HomeMy WebLinkAbout08-25-10 (2)150561D1D1
REV-1500 Exlol_,o, ~
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes "` "`~`~` County Code Year FNe Number
___ .
PO BOX 28o6oi _ _...... _
INHERITANCE TAX RETURN "
Harrisburg, PA iTi28-o6oi RESIDENT DECEDENT ~i! ~ O Q U J~ 7 b i.
ENTER DECEDENT INFORMATN)N BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
204-12-4780 12/17/2009 10/07/1925
Decedent's Last Name Suffix Decedents First Name ' MI
__._ __
-~ i _ _
Czarnecki ~ ~ Leonard ~ ~ ~ F~
_._ ,
(If Applicable) Enter Surviving Spouse's Information Below ',
Spouse's Last Name ~ ~~ Suffix Spouse's First Name MI
__~ ( _.. ~
_.. _. _. r _._ _.
L_____J
Spouse s Social Security Number
~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
' ___~ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (fate of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax ~tetum Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Sat}s Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigatiat Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax unde~ Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS 8ECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFORMATION SHOULD BE E D TO:
Daytime Telephone Num r
Name 717 249-3255 ~~
Richard Czarnecki _ ( )
_...
_ _ra-...........
REfiISTER USE O~
First line of address f
121 E Countryside Drive ~ ~ --
-
' ~
F-
Second line of address ~
~
~ --, `
1
C
;~
~ ~
....... .......... __..... ___. ........i -~
City Or Post Office State ZIP Code D FiU
_..
Boiling Springs PA 17007-9445
Correspondent's e-ma11 address: rlch_CZar@COmcaSt.net
Under penalties of perjury, I dedare that i have examined this return, inducting
R is true, yegsc,K and canplete. Dedaradon of preparer other than the persona
SIGNlrOF PERSAN SIBLE FORFILING RETURN
121
PA 17007
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
schedules and statements, and to the best of my kr
s is based on all irtforrnation of which proparor has
DATE
~~'
DATE
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and belief,
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ADDRESS
PLEASE USE ORIti1NAL FORM ONLY
Side 1
L 1505610101 1505610101 J
r r
J 1505610105
REV-1500 EX
Decedent's Social Security Number
1 20412-4780
Decedent's Leonard F. CZarneCki
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1. ', 139,900.00
2. Stocks and Bonds (Schedule B) ....................................... 2.j '~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3..
4. Mortgages and Notes Receivable (Schedule D) ........................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. '; 1,107.00
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. % 379.00
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~'; '~ 141,386.00 ,
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ li 26,860.00 '!
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. '; !, 26,969.00
11. Total Deductions (total Lines 9 and 10) ................................. 11. I $3,829.00
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. i ~ 87,557.00
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ........................ 13. '
i 0.00
F
14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~~ 87,557.00
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES i
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
at lineal rate X .0 4;t 16.
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.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105
1505610105
O
J
REV 1500 EX Page 3
Decedent's Complete Address:
DECEDENTS NAME
Leonard F. Czamedci
STREET ADDRESS
411 Norman Road
c Camp Hitl ~A~PA z P1 T011
Tax Payments and Credits:
1. lax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. D'~soount 0.00
3. Interest
4. ff Line 2 Ls greater than Line 1 + Line 3, enter the difference. This is tlse OVERPAYMENT.
Fill in oval on Pagt 2, LN-e 20 to request a refund.
File Number
(1)
---+
Total Credits (A + B) (2)
(3)
(~)
5. ff Line 1 + Line 3 Ls greater than Line 2, enter the difference. This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
3,940.00
0.00
0.00
3,940.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes ' Nb
a. retain the use or income of the property transferred; .......................................................................................... ^
II~
b. retain the right to desgnate 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 Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^ ~ 0
3. Did decedent own an intrust for' orpayable-upon-death bank acoouM or securiiy 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 R AS PART OF THE RETURN.
For dates of death on or after Juty 1,1994, and before Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use ~ the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviv~ng spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (a)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements fa disobsure of assets and
filing a tax return are still applicatsle 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 21 years of age or younger at death to or for the use of ~a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
e The tax re~ unposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percelnt, except as noted in
72 P.S. §9116(1.2) (72 P.S. §9116(x)(1}].
The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent [12 P.S. §9116(x)(1.3)], Alsibling is defined, under
Section 9102, as an individual who has at least one parent in common witlti the decedent, whether by blood or adoption.
0.00
REV-iSUZ EX+ (11-08)
Pennsylvania SCHEDULE A
DEVARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Leonard F. Caamedci 21-10-0578
All real property owned solely or as a tenant in cannon must be reported at fair market value. Fair market value is defined as the rice at which property
would be exchanged between a wifling buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge f the relevant facts.
Resi property that is joiMiy-owned with right of surviror~ip mwt be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold. j
N M ER Include a copy of the deed showing decedents interest if owned as tenant in common. ',VALWE AT DATE
DESCRIPTION OF DEATH
i • Property: 411 Norman Road, Camp Hill, PA 17011(Settlement Sheet Attached) ~~~ ~~ ~ ~ ~ ~ ~ ~ ~~
~ ~ 139,900.0
w~~. ~.;
. ,~ ~u ,. , ~ .. ~. ~ . ~ - -
REV-1508 F,(+ (698)
sc~ou~ E
COMMONWEALTH OF PENNSYLVANIA CASN~ BANK DEPOSITS 8c MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
ESTATE OF - FILE NUMBER
Leonard F. Czarnecki ~1-10-0578
Inctuie the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntltt•awmd with rlgM of survivorship must bs diswossd on SchsduN F.
