HomeMy WebLinkAbout08-03-11 (2)1505610143
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POaQO<.2o0e07 IN ~~ T 21 11 0079
tiarrlebwp, PA 1772a-0E07
ENTER D~IT BaT01Ml1AT10N !FLOW
Sodel Seaeigr Number l>•Is d Dsetl~ Dols d Btdh
579 58 7750 11 05 2010 04 20 1943
Deoedent'e Lest Nems SufRx Deoeda-t's Fiat Nams MI
GORD00l~ ]1Z7N iP
(M Applicably Enrr tiurvMnp spouse's hNonnetlon Below
Spouse's Last Name SuRbc Spa»e's Fbet Name MI
Spowe'e SodN Sscurtty Number
THIS RETURN MUST BE FILED IN DUPLICATE WTTH THE
REGISTER OF WILLS
FlLL IN APPROPRUTE OVALS BELOW
X^ 1. OrlpinM Rerun ^ 2. SippNrtienW Rebnn ^ 3, Rannilder RaeRn (der of deelh
pdor b 12-13e2~
^ 4. 1Jm11W I.MMe ^ Cm~m~Ir
,a. j0 i da~iui M 12-722) ^ 6. Fadaral F~rle Tex RNum RequM~d
^ e' ^ 7
~
~~
~
T^~ 0 B. TdM NUn~eMWSeb I*lOMt l~p0l6
(AWMCapyafwip . ~
)
^ 9. LEp~llOn Proossdt ReoMwd ^ ~
q
10.11~~~-i~s~ ~ ^ 11.Sbfi. O)und~r Sec. e113(A)
CCR It!lPOIIDINT • 71eti aECT10N IltltiT EE f~LITED. ALL CORREIPONDENCE AND COI InINTY LL TAX INFORMATrON IIIOULD BE Oe1ECTlD TO:
Nam e Deytlme TeNplwne Number
DQRIaLLSi F H71LEN ~3Q 717 540 4332
Fh~t INn d adrkees
2000 LI>!T(iLEB'POOfN RiQAD
s«~a a.» d.dw..e
StTITa 202
clq~ or Poet oBica
871RRI8BS7RG
REGIBTER~Q UbMDNLY
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Conwpa~derK'e ernNl edkYres:
L 1505610143
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3505610143 J
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2000 LNtpN»Wwn Road, SWb 202, HarrNburp. PA 17110
Side 1
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1505610243
REV-1500 EX
Decedent's Social Security Number
o's~^~ Gordon, Ann W 579 58 7750
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. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 10 , 925.30
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6 , 67 9.96
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous I~oq Probate Property
Se
arate Billin
(Schedule G
Re
uested
) u
p
g
q
............ 7. 13 , 421.32
8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 31 , 02 6.58
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. 10.
11. Total Deductions (total Lines 9 8 10) ................................................................... 11.
12. Net Valus of Estate (line 8 minus Line 11) .......................................................... 12.
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 t3) ............................................... t4.
TAX COMPUTATION -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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 9 348.5 9
~ 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0.00 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 . 0 0 18.
19. Tax Due ..................................................... ............................................................ . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
7,638.38
14,039.61
21,677.99
9,348.59
9,348.59
0.00
420.69
0.00
0.00
420.69
Side 2
150561D243 1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-11-0079
DECEDENTS NAME
Gorton, Ann W
STREET ADDRESS
1000 West South Street
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CredRs/Payments
A. Prior Payments
B. Discount
3. Interest
0.00
4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
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.
Make
to:
OF
(1)
Total Credits (A + B) (2)
(3)
(4j
(5)
420.69
0.00
420.69
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRUITE 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 :.................................. ^
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? .................................................................................................................... x
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? .................................................................................................................. x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A8 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 peroent [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 p2 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 rete 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 bloo~ or adoption.
RW-1607 EX+ (•-96)
SCHEDULE D
MORTGAGES ~ NOTES
RECEIVABLE
co~oNwEA~TN of PENI~SVI.vANIA
INHERRANCE TAX RETIMN
RE6XIENT DECEDENT
ESTATE OF
W
FILE NUMBER
21-11-0OT,9
All prop•ny )oinnyownw vAlh IOM of •urvlvonNNp muse bs asdosW on sch•duN F.
pt more space is rNN:ded, additional papea of the name size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Forth PA-1800 Schedub D (Rev. 6-98)
Rw-160! EXa (~)
SCHEDULE E
CASH, BANK DEPOSITS, 8t MISC.
