HomeMy WebLinkAbout09-09-11 (2)- I 1505611185
REV-1500 EX (02-11) (FI)
OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes
Po Box 28oso1 INHERITANCE TAX RETURN ~ ~ 1 ~ ~~ (,
Harrisburg, PA 17128-0601 RESIDENT DECEDENT Q
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
207-28-8525 10172010 01],91936
Decedent's Last Name
CAMPBELL
Suffix Decedent's First Name
PATRICIA
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
RE~lS~E~ ~~ \ll~lLLS
MI
K
MI
FILL IN APPROPRIATE BOXES BELOW
X^ 1. Original Return ~ 2. Supplemental Return ^ 3. Remainder Return (Date of Death
^ 4
Limited Estat
^
4
F
I Prior to 12-13-82)
^
.
e a.
uture
nterest Compromise (date of 5. Federal Estate Tax Return Required
6
Decedent Died Testate
^ death after 12-12-82)
7
Decedent M
int
i
Li
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i
T
t
8
T
. .
a
a
ne
v
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ng
rus .
otal 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 Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ROBERT L• DLUGE, JR•, ESQ 570-672-2536
First Line of Address
1,33 MT- CARMEL AVENUE
Second Line of Address
P•0• BOX 304
City or Post Office State ZIP Code
ELYSEI!PG PA 17824
Correspondent's a-mail address:
REGISTER OR;V~LLS USE ONLY`-
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D3pFE FILED ~+ `.,~
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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 rrect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG OF P ON R ONSIBLE FOR FILING RETURN DATE
ADDR
257 OUTHLA E DRIVE, ST• AUGUSTINE, FL 32092
SIG R PREPA ER OTHER THAN REPRESENTATIVE DA E
~ _~- ~ ~
P•0• ELYSBURG, PA 17824
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611185 1505611185 J
OW4647 3.000
~Y f~~~'l
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J
1505611285
REV-1500 EX (FI)
Decedent's Social Security Number
207-28-8525
Decedent'sName: PATRICIA K • CAMPBELL
RECAPITULATION
1. Real Estate (Schedule A) 1 121, , O O 0.O 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. 4 , 71 O • O 5
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6. 911, • 01
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested 7.
8. Total Gross Assets (total Lines 1 through 7) 8 12 6 , 6 21.0 6
9. Funeral Expenses and Administrative Costs (Schedule H) . g, 6 , 2 2 3.3 5
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) i o. 8 9 , 7 0 2 -2 6
11. Total Deductions (total Lines 9 and 10) , 11 9 5 , 9 2 5.61
12. Net Value of Estate (Line 8 minus Line 11) _ 12 3 O , 6 9 5. 4 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. 3 O , 6 9 5.4 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
15.
16. Amount of Line 14 taxable
at lineal ratex.o4.i 30, 695.45 1, 381.30
i6
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15
18.
19. TAX DUE 19.
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505611285 1505611285
OW4648 3.000
1, 381.30
J
REV-1500 EX (FI) Page 3
Decedent's Complete Address
File Number 21-10 -1218
DECEDENTS NAME
PATRICIA K• CAMPBELL
STREET ADDRESS
112 TOUCHSTONE DRIVE
CITY
CARLISLE STATE
PA ZI P
17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
(1)
Total Credits (A + B) (2)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in 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.
(3)
(4)
(5)
1,381.30
1,381.30
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 ^
b. retain the right to designate who shall use the property transferred or its income ^
c. retain a reversionary interest ^
d. receive the promise for life of either payments, benefits or care? ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ^
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 GIUESTIONS 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. §91 16 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §91 16(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(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.
OW4671 2.000
REV-1502 EX + (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF:
FILE NUMBER:
PATRICIA K. CAMPBELL 21-10-1218
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
~~ Real estate situate at 112 Touchstone Drive, Carlisle, Cumberland
County, Pennsylvania, more fully set forth in Instrument No.
200744515. Valuation based upon the sale of the same. 121,000.00
TOTAL (Also enter on Line 1, Recapitulation.) I $ 121 000 00
OW4695 1.000 If more space is needed, use additional sheets of paper of the same size. ,
REV-1508 EX+ (11-10)
pennsylvania SCHEDULE E
DEPARTMENTOF REVENUE CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
PATRICIA K. CAMPBELL 21-10-1218
Include the proceeds of litigation and the date the proceeds were received by the estate.
All ro ert 'ointl owned with ri ht of survivorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 1. Checking Account #0537772873 with Metro Bank 4,710.05
TOTAL (Also enter on line 5, Recapitulation) $ ~ 4, 710 05
owasAD 2.00o If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
PATRICIA K. CAMPBELL 21-10-1218
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. Lori A. Smith 257 Southlake Drive Daughter
St. Augustine, FL 32092
B.
C.
