HomeMy WebLinkAbout04-13-091505607121
RE4~-1500 Ex (06-05)
OFFICIAL USE ONLY
PA Deparbnent of Revenue
Bureau of Individual Taxes County Code Year Fife Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 0 8 0 0 2 6 8
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 8 8 1 2 3 7 5 5 0 2 2 2 2 0 0 8
Decedent's Last Name Suffix Decedent's First Name MI
KEEPER ART HUR J
(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
4. Limited Estate
^X 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82) 0
7. Decedent Maintained a Living Trust _
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONUtNGt ANU CUnrlutN I IAL I A1C rnrultmwr wn srluulu est uintc i to i u:
Narne Daytime Telephone Number
w .~ r ~ ~ ~ w~ v n n n we o 7 1 7 ~ Z ') Z~ 7 fl
Firm Name (If Applicable)
First line of address
4 9 WEST ORANGE STREET
Second line of address
S U I T E 3
City or Post Office
SHI PPENSBURG
State ZIP Code ~
P A 1 7 2 5 7
Cl
- f~ ~
.a
REGISTER pF AUILLS USE LY
~~ ~ ~}
C.J
C i c~ -cy
:~--
-~_~
Y S"
DATE FILED
--;'~
.`.7
--~
'.` I
~j
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~_-°~
_ ,..,..7
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Correspondent's a-mail address: htadamslawl'a~embargmail corn
Under penalties of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, coned and complete. Declaration of prepare other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUR~t OPON RE~ONS~LFJFO ILING RETURN DATE
ADDRESS
SIGNAI~U EPRESENTATIVE ~ ura _ rl i"Yr~
O L~J
__.,..
ADDRESS ~~--.. (( ,l
PLEASE USE ORIGINAL FORM ION~.Y
Side 1
L 1505607121
1505607121
J
1505607221
REV-1500 EX
Decedent's Social Security Number
oecedenrsName: ARTHUR J. KEEPER 1 8 8 1 2 3 7 5 5
RECAPITULATION
1. Real estate (Schedule A) 1. 2 0 0 0 0 0, 0 0
........................................
2. Stocks and Bonds (Schedule B) .................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages i~ Notes Receivable (Schedule D) ........................ 4.
5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) ^ 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.
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 5 6 2 5,5 5
2 8 8 7 8, 9 4
254504,49
3 9 3 7 3, 6 2
3 9 3 7 3, 6 2
2 1 5 1 3 0, 8 7
2 1 5 1 3, 0 0
1 9 3 6 1 7, 8 7
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
'15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X.0 _ 0 . 0 0 15.
16. Amount of Line 14 taxable 1 9 3 6 1 7
8 7
at lineal rate X .045 . 18,
'17. Amount of Line 14 taxable
0 0
~
at sibling rate X .12 17.
'18. Amount of Line 14 taxable
~ ~
~
at collateral rate X .15 18
~19.Tax Due ................................................19.
?0. FILL IN THE OVAL iF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0. 0 0
8 7 1 2. 8 0
0. 0 0
0. 0 0
8 7 1 2. 8 0
Side 2
1505607221 1505607221
REV-1500 Ex. Page 3
13ecedent's Complete Address:
File Number
21 08 00268
DECEDENT'S NAME
ARTHUR J. KEEPER _
_ _____
STREET ADDRESS
26 CRAMER ROAD
CITY
SHIPPENSBURG STATE
PA ZIP
17257
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19}
2. CreditslPayments
A. Spousal Poverty Credit _
B. Prior Payments
(1) 8,712.80
C. Discount
Total Credits (A + B + C) (2) 9, 000.00
3. InterestrPenalty if applicable
D. Interest
E. Penalty
Total InterestiPenalty (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)
0.00
(4) 287.20
(5) 0.00
(5A)
(56)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
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 : ................................................................ ...... ^
^ 0
^
b. retain the right to designate who shall use the property transferred or its income; ......................... ......