PERSONAL PROPERTY
COI,RAONVJEALTN OF PENN8YLVANIA
INIfRAANCE TAX RETURN
RESIOEM DECEDENT
ESTATE OF FILE NUMBER
InUUtle the proceeds of lirppaalion atW the Este tlw proceeds were receivetl by the estate.
All property Jolntlyownsd wlth tln r1eM of wrvlvoreMp moat be dledoaed on sehedWe F.
Copyright (c) 2002 form software only Tha Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
(If more space is needed, additional pages of the same size)
R«-~afo Ex. t~el
SCHEDULE G
INTER-VIVOS TRANSFERS ~
MISC. NON-PROBATE PROPERTY
CO-MOrI W EALTH OF vertNanwwu
Na1ERITANCE TA% RET Vial
RESIDENr DECEOEHr
ESTATE OF
Ann W
LE NUMBER
21-11-0079
Thls sehedWe must ba corrpbled and mad if the answer to any of queationa 1 Uxouph 4 on the reverse side of the REV-1500 COVER SHEET is yea.
ITEM
NUMBER DESCREIPTION OF PROPERTY
THE D E OF TR4NF SFRER.SA TACFI A C0~ OFTTHE DEED FOR REAL EsT~n~. DATE OF DEATH
VALUE OF ASSET %OF DECD'S
INTEREST F~CCLUSION
(Ip pppLICABLE) TAXABLE
VALUE
1 TIAA CREFF Account # IF59750-5 -Beneficiary is 4,156.85 4,756.85
Decedent's aon, Karl Gordon
2 TIAA CREFF Account # OU438149 -Beneficiary is 9,264.47 9,264.47
Decedent's son, Karl Gordon
TOTAL (Also enter on Line 7, Recapitulation) I 13,421.32
(If more space is needed, atltlitlonal pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Forth PA-1500 Schedule G (Rev. 6-98)
Rte.„s, ~x+„~„ SCHEDULE H
~~„~~~~~,,,,,,,,~ FUNERAL EXPENSES 8
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Gordon, Ann W 21-71-0079
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 2,1a0.00
B. I ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(sl Commission paid Waived
z. Attomev~s Fees Hazen Elder Law 5,000.00
3. Family Exemption: (If decedent's address is not the same as Gaimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 96.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 401.88
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 7,638.38
Copyright (c) 2009 forth software only The Lackner Group, Inc. Forth PA-1600 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Gorton, Ann W 21-11-0079
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex nses
1 Hoffman-Roth Funeral Home 8 Crematory -Funeral Expense 2,140.00
H-A 2.140.00
Other Administrative Costs
2 Cumberland Law Journal -Estate Notice 75.00
3 Hazen Elder Law -Disbursements g,64
4 Healthport -Research Fee 56.96
5 The Sentinel -Estate Notice Y63,Y8
H-B7 401.88
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rw-1672 FX« (12-0a)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
DO MIAONVJEALTN aF I~ENNSrLVnNIA
x1/1EWTANCE TAx RETURN
RESxXiNT DECEDENT
ESTATE OF FILE NUMBER
Gordon, Ann W 21-11-0079
Rport dabb Ineurrad hY Uta dacadant pRw to death that remalnad unpaid at tM date or daalh, Ineludina unrslmDUnW madleal axptxtasa.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Carlisle Regional Medical Center -Medical Bill 1,050.00
2 Goodwill Fire Rescue EMS -Transportation from Sarah A Todd Memorial Home, Inc. to 200.00
Carlisle Regional Medical Center
3 Nelson & Company P.S., CPAs -Preparation of Decedent's 2009 income taxes 565.00
4 Sarah A. Todd Memorial Home -Nursing home bill 12,224.61
TOTAL (Also enter on Line 10, Recapitulation) I 14,039.61
(K more space is needed, additbnal pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1800 Schedule I (Rev. 12-05)
REV-1677 EX. (77-06)
SCHEDULE J
ooMy[~~4;f~~nr,v, BENEFICIARIES
ESTATE OF
FILE NUMBER
uomon wnn w 21-11-0 079
NUMBER
NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT
SHARE OF ESTATE
AMOUNT OF ESTATE
