HomeMy WebLinkAbout04-28-11J 1505610140
REV-1500 EX (°'-'°)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisbur , PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 1 0 2 1
ENTER DECEDENT INFORMATION BELOW -
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 2 2 0 4 4 1 1 0 9 3 0 2 0 1 0 1 0 0 1 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name
B L O S S E R MI
T H E L M A A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE VWITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return
3. Remainder Return (date of death
4. Limited Estate ~ prior to 12-13-82)
4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
OX 6. Decedent Died Testate ~ 7. Decedent Maintained a Livin Trust
(Attach Copy of Will) g 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tai: under Sec. 9113(A
between 12-31-91 and 1-1-95) (Attach Sch. O) )
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
Daytime Telephone IVurnber
S U S A N H C O N F A I R 7 1 7 7 6 .3 1 3 8 3
First line of address
2 3 3 1 M A R K E T
Second line of address
City or Post Office
C A M P H I L L
S T R E E T
State ZIP Code ~_
P A 1 7 0 1 1
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address: SCONFAIRaREAGERADLERPC . COM
Under penalties of perjury, 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 and com lete. Declaration of preparer other than the personal representative is based on all information of which preparer teas any knowledge.
SIGNAT BLE FOR FILING RETURN
ATE
ADDRESS :-~ 7 l
507 EUTAW AVENUE NEW CUMBERLAND
SIGNATURE OF EPARER OTHER THAN REPRESENTATIVE P A 17 0 7 0
,.t._„ ~ ~,;.~~_ ... DATE
ADDRESS ~ ~ ~ ~~ -~~~ ~/'~
2331 MARKET STREET CAMP HILL
PLEASE USE ORIGINAL FORM ONLY P ~ 1 '7 011
Side 1
1505610140 1505610140 J
~.
J
REV-1500 EX
1505610240
Decedent's Social Security Number
Decedent's Name: T H E L M A A• B L O S S E R 2 0 2 2 (] 4 4 1 1
RECAPITULATION
1. Real Estate (Schedule A) ..................................... ...... 1. 2 1 8 ~ 6 2 . 5 0
2. Stocks and Bonds (Schedule B) ...
..................... .
.......
...... 2.
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. 3 3 7 ~ 9 4 . 3 6
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested
..
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ..... 6.
(Schedule G) ^ Separate Billing Requested .. ..... 7.
8. Total Gross Assets (total Lines 1 through 7) ...................... ..... 8. 5 5 6 7 5 6
8 6
,
9. Funeral Expenses and Administrative Costs (Schedule H) ............. ..... 9. 2 6 6 3 6 . 8 9
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ ..... 10. 1 4 9 7 2
11. Total Deductions (total Lines 9 and 10) .......................... ..... 11. 2 6 ~ 8 6 . 6 1
12. Net Value of Estate (Line 8 minus Line 11) ........................ .... 12. 5 2 9 9 7 0
2 5
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which .
an election to tax has not been made (Schedule J) .................. .... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .................. .... 14. 5 2 9 9 7 0 . 2 5
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
16. Amount of Line 14 taxable 15. 0. 0 0
at lineal rate X -045 5 2 9 9 7 0. 2 5 16. 2 3 8 4 8
6 6
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 collateral rate X .15 0 0 0 1 g. 0 0 0
19. TAX DUE ...................................................... 19. 2 3 .3 4 8. 6 6
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:
DECEDENT'S NAME
THELMA_A_• BLO_S_SER__ _
STREET ADDRESS -----
315 FIFTH AVENUE __
CITY -
NEW CUMBERLAND
Tax Payments and Credits:
~ ~ Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 2 2, 6 5 0.0 0
B. Discount 1,19 2.0 7
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
File Number
21 1D 1021
---------------- ----- -
STATE ZIP
PA 17070
(1) _ 23, 848.66
Total Credits (A + 6) (2)
._ 23,842.07
(3) _
(4) ._ D . 0 0
(5) - 6.5 9
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRI
ATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred : .................... Yes No
b. retain the right to designate who shall use the ro ert transferred or its income, ^ ^
P P y ~ ............................... ^
c. retain a reversionary interest; or ...................................... ^
.......................................................... ^ X
d. receive the promise for life of either payments, benefits or care? .......................... ^ 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?
