HomeMy WebLinkAbout06-22-11J 15056],0140
REV-1500 EX (°'_'°'
PA Department of Revenue OFFICIAL USE ONLYY_
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 L 0 1 3 4
ENTER DECEDENT INFORMATION BELOW -
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 4 0 3 8 8 2 1 0 1 2 7 2 0 1 1 0 9 3 0 1 9 1 9
Decedent's Last Name Suffix Decedent's First Name
MI
Y E N T Z E R R U T H V
(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 VIIITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-1:4-8:?)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate 1'ax Return Required
death after 12-12-82)
QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name
Daytime Telephone Number
W I L L I A M A D U N C A N 7 1 7 2 LI 9 7 7 8 0
REGISTER OF WILLS USE ONLY
First line of address C'1 ' ''
~"' " ' :.z-~
._..
1 I R V I N E R O W
r~ --r-
~~~c7 '~~~ ~..~~' {-~~'
Second line of address .Cr
~~
~~
t1
City or Post Office State ZIP Code ~ILED
C A R L I S L E P A 1 7 0 1 3 ~' ~'`~ `~'' `~'
-
,,
Correspondent's a-mail address: b 1 11 d U n C a n a~ p d. n e t
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 complete. Declaration of preparer other than the
,
personal representative is based on all information of which preparer has any knowledge.
SIGNATURE O PERSON RESPONSI FOR FILING RETURN -
G G. DA~TE
, Q ~
/~
ADDRES =
~
1146 SOUTH PITT STREET CARLISLE PA X67013
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE -
DA'TE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY -
Side 1
],505610140 1505610140
~~~
J
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: RUTH V- Y E N T Z E R Z 0 4 0 3 8 8 2 1
RECAPITULATION _
1. Real Estate (Schedule A) ........................................... 1. 1 5 2 OI 0 0 , 0 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. 6 3 ? 8 5. 8 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers 8 Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested ..... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ...... .. _ . , g, 2 1 5 ? 8 5 , 8 0
9.
Funeral Expenses and Administrative Costs (Schedule H)
................
9.
..
1 8 .
5 3 1
1
5
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) ........... .. 10 3 6 8 8 . ? 9
11. Total Deductions (total Lines 9 and 10) .............................. . 11 2 2 2 1 9 . 9 4
12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 1 9 3 5 6 5. 8 6
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. 1 9 3 5 6 5 . 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 1 9 3 5 6 5. 8 6 16. 8 ? 1 0. 4 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. 8 ? 1 D • 4 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
15D5610240 1505610240
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
RUTH V• YENTZER
--- -
__ ---_ _ _
STREET ADDRESS
3021 LISBURN ROAD
-- -- --__
CITY
MECHANICSBURG
Tax Payments and Credits:
~ Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
8,000.00
B. Discount
3 Interest
420.80
File Number
21 11 0134
Total Credits (A + B) (2) 8 , 4 2 0.8 0
(3)
(4) _ 0.00
(5) _ 289.66
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 ZO to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP ROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;
..............................................
....................... Yes
. No
^
X
b. retain the right to designate who shall use the property transferred or its income; .............................. . ^
c. retain a reversionary interest; or .............
... ............................................................................. ^ 0
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?
...................................................................................... ^
. 0
3. Did decedent own an "in trust 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? .....................................................
............................................
. D
xD
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~ o~f 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 siblin s is 12 ercent 72 P.S. 9116 a 1.3~ . A siblin is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood[or adop§on. ()( )] g
~lEV-1502 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
rc~rwr~ ~~
SCHEDULE A
REAL ESTATE
vv~n~~ VI -- _
FILE NUMBER:
RUTH V• YENTZER 21 11 0134
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
DESCRIPTION OF DEATH
1• 13021 LISBURN ROAD
MECHANICSBURG, PA 17055
SEE HUD SHEET ATTACHED]
152,000.00
TOTAL (Also enter on Line 1, Recapitulation,) S 15 2 , 0 D 0 •0 0
If more space is needed, use additional sheets of paper of the same size.
