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HomeMy WebLinkAbout03-25-0915056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 2 ~ O ~ 8~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 06/26/2008 11 /22/1921 Decedent's Last Name Suffix Decedent's First Name MI Graffius Gertrude E (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 Retum 2. Supplemental Return 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Retum Required death after 12-12-82) 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 Jeffrey W. Graffius (717) 343-2853 ~, n Firm Name (If Applicable) ~_~ REGISTER OF USE ONL~,'_ :-17 First line of address ~" '~~ C.II 30 W Broadway _, -~ Second line of address - --- -`°° ~.,~ ~ ~ --; .. Clty Or POSt Office State ZIP COde DATE FILED Red Lion PA 17356 Correspondent's a-mail address: 19raffiUS@angaSSOCiateS.COm Under penalties of perjury, I declare that I have examined this r um, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, rrect and mplete. Declaration of preparer other an a personal representative is based on all information of which preparer has any knowledge. SIGNATU OF PE ON SP N BLE FO ING R U DATE 03/25/09 -- __ - -_ ADDRESS 30 W Broa wa , Re Lion, PA 1 6 SIGNATURE OF PREP ER OTHER THAN REPRESENTATIV ESS PLEASE USE ORIGINAL FORM ONLY -~ .. Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number Gertrude E Grafflus ' s Name: Decedent __ RECAPITULATION 1. Real estate (Schedule A) . ......................................... ... 1. 0.00 2. Stocks and Bonds (Schedule B) .................................... ... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. Mort a es & Notes Receivable Schedule D 9 9 ( ) .......................... ... 4. 0.00 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... ... 5. 32,175.00 6. Jointly Owned Property (Schedule F) Separate Billing Requested .... ... 6. 477.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested..... ... 7. 0.00 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 32,652.00 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 2,660.00 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ............. ... 10. 0.00 11. Total Deductions (total Lines 9 8 10) ................................ ... 11. 2,660.00 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 29,992.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 29,992.00 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. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 16. 1, 350.00 17. Amount of Line 14 taxable at sibling rate X .12 17. 0.00 18. Amount of Line 14 taxable at collateral rate X .15 18. 0.00 19. TAX DUE ....................................................... ..19. 1,350.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 1505 REV-1500 EX Page 3 File Number Decedent's Complete Address: Gertrude E Graffius STREET ADDRESS 404 4th St. cITV Summerdale DECEDENTS SOCIAL SECURITY NUMBER 167-14-8439 _- - -- ;STATE .ZIP PA 17093 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (5B) 1, 350.00 0.00 0.00 0.00 1, 350.00 0.00 1,350.00 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 :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ 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? .............. ^ 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. §9116 (a) (1.1) (i)j. 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)j. 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-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Gertrude E. Graffius Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (It more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~lLE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Gertrude E. Graffius 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• Jeffrey W. Graffius 130 W Broadway, Red Lion, PA 17356 ~ Son B. C 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. 