....................................................................................... ^ a
3. Did decedent own an "in trust for" or payable-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 RET
URN.
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 ~~
3 percent [72 P.S. §9116 (a) (1.1) (i)]. the use of the surviving spouse is
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 survivin souse is 0 erce
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a survivin souse from tax, g P P nt
filing a tax return are still applicable even if the surviving spouse is the only benefciary. and the statutory requirements for disclosure of assets and
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 ar
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. pent, an
• 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 . A sibfin is def
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. )] g med, under
REV-1502 EX+ (01-10)
Pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
THELMA A • BLOSSER FILE NUMBER:
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defin0ed as the pr ce at which ro ert
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the releva t facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM Attach a copy of the settlement sheet if the property has been sold.
NUMBER Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
DESCRIPTION OF DEATH
1• 315 FIFTH AVENUE, NEW CUMBERLAND, PENNSYLVANIA - SOLD FOR
$40,000.00 SETTLEMENT SHEET ATTACHED, SPECIFIC BEQUEST TO 40,000.00
RICHARD D• BLOSSER
2• 507 EUTAW AVENUE, NEW CUMBERLAND, PENNSYLVANIA -
FAIR MARKET VALUE - SPECIFIC BEQUEST TO RICHARD D• BLOSSER 178,862.50
TOTAL (Also enter on Line 1, Recapitulation) I ~6
If more space is needed, use additional sheets of paper of the same size. 218 , 8 6 2 • 5 0
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, a MASC.
'N RESIDENT DECEDENTRN PERSONAL PROPERTY
ESTATE OF
THELMA A • BLOSSER FILE NUMBER
21 10 1021
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
NUMBER DESCRIPTION VALUE AT DATE
~• PNC BANK - ACCOUNT #5140095817 OF DEATH
600 GRANT STREET, PITTSBURGH, PA 15219 337,145.46
2• HIGHMARK REIMBURSEMENT
179.10
3• ITHE PATRIOT-NEWS REIMBURSEMENT
4• PERSONAL PROPERTY
69.80
500.00
_ TOTAL (Also enter on line 5, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size) 3 3 7 , 8 9 4 • 3 6
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
THELMA A. BLOSSER
SCHEDULE H
FUNERALEXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
~, ,~
y
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
A. FUNERAL EXPENSES:
~• PATHEMORE FUNERAL HOME 8 CREMATION SERVICES, INC-
B
021
AMOUNT
7,886.39
ADMINISTRATIVE COSTS:
~ • Personal Representative Commissions:
Name(s) of Personal Representative(s) RICHARD B L O S S E R
Street Address 50? EUTAW AVENUE
City NEW CUMBERLAND State PA ZIP 17070
Year(s) Commission Paid: 2 011
2. AttomeyFees: REALER & ADLER, PC
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4• Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS
5• Accountant Fees:
6• Tax Return Preparer Fees:
~• LEGAL ADVERTISEMENT - CUMBERLAND LAW JOURNAL
8• LEGAL ADVERTISEMENT - CENTRAL PENN BUSINESS JOURNAL
9• FILING FEE RETURN >~ INVENTORY
TOTAL (Also enter on Line 9, Recapitulation) I ~$
If more space is needed, use additional sheets of paper of the same size.
12,000.00
6,000.00
523.50
75.00
122.00
30.00
26,636.89
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
tSTATE OF
FILE NUMBER
THELMA A• BLOSSER
21 10 7,021
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburs;ed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1• UTILITY - VERIZON
7.08
2• UTILITY - PPL ELECTRIC
31.79
3• UTILITY - PENNSYLVANIA WATER
13.30
4• SEWER & TRASH - NEW CUMBERLAND BOROUGH
97.55
TOTAL (Also enter on Line 10, Recapitulation) $
If more space is needed, insert additional sheets of the same size. 14 9 • 72
REV-1513 EX+ (01-10)
pennsylvania
SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
THELMA FILE NUMBER:
A• BLOSSER
21 10 :L021
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
I Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [Include outright spousal distrib
ti OF ESTATE
u
ons and transfers under
Sec. 9116 (a) (1.2).]
