HomeMy WebLinkAbout06-27-111505610143
REV-1500 ~``°'-'°'
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes oErnRTMENr OF REVENUE
Po Box.2soso~ INHERITANCE TAX RETURN 21 10 1272
Harrisburg, PA 1 7 7 28-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
224 22 1434 12 O1 2010 07 06 1924
Decedent's Last Name Suffix Decedent's First Name MI
MAYS EARL P
(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 OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
1. Original Retum ^ 2. Supplemental Return
^ 4. Limited Estate ~ 4a. Future Interest Compromise
(date of death after 12-12.82)
x^ 8 Decedent Died Testate
(Attach Copy of Will) ~ ~• AttacdheCopy of Trust)a Living Trust
^ 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date ~f death
between 12-31- 1 and i-1-95
^ 3, Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
MI
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 SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JERRY A WEIGLE ESQUIRE 717 532 7388
First line of address
126 EAST KING STREET
Second line of address
City or Post Office
SHIPPENSBURG
State ZIP Code
PA
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address:
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.
SI~'ATURE OF PER ON R PONSIBLE FOR FILING RETURN uv, i t
~ UI ~.,,.. ~ ~ ~~- ,~ .~, ~~ Deborah P. Fitzsimmons ~p "-2 ~~~
ADDRESS
SIGN UR OF PREPARER OTHER THAN REPR T IVE DATA ~ /
J rry A. Weigle Esquire (/f/" 2 3`~
ADDRESS
126 East Kin Street, Shi ensbur ,
Side 1
L 1505610143 1505610143
~n
REV-1500 EX
Decedents Name: Mays, Earl P.
Decedent's Social Security Number
224 22 1434
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4.
5.
6.
7.
g. Mortgages & Notes Receivable (Schedule D) ........................................................
Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...............
Jointly Owned Property (Schedule F) ^ Separate Billing Requested............
Inter-Vivos Transfers & Miscellaneous i~oq Probate Property
(Schedule G) U Separate Billing Requested............
Total Gross Assets (total Lines 1-7) ..................................................................... 4.
5.
6.
7.
g.
16 , 319.0 7
6 , 319.07
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 7 , 0 2 5 . 0 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 54 , 702.35
11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 61 , 727.35
12 Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. - 4 5 , 4 0 8 . 2 8
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. - 4 5 , 4 0 8 . 2 8
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15 0.00
(a)(1.2) X .00
16. Amount of Line 14 taxable 0 . 0 0 16. 0 . 0 0
at lineal rate X .045
17. Amount of Line 14 taxable
0 . 0 0
17. 0 . 0 0
at sibling rate X .12
18. Amount of Line 14 taxable 0 . 0 0 18. 0 . 0 0
at collateral rate X .15
19 0 . 0 0
19. Tax Due ................................................................................................................ .
..
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
1505610243
Side 2
155610243 15i]5610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10-1272
DECEDENT'S NAME
Mays, Earl P.
STREET ADDRESS
Shippensburg Health Care Center
121 Walnut Bottom Road
CITY STATE ZIP
Shippensburg PA 17257
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
0.00
(1)
Total Credits (A + B) (2)
0.00
0.00
3. Interest (3)
q. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q)
Check box 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. (5)
~.~~
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 :............................................................................... ^ ^x
b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x
c. retain a reversionary interest; or ............................................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ............................................................ ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without _~
receiving adequate consideration? .................................................................................................................... U
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x
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 January 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)J.
. 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
sibling 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-1508 EX+~6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF (FILE NUMBER
Mays, Earl P. 21-10-1272
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jofntlyowned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 Aetna Life Insurance -medical benefit 1.76
2 Aetna Life Insurance -medical benefit 34.36
3 Aetna Life Insurance -medical benefit 2.65
4 Aetna Life Insurance -medical benefit 6.35
5 County Tax Proration at real estate settlement 0.34
6 Fuel refund at real estate settlement 100.08
7 Lot Fund Proration at real estate settlement 10.32
8 Millville Mutual Insurance Company -return of premium 191.00
9 School Tax Proration at real estate settlement 121.19
10 SKF Pension Plan -final check 345.85
11 M & T Bank Checking Account 97380105 1,505.17
12 1995 Skyline Mobile Home -sold 12-30-2010 14,000.00
TOTAL (Also enter on Line 5, Recapitulation) I 16,319.07
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 EX+(10.06)
a
COMMNHERITANCE T~ R€TUYRN ANIA
RESIDENT DE ED N
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Mays, Earl P. 21-10-1272
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES:
See continuation schedule(s) attached
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Deborah P. Fitzsimmons
Street Address 105 S.M.E.