^ 0
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? .................................................................................
d
h?
'
" ......
^
...
eat
or payable upon death bank account or security at his or her
intrust for
3. Did decedent own an ......
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 (/2 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 exemat 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 p2 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 [T2 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
ARTHUR J. KEEPER 21 08 00268
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 properly 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 orooertv which is jointly-owned with rieht of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Lot of land together with improvement erected thereon lying and being situate at 200,000.00
26 Cramer Road, Southampton Township, Cumberland County, PA
TOTAL (Also enter on line 1
(If more space is needed, insert additional sheets of the same size)
REV-1503 E)(+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
UNHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE
FILE
ARTHUR J. KEEPER 21 08 00268
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Manlife Financial 658 sahres of common stock 25,205.55
2. ACV Coop Stock 42 Shares @ 10.00
TOTAL (Also enter on line 2, Recapitulation) ~ $
420.00
25
(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.
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ARTHUR J. KEEPER 21 08 00268
Indude the proceeds of litigation and the date the proceeds wen; received by the estate.
All oropertv jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Personal Property sold at auction 9/13/08 5,595.75
2. Susquehanna CD 0304003833 3,716.65
3. School tax refund 641.40
4. Checking Account 18,573.61
Bank # 9842437064
5. Refund of Homeowners Ins. Premuim 163.00
6. Adams Electirc Patronage Div. 188.53
TOTAL (Also enter on line 5, Recapitulation) ~ S 28
(If more space is needed, insert additional sheets of the same size)
RSV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~
IN R SI DENTEDECEDENTRN ADMINISTRATIVE COSTS ~~
ESTATE OF FILE NUMBER
ARTHUR J. KEEPER 21 08 00268
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Fogelsanger-Bricker Funeral Home 8 227 24
2. Spring Hill 575.Ou
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City
Year(s) Commission Paid:
State Zip
2, Attorney Fees
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees to Register of Wills
5 Accountants Fees
6. Tax Return Preparer's Fees
7. County Twonship
8. Appraisal to Ausherman
9. Battery for car sold at aution
10. Advertising for auction
11. Auctioneer Fee & Costs
12. Embarq
13. Adams Electric
14. Nationwide for Insurance
15. Nationwide Home Owners
16. Shippensburg Healthcare
17. Robert Traylor
18. ProLawn Landscaping
10,622.53
TOTAL (Also enter on line 9, Recapitulation) I $ 39,373.62
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
ARTHUR J. KEEPER 21 08 00268
Decedent's Name Page 1 File Number
Schedule H -Funeral Expenses & Administrative Costs - B7.
ITEM
NUMBER
DESCRIPTION
AMOUNT
19. Vivian Coy (Real Property Taxes) 2,209.42
20. Premiere Property Services (Septic) 175.('r
21. Funks Drilling 79.50
22. Ann Bennett 320.00
23. Lisa Thorne 350.00
24. Shippensburg Auction Center 250.00
25. Southampton Township variance 550.00
26. McCunes (window for house) 96.44
J:/
SUBTOTAL SCHEDULE H-B7 ~ _ 4,030.36
REV-1513 EX + (y-pp)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ARTHUR J. KEEPER ~~ nQ nn~au
RELATIONSHIP TO DECEDENT v AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [nclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Kim Cook Lineal 2,151.31
49 Corbin Heights Way
Martinsburg, WV 25404
2. David Kelbaugh Lineal 2,151.31
35 Moonight Lane
Martinsburg, WV 25401
3. Kevin Price Lineal 2,151:31
1001 Wilson Place
Frederick, MD 21701
4. Sharon Price Lineal 2,151.31
7746 Edgewood Chruch Road
Frederick, MD 21701
5. Dustin Keefer Lineal 2,151.31
9798 Alvin Drive
Shippensburg, PA 17257
6. Jaime Keefer Lineal 2,151.31
50 North Star Drive
Harrisburg, PA 17112
7. Brian Keefer Lineal 2,151.1
1317 Ritner Highway
Shippensburg, PA 17257
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS :~.
