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Home My WebLink About02-23-1015056051058 REV-1500 Ex (~-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year Filse Number Bur~u of Individual Taxes INHERITANCE TAX RETURN Po Box 280601 21 09 0079 Harristwrg, PA t~tza-0so1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 189-18-5362 11 /30/2008 11!15/1923 Decedents Last Name Suffix Decedent's First Name MI Tezak Rudolph J (If Applfcabie) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRWTE OVALS BELOW • 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 3. Remainder Return (date of death prlorto 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required 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 Wiil) (Attach Copy of Trust) 9. Lltigatbn Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Tricia D. Naylor Finn Name (If Applicable) LawOfflceofJohnC.O szustowicz First line of address 104 S. Hanover Street Ser~nd line of address City or Post Office Carlisle correspondents a-man address: tnaylor@carlislepalaw.com (717) 243-7437 REGISTER OF WILLS USE ONt~ n ~O a ~7 'Ti ~ ~ ~ ~~ G ~ N W ~~ ~ ~~ ` ~ C7 C7 r't DAD State ZIP Code --t PA 17103 ~ t,o c~ Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and moments, and to the tit of my knowledge and belief, rt is true, ported and complete. Declaration of preparer other than the personal representative "s based on all information of which preparer has any knowledge. SI NATUR,E OF PERS 1RESP'O~"SIBLE FQR FILING RETUP.N DATE AD~RESs 10~ S. dge , Boiling Springs, PA 17007 . OF PR R T THAN REPRESENTP.TIVE 104F~S. Hanover St~leei~~a~jsle, PA 17013 PLEASE USE DATE ~ I ! ~ ~ U .Y Side 1 15056051058 15056051058 -T.7 ~ , ...., r-r~ r.'".7r {,~~~ t r 7 i `i _... a . ,~ r...ti ..~ - i~ ~.= ; - ;,:r=t tom L.,.~ J 15056052059 REV-1500 EX Decedent's Social Security Number Rudolph J Tezak 189-18-5362 Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. 155,000.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 483.21 3. Closely Held Corporation, Partnership or Sole-Proprietorsh~ (Schedule C) ... .. 3. 4. Mortgages 8 Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ...... .. 5. 5,708.70 6. Jointly Owned Property (Schedule F) Separate Billing Requested ..... .. 6. 74,566.81 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 235,758.72 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 36,586.03 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............. .. 10. 377.93 11. Total Oeducdons (total Lines 9 8 10) ................................. .. 11. 36,963.96 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 198,794.76 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. 198,794.76 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sac. 9116 (ax1.2) X .0~ 15. 16. Amount of Line 14 taxable at lineal rate x .0 45 198,794.76 1B. 8,945.76 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. 8,945.76 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 09 0079 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Rudolph J Te2ak 189-18-5362 STREET ADDRESS 504 Beacon Hill Rd.q ~ITy New Cumberland STATE PA ZIP 17070 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19} (t) 8,945.76 2. CreditslPayments A. spousal Poverty credit - B.PriorPayments __ ______ _-.__10,000.00 C. Discount 447.29 ------ Total Credits (A + B + C) (2) 10,447.29 3. InteresUPenalty if applicat~Ie D. Interest _ E. Penalty -------__.-._ _ _- __.