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HomeMy WebLinkAbout11-05-10~,505607Z2~, Y ~ ~ ~ Q ~ EX (oC-05) 0t= FICIAL USE ONLY PA Department of Revenue aureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Dumber Po Box 28oso1 2 1 0 9 1, 0 7 ], Harrisburg, PA 17128-0601 RE_SIDEN_ T_ DECED_ ENT ENTER DECEDENT INFORMATION BELOW ~ ~~~ ... -~ ~ Social Security Number Date of Dea#h Date of t3ir#h 2 0 6 3 2 1 3 8 6 1 0 2 2 2 0 0 9 0 2 0 1 9 1 4 Decedent's Last Name Suffix Decedent's First Name MI A S H M O R E M A R Y ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M) Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ^ 1. Original Return l^.f ^ 4. Limited Estate ^ ^ fi. Decedent Died Testate ^ (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ THIS RETURN MUST BE F1LED IN DUPLICATE WITH THE aEO~sT~R of w~~.~.s 2. Supplemental Retum ^ 4a. Future Interest Compromise (date of ^ death after 12-12-$2) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 1 Q. Spousal Poverty Credit (da#e at death ^ between 12-31-91 and 1-1-95} 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate 'Tax Return Required t3. Total Number of Safe Deposit eaxes 11. Election to tax under Sec. 9i 13(A) (Attach Sch. O) ~ ~ - _ _. City or Post C+ffice State ZIP Code '_. ______ bAtLED --- ~ ~ _~ C A M P ~i T L L P A 1 7 0 ~, 1 -,--. -_~ _~ 1- Correspondent's a-mail address' SCONFAIRaEREAGERADLERPC • COI~i Under ties of penury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is W rrect a fete. i7eclarafian of preparer other than the personal representatrue rs based on all information of which preparer has any knowledge, SI URA ~ PER ON R ~ L~~O FI~RETURN /1SST, VIC: s~'; , :.:..'d~,°; DP~E _ . / CORRESPONDENT -THIS SECTION MUST BE COAAPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO; Name Daytime Telephone Number S U S A N H C O N F A T R ? 1 7 7 6 3 1 3 8 3 Firm Name (tf Applicable) ...._.._._...__.._....~........_._..___~._._. REGISTER OF W1LLS USE Y R E A G E R & A D ~. E R P C C~ `~ -~~ I f ' Firs# Line of address ~-~ -~~• ~~ , f~ ~~~ 2 3 3 1 M A R K E T S T R E E T ~ ~w1~ r~ ~~ •, ~~ I ,~ ~, Second line of address - F i =~ CJ"I 213-f~ARKET STREET ` HARRISBURG PA 17101 SIGNATURE OF REPARER OTHER THAN REPRESENTATIVE DAT~E~~ O ADDRESS / `~`~-- 2~31 f~ARKET STREET CAMP HILL PA ;7011 PLEASE USE ORIGINAL FORM ONLY Side '! ],505607221 15D56D7121 J ~~~ J 1,SQ56~7221, REV-1500 EX f7ecedent's Social Security Number Decedent's Name: MARY J• A S H x"10 R E 2 0 6 3 2 ], 3 8 6 RECAPITULATION 1. Real estate (Schedule A) ........................................ 1. 2. Stocks and Bonds (Schedule 8) .................................. ~• ' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C} ..... 3. • 4. Mortgages & Notes Receivable (Schedule b) ........................ 4. • 5. Cash, Bank Deposits & Miscellaneous Persona( Property (Schedule F} ....... 5, 6. Jointly Owned Property (Schedule F} Q Separate Billing Requested ....... 6• 7. inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} ~ Separate Billing Requested ....... 7. • 8. Iota! Gross Assets (total lines 1-7} ........................... 6. • 9. Funeral Expenses & Administrative Costs (Schedule F-I) ................ 9. • 14. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule 1} ............ 10. 1 2 2 9 7 , 5 3 11, Total Deductions {Iota! Lines 9 &~ t0) . .......................... 11. ~- 2 2 9 7. 5 3 '{ 2. Net Value of Estate {Line 8 minus Line 11) .......... ...... _ .. 12• 1 2 2 9 7 , 5 3 13. Charitable and Governmen#al BequestsJSec 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) ................ . . i4. - ~ ~ 2 9 ? . S ~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPL{CABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sea 911E (a)(1.2) X .0 15. 