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HomeMy WebLinkAbout12-01-09 1505607120 ~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue county code veer File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 PO 60X.280601 0 9 - 0 5 5 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 172247851 05262009 04261929 Decedent's Last Name Suffix Decedent's First Name MI HESS DORIS ~ p~ (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 Retum ^ 3. Remainder Retum (date of death prior to 12-13-82) ^ 4. Limited Estate ^ qa, Future interest Campraniee ^ 5. Federal Estate Tax Retum Required (date of death after 12-12-82) 0 ® 6. Decedent bled Testate ^ ~ Decedent MaMtteined a Living Trust 8. Total Number of Safe De sit Boxes (Attach copy a vvw) (Attach copy of Trust) Po ^ 9. Litigation Proceeds Received ^ 10. ~~~~~ ~ ,~ ~~ ~~ ^ 11 _ Election to tax under Sec. 9113(A) (Attach Sch. O) -C,ORRE8PONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRADLEY L GRIFFIE 7172435551 rv ~-~, Firm Name (If Applicable) ~ GRIFFIE & ASSOCIATES REGISTER OFD USEOI~' _ t-''~-~~' i First line of address ~ ~ t _ , , { J -i i 2 0 0 NORTH HANOVER STREET C~ ~~ r C7~~ ~ Second line of address _ ~ N _~ ~ _ } City or Post Office State ZIP Code DATE FILED ~` CARLISLE PA 17013 correspondent'se-malladdreas: bgriffie~griffielaw.com Under penalties of perjury, I declare that I have examined this return, including accomparrying schedules and statements, and to the hest of my knowledge and belief, it is true correct and complete. Dedarefiorl of preparer other than the personal representative is based on all information of which ~ preparer has any knowledge. Denise K. Beam 301 Front Street, Boiling Springs, PA 17007 IIGNA ARER OTHER THAN REPRESENTATIVE Bradley L Griffie Street, Carlisle, PA 17013 i DATE 3a1~ Side 1 1505607120 1505607120 J ADDITIONAL Personal Representatives Hess, Doris A. SS# 172-24-7851 5/26/2009 Under penalties of perjury, the undersigned declare that they have examined this return, including accompanying schedules and statements, and to the best of their knowledge and belief, it is true, correct and complete. 2 Signature Name Debra J. Brymesser Address 146 Sable Drive City, State, Zip Date 3 Signature Name Address City, State, Zip Date 4 Signature Name Address: City, State, Zip Date 5 Signature Name Address: City, State, Zip Date 6 Signature Name Address: Carlisle PA 17013 /l a C~9 City, State, Zip Date S z REV-1500 EX oecedenrs Nema: HESS , D O R I S A. Decedent's Social Security Number 172247851 RECAPITULATION 100,000.00 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 9,802.96 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 3 4 8 7 0 5 (Schedule G) ^ Separate Billing Requested ............. 7, , . 8. Total Gross Assets (total Lines 1-7) ....................................................................... g. 1 1 3, 2 9 0. 0 1 14,135.73 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 3 , 2 3 7 . 9 2 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 11. Total Deductions (total Lines 9& 10) ...................................................................... 11. 1 7, 3 7 3 6 5 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12, 9 5 , 9 16.3 6 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, 9 5 , 9 16.3 6 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 9 5 , 9 16.3 6 at lineal rate X .045 16, 4 , 3 16.2 4 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. 4 , 3 16.2 4 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505607220 Side 2 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 09 - -0559 Hess, Doris A. STREET ADDRESS 108-110 Second Street CITY Boiling Springs STATE PA ZIP 17007 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 4,316.24 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Total Credits (A + g + C) Interest/Penalty if applicable (2) 0.0 0 p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.0 0 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q) 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) 4, 316.24 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 4, 316.2 4 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1, Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. x b. retain the right to designate who shall use the property transferred or its income :.................................... 