-_- _----- -_-__-_-_-- Total Interest/Penalty l 0 + E) (3) 4. If Line 2 is greater Than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Pagts 2, Line 20 to request a refund. (4) 1,501.53 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. (56} 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 iruorrre of the properly transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest: or .......................................................................................................................... ^ d. receive the promise for 1rfe of either payments, benefits or care? ...................................................................... ^ 2. If death ocx:urted after December 12,1982, did decedent Unsfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3, Did decedent own an 'in trust for• or payable upon death bank accamt or security at his or her death? .............. ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate propeRy 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 cn 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 (O) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for discbsure of assets and filing a tax return are still applicable evenrf 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-0ne 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)j. 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)j. Asibling Ls 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+ (11-08~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 All real properly owned solely or as a tenant in common mutt 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 be disclosed on schedule F. Attach a copy of the settlement sheet if tfie 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 504 Beacon Hill Rd., New Cumberland, Cumberland County, PA ~ 155,000.00 TOTAL (Also enter on Line 1, Recapitulation.) ~ ~ 155,000.00 If more space is needed, insert additional sheets of the same size. REV-4503 EX+ (B•98) scNEOU~ s COMMONWEALTH OF PENNSYLVANIA STOCKS Fc BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 All property Jolntlyownsd with right of survivorship must ba dlaclosed on Schedule F. (H more space is needed, insert additional sheets of the same size) REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~CMEptILE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 Include the proceeds of litigation and the date the proceeds were received by the estate. Ali property joirttlyowned with right of survivorship must be disabled on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) ~~~~~~~ COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF PILE NUMBER Rudolph J. Tezak 21-09-0079 Man asset waves made joint wkhin one year of Mf dened~nt§ d>wh of daalh, it must bae reported on Sohaduk t3. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• Marianne Dell 101 S. Ridge Rd. daughter Boiling Springs, PA 17007 B. C. JOINTLY-0WNEO PROPERTY: REM NUMBER LETTER FOR JOMT TENANT DATE MADE JgNT DESCRIPTION OF PROPERTY INCWDE NAME OF fINANCWI INSTITUTION AND BANK ACCOUNT NUMBER qt SIMILAR IDENTIFYING NUMBER. ATTACH DEED fORJOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET s of DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS tiTEREST 1. A. 09/15!07 PSECU Checking Account M0189185362 3,664.24 50°k 1,832.12 2 • A 09/15107 PSECU Savings Account #10189185362 7.53 50% 3.77 3. A 09/15107 PSECU Money Market 110189185362 145,461.83 50% 72,730.92 TOTAL (Also enter on line 6, RecapihJlation) I S 74,566.81 (tf more space is needed, insert addftional sheets of the same s¢e) REV-1511 EXt ;10 99) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 Decedent's debts must be reported on Schedule i. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: 1' Parthemore Funeral Home 11,065.24 2. Mercy Services - St. Theresa Roman Catholic Church -funeral luncheon 500.00 s. BJs Wholesale Club -funeral luncheon 93.57 B. 1 ADMINISTRATNE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ Year(s) Commission Paid: State _ _ ZIP 2. Attorney Fees: 3. Family Exempbon: (If decedent's address is not the same as daimant's, attach explanation.) Claimant Street Address City ----- ------- -State - Relationship of Claimant to Decedent __~ 4. Probate Fees: 5. Accountant Fees: 6. Tax Retum Preparer fees: 7~ Legal Advertising -Cumberland Law Journal s. Legal Advertising -Patriot News s. Filing Fee ~o. Postage 1 ~ . Chapman Oil -heating oil 12. Additional Expenses from Continuation Schedule 1,550.00 380.00 75.00 95.66 15.00 16.80 599.71 22,195.05 7ATAL (Also enter on Line 9. Recaoitulationl I S 36,586.03 Z[P If more space is needed, use additional sheets of paper of the same size. REV-1512 EX* (12-0~} pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. RFV-i5i3 EX + ! .-08j pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Rudolph J. Tezak 21-09-0079 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Robert J. Tezak 408 Kennedy Rd., Collegeville, PA 19426 son 41409.32 2. Thomas M. Tezak 4130 The Burns Rd., Mechanicsburg, PA 17055 son 41409.32 3. Marianne Delt 101 S. Ridge Rd., Boiling Springs, PA 17007 daughter 115976.12 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 DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECiTON 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 ~ tf more space is needed, insert additional sheets of the same size. ~_ ~ 1 ~ ~--t t v.Y 1I~ l~l~ °~B~P ~? •~ ~' day of y/~e~U A. D. one thouaard nine hundred and sixty-three (1953) between the Corporation by the name, style and title of CA?dP HILL GAP~ENS, INC ., a Pennsylvania corporation, having its principal place of business in R. D. 2, Linglestown Road, Harrisburg, Dauphin County, Pennsylvania, ~pdT!~R Tarty olr~flSe one art and ? ,7,^T °H J . T'''AK and ',IARY , . T ^.'P.K, his wife of the City of Harrisburg, County of Dauphin in the Sate of Pennsylvania, GRANTEES, parties of the other part ~{21[fSSPt~ That the said CAZdP HILL GARDENS, INC . fur and is eon• aideration of tl~e sum of Seventeen Thousand Nine Hundred and-------------------00/100 17,9pp,pp) --__-_-r~ Dollars, lawful money of the United Sates, to it in hand paid by the said 3UDOLPH J. TEZAK and MARY C. TEZAK, his wife, at the time of the ezecution hereof, the receipt whereof is hereby acknowledged, has granted, ~r8~~, sold, aliened, enfeoffed, released sad confirmed, and by these presents don grant, bargain, sell, alien, enfeoff, re- lease and conSrm onto the said RtJDOLPH J. TEZAK and MARY C. TEZAK, his wife, their heirs and assigns, all that certafn piece or parcel of land, situate in the Borough of New Cumberland, County of Cumberland, State of Pennsylvania, more particularly 'oou:,ded and descrioed as follows, to wit:- BEGINNING at a point on the southern side of 3eacon Road at the division line between Lots Nos. 21 and 22 on the hereinafter mentioned Plan of Lots, said point being one hundred fifty-eight and ninety-seven one-hundredths (158.97) feet east of the southeast corner of 3eacon Road and 3~itaw Avenue; thence along said last mentioned line, south thirty--six degrees twenty-nine minutes east ;C 35° 29' =') one hundred (100) feet to a point at the division line between Lots Nos. 19 and 22 on said Plan; thence eastwardly along said last mentioned line and along the division line between Lots Nos. 22 and 21~, seventy (?