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Home My WebLink About02-14-111505610140 1500 EX ~°'-'°' REV - OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 `~ ~ ~` L' ~ ~, c ~" Harrisburg, PA 17128-0601 RESIDENT DECEDENT -- _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 2 5 4 9 6 2 4 3 4 0 3 1 6 2 0 1 0 0 6 2 9 1 9 5 6 Decedent's Last Name Suffix Decedent's Fi rst Name MI N O B L E M I C H A E L D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OPALS BELOW 0 1. Original Return 4. Limited Estate fi. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) MI 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SrlouLU ~t ulrctc i to i u: Name Daytime Telephone Number KARL E ROM { N G E R 7 1 7 2 4 1 6 0 7 0 First line of address 155 SOUTH Second line of address City or Post Office CARL I S L E H A N O V E R S T R E E T State P A ZIP Code ~ 1 7 0 1 3 REGISTER OFx111LLS USE OI~C'1t' ~f^ll ~ L _~ C - ~. ~ ,. t:_+-- ~_..~ ~T r-~ ---- .~r1^ ~.... Yw. . T , :~ ^~ ,u.. _.~ J T t. _ _ J -6'll . '- ~ r-... DA~jFtL~D ~°. ~::.:, '~3 + `'-~ r~ C":7 ':~ ~ '-~ i"~~ ~Yl ,..~ t._.^~,^.~~ A~ .... ~ f - '(~1 ~n' ~:.•'7 C~ --c~ Correspondent's a-mail address: Under penalties of peryury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct an complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNf1TlJ~~OF E~ R ONSIBLE FOR FILING RETURN 2 ~~ T~+I ff ~~ yy~~ 2145 ~ain Road Wesson MS 39191 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610140 Side 1 1505610140 .~~~ 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: MICHAEL D. NOBLE 2 5 4 9 6 2 4 3 4 RECAPITULATION - 3 6 0 3 5 8 1. Real Estate (Schedule A) ......................................... .. 1. . 2. Stocks and Bonds (Schedule B) .................................... .. 2. 1 0 0.0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. • 4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4. 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 6 2 2 4 6 • 8 1 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. • 7. Inter-Vivos Transfers 8~ Miscellaneous N -Probate Property ~ (Schedule G) Separate Billing Requested ..... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 5 8 7 4 3. 2 3 9. Funeral Expenses and Administrative Costs (Schedule H) .... ....... ..... .. 9. 1 1 9 9 7. 9 5 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ...... ..... .. 10. 1 6 2 5 5. 4 2 11. Total Deductions (total Lines 9 and 10) ................. ....... ..... .. 11. 2 8 2 5 3 • 3 7 12. Net Value of Estate (Line 8 minus Line 11) .............. ....... ..... .. 12. 3 0 4 8 9 . 8 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for whi ch an election to tax has not been made (Schedule J) ........ ....... ..... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........ ....... ..... .. 14. 3 0 4 8 9 . 8 6 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a>(1.2) x .0 0 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 3 0 4 8 9. 8 6 16. 1 3 7 2. 0 4 17. Amount of Line 14 taxable at sibling rate x .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at ll l t X 15 t 0 0 0 0 0 0 era ra co a . e 1 g. . 19. TAX DUE ......................................... ...... ..... ..19. 1 3 % 2. 0 4 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 00 DECEbENT'S NAME MICHAEL D. NOBLE STREET ADDRESS 831 West Louther Street __ CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. Total Credits (A + B) (2) (4) (1) 1, 372.04 (3) 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1, 372.04 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ................................................................ ...... ^ Q b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ Q c. retain a reversionary interest; or .......................................................................................... ...... ^ X^ 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? ................................................................................. ...... ^ Q 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ... ...... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................ ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of 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 surviving spouse is 0 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 disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 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)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (01-10) - ~ . ~ pen~nsylvania SCHEDULE A ' DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MICHAEL D. NOBLE 0 0 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 831 West Louther Street, Carlisle, PA-Purchase Price ~ 130,000.00 Settlement Charges ~ -12,756.50 Pay off 1st Mortgage, PNC Bank #9585942 ~ -94,366.31 Pay off 2nd Mortgage, Fifth Third Bank #0086147121 ~ -20,644.47 County Taxes ~ -26.39 Seller Assist ~ -6,400.00 ents ~ 590.09 TOTAL (Also enter on Line 1, Recapitulation.) I $ -3,603.58 If more space is needed, use additional sheets of paper of the same size. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Savings Bond-0250762875 EE 100.00 TOTAL (Also enter on line 2, Recapitulation) I $ 100.00 (If more space is needed, insert additional sheets of the same size) REV-1504 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ___ -- FILE NUMBER MICHAEL D. NOBLE 0 0 Schedule C-1 or C-2 (including all supporting information) must be attached for each closelyfield corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 3, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1505 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Product/Service Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Votin Non-Votin SHARES OUTSTANDING pAR VALUE OWNED BY THE DECEDENT DECEDENTS STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ....................................... ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ............ ^ Yes ^ No If yes, provide a copy of the agreement, 10. Was the decedent's stock sold? ................................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ....................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ...................... ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. State of Incorporation Date of Incorporation State Zip Code Total Number of Shareholders (If more space is needed, insert additional sheets of the same size) REV-1506 EX + (9-00) • , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 1. Name of Partnership Address Date Business Commenced Business Reporting Year City State Zip Code 2. 3. 4. 5. Federal Employer I.D. Number Type of Business Product/Service Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPRAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7 8. 9 Was the Partnership indebted to the decedent? ................................ ^ Yes ^ No If yes, provide amount of indebtedness $ Was there life insurance payable to the partnership upon the death of the decedent? ........ ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the oolicv Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death?........ ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................. ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. Date 13. Was the decedent related to any of the partners? ................................ ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? ................. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX + {6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER MICHAEL D. NOBLE ___ _ 0 0 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 4, Recapitulation) ~ $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. USAA Member Account #014221191 1,248.99 Honda Accord 3,585.00 Members First Savings Account 15,611.59 Members First Checking Account 7,732.06 Metro Bank Checking Account 8,366.43 Members First Money Management Account 1,078.85 Household items and collectibles sold at auction 7,252.71 United Services Auto Association 5,968.21 Andrew Federal Credit Union 11,261.73 USAA Homeowners Insurance Refund Check 141.24 TOTAL (Also enter on line 5, Recapitulation) ~ $ 62,246.81 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) . .~ pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MICHAEL D. NOBLE 0 0 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) A. B. JOINTLY-OWNED PROPERTY: RELATIONSHIP TO DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOfNTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTERESI 1. A. TOTAL (Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE INTER-VIVOS TRANSFERS AND DISC. NON-PROBATE PROPERTY ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. TOTAL (Also enter on Line 7, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) . ~ ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Ewing Brothers Funeral Home 1,780.06 Cumberland Law Journal-Advertising 75.00 The Sentinel-Advertising 225.05 Vital Statistics-Birth Certificate 20.00 Certificate of Title 22.50 B 2. 3. 4. City State ZIP ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: Attorney Fees: Karl E. Rominger, Esquire Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address Relationship of Claimant to Decedent Probate Fees: Cumberland County Register of Wills 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 9,617.34 258.00 11.997.95 REV-1512 EX+,(12-08) . .~ .~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF MICHAEL D. NOBLE FILE NUMBER 0 0 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. AAFES/Military Credit Program 3,876.49 Cumberland Goodwill EMS 1,335.00 Chase Credit Card 150.42 Chase Credit Card 2,182.26 AT&T 67.26 Century Link 111.28 Comcast 641.34 State Farm Insurance 160.00 PP & L -Electric Bill 490.57 Stor-Mor Storage 118.10 R.T. Carey Trucking (dumpster) 635.84 Let's Move It 962.50 Toll Violation 40.15 North Middletown Water Bill 384.75 Fluss Flooring-(Repair Floor) 1,000.00 TOTAL (Also enter on Line 10, Recapitulation) I $ 16,255 42 If more space is needed, insert additional sheets of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent MICHAEL D. NOBLE Decedent's Name Page 1 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, ~ Liens ITEM NUMBER DESCRIPTION AMOUNT Gilbert's Pest Control 1,163.88 Suburban Oil 691.75 Dean Hankinson-House Clean up for sale of property 2,243.83 SUBTOTAL SCHEDULE I 4,099.46 GRAND TOTAL SCHEDULE I $ 16,255.42 REV-1513 EX+ (01-10) Pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MICHAEL D. NOBLE 0 0 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 (Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Susan Noble Lineal 100.00 340 Arbor Drive Ridgeland, MS ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. REV-1514 EX+ (4-09) Pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box 280601 Harrisburg PA 17128-0601 SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CHECK BOX 4 ON REV-1500 COVER SHEET) ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 This schedule should be used for all single-life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME OF LIFE TENANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ...................................... $ 2. Actuarial factor per appropriate table ...................................... Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate(Line1multipliedbyLine2) ................................. $ • NAME OF LIFE ANNUITANT - DATE OF BIRTH ~ NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ... . . . . . .. . . . ... . . .......... . ..... $ 2. Check appropriate block below and enter corresponding number . . . . . . .. . .... . ........ . . . . . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per Period ......................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 . . . . . . .. . .................. . . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructions) 7. Value of annuity - If using 3.5%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ...........................$ If using variable rate and period payout is at beginning of period, calculation is (Line4xLine5xLine6)+Line3 .................................................$ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. REV-1644 EX+ (01-10) . pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT I. ESTATE OF NOBLE. MICHAEL D. I I. III. 0 0 This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on __ (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of Years Income or Annuitant(s) of Election or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ......................... $ 3. Closely Held Stock/Partnership ............... $ 4. Mortgages and Notes ....................... $ 5. Cash/Misc. Personal Property ................ $ 6. Total from Schedule L-1 .................................................... $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities .......................... $ 2. Unpaid Bequests .......................... $ 3. Value of Non Includable Assets ............... $ 4. Total from Schedule L-2 .................................................... $ E. Total Value of Trust Assets (Line C-6 minus Line D-4) ............................... $ F. Remainder Factor ........................................................... G. Taxable Remainder Value (Multiply Line E by Line F) .............................. $ (Also enter on Line 7, Recapitulation) INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed ...........................................................$ D. Remainder Factor ........................................................... E~ Taxable Value of Corpus Consumed (Multiply Line C by Line D) ........................ $ (Also enter on Line 7, Recapitulation) INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST CORPUS FILE NUMBER REV-1645 EX+ (11-091 . : pennsylvania INHERITANCE TAX . SCHEDULE L-1 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -ASSETS- I. ESTATE OF FILE NUMBER NOBLE, MICHAEL D. p p II. ITEM NO. DESCRIPTION VALUE A. Real Estate (Please describe.) Total Value of Real Estate $ (Include on Section II, Line C-1 on Schedule L.) B. Stocks and Bonds (Please list.) Total Value of Stocks and Bonds $ (Include on Section II, Line C-2 on Schedule L.) C. Closely Held Stock/Partnership -Please list. (Attach Schedule C-1 and/or C-2.) Total Value of Closely Held/Partnership $ (Include on Section II, Line C-3 on Schedule L.) D. Mortgages and Notes (Please list.) Total Value of Mortgages and Notes $ (Include on Section II, Line C-4 on Schedule L.) E. Cash and Miscellaneous Personal Property (Please list.) Total Value of Cash/Miscellaneous Personal Property $ Include on Section II Line C-5 on Schedule L. III. TOTAL (Also enter on Section II, Line C-6 on Schedule L.) $ If more space is needed, attach additional sheets of paper of the same size. REV-1646 EX+ (11-09) pennsylvania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L-2 INHERITANCE TAX RETURN RESIDENT DECEDENT REMAINDER PREPAYMENT ELECTION -CREDITS- I. ESTATE OF FILE NUMBER NOBLE, MICHAEL D. 0 0 II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Assets Reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV-1647 EX+ (02-10) - pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on REV-1500) ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. I Beneficiaries III. NAME OF BENEFICIARY I RELATIONSHIP I DATE OF BIRTH I NEAR ST BIRTHDAY ~. 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest .................................................. $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) ...... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ^ 6%, ^ 3%, ^ 0% ................ $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ^ 6%, ^ 4.5% ...................... $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) ...... $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) ...... $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ..................... $ If more space is needed, use additional sheets of paper of the same size. REV-1648 EX (02-09) SCHEDULE N Pennsylvania DEPARTMENT OF REVENUE SPOUSAL POVERTY CREDIT • Bureau of Individual Taxes PO Box 280601 FOR DATES OF DEATH 01/01/92 TO 12/31/94 7 ESTATE OF FILE NUMBER MICHAEL D. NOBLE 0 0 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1. Taxable assets total from Line 8 (cover sheet) 1 • ...................................................................................... 