1. Messiah United Methodist Church 21,513.00
30 S. Penn Street
Shippensburg, PA 17257
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S 21 513.00
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
ARTHUR J. KEEPER 21 08 00268
Decedent's Name Page 2 File Number
Schedule J -Beneficiaries -1
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS (include outright spousal distributions)
8. Judy Lefever
19823 Marcia Court
Boonsboro, MD 21713
9. Robert E. Keefer
1317 Ritner Highway
Shippensburg, PA 17257
10. William A. Keefer .
14 Cramer Road
Shippensburg, PA 17257
11. Terry L. Price
1001 Wilson Place
Frederick, MD 21702
12. Bradley Keefer's heirs
RELATIONSHIP TO DECEDENT f AMOUNT OR SHARE
Do Not List Trustees) I OF ESTATE
Lineal I 25,815.07
Lineal ~ 51,630..14
Lineal I 51,630.14
Lineal ~ 25,815.07
Lineal ~ 2,151.31
13. ~ Darrin Kelbaugh's heirs
Lineal I 2,151.31
Last ~ViCI ancf ~Iestament of
.~rthur,~. fee er __ -
,_ }
c ~_~_ __
I, ARTHUR J. KEEFER, of Southampton Township, Curnberland_~o}~nty~ ~;
~~ ;~ ._..
Pennsylvania, being of sound mind and memory declare this to be my Last V~?~l'and~estament_'
and revoke any will or codicil previously made by me. _ _= ` ' = ``
`j m
ITEM I: I direct that all my just debts and funeral expenses, including my grave
marker and all expenses of my last illness, shall be paid from my residuary estate as soon as
practicable after my decease as a part of the administration of my estate.
ITEM II: I direct that my executors, hereinafter named, shall sell my real estate
together with the contents thereof, as soon as practicable after my decease.
ITEM III: I give, devise and bequeath all of my estate of every nature and
wheresoever situate as follows: ten (10%) percent to Messiah United Methodist Church, 305
South Penr. Street, Shippensburg, Pennsylvania, its successors and assigns: twenty-six and two-
thirds (26 2/3%) percent to my son, Robert E. Keefer, his heirs and assigns; twenty-six and two
thirds (26 2/3%) percent to my son William A. Keefer, his heirs and assigns; thirteen and one-
- - -- -third (l3 i/3°fo) percent to Terry Lee Price, his-heirsand-assigns;-thirteen and onethird______ __
(13 1/3%) percent to Judy Lefever, her heirs and assigns; and the remaining ten (10%) percent to
be divided in equal shares to my hereinafter named grandchildren or their heirs: the heirs of
Bradley Keefer, Jamie Keefer, Dustin Keefer, Brian Keefer, Kevin Price, David Kelbaugh, the
heirs of Darrin Kelbaugh, Kimberly Cook, and Sharon Price, their heirs and assigns.
ITEM IV: I direct that all taxes that may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as
part of the expenses of the administration of my estate.
ITEM V: I appoint WILLIAM A. KEEFER, Executor of this, my Last Will and
Testament. Should he fail to qualify or cease to act as Executor, I appoint ROBERT E.
KEEFER, executor of this my Last Will and Testament.
ITEM VI: I direct that my Executors or their successor shall not be required to give
bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I hereunto set my handand seal to this my Last Will and
Testament, written on _~ sheets of paper, dated this ~U~ "l day of Fes, 2007.
(SEAL)
The preceding instrument, consisting of this and/ /TnR.. other typewritten page(s),
each identified by the signature of the testator, ARTHUR J. KEEFER, was on the day and date
thereof signed, published and declared by ARTHUR J. KEEFER, the testator herein 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 other, have subscribed our names as witnesses hereto.