(If more space (s needed, insert additional sheets of the same sae)
REV->So9 EX+ (oi-io)
Pennsylvania SCNE1~11L~ F
DEPARTMENT Of REVENUE
INHERITANCE TAX RETURN JOINTLY-OIAINE~ pRQpERTY
RESIDENT DECEDENT
ESTATE OF:
Leonard F. Czarnecki ~~ MBER:
21-10-078
If an asset became joimiy ownat wftl~in ons year o/ the decedanYs date of death, n must be
reported on 41e G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS
REIATI HZP TO DECEDENT
A° Susan M. Peliman 405 Hemlock Drive, New Cumt~erland, PA 17070 DaughtE~r
B.
C.
i
70INTLY OWNED PROPERI'1f: _ _
t.ETTER DATE ._ DESCRIPTION OF PROPERTY ~~"""~~-~~,
ITEPI FDR JO1Ni MADE INCLUDE NAME OF FINANCIAL INSnTIRIDN AND BANK ACCDUNi NUMBER OR SIMILAR DATE OF DEATH DECEDEN7i; ~~ ~ DEATH
NUMBER TENANT JDINT [DENrtMNG NUMBER. ATTACH DEED FOR JOINTLY HELD ATE. VALUE OF ASSET I I VALUE OF
,e„ e . ~ __._ _. __~.~..._ ._. DECEDENT'S INr6tESi
1. A. __ __ ..~ _._
`06/01/04 PA State E _
mployees Credit Union - Acd. # 0204124780 757.00 50 379.00
TOTAL (Also enter on Line 6, Reppitulation) ; 379.00
If more space is needed, use additional sheets of
paper of the same size.
REV-1511 EX+ (10-09j
pennsytvania
DEPARTMENT OF REVENUE
1NHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER'
Leonard F. Czarnecki 21-10-0578'
Detedetit's defile must be reported on Scf-eduM i.
ITEM
NUMBER DESCRIPTION AMOUNT
A. Fl)PiERAI EXPENSES: _ '',
I' Services and Merchandise (see attached sheet) 9,749.00
2.' Funeral Luncheon 8 Refreshments _ 521.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s) of Personal Representative(s) Richard CZamecki
street address 121 East Countryside Drive
city Boiling Springs state Pp- zIP 17007
Year(s) Commission Paid: N/A
2. Attorney Fees:
3. Famiiy Exemption: (If decedent's address is not the same as daimanYs, attach expianaHon.)
Gaimant Ronald Czarnecki
street address 121 East Countryside Drive (see attached explanation)
Gty Boiling Springs state PA ztP 17007
Relationship of Claimant to Decedent SOn
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7. P Settlement Cos _ ~ .
is {see aittached property settlement sheet)
~nY
a. Property Repairs {411 Norman Road, Camp Hill, PA)
s. The Cumberland Law Journal
~o. The Patriot-N~nrs Company
~ ~. Cumberland County Register of Wills
TOTAL (Also enter on Line 9, Recapitulation) ~
1,293.00
3, 500.00
0.00
0.00
0.00
9,015.00
2,508.00
75.00
169.00
30.00
26,860.00
If more space is needed, use additional sheets of paper of the same size.
Form REV-1500 -Schedule H
The following is explanation of the claimant's address currently being di~fenent than
decedent's address:
Family exemption claimant Ronald Czamecki, son of decedent Leonard F. I Czamecki,
resided with the decedent at the decedent's residence at 411 Norman Road,~~, Camp Hill,
PA his entire life. This address has always been his legal residence. Ronald Czarnecki
continued to live at that residence white making improvements to the property while
listed for sale on the real estate market.
The decedent's property at 411 Norman Road, Camp Hill, PA was sold and settlement
on the property occurred on June 11, 2010. At that time, Ronald Czarnecki owed into
his brother's (Richard Czarnecki) residence at 121 East Countryside Dri~e, Boiling
Springs, PA.
REV-1512 EX+ (12-OS)
Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE ~E6~ OF DECEDENT,
INHERITANCE TAX RETURN MV~T '~~`E ~iABI~iW` & LiC•NS'
RESIDENT DECEDENT
ESTATE OF FILE NtlkMIBER
Leonard F. Czarnecki 21-10-0578.
Report debts inwrt+ed by the decedent prior bo death that remained unpaid st the date of death, including unreimbursad ital expenses.
ITEM ', VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 • Mebo Bank -Installment Loan (lien on property at 411 Norman Road, Camp Hill, PA) 12,247.00
2. Jntemal Revenue Service 20071040-A (fax Due) 62.00
3. West Shore Emergency Medical Service 866.00
4.' J.C. Penny Department Store 205.00
5. HSBC Card & Retail Services (BosooYs) 550.00
6.' ';Dell Financial Services 1,300.00
7.' '.Sears Premier Card (CitiBank S.D., NA) 1,388.00
8.' Sunoco Consumer Card (CitiBank S.D., NA) 295.00
9. ` CitiBank Mastercard (CiGBank S.D., NA)
__ _ . 3, 079.00
10. The Home Depot -Consumer Card 938.00
11. 'Verizon (Telephone) 87.00
12.• 'PPLUtilities 390.00
13. , Pennsylvar-ia American Water 48.00
14. " ! UGI Gas Services 571.00
15. 'Cumbeiiand County Real Estate Taxes (411 Norman Road, Camp Hill, PA) 4,573.00
16. Lower Allen Twp. -Final Sewer l~ Trash 216.00
17. Lower Allen Twp. -Delinquent Street Light Fee 57.00
18., Donegal Insurarroe (Homewoners Insurance)
_, 97.00
TOTAL (Also enter on Line 10, Recapitulation) $ 26,969.00
If nwre space is needed, insert additional sheets of the same s¢e.
REV-1513 EX+ (01-10)
pennsytvarria SCHEDULE ~
DEPARTMENT OF REYENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
If mare space is needed, use additions{ sheets of paper of the same size.
`, I , /
`` /~
A Family Tradition Of Caring®
PARTHEMORE Funeral Home & Cremation Services, Inc.