2. Insurance proceeds on life of decedent ................................................................................................ 2. 3. Retirement benefits ............................................................................................................................... 3. 4. Joint assets with spouse ...................................................................................................................... 4. 5. PA Lottery winnings .............................................................................................................................. 5. 6a. Other nontaxable assets: List and attach schedule if necessary .. 6 a. 6 b. 6 c. 6 d. 6. SUBTOTAL (Lines 6a, b, c, d) ......................................................................................................... 7. Total gross assets (Add Lines 1 thru 6) ........................................................................................... 8. Total actual liabilities ....................................................................................................................... 9. Net value of estate (Subtract Line 8 from Line 7) ............................................................................. If Line 9 is greater than $200, 000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part 11. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 a. Spouse ............................. 1 a. 2a. b. Decedent ......................... 1 b. 2b. c. Joint ................................. 1 c. 2c. d. Tax-exempt Income ......... 1 d. 2d. e. Other income not listed above ..................... 1 e. 2e. I~ f. Total ................................. 1 f. 2f. 4. Average joint exemption income calculation 4a. Add joint exemption income from above: (1fl + (2~ + (3fl 4b. Average joint exemption income ....................................................................................................... If line 4(b) is greater then $40, 000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ............................... 2. Multiply by credit percentage (see instructions) ............................................................................ 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet ..................................................... 4. For nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................................................................... 5. Multiply Line 3 by Line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet 743.23 6. 3. TAX YEAR: 19 ~. 58 743.23 8. s. 58, 743.23 3b 3f. (=3) 3. 4. REV-1649 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT. SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER MICHAEL D. NOBLE _ 0 0 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance ~ Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit. etc.l. If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's (If more space is needed, insert additional sheets of the same size) REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: Discount: 0.00 Interest Table Days Delinquent Year !, this time period Balance Due ~~~ Interest this year % this period Before 1981 1982 _ - 1983; 1984 ~ -___ -1 - ---~ 1985 1986 ____ -- - 1987 1988 throw h 1991 - 1992 _ __-_ 1993 throw h 1994 1995 throw h 1998 _ __ 1999 ~ -- 2000 - -- -- 2001 2002 ~ _ ---- 2003 -- 2004 ~, _ -- -- 2005 '~ 2006 2007 - ~ - 2008 __ ~- --~ 2009 2010 -- I- ~ - i TOTALS ~__ Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: `~`'`~' ~\\ A. Settlement Statement HUD 1 OMB Approval No 2502-0265 I!~il~ll %~ .- a .. 