1. RICHARD BLOSSER - SON Lineal
507 EUTAW AVENUE 218,862.51
NEW CUMBERLAND, PA 17070
2• CAROLYN SUE BLOSSER-HILL - DAUGHTER Lineal
27 S• THIRD STREET, APT• 5 103,702.58
HARRISBURG, PA 17101
3• DEBORAH A• MILLS - DAUGHTER Lineal
18 ROSS AVENUE 103,702.58
NEW CUMBERLAND, PA 17070
4• MELANIE RAE YADOUGA - DAUGHTER Lineal
121 MARKET STREET 103,702.58
NEW CUMBERLAND, PA 17070
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINE
II S 15 THROUGH 18 OF REV-1500 COVER SI-IFFY
A S APPROPRIATE
. ,
NON-TAXABLE DISTRIBUTIONS: .
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS N
1. OT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, g;
If more space is needed, use additional sheets of paper of the same size.
dlb\wills\blosser.ta
Decerr~.•er 31, 199? R
~,
.
r~
LAST WILL
AND TESTAMENT _
;:=~::J
-- - -~. ~ ~
THELMA A. BLOSSER >; ~, ``-~r
- -=- ~~
-.~
._, _, . .
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;,~
I, THELMA A. BLOSSER, of ~~~
New Cumberland, Cumberland. County,
Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this my Last
Will and Testament, hereby revoking any and all prior wills and
codicils thereto by me at any time heretofore made.
FIRST
I direct that all mt~r just debts and the expenses of my last
illness and funeral shall be paid from the assets of my estate as
soon as practicable after my decease.
I authorize my personal representative to expend fund~> from my
estate, in such amounts as my personal representative shall
consider necessary and desirable, for the purchase, erection and
inscription of a suitable marker for my grave.
SECOND
I give and bequeath all automobiles, household eff~ec;ts and
other tangible personal property, not including cash or securities,
owned by me at my death, together with all policies of insurance
thereon, to my four (4) children, RICHARD D. BLOSSER, CAROr~YN SUE
BLOSSER-HILL, MELANIE RAE BLOSSER, and DEBORAH ANN NEVER, providing
dlb\wills\blosser.ta
Decemb.~r 31, 1997
that they are living on the sixtieth (60th) day after the date of
my death. Should my four (4) children not be living on the
sixtieth (60th) day after the date of my death, I bequeath such
tangible personalty and insurance thereon to such of my children as
are living on the date of my death, to be divided between or among
them as they shall agree. In the event that no agreement is
reached, the said personalty shall be sold, in whole or in part, as
my personal representative shall determine, and the proceeds shall
become a part of my residuary estate.
THIRD
I give and bequeath the following items of real property, as
follows:
I give and bequeath my personal residence located at X315 5th
Avenue, New Cumberland Cumberland County, Pennsylvania, and real
estate located at 507 Eutaw Street, New Cumberland, Cumberland
County, Pennsylvania, to my son, RICHARD BLOSSER. In th~e~ event
that my son should predecease me, then I leave the above real
estate to my grandson, NATHAN S. BLOSSER.
FOURTH
I give, devise and bequeath all of the rest, residue and
remainder of my estate, of every nature and wherever sit~aa.te, in
equal shares to my three (3) daughters, CAROLYN SUE BLOSS:ER-HILL,
MELANIE RAE BLOSSER, and DEBORAH ANN NEVER. Provided that, if any
dlb\wills\blosser.ta
December 31, 1997 '
of my named daughters shall predecease me leaving a child or
children who survive me, then I leave the share of that deceased
daughter to her child or children, who survive me, per stir~pes; and
provided further that if all of my daughters shall predecease me or
none leave a child or children who survive me, then I leave the
remainder of my estate to my son, RICHARD D. BLOSSER, oar in the
event that he shall predecease me then to my grandson, NATHAN S.
BLOSSER.
FIFTH
All principal and income, until
beneficiaries, shall be free of the dek
alienations and anticipations of any
shall not be subject to any levy,
sequestration.
actual distribution to the
-ts, contracts, assignments,
beneficiary, and t:he same
attachment, execution or
SIXTH
I direct that all taxes that may be assessed in consequence of
my death, of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expE~nses of
the administration of the estate.
