Loading...
HomeMy WebLinkAbout01-11-10 iOJGOJ 1058 REV-1500 EX (OG-05) bFFICIAL USE ONLY PA Department of Rovonuo County Codo Yoar Filo Numbar Bureau oflndlvidualTaxes s INHERITANCE TAX RETURN J PO BOX 280601 _~ ~ (~~ l ~~~ Harrisburg, PA 17128-0601 ' RESIDENT DECEDENT t7r' ~/ ` /// ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 173-38-5938 01 /08/2002 Oncednnl's Last Namc Hollenback (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Hollenback ' S t N bor Dale of Birth 08/14/1949 Sulhx f )crc~lent's I ir:a Nnmc MI Marti ~ Sutfix Spouse's First Namc MI Frank F Spouse s Social ecun y um THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW <~ + 1. Original Return - 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-02) 4. Limited Estate 4a. Future Interest Comprornisc (date of 5. Federal Eslale Tax Return Requued death after 12-12-82) - 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Litigation Proceeds Received ~ ~:: 9 10. Spousal Poverty Credit (date of death under Sec. 9113(A) 11. a l a . ... between 12-31-91 and 1-1-95) p ch Sch A tt ( ) CORRESPONDENT - THIS SECTION MUST BE CO MPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Daytime Telephone Number Name r-a (717) 2~-4777 `~ ='"'' John F. Lyons, Esquire C© "--, ~ ---• ~~ ~ Firm Name (If Applicable) _ RECir~~oF vJILL$C~SE orJi,Y r,; - *' . r. ~~y~ ..... ;-,; r,., ` First line of address ~~" ~~ `~ t ~ `-., t - C7 ~ T~+ 112 Walnut Street ~^~ ~"' N" ~ ' Second line of address 't ~~ ~-,'± <' r n ~ rT" - W DATC- FILED City or Post Office State ZIP Code Harrisburg PA 17101 Correspondent's a-mail address: Under penalties of perjury, I declare that 1 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 representative is based on all information of which prcparer has any knowledge. cmnreniaeAF PERSON RESPONSIBLE FOR FILING RETURN DATE est Curtiss Street, Apartment #2, Bozeman, MT 59715 ____ _ DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505G051U58 15056051058 J 15U5UU5~U5J REV-1500 EX Decedent's Social Security Number Marci J Hollenback 173-38-5938 Decedent's Name: REC APITULATION 1 94,000.00 1. Real estate (Schedule A) . ........................................... . . 0.00 2. Stocks and Uonds (Schedule L3) ............... ....... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 0.00 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 0.00 5. Cash, Bank Deposits S Miscellaneous Personal Property (Schedule G) ...... .. 5. 0.00 6. Jointly Owned Property (Schedule F) Separate Billing Requested ..... .. 6. 0.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property 00 0 (Schedule G) Separate Billing Requested...... .. 7. . 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 94,000.00 9. Funeral Expenses 8 Administrative Costs (Schedule H) ................... .. 9. 22,665.58 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 18,003.43 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 40,669.01 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 53,330.99 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 00 0 an election to lax has not been made (Schedule J) ...................... .. 13. . 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 53,330.99 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 14 taxable 53,330.99 al lineal rate X .0 45 16, 2,399.89 17 Amount of Line 14 taxable . at sibling rate X .12 17. 18. Amount of Line 14 taxable 18 at collateral rate X .15 . 2,399.89 19 . TAX DUE ...................................................... ... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 07 1058 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Marci J Hollenback __ __ _ __ _ _ 173-38-5938 STREET ADDRESS 12 Campbell Place _ CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments __ C. Discount 2,399.89 Total Credits (A + B + C) (2) 3. InteresUPenally if applicable D. Interest ___ - E. Penalty ------ --- - -- - ---- - - -- Total IntcresUPenalty (D + E) (3) 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. (4) 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) Make Check Payable fo: 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 trans(erred :.................................................................................... ...... ^ 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 race 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 fhe 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 exernot 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)J. 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. RED/-1502 EX+ (11-Of3} j-x ~' pennsylvania SCHEDULE A ~1~' DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Marci J. Hollenback 21-07-1058 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 willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must he disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1• 12 Campbell Place, Camp Hill, Curnbcrland County, PA (Parcel 1147-19-1590-064-U--12) 94,000.00 (Property sold on August 28, 2008 (or $57,000.00. See attached copy of HUD-1 Settlement Statement. From the date of death (January 8, 2002) to the date of the sale of tlic property, the property suffered severe damage. Therefore, the best estimate value at the time of death was calculated by adding the sale price plus mitigation costs per the attached estimate.) TOTAL (Also enter on Line ], Recapitulation.) I $ 94,000.00 If more space is needed, insert additional sheets of the same site. REV-1510 EX+ (G-98)~~~~~~ J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT Di_CEDENT SCHEDULE G INTER-VIVOS TRANSFERS 8~ M15C. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Marci J. Hollenback 21-07-1058 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE T11E NAME OF IHE TMNSFLREE. 111E111 HEUIION$nV f0 UECEDLNfAND THE O~fE OF TRANSfER. Al1ACMACOPV OF INE DEED FON HE~I ESfAiE Dnre or- DEAn I VALUE OF ASSET % OP DECD'S INTEREST [XCLUSION (IF AI'1'IICAl11 E1 TAXAOLE VALUE ~ • PA Public School Employees' Retirement System Death Benefit (06107102) 442,335.44 442,335.44 0.00 Beneficiary: Frank P. Hollenback, Spouse of Decedent p TOTAL (Also enter on line 7 Recapitulation) 5 I 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99)~~ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Marci J. Hollenback 21-07-1058 ITEM IUMnEF A. 1 B. 1 2. 3. 4. 5. 6. 7. a. 9. ~ o. FUNEHALEXPENSES: Neill Funeral Home Cit Camp Hill State PA Zip 17011 Debts of decedent must be reported on Schedule 1. DESCRIPTION ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (It decedent's address is not the same as claimant's, attach explanation) claimant Amy Seaman street Address 12 Campbell Place Y Relationship of Claimant to Decedent Daughter Probate Fees Accountant's Fees Tax Return Preparcr's Fees Cumberland Law Journal (Estate Advertisement) The Sentinel -Legal (Estate Advertisement) lonni Abstract (Cumberland County Real Estate Records Research) Postage (Certified Mail to Frank P. Hoilenback, Spouse) TOTAL (Also enter on line 9, Recapitulation) ~ ~ (Ii more space is needed, insert additional sheets of the same size) Zip AMOUNT 8,634.00 10,015.51 3,500.00 216.00 75.00 174.58 45.00 5.49 22,665.58 REV•1512 Ex+ (12-04) E:; :p~ :,,,, <. ;.