1303 Bridge Street
P.O. Box 431
New Cumberland, PA 17070
(717) 774-7721
(Fax)774-5546
www.parthemore.com
Gilbert W. Parthemore,
Founder
Gilbert J. Parthemore,
Supervisor
Stephen K. Parthemore,
CFSP
Bruce R: Parthemore,
Pre-Need Coordinator, CPC
Professional Memberships:
NFDA • PFDA
DCFDA • CCFDA
G~~~
LE
The Rule Yoer Know,
The People You Trust
Mr. Richard Czarnecki 12/18/2009
121 E. Countryside Drive
Boiling Springs, PA 17007
For the Service of Leonazd F. Czarnecki
We sincerely appreciate the confidence you have placed in us and will continue to ist you in every way
we can. Please feel free to contact us if you have any questions in regard to this stat~nent. The following
is an itemized statement of the services, facilities, automotive equipment and rra;rcha#-dise that you selected
when making the funeral an angements.
Terms Due Date Account #
Net,30 1/17/2010 2009098.0
Description Amount
SERVICES & MERCHANDISE
Traditional Funeral Service 5,750.00
On Freedom's Wings Stationery Set I 165.00
18 Gauge Steel Veteran's Casket 2,650.00
Total Services and Merchandise 8,565.00
CASH ADVANCE ITEMS
Death Notice, Harrisburg Patriot ~ 453.52
10 Certified Copies of Death Certificate 60.00
Clergy Honorarium 2~•~
Organist Honorarium ' 125.00
Soloist Honorarium 75.00
Altar Servos '~. 15.00
Flowers, Casket Spray 280.00
Honor Guard 75.00
Total Cash Advances 1,283.52
+~..t10 u.1 ~ W't. Cp~(~ ~`1~{'1 ia.-e_ ~'O
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NO. 19bib ~ 4 ~ THIS i"JOENTURE, ° '
.DEED ' ~ ~ PENNA MADE THE 215T DAY OF AUGUST IP: THE'YEAft OF OUR
N , P . N I NIVEMAN, 1 NCORPORATED ~ ~1~10~2 I • LORD ONE THOl13ANd N l NE HUNDRED AND F I FAY-Tl'GO ;
TO ~ ~ ~ jE TAX ~ BETWEEN N.; P. NiNNEMAN, INCORPORATED,, A 4
LEONARD F, CZARNECKI'LT UX CORPORATION ORGANIZED AND EXISTiNG~UNDER THE LAWS
CONS, #12,700,00 ~ `~OF PENNSYLVANIA, HAVING ITS PLACE OF BUSINESS IN THE TOYJNSHIPi
LOC, LOWER ALLEN TOWNSHIP ~OF~LOWER'ALLEN, COUNTY OF CUMBERLAND ANq 5TA'l~E OF PENNSYLVANIA,
DATED AUG!}ST 21, 1452 PARTY OF THE FIRST PART, AND -.
ENTD, AUGUST 21, 1952 ~ LEONARD F. CZARNECKI ANU MARIE A, CZARNE~Kl, HIS WIFE,
TINE 2116 PM '~OF WILLtAMSTOWN, DAUPHIN COUNTY, STATE OF PENNSYLVA~41A,
PARTIES OF 7HE SECOND PART, .
~_~__+~-_~+T~~--~~_~~~+r+Z_~~_~ WITNESSETH, THAT THE SAID PARTY OF THE F~RST PART FOR
ANO 1N CONelOERATION OF THE SUM OF TWELVE THOUSAND SEVEN HUNDRED DOLLARS~LAWF~UL MONEY OF
THE UNITED STATES OF AMERICA, UNTO IT WELL AND TRULY PAID 8Y THE 8Al0 PARTIE~ OF THE SECOND
PART AT AND BEFORE THE SEALING AND DELIVERY OF THESE PRESENT~3, THE RECEIPT WF~EREOF IS ~
HEREBY ACKNOWLEDGED, H A5 GRANTED, BARGAINED, SOLD, ALIENED, ENFEOFFED, RELEASED AND CONFIRMEb,
ANO pY THESES PR~SENTS OOEJS GRANT, BARGAIN, SELL, AL1EN,'ENFEOFF, RELEASE AND CONhIRM UN70
. ~
THE SAID PARTIES OF THE SECOND PART, THEIR HEIRS AND A5SIGSN,
ALL THAT CERTAIN LOT OF LANG SITUATE IN THE TOWNSHIP OF LOWER ALLEN,~COUNTY OFlCUMB-
ERLAND ,AND STATE OF PENNSI~LVANIA, 60UNDE0 ANC DEtiCR18ED AS FOLLOWS:
BEGINNING AT A POINT A7~THE SOUTHWEST CORNER OF NORMAN AND KINGSLEY ROADS A5 SHOWN
ON THE HEREINAFTER MENTIONED PLAN OF LOTS; THENCE IN A SOUTHERLY OtRECT(ON ALONG TWE
WESTERLY LINE OF KINGSLEY ROAD, SEVENTY-FOUR ANO SIXTY-91X HUNDREDTHS (74.66)IFEET TO A ~
- PO{N7 ON,LINE OF LANDS OF ELMERIE, ZIMMERMAN; THENCE ALONG SAID LANO5 iN A WESIrERLY DfRECT10
ONE HUNDRED (100) FEET TO A POINT AT LINE OF LOT N0. 16,, BLOCK "U"; ON RAID pL'AN; THENCE
ALONG., THE LATTER LOT IN A NORTHERLY DIRECTION SEVENTY-FOUR.AND SIXTY-S!'X~HUNOR~DTH5 (74,bb)I
FEET TO A 'p01NT, ON THE SOUTHERLIY LINE OF, NORMAN ROAD; THENCE ALONG NORMAN ROAD IN AN EASTER Y
---~---DIRECTLON ONE HUNDRED (10Qj fEE7 TO A POINT, THE PLACE OF BEG.INNIND.