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSY LVANIA CASH, BANK DEPOSITS
& MISC
INHERITANCE TAX RETURN
RESIDENT DECEDENT ,
.
PERSONAL PROPERTY
ESTATE OF
RUTH V • YENTZER FILE NUMBER
21 11
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorshi
must b
di GI134
ITEM p
e
sclosed on Schedule F.
NUMBER DESCRIPTION VALUE AT DATE
~. PROCEEDS OF 1N BANK ACCOUNT # 290004942 OF DEATH
[SEE DOD LETTER ATTACHED3 28,088.41
2• PROCEEDS OF ORRSTOWN BANK ACCOUNT # 149000417
[SEE DOD LETTER ATTACHED 2,934.39
3• PROCEEDS OF ORRSTOWN BANK ACCOUNT # 14900041
6
[SEE DOD ,
LETTER ATTACHED] 30,956.40
4• EVERENCE REFUND
347.21
5• (UNITED HEALTHCARE SVC• INC•
6• ~COMCAST REFUND
7• CHAMPION ENERGY REFUND
8• IALLSTATE HOMEOWNER'S REFUND
9• PINNACLE REFUND
10. (CREDIT FOR TAXES PAID - REAL ESTATE
[SEE HUD SHEET ATTACHED]
32.40
48.59
458.34
274.00
34.89
611.17
TOTAL (Also enter on line 5, Recapitulation) l a 6 3 7 8 5 8 0
(If more space is needed, insert additional sheets of the same size) ~ -
REV-1511 EX+ (10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF _
RUTH V
• YENTZER FILE NUMBER
21 11 0134
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES: AMOUNT
~. MOHLERrS CHURCH OF BRETHERAN - DONATION
2• GINGRICH MEMORIALS - GRAVE MARKER 200.00
3• ROYER'S FLOWERS 160.00
4• MYERS FUNERAL HOME 148.40
7, 942.00
B, ADMINISTRATIVE COSTS:
1 ~ Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees: DUNCAN & HARTMAN, PC
3. Family Exemption: (If decedenCs address is not the same as claimants, attach explanation.) 9 ~ D 2 D • 3 3
Claimant
Street Address
City
State Zlp
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS
393.50
5. Accountant Fees:
6• Tax Retum Preparer Fees:
7~ CUMBERLAND LAW JOURNAL - LEGAL NOTICE
8• THE SENTINEL - LEGAL AD 75.00
9• REGISTER OF WILLS - FILING FEE 176.92
10• HELD IN RESERVE 15.OD
400.00
TOTAL (Also enter on Line 9, Recapitulation) S
If more space is needed, use additional sheets of paper of the same size. - 18 , 5 31 • 15
REV-1512 EX+ (12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES ~ LIENS
RESIDENT DECEDENT ~
tsiAit ur
FILE NUMBER
RUTH V• YENTZER
21 11 0134
Rep _
ort debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical ex
penses.
ITEM
NUMBER
DESCRIPTION -
VALUE AT DATE
OF DEATH
1. DILLSBURG SEPTIC - PUMP TANK _
221,•00
2• PATRIOT NEWS - PROPERTY AD
1,77.95
3• BONNIE K• MILLER - 2011, PERSONAL TAX
9.80
4- HOME PARAMOUNT PEST CONTROL - TERMITE TREATMENT
1,200.00
5• UNITED WATER
26.8?