City Shippensburg State PA Zip 17257
Yearlsl Commission paid 2011
2. Attorney's Fees Weigle 8a Associates, P.C.
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. ~ Probate Fees Register of Wills, Cumberland County
1,000.00
1,700.00
111.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 534.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 7,025.00
3,680.00
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Mays, Earl P. 21-10-1272
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e~nses
1 Fogelslanger-Bricker Funeral Home 3,680.00
H-A 3,680.00
Other Administrative Costs
2 Cumberland Law Journal -advertising Letters Testamentary 75.00
3 Linda K. Klein -notary fee 20.00
4 News Chronicle -advertising Letters Testamentary 96.50
5 Register of Wills, Cumberland County -filing PA Inheritance Tax Return 15.00
6 Register of Wills, Cumberland County -filing First and Final Account 300.00
7 Weigle & Associates, P.C. -reimbursement for postage, xerox copies, and long distance 27.50
telephone calls
H-B7 534.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mays, Earl P. 21-10-1272
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 Adams Electric 49.06
2 Century Link 155.12
3 M & T Bank Checking Account 97380105 -checks clearing bank after date of death and prior 359.51
to closing of account
4 M 8~ T Bank Line of Credit 536001 2,860.92
5 Pharmacare Pharmacy 5,177.58
6 Real Estate Settlement Charges -including realtor's commission - $2,000.00; and repairs - 2,135.00
$135.00
7 Shippensburg Health Care Center 43,749.08
8 Tanner Home & Energy -owed from real estate settlement refund 100.08
9 U. S. Treasury - 2010 1040A federal income tax 116.00
TOTAL (Also enter on Line 10, Recapitulation) ( 54,702.35
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV•1513 EX+ (11-08)
~ q~( E U SCHEDULE J
COMMNHERITA~DEC DENTRNANIA BENEFICIARIES
RESIDE
ESTATE OF ~ I FILE NUMBER
Mavs. Earl P. 21-10-1272
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT
t ist Trustee s (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
~ distributions, and transfers
under Sec. 9116 a 1.2
NOT RELEVANT AS ESTATE IS INSOL
t
Total
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 15 00 cover sheet, as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,•
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS Urv urvt i s ur rcty-i ouu twvtn ar,cc i t
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
LAST' ~/ILL ANI? TESTAI~~'NT'
I, Earl P. Mays, presently residing at 411 ;Tifton Road, Shippensburg, Franklin County,
Pennsylvana 17257, being of sound mind, memory and disposition, do hereby make, publish and
declare this my Last Will and Testament, hereby rev.~~:ing and making void all Wills by me at any
time heretofore made.
FIRST. I order and direct the payment of all my legally enforceable debts and
funeral expenses as soon as maybe convenient after my decease.
SECOND. I give, devise and bequeath all my estate, real, personal and mixed,
whatsoever and wheresoever situate, to my beloved wife, Helen L. Mays, provided that she
survive me by a period of sixty (60) days.
THIRD. In the event that the said Helen L. Mays should predecease me or
is not living on the 60th day following my death, I then give, devise and bequeath all my estate,
real, personal and mixed, whatsoever .and wheresoever situate to my daughters, namely,
Jacqueline R. Warren and Deborah P. Fitzsimmons, in equal shares, on a per stirpes
distribution basis.
FOURTH. I nominate, constitute and appoint Deborah P. Fitzsimmons, presently of
56 Rustic Drive, Shippensburg, Pennsylvania 17257, to be the Executrix of this my Last Will and
Testament. In the event that she be unable to fulfill the duties of Executrix, I then nominate,
constitute and appoint Jacqueline R. Warren to be the Executrix of this my Last Will and
Testament.
FIFTH. I direct that my personal representative(s) shall not be required to give bond
for the faithful performance of their duties in any jurisdiction.
C7VTT7 T .7:...... T_, _. a.,.. ~.. 4,.:... 4L„ `. .p T_..,... A, ~T i_; ,~1 .. T: ,. .., ~
il 1111. 1 llll Ci\+t llly 1..iAC+i+ULVi LV lei LCLllI L11G JNi V1Vi+J Vl Jvil~ i i. YV Ci1~1L~ L..~LIZAli G, Wllll
offices located at 126 East King Street, Shippensburg, Pennsylvania 17257, with respect to the
settlement of my estate due to his familiarity with my affairs.