BEING LOT NO, 17r BLOCK "U"r ONE THE. PLAN OF LOTS bF A PORTION OF HIGHLAND Ak}h`;~•~RECORDE
IN THE CUMBERLAND COUNTY RECORgER`S:OFFlCE !N PLAN BOOK 5, PAGE 24. '
HAVING THEREON ERECTED A SINGLE FRAIAE DWELLING HAUSE N0, 411 NORMAN ROAD, h~(GHLANO
PARK, CAMP HILL, PENNSYLVANIA,
'BEING A PORTION OF THE PREMISEtlI-WHICH ELMER E. ZIMMERMAN BY DEED DATED AUGU~iT 31, 1951
ANO RECORDED IN THE CUMBERLAND COUNTY RECORDERS OFFICE IN DEED BOOK 01V", VOL, ~.~,''pATE 29,
ORANTEO ANO CONVEYED UNTO N. P. NiNNEMAN, INCORPORATED, GRANTOR HERE(N~ '
~ i
TOGETHER WITH ALL ANO SINGULAR THE WAYS, WATER5,~WATER-COURSES, R1GHT8, LIB.~RTIES,~
PRIVILEGES, HEREDITAMENTS AND APPURTENANCES WHATSOEVER THEREUNTO BELONGINGS OR 'IN ANY W18rr
. APPERTAINING, AND THE REVERSIONS ANO REMAINDERS, RENTS, ISSUES AND PROFITS THEREOF; AND ALL
I
THE ESTATE, RIGHT, TITLE, INTEREST, PROPERTY, CLAIM ANO DEMAND WHATSOEVER, OF PAFdTY~OF THE
..FIRST PART IN LAW, EQUITY, OR OTHERw{SE HOWSOEVER, OF, IN, AND TO tHE SAME ANQ~E1~ERY PARTi'
THEREOF, ~ ~ i
. .t.
• Td HAVE AND TO HOLD THE SA10 HEREIN DESCRIBED HEREDITAMENTS AND pREMISEB HERIFBY GRANTED
OR MENTIIONED AND INTENDED SO TU BE, WITH THE APPURTENANCES, UNTO THE SAID PARTIESI~~,OF THE ~ ~
SECOND PART, THEIR HEIRS AND .ASSIGNS, TO ANd FOR THE ONLIY PROPER USE ANO EEHOOF OE THE SAID
' I
PAOTICV nr ~.•.- .••••--•-- _
~~ J A+'~D THE SAID PARTY OF THE 1-{R5T PART DOES BY THESE PRESENTt3, COVENANT, G'RA,'VT AND AGREE.
TO AND ~tITH THE SAID PARTIES OF THE SECOND FART, THEIR HEiR5 AFID ASSIGt~5, THAT IT THE SAID
PARTY OF THE FIRST PART ALL ANI? SINGULAR THE HEREpITAMENTS aND PREINISEB HEREIN ABOVE DESCRiB
AND GRAtVT$D, OR MENTIONED AND INTENDED SO TD BE, WITH TH£ APPURTENANCf,5, UNTO 7H~ SAID A1VD
ASSIGNS, AGAINST THE SA{D AND AGAINST ALL AND EVERY PERSON OR F:rRSONS 1~40M5t?EVEn LAlIFULLY 1
CLAIMING pR TO CLAIM THE SAME 8R ANY PART THEREOF, SHALL. AND WELL WARRANT AND FrZREVER DEf`END~
ANq THE SAID PARTY OF THE FIRST PART BOTH HERESY CONSTITUTE AN4 A?POINT~N.'P, NINNEMA#t.~
TO BE l T5 ATTORNEY, FOR I T AND I N ITS f~lAME, • AND AS AN>) FOR t T'S CORPORATE ACT. AN~3 DEED, TO, 1
ACKN01l~t.EBGE T'N 1 S f NDENTURE BEFORE r ANY PERSON H Av i NG AUTHORITY BY THE LA'Nf3 OF Ti•EE GOMaONYPEALTFI
~OF PENN9YLVAIV I A TO TAKl:• SUCH ACKNO'lII1..EDC~~NT, TO THE INTENT THAT THE SAME MAY Bi~l` aULY RECORDED .
!N .MiTyEliss NrHEREOF, THE iSAla N. P, NlNNEMAN, tNCORRORATEa HAi3 HEREUNTO CAU~SEt'1 iT5 ,
+GgRPORATE SEAL TO BE AFFIXED AND ATTESTEa THIS 21tiT DAY OF AUGUST A. D, ONE THO~lSAND NINE
{!•tUNOREL~ AND FIFTY-TYPO Y t r ~ . , !
k Sl~ALEtI AtdD DEL I VEREa ~ , N . P. N { NNEhIAN, I NGORPORATED
{F! THE PRt:SENC£ OF U3= ~aIIPlIRATCdIt 8Y N, P, K { NNEMAN
1
r ! I • t ATTEST; i
r (SARA W, MARE
ASS' SECRETARY t
RECEIVED, THE D~,Y OF THE BATE OF,THE ABOVE INDENTURE, qF THE At3CJ~'•~i'A1~IE'D"""__""`"""""'"""
STATE OF PENNt3YLVA.NIA, ~ ~~ r ! .