PERSON(S) RECEIVING PROPERTY (Words) ($ai;)
I
• TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 a 1.2
Karl Gorton Child 1!3 of residue of
3033 5th Ave estate
Parkville, MD 21234
Mario Gordon Child 1/3 of residue of
11 White Birch Lane estate
Mechanicsburg, PA 77050
Robert Gordon Child 113 of residue of
2812 194th Ave KPS estate
Lakebay, WA 98349
Total
Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet as a r o riate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright (c) 2009 form software only The Laekner Group, Inc. Fonn PA-1500 Schedule J (Rev. 11-08)
REGISTER OF WILLS
CUMBERLAND COUNTY
PENNSYLVANIA
CERTIFICATE OF
GRANT OF LETTERS
ADMINISTRATION
No . 20 1 1- 00079 PA No . 21- 11- 0079
Estate Of : ANN W GORDON
/First, Middle, Castl
Late Of : CARL/SLE BOROUGH
CUMBERLAND COUNTY
Deceased
Social Security No: 579-58-7750
WHEREAS, ANN W GORDON
/Fast, Middle, 4st1
late of CARLISLE BOROUGH CUMBERLAND COUNTY
died on the 5th day of November 2010 and,
WHEREAS, the grant of Letters of Administration
is required for the administration of the estate.
THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsyl vania, have
this day granted Letters of Administration to:
MAR/O GORDON
who has duly qualified as ADMINISTRATOR(RIX) of the estate
of the above named decedent and has agreed to administer the estate
according to law, all of which fully appears of record in my office at
CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVAN/A.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 19th day of January 2011.
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
BankofAmerica "'
March 3, 2011
Hazen Elder Law
2000 Linglestown Road, Suite 202
Harrisburg, PA 17110
Dear Nicole M. Kerns:
Bank of America received your request regarding the Estate of Ann W. Gordon, Date of Death
11 /05/2010. Below find the financial information requested on accounts held in the name of the
decedent:
heckin Account Number: * * * * * * * * 5633
ate of Death Balance: 6679.96
ccrued Interest: 0.57
tatus: ~ 5/24/2001
itle: W GORDON
avin s Account Number: * * * * * * * * 563 3
ate of Death Balance: 0.00
ccrued Interest: 0.00
tatus: 5/24/2001
itle: W GORDON
Comments:
No Safe Deposit Box found.
Should you need additional assistance regarding the above named Estate such as obtaining statement
copies or closing accounts, please direct requests to the address noted below:
D
h1A? 0 9 2011 s~
e
~.
------------------------
FINANCIAL SERVN:I-3i
FOR THE GREATER 0000'
www.tiaa-cref.org
July 14, 2011
Hazen Elder Law
2200 Linglestown Road, Suite 202
Harrisburg, PA 17110
Re: TIAA No.: IF59750-5
CREF No.: OU43814-9
Ann W. Gordon, deceased
Dear Mr. Ms Weigel:
I am responding to a request for information for the above referenced annuities.
As requested, enclosed is a copy of a statement, in place of Form 712 for each
annuity.
If you have questions, please call our Telephone Counseling Center at 800 842-
2776 Monday to Friday from 8 a.m. to 10 p.m. ET, and Saturday from 9 a.m. to 6
p.m. ET. To call the toll-free number outside the United States or Canada, use
AT&T's international access code, which is listed on our Web site at www.tiaa-
cref.org/contact/outside_us.html
Sincerely,
~el~,~'lcla~r~y S~wt'ced 7ea~c
Beneficiary Services Team
TIAA-CREF Individual & InstRutional Services, LLC, Member FINRA/SIPC
8500 Andrew Carnegie Blvd, Charlotte, NC 28262
SUBSTITUTE FORM 712
This statement has been prepared as a substitute for U.S. Treasury Department Form 712 which does not apply
to our annu#y contracts or cert~ates since they have no life insurance features.