__
-__
__ _ .
G'y ~ residing at
~~ ~~
residing at ~_
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS
We, ARTHUR J. KEEFER, the testator in, and the undersigned witnesses to, the will,
the attached or foregoing instrument, who have signed the instrument, having been qualified
according to law do depose and say:
(a) that I, the testator, do hereby acknowledge that I signed the instrument as
my will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b) that we, the witnesses, were present and saw the testator sign and execute
the instrument as his will, that he signed it willingly and executed it as his free
and voluntary act for the purposes therein expressed; 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 years of age, of sound mind
and under no constraint or undue influence.
Witness
Gr~.
Witness
Subscribed to and subscribed or
affirmed and acknowledged before me
by ARTHUR J. KEEFER, the testator
and the witnesses whose names are signed above
this( day of , 2007.
Nt~7ARIAL SEAL
JEANPd~ i~;? r1RNOLL~, NOTARY PUBLIC
Notary UbIIC Souinampr_;; Twp., Franklin County
fly Commis,~~ r•, (;xpires April 12, 2008
4
I
i~ " °'~"~` U.S. Department of Housing , r
A. Se~I~r~titGl-tL~~j~~~n ` ` and Urban Development OMB No. 2502-0265 (Page 1)
3. Type of Loan
. IJ FHA 2. U FmHA 3. ®Conv. Unins. 6. File Number 7. Loan Number 8. Mortgage Insurance Case Number
1. ^ VA 5. ^Conv. Ins. 3286-S 05280367-10
:. Note: Thls form b f^r^lehed ro dive you a statement or act^al settlement rnsb. M^ou^b paid ro and by the settlement a><ent are showa4 Items marked °(p.o.u)^ wen paid outside Me rlosm`; they an shown here for
inforsaatlenal p^rpow and arc ^ot iael^ded is the totab.
1. Name and Address of Borrower .Name, Address, and Taxpayer identification # of Seller F. Name and Address of Lender
James S. Laid Estate of Arthw J. Keefer AgChoice Farm Credit, ACA
Louise M. Leid by William A. Keefer, Executor 3301 West Market Street
800 Britton Road York, PA 17404
Shippensbwg, PA 17257
I. Property Location
26 Cramer Road, Shippensbwg, PA 17257
Settlement Agent Name, Address and Taxpayer Identification Number
Hamilton C. Davis
20 East Bwd Street, Suite 6 \\
Shippensbwg, PA 17257 ~- 251530888
ice of Settlement I. Settlement Date
20 East Bwd Street, Shippensbwg, PA 17257 2/19/2009
. Summary of Borrower's Transactions K. Summary of Seller's Transaction
00. Gross Amount Due From Borrower 400. Gross Amount Due To Seller
01. Contract sales price 200,000.00 401. Contract sales price 20Q000.00°
02. Personal Property 402. Personal Property
03. Settlement charges to borrower (line 1400) 9,842.05 403.
04. 404.
O5. 405.
Adjustments f'or items paid by seller is advance Adjustments for items paid by seller in advance
06. City/town taxes to 406. Cityltown taxes to
07. County taxes to 407. County taxes to
08. Assessments to 408. Assessments to
09. School Tax 02119!09 to 06/30/09 641.40 409. School Tax 02!19!09 to 06/30/09 641.40
10. Gazbage Fee 410. Garbage Fee
11. 411.
12. 412.
Z0. Gross Amount Due From Borrower 210,483.45 420. Gross Amount Due To Seller 200,641.40
Dtl, Amounts Paid By Or in Behalf Of Borrower 500. Reductions in Amount Due To Seller
D 1. Deposits or earnest money 501. Excess deposit (see instructions)
D2. Principal amount of new loan(s) 160,000.00 502. Settlement charges to seller (line 1400) 0.00
D3. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
)4. 504. Payoff of first mortgage loan
)5. 505. Payoff of second mortgage loan
lb~ ._j' 506.