$) feet to a point at the division line between Lots Nos. 22 and 23 on said Plan; thence along said last mentioned line, north thirty-six degrees twenty-nine min,ites west ("; 35° 2S' ~+) one hundred (100) feet to a point on the southern side of 3eacon Road; thence westwardly along the southern side of Beaccn Road, seventy (70) feet to a point,. the Place of 3EGI'idNING. :~ I~ BEING Lot No. 22 on the Plan of Lots of Hillside ;F.anor, which Plan is •4 recorded in the Office of the Recorder o£ Deeds in and for Cumberland County, Penn- C Sylvania, in Plan Book 11, Page 21. !~ X o HAVING THEF.F:ON ERECTED none-story brick and aluminum siding dwelling Together with all sad singular the buildings, privileges, hereditamenta and appurtennnces whniscecet thereunto belonging, or in aaywise appertaining, and the reversions and remainders, rents, issues and profits thereof; and all the estate, right, title, interest, property, claim and demand whatsoever of it, the said Camp Hill hardens, Inc. either {n law or equity, of, is and to the same. UiII lt~Ue MtI~ t11 ~It~ the said messuage ___or r•••_•••_~* _ and InL a:-_- -- piece of gmnnd above described, heredit.aments and premises hereby granted, hargnined and sold, or mentioned, or intended so to be, with the appurtenances, unto the said Rlldolph J. Tezak and Mary C. Tezak, his wife, their heirs and assigns, to and for the only proper use and behoof of the said Rudolph J. Tezak and ?dar.y C. Tezak, his wife, their heirs and assigns forever. And the said party of the first part for itself and its successors, .does hereby covenant and agree to and with the said Rudolph J. Tezak and Mary C. Tezak, his wife, their heirs and assigns, thnt It • the said party of• the first part and its successors, all and singular the avid hereby granted. premises, with the appurtenances, unto the said Rudolph J. Tezak and Mary C. Tezak, his wife, their heirs and assigns, against it the said party of the first part and its successors, and against all and ever other person and persoaa whomsoever lawfully claiming or to claim the same or any part thereof ~~Mll ~ ill ~ttPrttriY ttri~ ~Dxl'ttPx ~P~PriI~ by these presents. ~tt~ the said CAb~ HILL ^A?1l~?~S, INC, doth hereby constitute and appoint earl D. Latsha to be its attorney, for it and in its name, and as and for its corporate act and deed to acl-nowledge this deed before any person having authority by the laws of the Commonwealth of Pennsylvania to take aucl~ acknowledgment, to the intent that the same may be duly recorded. ,~ri ('Ilpstt'tltt~tt~__~+r~nf _ the said CAMP HILL GARDENS, INC. has caused this Indenture to be signed by its President, attested by its Sec- retary and affixed hereunto the common and corporate seal of the said Corpu- ration, that the seal affixed hereto is the aenl of said Corporation, that it was eo affized by order of the Board of Directors of said Corporation, and that they signed their names heretq~y like order, the d a ,ear firstlgbove written /f /i /~ the said (:8mp Hill Uaraens, tne. either 1n law or equity, of, is sad to the acme. tin f~uur and fn mail the said mea.uage __ ___~r..~~-~-n. and ,~. o< piece of ground above described, heredit.aments and premises hereby granted, bargained and sold, or mentioned, or intended so to be, with the appurtenances, onto the said Rudolph J. Tezak and Mary C. Tezak, his wife, their heirs and assigns, to and for the only proper use and behcef of the said Rudolph J. Tezak and `dary C. Tezak, his wife, their heirs and sasigm forever. And the said psrtp of the first part for itself and its ,aucceaspra, .does hereby covenant aad agree to and with the said Rudolph J . Tezak and Mary C : Tezak, his wife, their heirs _ ~ and assigns, thnt it the said party of~ the first part and its successors, all and singular the said hereby granted, premises, with the appurtenances, unto the said Rudolph J. Tezak and Mary C. Tezak, his wife, their heirs and assigns, against it the said party of the first part aad its successors, and against all and every other person and persona whomacever lawfully claiming or to claim the same or any part thereof ~~~Il ~ tU ttxrttrit ttri~ .