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? ....................................................................................................................... ^ 3. Did decedent own an "intrust 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? ...................................................................................................................... 0 ^ 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 ff 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 p2 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. COMMDNWEALTH of PENNSYLVANM WNERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE FILE NUMBER ESTATE OF Hess, DOrIS A. 21 - 09 - -0559 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 1 108-110 Second Street, Boiling Springs, PA, 17007. 100,000.00 (See attachment) I TOTAL (Also enter on Line 1, Recapitulation) ~ 100,000.00 SCHEDULE E CASH, BANK DEPOSITS, & MISC. °~TM°F~'1N812"^"~' PERSONAL PROPERTY WHERRANCE TAX RENRN fiE81DENT DECEDENT FILE NUMBER ESTATE OF H@SS, DOfIS A. 21 - 09 - -0559 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 Tax proration credit from real estate settlement (school) 771.14 (See attachment) 2 -Tax proration credit from real estate settlement (Township and County) 67.56 (See attachment) 3 Water and Sewer adjustment from real estate settlement 20.71 (See attachment) 4 PNC Bank Checking Account No. 5140185783 3,708.58 (See attachment) 5 Auction of personal property 3,029.75 (See attachment) 6 Health Insurance Premium refund (Highmark) 355.70 7 Reimbursement of credit on fuel oil account (Leffler) 1,526.39 8 Embarq Refund 17.92 9 Direct TV Refund 15.83 10 I Direct Deposit to PNC checking I 289.38 Post -date of death Fidelity Investment TOTAL (Also enter on Line 5, Recapitulation) I 9,802.96 COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Hess, Doris A. FILE NUMBER 21 - 09 - -0559 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY Inchide the name of the transferee, their relatbnship to decedent arM ~ date of transfer. Attaeh a copy of the deed for real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION pF APPLICABLE) TAXABLE VALUE 1 TransAmerica Annuity, Annuity Number 02TF6036687 3,487.05 0.00 3,487.05 (Also known as PNC Investment Acct. No. 42164926) (See attachment) TOTAL (Also enter on line 7, Recapitulation) 3,487.05 SCF'EDULE H F1J1~2AL D~BVSES & co~oNwEwTw of PENNav~vnNu w~M~ p~ INHERRANCE TA1C RETURN /~11JIr.1~~1~1~ ~~ RESDENT DECEDENT ESTATE OF Hess, Doris A. I FILE NUMBER 21 - 09 - -0559 Debts of decedent must be reported on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Hoffman Roth Funeral Home & Crematory, Inc. 8,627.18 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees Griffie and Associates 3, Famiy Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. ~ Accountant's Fees 2009 Personal Returns 6. ~ Tax Return Preparer's Fees 7, Other Administrative Costs 1 Cumberland Law Journal (Estate advertising) 3,200.00 336.00 150.00 75.00 TOTAL (Also enter on line 9, Recapitulation) 14,135.73 Sched~,ie H p « COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Hess, Doris A. 21 - 09 - -0559 2 The Sentinel (Estate advertising) 198.16 3 Diversified Appraisal Services (Real Estate appraisal) 400.00 4 Auction of personal property -Expense and fees 493.33 5 Met Ed (Electric) 11.08 6 Encompass Insurance (Homeowners Insurance) 62.30 7 Encompass Insurance 62.30 8 Med Ed 20.38 9 Reserves 500.00 Page 2 of Schedule H SCHEDULEI DEBTS OF DECEDENT, MORTGAGE QOAM1ON1NE"TMOFPEN1"'$`'"'""'" LIABILITIES, & LIENS MIHERRANCE TAX RERIRN RESID@IT DECWENT ESTATE OF Hess, ~OfIS A. FILE NUMBER 21 - 09 - -0559 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Notary fees from real estate settlement 15.00 2 Real Estate tranfer tax from real estate settlement 1,000.00 3 Trash collection from real estate settlement 50.91 4 South Middleton Township Municipal Authority -Final water and sewer billing from real estate 108.77 settlement. 