SEVENTH
My personal representative shall have the following pc>wers in
addition to those vested in them by law and by other provi~;ions of
this Will:
3
dlb\wills\blosser.ta
Decemt~er~ 31, 1997 ,
A. To retain any or all assets of my estate, real or
personal, without regard to any princi.p.le of
diversification, risk or productivity.
B. To invest in all forms of property as my f iduciary may
deem proper, without regard to any princi~>le of
diversification, risk or productivity.
C. To purchase investments at a premium or discount.,
D. To exercise all rights of a security holder or
shareholder in any corporation; to give proxies; to join
in any merger, consolidation, reorganization, voting
trust plan, or other concerted action of ;security
holders; and to delegate discretionary duties with
respect thereto.
E. To sell at public or private sale, to exchange or to
lease, for any period of time, any real or personal
property, and to give options for sales, exchanges or
leases, for such prices and upon such terms or conditions
as my fiduciary deems proper.
F. To allocate receipts and expenses to principal or income,
or partly to each.
G. To borrow money from my corporate fiduciary or others and
to mortgage or pledge any real or personal pro~-e:rty as
security therefore, in my fiduciary's sole discretion.
dlb\wills\blosser.ta
December 31, 1997
H. To compromise any claim or controversy without order of
court or consent of any beneficiary.
I. To exercise any option, right or privilege granted in
insurance policies or arising from owner:~h.ip of
investments.
S. To make any distribution herein provided for in cash, in
kind, or partly in each, at valuations fixed by my
personal representative at the time of distribu~ti.on.
K. My fiduciary may, in his or her sole discretion, donate
any part or all of my tangible personal property to any
charitable organization(s) which would benefit from such
donation. My f iduciary is then instructed to use the
value of said donation(s) as an tax deduction for any
inheritance tax return which may be required to be filed
as a consequence of my death.
EIGHTH
I appoint my son, RICHARD BLOSSER, Executor, of this, my Last
Will and Testament.
NINTH
My Executor shall not be required to post security _i.n any
jurisdiction.
5
~ ~ ~~~-~z=~~
dlb\wills\blosser.ta
~ecemher 31, 1997
IN WITNESS WHEREOF, I have hereunto set my hand and :peal to
this, my Last Will and Testament, consisting of six (6) typewritten
pages, the first five (5) of which bear my signature in the margin
for the purpose of identification, this 31st day of December, 1997.
._
,~ ~ _
THELMA A. BLOSSER, Testatrix
Signed, sealed, published and declared by the above-named
Testatrix, THELMA A. BLOSSER, as and for her Last T~1i11 and
Testament, in the sight and presence of us, who, at her request, in
her sight and presence and in the sight and presence of each other,
have hereunto subscribed our names as witnesses.
lam-.. ~~~
Address ~ 3 .~~ ~ ~~ ~-~-~ ;fit .
J
,~ ~ _
/ L- ~..
Address ~
6
dlb\wills\blosser.ta
December 31, 19ci7
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
I, THELMA A. BLOSSER, the Testatrix, whose name is signed to
the foregoing instrument, having been duly qualified according to
law, do hereby acknowledge that I signed and executed the
instrument as my Last Will and Testament; that I signed it
willingly; and that I signed it as my free and voluntary act for
the purposes therein expressed.
Sworn or affirmed to and acknowledged before me by TIHELMA A.
BLOSSER, the Testatrix this 31st day of December 1997
{'Jotariai Seal
Susanna K.. Sathor, rotary Public
Camp 6-1i1! Sore, Curnbrland Gounty
My Commission l.xpires Rug. 2~, 2001
Member, Pennsylvania Association of Notaries
i
C.~ .~~
THELMA A. BLOSSER, Testatrix
otary Public
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
~~. ~~ ~ lei ~
W e , ~~-c~~ cu., .{-~ . (.~;r.~ ~, ~=~ and ~Q ~ ~P ~4
the witnesses whose names are signed to the foregoing insttrument,
being duly qualified according to law, depose and say that we were
present and saw the aforesaid Testatrix sign and execute the
instrument as her Last Will and Testament; that she signed
willingly and that she executed it as her free and voluni~ary act
for the purposes therein expressed; that each of us in the hearing
and sight of the Testatrix signed the Will as witnesses; and that
to the best of our knowledge the Testatrix was at the time eighteen
(18) it more years of age, of sound mind and under no constraint or
undue influence .