04/28105 Joint checking account (Gertrude & Jeffrey) 953 00 50% . 477.00 _ TOTAL (Also enter on line 6, Recapitulation) I S 477.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Se INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Gertrude E. Graffius Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~' Funeral Home 2,131.00 Funeral Reception 202.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) 2. 3. Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Zip 4. 5. 6. ~. Probate Fees Accountant's Fees Tax Return Preparer's Fees Estate Legal Notice publishing Zip 195.00 TOTAL (Also enter on line 9, Recapitulation) I $ 2,660.00 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-08) Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Gertrude E. Gra~us 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. 2116 (a) (1.2).] 1. Donna G. Amig; 107 Valley View Rd., New Cumberland, PA 17070 Daughter 33.3% 2 Patty G. Plummer; 305 W. Washington St., Urbana, IL 61801 Daughter 33.3% 3 Jeffrey W. Graffius; 30 W Broadway, Red Lion, PA 17356 Son 33.3% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. 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. .• .+ ~~[1 i~~'•~~ . ;.'?~?/ ;iY~'/'C./ fL.s' ,r -L--? 2 .~[ lG Z .,,L':..~ :TG-f'1~~ /~~'r' ~. / , . ~ •~ % /'. ./ .~ ~ %. ih/L / f GGL~C l~. ~ ,~l `%~-t Gr" ! / :~'t'-~i~f~L~ /•L ~~/(. ! ~ i ~1,~.. I ~l jl /~ ( ~_ ,t ?-/._ :1.1'? G-lt-j ~.'~J~ ~ ~S~ C.-~. .f C~ ~J~- L _ l ~ ~C ! ~? R. ,, ~ ~~t Z_ .r /tf~,~,i r i l Ly' CL /. ~'~~t- ~. ~~~,~ /.: ~ l~ .~' ^L%,C.~~ / _ `4 /` ~ 7 L/ ~ / ' i ~ ~. `'C ClL''-t-; ( :~-:-j. /-! !t 'X-! F' -l ~' f r~~. t _i ~ ~ /ice ~: _ r. ~, ~ ' ! ~; r. ~ ~ _. i ~ i r'....~;t i ~~ :d. rc :.. .. , ~z -*~-~ ,,,i ' L .1! ,CS~-~1 ~i: J ~/L ./ ~ E' /t ,/`.~ - rc'/, '. r t ~.~ L f~; 4 .tGx-~c.,~' . i , ~l ' f ., , .. -l~ // i v~ ~~/7Ci L.~Cx2 j~/~~p~~ ,, ~'~"~ y Sovereign Bank STATEMENT OF ACCOUNTS Stab~ment. Period 01l22lOY TO OTJ2?!0!) 1-877-T6t1-1143 www.aovereignbank.oom gOyERE!<,N PREMIER CHECKING ESTATE t~F GER777UDE E GRAFFIUS JEFFREY GRAFFlUS IXEC Bala~+ces Account # 401124436 _, ,,. .., ~~ ,, ~{ . ;' : _ Wit; ~ '' ~°~fdi~ i . ~-Aks ,. ,~ ~ ,.. .~.. t ;.. Deposits/Crodits +34.30 Average Daily Balance 524,496.64 ~Il~Itiltt Eamed this Period 3 4.30 Paid Last Year 319.62 ''The interost earned and the interest paid may differ depending on when interost is credited to your account. Acwunt At:tfvity Dats Osscriptbn Additions 8ubtractlons Balance 01-22 Beoinnine Balance ~,~Q .;, ; 624,498.64 page 3 of 3 401 /24436 PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 08-0835 Po Box 290601 TAXPAYER RESPONSE ACN 08156332 HARRISBURG PA 17128-0601 DATE 11-25-2008 REV-1543 E% I1FP (09-OB) JEFFREY W GRAFFIUS 30 W BROADWAY RED LION PA 17356-2135 EST. OF GERTRUDE E GRAFFIUS SSN 167-14-8439 DATE OF DEATH 06-26-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. SOVEREIGN BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-8327 with questions. COMPLETE PART I BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 2561000818 Date 01-22-2002 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 952.84 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NDTE: If tax payments are made within three Amount Subject to Tax $ 476.42 months of the decedent's date of death, TaX Rate X , lrj deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~` 71.46 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX AS5E55MENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL U5E ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ) WORK TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of Tax Computation) 8 GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, Dlace an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. - TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk (~~) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 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 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use B 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. TAXPAYER ASSISTANCE IF YDU NEED FURTHER INFORMATION OR ASSISTANCE, CONTACT ANY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE OR THE BUREAU OF INDIVIDUAL TAXES, AT C717~ 787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-80-447-3020. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent ui/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent Form A U.B. DEPARTMENT OF F10UBING AND URBAN DEVELOPMENT B. TYPE OF JOAN SETTLEMENT STATEMENT 1. FHA 2. FMHA 3. CONV. UNINS. Affiliated Settlement Services Group, LLC a. ^ vA 5. Gcl cony. INS. 3912 Market Street 6. ESCROW FILE NUMBER: 7. LOAN NUMBER: 00083535-001 RRH 43940-52 Camp Hill, PA 17011 B. MORTGAGE {NSURANCE CASE NUMBER: (717) 975-7839 FINAL C. NOTE: This form is fum/shed 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 the dosing; they are shown here for informational purposes and are not included in fhe totals. o. NAME of BoRROwER: Theresa A. Jansen and Nicole E. Jansen ADDRESS OF BORROWER: P.O. BOX 307 Summerdale PA 17093 E. NAME OF SELLER: Estate Of Gertrude E. C7raffiUS ADDRESS OF SELLER: F. NAME OF LENDER: AmerICh01Ce Federal Cfedlt Union ADDRESS OF LENDER: 2175 Bumble Bee HOIIOW Road Mechanicsburg, PA 17055 G. PROPERTY LOCATION: 404 Fourth Stf@@t Summerdale, PA 17093 Cumberland County 09-11-3004-057 Parcel #09-11-3004-057 H. SETTLEMENT AGENT: Affillated Settlement $efVICeS GrOUp, LLC PLACE of sETTLEMENT: 3912 Market Street, Camp Hill, PA 17011 I. SETTLEMENT DATE: 9/29/2008 PRORATION DATE: 9/29/2008 DISBURSEMENT DATE: J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 101. Contract Sales Price 127,900.00 401. Contract Sales Price 127,900.00 102. Personal Property 402. Personal Property 103. Settlement charges to Borrower (line 1400) 5,310.64 403. 104. 404. 105. 405. en ~~ ~cre¢ure eno ~reuc oeln wv cci I ca Iti enve NRF• AD.II ISTMENTS FOR ITEMS PAID RY SELLER IN ADVANCE 106. C' !Town Taxes 406. Cit !Town Taxes 107. Coun Taxes 09/29/08 to 12/31/08 97.72 407. County Taxes 09/29/08 to 12!31!08 97.72 108. Assessments 408. Assessments 109. School Tax 09/29/08 to 06/30/09 948.19 409. School Tax 09/29!08 to 06/30lOG - ^48.'.9 110. Sewer 09/29/08 to 09/30/08 1.26 410. Sewer 09/29/08 to 09/30!08 1.26 111. 411. 112. 412. 113. 413. 114. 414. 115. 415. 12Q. GROSS AMOUNT DUE FROM BORROWER: 134,257.81 420. GROSS AMOUNT DUE TO SELLER: 128,947.17 201. Deposk or earnest money 1,000.00 501. Excess deposit (see instructions) 202. Principal amount of new loan(s) 115,110.00 502. Settlement char es to Seller (line 1400) 18,433.10 203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to 204. ..,.~ 504. ~... Payoff of 1st mtg. loan to National City .. .. _... _ .._.. _ _ . .. .. 76,323.27 „ e.,, ~, 114. 414. 115. 415. 120. GROSS AMOUNT DUE FROM BORROWER: 134,257.81 420. GR033 AMOUNT DUE TO SELLER: 5-~ 128,947.17 201. Deposit or earnest money 1,000.00 501. ~ Excess deposit (see instructions) 202. Principal amount of new loan(s) 115,110.00 502. Settlement charges to Seller (line 1400) 18,433.10 203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to 204. 504. Payoff of 1st mtg. ban to National City 76,323.27 205. 505. Payoff of 2nd mtg. loan to Sovereign Bank 9,893.21 206. Seller Paid Closing Costs 1,500.00 506. Seller Paid Closing Costs 1,500.00 207. 507. 208. 508. 209. 