Suite 260, Ambier, PA 19002
522, 986.67
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 522,986.67
LAST WILL AND TESTAMENT
OF
DONALD L DELLINGER
I, Donald L Dellinger, of Mechanicsburg, Pennsylvania, revoke my former Wills and Codicils
and declaze this to be my Last Will and Testament.
ARTICLE I
IDENTIFICATION OF FAMILY
I am married to Maureen Dorothy Dellinger and all references in this Will to "my spouse" aze
references to Maureen Dorothy Dellinger.
The names of my children aze Cathleen A Olinick, Shirley G Theofiles, and Donna Leigh
Spoonhour. All references in this Will to "my children" aze references to the above-named
children.
ARTICLE II
PAYMENTS OF DEBTS AND EXPENSES
I duect that my just debts, funeral expenses, and expenses of last illness be first paid from my
estate.
ARTICLE III
DISPOSITION OF PROPERTY
A. Specific Bequests. I direct that the following specific bequests be made from my estate.
1. $100.00 shall be distributed to Cathleen A Olinick. If this beneficiary does not survive
me, this bequest shall be distributed with my residuary estate.
2. $100.00 shall be distributed to Shirley G Theofiles. If this beneficiary does not survive
me, this beque~hall be distributed with my residuary estate.
3. $100.00 shall be distributed to Donna Leigh Spoonhour. If this beneftCiat~aes not
survive me, this bequest shall be distributed with my residuary estate.
B. Residuarystate. I direct that my residuary estate be distributed to ALS Assn Phila Chapter,
of 321 Norristown Rd suite 260 Ambler Pa, Pennsylvania. If such beneficiary does not survive
me, my residuary estate shall be distributed to American Heart assosiation, of Harrisburg,
Pennsylvania. If such beneficiary does not survive me, my residuary estate shall be distributed to
the following beneficiaries in the percentages as shown:
100.00 % to my heirs-at-law, their identities and respective shazes to be determined under
the laws of the State of Pennsylvania, then in effect, as if I had died intestate at the time fixed
for distribution under this provision.
0.00 % to my spouse's heirs-at-law, their identities and respective shazes to be determined
under the laws of the State of Pennsylvania then in effect, as if my spouse had died intestate
at the time fixed for distribution under this provision.
100.00 % -Percent Total
ARTICLE IV
NOMINATION OF EXECUTOR
I nominate Robert Lichliter, of 3641 Chestnut st Camp Hill, Pennsylvania, as the Executor,
without bond or security. If such person or entity does not serve for any reason, I nominate
Timothy Hoffrnan, of Lewisbemy, Pennsylvania, to be the Executor, without bond or security.
ARTICLE V
EXECUTOR POWERS
My Executor, in addition to other powers and authority granted by law or necessary or
appropriate for proper administration, shall have the right and power to lease, sell, mortgage, or
otherwise encumber any real or personal property that may be included in my estate, without
order of court and without notice to anyone.
My Executor shall have the right to administer my estate using "informal", "unsupervised", or
"independent" probate or equivalent legislation designed to operate without unnecessary
intervention by the probate court.
ARTICLE VI
MISCELLANEOUS PROVISIONS
A. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for
reference purposes only and are not to be considered as forming a part of this Will in interpreting
its provisions. All words used in this Will in any gender shall extend to and include all genders,
-2-
and any singular words shall include the plural expression, and vice versa, specifically including
"child" and "children", when the context or facts so require, and any pronouns shall be taken to
refer to the person or persons intended regazdless of gender or number.
B. Thirty Day Survival Requirement. For the purposes of determining the appropriate
distributions under this Will, no person or organization shall be deemed to have survived me
unless such person or entity is also surviving on the thirtieth day after the date of my death.
C. Common Disaster. If my spouse and I die under circumstances such that there is no cleaz or
convincing evidence as to the order of our deaths, or if it is difficult or impractical to determine
which person survived the death of the other person, it shall, for the purpose of distribution of my
life insurance, property passing under any Trust or other contracts, if any, and property passing
under this Will, be conclusively presumed that I predeceased my spouse, and notwithstanding
any other provision of this Will, my spouse (or my spouse's estate as the case may be) shall
receive the distribution to which my spouse would otherwise be entitled to receive without regazd
to a survivorship requirement, if any.
D. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of
fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my
estate shall indemnify such natural person from any and all claims or expenses in connection
with or arising out of that fiduciary's good faith actions or nonactions as the fiduciary, except for
such actions or nonactions which constitute fraudulent conduct or bad faith.
E. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or
among two or more beneficiaries, the specific items of property comprising the respective shazes
shall be determined by such beneficiaries if they can agree, and if not, by my Executor.
IN WITNESS WHEREOF, I have subscribed my name below, this 6'~ay of
6~ Gtny~ e ~ .Z.fi d G.
Testator Signature:
Donald L Dellinger
-3-
We, the undersigned, hereby certify that the above instrument, which consists of pages,
including the page(s) which contain the witness signatures, was signed in our sight and presence
by Donald L Dellinger (the "Testator"), who declared this instrument to be his/her Last Will and
Testament and we, at the Testator's request and in the Testator's sight and presence, and in the
sight and presence of each other, do hereby subscribe our names as witnesses on the date shown
above.