Name of Fiat Aoauigot Date of Birth Date of Death
DONALD R GORDON 02/27/1941 05/25/2004
Name of second Aoauigat Date of Birth Date of Dath
ANN W GORDON 04/20/1943 11/05/2010
Name of Decedent Date of Birth Date of Death
ANN W GORDON 04/20/1943 11/05/2010
VALUE OF CONTRACT/CERTIFICATE AT DECEDENT'S DEATH
Co~h~act/Cff~
N~~ber I:e of tiiee
Cestir~tct~Certfieste Date of Dew V of
tice
Coatraa~C~~e Investment
in tl~e
+Co~ract/Certif~ate
TIAA No.: IF59750-5 03/01/1997 $ 4156.85 $0
CREF No.: OU43814-9 03/01/1997 $ 9 64.47 $0
Notes:
The Federal Estate Tax Value (Date of Death Value) of an annuity at death is what it would cost the
surviving annuitant or beneficiary to replace the continuing benefits. The value is calculated as of the
date of death and therefore does not change. The value does not represent the cash entitlement a
beneficiary is due and is used solely for estate tax purposes. TIAA-CREF follows accepted industry
standards and procedures in determining the value of payout annuities for the estate of a deceased
annuitant.
The Remaining Investment in the Contract/Certificate represents any remaining after-tax contributions in
the Contract or Certificate owned by the annuitant. The Remaining Investment in the Contract/Certificate
is non-taxable to the surviving annuitant or beneficiary when it is paid.
THE UNDERSIGNED MANAGER OF TIAA-CREF HEREBY CERTIFIES THAT THIS
STATEMENT SETS FORTH CORRECT AND TRUE INFORMATION.
Signature Date
~~~~~~ St~u~ed n~ July l4, 2011
PROMISSORY NOTE
Amount of Loan: $11,000.00
Date: September 27, 2010
FOR VALOE RECEIVED, the undersigned, MARIO R. GORDON, of 11 White Birch Lane,
Mechanicsburg, Pennsylvania 17050 (hereinafter referred to as "Borrower"), hereby promises to pay to the
order of ANN W. GORDON, of 11 White Birth Lane, Mechanicsburg, Pennsylvania 17050 (hereinafter
referred to as "Lender"), in lawful money of the United Stag of America the principal sum of ELEVEN
THOUSAND and 00/100 DOLLARS ($11,000.00), together with interest accruing on the outstanding principal
balance from the date hereof, subject to the terms and conditions set forth below:
1. REPAYMENT TERM. The "Repayment Term" shall be 120 months, beginning October 1,
2010. If, on October 1, 2020, the Borrower still owes amounts under this Note, the Borrower will pay those
amounts in full on that date, which is called the "maturity date." Payments received will be applied to charges,
fees and expenses (including attorneys' fees), accrued interest and principal in any order the Lender may
choose, in her sole discretion. The schedule of payments may be amended to comply with an "actuarially
sound" repayment term (as detemiirted in accordance with actuarial publications of the Office of the Chief
Actuary of the Social Security Administration).
2. INTEREST RATE. Amounts outstanding under this Note will bear interest at a rate of Four
(4%) percent per annum beginning on the 27th day of September, 2010. Interest will be computed on the basis
of a year of 365 days and paid on the actual number of days elapsed. In no event will the rate of interest
hereunder exceed the maximum rate allowed by law.
3. MONTHLY PAYMENT. The Borrower shall repay the loan in equal monthly installments
of principal and interest, with no deferral and no balloon payments made, in the amount of ONE HUNDRED
ELEVEN and 37/100ths ($111.37) Dollars, with the first payment due and payable on October 1, 2010 and
subsequent payments due and payable on the first day of each month thereafter until the entire balance due
hereunder, including principal, interest and any other charges owed by Borrower under this Note are paid.
4. PREPAYMENT RIGHT. At Borrower's option, and in Borrower's sole and absolute
discretion, the indebtedness evidenced by this Note may be prepaid in whole or in part at any time prior to
maturity without premium or penalty.
5. PROHIBITION ON CANCELLATION. Upon the death of the Lender, any balance then
due under this Note shall not be cancelled.