1. ~ FHA 2. ~ RHS 3. Q Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 10-602 6800391893 10-10-60617378 4. QX 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: NELSON J. RODRIGUEZ, KRISTA A. RODRIGUEZ THE ESTATE OF MICHAEL D. NOBLE MEMBERS 1ST FEDERAL CREDIT UNION 121 Walnut St., Carlisle, PA 17013 P.O. Box 40, 5000 Louise Drive, Mechanicsburg, PA 17055 G. Property Location: H. Settlement Agent: I. Settlement Date: OV28/2011 831 WEST LOUTHER STREET, NORTH Homesale Settlement Services Disbursement Date: OV28/2011 MIDDLETON TOWNSHIP 4309 Linglestown Road, 717-671-9876 Fax 717-671-9676, CARLISLE, PA 17013 Harrisburg, PA 17112 North Middleton Township Place of Settlement: TitleExpress 4309 Linglestown Road, 717-671-9876 Fax 717-671-9676, Printed OV28/2011 at 2:02 pm Harrisbur , PA 17112 by KR :. e 100. Gross Amount Due fcom~Borrawei 101. Contract sales price 130,000.00 102. Personal ro ert 103. Settlement charges to borrower (line 1400) 8,683.45 104. 105. Ad•ustments for items aid b seller in advance 106. City/town taxes to 107. County taxes to 108. Assessments 01/28/2011 to 06/30/2011 590.09 109. 110. 111. 112. 120• Gross Amount Due from Borrower 139,273.54 200. .Amounts Paid b or tr Behalf of Borrower - 201. Deposit or earnest money 500.00 202. Principal amount of new loan(s) 132,750.00 203. Existin loa s taken sub~ect to 204. Credit for Amount Paid 375.00 205. 206. 207. Seller Assist 6,400.00 i 208. 209. Ad'ustments for items un aid b seller 210. Cityltown taxes to 211. County taxes 01!01/2011 to 01/28/2011 26.39 212. Assessments to 213. 214. 215. 216. 217. 218. 219. 220• Total Paid b Ifor Borrower 140,051.39 300. ` Cash at'Settlenient fromlfo Borrotin-er 301. Gross amount due from borrower (line 120) 139,273.54 302. Less amounts paid by/for borrower (line 220) 140,051.39 303. Cash ~ From ^X To Borrower 777.85 400. ".S~oss,i4ina~rif~Dtte~to Sel,{er 401. Contract sales price 130,000.00 402. Personal ro ert 403. 404. 405. Ad•ustments for items aid b seller in advance 406. City/town taxes to 407. County taxes to 408. Assessments 01128/2011 to 06/30/2011 590.09 409. 410. 411. 412. 420. Gross Amount Due to Seller 130,590.09 5Q0.. 'Re uckioris'tn Amount~Due-to'Set{er 501. Excess deposit (see instructions) 502. Settlement charges to seller (line 1400) 12,756.50 503. Existin loa s taken sub~ect to 504. Payoff of first mortgage loan #9585942 to PNC 94,366.31 505. Payoff of second mortgage loan to DCM Services 20,644.47 506. 507. Seller Assist 6,400.00 508. 509. Ad'ustments for items un aid b seller 510. Cityltown taxes to 511. County taxes 01101!2011 to 01/28/2011 26.39 512. Assessments to 513. 514. 515. 516. 517. 518. 519. 520. Total Reduction Amount Due Seller 134,193.67 60Q Ga~lratSett{e,[Rentto/frorn~Seller `` 601. Gross amount due to seller {line 420) 130,590.09 602. Less reductions in amount due seller (line 520) 134,193.67 603. repo mq Cash ~ To ^X From Seller e a a. ~5 agency may no co e rs m ortna sort an you are no requve 3,603.58 o cmm~ n,s form, unless it tliSpaYS a currently valitl OMB control number. No rgnfitlenbalily is assureo; Ihis OisUOwre is msntlalory. This is tlesignetl to provitle the parries to a RESPA coveretl tnnsacbon with ,nfonnabon tlunng the settlement Drocess. Previous editions are obsolete Page 1 of 4 HUD-] 700. Total ReaLEstate Broker Fees "$7;800:00 Pdid From Paid From Division of commission' line 70Q as follows: Borrower's Seller'S 701. $3,900.00 to Prudential Homesale Services Group Funds at Funds at 702. $3,900.00 to B-H Agnecy Real Estate Settlement . Settlement 703. Commission paid at settlement 7,800.00 800. Items Pa able in Connection withLoan 801, Our origination charge (Includes Origination Point % or $0.00) $305.00 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $331.88 (from GFE #2) 803. Your adjusted origination charges (from GFE A) 636.88 804. Appraisal fee to MEMBERS 1ST FEDERAL CREDIT UNION (from GFE #3) 375.00 805. Credit report to MEMBERS 1ST FEDERAL CREDIT UNION (from GFE #3) 20.00 806. Reinspection Fee to (from GFE #3) 807. Flood certification to MEMBERS 1ST FEDERAL CREDIT UNION (from GFE #3) 12.50 808. Va Funding Fee to MEMBERS 1ST FEDERAL CREDIT UNION (from GFE #3) 2,795.00 ., 900. Items. Re uired°b Lender to be:Aaid in Advance 901. Daily interest charges from from 01/28/2011 to 02/01/2011 @ $16.59391day (from GFE #10) 66.38 902. Mortgage insurance premium for months to (from GFE #3) 903. Homeowner's insurance for 1 ears to MEMBERS 1ST FEDERAL CREDIT UNION (from GFE #11) 343.00 904, months to from GFE #11 1000. Reserves De osited with Lender 1001. Initial deposit for your escrow account (from GFE #9) 1,074.94 1002. Homeowner's insurance 3 months $ 28.58/month $85.74 to MEMBERS 1ST FEDERAL CF 1003. Mortgage insurance months $ 0.00/month $ to MEMBERS 1ST FEDERAL CF 1004. Property taxes 13 months $ 29.74/month $386.62 to MEMBERS 1ST FEDERAL CF 1005. months $ 0.00/month $ to MEMBERS 1ST FEDERAL CF 1006. School Taxes 9 months $ 118.93/month $1,070.37 to MEMBERS 1ST FEDERAL CF 1007. Aggregate Adjustment $-467.79 to MEMBERS 1ST FEDERAL CF ._. 