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET ~o OF
DECEDENTS
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1. A. Checking Account #1000099476888
with SunTrust Bank 1,822.02 50~ 911.01
TOTAL (Also enter on Line 6, Recapitulation) $ 911.01
OW46AE 1.000 If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania
DEPART~vIENTOF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
PATRICIA K. CAMPBELL
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
21-10-1218
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Craig Funeral Home, Inc. 2,251.00
2. St. Patrick's Church 475.00
3. Molesevich Monuments 95.00
4. U.S. Postal Service 215.85
5. Carlisle Fairgrounds 700.00
6. Memorial service notices 286.65
B.
1
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State
ZIP
2. Attorney Fees: 1, 500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
4.
5.
6.
7.
8.
9.
City State ZIP
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
The Sentinel
Cumberland Law Journal
Federal-Express
323.50
263.28
75.00
38.07
TOTAL (Also enter on Line 9 Recapitulation) ~ $ 6 , 223 35
owasAG i.ooo If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
SCHEDULE
DEPARTMENT OF REVENUE DEBTS O F DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATRICIA K. CAMPBELL 21-10-1218
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. UGI Gas Service 166.51
2. PPL Electric Utilities 429.48
3. South Middletown Township Municipal Authority 226.86
4. Lori Smith - reimbursement 1,229.49
5. Allstate Insurance 504.00
6. CitiMortgage, Inc. - mortgage payments 4,548.98
7. T Mobile 84.78
8. U-Haul and gas 1,205.98
9. CenturyLink 159.32
10. Target Visa 350.34
11. Sears Mastercard 21.11
12. Macys 319.44
13. Sears Card 620.77
14. FIA Card 1,233.79
15. American Express 133.35
16. The Bon Ton 221.62
17. JC Penney 185.24
18. CitiMortgage, Inc. - mortgage payoff 67,320.03
19. Wolf & Company - realtor's commission 3,630.00
20. Prudential Homesale Services - realtor's commission 3,630.00
21. Robert Cairns, Tax Collector 1,029.15
22. Recorder of Deeds - 1$ transfer tax 1,210.00
23. Alachua Co. Dept. Public Safety 459.75
24. Apria Healthcare 43.88
25. Walnut Bottom Radaiology LLC 35.00
26. University of Florida Physicians 437.79
27. Radiation Oncology at Shands Medical Plaza 165.60
28. Baptist Medical Center 100.00
TOTAL (Also enter on Line 10
89,702.26
OW46AH 1.000 If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF:
FILE NUMBER:
YAiKl(:lA K. (:AMPl31~LL 21-10 -121$
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1.
1. Lori Ann Smith Daughter 1/2 residuary
257 Southlake Drive
St. Augustine, FL 32090
2. Lisa Ann Engdahl Daughter 1/2 residuary
2944 South Nebraska Street
Chandler, AZ 85248
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE.
~~ NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECl10N 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
OW46A1 1.000
LAST WILL AND TESTAMENT
OF
PATRICIA K. CAMPBELL
CARLISLE,
CUMBERLAND COUNTY, PENNSYLVANIA
I, PATRICIA K. CAMPBELL, of One Eastwick Lane, Carlisle,
Cumberland County, Pennsylvania, do make, publ~~sh and declare this
to be my Last Will and Testament, hereby rev~aking all Wills and
Codicils at any time heretofore made by me.
F IDST : I direct that ~r~y funeral be conducted in a
manner corresponding with my estate and situation in life and that
all costs of administration and my funeral ex~~enses be fully paid
and satisfied as soon after my death as practicable. I further
direct that I be interred in my cemetery lot situate at St. Mary's
Cemetery, Kulpmont, Pennsylvania.
SECOND: I give, devise and bequeath my entire estate,
whether real, personal or mixed, of whatsoever nature or kind and
~..~heresoever the same shall be situate at the time of my death, in
equal shares unto my daughters, Lori .Ann Smith, of 127 Partridge
Circle, Carlisle, Pennsylvania, and Lisa Ann Martinez, of 3944
South Nebraska Street, Chandler, Arizona. In the event that either
of my said daughters shall predecease me, I direct that their share
shall be distributed to their remaining, surviving issue, per
stirpes, as determined as of the date of my death. In the event
that she shall leave no remaining, surviving issue, I direct that
her share shall lapse and be distributed to my :remaining, surviving
daughter as determined as of the date of my death.
In the event that both of my said daughters shall
predecease me and leave no remaining, surviving issue, I give,
--r
--~ - 1 -.
:" ' .;
PATRICIA K. CAMPBELL
devise and bequeath the same unto my brother, David Nemeth, of Camp
Hill,. Pennsylvania.
THIRD: In the event that a minor shall become a
beneficiary under this my Last ti~dill and Testament, I nominate,.
constitute and appoint my remaining, surviving daughter as Guardian
of the Estate of such minor(s) and direct that any legacy or share
to which the said minor may become entitled to from my estate or
from any life insurance which I may have, shall be placed in
separate trust for them and may be invested or• retained in a bank
account or accounts as to the said Guardian, in her sole
discretion, shall deem proper; and authorize her to accumulate or
expend such parts of the income and principa~_ as to she, in her
sole discretion, may appear to be necessary for all educational
expenses of the said minor(s), with any balances remaining in the
hands of the said Guardian to be distributed t:o the said minor(s)
upon their attaining the age of 21.