)7. ~
)8. 507.
508.
)9. 509.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
10. City/town taxes to 510. City/town taxes to
l 1. County taxes 01/01/09 to 02/19/09 Si.50 511. County taxes 01/01/09 to 02!19109 51.50
12. Assessments to 512. Assessments to
13. School Tax to 513. School Tax to
14. 514.
l5. 515.
C6. 516.
i7. 517.
l8. 518.
i9. 519.
;0. Total Paid By/For Borrower 160,051,50 520. Total Reduction Amount Due Seller 51.50
10. Cash At Settlement FromlTo Borrower b00. Cash At Settlement To/From Seller
11. Gross Amount due from borrower (line 120) 210,483.45 601. Gross Amount due to seller (line 420) 200,641.40
~2. Less amounts paid by/for borrower (line 220) ( 160,051.50 602. Less reductions in amt. due seller (line 520) ( 51.50)
3. Cash ~~ From ^ To Borrower $ 50,431.95 6Qi. Cash X^ To ^ From Sell $ 200,589.90
:ve carefully reviewedthe IIUD-1 Settlement Sfatemeot and to tfte best of my lmowledge and belief it is a true and acctuate sla nt of all receipts and dis n de on my
punt m by me in this transacti .1 ~ t I ha~cely~d a completed copy of pages 1 and 2 of this HUD- SetUStatement.
~ !, ((~ G 1
rower James S. Leid Set r state of Arthw J. Keefer, by I t A. Keefer, Exec.
ower Louise M. Leid Seller
SETTLEMENT AGENT CERTIFICATION Seller's Taxpayer Identification Number Solicitation and Certification
IUD-1 ttlement Ststement which I have pr~pa,~d to a true and sccutab axount of this tnmsagion. I have You ate required by law ro provide the Settlemartt Agent vaned shove with your correct tsxpaya identification
the da ro be dis ed in accordance w~"th tfiia abtemm~t numbx. If yyou do not provide tha Settlement Ape~t with Your cortect ta~cpayer idrntification Dumber, you ma
be subject W civil or avmua!! pemhies imposed by Isw. Under yenelties or peryury, I cuti[y that the numbayr
ahowD on this statement is my correct taxpayer iden fieation number.
Settlement AgentDate r
r7nJG It is • crime to knowingly make false sMtements ro the United States on this or any other similar form.
ies u n conviction caD include s fim end imprisonment For details see: Title 18 U.S. Code auction 1001 snd
n lob. Seller's Signature Date
~ - 1 3/91 ItESPA, HB 4305.2
!
, Page 2
L. Settlement" Charges
700. Total SalesBroker's Commission based on $ ~ %= "Paid From
' Paid From
ll
'
Division of Commission (line 700) as follows: Borrower
s
Funds at er
Se
s
Funds at
701. $ to ettlement Settlement
702. $ to
703, Commission paid at Settlement
704.
An0_ itemv Pavahle in C_onnectinn With Loan
801. Loan Origination Fee 1 % to; AgChoice Farm Credit, ACA 1,600.00
802. Loan Discount
803. Appraisal Fee to AgChoice Farm Credit, ACA 375.00
804. Credit Keport to
805. Lender's Inspection Fee to
80b. Mortgage Insurance Application Fee to
807. Stock Participation Fee to: AgChoice Farm Credit, ACA 1,000.00
808. Flood Certification Fee to: AgChoice Farm Credit, ACA 18.00
809. Application Fee to: AgChoice Farm Credit, ACA 350.00
810. Wire Transfer Fee to: AgChoice Farm Credit, ACA 15.00
811.
onn i~e...~ Ranui~nd Rv i sndor Tn Rn Paid rn Advanrw
901. Interest from 02119!09 to 03/01/09 @ $ 39.47 /day 394.67
902. Mortgage Insurance Premium for months to
903. Hazard Insurance Premium for years to
904.