16. Amount of Line 14 taxable at finea! rate X .0 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 ~ 8• 19. Tax Due ........................................... .....19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 y5~56Q722~ 15t~5607221 J RE's/-7590 EX Page 3 File Number Decedent's Compi®t® Address: ~~ D~ ~°71 DECEDENT'S NAME STREET AD17#tESS 3D11 YALE AVENUE CITY STATE - ~ ~.~__ ~ ZIP CA~tp HILL ~ PA 17D7~3, Tax Payments and Credits: ~• Tax Due (Page 2 Line 19) {1) 2. CreditslPayments A. Spousal Poverty Credit 8. Prior Payments C. Discount Total Credits (A + #3 + C) (2) 3, lnteres#/Pena(ty if applicable D. Interest E. Penalty Total Interest/Penalty { D + E) {3) 4, if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. IFiil in oval on Page 2, Line 20 to request a refund. (4) 5. tf 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) t3. Enter the total of Line 5 +SA. This is the BALANCE UUE. (5B) Make check Payable ~o: REGISTER OF WILLS, AGENT PLEASE ANSWER THE F4LLOWlNG QUESTIONS BY PLACING AN "X" MN THE APPROPRl.ATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : .... . ............... . ................................................ . ^ ^ b. retain the right to designate who shall use the properly transferred or its income; ..... . . . ...................... . ^ ^ ^ ^ c. retain a reversionary interest; or ............................................................................................... . ^ ^ d. receive the promise for life of either payments, benefits or care? ....... . .............................. ................ . 2. if death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................... " " . ^ ^ ^ ^ or payable upon death bank account ar security at his or her death? ........ in frost for 3. Did decedent awn an . A. Did decedent own an Individual Retirement Account, annuity, ar other non-probate property which contains a benefciary designation? ...............................,....................,............,..........................,,... . ^ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS !S YES, YOU MUST COMPLETE SCHEQULE G AND FfLE !T AS PART OF THE RETURN, ,- . ~~...,,; :;~~..~. For dates of death an 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 far dise{osure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2004: The tax rate imposed an 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 adaptive 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 benefiaaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) (72 P.S. §9116(a}(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12} percent (72 P.S. §9i 1fi(a)(1.3)}. A sibling is defined, under Section 9102, as an individu~ who has at least one parent in common witf- the decedent, whether by bland or adoption. REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA 'i INHERITANCE TAX RETURN ~ RESIDENT DECEDENT ' SCHEDULE t DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE Of FILE NtlMBER MARY ~l • ASHMORE 21 il9 3~D71 Report debts incurred by the decedent prior to death which remained unpaid as o! the date of death, including unreimbarsed medical expenses. REV-1513 EX + t9-00) SCHEDULE J CaMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT ©ECEDENT ESTATE OF FILE iVlIMBER MARY J. ASHMORE 21 09 1D 71 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Uo Iva# list Trustee~s~ OF ESTATE ~ TAXABLE DISTRIBUTIONS jficlude outright spousat distributions, and transfers under Sec. 9116 ~a) (1.2)] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN A80VE ON LINES 15 THROUGH 1$, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. HOSPICE 01" CENTRAL PENNSYLVANIA 132[3 LINGLESTOWN RAO3) HARRISBURG, PA I,711U 2• AMERICAN CANCER SOCIETY $4Q~ SILVER CROSSiPIG OKLAHOMA CITY, OK 73132 3• AMERICAN HEART ASSOCIATION PO HOX 22249 ST• PETERSBURG, FL 