COUNTY OF gAUPHIN ~r r ~ r ,
r a 1
t HEREBY CERT t FY, THAT ON TH f 8 21~T DAY OF At1GU8T I N THE YEAR OF DUR LOt~ O~IE THOUSAND "
NINE kUNQRlD ANq F t ~'TY-•TY-D aEFORE IUE, THf~ liU83CR 1 aE12t A NOTAitY PUaL I C, REfy I D I NG I N THE COURtTY
.,~
OF DAUPHIN PERt•301VALLY APPEARED N . P, N I NIVEMAN 'I'H,E A'~'TORNEY NAA~D t N THE FOREGO I Nq I ND~.NTURE ,
At~J `BY Y I RTU€ AND t1~ FURt~UAfiCI qF ~Ft AUTHOR l TY TI jERE t ~t IrONFERRED UP~dN HIM, ACKNOIWk.EOGED THt:
SAID {NI~EttTUR£ TD aE THE ACT' AND DEED qF .THE RAID N. R. NIN~IEMAN, INCORPDRATtD
Ir l TNEtiS trlY HAND AND NC~TAR { AL SEAL THE DAY AND YEAR A~F'DRESA I D , t ~ ,
r ~ ~ HARRY L. aOtYEt~3 r
. r S~AI NgTARY PUBLIC t
s r MY'COMbIttISION EXPIRES IdARCH ~5, 195J I
THE ADDRE53 ~OF THi` ~YYtTHIN-NAMED GRANTEE
t S 411 ,NORMAN RgAD, H IGHI,AND PARK, CAMP H 1 Y,L, PA, !
I
I
T, I'!OI~SAli t . 1tIYE f~=i _. ~.,„
5TA~ES
NPN
'~v~rluc
s
Ref# 3632
Payoff Statement
Date Requested: 6/1!2010
Borrower Name: Ronald Czamecki
Loan Number: 400213339
Loan Type: Installment
Contract Date: 3!7!2006
Original Loan Amount: $40,853.74
Listed below is a breakdown of the payoff figure for the above referenced loan. Payments must be received by the dose
of business, 6:OOpm, a s of the date the payoff was calculated to avoid additional charges.
Principal: $10,764.92 I!
Interest: $190.79
Satisfaction Fees: $50.50
Escrow Balance: $0.00
Late Fees: $1,263.68
Prepayment Penalty: $0.00 ',
Prepayment Penalty Waived: $0.00
Life Insurance ($22.79)
Total: $12,247.10
Per Diem: $1.77
Co{lateraf: 411 Norman Rd., Camp Hilt, Cumberland County
The above figures were calculated as of : 6/11/2010
To calculate the amount of the payoff for a date after the effective date. of the payoff calculated by Metro Bank, multiply
the amount of the per diem by the number of days until payment will be made and add to the interest.
The above figure is quoted considering that no payments will be made until final payoff is received. Any payments
received before the final payoff will reduce the payoff amount. If this loan is a line of credit, the payoff is quoted
considering that no advances will be taken after the payoff has been quoted. If the payoff is not received by the loan Qlue
date, a 5% late fee may be assessed based on the amount of the monthly payment. ~
K this loan is a Line of Gr~edit. signed authorization from the customer must be obtained fn order to close the '~,
I n~ in full.
Contact Information: Mail Payoff To: Wire Instructions:
Loan Servicing Customer Care Metro Sank Metro Bank
Phone: (717) 412-6998 Attn: Loan Servicing Department -Payoffs ABA# 031301846
Fax: (717} 901-8220 3801 Paxton Street GL WIP# 133899909997
Harrisburg, PA 17111 Loan # 400213339
Name: Ronald Czamecki
Ref: Loan Payoff i,
' i
' PROMISSORY NOTE ..
__ ttn A"'A ~ ~ ~~'"/
~.+trt:,q-ar t»u~rt r,+axttc rvrus~7tFry fNFisTfF NO: ~r 7;~Q1I iiii[CCOttt?i Q.Bi' lnt~~ES
References in the shaded area are for Lender's use only and do not limit the applicability of this document to any particular loan or item.
Any item above containing "" "" has been omitted due to text length limitations.
BtllrrOWer: Ronald Czarnecki (SSN: 198-60-0765) Lender: COMMERCE BANK/HARRISBUf;IG N.A.
411 Norman Road CEDAR CLIFF
Camp Hill, PA 17011 1102 CARLISLE ROAD
CAMP HILL, PA 17011
(7171909-3200
COSlgner: Leonard F. Czarnecki (SSN: 204-12-4780)
411 Norman Road
Camp Hill, PA 17011
principal Amount: 340,853.74 Interest Rate: 5.990°,6 Date of Note: March 7, 2006
Maturity C~ata: March 11, 2011
PROMISE TO PAY. I and all cosigners signing this Note ("Borrower") jointly and severally promise to pay to COMMERC~ BANK/HARRISBURG
N.A. ("Lender"), or order, in lawful money of the United States of America, the principal amount of Forty Thousand Eight Hundred Fitty-three &
741100 Dotlara ($40,853,74), together with interest at the rate of 5.990% per annum on the unpaid principal balance f om March 11, 2006,
until paid in full. The interest rate may change under the terms and conditions of the "PREFERRED RATE REDUCTION" rer~tlon. Unleec waived
by Lender, any increase in the interest rate will increase my number of payments.
PAYMENT. 1 will pay, this loan in 60 payments of 5789.64 each payment. My first payment is due April 11, 200 ,and all cubaequent
payments are due on the same day of oath month after that. My final payment will be due on March 11, 2011, and will ~e for all principal and
ail accrued Interest not yet paid. Payments include principal and interest. Unless otherwise agreed or required by appli¢a la law, payments will
be applied first to any unpaid credit insurance premiums, accrued to the date of receipt of payment; then to any accrued u paid interest; than to
principal;-then to any unpaid collection costs; and then to any late cha-gas. Inte-est on this Note is computed on a 3 5/365 simple interest
basis; that is, by applying the ratio of the annual interest rate over the number of days in a year, multiplied by. the outstan ing principal balance,
multiplied by the actual number of days the principal balance is outstanding. I will pay Lender at Lende-'s address shown bove or at such other
place as Lender may decignate in writing.
PREFERRED RATE REDUCTION. The interest rate on this Note includes a preferred rate reduction. Following is a description of the event that
would cause the preferred rate reduction to terminate, how the new rate will be determined upon termination of the preferred rate reduction and
any rules pertaining to the termination of the rate reduction.
Description of Event That Would Cause the Preferred Rate Reduction to Terminate.