11:00. Title`Char es - 1101. Title services and lenders title insurance from GFE #4 1,293.75 1102. Settlement or closing fee to $ 1103. Owner's title insurance from GFE #5 1104. Lender's title insurance $1,023.75 1105. Lender's title policy limit $132,750.00 Lender's Policy 1106. Owner's title policy Limit $130,000.00 Owner's Policy 1107. Agent's portion of the total title insurance premium $911.14 1108. Underwritels portion of the total title insurance premium $112.61 1109. 1200. Government Recordin sand Tiansfer.-Char es ` 1201. Government recording charges $ (from GFE #7) 252.00 i 1202. Deed $65.00 Mort a e $125.00 Release $ to Recorder of Deeds 1203. Transfer taxes $ (from GFE #8) 1,300.00 1204. City/County tax/stamps Deed $1,300.00 Mort a e $ to Recorder of Deeds 1205. State Taxlstamps Deed $1,300.00 Mort a e $ to Recorder of Deeds 1,300.00 1206. Deed $ Mort a e $ to 1207. Record Assignment $62.00 to Recorder of Deeds 1300. Additional~SettlemenYChar es - --- ; 1301. Required services that you can shop for (from GFE #6) 1302. Survey to ~ $ 1303. Pest Inspection to $ 1304. Prepaid Tax Cert Fee to Homesale Settlement Services, Inc. 5.00 1305. Overnight Fee to Romin er & Associates 45.00 1306. Deed Prep Fee to Romin er & Associates 250.00 1307. Home Warranty to American Home Shield 514.00 1308. Wire Fee to Homesale Settlement Services, Inc. 20.00 1309. Water/Sewer Bill to North Middleton Townshi Authorit 48.87 1310. Municipal Lien to North Middleton Townshi Authorit 3,287.63 ~ ~ • - ~ ~ 8,683.45 12,756.50 'Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er. "Credit by lender shown on page 1. "`"Credit by seller shown on page 1. previous editions are obsolete Page 2 of 4 HUD-J Com rson o~Good~Fa~th~',E~met~ :: .p-~~,jr s - ~:- ., '. .,~ Gaod Faith Estir[isfe FI11D-1 F _...~ Char esx~iat~anrtso~flnc4easE~ ~.. '`',_ ,.4t'y~ ,~~'~;<}.~`~ :.. ~-EIU 19u'mt~eix, ?, '' ~' .. ,;,~w Ourorgr~~ge;~ ~' $.'~. =~>',`~ ~:'r ~"~ ~Y .c:t,.,y,.,_:: 455.00 305.00 Your c~eds~'~oc., ar i spec{fib:~t'eresf,date';cha~err~,"~`#~`~;8~''.., ~;h' ~.; `, ' ~:~ 331.88 331.88 Yqur ad~troi-gl'rtafiorr cti~rgi;s. ~ ~ ~ s . ~` 8~33w ',_ = ~h ~* ~ ; . 786.88 Ei36.88 Transfertaxesi .. ~ ; --'~,-.420 _r.- `R `` 1,300.00 1,300.00 G~odJFdittr Estimate ' HUD-1`> 238.00 252.00 400.00 375.00 20.00 20.00 100.00 0.00 12.50 12.50 2,795.00 2,795.00 0.00 0.00 3,565.50 3,454.50 $ -111.00 or -3.1132% .. ,, ~-~. Char ,.s'Ihat`Cae~Chan e' ~~ -' _.., , ;.:k -~ -~''-~ . ¢~ , ,-~~,~~;~ .~, 7 t , Initial d`eppstE~~yESe ev~aECOerit' I , .Daily irfts~~harg8s €r~in ^` a, ;~, ~ r ~~~ ~~ ~ ~,,t ~~ f~_~ _ r . T r.. m-k_~r x.'- . Y . HOIR~wnF.rr~t~SElC2~C~-'; .' '. °~ "`fit "=* Y,t,'`rvsc"y ~~,~. ~~i~.~ 'z'~..•Yj, 3~ie~L Titfe.serviees and.ienders tale;ins~ra~ce~ ~ --'_ + ~ ~~ ~ 4`.^:~~` ~~- . ~ , Pest lnsp~tlon ,. _ f~° 4 ' > ~.y.~~~ ~a_.~ r , ~ 1 . it .5 ... q. tktiry_. i ~'YY.. .t ,. ' ~ Loan Terms -~-~GootC"Fa'ith"EStimate ~:~HkJD'9~~ 1,079.32 1,074.94 282.03 66.38 500.00 343.00 1,608.75 1,293.75 50.00 0.00 Your tnitiai-loan amount is - .; ~, ti - $132,750.00 ,.~ ~. Your loan terrrLis ~, ;'~, ,~ , 30. years j 4 ~ 4 ~2 J .Your initiat interest rata is ~ r r :' ~ ~'~,, ~ 4.5000% Yourinif~aF monthly ~Fnaur~towed-for prinapa~~nt~.Fest;~anc~a~~y'rnor~g~ e -- ~ ~ ~- _ $672.63 includes u~suranee ~s , , ~ ~ - Q Principal "; ~ } ^X Interest ~ ~ rf ~, ~. S ' ~' ~`" ~~ ~` ~ }> ^ Mortgage Insurance Can yourinterest rate Ftse2~ ~ ,~ ~ayt ,~ ? ~ ~~~' ~ r .~ ,h -~ ~~~ ~~~~.