5 South Middleton Township Tax Collector -real estate taxes from real estate settlement. 6 Robert Caims, Tax Collector (personal taxes) 7 Waste Management (Trash collection) 8 Embarq (phone service) 9 Robert Caims, Tax Collector (real estate taxes) 10 Med Ed. (Electric) 11 Carlisle Regional Medical Center (medical bills) 12 South Middleton Township Municipal Authority (water & sewer) 13 Time Wamer Pension Plan (overpayment of pension annuity) 14 Encompass Insurance (Automatic deduction from PNC Checking post-date-of--death 1,079.75 5.00 50.91 47.73 296.03 31.14 100.00 106.00 289.38 57.30 I TOTAL (Also enter on Line 10, Recapitulation) I 3,237.92 REV-1615 EX+ (9-00) SCHEDULE) COMMOMNEALTH of PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hess Doris A. ~ FILE NUMBER , 21 - 09 - -0559 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS[include.outright s ousel distributions, and transfers under Sec. 9116 (a) (1.2)J 1 Denise K. Beam Daughter Twenty-Five Percent 301 Front Street Boiling Springs, PA 17007 2 Debra J. Brymesser Daughter Twenty-Five Percent 146 Sable Drive Carlisle, PA 17013 3 Richard A. Hess Son Twenty-Five Percent 15 Shirley Lane Boiling Springs, PA 17007 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropriate, on Rev 1500 cover sheet II NON-TAXABLE DISTRIBUTIONS: I A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I 0.00 REV-lets Exr (9.00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE) BENEFICIARIES continued ESTATE OF Hess, Doris A. I FILE NUMBER i 21 - 09 - -0559 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 4 David M. Hess Son Twenty-Five Percent 142 Leeds Road Newville, PA 17241 Page 2 of Schedule J ~~st ~iCC~nb ~es't~ment OF DORI5 AMY HESS I, DORIS AMY HESS, of 108 2°d Street, Boiling Springs, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. FIRST I order and duect my Executor/Executrix hereinafter named to pay all of my just ,. debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my Executor need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. If I do not own a burial plot or a grave marker at the time of my death, I authorize my Executor/Executrix, in his, her or its sole discretion, to purchase a burial plot and to erect a suitable grave marker at my grave, and to expend sums from my estate for this purpose. GRIFFIE & ASSOCL4TES Attorneys At Law 1200 N. Hanover Street rnrlicly_ P,4 17/113 38 N.1Kain Street FOURTH I grant my Executor/Executrix the following powers in addition to and not in limitation of such powers as my Executor/Executrix shall hold by law: (a) To retain all property received including the stock of any corporate fiduciary acting hereunder, provided such property remains productive. (b) To join in any corporation, partnership, recapitalization, merger, reorganization or voting trust plan; to delegate authority with respect thereto; to deposit investments under agreements and pay assessments; and generally to exercise all rights of investors, including but not limited to, the voting of shares. (c) To manage, operate, repair, improve, mortgage or lease on any terms any real estate held or owned by my estate. (d) To operate any business that I may own at my death. (e) To invest any funds of my estate in any stocks, bonds, notes or other securities or property, real or personal, without regard to the principle of diversification or any other statute or general rule of law in his, her or its absolute discretion, it being my intention to give my Executor/Executrix the broadest investment powers possible, providing such investments do not unnecessarily prevent the prompt settlement of my estate. (f) To sell or otherwise dispose of any property, real or personal, tangible or intangible, at any time forming a part of my estate in any manner and on such terms and conditions as my Executor/Executrix shall see fit in his, her or its absolute discretion. GRIFFIE & ASSOCIATES Attorneys At Law 200 N. Hanover Street !'