IF THE AUTOMATIC PAYMENT IS DISCONTINUED BY THE BORROWER OR THE LENDER.
How The New Rate Will Be Determined Upon Termination of the Preferred Reduction.
THE INTEREST RATE WILL INCREASE BY ONE-HALF OF ONE PERCENT (.500%).
Rules,
THERE IS AN ADMINISTRATIVE FEE OF 525.00.
PREPAYMENT. I may pay without penalty all or a portion of the amount owed earlier than it is due. Early payments will hot, unless agreed to
by Lender in writing, relieve me of my obligation to continue to make payments under the payment schedule. Rather, early~ayments will reduce
the principal balance 'due and may result in my making fewer payments. If I prepay this loan in full, 1 will receive a re ate of any unearned
insurance premiums. I agree not to sand Lender payments marked "paid in full", "without recourse", or similar langua e. 'If 1 send such a
payment, lender may accept it without losing any of Lender's rights under this Note, and I will remain obligated to pay any further amount owed
to Lender. All written communications concerning disputed amounts, including any check or other payment instrument'tfhat indicates that the
payment constitutes "payment in full" of the amount owed or that is tendered with other conditions or limitations or as full satisfaction of a
disputed amount must be mailed or delivered to: COMMERCE BANK/HARRISBURG N,A., LOAN SERVICING, PO BOX 1 X195 CAMP HILL, PA
17011-1195,
LATE CHARGE. If a payrnent is 15 days or more late, I will be charged 5.000% of the regularly scheduled payment.
INTEREST AFTER DEFAULT. Upon default, including failure to pay upon final maturity, Lender, at its option, may, if permi~ad under applicable
law, increase the interest rate on this Note 2.000 percentage points. The interest rate will not exceed the maximu rate permitted by
applicable law. If judgment is entered in connection with this Note, interest will continue to accrue on this Nota after jud~ment at the existing
interest rate provided for in this Note.
DEFAULT. I will be in default under this Note if any of the following happen:
Payment Default. I tail, to make any payment when due under this Note.
Break Other Promises. I break any promise made to Lender or fail to perform promptly at the time and strictly in that manner provided in
this Note or in any agreement related to this Note, or in any other agreement or loan I have with Lender.
Default in Favor of Third Parties. I or any Grantor defaults under any loan, extension of credit, security agreement, purchase or sales
agreement, or any other agreement, in favor of any other creditor or parson that may materially affect any of my property or my ability to
repay this Note or perform my obligations under this Nota or any of the related documents.
False Statements. Any. representation or statement made or turnished to Lender by me or on my behalf under this'Nota or the related
documents is false or misleading in any material respect, either now or at the time made or furnished.
Death or Insolvency. Any Borrower dies or becomes insolvent; a receiver is appointed for any part of my property; I rhake an assignment
for the benefit of creditors; or any proceeding is commenced either by me or against me under any bankruptcy pr insolvency laws.
However, my death will not be an event of default if as a result of the death the Indebtedness is fully covered by credit I~fe insurance.
Taking of the Property. Any creditor or governmental agency tries to take any of the property or any other of my propelrty in which Lender
has a lien. This includes taking of, garnishing of or levying on my accounts with lender, However, if I dispute in goo faith whether the
claim on which the taking of the property is based is valid or reasonable, and if I,give Lender written notice of the claim and furnish Lender
with monies or a surety bond satisfactory. to tender to satisfy the claim, then this default provision will not apply.
PROMISSORY NOTE
Loan No: 400213339 (Continued) Page 2
Detective Collateralization. This Note or any of the related documents ceases to be in full force and effect (includirl9 failure of any collateral
document to create a valid and perfected security interest or Iien1 at any time and for any reason.
Collateral Damage or Loss. Any collateral securing this Note is lost, stolen, substantially damaged or destroyed and the loss, theft,
substantial damage or destruction is not covered 6y insurance.
Events Affecting Guarantor. Any of the preceding events occurs with respect to any guarantor, endorser, surety, for accommodation party
of any of the indebtedness or any guarantor, endorser, surety, or accommodation party dies or becomes incompetent, or revokes or
disputes the validity of, or liability under, any guaranty of the indebtedness evidenced by this Note. In the event f a death, Lender, at its
option, may, but shall not be required to, permit the guarantor's estate to assume unconditionally the obligations wising under the guaranty
in a manner satisfactory to Lender, and, in doing so, cure any Event of Default,
Insecurity. Lender in good faith believes itself insecure.
Cure Provisions. If any default, other than a default in payment is curable and if I have not been given a notice ~f a breach of the same
provision of this Note within the preceding twelve (12) months, it may he cured if 1, after receiving written notioeifrom Lander demanding
cure of such default: (1) cure the default within fifteen (151 days; or (21 if the cure requires more than fiftaenl~ (15) days, immediately
initiate steps which Lender deems in Lender's sole discretion to be sufficient to cure the default and thereafter c ntinue and complete all
reasonable and necessary steps sufficient to produce compliance as soon as reasonably practical
LENDER'S RIGHTS. Upon default, Lander may, after giving such notices as required by applicable law, declare the entire unpaid principal
balance on this Nota and all accrued unpaid interest immediately due, and then 1 will pay that amount,
ATTORNEYS' FEES; EXPENSES. Lander may hire or pay someone else to help collect this Nota if I do not pay, I will play Lender that amount.
This includes, subject to any limits under applicable law, Lender's attorneys' fees and Lender's legal expenses, whether dr not there is a lawsuit,
including attorneys' fees, expenses for bankruptcy proceedings (including efforts to modify or vacate any automatic $tay or injunction), and
appeals. ff not prohibited by applicable law, I also will pay any court costs, in addition to all other sums provided by law. j
GOVERNINi3 LAW. This Note will be governed by federal law applicable to Lender and, to the extent not preempted by ~ederal law, the laws of
the Commonwealth of Pennsylvania without regard to its conflicts of law provlsions. This Note has been acre tad by Lender in the
Commonwealth of Pennsylvania
RIGHT OF SETOFF. To the extent permitted by applicable law, Lender reserves a right of setoff in all my accounts with Lender (whether
checking, savings, or some other accountl. This includes all accounts I hold jointly with someone else and all accounts 1 Y~nay open in the future.