Sworn or affirmed to and
day of December, 1997.
Susanna 1 ~ SattaerSP~atar}~ Public
Camp HifP Sara, Gumb~r'and Gounty
My Commission expires fit~g. 25, 20:~~
Member, Pennsylvania Association of r'~otaries
subscribed o before me, this 31st
Witne s ti
/~,
Witness ~ -~
~~~~~ ~ t ;~~~
otary Public _
7
OMB Approval No. 2502-0265
• ~~#illl ~ A. S.. _clement Statement HUD-1
11~IIIII
B. Type of Loan
6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number:
1. ~ FHA 2. ~ RHS 3. ~ Conv. Unins. CAA-Grossman- Cash Deal
4. ~ VA 5. ~ Conv. Ins. A06096335
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked
"(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in 1:he totals.
D. Name 8 Address of Borrower: E. Name & Address of Seller F. Name 8 P.ddrE:ss or Lender:
Harry Grossman Richard D. Blosser
PA 507 Eutaw Avenue
New Cumberland, PA 17070
Suzy Grossman
PA
G. Property Location: H. Settlement Agent: I. Settlement Date:
315 Fifth Avenue Capital Area Abstract, lnc., David J. 12/03/2010
New Cumberland, PA 17070 Lanza
Phone Number: 717-303-0322
Cumberland County 2133 Market Street, Suite 215
Camp Hill, PA 17011 _
Piace of Settlement:
2132 Market Streef, Camp Hill, PA 17011 Disbursement Date:12/03/2010
J. Summary of Borrower's Transaction K. Summary of Seller's Transaction_
100. Gross Amount Due From Borrower 400. Gross Amount Due To Seller
101. Contract sales price $40, 000.0 0 401. Contract sales price $40, 000.00
102. Personal property 402. Personal property
103. Settlement charges to borrower (line 1400) $980.5 0 403.
104. 404.
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. City/town taxes to 406. City/town taxes to
107. County taxes 12/03/2010 to 12/31/2010 $46.63 407. County taxes 12/03/2010 to 22/31/2010 $46.63
108. Assessments 12/03/2010 to 06/30/2011 $552.92 408. Assessments 12/03/2010 to 06/30/2011 $552.92
109. Refuse: 12/03/2010 to 12/31/2010 $11,75 409.Refuse: 12/03/2010 to 1.2/31/2010
$11.75
110. 410.
111. 411.
1 12. 412.
120. Gross Amount Due From Borrower 541, 591 . ao 420. Gross Amount Due To Seller $40, 611 .30
200. Amounts Paid By Or In Behalf Of Borrower 500. Reductions In Amount Due To Seller
201. Deposit or earnest money 501. Excess deposit (see instructions)
202. Principal amount of new loan(s) 502. Settlement charges to seller (linE: '400) $2, 256.14
203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
204. __
504. Payoff of first mortgage loan
205. 505. Payoff of second mortgage loan
206. Seller's Credit $2,000.00 506.Seller's Credit $2,000.00
207. 507. --
208. -
508.
209. 509. --
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. City/town taxes to 510. City/town taxes to
211. County taxes to 511. County taxes to
212. Assessments to 512. Assessments to
213. Sewer: 10/01/2010 to 12/03/2010 541.01 513.Sewer: 10/01/2010 to 1.2/03/2020 $41.01
214. 514.
215. -
515. -
216. 516. -
217. 517.
218. --
518.