~:;~' pennsylvania l~.tl DEFARTMENT OF REVGNUE INHERITANCE TAx RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Marri .L Hollenback 21-07-1058 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCR1PTlON OF DEATH 1• Costs of Salc (12 Campbell Place, Camp Hill, Cumberland County, PA) 18,003.43 Trash/Sewer (2005-2008) ~ 652.30 Tax Cert Fee 10.00 Real Estate Transfer Tax 570.00 Attorney Fees 2,997.07 Tax Claim (200612007) 4,341.50 County Tax Penalty (2008) 648.33 School Tax (2008) 1,179.23 Unpaid Monthly Assessment 1,820.00 Late Fee for Unpaid Monthly Asses sment 1,560.00 Excess Water Billings 4,225.00 TOTAL (Also enter on Line 10, Recapitulation) I $ 18,003.43 If more space is needed, insert additional sheets of the samesize. REV-1513 [Y,+ (11-U4) C' . ~ pennsylvania ~~~ 'DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Marci J. Hollenback 21-07-1058 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Nat List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).) 1. Frank P. Hollenback, 21 Ray Road, Middletown, ('~ 17051 Spouse 50`% 2. Amy Seaman, 740 West Curtiss Street, Apt. >'rz, [3ozeman, MT 59715 Daughter 25% 3. Robert Seaman, USCGC Spcncer,427 Cornmcrcial St., [3oston,MA 0210) Son 25% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTR)BUTIONS UNDER SECTION 2113 FOR VJIIICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, insert additional sheets of the same size. n. 5l;ll~l;llll;lll 5lillCalll;llt a :. u.:L.ll hin•nl ul u,~,~ .a.,l .~~~~I ull~.ni U,:~rtu~lnin lit 0. Type of Loan OMI1 Anoroval No. 2507-0765 rrsr.ur•-. t Irznnnnm „ _ ~- ---- --- - -- ---- ------ 1. OFHA 2. OFmHA 3. OConv. Unins. 6. File Number l 7. Loan Nurnbcr 8.1.1nrlr)r,r In;uranr:c Cisc Numb(:r 4. VA S. C7Conv.lns 29412SALTER irriiiri rs lurrwshedto give yai a slalnncnl of aclirar3elllcmenl ¢osls-Amon di n.~~d to-anJ by lhn-sclllcmnnl a~rnl ~arr sho..n _ C. NOIC: gems mad,ed'tp.o G,)' wtte paid Outside MC ClOSinq; they ar! sbovm herOlIX mlormaLOn purposes and arc net meludcA ~n lhC totals TIIICtxprC$$ SCIIIenlcnl S stem WARNING: M H s dime l0 4nowngly maMC raise slalemmis to the Urnleb Stales On (his Or any Other 5~mdar lOrm Penalbcs upon y fodvKhon can incFlAC a line and- frisonm~nl. For delad5 see idle Ifl U_5 fndr Seumn t(1pt ,inA ;~uron IOIn____----_- _ -____--_ _. .. Pfl'lIC(1 ~f3/26/2~~$ al 1632 (.LT D. NAME OF BORROWER: Rose Marie Salter ADDRESS: 11 Campbell Place, Camp Hill, Pa 17011 E. NAME OPSELLER: Estate of Marci J. Hollenback, formerly known as Marci J. Seaman ADDRESS: 12 Cam bell Place Cam Hill Pa 17011 ___ _________ __ _ F. NAME OF LENDER: -"-- AOORESS: G. PROPERTY ADDRESS: 12 Campbell Place, Camp Nill, PA 17011 _ Wonnlcysburg Borough_____ ___ _ H. SETTLEMC-NT AGENT: Cedar Clitl Abstract Agency, Inc., Telephone: 717-77.1.7.135 F:tx: 717-714.3069 -PLACE OF SETTLCMENT: 414 Oridgc Slrcet, New Cumberland, PA 17070 I. SETTLEMENT DATE: 08129/2008 ___ _ _ _ __ _ J. SUMMARY OF BORROWER'S TRANSACTION _ -k. SUMMA_RY_ O_F_SEL_LER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER 101. ConlraG sales ' e 57,000.00 - - _401,._ -Contract s~lcs price - ------ - ------ 57 000.00 102. PcrsonalProperty -- _ _ 402. Personal Properly , 103. Setllemenl charges to borrower (line 1400) __-__ 1,619.50 . _-___ -_____ _ 403. 1~• 404. 105. ---- -- - .. .. - Adjustment.^, for items paiA by scllrr in advance _-_ - _ 405. Ad/u::hncnL, lur Ilrru:, p:ud Iry :,cllnr m ddvanrc tOG. G11YAown taxes - -_ _ --_ _ -- -... . 106. Gly/town taxes 107. County lazes 08129!08 l012131108 199.68 407. County taxes 08129108 to 12131103 199.68 108. School taxes 08129/081006130109 985.38 ___ 406_ School taxes 081291081006130109 _ 985 38 109. _ _ _ ______ 402 --- - -------- . ----- - 110. Month) common ex -AO @BlO8to08131108 9.03 410. Monthh commoncx -A0,~139108to08131l08 I 9.03 111. SewerlTrash 081291081009130108 112. - - 42.08 411. Sewer7Trash 08129108(009130108 412. - 42.08 - ------ 120. GROSS AMOUNT DUE FROM BORROWER - ---- - 59,855.67 - ---- _ _ 420_GROSS AMOUNT DUE TO SCLLER -------------- 58 236 17 _ ____ 200. AMOUNTS PAID BY OR ON BEHALF OF BORROWER _ _ _ _ _ _ , . 