However, this does not include any IAA or Keogh accounts, or any trust accounts for which setoff would be prohiblit~d by law, I authorize
Lander, to the extent permitted by applicable law, to charge or setoff all sums owing on the indebtedness against any and~,all such accounts.
COLLATERAL. I acknowledge this Note is secured by 41 1 Norman Road, Camp Hill, lower Allen Township, Cumberland bounty, Pennsylvania.
CREDIT INSURANCE.I have chosen to purchase Single Life Insurance for this loan. Information concerning the premiums and the term of this
insurance are set forth in the Disbursement Request and Authorization, all the terms and conditions of which are hereby incorporated and made
a part of this Note.
PROPERTY INSURANCE. I understand that I am required to obtain insurance for the collateral securing this Note. Further information
concerning this requirement is set forth in the Mortgage and in the Agreement to Provide insurance, all the terms and conditions of which are
hereby incorporated and made a part of this Note.
SUCCESSOR INTERESTS. The terms of this Note shall 6e binding upon me, and upon my heirs, personal representatives, successors and
assigns, and shall inure to the benefit of Lander and its successors and assigns.
NOTIFY US OF INACCURATE INFORMATION. WE REPORT TO CONSUMER REPORTING AGENCIES. Please notify us if we~report any inaccurate
information about your account(s) to a consumer reporting agency. Your written notice describing the specific inaccuracy( es) should be sent to
us at the following address: COMMERCE BANK/HARRISBURG N.A. LOAN SERVICING PO BOX 1135 CAMP HILL, PA 17p1'11-1195.
GENERAL PROVISIONS. If any part of this Npte cannot be enforced, this fact will not affect the rest of the Note. tend r may delay or forgo
enforcing any of its rights or remedies under this Note without losing them. 1 and any other person who signs, guar$n~ees or endorses this
Note, to the extent allowed by law, waive presentment, demand for payment, and notice of dishonor. Upon any ehang¢¢ in the terms of this
Note, and unless otherwise expressly stated in writing, no party who signs this Note, whether as maker, guarantor, act mmodation maker or
endorser, shall be released from liability. All such parties agree that Lender may renew or extend (repeatedly and for any length of time) this
loan or release any party or guarantor or collateral; or impair, fail to realize upon or perfect Lender's security interest in th¢ eollaterai. All such
parties also agree that Lender may modify this loan without the consent of or notice to anyone other than the party with w~tom the modification
is made. The obligations under this Note are joint and several. This means that the words "I", "me", and "my" meer~ each and all of th.e
parsons signing below.
PRIOR TO SIGNING THIS NOTE, I READ AND UNDERSTOOD ALL THE PROVISIONS OF THIS NOTE AND THE NOTICE'', TO COSIGNER SE7
FORTH BELOW. I AGREE TO THE TERMS OF THE NOTE.
I ACKNOWLEDGE RECEIPT OF A COMPLETED COPY OF THIS PROMISSORY NOTE.
THIS MOTE IS QIVEN UNDER SEAL AND IT IS INTENDED THAT THIS NOTE IS AND SHALL CONSTITUTE AND HAVE', THE EFFECT OF A
SEALED INSTRUMENT ACCORDING TO LAW.
BORROWER:
.~
X:.; L .' (Seal)
Ronald Czarnecki
.,~ ,.
` ~ ''I
III
..' .
PROMISSORY NOTE
Loan No: 400213339 (Continued) Page 3
COSIGNER:
X> ~f'~2-r.G~k-;;./' fj .:.ir.~-cl~.,~:.`.. '(Seat)
Leonard F. Czarnecki
NOTICE TO COSIGNER ~~
You are being asked to guarantee this debt. Think carefully belora you do. If the borrower doesn't pay the debt, you will have to. Be sure you
can afford to pay if you have to, and that you want to accept this responsibility. II
You may have to pay up to the full amount of the debt if the borrower does not pay. You may also have to pay late fa4a or coflection costs,
which increase this amount.
The Lender can collect this debt from you without first trying to collect from the borrower. The Lander can use the sar~ha collection methods
against you that can be used against the borrower, such as suing you, garnishing your wagec, etc. If this debt is ever in aetault, that fact may
become a part of YOUR credit record.
Thie notice is not the contract that makes you Ilable for the debt.
I~AE~w,o l«.«~a. yr caomaw cm, ~.,...e ~..rwN C+.,b..,. Me .w.. mon a~nym, +...wa ~.. wuwl/mu.w~nfnn~q~mn.~ M.~n,> r,.>.
:(tkma era obsolete form HUD-1 (3198) ref Handbook 4305.2
etaement Statement U.S. Depattm@nt of Housing and Urban Development
nMR Aeere~91 No. 2502-0285
HA 2. ^FmHA 3. ~Conv. Unins. 6, File Number 7. Loan Number 8. Mortgage Insurance Case Number
'A 5. Conv.Ins, 1Q37
1 Ole
@: Items marked "(p.o.c.)• ware paid outside Me cbetrq: tMy ens shown Mrs for bltormetion purr~pyocses end en not InGudsd in the table. TItIBEXpr@SS SBttlement ystem
~~N~INnG:Gltn s~~ a kr~rgly make UlpFsforaidesmWls ~s Title i B U.S Coda Section 1001 and Sedlon,0~10~naWee upon Printed 06f1112010 at 11:32 SDC
AE OF BORROWER: SCOtt C. BroMm and Dina L. Brown
_tDRESS: 17 Monarch Lana Mechanlcsbu PA 17050
CIE OF SELLER: Estate of Leonard F. Czamecld
DDRESS:
ME OF LENDER: Adams County Natlonal Bank
DDRESS: 875 Old Harrlsbu Road sbu PA 17325
;OPERTY ADDRESS: 411 Norman Road, Camp Hill, PA 17011
Lower Allen Townshi
77LEMENrAGENT: The Law Oiflc:e of Andrew H. Shaw, PC, Telephone: 717.243.7135
:CE OF SETTLEMENT: 200 8. rf Garden Str Su(b 11 Carlisle PA 17013
iiLEMENT DATE: 06N1l20f0
J. S
GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER
Contract sales ice 139 900.00 401. Contract sales rice 139900.00
Personal ro 402. Personal ro
Settlement cha es to borrower line 1400 3080.53 403.