..rl.~.l., DA 7'781? 38 N. Main Street ~'bn~l~n~.ol.iirir Ad 177/l7 (g) To borrow money for the payment of taxes or for any other proper purposes in the administration of my estate, and to mortgage or pledge estate assets as security. (h) To compromise claims without court approval including, but not limited to, any controversies with the United States of America or the Commonwealth of Pennsylvania concerning estate and inheritance taxes on any interests that may pass under this my Last Will and Testament. (i) To distribute in cash or in kind upon any division or distribution of my estate. (j) To undertake any and all acts deemed necessary and proper by my Executor/Executrix for the proper, advantageous and prompt management of the settlement of my estate. (k) In general, to exercise all powers in the management of my estate which any individual could exercise in the management of similar property owned in his own right, upon such terms and conditions as to him, her or it may seem best and to execute and deliver all instruments and to do all acts which he, she or it deems necessary or proper to carry out the purposes of this, my Last Will and Testament. FIFTH No interest of any beneficiary of my estate, either in income or in principal, shall be subject to anticipation or pledge, assignment, sale or transfer in any manner, nor shall any beneficiary have the power in any manner to charge or encumber his interest either in income or principal, nor shall the interest of any beneficiary be liable or subject in any GRIFFIE & ASSOCIATES Attorneys At Law 200 N. Hanover Street ~'~~.Iin/n Dd 17/17? 38 N. Main Street !'LnsHhor~l~~irn Ad 177n7 manner while in the possession of my Executor/Executrix for the liability of such beneficiary. SIXTH I nominate, constitute and appoint my daughters, Denise Kay Beam and Debra Jo Brymesser, as Co-Executrixes of this my Last Will and Testament. In the event either of my daughters are deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint my son, Richard Alan Hess, as Co-Executor of this my Last Will and Testament, with my surviving or remaining daughter. I direct that my Executor/Executrix shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. SEVENTH I hereby declare it to be my expressed desire that my Executor/Executrix employ the law firm of Crriffie & Associates, of Carlisle, Pennsylvania, for legal advice and assistance regarding this my last Will and Testament, they having considerable knowledge of my affairs, views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament this /d ~' day of /~' ~~ , 2004. WITNESS: ~~~ DORIS AMY SS GRIFFIE & ASSOCIATES Attorneys At Law 300 N. Hanover Street 38 N. Main Street /'+L.....L......L....... n~ 7~~fnT ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA: . SS. COUNTY OF CUMBERLAND I, DORIS AMY HESS, the Testatrix 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 and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. _ ~~~ DORIS AMY SS Sworn or affumed and acknowledged before me by DORIS AMY HESS the Testatrix this ~' day of __ _ / It.~c.r.~-- , 2004. GRIFFIE & ASSOCL4TES Attorneys At Law 200 N. Hanover Street 38 N. Main Street !'nr/iclo Ad 19/12 /'bnrNl~es.ol~~irir DA 777/17 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA: . SS. COUNTY OF CUMBERLAND WE, ~'• rr sG ~ n..~..~, and 6~c~-d /e>, r' • G~-; th r ,the witnesses ~~-~~~ ~ whose names are attached to the foregoing document, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Last Will and Testament as witnesses and that to the best of our knowledge the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. u Sworn or affirmed and subscrib ore me by ~~„ ~~/~ rn~ and (~e ,~ this /C~ ~~ day of j~~~l~- , 2004. Notary Public NOTARIAL SEAL ROBIN 1.60SHORN, NOTARY PUBLIC CARLISLE BORO., CUMBERLAND COUNTY MY COMMISSION EXPIRES APRIL 11 2007 GRIFFIE & ASSOCIATES Attorneys At Law 200 N. Hanover Street 38 N. Main Street Attachment to Schedules "A", `B" and "I" 'tS• "~ HUD 1 UNIFORM SE I-t L~.M rn t ~ r w r cmr.i• . , , ~,u - - - ~ a, ~ ~.