500. REDUCTIONS IN AMOUNT DUE TO SELLER 101. sit or eamesl mono _J000.00 501. Exress Deposit (sec inslmdions~____ _ 202. PrinaDal amount of new loans __ _502 Selllemenl charges to seller (line 1400J_ __ _ __ ___ _ _ 18 003.43 203. Exisli ban 5 taken sub'eel l0 503_Exislin loan( taken subject 10 _ ____ _____ _ ~• _ _ _504. Payoff of Firs( Morlga 1r c Loan _ ___ ___ _ _ 205. _ _ _ 505. - - 206. - 506. - ------- 207. -------------------------- 507. - - - 208. _500._ --------- --- -- 209. ---- - --- -------- 509_. ---- Ad-ustmenls!or items unpaid by seller ___ __ __ Adjustments for items u_n_paid by scller____ _210. CilyAown lazes - 510. Cilyllown taxes-_ - _ 211. Count taxes ------ 511. County taxes 212. School lazes _ - _- 512. School lazes 213• - - -- -- 513. ---------------- 214. 514. -- 215. 515. -- ----- ---- 216. _516. - ----- --- -- 217. _517---- --- -- 218. 518. 219. 519. 220. T07AL PAID BYIFOR BORROWER 5 000.00 __ 520. TOTAL REDUCTION AMOUNT DUE SELLER 18 003.43 300. CASH AT SETTLEMENT FROM OR TO BORROWER _ 600. CASH AT SETTLEMENT TO OR FROM SELLER 301. Gross amount due Irom borrower line 120 59 855.67 601. Grass amount due to seller (line 420) 58,236.17 ~1. Less anaunts id b /lor borrower line 220 5 000.00 602. less reduction amount due seller (line 520) ~ 18 003.43 303. CASH FROM BORROWER _ _ 54,855.67 603 -CASH TO SELLER __ __ ______ _ - 40,232.74 SUDSTITUTE FORM 1099 SELLER STA iCMENT: Thn inlOrmalmn canlamM bermn is imprulanl la. inlnrmabpn anA tt bcmq lumchcd In Il,c- Inlrrnal Rcvcnve Service II ynn arc rcrtu~rcA to (dc a return. a negl~gene! penMly p IMher sanction will De anpOSed Or1 yeu it Ibis dem rs Mqured la be reported and II,e IRS dclermmes Thal rl has not been repMlcd. the CadraU Sales Pnce described a1 sne W I ~YOw coro4Mp Ole Woss Proceeds of INS MansacNOn. you Me reouked by bw to provide Ibe 3llOemenl agent (Fed. Ta. ID N¢ ) wuh your correct la.nayer ~Aenbhcabon number, I( yoo do not pro~~AC your correct In.pa~cr ~denLGWbon rRarlbN, you may De srdyeG Io civil IX avninal pcn~GCS imposed bylaw. (TdC/ pchalbCS arper(ury, I cMdy Ina! the number shown on Ih~s statement ~s my Wrrcc( Iaapa'i cr iden;ilic.ilion numocr. TIN / SELLERIS)SIGNATURCISI I SELLER(S) NEW MAILING ADDRESS: SEILER(S)PNONE NUMDERS: fell nn.l ~,„~~ui ~I i, ni~.li ~Il ~~niwnd.,, ::I~1/,'.,,~I II IC I•,r .l SETTLEMENT STATEMENT _- - IIu~:L.iI.II:;,,„•ulcnli:nl~l;~.ll:nl r....I~~JUlIL~nr,alua,~l ll,.l.~l:I I I--- - ' '' - ----_-_-. -_ _ 700. TOTAL SALES/OROI<ER'S COMMISSION basal on pnrc 357000.00 =- Division of commission (line 700) as lollows: _- 701• $ to _ _. --______ __ 702. to PAID F•ROI~1 UGHHOWGH'S FUND; nT _ SETTL[t<1ENT PND PROPA SLI_Llft'S FUNDS AT SGTTLCMCNT 703. Commission aid al Settlement - --- 800. ITEMS.P YABLE IN CONNECTION WITH LOAN -- 801. loan rigination Fce 802 -- --------- -- . Loan iscount % -- --- - - 3. Appraisal Fee --= redit~rl ------ --- 805. Lender's Inspection Fcc_ -----. _ _ _IIW. Monyage ~ppliwtion Fcc_, _ _-_ --._ 807, Assunaplion Fcp 808. 810. -- ---------------- __ --- ._-._--_--_-.__-- _ 811. -------- ------------- - - -- - _ _ _ - .ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From to _____________(nl~ /daY - - - - --- -- - ----_-- - 902. Mon a Insurance Premium for to 903. Hazard Insurance Premium for to - --- -- -- - 905. ------- - ---- --- 1 00. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard Insurance mo. Imo -- --- - - ------- _ 1002. Mort Insurance mo. @ $ !mo 1003. CiI Pr n Tax mo. /mo _ - ------- - --- ----- -- 1004. County Propene Tax mo (~_~ 49.12 !mo - ------- -------- --- 5. taxes mo. R 98.27 Imo C-~ ----- -- -------- - -- - --- -- .