~t~rPttPx ~P~Pri~1 by these presents. ~ri~ the said CA :1H HILL GA??1_''~S, I13C. dot6 hereby constitute snd appoint gar 1 D . Lars ha to be its attorney, for it aad in its name, and sa aad for its corporate act and deed to acknowledge this deed before nny person having authority by the laws of the Commonwealth of Pennsylvania to take suct+ acknowledgment, to the iateat that the same may be d sly recorded. ,~ri U~PSfZttW2i1~.-PYPitf _ __the avid _ __ CAMP HILL GARDENS,, IxC. _. hsa caused this Indenture to be signed by its President, attested by its Sec- retary and affixed hereunto the common and corporate seal of the said Corpo- ration, that the seal affued hereto is the seal of said Corporation, that it was so affixed by order of the Board of Directors of said Corporation, and that they signed their names heretp~y like or er, the d ar first bove written. ~ _ Signed, Sealed and Delivered _ .. __ .......... ............ J~:..............................................................__....._ in the presence of ~.arl J, Lats President. ,,.,.., R D~ - _ ....:..:..................,........................................................._._....._ v ,.R~'~j2r>,~.~'~~~a1n Secretary ;~ = •- L+ C ) . a ; fir..: ., -'.~ A(lOK /1 ~nrA~E ~01 ~ a;~ °~ri::; ~~ ' °,; 6001(x ~O PAGE $O2 State of - - Com=ty of ~ as -. On thL, the dsy of , 19 , before tx the naderdgned offiecr, Pe~~p aPPa~ ,who acJcnowkdged himself to be the of a oorporstion, and that he as etch ,being anthortsed to do so, ezeouted the foregoing inatrameat for the purposes therein contained by signing the name of the corporation by himself as In witness whereof, I hereunto set my hand sad o~iclal seal. 3ECDRDED OFFIOE OF THE RETARDER O/F/pEEDS /U ~ ~a /9/1~ Tien o~ o8io~r - ..._ _ .. State of PENNSYLVANIA 1 sa Cotmty of DAUPHIN CUMBlRIAND.~OUNiY 11 PENiFSnrn,rlA .~ /J_ f hereby certify that on this ~ Ca ~ day of ~s(•G(~(Il" in the year of onr Lord, one thousan"d" n~ine hundred and sixty-three ( 953) before me, the anbseriber tl. ~Stt.r~~- personally appeared Earl D. La ha ,the attorney named in the foregoing Deed, and by v~i~w/r,tpd in pursuance of the authority therein conferred upon ~~ ~ AN ~ t /~•~•_.; him, acknowledged the said deed to be the act and decd ~y~Qt 'Z~'t~P HILL GARDENS, INC. *:~ ~` =•T .. . . " ~F YVk,~pa tog hand and official sral the dac n d ear aforuaid. ~~~ ~~ ~~ Title of O~tleti n i O N h t` ~ A ° ~ i r~ ~ t 8 ~ + ~ ~ ~ ~a is N ~ it ~ a, i ~ ! ?~ io '~ ~ i ~ w a ' `O z r g ~ '° ~ ~ '0 ~ t~ ~(D ~, ~ a ~~ ~ `8 ~ E r ~ iµ ~ ~ ' , o ~, Comm nwealt6 of Pe ylvan ia, ...~ .. .. ..__ __.......__ F .._......._ . ............ County, ~ aa. ~-, n ~ 0 I ~~ x ~H ~ :A, !r 'V Ir ~ .~. I ~ •. i ?a ; E~ ~ `" ~_ -- . _ ,- T.A. Financial Services, Inc. 2831 Banksville Road Pittsburgh, Pennsylvania 15216 412.531-1050 fax: 412.531-1180 I. ^X FHA 2. ~FMHA 3. ~ CONV.I)NINS. UvTT~~~~..C 4. ~ VA S. ~ CONV. MS. ~~ - ` ~ y 6. File Number 1. Lan Number. PIT123-37677 0920760 8. Mmgege Iro. Gee No.