6• R•B• HOBAUGH & SON, INC•
214.50
7• HERITAGE MEDICAL GROUP
82.00
8- CENTRAL PENNS HOME INSPECTIONS
72.00
9• SETTLEMENT CHARGES - REAL ESTATE
[SEE HUD SHEET ATTACHED3 1,520.00
],0• COUNTY TAXES DUE - REAL ESTATE
[SEE HUD SHEET ATTACHED3 164.67
TOTAL (Also enter on Line 10, Recapitulation) I :~
If more space is needed, insert additional sheets of the same size. L 3 ~ 6 8 8 • 7 9
REV-1513 EX. (01-10)
Pennsylvania
SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~ PT ~ Tr Ar_
_
VVIA~L. V
RUTH r. _
V • YENTZER
FILE NUMBER:
21
_
11 0134
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVIN RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
G PROPERTY Do Not List Trust
] ee(s)
TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under OF ESTATE
Sec. 9116 (a) (1.2).]
1. VIRGINIA ADAMS Lineal
PO BOX 63
PLAINFIELD, PA 1708], 1/7 SHARE
2• JUDY SALTSBURG Lineal
248 OLD CABIN HOLLOW ROAD
DILLSBURG, PA 17019 1,/7 SHARE
3• KAREN BRINLEY Lineal
852 OLD FORGE ROAD
NEW CUMBERLAND, PA 17070 ' 1/7 SHARE
4• ROBERT D• YENTZER Lineal
126 GREEN RIDGE ROAD
CARLISLE, PA 1,7015 L,/7 SHARE
5• JACK YENTZER Lineal
471, CRISWELL ROAD
BOILING SPRINGS, PA 1700? 1,,~7 SHARE
6• BONNIE BIXLER Lineal
1,040 HIGHLAND DRIVE
MECHANICSBURG, PA 17055 1,i7 SHARE
7• RODNEY L• YENTZER Lineal
1146 S • PITT STREET
CARLISLE, PA 1701B ],~'7 SHARE
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET
A S APPROPRIATE
ll.
NON-TAXABLE DISTRIBUTIONS: , .
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECT ION TO TAXIS NOT
1. TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1
TOTAL OF PART ! 1 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I ;6
It more space is needed, use additional sheets of paper of the same size.
LAST WILL
~c
TESTAMENT
I, RU"TH V. YENTZER, of 3021 Lisburn Road, Mechanicsbur ,Lower A
Cumberland County, Pennsylvania, being of sound and disposin mind me lle~n "Township,
do hereby make, publish and declare this as and for my Last Wg l and'Te mory and understanding,
any and all other wills and codicils heretofore made by me. stament, hereby revoking
FIRST. I direct that all. my just debts and funeral expenses be aid from
soon after my death as practically and conveniently may be done. P mY f=state as
SECOND. I direct that my remains be interred within my famil 's burial
with my expressed wishes. Y plot in accord
THIRD. I authorize mX personal representative to expend funds from
amounts as my personal representative shall consider necess mY estate, in such
erection and inscription of a suitable marker for my grave. ~ and desirable for the purchase,
FOURTH. I give, devise and bequeath all of my estate of whatever natu
personal or mixed, and wherever situate unto my seven (7) children, in a ual sh re, be it real,
q aces, per capita:
A• VIRGINIA R. ADAMS;
B. JACK H. YENTZER;
C• RODNEY L. YENTZER;
D• ROBERT D. YENTZER;
E• JUDY A. SALTSBURG;
F. BONNIE L. BILLER; and
G• KAREN S. BRINLEY.
In the event any of my children fail to survive me by thirty 30 da s
whatever nature, be it real, personal or mixed, and wherever situate sh) Y 'then my estate of
children in equal shares. all pass to my surviving
FIFTH. I direct that any and all Inheritance, Estate and Transfer tax
estate passing under my will or otherwise, shall be paid out of the rinci ~ es imposecl upon my
estate. P p of my residuary
SIXTH I hereby nominate, constitute and appoint RODNEY L.