-- 1009. Aagre9ate Analysis Adiustmenl _ _ _ __ 0 00 0 00 . 1100. TITLE CHARGES -- - ----- ----- . 1101. Seltlemenl or dosin lee -- -- -- -------- 1102. Abslrad a title search -- 1 .Title examination 1101. Title insurance tinder -- 1105. Document Preparation 110G. Nolarv Fees - --- ---- ---- --- ------ --- - --- - 1107. Allome 's lees Io Stone Lafaver &Sheklelski 750.00 includes above items No: ~-_ 1108. Title Insurance _- includes above items No: - -- ~ - - -- ---- - ----- - - --- _ 1109. Lender's Cover - ----- ----- -- - 1110. Owner's Covcra a 57 000.00 - -- 1111. TrashlSewer-Ith Ir to Wormle sburg Borough 121 00 - 1112. Trash/Sewer•2005.08 to Wormleysburg8orough ______ . 652 30 -"--_ ----- - _ ._ ._-. __ 111 .Tax CeA Fee to Stone Lafaver &Sheklelski - - ----------------------__-- 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES _ . - -- ----_--- . -------------- ------ 10.00 - _ 1201. Recordi Fees Deed 38.50 • Mongage $ ; Rclcase $ 38.50 _____ 1202. Ci1y/Coun(y lax/stamps Deed $570.00 • Mongage $ ____ 570.00 __ _ 1203. Seale Tax/stam s Decd 570.00 • Mort age $ __ ___ ____ __ 570.00 1204. Attome lees to Lon meadows Townhouse Association ____ _ _ _ 2 gg7 07 1205. Monthl commorn ex -Seel to Longmeadows Townhouse Association 140.00 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve 1302. Pest Inspection __ _ 1303. 2006-07 Tax Claim to Cumberland County Tax Claim Bureau 1301. 2008 Co Tax-Penalty to William O'Donnell' _ ____ 4 341.50 648.33 1305. 2008 Scholl Tax to William O'Donnell' __ _ - 1 179 23 1306. unpaid monthly assessment to Longmeadows Townhouse Association 1 820.00 1307.1aleteeforun assmis to Lon meadows Townhouse Association _ __ 1,560.00 1308. excess water billin s to Lon meadows Townhouse Association __ 4 225.00 1400. TOTAL SETTLEMENT CHARGES enleron lines 103 Section 3 and 502 Section K 1,619.50 18,003.43 IIUD CERTIFICATION OF DUYER ANp SCLLER 1 have a ChNyflNewCA ih! RUD-1 SCIIICmeM S101CmCn1 anA to Ine heal CI my MnowiM7~ and bel,Cl. ~I is a INC and accurate SIalCmeni of JII rCCC,pI+ ano dispunemenls matte on my JGGOUnI p uy es Vansscuon. I M111er GMily Ih have rMeC'Cd i Copy o/ the HUO.1 Selliemenl SIaICnfCnl. AAww ''!' ~ Z.~~ ~ R' i n Te IIUD•I 5°ulemenl $IelCm^ a navC prp ;d n Iruc and accurate account of ihia ransacAon. I have cemn . ~ caus° I ~ .n s o ~s0ursad in eccoruanco wdn Ih~s slatem°nt. SETTLEIdENi AGCNT: nn+~ -~~'~lj• //4:58(i~J UI 'i.t // ~~ ni iili I'i ui~ i I i.~ S~ Parcel No. 47-19-1590-064-412 ADMINISTRATRIX'S DEED THlS DEED, made t day of August, 2008. BETWEEN Amy Seaman, Administratrix for the Estate of Marci J. Hollenback, formerly known as Marci J. Seaman, deceased, Grantor AND Rose Marie Salter, a single woman, of Camp Hill, Cumberland County, Pennsylvania, Grantee WHEREAS, Marci J. Hollenback, during her lifetime owned, in fee simple, certain premises, together with the building and improvements thereon erected in the Borough of Wormleysburg, Commonwealth of Pennsylvania and known as 12 Campbell Place, Camp Hill, Cumberland County, Pennsylvania, and said Marci J. Hollenback died on January 8, 2002, resident of Cumberland County, Pennsylvania, intestate, and thereafter, Amy Seaman was duly appointed as Administratriz of -her Estate on Augusf~ 11, 2008, said appointment being reflected in the records of the Register of Wills of Cumberland County, Pennsylvania at No. 2007-01058 for the Estate of Marci J. Hollenback. WITNESSETH, that in consideration of Fifty-Seven Thousand ($57,000.00) Dollars, in hand paid, the receipt whereof is hereby