~ ~ ~ .: _ ;: SETTLEMENT STA .U.S. DEPARTMENT F HO SING AND URBAN DEVELOPMENT .4 ~ "~ "~ ,; 1 ~ _ . s ~ :7 Loan Number:. 9. TYPE OF LOAN ~ '; ~ ~ ,.ia ~, ";1 6. File Number ~, ;` : , - 1: FHA 2. FmHA 2009 37 3. Conv. Unins. 4. VA S. Conv. Ins. 8. Mortgage Insurance Case Number C. NOTE: This foam is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(~ were paid outside the closing; they are shown hero for informational purposes and are not included in the totals. NOTE: TM =Tax rs Identification Number D. NAME AND ADDRESS OF BORROWER: E. NAME, ADDRESS AND TIN OF SELLER: F. NAME AND ADDRESS OF LEN[ Jean D. Hench Est of Doris A. Hess/ Denise Larry Warner Eric N. Hench K. Bream/Debra J. Brymesser CarlEsleldPaor17015d P.O. Box 952- 108-110 Second Street Boiling Springs, Pa 17008 Boiling Springs, Pa 17007 G. PROPERTY LOCATION: H. SETTLEMENT AGENT NAME, ADDRESS AND TM 108-110 Second Street Jacqueline M. Verney, Esquire Boiling Springs, , PA 17007 49 South Hanover Street Carlisle PA 15ETfLEMENTDATE PLACE OF SETTLEMENT ,,. _ 99 South Hanover Street ~ 10/07/~009~ "~'" Carlisle PA. 17007 •rc lVU. AR7VU1~ •o rr+av .. -- - --- - 201. it or earnest mon 202. Princi 1 amount of new loan s 203. Existin loans taken subject to 204. 205. 206. 207. 208. 209. ... .. SELLER'S STATEMENT The information contained in Blocks E, G, H, and I and on line 401 (or, if line 401 is aste ~ k~ Iinepe403rynd 404) is important tax information and is being furnished to the Internal Revenue Service (see Seller Certification). If you aro required to file a return, a ne li ce nal or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported. You are required to provide the Settlement Agent with your correct taxpayer identification number. If you do not provide the Settlement Agent with your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed by law. Under penalties of perjury, I certify that the number shown on this statement is my correct taxpayer identification number. (Sellers Signature) Est of Doris A. Hess/ Denise © EASY SOFT, Inc. 2001 Previous editions aro obsolete (Sellers Signature) K. Bream/Debra J. Brymesser Page 1 form HUD-I (3/86) ref Handbook 4305.2 i ,t ~`` +~. ~ ~ .s.:M~.k~,~e`~~. fn`~~ ~"~a ~,~ ~+SETTLEMENTCHARGES a `; ,.~_ • ~ 700. TOTAL SALESJBR R's COMMISSION based on rice 5100 000:00 ~ ''r-t~•> ~ : ~ ~~ . PAID FROM PAID FROM '..' Division of m sion line 700 as follows:'~s°~ °r`z°. .. °,~ a , : :,. ,:.~ .. _ . ~:.; ,. >. max,,,:: > F ,::, ... , ~r BORROWER'S ;SELLER'S .'. ._' ,' .: FUNDS AT FUNDS AT .., 702. , . ,.. ETTLEMENT SETTLEMENT 703. Commission id at Settlement .. 704. 800. ITEMS PAYABLE IN CONNECTION W-TH LOAN 801. Loan Ori 'nation Fce 802. Loan Discount 803. A sisal Fee to 804. Credit re rt to 805. Lenders [ns ion Fee 806. 807. 808. 809. 810. 81 i. 812. St3: ~ ' 900. ITEMS RE UiRED BY LENDER TO BE PAID IN ADVANCE - - 901. Interest from 902. Mort a issuance Premium for 903. Hazard insurance Pranium for - ~ .: w•. ' 904. ... . 905. ~ _ .. .. 1000. RESERVES DEPOSITED WITH LENDER ~ • • •- 1001. Hazard insurance ' 1002. Mort issuance 1003. Ci P Taxes 1004. Couu Taxes 1005. Annual assessments 1006. 1007. 1008. to Aecountin Ad'ustment 1100. TITLE CHARGES IIOI.Settlementorclosin fee to Jac ueline M. Verne Es 500.00 1102. A ct or•titk search to Coon & Com an l 13.50 1103. Title Examination to l 104. Title insurance binder to 1105. Document lion to 1106. N fees to Valerie F. Gsell 10.00 15.00 1107.Attorn sfeestoBradle L. Griffie POC includes line numbers: 1108. Title Insurance to includes line numbers: 1109. Lenders covers e S 0.00 I I l0.Owners covers S 100000.00 llll. 1112. 1113. 1200. COVERNM NT RECORDING AND TRANSFER CHARGES 1201.Recordin foes: Deeds 98.50 Mort es 56.50 Releases 105.00 1202.Ci /cn tax/stam Deeds 1 000.00 Mort eS 1 000.00 1203. State tax/stam Deed S 1 000.00 Mort e s 1 000.