33742 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) C©ntinuation of REV-'1544 Inheritance Tax Return Resident Decedent MARY J. ASHMORE 2 ~ 09 '~ 07 ~ Decedent's Name Page 1 Fife Number Schedule J -Beneficiaries - 28 NOTICE OF INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT DF TAX PO BOX 280601 HARRISBURG PA 17126-0601 SUSAN H CONFAIR REAGER K ADLER PC 2331 MARKET ST CAMP HILL PA 17011 C1) 170,000.00 C2) 661 , 717 .23 C3) .00 c4) .00 C5) 118 , 720 .46 c6) .00 C7) .00 CUT ALONG THIS LINE -~ RETAIN LOWER PORTION FOR YOUR RECORDS f-~ ------------------------------------------------------------------------------------------- REV-1547 EX AFP C12-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT DF TAX ESTATE DF: ASHMORE MARY JFILE N0.:21 09-1071 ACN: 101 DATE: 09-27-2010 7AX RETURN WAS: C ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held StocklPartnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) b. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) pennsylvan~a ~`~~~ DEPARTMENT OF REVENUE REW-1547 EX AFP C12-09) NOTE: To ensure proper credit to your account, .submit the upper portion of this form with your 'tax payment. C8) _ 950,437.69 c9) 50 , 557.29 clo) 33, 102.87 11. Total Deductions C11) _ 83,660.16 12. Net Value of Tax Return C12) _ 866,777.53 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) ,~ $ b 4,7 7 7.5 3 14 Net Value of Estate Subject to Tax C14) 2,000.00 . _ NOTE: If an assessment was issued previously, lines 14, 15 and/ar 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to d ate. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .0 0 X 0 0 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) .0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate C17) .0 n X 12 _ .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate C18) 2, 000.00 X 15 = 300.00 19. Principal Tax Due C14)° 300.00 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID 01-20-2010 CD012259 15.00 285.00 TOTAL TAX PAYMENT 300.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CC:R), YOU MAY BE DI,IE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FDR INSTRUCTIONS. DATE 09-27-2010 ESTATE OF ASHMORE MARY J DATE OF DEATH 10-22-2009 FILE NUMBER 21 09-1071 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 11-26-2010 ( See reverse side under Objections ) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SWUARE CARLISLE PA 17013 REV-1470 EX (pt-1R) / ~nnS~/wanla INHERITANCE TAX P DEPARTMENT OF REVENUE EXPLANATION BUREAU OF INDIVIDUAL TAXES OF CHANGES PO Box 280601 H B R A 17 8-0601 DECEDENTS NAME FILE NUMBER Mary J. Ashmore 2109-1071 REVIEWED BY ACN Sheifa Megonnell 101 ITEM SCHEDULE NO, EXPLANATION OF CHANGES I 7 & 18 Repairs to real estate cannot be used as deductions against the decedent's estate unless the real estate has been sold. .,.,,r°~ -- OMB Approval No. 2502-0265 (7~~x~~~~~~~x~ A. Settlement Statement (HUD-1) ~~, . ~11~~f~~ :~ .- • ~. ^ RHS 3. ^Conv. Unins. X^ FHA 2 1 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: . . 10-412 0096203604 446-0339366-703 4. ^ VA 5. ^Conv. Ins. C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower: E. Name & Address of Seller: F. Name ~ Address of Lender: ANTHONY P{STILLI, KAREN PISTILLI THE ESTATE OF MARY JANE ASHMORE SOVEREIGN BANK 2012 Logan St., Camp Hill, PA 17011 ISAOA, ATIP~IA, 1130 BERKSHIRE BLVD., WYOMISSI~JG, PA 19610 G. Property Location: H. Settlement Agent: I. Settlement Date: 08/19/2010 3011 YALE AVENUE, BOROUGH OF CAMP HILL Homesale Settlement Services Disbursement Date: 08/19/2010 CAMP HILL, PA 17011 Camp Hill Borough Place of Settlement: TitleExpre:;s 4309 Linglestown Road, 717-671-9876 Fax 717-671-9676, Printed 08/19/2010 at 9:08 am Harrisbur , PA 17112 by KR J. Summary of Borrower's Transaction 100. Gross Amount Due from Borrower 101. Contract sales price 179,000.00 102, Personal ro ert 103. Settlement charges to borrower (line 1400) 8,990.20 104. 