acknowledged, the said grantor does hereby grant and convey to the said grantee, ALL that certain unit designated as No. 12, Long Meadows Townehouses, a condominium, located in the Borough of Wormleysburg, Cumberland County, Pennsylvania under the Declaration of Condominium, as recorded in the Office of the Recorder of Deeds in and for the said County of Cumberland, in the Miscellaneous Book 229, Page 142, and designated in the Declaration of Plans as recorded in the said office, in Plan Book 30, Page 85. . BEING the same premises which Marci J. Seaman, Executrix to the Estate of Frieda R. Seymour, by Deed for aforesaid Unit 12 dated September 8, 1995, recorded in the Cumberland County Recorder of Deeds Office in Deed Book 128, Page 262, granted and conveyed onto Marci J. Seaman. Marci J. Seaman subsequently intermarried with Frank 11~13HfiD (11 'ra ~I~ ~~ iii (17l 1 (I JO(1!1 % 1:, P. Hollenback. The said Marci J. Hollenback died on January 8, 2002 in seizin of these premises. The Grantee, for and on behalf of the Grantee and the Grantee's heirs, personal representatives, successors and assigns, by the acceptance of this Deed covenants and agrees to pay such charges for the maintenance of, repairs to, replacement of and expenses in connection with the Common Elements as may be assessed from time to time by the Council in accordance with the Unit Property Act of Pennsylvania, and further covenants and agrees that the unit conveyed by this Deed shall be subject to a charge far all amounts so assessed and that, except insofar as Sections 705 and 706 of said Unit Property Act may relieve a subsequent Unit Owner of liability for prior unpaid assessments, this covenant shall run with and bind the land or Unit hereby conveyed and all subsequent Owners thereof. TOGETHER, with all and singular the buildings, improvements, ways, streets, passages, waters. watercourses, rights, liberties, privileges, hereditaments and appurtenances whatsoever thereunto belonging, or in any wise appertaining, and the reversions and remainders, rents, issues, and profits thereof; and all the estate, right, title, interest, property, claim and demand whatsoever of MARCI J. HOLLENBACK at and immediately prior to the time of her decease in law, equity, or otherwise howsoever, of, in, and to the same and every part thereof. TO HAVE AND TO HOLD the said lot or piece of ground above described, with messuage or tenement thereon erected, hereditaments and premises hereby granted, or mentioned and intended so to be, with the appurtenances, unto the said Grantee, his heirs and assigns to and for the proper use and behoof of the said Grantee, her assigns forever. AND, the said AMY SEAMAN, ADMINISTRATRIX for the ESTATE OF MARCI J. HOLLENBACK for herself and her heirs, executors and administrators, does covenant, promise and agree, to and with the said Grantee, and Grantee's heirs, assigns, by these presents, that she, the Administratrix, has not done, committed, or knowingly or willingly suffered to be done or committed, any act, matter or thing whatsoever whereby the premises hereby granted, or any part thereof, is, are, shall or may be impeached, charged or encumbered, in title, charge, estate or otherwise howsoever. AND the said grantor will SPECIALLY WARRANTANDFOREVER DEFEND the property hereby conveyed. 2 / /4a8(ifl n I '~~1 I.t ~~ ni uft I'i luu'i t /'~ IN WITNESS WHEREOF, said grantor has hereunto set her hand and seal the day and year first above-written. y Amy Se man, Administratrix for the Estate of Marci J. Hollenback Certificate of Residence I hereby certify, that the precise residence of the grantee(s) herein is as follows: ~l 3C ,(~~n.