219. -
519. -
220. Total Paid By/For Borrower $2, 041.01 520. Total Reduction Amount Due Seller $4, 297.15
300. Cash At Settlement From/To Borrower 600. Cash At Settlement To/From Seller
301. Gross amount due from borrower (line 120) $41, 591.80 601. Gross amount due to seller (line 420) 540, 611 .30
302. Less amounts paid by/for borrower (line 220) ( $2, 041.01 602. Less reductions in amt. due seller (lint: 520) $4, 297.1
303. Cash ®From ~ To Borrower 539, 550.79 6 03. Cash ®To ~ From Seller 536, 314.15
The public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting, reviewing, and
reporting the data. This agency may not collect this information, and you are not required to complete 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 3 HUD-1
L. Seclement Charges
700. Total Real Estate Broker Fees ~ an' f P
id F P
id F
Division of Commission (line 700) as follows: rom
a
Borrower's rom
a
Seller's
701. $ tp Funds at Funds at
702. $ to Settlement Settlement
703. Commission paid at Settlement
704. P.O.C. by
800. Items Payable In Connection With Loan
801. Our origination charge $ (from GFE #1 I
802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2 f
803. Your adjusted origination charges (from GFE A) $0.00
804. Appraisal fee to , a o c by t (from GFE #3 ~
805. Credit report to ( Po-c by 1 (from GFE #3 )
806. Tax service to ; P o.c. by ; (from GFE #3 )
807. Flood certification P o c by ~ (from GFE #3 )
808.
809.
810.
811.
812.
900. Items Required By Lender To Be Paid In .4dvance
901. Daily interest charges from to @$ /day (from GFE #10
)
902. Mortgage Insurance Premium for months. (from GFE #3 '~
to
903. Homeowner's insurance for years. (from GFE #11 ;~
to T--
904. years. r
I
to
905. ~-
1000. Reserves Deposited With Lender
1001. Initial deposit for your escrow account (from GFE #9)
1002. Homeowner's insurance months @$ per month $
1003. Mortgage insurance months @$ per month $
1004. Property taxes months @$ per month $
1005. months @$ per month $
1006. months $
@ per month $
1007. Aggregate Adjustment -$ 0.00
1100. Title Charges
1101. Title services and lender's title insurance (from GFE #4) 525.00 $10.00
1102. Settlement or closing fee $
1103. Owner's title insurance xarry & suzy Grossman (from GFE #51 5492.50
1104. Lender's title insurance $ _
1105. Lender's title policy limit $
1106. Owner's title policy limit $ 40, 000. 00 -
1107. Agents portion of the total title insurance premium cAAbstract, Inc. $ 418.62
1108. Underwriter's portion of the total title insurance premium Security Title $ 73.88
1109. Basic -
1110. Notary Fee to Notary Public $10.00 $10.00
1111. Deed Prep Fee to Reager & Adler $125.00
1112. -
113.
1114. --
1115. --
1200. Government Recording and Transfer Charges
1201. Government recording charges: (from GFE #7) $63.00
1202. Deed $63. oo ;Mortgage $ :Releases $
'203. Transfer taxes (from GFE #8) $400.00 $400.00
1204. City/County tax stamps: Deed $ 400.00 Mortgage $
1205. State tax/stamps: Deed $ 400.00 Mortgage $
1206. $ --
1207. $ -- -
1208. $ -
209. -- -
1300. Additional Settlement Charges -
1301. Required services that you can shop for (from GFE #6)
302.
~ I
I - -
1303. $ -
1304. - -
1305. -
1306. Inheritance Taxes of 4.5~ (ESCROW) for the Thelma A. Blosser Estate $1,711.14
1307- -
1308. --
1309. -
1400. Total Settlement Charges (enter on lines 103, Section J and 502, Section K) i $960.50 $2, 256.14
Previous editions are obsolete Page 2 of 3 HUD-1
Certification
(continued from HUD-1)
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.
J~) ,;
Borrower, / ' ~ ate:
rr~ Grossman
Seller or - ~'
Agent: " c:j~y~-Date: ~~~~/~J
Richard D. Blosser
507 Eutaw Avenue
New Cumberland, PA 17070
Borrower: Date:
Suzy Grossman
Seller or
Agent:
Date:
The HUD-1 Settlement which I have prepared is a true and accurate account of this transa<tion. I have
caused or will cause the funds ~to be disbursed in accordance with this statement.
Date: Settlement Agent: ~~%~V ~-- Date: , .. 4~ ~J
David J. Lanz2~
WARNING: It is a crime to knowingly make false statements to the United States on this or any other
similar form. Penalties upon conviction can include a fine and imprisonment. For details
see: Title 18 U.S. Code Section 1001 and Section 1010.