~ ~ ~ ' "~~ ` ` '"'' X No. ° ^ ^ Yes, it can rise to a maximum of /°. The first change ~i r ~~ t 1 .. , ~ '~ ~, ~ ' ' ` '' `~ TM" will be on ! / and can change again every years after I I .Eve than e ry 9 ' ~. r ~ fi~ ~ ~ <w ° ~ ~:„ .~ i~, date, your interest rate can increase or decrease by %. Over the life of the loan, your * ' ~ ~x „~ ,'~ ° A- interest rate is guaranteed to never be lower than % or higher than %. ~~x n1 y 1 . .y .'--4. ~ 11 Euen,f.yau cnake~~ayr~ents3.~wimie;~ _ ^X No. ^ Yes, it can rise to a maximum of $ F Even if you rnake.payrnen~s~gy ~Fx, 43 ^X No. ^ Yes, the first increase can be on / ! and the monthly ~~'.. pnnczpal; interest~~artd mo~,e 1~ ~~; ,.~~ f ~ y. ; 1 ~ ~ ~ amount owed can rise to $ ~; ~. ,~ _~, ,~~~~' ~ ~ ~'~~z ~~ The maximum it can ever rise to is $ Qoes.yotir 14an:~~~~ ~ ~~ ~ ~ ~ ~~,~ ~ ^X No. ^ Yes your maximum prepayment penalty is $ ~°i~' Roes your Ioanh2v@~~6~~~OR~~ ~" ~ `~~ ~~~~- ~ , ^X No. ^ Yes, you have a balloon payment of $ due in . ~~`~'~ ~ ~ ~ ~ ~' ~~~ ~ years on I 1 t ..~ } t 5~~ ~.~ <,. Total rnorrfhfy amobntouedreiclud~ng~eS~xBU~.:ate trpay~r~ecits~~~~~' ~,: ^ You do not have a monthly escrow payment for items, such as property taxes ° :r. „ ; ` :~ R,. and homeowners insurance. You must pay these items directly yourself. - _ ~i~. - ~ t ~, S -~ ; , . . ^X You have an additional monthly escrow payment of $177.25 ~,, ~ ~, i ~ '` ~. ~ ; ~ `~,;` ' Y that results in a total initial monthly amount owed of $849.88. This includes principal, interest, any ~ ~1~, s ~~ £~ ~ -~-~ !.5 r~. +rx i r mortgage insurance and any items checked below: ~ ,; .~;t r ~'} ~~~~ '~~ r ~° ~'~ ' ,i ~ zA ~- ~_,. ^ Property taxes ^ Homeowner's insurance -~ a.- ~ ,: ~ `'~ :::~~'~' ~ -~~ r* } ~ ~` ^ Flood insurance ^X School Taxes tote: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. revious editions are obsolete Page 3 of 4 HUD-] .~• 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. ,-- ~ ~ ~ NELSON J.-RODRIGUEZ ~ ST A. 0 RIGUEZ ~--~ THE ESTATE OF MICHAEL D. NOBLE 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. ~ 1 SETTLEMENT AGENT DATE ~, ~ NARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON :ONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010. previous editions are obsolete Page 4 of 4 HUD-] Itemization of Your Loan Origination Charges ~ Name o` Borrower: Name of Seller: File Number: NELSON J. RODRIGUEZ THE ESTATE OF MICHAEL D. NOBLE 10-602 KRISTA A. RODRIGUEZ Prepared 01;28/2011 at 2:02 pm Note: This page displays an itemization of the adjusted origination charges shown in section 800 of the HUD-1 Settlement Statemen This page accompanies but is not a part of the HUD-1 Settlement Statement. If a discrepancy exists, the information on the HUD-1 Settlement Statement applies. Your Loan Origination Charges Borrower Seller 801. Our origination charge (Includes Origination Point % or $0.00) Document Prep Fee to MEMBERS 1ST FEDERAL CRE$ 305.00 Borrower 802. Your credit or charge (points) for the specific interest rate chosen Discount Points to MEMBERS 1ST FEDERAL CRE$ 331.88 Borrower 803. Your adjusted origination charges 636.88 0.00 Name of Borrower: Name of Seller: File Number: NELSON J. RODRIGUEZ THE ESTATE OF MICHAEL D. NOBLE 10-602 KRISTA A. RODRIGUEZ Prepared 01!2812011 at 2:02 pm Note: This page displays an itemization of the charges shown on line 1101 of the HUD-1 Settlement Statement. This page accompanies but is not a part of the HUD-1 Settlement Statement. If a discrepancy exists, the information on the HUD-1 Settlement Statement applies. 1100. Title Charges Borrower Seller 1101. Title services and lender's title insurance to 1,293.75 0.00 Notary Fee to Nota Public $ 45.00 Borrower End 100 to Old Re ublic Title $ 50.00 Borrower 300 to Old Re ublic Title $ 50.00 Borrower 900 to Old Re ublic Title $ 50.00 Borrower ClosingSvcLtrlCL to Old Re ublic Title $ 75.00 Borrower Subtotal S 270.00 1102. Settlement or closing fee to $ 0.00 1104. Lenders title insurance to Old Re ublic Title $ 1,023.75 SellerlLendec credits shown on a e 1 POC = Paid~Oufside Ctosita - >revious editions are obsolete Page 1 of 1 HUD-]