~~ct I- Attorney or ra e 3 Sealed and delivered in l743Rfi~J U1 '~4 7/ ~~ m (N3 1!i 70tH) ~1 /:> COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN ON THIS, the ~o ~ day of ~t,~~(1~5~ , 2008, before me, a Notary Public, the undersigned officer, personally appeared Amy Seaman, Administratrix for the Estate of Marci J. Hollenback, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and seal. otary Pubic Mom >~t My Commission Expires: ~~~~woMCt car a ~w+w, ~~ ~~, 4 / /Tit3(i!) U I 1, ~1 •17 I' ni Ufi I'.l lUU!l :, i:, ROBERT P. ZIEGLER RECORDER OF DEEDS CUMBERLAND COUNTY 1 COURTHOUSE SQUARE CARLISLE, PA 17013 717-240-6370 Instrument ]Number -100829960 Recorded On 9/3/2008 At 2:34:22 PM * Instrument Type -DEED Invoice Number - 28275 User ID - RAK * Grantor - HOLLENBACK, MARCI J * Grantee -SALTER, ROSE MARIE * Customer -CEDAR CLIFF * FEES STATE TRANSFER TAX $570.00 STATE WRIT TAX $0.50 STATE JCS/ACCESS TO $10.00 JUSTICE RECORDING FEES - $11.50 RECORDER OF DEEDS AFFORDABLE HOUSING $11.50 COUNTY ARCHIVES FEE $2.00 ROD ARCHIVES FEE $3.00 WEST SHORE SCHOOL $285.00 DISTRICT WORMLEYSBURG BOROUGH $285.00 TOTAL PAID $1,178.50 I Certify this to be recorded in Cumberland County PA * Total Pages - 5 Certification Page DO NOT DETACH This page is now part of this legal document. r rs . ~4 n ~.~ ° ~J ° RECORDER O r ssso • - Information denoted by an asterisk may change during the vrrification process and may not be rellected on this page. IIIIIIIII~IIINIIII 11.26/2007 13:24 7172329936 RestoreCore 2322 North Seventh Street Harrisburg, Pennsylvania 17110 717-232-15(10 tax 717-232-9936 FIN ZS-1767775 C1icnC. Trollcnbach, Drank Property: 12 Campbell Place Csmp HILL, Pn 17o I 1 Opcrs[or Lrtfo: Operator: MIKE.C Estimator: Michael Colechiu Title; Estimator Company: RestoreCore Business: 2322 N. 7th St. 1-ixrrisburg, PA 1711 U Type of Fsttmatc; )MOLD DACES; Date Entered; 05/17/2007 Date Fst. Completed: OR/17/2007 Date i\ssigned: OS/ t 7/2007 Price List: PAHr14B7C Ttestorati on/Scrvicc/Rem odel Estimate; 10-0703-1030-t•? Business: (7l 7) 232-1500 This ectimatc prepared to address the inventor} and removal oC water and mold damaged contents, removal of wal:cr damaged tloorinfi materials, walls, And ceilings, and clcartinfi of all rooms at 12 Campbell Place, Camp Tiill, Pa. 17011. 'T'ransportation and storage of any eontcntt Raved is available at RestoreCore for additonal charge, and is not included in this ¢stimlte. This estimate is eontinRent to having electrical and water services available at beginning of work. if these services are not available, RestoreCore x•ill provide temporary services and the charges will be in addition m this cstim~tc. T~omcowner is responsible for any air yuallty testing at conclusion of work, and testing mace be completed rrlthin 4g hours after work is done by RestoreCore, Cost of testing is responsibility of lromcowncr. insufficient ventilation, high humidity, and the presence of moisture can lead to recontamination. This estirnat:e is based upon conditions present on the day nn which tl~e estimate waF prepared. Mold is a living organism and, trader certain conditions will continue to gro~~ rapidly. This estimate is subject to our rc~ie~~- and revision when the job is authorized to proceed. Mold remcdiat:ion ~r•ill only remove mold to levels approximately equal to outside levels of mold. No reeonstruction lahor, tasks or materials arc included in tlr,is csNmate. All non salvagahle contents and material removed from rnnm4 will he disposed of in RestoreCore dumpster. 