105. Ad'ustments for items aid b seller in advance 106. Cityltown taxes to 107. County taxes 08/19/2010 to 12/31/2010 349.56 108. Assessments 08(19/2010 to 06/30/2011 1,958.16 109. Sewer Bill Proration 08/19/2010 to 09/30/2010 33.89 110. 111. 112. 120. Gross Amount Due from Borrower 190,331.81 200. Amounts Paid b or in Behalf of Borrower ........... . 201, Deposit or earnest money 1,000.00 202. Principal amount of new loan(s) 176,621,00 203. Existin {oa s taken sub~ect to 204. Application Fee Credit 399.00 205. Lock Fee Refund 500.00 206. Seller Assist 6,000.00 207. 208. 209. Ad'ustments for items un aid b seller 210. City/town taxes to 211, County taxes to 212. Assessments to 213. 214. 215. 216, 217. 218. 219. 220• Total Paid b Ifor Borrower 184,520.00 '300. Cash'. at Settlement fromlto Borrower 301. Gross amount due from borrower (line 120) 190,331.81 302. Less amounts paid by/for borrower (line 220) 184,520.00 303. Cash ^X From ^ To Borrower 5,811.81 400. Gross Amount Due to Seller 401. Contract sales price 179,000.00 402. Personal ro ert 403. 404. 405. Ad'ustments for items aid b seller in advance 406. City/town taxes to 407. County taxes 08/19/2010 to 12/31/2010 349.56 408. Assessments 08/1912010 to 06/30/2011 1,958.16 409. Sewer Bi11 Proration 08/19/2010 to 09/30/2010 33.89 410. 411. 412. 420• Gross Amount Due to Seller 181,341.61 5.0.0. Reductions In Amount Due to Sellet 501. Excess deposit (see instructions) 502. Settlement charges to seller (line 1400) 13,930.00 503. Existin loans taken sub'ect to 504. Payoff of first mortgage loan 505. Payoff of second mortgage loan 506. Seller Assist 6,000.00 507. 508. 509. Ad'ustments for items un aid b seller 510. City/town taxes to 511. County taxes to 512. Assessments to 513. 514. 515. 516. 517. 518. 519. 520. Total Reduction Amount Due Seller 19,930.00 600. Cash at Settlement to/from Seller _ __ 601. Gross amount due to seller (line 420) 181,341.61 602. Less reductions in amount due seller (line 520) 19,930.00 603. Cash ^X To ^ From Seller re o mg e a a is agency may no co ec is m orma ion an you are no require o como e e 161,411.61 Ina t'Ub11C KepOning tlufOen Tor Ines couecUUn o~ n~~ui~~iuiiu~~ ~a cai~i~iaicu ni ~~ ~i ~~.~uwa ,.c~ .oal+.n.~c .~. w.ro~..~.y, ~~.......~~y, ..~~ p this form, unless it displays a currently valid OMB control number. No confidentiality is assured; this disclosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. Previous editions are obsolete Page 1 of 4 HUD-J 700: Total Real Estate Broker Fees $ 10,935.00 P~~id From Paid From Division of commission Line 700 as follows: Bc-rrovver's- Sel{er's 701. $5,565.00 to Prudential Homesale Services Group Funds at Funds at 702. $5,370.OU to Remax Cornerstone Settlement Settlement '- 703. Commission paid at settlement 10,935.00 704. to ,.809. Items Pa able in Connection vrith Loan 801. Our origination charge (includes Origination Point % or $0,00) $749.00 (from GFE #1) 802. Your credit or charge (points} for the specific interest rate chosen $-883.11 (from GFE #2) 803. Your adjusted origination charges (from GFE A) -134.11 804. Appraisal fee to Steven W. Barrett Real Estate & A raisal (from GFE #3) 392.00 805. Credit report to CBC Innovis (from GFE #3} 18.33 806. Tax service to from GFE #3 807. Flood certification to LPS National Fiood (from GFE #3) 7.50 808. to '900, items Re sired b >Lenderto be Paid in'Advance 901. Daily interest charges from from 08/19/2010 to 09/01/2010 @ $23.3042/day (from GFE #10) 302.95 902. Mortgage Ins. Premium for months to De t of HUD (from GFE #3) 3,886.54 - 903. Homeowner's insurance for 12 months to Nationwide Insurance $680.00 P.O.C. B* (from GFE #11} 904. months to from GFE #11 1000. 