~. C. NOTE: This form is furnished ro give you a statement ojoctua! settlement rnsts. Amounts paid to and by the settlement agent are shown. Items marked (noel were raid o utside the closinr. Thev are shown here for informational ourtwses and are not included in the totals. D. Borrower: Douslas E. Maynard E. Seller: Marianne Dell. Executrix of the Estate of Rudolph 1. Tezak, deceased Susquehanna Bank and/or the Secretary of Housing and Urban Development F. Lender: 4185 West Market St York. Pennsylvania 17408 504 Beacon Hill Road New Cumberland, Cumberland County, Pennsylvania 17070 G. Pro a p ~' New Cumberland Borough Lot No. 22, Plan of Lots of Hillside Manor. Book 11, Page 21, Cumberland County, Pennsylvania H. Settlement Agent: T. A. Financial Services, Inc. Place of Settlement: 530 N Lockwillow Ave, Harrisburg PA 17112 Dauphin Counri i. Settlement Date: Januarv 15. 2010 J. Summary of Borrower's TransaMion K Summary of Seller's Transaction 1 0 Am un m rrower: 400. Gro s Amo of D To eller: 101. Contract Sale Price 155 000.00 401. Contract Sales Price 155.000.00 102. Personal Pro 402. Personal Pro rt 103. Settlement Cha es to Bortower line 1400 10 000.72 403. Ad'ustments for Items Paid b Seller in Advance: Ad'ust eats for Items Paid b Seller in Advance: 106. Ci /Town Taxes 406. Ci /Town Taxes 107. C un /Parish Taxes 407. Coun /Parish Taxes 108. Assessments 408. Assessments 109. 2009-2010 School Taxes Jan I5, 2010 thru Jun 30 2010 564.20 409. 2009-2010 School Taxes Jan I5, 2010 thty Jun 30 2010 564.20 110. Trash 1st qtr 2010 Jan I5, 2010 thru Mar 31, 2010 35.97 410. Trash 1st qtr 2010 Jan 15, 2010 thru Mar 31, 2010 35.97 1 roes A punt Due fro Borrower: 165 600.89 420. Gross Amount Due to eller: 155 0.17 200. Amounts Paid b or in Behalf of Borrower: 500. Reductions in Amount Due to Seller: 201. De osit / Earnest Mon 501. Excess De osit see instructions 202. Princi I Amount of New Loan 152 192.00 02. Settlement Char es to Seller Line 1400 ] 0 664.29 203. Existin Loans 503. Existin Loan s 204. Seller Assist 8 370.94 504. Pa off of First Mort a e 205. 505. Pa off of Second Mort a e 206. 506. Pur hale Mone Mort a e 207, 507. Seller Assist 8 374.94 A 'astm nts for Items Un aid b Seller: Ad ustments for Items Un aid b S Iler: 210 2010 Borough & County Taxes Jan 1, 2010 thru Jan 14.2010 28.78 510. 2010 Borough & County Taxes Jan 1, 2010 thru Jan 14 2010 28 78 211. Coun /Parish Taxes 511. Coun /Parish Taxes 212. Assess ants 512. Assessments 213 Sewer 1st Qtr 2010 Jan 1, 2010 thru Jan 14, 2010 9.17 513. Sewer 1st Qtr 2010 Jan 1, 2010 thru Jan 14, 2010 9 17 220. Total Paid b /for Borrower: 160 600.89 520. Total Reductions in Amount Due Seller: 19 073.18 3 . Cash at SetUem n from / to Borrower: 600. Cash at Settlem nt to / f m Seller: Ol. Gross m unt du rom Borrower line 120 165 600 89 601. Gross Amount due to Seller line 420 155 600.17 302. Liss Amount Paid by/for Borrower (line 220) 160,600.89 602. 520s Reductions Amount due Seller (line 19,073.18 303. Cash From Borrower: $5,000.00 603. Cash To Seller: $136,526.99 1 have carefully viewed the li[JD-1 Settlemrnt Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements account or by me in this transaction. [further certify that i have received a copy of FI1JD-1 Settlement Statement. Borrower: Seller: Dou s E. Maynard Marianne Dell, Executrix of the Estate of Rudolph J. Tezak, deceased The I-I[JD-1 Settlement Statement which I hove prepared is a true and accurate account of this transaaion. I have caused or will cause the funds to be disbursed in accordance with this statement. FA `, ,~ ~ ~~ ~~n J /% ' Date: January 15, 2010 SettlementAgrnt: 6f`7 ~C AI~I~v W~nr4~l ~. ~emement Cnar es 700. Total 3aless' Broker's Commission: Based on Price 8]55,000.00 is S8,992.74 Divis'on of Commission as follows Paid from Borrower's Funds at Paid from Seller's F 701. 4 618.87 to Prudential Homesale Services Grou Settlement unds at Settle t 702. 