11/2b/2007 13: 24 r 112~2`_I'J.jb RcstoreCore 2322 North Seventh Street Harrisburg, Pennsylvania 17110 717-232-] 500 fax 717-232-9936 ETN z5-1767775 Rouyn: General Services t 0-11711N-10311-1bi Water extraction and remediation services 1,00 L-A Note: ReAtot'eCore will Inventory, remove and dispose of damaged contents, remove water and mold damaged inte rior strttetural components -carpet, pad, vinyl flooring, cabinetry, appliances,window treatments, duc~+•orl;, and affect ed drywall and insulation. netail hepa vac twice and dlslnfeetant all suri'aces with Fosters 40-80. Cleaning and remediation -supervisor 1.00 EA Add for personal protective equipmcut (hazardous cleanup) 50.00 EA Note: 1 act per day per employee. Dehumidifia~ (per 24 hour pctiod) - XLargc - No monitoring 42.00 >rA Neg. air fan/Air scrub: Large (per 24 hr pctiod)-No rttonit. 42.00 17A Note: 3 negative air machlncs Hod 3 low gram dehumidiflcr~ for 14 days each. Equipment scntp, take down, and monitoring (hourly charge) 12.00 HR Add for HEPA filter (for eannister/bacl;pac;k vacuums) 6.00 EA Add for HEPA filter (for neg. a.ir machine/vacuum - Latgc) 3.00 EA. Lquipmrnt deermtsmination charge - TiVY, per piece of equip h.00 r,4 Containment Barrier/Airlock/.Dccon. Chamber. 300.00 SF Dumpster Igad. - Approx. 40 yards, 7-S tons of debris 3.00 EA Megohmmeter ehecl: elc;ett'ieal eireuite - avcrsge residence 1.00 EA Plumbing inspection 1.00 EA Heating and ventilation ryctem affected by water and mold, will need to he Inspected by outside service contractor. inspection, materials, and repairs price not part of Phis estimate. (orErr iTEIvl ~ l.oo >y4 i3acement lev )<Loom: Basement lev Ceiling T•ieight: 8' ULV forging with X-580 Microban 6,060.67 CF plain Level Room- l~ct floor ~ Ceiling Height: R' ULV fogging with X-SRO Microban 6,060.67 CF 2nd floor Room: 2nd floor Ceiling Height: 8' 1,Ji,V fogging with X-580 Microban 6,380.67 CF (.rand Total 36,970.66 10-0708-1030-M 11/26/2007 PHgc: 2 11/26/2007 13:24 7172329`36 f~LSTU(~L~UI~L I'i>d.aL ~-11i 11. ~~sto~e~or~ I~rsocing homes. ~>~ ~ u>~ FACSIMILE TRANSMITTAL SHEET TO: FROM: ~•i bsC_ C'U~ eG~^' PA~i NU1~iBBR: DATE: TOTAL NO. OF ~,A,GES INCLUDING RE: COVER: ~ /_/ ~~1Pr-~udn ^ URGENT~~. FOR REV1E~1! ^ PLLASG COMbfENT ^ PLLhSF_ RFPf..Y ^ P1.FAS. RFCYGLf NOTESJCOMMENTS: 1"`~ ~~ CENIILA.L PA LEHIGH VALLEY PHILADELPHIA NITIANY VALLEY 2322 North 7* Sttcct 431 Cl~,ttf~cld StcYCL (.i50 Ckv>< Avenue, Suitt B 234 South Potter Scrcec Hutivhutg. PA 17110 Bethlehem, PA 18017 King of Pcus: ia, PA 194C1G Bc1lcFnnCe, PA 1GBZ3 717-232.1500 G7O_RG}1C600 G10-992-9100 Btd-:53-7333 Fa~t:717-232-993G Fa¢: GlO-8G9-8090 Fne: Glfl-9729119 Far. 9 1 43417 3 3 5 1.60f1~231.71fl1' 1•RGlrG30-GG00 1-8Q0-747-19Fif1 7-877-755-GG27 Il:~il•1/:'Ull`_i l~._~ii ;'li:_~1_.1:~:1111 IILILL_I inu.~ ~u_i~ uu ~,_.i_. i~~ 05/14/2009 01:05 17177371859 NEZLL FH CAMP HILL PAGE 01 D ~} v J j Mr. Fr~-nk Hollenback 12 Campae(I Ptac© CAMP HILL, PA 17011 This is an itemized bill for the f~ natal of: Marcl J. Hollenback PROFESSIGINAL SERVICES Ah D IIAERCFIANDISE SELECTED Complete Traditionai Jewisf•, Service .............. • ... $ Traditional Jewish Shroud .................... . ... . . Memorial Register Book .. ...................... . . . Solid Mahogany Casket u+itFl Linen (1 H72) ... . ......... . Concrete grave liner ............................. . . June 25, 2002 2,825.00 50.00 29.00 3,365.00 esa.oo Sub -Total $ 6=9i 9.00_ CASH ApYANCES Deeth Cer#ificates; Cash Act ranee . . .. . ....... . ..... . . S zo.oo Beth EI Cemetery; Cash Acl~rance ................... . 1,zao.oo Cantor Naimark; Cash Adv~9nce .................. . ... 150.00 Cemetery equipment rental; Cash Advance ........ _ _ 95.00 Chevra Kadisha; Cash Adve nee .................. . 250.00 Sub -Total $ 1,715.00 Total Fun®rsi Charges $ 8,634.00 Payment Received $ (8,634.00) Balance Due an Account $ $0.00 Ref No.:1 D0068~4 f 0725