'Reserves De osited with Lender 1001. Initial deposit for your escrow account (from GFE #9) 983.24 1002. Homeowner's insurance 3 months $ 56.67/month $170.01 1003. Mortgage Insurance months $ 78.62/month $0.00 1004. City Property Taxes months $ 0.00lmonth $0.00 1005. County Property Taxes 7 months $ 78.76/month $551.32 1006. Assessments 3 months $ 192.33/month $576.99 1007, Aggregate Adjustment $-315.08 1100. Title Char es 1101. Title services and lender's title insurance (from GFE #4) 1,586.75 1102. Settlement or closing fee to $ 1103, Owner's title insurance (from GFE #5) 1104. Lender's title insurance $1,243.75 1105, Lender's title policy limit $176,621.00 Lender's Policy 1106. Owner's title policy limit $179,000.00 Owner's Policy 1107. Agent's portion of the total title insurance premium $1,106.94 1108. Underwriter's portion of the total title insurance premium $136.81 1109. 1200. Government Recordin and Transfer Char es ___ 1201, Government recording charges (from GFE #7) 157.00 1202. Deed $64.00 Mort a e $93.00 Release $0.00 1203. Transfer taxes (from GFE #8) 1,790.00 1204. City/County tax/stamps Deed $1,790.00 Mort a e $0.00 1205. State Tax/stamps Deed $1,790.00 Mort a e $0.00 1,790,00 1206. Deed $0.00 Mort a e $0.00 1207. 1300. Additional Settlement Char es 1301. Required services that you can shop for (from GFE #6) 1302. Survey to $ 1303. to 1304. Notary Fee to Nota Public 20.00 1305. Home Warranty #97456762 to American Home Shield 435.00 1306. Radon Mitigation to H.E. Beers Co. 750.00 1307. to $ ~ E . • E ~ 8,990.20 13,930.00 *Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er. Previous editions are obsolete Page 2 of 4 HUD-] Char es That in Total. Cannot Increase Wore Than 10°Ifl Governmenf recording charges Appraisal fee # 1201, Credit report # 804 Flood cettification ` # 805 , Mortgage lns• Pr-emium ' # 807 # 902 # X304 # 1305 # 1306 '' ... ~ 1307 Char es That Can Chan e Initial deposit for your escrow account ' Daily interest charges from #t 1001 Homeowner's insurance # 901, ' $233042/da Title services and lender's title insurance # 903 Owner's title insurance # 1101! # ,1103 Loan Terms ~. / JVU /0 v~vv..~v ii it,iUVCJ X^ Principal ^X Interest ^X Mortgage Insurance . -- u ~ ~~• ~..~ r es, i[ can nse to a maximum of %. The first change will be on / / and can change again every years after / / date, your interest rate can increase or decrease by %. Over the life of the loanng our interest rate is guaranteed to never be lower than % or higher than /0• ° ~~~• u ~ G~, ~~ pan nse to a maximum of $ X No• ^ ^ Yes, the first increase can be on / / and the monthly amount owed can rise to $ • The maximum it can ever rise to is $ • ^X No. ^ Yes, your maximum prepayment penalty is $ • ^X No. ^ Yes, you have a balloon payment of $ due in years on / / • - u ~ ~u u~ ~~~~ have a montrny escrow payment for items, such as property taxes and homeowner's insurance. You must pay these items directly yourself. ^X You have an additional monthly escrow payment of $327,77 that results in a total initial monthly amount owed of $1,327.72. This ~~ncludes principal, interest, ar mortgage insurance and any items checked below: 0 Property taxes 0 Homeowner's insurance ^ Flood insurance ~ School Tax ^ ^ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this for m, please contact your lender. 'revious editions are obsolete Page 3 of 4 HUD-l HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement. /' i HONY PI TILL REN PISTILLI THEE TATE OF MARY JANE ASHM R N-~~ ~~ The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. ..:~ _, ~,, x~,.: A j~. SETTLEMENT AGENT /Xj / ~ ~/L~ V DATE NARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON TH1S OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010. revious editions are obsolete Page 4 of 4 HUD-]