IN WITNESS WHEREOF, I, Earl P. Mays, have hereunto set my hand and seal to this my
Last Will and Testament, written on two (2) pages, the first page signed for identification only,
this ,~~ _ day of !F~., ,~- , 2006.
,~, ( )
~ -~F~Z.~'' ;;%=~ ~',,~~r%' r;,..~..~./ SEAL
:,T-~ - ,,
i'
VJEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - i26 EAST KING STREET - SHIPPEN SBURG. PA 77257-1397
This instrument was by the Testator, on the date hereof, signed, published and declared by him to
be his Last Will and Testament, in our presence, who at his request and in the presence of each
other, we belie~~ing him to be of sound and disposing mind and memory, have hereunto subscribed
our names as witnesses.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS
I, Earl P. Mays, the person 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; that I signed it willingly; and that I signed it as my free and voluntary act for the
purposes therein expressed.
~r~21 i~ ~`~~~~~ s1
,~
,~7i%vGiii ~r of iiiied tG and acknowledged before
me by Earl P. Mays, the Testator,
this (o"'`~ day of `ju r~ , 200
' TARIAL SEAL
.,.:. , ..
- - ~ J daigla, Notary Public
Sh#n~bur~, i~;~ C;rr ~:~erland County
` - ~ - ~ ... ~fy ~omrra~~~t °~ C~ober 7, 2006
WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 1Z6 EAST KING STREET - SHIPPENSBURG, PA 17257-1397
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
~. ~,,, ~;, ,d
We, ~~~~/ ~~` /C ~ ~.~~,-,~~ ,and ~
the witnesses whose names are signed to the foregoing instrument, bein
F t
F ~~
~,~ ,~ ~ ~ .~,~i
g duly q'~ia~li-fled accordir.
to law, do depose and say that we were present and saw Earl P. Mays, the Testator, sign an
execute the instrument as his Last Will; that he signed willingly and that he executed it as his fre
and voluntary act for the purposes therein expressed; that each of us in the heur~~~;; and sighi c
the Testator, signed the Will as witnesses; and that to the best of our knowledge the Testate
was at the time eighteen (18) or more years of age and of sound mind and under no constraint c
undue influence.
i~
Sworn or affirmed to and subscribed before me
by Miles x. Linn
and Richard I. Johnson
s, this ~o~ day of ~ ~
~ hi(~"tARfAL SEAL
Jerry A, Wey~ie, Notary Public
Shippensburg, ~,a ~.;amberland County
My Commissio; ~ ~;:~ir s October 7, 2006
WEfGLE & ASSOCIATES, P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397
pn~~
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302) 934-2955
January 7, 2011
Weigle and Associates PC
126 East King Street
Shippensburg, PA17257-1397
Re: Estate of Earl P Mavs
Social Security: 224-22-1434
Date of Death: December 1, 2010
Dear Sir or Madam:
Per your inquiry on December 31, 2010, please be advised that at the time of death, the above-named decedent
had on deposit with this bank the following:
1. Type of Account
Account Number
Ownership (Names oj~
Opening Date
Balance on Date of Death
Accrued Interest
Total
2. Type of Account
Account Number
Ownership (Names o, fl
Opening Date
Balance on Date of Death
Current Balance
Checking Account
97380105
Earl P Mays
Helen L Mays
0128/08
$1,505.17
$ .00
$1,505.17
Installment Loan
12044457735536001
Earl P Mays
02/17/09
$2,640.07**This amount is not to be
used for payo, f,~' purposes. For a payof,)"
balance, please call 1-800-724-2440
$2, 687.63 * * This balance is not a payoff'
balance
HOLD DOCUMENT UP TO THE UGH7 TO VIEW TRUE WATERMARI ~ pFFICIAL CHECK ~•~ HOLD DOCUMENT U? TO THE LIGHT TO VIEW TRUE WATERMARK
u r~ N~&~ ~~n~c an ~~ `~ ~----------------- --__- ~~ 2 0 017 0 9 5 0 - 0
BUFF LO NrY a'I4240aders Trust Comp y
10-4/220
- y .r~
a~ ,. ,~- ~_. - ~... DATE . _ _ ..... ~ m;~
REMfTTER -...... ... ... . -.. .~ ^ ._ ' ~ ..... _ oeiain on
PAY TO TH'E ORDER OF ~ $
.~
... e I ._ ~ _4....,... :1..,4 _. .'; if r~' .._. ~-' -,4 ; ~ ~.~, .-. 1 ~~ -... _. :. !_4i„i:?:.:7:`;:'._f .. r .~;. ~4.: _.