905.
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1001. Hazard Insurance s PeC
1002. Mortgage Insurance s Per
1003. City property taxes s Per
1004. County property taxes s Per
1005. Annual assessments s per
1006. School 'faxes s per
1007. s per
1008. Aggregate Reserve Adjustment.
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1101. Settlement or closing fee to
1102. Abstract: or title search to
1103. Title examination to
1104. Title insurance binder to
1105. Document preparation to
1106. Notary's fees to
1107. _
Attorney's fees to
(include;: above items numbers: )
1108. Title insurance to .Hamilton C. Davis, Esquire, Agent for CTIC 1,358.75
(includes above items numbers: )
1109. Lender's coverage $ 160,000.00
1110. Owner's coverage $ 200,000.00
1111. Insured Closing Protection Letter 35.00
1112. Endorsements 160/300/900 150.00
1113. Package Download Fee _ _ 25.00
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~~..... .~... ~. ..._.___' _'--_' ____o _____ _ _ _ -_ _ o
1201. Recording fees: Deed $ 38.50; Mortgage $ 48.50; Releases $
87.00
1202. City/county tax stamps: Deed $ 2,000.00 ;Mortgage $ 2,000.00 0.00
1203. State taxfstamps: Deed $ 2,000.00 ;Mortgage $ 2,000.00 0.00
1204. UPI Tax Certification Fee to: Recorder of Deeds 20.00
1205.
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a/ov. cavu.~.v..w. v~.a.v ................ ....
1301. 2009 County/Townshi Real Estate taxes to: Vivian Coy, Tax Collector -
383.63
1302. Overnight Mai{ Fee to: Hamilton C. Davis, Es air 30.00
1303.
1304.
1305.
1306.
1307.
1308.
1309:
1400 Total Settlement Charges (enter on lines 103, Section J and 502, Section K) _ 9,842.05 u.uu
Initial Escrow Account Statement Required by Secton 10 (c) (1) of the Real Estate Settlement Procedures Act (RESPA)
If checked, ~ the terms of your loan requve you to have an escrow account to assure that the certain obligations relating to the mortgaged property, such as taxes, insurance
'premiums and other charges are paid. The amount specified below will be collected, along with your mortgage principal and interest payments, during the fast 12 months after
your account is opened to pay these anticipated expenses: FeetvwAouormt
Beginning Date: Your escrow account payment will be S per
Payee Purpose Anticipated Due Date Estimated Amount
HUD - 1 3/91 RESPA, HB 4305.2
x,
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Date: q ~ - 3 ~ og
~~ N u~y , Skb . Q~ ~'- ~ s~
eil AU# 003699-L Clerk: ~~~~ Cashier: ~~~~
man AU# 00266fi-L
~-
~SALE. ~
$ (~ ~
x Cash ......................
T
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7
f " checks $ '-~ - ~ q ~J . O O
F'~f
Other ...................... $
TOTAL PROCEEDS OF SALE'$ ~ ~~ ~qS, ~) J
Less Seller's Expenses:
Auctioneer's Fee .....~.rJ.~l.+~'..........• $ ~3L1.3w
Other seller's expenses:
Advertising costs:
~n~~ ~~ _ ~ 131.0 _,
$ ~,n. ~a o
. u $ 11.Q. o ~ /
> O ~ $ 3at~• a5
Miscellaneous expenses:
~ r S l~.oo /
s
Total Seller's sale expense:
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Total Net Proceeds to Seller: S ~ ~ i ~ ~ y
I (we), the seller of goods, merchandise and/or property sold at public auction on above date and .
location, acknowledge and accept this settlement of proceeds of sale. I (or we) agree to .accept all
responsibility for providing merchantable title to alt goods, merchandise, and/or propertysold,`and-.for
deliver aftitle to purchaser.
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(d ) Seller's signature)
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:(Auctioneer's signature) (Seller's signature)
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