of this my Last Will and Testament. In the event of renunciation d YENTZER as :Executor
to act for any reason whatsoever of RODNEY L. YENTZER, I nom a resignation or inability
BONNIE L. BIXLER as Executor of this my Last Will and Testam e, constitute and appoint
Executor from the necessity of posting security in connection wit ent I hereby relieve my
jurisdiction in which he may be called upon to act insofar as I amh his duties, as such, in any
addition to the powers conferred by law, I authorize my Executor able by law to do so. In
n his absolute drscretiion, to
retain in the form received, and: to sell either at public or private sale an
property owned by me at the time of my death. Y real or personal
IN WITNESS WHE~OF, I have hereunto set my hand an seal to th'
Testament, consisting of one typevvri en page this ls, my Last Will and
t~4~t/l/`- ~ , 2009. d;~y of
~r~„ J- v 21
RUTH V. PENT
Signed, sealed published and declared by the above named Testatrix
for her Last Will and Testament, in the presence of us, who at her r RUTH V. YEN~['ZER as and
presence and cn the sight and presence of each other, have hereunto subscribe her sigtlt ;end
witnesses. dour names as
~Q~~2~~~
~ A -.
COMMONWEALTH OF PENNSYL VANIA
COUNTY OF CUMBERLAND SS.
I, RUTH V. YENTZER ,Testatrix whose name is signed to the attach
instrument, having been duly qualified according to law, do hereb ed or foregoing
and executed the instrument as my Last Will; that I signed it willin Icknowledge that I signed
free and voluntary act for the g Y, and that I signed it as my
purposes therein expressed.
~ ~~
RUTH V. YENT --
Sworn or affirmed to and
acknowledged before me, by
RUTH . YE ~~~
E this day
of ~~ , 2009.
Notary blic
C MMONWEALTN OF PENN3YLVAN A
NOTARIq~ St:AI
JOAN D. ADAIbIS, Notary Public
Ca~i~ 8oro. Cumbertar~d Coun
Commission Ex fires M ty
X1,2011
COMMONWEALTH OF PENNSYL VANIA ;
COUNTY OF CUMBERLAN]~ :SS.
We, w1 ~/V1A~ /9 ~ ~ ~N~~~ a
the witnesses who and ~~ ~~r ~~ ~~ ~-~~G'~ ~/
se names are signed to the attached or foregoing instrument, bein , dul
qualified according to law, do depose and say that we were rese B y
YENTZER sign and execute the instrument as her Last Wilp th nt and saw RUTH W.
she executed as her free and voJunt at she signed willingJly and that
the hearing and sight of the Tes~ atria sianefor the purposes therein expressed; that each of us in
knowledge, the Testatrix w ~ g d the will as witnesses; and that to the best oaf o
as a that time eighteen (18) or more yeazs of age, of sound mind and
under no constraint or undue in uence.
~~~~
-_
Sworn or affirmed to and
subscribed be or me by
r D ~NG~ ~ and
G ~ v~~~ v~F~.-ice ~~'~ 1--"wi
this -~-~ day of messes,
~~~~%%~~~~ , 2009.
~(/ ,
Notary ublic
COMMONWEALTH OF PENNSYLVAN
NOTARIAL SEAL
JOAN D. ADAMS, Notary Public
Carlisb 8oro., Cumberland County
Commission Ex fires March 7, 2611
~RRSTQ~VN
B~~
A 7iuclitio~i cf I:,~c~llc~tcc+
i~9av ~?, ~(>1 1
Vvilli~nn A. C)unc.a[1, ~syuirc:
Uunc:~u~ d;. Ilat~tm~tn, I'.C~.