6. DEFAULT AND ACCELERATION. If Borrower fails to comply with any of the payment
obligations herein, and upon thirty (30) days advance written notice to Borrower of such failure, Borrower has
not rectified such default by paying the entire amount then due under this Note, the entire principal balance
under this Note shall become due and payable.
7. RELATIONSHIP. This instrument creates adebtor/creditor relationship between the parties.
It does not create a fiduciary relationship between the parties, and Borrower is under no fiduciary obligation to
Lender.
1
S. NON-ASSIGNMENT. This Note is not an instrument governed by Article III of the Uniform
Commercial Code, is not negotiable and shall not be assigned or endorsed b~ Lender. The Lender shall have
no right and no power to assign or endorse this Note (or the income stream derived from this Note) and any
attempted assignment or endorsement shall be void and ineffective for all purposes. Borrower's obligation
under this Note is to Lender only, or to Lender's estate. Notwithstanding any purported voidness, statutory or
otherwise, of this prohibition of assignment by Lender, under no circumstances shall Borrower have any
obligation under this Note to Lender's purported assigns or transferees, nor shall Lender assign his income
stream from this Note to anyone else, including factors or other prospective secondary market purchasers.
9, MODIFICATION & WAIVER. No modification or waiver of any terms of this Note shal I
be permitted unless evidenced by a written agreement signed by all the parties or their Agents under Power of
Attorney. Failure of the parties hereto to exercise any rights they may have in the event of any default
hereunder shall not constitute a waiver of the right to exercise such rights or any other rights in the event of any
subsequent default, whether of the same or different nature.
10. SEVERABILITY. The unenforceability or invalidity of any provision of this Note shall not
affect the enforceability and validity of the remainder of this Note, which shall continue in full force and effect.
11. BINDING EFFECT. The covenants, obligations and conditions contained herein shall be
binding upon and inure to the benefit of the Borrower, the Borrower's heirs, legal representatives and assigns,
the Lender, the Lender's estate, and not to any other entity.
12. DESCRIPTIVE HEADINGS. The descriptive headings used herein are for convenience of
reference only and are not intended to have any affect whatsoever in determining the rights or obligations under
this Note.
13. GOVERNING LAW. This Note shall be governed, construed, interpreted, and enforced by,
through and under the laws of the Commonwealth of Pennsylvania and the United States of America. It is
intended to comply with federal law requirements of 42 U.S.C. Section 1396p(c)(1)(I), so as not to be
construed as a transfer of assets by Lender to Borrower, and this Note shall be construed in accordance with
applicable federal regulations so as to not be considered a resource of Lender for purposes of any state Medical
Assistance program. The relationship of the Borrower and Lender shall be that of debtor and creditor and
neither shall have a fiduciary obligation to the other.
IN WITNESS WHEREOF, this Promissory Note has been executed, as of the date first above written,
with the intent to be legally bound hereby, by Borrower and Lender on this alas day of~, Two
Thousand Ten (2010).
SIGNED, SEALED, AND WITNESSED
in the presence of:
~~ ~ ~ ~~
~~~ `fir. ~~~
-T
L%ENDER
Robert E. ordon, Agen or
Ann W. Gordon
BORROWER
~~
Mario R. Gordon
2
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
SS:
On ~~ ~~ a~ , 2010, before me a Notary Public for the Commonwealth of
Pennsylvania, personally appeared Mario R. Gordon and Robert E. Gordon, Agent for Ann W.
Gordon, known to me to be the persons whose names are subscribed to the within instrument and
acknowledged that they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
`~ l~n
~ -~y/• ~~
Notary Public
oa4MONweun+ of ~r~v
Noarw s.r
~,~'
~ CAS prykv Au .11 2014
3
Sep 24/2010 Law Office of Marielle F. Hazen Page
Mortgage Amortizatior. .