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Su to 1302. Pest ins lion to 1303. i 1304. Waste Mana ement Se t thru Nov 2009 50.91 ! I305.South Middleton Final Water ~ Sewer 108.77 1306. Robert Cairns S. Middleton Tax Col. 2009 2010 School Taxes 1 079.75 1400. TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 1 728.50 2 259 .4 3 CERTiFICATiON: i have carefully reviewed the HUD-I Settlement Statement and to the best of my knowledge and ballet; it is a true and accurate statement of all receipts and disbursements m on my account or by me in this nsaction. i further certify that i received a copy of a HU 1 Settlement Statement. Seller Est of Doris A. Hess/ Denise Borro Jean D. ench t" Seller K. Bre era J. Brymesser Borrower r c Hench The HU0.l Settlement Statement which I repared is a true and accurate account of the funds disbursed or to be disbursed y the undersigned as part of the settlement of th' nsaction. 10/07/2009 S i t gent Jacqueline M. Ver , Esquire Date ARNI : It is a crime to knmvingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010. O EASY SOFT, inc. 2001 Previous editions are obsolete Page 2 form HU0.1 (3/86) ref Handbook 4305.2 Attachment to Schedule `B" ` JUO, L7. LUUY I ~ 17rm Ids um~n 7~c Zvi cr,~ ~~ June 25, 2009 Bradley Criffie Attorney at Law 200 N Hanover St Carlisle, PA 17013 RE: Name: Doris A Hess ssN: In-Za.7ssl DOD: OS-26-2009 Dear Mz. GR'if~'ie; In response to your request for Datc of Death (DOD) balances for the customer noted above, our records show the following: Checktng Account Account # 5140185783 Esffiblished: 01-01-1978 DOlZI5 A HESS DOD balance: $3.780.58 non intcreat bearing ~rrve~mient Account The decedent tneimtafned annvestment Accatmt # 42164926. For fiuther inform ion, you may cal] the Bzokerago Departm~ at 1-800-7b2-bl 11. Lola Aaoant Tlu decedent mamtaira~ Leas Account # 4003048110992554. For further information, please call 1 88&762 2255. Select option 1, than option 3 and then 0(zero). A&er pressing zero, please remain on the line to t~ealc to a I.osu Service ltepreseatetive. We do not ]rave accaa to Ian hsformation; you mwt contact the Loan Area at the above number for furtlrer astdsta~ree. Please note that this ogee providea dare of loth balances for deposit sccowits (IRAs, CDa, Checking and Saviipgs). We do not proves nay t~atcial h~nsaetlioas or provble:baemeati. If you need assisumee with any of these items, pbere all 1-E88-PNC-BANK (] -8E8-762 2265) ar stap by ycnu Iooa1 ~fC Hoak bxmch o~"ioo. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC Page 1 of 1. SETTLEMENT SELLER ADDRESS r~. i Y101S. 1 DATE OF SALE ~ e~T O PHONE zIP ~ 7 ~ ~ +7 r LOCATION OF SALE ~ Q.I'Y1 Q- Q.S a b o ~ ~ AUCTIONEER ~ J ~~ ~ ~ `. ~ 1` Lk a ~" - PHONE ~ ~ / ' ~ ~~ " ~ ~ T AUCTIONEER ' D/ CLERK ~ O l 6 CASHIER OTHER EXPENSES c . $ .~0 .qg $ 10.35- LESS TOTAL EXPENSES $13a ~ 5a $ 1 '7 DS~. ~ .5! $ 4 7S ~ X9.3.33 I (or we), the seller, accept this settlement and acknowledge receipt of the above speciFied net proceeds from the auction of my goods and property sold on the above date. I accept all responsibility for providing merchantable title to all goods, and property sold, and for delivery of title to the purchaser. ~' Date Auctioneer or Cashier's Signature (Seller's Signature) q -f "I -D9 Date Date \ ~ R ~~ - t ~ ( ---t-{,,~ ( (Seller's Signature) ~~~,r~ s nd sf ass CASH CHECKS OTHER RECEIPTS TOTAL RECEIPTS Attachment to Schedule "G" TRANSA-11~RICA ' ~ LIPE INSIJAANCB CObIRANY August 24, 2009 Denise Kay Beam .; c/o Bradley L Griffie . 200 North Hanover Street Carlisle PA 17013 RE: Auauity Nt:mber(s) 02TF8036687 Dear Denise Kay Beam: Transamerica Life Inauraace Company 4333 Edgewood Road NE PO Boz 3183 Cedar Rapids, Iowa 52406-3183 Our office has received your request concerning the above listed non- qualified tax deferred annuity. Value as of 05/26/2009: $3,487.05 Any additional questions regarding this annuity can be directed to the Annuity Service Center at 1-800-553-5957. A Transamerica Life Insurance Company representative will gladly assist you with any. questions you may have regarding this annuity and help you meet your financial goals. Sincerely, Justin Keiper Transamerica Life Insurance Company Claims Member of the `EG011~. Gronp •