~. r
` TWOVAUTHORIZED SIGNATURES REQUIRED FOR AMOUNTS $10,000.00 & OVER
u' 200 L 709 50~~' ~:0 2 2000046: ~ 700 20 L99 2604 7~~'
~ ~~
C~-~~~~
„~, et~:1e1110111 ,S1:c`1101110111: -
A U.S. Department of Housing and Urban Development : I
. OMB royal No. 2502 0265 I
rJ T' a of Loan
OFmh1A 3. ^Conv. Unins. 6. Fle Number
^FhIA 2
1 7.. Loan Number 8: Mortgage Insurance Case Number
.
.
4. VA 5. Colw.lns. 10MAYS e g -
16 n u e a ¢ e a a ~ TiOeExpress Settlement System. .i
C. Note: IW
a enms orlmpordnph' mdse Idle statements to the U^Ratl Sides on This o~enYOdhsr s~mlfs rwm~P d:t ss upon ~g Pht>ted 121.OR010 at.15:05 RLH
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conWdion can Include a Ane end im nsanmenl For deleAS sea: TIAe 1e U. 5. Code Section 1001 end Sedron 10
D. NAME OF BUYER: Nancy C. Tritt - -
ADDRESS: -
:E;NAME OF SELLER: Estate of Earl P. Mays
~'
ADDRESS:
i F. NAME OF LENDER: -
ADDRESS:
1995 Slryline Mobile Home, situate on Lot 86 SME, Slilppensburg, PA~17257 -
ESS
:
G. PROPERTY ADDR
South Central Home SetOement& Inc., Telephone: 717-532-7387 Fax 717 532 6552+ r`.
tl. SETTLEMENT AGENT:
Pre ared on behalf of Seller 126 East Kin Stree ShI ensbur PA97357 ~
PLACE of SETTLEMENT: ~
L SETTLEMENT DATE: 12(3012010
' -
K SUMMARY OF SEL'ER'S TRANSACTION
S TRANSACTION:
SUMMARY OF QUYER
• J -
. GROSS AMOUNT. DUE TC) SELLER
400
100.::GROSS AMOUNT DUE FROM BUYER .
" - ~ ' "14 ODO OD
~`Cgnhactsales rice
401
14 000.00 401. Contrast sales• rice
. 402. Personal ro art
102. Personal roe
- - 50 403
57
103. Settlement she es fo b er ine 1400 . _
.
04 404.
.
1 405.
105. N ,
Ad ustments for Items altl b Salle In advance
Ad'ustments for Items aid b seller In advance 12130110.101211110'' •~'
Count taxes
34 407
107. Count lazes 12/30110 to 12131110 .
.
.
'+ :121 19 •
School Taxes u: 12130110t`0613011:_ ._ -
19 408
121
100. school Taxes 121301101006130111 :
.
A:: 40 92
Lot RenC^ f`. '1?I30110'l0 2131110'
10
32 409
109. Lot Renl 1 213011 0 10 1 21311.10 .
.
100.08 410. 12etundfgrFUeVPro one _ " 100 08
.110. Refund forFueVPro one
:
~ 411. - - *"
:.
:
111.
412.
112.
DUE FROM-BUYER : _
GROSS AMOUNi
i 120
14 231 93
14289.43 420. GROSS AMOUNT DUE TO SELLER
'
.
.
AMOUNTS PAID BY OR ON BEHALF OF BUYER
200 DUE TO SELLER
500. REDUCTIONS IN AMC)UM
. 500.00 501. Excess De osil see.instrudions ;
201. De oslt or earnest mane
• Settlement char es to seller. ine 1400 i _ 7135 00
502
202. Prmci al amount of new leans
• .
E7dstih loan s takeh sub ed to :`.' w ~~ '
503
ect to
203. Exislin loans taken sub .
a Loan ' ~*
504 P off oi:Frst Mad a
204. ~~~
_
- .": ~ "'~ # .1 •1~'
.505.