' Nov 1/1991 to Sep 1/2021
Prepared Fox: gordon
Re: Years 10.00
Principal: 11000.00 Payment 111.37
Rate: 4.0000 Payment Frequency: Monthly
Compounded: 12 Interest Factor 1.003333333
Payment Total Interest Principal Balance Total Int
Date Number Payment Payment Payment Loan Per Year Pei Diem
Oct 27/2010 1 111.37 36.67 74.70 10925.30 36.67 1.21
Nov 27/2010 2 111.37 36.92 79.95 10850.35 73.09 1.20
Dec 27/2010 3 111.37 36.17 75.20 1075.15 109.26 1.19
Dec 31/2010 Sub-Total 109.26
Jan 27/2011 9 111.37 35.92 75.95 10699.70 35.92 1.19
Feb 27/2011 5 111.37 35.67 75.70 10629.00 71.59 1.18
Mar 27/2011 6 111.37 35.91 75.96 10548.04 107.00 1.17
Apr 27/2011 7 111.37 35.16 76.21 10471.63 142.16 1.16
May 27/2011 8 111.37 39.91 76.46 10395.37 177,07 1.15
Jun 27/2011 9 111.37 39.65 76.72 10318.65 211.72 1.19
Jul 27/2011 10 111.37 39.40 76.97 10291.68 296.12 1.19
Aug 27/2011 11 111.37 34.19 77.23 10164.95 280.26 1.13
Sep 27/2011 12 111.37 33.88 77.49 10086.96 319.14 1.12
Oct 27/2011 13 111.37 33.62 77.75 10009.21 347.76 1.11
Nov 27/2011 19 111.37 33.36 76.01 9931.20 381.12 1.10
Dec 27/2011 15 111.37 33.10 78.27 9852.93 919.22 1.09
Dec 31/2011 Sub-Total 919.22
Jan 27/2012 16 111.37 32.84 78.53 9779.40 32.89 1.08
Feb 27/2012 17 111.37 32.58 78.79 9695.61 65.92 1.08
Mar 27/2012 18 111.37 32.32 79.05 9616.56 97.79 1.07
Apr 27/2012 19 111.37 32.06 79.31 9537.25 129.80 1.06
May 27/2012 20 111.37 31.79 79.58 9957.67 161.59 1.05
Jun 27/2012 21 111.37 31.53 79.84 9377.83 193.12 1.04
Jul 27/2012 22 111.37 31.26 80.11 9297.72 224.38 1.03
Aug 27/2012 23 111.37 30.99 80.38 9217.39 255.37 1.02
Sep 27/2012 24 111.37 30.72 80.65 9136.69 286.09 1.01
Oct 27/2012 25 111.37 30.46 80.91 9055.78 316.55 1.01
Nov 27/2012 26 111.37 30.19 81.18 8979.60 346.74 1.00
Dec 27/2012 27 111.37 29.92 81.95 8893.15 376.66 0.99
Dec 31/2012 Sub-Total 376.66
Jan 27/2013 28 111.37 29.69 81.73 8811.92 29.69 0.98
Feb 27/2013 29 111.37 29.37 82.00 8729.92 59.01 0.97
Mar 27/2013 30 111.37 29.10 82.27 8697.15 88.11 0.96
Apr 27/2013 31 111.37 28.82 82.55 8569.60 116.93 0.95
May 27/2013 32 111.37 28.55 82.82 8981.78 145.98 0.99
Jun 27/2013 33 111.37 28.27 83.10 8398.68 173.75 0.93
Jul 27/2013 39 111.37 28.00 83.37 6315.31 201.75 0.93
Aug 27/2013 35 111.37 27.72 83.65 8231.66 229.97 0.92
Sep 27/2013 36 111.37 27.99 83.93 8147.73 256.91 0.91
Oct 27/2013 37 111.37 27.16 89.21 8063.52 284.07 0.90
Nov 27/2013 38 111.37 26.88 89.99 7979.03 310.95 0.89
Dec 27/2013 39 111.37 26.60 84.77 7899.26 337.55 0.88
Dec 31/2013 Sub-Total 337.55
Jan 27/2019 90 111.37 26.31 85.06 7809.20 26.31 0.87
Feb 27/2019 91 111.37 26.03 85.34 7723.86 52.39 0.86
Mar 27/2019 42 111.37 25.75 85.62 7638.29 78.09 0.85
Apr 27/2019 43 111.37 25.96 85.91 7552.33 103.55 0.84