_ 404.
405.
Ad ustmenta for items aid b sell@r i n advance Ad ustments for items aid b seller i n dvance
C flown taxes ~ 406. Cit !town taxes
Coun taxes 06/11110to12131N0 338.49 407. Count taxes 08M1110to12~31/10 338.49
School taxes 08/11110 to 08130110 87.73 408. School taxes 06111110 to 06130M0 87.73
_
2nd Quarter werlTras86111M0to08130110 21.52 409. 2nd Quarter SewerrTras88111M0to08130110 21.52
410.
- 411.
- 412.
GROSS AMOUNT DUE FROM BORROWER 143408.27 420. GROS8 AMOUNT DUE TO SELLER 140 327.74
AMOUNTS PAID BY OR ON BEHALF OF BOR ROWER 500. REdUCTIONS IN AMOUNT DUE TO SELLER
De sit or earnest mores 501. Excess De sit see instructions
Princi al amount of new loans 1 925.00 502. Settlement char es to sells line 1400 9062.20
xis
tin loan s taken sub ect to
E 503. Existin loans taken s b'ect to
_
_
_ 504. Pa off:400213339 7 ~ `~
Metro Bank
505.
Seller's Assist 2798.00 506. Seller's Assist 2 798.00
Credit for Re airs 2000.00 507. Credit for Re airs 2000.00
508.
509.
Ad usbnent: for items un d atler . Ad wtment~ br )terns un ~ let
Cit Rows taxes 510. Ci /town taxes
Count taxes
~ 511. Count taxes
_
School taxes 512. School taxes
513.
514.
- - - 515.
516.
517.
516.
- 519.
TOTAL PAID BYIFOR BORROWER 109 723.00 520. TOTAL REDUCTION AMOUNT DUE SELLER.. 28119.89
CASH AT SERLEMENT FROM OR TO BORR OWER B00. CASH AT SETTLEMENT TO OR FROM 8ELL
Gtnss amount due from borrower line 120 143 408.27 601. Gross amount due to seller line 420 140 327.74
ss amounts aid b/For borrower line 220 109723.00 602. Less reduction amount due seller line 520 26119.69
ASH FROM 80RROWER 33 685.27 803. CASH TO SELLER 114 208.05
=TITUTE FORM 1009 SELLER STATEMENT: The IrNomia9on conWnsd herein Is knportant tax information end is bslnp famished to the IMSmeI Rewnus SerWca. K you ere required to rtle ^ return,
'- penaay or otMr pnctWn wNl bs tmpossd on you K thb Item le regWrsd to De reported and the IRS datemlines Vlal K has not been sported. The Contract Sales Price deAcAtxd on
0 above corlstltutss tl» Oros Proceeds of tMs transaction.
ro required by law to provide the settlement spent (Fed. Tex ID No; 281644565) with your correct taxpayer identlrtatlon number. tf you do not provide your correct taxpayyer kten~tcatbn
~r, you may be sub)ed M dull or criminal penalties Imposed by law. Under penaltlss of perjury, I Grtiry that the number shown on this elabmsnt Is my corrsd taxpayer IdentHtcaljon number.
- ! SELLER(S) SIGNATURE(S): !
ER(S) NEW MAILING ADDRESS:
ER(Sj PHONE NUMBERS: (H) (VV)
R
~eetlions aro obsdsls
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
E-
• ~-
File Number.10.37
form HUD-1 (3/88) rat Handbook 4305.2
PAGE 2
inted 06!11!2010 at 11:32 SDC
PAID FROM PAID FROM
BORROWER'S SELLER'S .
FUNDS AT FUNDS AT
SETTLEMENT SETTLEMENT
~...........^. ^ ....^ I
. t t rrnv rw ~ wo~~ ua vv^~nrv ^ ^v^. ^^ ^ ^ ....
. Loan Ori ination Fee %
--
~. Loan Discount
°k
.. A sisal Fee to Adams Cou National Bank .O.C. 375.00 B sr
. Credit Re rt
-- -
,. Tax service
to Adams Cou
National Bank P.O.C. 1050. B er
~. Flood certification to Adams Cou National Bank 350
.Origination Fee to Adams Cou National Bank P.O.C. 250.00 B er
~. Ovemi ht Fee
to Adams Cou
National Bank 14.7
---- -
)
PAID IN
WRH
mo.
D.
w - rev.
DO -17
of A. H.
of A. H.
to
H.
Coilsdor
~~ HUD CERTIFICATION OF BUYER AND SELLER
Ve cerelylly rovisvred the HUD-1 6sttlemerri Statement and to tha best of my knowledge end bNbt, k b • true and accurob etetement of all rocelpta and diaburoemsnU made on ~y account
•y me(p~~da tnnaadion. (-further certify (hat I haw rowived a copy or the HUD-1 Settlement 3tWamsnt
,~ rr'~to~rrr _ .
~/
` ~~~///r
eje su.aenara F. czamean
.RNING: rc IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 SeWem~
(TED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION Venuctlon. I have
N INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18:
=. CODE SECTION 1001 AND SECTION 1010.
SETTLEMENT AGE
amsnt.
~/ ~~ld