Witness Signature:
Name:
City:
State:
Witness Signature: ,t
Name: !
City: /' //
State:
Witness Signature:
Name:
City:
State:
-4-
. _
PENNSYLVANL~
Self-Proving Clause
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I, Donald L Dellinger, the Testator, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed
and executed the instrument as my Last Will; that I signed it willingly and as my free and
voluntary act for the purposes expressed in the instrument.
Sworn to or affirmed and acknowledged before~m~e~b~y Donald L Dellinger, the Testator, this
7~"l~ day of ~~ G771~2°~/~ , L~~.~
Testator Signature ~ ~
Donald L Dellinger
,'. -
Signature of officer /~_ ~, ~
Official capacity of officer
COMMONWEALTH OF PENNSYLVANIA
(Se ~ OllviaA. Reeder, Notary Public
South Middleton Twp., Cumberland County
My Cammissan E~ires Mar. 7, 2009
Member, Pennsylvania Association of Notaries
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Q R-4p~~'t ~ ~>~2.c.A ~N and ___~ ! ~. ~D /~~
and ,the witnesses wl~iose names are signed to the
attached or foregoing instrument, being duly qualified according to law, do depose and say that
we were present and saw the Testator sign and execute the instrument as the Testator's Last Will;
that the Testator signed willingly and executed it as the Testator's free and voluntary act for the
purposes expressed in it; that each of us in the hearing and sight of the Testator signed the Will
as a witness; and that to the best of our knowledge the Testator was at that time 18 or more yeazs
of age, of sound mind and under no constraint or undue influence.
Sworn to or and subscribed to before me by i~~G2~~~
and and ~ ~ ~ ,
witnesses, 's y of ~~~f
Witness Signature:
Name: U R~tU ~ S G F,P c,A~N
City: C-h2.us ~
State: P/k
Witness Signature: a'
Name: /~ /1r1,
City: S
State: f~"
Witness Signature: ~j~~~~ ~ ~~
Name: ~/P~n 'c l~/ ,-~~l ~
City: ~'/ai-~ s~
State: /%5'
COMMONWEALTH OF PENNSYLVANIA
~~ ~
OIMa A Reeder, Notary Public L~~/"~v~-GiC/ ~ "~~C •~t_~
South Middletrn TM'P•. Cranberiarrd County /
My Commission E~ires Mar. 7, 2009 ~~ ~ '~ - 0~
Member, ?ennsylvanie Association of Notaries
r1MR AIA oeno nece ~•~
A• ~ •~• - LVV
B.. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.QFHA 2.QFmHA 3. QCONV. UNINS. 4. QVA 5. QCONV. INS.
SETTLEMENT STATEMENT 6. FILE NUMBER:
GREEN193-08 7. LOAN NUMBER:
8. MORTGAGE INS CASE NUMBER:
C. NOTE: This form is furnished to give you a statement o/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 (or informational purposes and are not included in the totals.
1.0 3/9B (GREEN193-OB PFDlGREEN193-08/4)
D. NAME AND ADDRESS OF BUYER:
GREEN RIDGE LEASING LLC
6375 BASESHORE ROAD
MECHANICSBURG, PA 17055 E. NAME AND ADDRESS OF SELLER:
ESTATE OF DONALD L. DELLINGER
1269 HILLSIDE DRIVE
MECHANICSBURG, PA 17055 F. NAME AND ADDRESS OF LENDER:
CASH
G. PROPERTY LOCATION:
1269 HILLSIDE DRIVE
MECHANICSBURG, PA 17055 H. SETTLEMENT AGENT: 25-1619811
ANDREW C. SFIEELY, ESQ. I. SETTLEMENT DATE:
November 13
2008
CUMBERLAND County, Pennsylvania PLACE OF SETTLEMENT
3414 CHESTNUT STREET
CAMP HILL, PA 17011 ,
J. SUMMARY OF BUYER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS t4MOUNT DUE FROM BUYER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 242,000.00 401. Contract Sales Price 242,000.00
102. Personal Pro ert 402. Personal Pro ert
103. Settlement Char es to Bu er Line 1400 2,728.50 403.
104. '404.-
105. 405.
Ad'ustments Forltems Paid 8 Seller in advance Ad'usfinents For Items Paid 8 Seller in advance
106. Cit /Town Taxes 11!13108 to 01/01/09 80.97 406. Cit /Town Taxes 11/13/08 to 01/01!09 80.97
107. Count Taxes to 407. Count Taxes to
108. SCHOOL TAX 11/13/08 to 07101!09 1,350.36 408. SCHOOL TAX 11/13/08 to 07/01/09 1,350.36
109. 409.
110. 410.
111. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BUYER 246,159.83 420. GROSS AMOUNT DUE TO SELLER 243,431.33
200. AMOUNTS PAID BY OR IN BEHALF OF BUYER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. De osit or earnest mone 24,500.00 501. Excess De osit See Instructions
202. Princi al Amount of New Loans 502. Settlement Char es to Seller Line 1400 2,434.00
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 Morl a e
206. 506. De osit retained b seller 24,500.00
207. 507.