Atlvct~~~y'ti ai f_.~tti~
(,[nc Ire rile fZc~;~
Cr:rlislc;, I'A 1 ?013
(~~ ~ Lstale vf~ Rull~ V. Ycntzcr
Su~ia1 Sccurit_y Numl?cr 2U4-()3-ti821
t71te u ('Death 1 /?_ 7! l l
IT fS I-fERFF3Y CERTIFIEp THAT THE ABOVE NAMED DEC'EI)EN'I' HAD '1'f-f E:
1~{--L.LC-V1~'EN(; f'~C'C:'UL~'TS WITI~[ URRSTUVVIV BA1~Ik:
C_-'lll; CYh'tN(_i .-1 CC'(~ LI,~~T
-- __ _~
Aea~uttt Nu.- 14y000~1G
,1ccc~unt Tvl~c- Mcmey Market
.ic-int Ac:c:uiit[t (natrte.`date)- fro
~~cc•ru~xl Inlerc~t:- ~-2.97
~'~rct-ui-t Nc-.~~ I~yUUU4l ?
.=~c;c~-urtt [~y~-f: 5()-~ Interest Checking
~)~ltl,' Of>~,t-t~t1 I "?i 17iU9
.Ic-itrt A~~~t.-un1 (n~une;"date)- No
~~eer-uerl Irtt~:rt~tii- ~t-.UI
I a[tt tu[ahle to L`a~.u~i~e any bank rc;curds t~ Esl~ate of Ruth V. Ycntzer c;~~~ W' .
f_syuire. It•yc-u w~_-uld Like to upon an estate accuunt, p~case contact a ~II~`ttTt fl. 1:)uncau,
rePretient.ttive at ~'~~ur ric:~lrest Orrslown Bank. We look furw<trd to serv nt7llller ..,~t ~. i~~
~, V<-u an lht future.
a~~t Reb~uds,
~Q ~C~ ' ~ .~ ~~~~ ~ z~~
Jill R. V1'orthiristutt
Deposit Procussin~ Clerk
~~;(~ jj ++
t'li~ai-~~.,~,i., ~~~i~_.. F~-~ ~;~-~ ,,
"1.888.ORRS TOWN
A. Settlement Statement (HUD-1) OMB Approval No 2502-02e5
I. []FHA 2. ~RHS 3. ~Conv. Unins. 6. Fik Number:
7. loan Number: 8. Mortgage Insurance Casc Number:
4 VA S. ^Conv.lns. REI!-18
C. NOTE: This form is furnished W give you a :ptement of actual settlement costs. Amounts paid to and by the settlement agent are shown. !terns
rrssrked "(p.o.c.)" were paid outride the chain
g; they arc shown here for inforrrntional purposes and aro not included in the totals.
D. Name & Addrcs: of Borrower(s):
Mark E. Ritchey E• Name dk Address of Seller(s):
Estate of Ruth V. Yentzer
1 SOI Shcepford Road, Mechanicsburg, PA 17055
3021 Lisburn Road, Mechanicsburg, P~A DOSS
F Name & Address of Lender:
N/A G• Property Location:
3021 Lisburn Road, Mechanicsburg, PA 1')055
Lower Allen Township, Cumberland County
13-2G-0249-010
Place of Settlement: _
1 Irvine Row, Carlisle, Pennsylvania 17013 H. Name of Settlement Agent:
Duncan dt Hartrttan, P.C. (717) 249-7780
I. Closing Date: Disbursement Date:
3-16-2011 2-16-2011
r M !~___ . - . _ _ ~r IaYetlora
follows:
to --
Paid From Paid From
Borrowers Sel)er1
Funds at Funds st
Settlement Settkn+errt
-~~"~.ic sran:rnent otan receipts and disbursements made on---- _~~~~~'° ~~" `" "" °at or my knowledge and hKlief, it is a true
I received a copy of the HUD-I Settlement Statement. ~' accotmt or by me in this tranaaction. 1 ttrrther certdfy that
1
Signature of Borrower Signature of Bortower
The HUD-I Settlement Statement which 1 have prepared is a true and accurate account of the funds dis ursed or to be diabursod by the
undersigned as part (the settlement of this transaction.
/ /
Signature of Settlemen gent
Signatu Seller f '~'~~ JS~~i~~Y~.v1l<~>
Signature of ~ ile ~ g, ~
i