May 27/2019 94 111.37 25.17 86.20 7466.13 128.72 0.83
Jun 27/2019 95 111.37 29.89 86.98 7379.65 153.61 0.82
Jul 27/2019 46 111.37 29.60 86.77 7292.88 178.21 0.81
Auq 27/2014 47 111.37 29.31 87.06 7205.82 202.52 0.80
Sep 27/2014 98 111.37 29.02 87.35 7118.97 226.59 0.79
Oct 27/2019 99 111.37 23.73 87.69 7030.83 250.27 0.79
Nov 27/2019 50 111.37 23.49 87.93 6992.90 273.71 0.76
Dec 27/2014 51 111.37 23.19 88.23 6854.67 296.85 0.77
Dec 31/2019 Sub-Total 296.85
Jan 27/2015 52 111.37 22.65 88.52 6766.15 22.85 0.76
Feb 27/2015 53 111.37 22.55 88.82 6677.33 95.40 0.75
Mar 27/2015 59 111.37 22.26 89.11 6588.22 67.66 0.79
Apr 27/2015 55 111.37 21.96 89.91 6498.81 89.62 0.73
May 27/2015 56 111.37 21.66 89.71 6409.10 111.28 0.72
Jun 27/2015 57 111.37 21.36 90.01 6319.09 132.69 0.71
Jul 27/2015 58 111.37 21.06 90.31 6226.78 153.70 0.70
Aug 27/2015 59 111.37 20.76 90.61 6138.17 179.46 0.69
Sep 27/2015 60 111.37 20.96 90.91 6047.26 199.92 0.68
Jct 27/2015 61 111.37 20.16 91.21 5956.05 215.08 0.67
Nov 27/2015 62 111.37 19.85 91.52 5864.53 239.93 0.66
7ec 27/2015 63 111.37 19.55 91.82 5772.71 254.48 0.65
>ec 31/2015 Sub-Total 259.48
Sep 24/2010
' Law Office of Marielle F. Hazen
Mortgage Amortization
Nov 1/1991 to Seo 1/2021 Paqe
~ ,
Prepared For. gordon
Re: Years 10.00
Principal: 11000.00 Payment 111.37
Rate: 4.0000 Payment Frequency: Monthly
Compounded: 12 Interest Factor 1 003333333
Payment Total Interest Principal Balance Total Int
Date Number_ Payment Payment Payment Loan Per Year Per Diem
Jan z7/2016 64 111.37 19.29 92.13
Feb 27/2016 65 111.37 18.99 92.93
Mar 27/2016 66 111.37 18.63 92.79
Apr 27/2016 67 111.37 18.32 93.05
May 27/2016 68 111.37 18.01 93.36
Jun 27/2016 69 111.37 17.70 93.67
Jul 27/2016 70 111.37 17.38 93.99
Aug 27/2016 71 111.37 17,07 94.30
Sep 27/2016 72 111.37 16.76 94.61
Oct 27/2016 73 111.37 16.99 94.93
Nov 27/2016 74 111.37 16.13 95.29
Dec 27/2016 75 111.37 15.81 95.56
Dec 31/2016
Jan 27/2017 76 111.37 15.99 95.88
Feb 27/2017 77 111.37 15.17 96.20
Mar 27/2017 78 111.37 19.85 96.52
Apr 27/2017 79 111.37 19.53 96.89
Hay 27/2017 80 111.37 19.20 97.17
Jun 27/2017 81 111.37 13.88 97.99
Jul 27/2017 82 111.37 13.56 97.81
Auq 27/2017 83 111.37 13.23 98.19
Sep 27/2017 89 111.37 12.90 98.97
Oct 27/2017 85 111.37 12.57 98.80
Nov 27/2017 86 111.37 12.29 99.13
Dec 27/2017 87 111.37 11.91 99.46
Dec 31/2017
Jan 27/2018 88 111.37 11.58 99.79
Feb 27/2018 89 111.37 11.25 100.12
Mar 27/2018 90 111.37 10.92 100.95
Apr 27/2018 91 111.37 10.58 100.79
May 27/2018 92 111.37 10.25 101.12
Jun 27/2018 93 111.37 9.91 101.96
Jul 27/2018 99 111.37 9.57 101.80
Auq 27/2018 95 111.37 9.23 102.14
Sep 27/2018 96 111.37 8.89 102.98
Oct 27/2018 97 111.37 8.55 102.82
Nov 27/2016 98 111.37 8.21 103.16