208. 508.
209. 509.
Ad'usfinents For Items Un aid B Seller Ad'ustments For Items Un aid B Seller
210. Cit /Town Taxes to 510. Cil /Town Taxes to
211. Count Taxes to 511. Count Taxes to
212. SCHOOL TAX to 512. SCHOOL TAX to
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID BY/FOR BUYER 24,500.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 26,934.00
300. CASH AT SETTLEMENT FROMITO BUYER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Bu er Line 120 246,159.83 601. Gross Amount Due To Seller Line 420 243,431.33
302. Less Amount Paid BylFor Buyer (Line 220) ( 24,500.00) 602. Less Reductions Due Seller (Line 520) ( 26,934.00
303. CASH (X FROM) ( TO) BUYER 221,659.83 603. CASH (X TO) ( FROM) SELLER 216,497.33
The undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein.
1 HAVE CAREFULLY REVIEWED THE HUD-1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE AND
ACCURATE STATEMENT OF ALL RECEIPTS AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY E IN THIS TRANSACTION. I FURTHER CERTIFY
THAT I HAVE RECEIVED A COPY OF THE HUD-1 SETTLEMENT STATEMENT. 7
i
Buyer GREEN RIDGE LEASING LLC Seller --' •~ L
B ` C ~ ESTATE O NALD .DELLINGER
TO THE BEST OF MY NO ~fl JdU TLE E T STATEMENT WHICH 1 HAVE PREPARED IS A TRUE AND ACCURATE ACCOUNT OF THE
FUNDS WHICH WERE R IV D AV E O BE DISBURSED BY THE UNDERSIGNED AS PART OF THE SETTLEMENT OF THIS
TRANSACTION. ,, ~
T EMENT OFFICE ••
ettlement Agent
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FAt_SE 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 8 SECTION 1010.
Page 2
L. SETTLEMENT CHARGES
700.'fOTAL COMMISSION Based on Price $ % PAID FROM PAID FROM
Division of Commission Ilse 7OO aS FOIIOWS: BUYER'S SELLER'S
701. $ 10 FUNDS AT FUNDS AT
702.$ 10 SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement
704. TRANSACTION FEE 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.
809.
810.
811.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to @ $ /day ( days %)
902. MIP Toilns. for LifeOfLoan for months to
903. Hazard Insurance Premium for 1.0 ears to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard fnsurance months $ er month
1002. Mort a e Insurance months $ er month
1003. Cit /Town Taxes months $ er month
1004. Count Taxes months $ er month
1005. SCHOOL TAX months @ $ per month
1006. months $ er month
1007. months @ $ per month
1008. AGGREGATE ESCROW ADJUSTME months $ er month
1100. TITLE CHARGES
1101. Settlement or Closin Fee to
1102. CLOSING PROTECTION LETTER to FIRST AMERICAN TITLE INSURANCE COMPANY
1103. TITLE SEARCH 8 HUD PREP to TRI-COUNTY ABSTRACT SERVICE 250.00
1104. Title Insurance Binder to
1105. Document Pre aration to DEBRA K. WALLET, ESQ. DEED POC 90.00
1106. Note Fees to CASH 6.00 8.00
1107. Attorney's Fees to ANDREW C. SHEELY, ESQ. POC
includes above item numbers:
1108. Title Insurance to TRI-COUNTY ABSTRACT SERVICE/AGENT FOR 1ST AMERICA
includes above item numbers:
1109. Lender's Coverage $
1110. Owner's Coverage $
1111. ENDORSEMENTS
1112.
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 52.50; Mortgage $ Releases $ 52.50
1202. Cit /Count Tax/Slam s: Deed 2,420.00 Mort a e 2,420.00
1203. Stale TaxlStam s: Revenue Stam s 2,420.00; Mort a e 2,420.00
1204.
1205. OVERNIGHT/COURIER FEES
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Surve to
1302. Pest Ins ection to
1303. TAX CERTIFICATION FEE to TRI-COUNTY ABSTRACT SERVICE RE-IMBURSEMENT 6.00
1304. AUCTIONEER FEE LANDIS AUCTION SERVICE POC 7,260.00
1305.
1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) 2,728.50 2,434.00
By signing page 1 0(Ihis statement, the slgnabriea acknowledge receipt of a completed copy of page 2 of mis two page stat°ment
T. EMENT OFFICER
Settlement Agent
Certified to be a true copy.
( GREEN193.OB / GREEN193-08 14 )
Lzndis Auction Service
4=112 Oregon Pike
Ephrata, PA 17522
(717) 898-9621
Total Cost of Goods Sold.
Commission -15%
Labor
Landis Auction Service
Carlisle Auctions
~ 158,179.50
-23,726.93
-1,130.00
Red Dellinger Estate
September 30, 2008
495.00
~~s nn
Sanitation - 2 Porta Pottys
Advertising
Full Color Brochures
Old Cars
Auto Locator
Sign
Postage
The Guide
1,297.97
960.00
355.10
105.83
56.85
303.80
-180.60
- 3,079.55
Net Profit ~ 130,062.42