4.373.87 to Keller Williams of Central PA East men 703. Commission Paid at Settlement 704. Transaction Fee to eller Williams of Central PA Eest 800. Items Psvable in Connection with Loan• 25.00 8,992.74 801. Loan n matron Fee to Sus uehanna Bank 0.375% 802. Loan Discount 560.91 803. A sisal Fee to ALS Inc./A sisal Lo istic Solutions Inc. c 5410.00 b Borcower 804._ 'Credit Reoort from Kroll Factual Data (POC Sts 00 by bore) 805. Lender's Insnectwn Fee -- -2.44 806. Mortaaae Insurance An~l~cation Fee 0 . Assam two F 808. lood Certification Fee to First American Flood Data Services 809. Commitment Fee to Susquehanna Bank (incl 821 FHLMC LP/Fee for a Guarantee of Loan Terms) 18.0_0 695.00 810, om let~on Cert Fee to ALS Inc./A sisal Lo ~suc Solutions Inc. 811. MERS Fee to MERS 900. Items aired b odor to be Paid in Advance: 125.00 6.95 ~ 901. Interest from Jan 15 20]0 to Feb ] 2010 20.8482 / da 902. Mort a Insurance Premium to HUD 903. Hazard Insurance Premium to Erie Insurance 904. Flood Insurance Premium 354.42 2 617.56 377.00 . 1000. Reserves De osited with Lender: 1001. Hazard Insurance 3 months 31.42 er month 94 26 1002. Mort a insurance 0 months 68.10 r month 1003. Ci Pro a Taxes 1004. oun Pro a Taxes 12 months 62.54 r month 750.48 1005. Annual Assessments 1006. School Taxes 8 months 100.71 r month 805.68 1099. A e ate Accountin Ad'ustment -470.10 1100. Title Cha es: 1101. Settlement or losin Fee 1102. Abstract or Title Search 1103. Title Examination 1104. Title Insurance Binder 1105. Document Pre aration eed 1106. No Fees to Abb F. Wendel 25.00 20.00 1107 Attorney Fees includes above item numbers: Title Insurance @ Basic to T.A. Financial Services, Inc. & First American Title Insurance 1108. Co. includes above item numbers: 1,133.75 1109, Lender's 152,192.00 Coves e 1110. Owner's 155,000.00 Coves e 1111 Endorsement ALTA 8.1, PA 100, PA 300 to T. A. Financial Services, Inc. & First American Title Insurance Co 150.00 1112. Closin Service Letter to First American Title Insurance Com n 75.00 1200. overnment Recordin and Transfer Cha es: 1201. Recor in Fees: Deed 64.00 Mort a e 102.00 Releases 0.00 166.00 1202. Ci /Coun Tax/Stam Deed 1550.00 Mort a 0.00 1550.00 120. State T Stam s: Deed 1 550.00 Mort a 0.00 1 550.00 1204. 1205. 1300. Additional Settl moot ha es: 1301. Surve 1302. Pest /Home /Radon Ins coon to A'n S Ins ect 385.00 1303. Document Overni ht Delive to T. A. Financial Services Inc. 30.00 1304. Electronic Document Delive to T. A. Financial Services Inc. 35.00 1305. Trash 1st r Jan -March 2010 to New Cumberland Borou h 42.60 1306. Final Sewer Bill -Oct -Dec 2009 to New Cumberland Borou h 58.95 1307. Escrow for final exterior scra e & aint to Sus uehanna Bank 293.25 1400. Total Settlement Charges (Enter on line 103, Section J and line 502, Sectton K) i 510,000.72 i 510,664.29 .TM .. .._..._.. ,.._.... _~ Continuation of Schedule H Estate of File Number Rudolph J. Tezak 21-09-0079 ITEM NUMBER DESCRIPTION AMOUNT 1. Erie Insurance -homeowners insurance 264.00 2. Lowes -paint and supplies for 504 Beacon Hill Rd. b57.52 3, Walmart -supplies for 504 Beacon Hill Rd. 50.11 4. BJs Wholesale -supplies for 504 Beacon Hill Rd. 37.07 5. PPL Electric -electric utility 291.51 6. PA AME -water 153.49 7. Borough of New Cumberland -sewer 8. 2009 County Real Estate Taxes Expenses from HLJD-1 Settlement Statement: 9. 2009-] 0 School Real Estate Taxes - ($1233.14 paid - $564.20 reimb) 10. 2010 County Real Estate Taxes 11. Seller's Assists - 504 Beacon Hill Rd. 12. Realtor's Commission 13. Notary Fees 14. PA Realty Transfer Tax 15. Borough of New Cumberland -trash ($42.60 paid - $35.97 reimb) 16. Borough of New Cumberland -sewer (Oct-Dec) 17. Borough of New Cumberland -sewer (Jan 1-14) 406.20 629.00 668.94 28.78 8370.94 8992.74 20.00 1550.00 6.63 58.95 9.17 Total $ 22,195.05