Dec 27/2016 99 111.37 7.86 103.51
Dec 31/2018
Tan 27/2019 100 111.37 7.52 103.85
?eb 27/2019 101 111.37 7.17 109.20
Oar 27/2019 102 111.37 6.82 109.55
1pr 27/2019 103 111.37 6.98 109.69
!ay 27/2019 109 111.37 6.13 105.24
tun 27/2019 105 111.37 5.77 105.60
Sul 27/2019 106 111.37 5.92 105.95
mq 27/2019 107 111.37 5.07 106.30
:ep 27/2019 108 111.37 4.72 106.65
pct 27/2019 109 111.37 4.36 107.01
ov 27/2019 110 111.37 9.00 107.37
sec 27/2019 111 111.37 3.65 107.72
ec 31/2019
an 27/2020 112 111.37 3.29 108.08
eb 27/2020 113 111.37 2.93 108.94
ar 27/2020 119 111.37 2.56 108.81
pr 27/2020 115 111.37 2.20 109.17
ay 27/2020 116 111.37 1.84 109.53
un 27/2020 117 111.37 1.47 109.90
~1 27/2020 118 111.37 1.11 110.26
~q 27/2020 119 111.37 0.74 110.63
ap 27/2020 120 111.37 0.37 111.00
:incipal Paid to Date
iterest Paid to Date
~tal Paid to Date
11000.00
2369.90
13369..90
5680.58
5588.15
5995.41
5402.36
5309.00
5215.33
5121.34
5027.09
9932.93
9837.50
9742.26
4696.70
Sub-Total
4550.82
9459.62
4358.10
4261.26
9169.D9
9066.60
3968.79
3870.65
3772.18
3673.38
3574.25
3979.79
Sub-Total
3375.00
3279.88
3179.93
3073.69
2972.52
2871.06
2769.26
2667.12
2569.69
2961.82
2358.66
2255.15
Sub-Total
2151.30
2097.10
1992.55
1837.66
1732.92
1626.82
1520.87
1414.57
1307.92
1200.91
1093.59
985.82
Sub-Total
877.79
769.30
660.99
551.32
991.79
331.89
221.63
111.00
0.00
19.29
38.16
56.81
75.13
93.14
110.89
128.22
195.29
162.05
178.49
194.62
210.93
210.93
15.99
30.66
95.51
60.09
74.29
88.12
101.68
114.91
127.81
140.38
152.62
164.53
164.53
11.58
22.83
33.75
99.33
59.58
64.49
74.06
83.29
92.18
100.73
108.94
116.80
116.80
7.52
19.69
21.51
27.99
34.12
39.89
45.31
50.38
55.10
59.46
63.96
67.11
67.11
3.29
6.22
8.78
10.98
12.82
19.29
15.90
16.19
16.51
0.64
0.63
0.62
0.61
0.60
0.59
0.58
0.57
0.56
0.55
0.59
0.52
0.51
0.50
0.99
0.98
0.97
0.46
0.45
0.99
0.43
0.42
0.91
0.40
0.39
0.37
0.36
0.35
0.39
0.33
0.32
0.31
0.30
0.29
0.27
0.26
0.25
0.29
0.23
0.22
0.21
0.19
0.18
0.17
0.16
0.15
0.19
0.13
0.11
0.10
0.09
0.08
0.07
0.05
0.09
0.03
0.02
fi O.E.
Sep 29/2010 Law Office of Marielle F. Hazen Paqe
~ Mortgage Amortization
`" Nov 1/1991 to Sep 1/2021
Prepared For: gordon
Re: Years 10.00
Principal: 11000.00 Payment 111.37
Rate: 9.0000 Payment Frequency: Monthly
C~ounded: 12 Interest Factor 1 003333333
Payment Total Interest Principal Balance Total Int
Date Number Payment Payment Payment Loan Per Year Per Diem
REPORT SELECTIONS
Report:
Layout Template:
Requested by:
Finished:
Date Range:
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Principal:
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Mortgage Amortization
All
ADHIN
Friday, September 29, 2010 at 09:09:91 PM
Nov 1/1991 to Sep 1/2021
gordon
All
11D00.00
9.00
111.37
6.60e