509. AUJU51 MtN I S hUK I 1 tM5 UNPAID HY SELLER ORIf ICTI~tCAITR rno iTO°~c i ~uoein ov ca ~ co. 210. Citylfown Taxes 510. Cit /Town Taxes 211. County Taxes 511. County Taxes 212. Assessments 512. Assessments 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER: 117,610.00 520. TOTAL REDUCTION8 IN AMOUNT DUE SELLER: 106,149.58 301. Gross amount due from Borrower (line 120j 134,257.81 601. Gross amount due to Seller (line 4201 128,947.17 302. Less amount paid by/for Borrower (line 22D) 117,610.00 602. Less reduction in amount due Seller {line 520) 106,149.58 303. CASH ( ®FROM) ( ^ TO) BORROWER: 16,647.81 603. CASH (^ FROM) (® TO) SELLER: 22,797.59 BASEO ON PRICES 126,400.00 (~ 6.000°~= $7,584.00 PAID FROM PAID FROM DMSION OF COMMISSION (LINE 700) AS FOLLOWS: BORROWERS FUNDS SELLER'S AT SETTLEMENT FUNDS AT 701. S 7,584.00 to M.C. Walker Realty SETTLEMENT 702. S to 703. Commission paid at settlement 7,584.00 704. Transaction Fee to Walker Realty 125.00 ~~ 801. Loan Ori ination Fee 1.0000 °i° to Hershey Mortgage Company Inc 1,151.10 802. Loan Discount Fee 803. Appraisal Fee to AmeriChoice Federal Credit Union 325.00 804. Credit Re ort 805. Lenders Ins coon Fee 806. Mort a e Insurance Application Fee 807. Assum tion Fee 808. Processin Fee to AmedChoice Federal Credit Union 250.00 809. Underwriting Fee to AmeriChoice Federal Credit union 550.00 810. Flood Cert to AmerlChoice Federal Credit Union 25.00 811. 901. Interest From 09/29/06 to 10/01/08 (~ 518.3856/day °~ (2 days) gg,77 902. Mortgage Insurance Premium for Month(s) to 903. hazard Insurance Premium for Years(s) to 904. 905. -_ 1. Hazard Insurance months ~ S per month 1 nn9 MnrtnanP Inenranne mnMh° /lip t ............w. ~. 905. ~1DOQ'. la"R 1001. Hazard Insurance months (~ $ per month ,, _SD02... J14ougag4-aasurar~ee-- Tenths ~ S - permmrMr _ ----- - --- --- - - - - 1003 City Property Taxes months (~ $ per month 1004. County Property Taxes months (~ $ per month 1005 Annual Assessments months ~ S per month 1006. months ®S per month 1007 months ®$ per month 1008 months ~ S per month 1101. Settlement or closing fee 1102. Abstract or title search 1103• Title examination 1104. TRIe insurance binder 1105. Document preparation to Affiliated Settlement Services Group,LLP 100,00 1106. Notary fees to SettlemenUClericallNotary Fees 31.00 24.00 1107. Attorney's Fees (includes above items numbers: 1108. Tale Insurance to Affiliated Settbment Services Group,LLP ggg.77 (includes above items numbers: ~ 1 f 09. Lenders covers e $ 115,110.00 1110. Owner's covers e $ 127,900.00 1111. Ends. 100, 300, 8.1, 710 to Affiliated Settlement Services Group,LLP 200.00 1 ] 12. Insured Closin Letter to Southern Tftle Ins. Corp. 35.00 1113. Ovemioht Fees to Affiliated Settlement Services Group,LLP 30.00 30.00 1201. Recording Fees: Deed $ 48.50 Mortgage $ 80.50 Release $ 129.004. 4 1202. Cit /Coup tax/stam s Deed $ 1,279.00 Mort a e $ 1,279.00 1203. State tax/stam s Deed $ 1,279.00 Mort a e $ 1,278.00 1204. Sat Fee to Recorder of Deed 37.00 1205. Inheritance Tax Escrow to ASSG •??,~; 1301. Survey '7 7,674.00 1302. Pest Inspection 1303. Tax Cert Fee to Affiliated Settlement Services Group,LLP 7 ~ 1304. 2008 School Taxes to Debbie Lupold 1,263.10 1305. Doc Trans/Wire Fees to Affiliated Settlement Services Group,LLP 40.00 1306. Home Warranty to AHS 435.00 1307. Sewer 10/1 to 12/31 to East Penn Consumer Office 11500 1400. TOTAL SETTLEMENT CHARGES (Enter on line 103,Sectlon J -and - line 502, Sedan IQ 5,310.64 18,433.10 I have raretully reviewed the HUD-1 Settlement Statement and b the best of rry kno~rledge and belief, it is a true and accurate statement of all reoeipls and disbursements made on my account or by mein this transadion. I further certify that I have received a coov of the HUD-1 Bafflement Statement 1 Theresa A. ansen ~' Nicole E. Jansen Borrowers Sellers The HU61 Settlement S ement which I red is a true and accurate account of this trensadan. I have o3u sad or will cause the fund s b be disbursed In accordance with this statement Settlement Agent ~ Date Affiliated Settlement Service o , LLC P Estate o rtr e . G ws WARNING: k is a crime to Icfowingly make false statements b the United States on this orany sinilarfonn. Penalties upon conviction can include a fine and imprisonment Fordetails see: fills 18 U.S. Code Section 1001 and Sedion 1010.