205. .
,
..:_ :,:
506. -
206. ,
_.
507.
:201:' . _. 508.
200. 509.
~ 209•
Ad'ustmenis for Items un aid b seller A ustments for Items un aid b seller
-
513:
213. _ 514. .
214. 515.'
215. 516. '
216. -
511: , `-`' :
217. .
518.
218. 519
219.: " .
00 520. TOTAL REDUCTION AMOUNT DUE'SELCER ' 135:OC
500
' '220. TOTAL PAID BYIFOR BUYER .
CASH AT SETTLEMENT TO OR FROM SELLER
600
CASH AT SETTLEMENT FROM ORTO BUYER
300 :
9:
14 231
.
` ,
Gross amount due fro 'h er ine 120
301 .
14 289.43 601. Gross amount rhle tg se9er fine 420 ..
0(
135
.
302.' Less amounts aid b lfarbu er line 220 .
500.00 602. less reduction amount due seller hne 520
303. CASFI FROM BUYER 13 789.43 603._CASN TO SELLER .: .. _ 1 096 9:
-
n r11A be tnpo~sedron ylou R Atls Ilam 5 required W beteportotlrendnNe IRS Aetorminesilh~ A lies n61 bean repotted. The GonlFdcl Sales Price desaibe dlor,'e_e. felurn
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line d09 above cmdlWles the Gross Proceeds of this IrenseeAVn.
Tex ID Nc:
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yer Idenglicellon number . ~
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SOUTH CENTRAL HOME SETTLEMENTS ~
EET NESTOGA
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REALESTA
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60-1503.313 Check# 4755
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PAY ~**$12,096.93**
TOTHE Estate of Earl P. Mays
ORDER OF DOLLARS
NINETY SIX DOLLARS and 93/100
TFlELVE THOIISAND
Estate of Earl P. Mays
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MEMO
1995 Skyline Mobile Home, - AIRHOR¢EL SIGNA7UrlE
situate on Lot 86 SME, Shippen urg, PA 17257
lOMAYS
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II^00475511° r:03L315036r: L03 00639LII'
i nave careralry reviewed the HUD-1 Settlement Statement end to the best bF.my knowletlpe end ballet, I[ Is e W e end ecarele statement W ell recei
~ t- In Ihls lrenseetion. I tudher certify that I have recarved a copy W the HUD-1 Settement Statement.
' ptc end disbursements made on my eecount or by me
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;ErTHie 31"ES~7P-1 ~,~1Da ~~,-,~~~ n. ~. ~~., ~ .~
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WARNING: IT IS A CRIME TO I<NOWINGLY MARE FALSE STATEMENTS TO THE The HUD-1 Setlement Statement which I have epered Is a True end accurate account of this lransecllon. ~'~-
UNITED STATES ON THIS OR ANY gMLAR FORM PENALTIES UPON CONVICTION
CAN INCLUDE A FINE AND IMPRISONMENT, FOR DETAILS SEE TITLE 16: I have etl or will cause the funds to a di r In Ecvrdance wllh this detament:
U.S. CODE SECTION 1001 AND SECTION 1010.
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. ur_rnn I MGV I OF HUU5ING ANf1 I IRaaM n~lrc nor,.r.rr - `'=` ="~~ '
- NOTICE OF CLAIM
ESTATE OF Earl Mays
No
To the Clerk of the Orphans' Court Division:
Cumberland
DECEASED
Enter the claim of Shippensburg Health Care Center in the
(Claimant) ~
amount of $ 43,749.08 ,against the above entitled Estate.
The Decedent, who resided at 121 Walnut Bottom Rd.
Shippensburg, PA 17257
(Street Address)
died on December 1,.2010
(Date of Death)
said claim was given to Deborah Fitzsimmons
(Personal Representative or his/her counsel)
at 105 SME Shippesburg, PA 17257
(Address)
on March 29, 2011
(Claimants Counsel)
Written notice of
(Date)
Allison Klimowicz Corp. Ops. Ctr Director
(Claimant)
1710 Underpass ~dJay, Ste 201
(Street Address)
Hagerstown, MD 21740
(City, State, Zip)
(Supreme Court I.D. No.)
(Address)
(Telephone)
(Filed Pursuant to 20 Pa. C . S . § 3532)
COURT OF COMMON PLEAS OF
COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Form OC-07 rev. 10.13.06
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