In the event that both of my s~~id daughters shall
predecease me, be unable or refuse to act as said Guardian of the
Estate, I nominate, constitute and appoint my brother, David
Nemeth, to act in their stead, with all the rights, powers and
duties as aforesaid.
FOURTH: I direct that all estate, i7lheritance and
succession taxes, whether on property passing under this will or
otherwise, shall be paid out of the principal of my residuary
estate as .if Sllch taxes ~•~ere PXpens.es c,f arum; ni:;tr~ti ~=-,, and all
property passing by reason of my death and all .Legacies, devises
and other gifts of principal and income made by this, my Last Will
and Testament, or by any Codicil hereto, shall k~e free and clear
thereof. Ire the absolute discretion of rr~y Executor and Trustees,
they may pay such taxes immediately, or they may postpone the
_.---
~ " i' .,
.=_•_ .- r
.. ~• , ; ,.
~PATRICIA K. CAMPBELL
payment of the taxes on future or remainder interests until the
time the beneficiary is entitled to possession thereof. I give my
Executors and Trustees full power o agree with any taxing
authority upon a compromise of any tax due from or upon my estate
or upon any devise, legacy or interest given or created by this
will.
FIFTH: I nominate, constitute and appoint my daughter,
Lori Ann Smith, as Executrix of this my Last Will and Testament and
direct that she shall not be required to enter security in any
jurisdiction in which she may act. In the event that my daughter,
Lori Ann Smith, shall predecease me, be unable or refuses to act, I
nominate, constitute and appoint my daughter, Lisa Ann Martinez,
as Executrix of this my Last Will and Testament and direct that she
shall not be required to enter security in any jurisdiction in
which she may act. In the event that my daughter, Lisa Ann
Martinez, shall predecease me, be unable or refuses to act, I
nominate, constitute and appoint my brother, David Nemeth, as
Executor of this my Last Will and Testament and direct that he
shall not be required to enter security in any jurisdiction in
which he may act.
PATRICIA K. CAMP.~3~~LL
IN WITNESS WHEREOF, I,
hereunto set my hand and seal
Testament, typewritten on three (3)
which I have also written my
~1'-`.k.~~4 ~ 2000.
PATRICIA K. CAMPBELL, have
to this, my Last Will and
sheets of paper, upon each of
name, this `-~'~' ~~~ day of
PATRICIA K. CAMPB-ALL
COMMONWEALTH OF PENNSYLVANIA SS
COUNTY OF NORTHUMBERLAND
I, PATRICIA K. CAMPBELL, testatrix, whose name is signed to the
attached or foregoing instrument, having bE~en 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.
--1 ~ ..;
~_ ~
-(~ ..t ~ l
PATRICIA K. CAMPB~~ L
Sworn or affirmed to and acknowledged before me,
Campbell, the testatrix, this `~1~~'~~ day of 4~~~:;\~"""~_ v'1
~'
ii l f ~ . ~~ if ~ (/ // 1
~ i . { l/{/ ~ %.
- j ivo ary F~
My Commission Expires . M;ti~({~~~."~"~"~ ='~`~° y'~~~ p
1 (R.{'~' ! .2. M~L.'LL:~.:t,Lr~'i'.J i~Y:i~~P~/ i U'A~'l:'P,
~r:.`A ~...n!A~~.,•sut.twM~=AM1x.;carARHrmr~lr::.trK.r.'rY~Y~•••v_
COT~Il`'TONWEALTH CF PET~TNSYLVAi1IA
SS
COUNTY OF NORTHUMBERLAND .
Patricia K.
2000.
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,>~ - ~~ lam' II
lic
WE, Robert L. Dluge, Jr., Esquire, and Kathy R. Reader, the
witnesses whose named are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the 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 voluntary act
for the purposes therein expressed; that each of us in the hearing.
and seeing of the testatrix signed the will a:~ witnesses; and- that
to the best of our knowledge, the testatrix was at the time 18 or
more years of age., of sound mind and under no constraint or undue
influence.
._~
Sworn or affirmed to and subscribed to before me by Robert L.
Dluge, Jr . , Esquire, and Kathy R. Reader, witnesses, this ~ ~ j ` da
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.
No,~ary Public
My Commission Expires . 'L~+.i.ri+r...:.ds„~~,~:,,-.. ~...~..:, .r...»:,,-,:.,...~.,.~....~:~~.~..:......~ ;:
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w,grs~sam.~o...nuu.^z.araw+w ~yc.u.ar.r:::.~ ss. • w~.y,---~~~--~•-.•••..._n:ww
A. Settlement Statement
U.S. Department of Housing and Urban Development
r,..~ ~_...,,,...~ ni,. ~~r»_rna~
T t
I. ^FHA 2. OFmHA 3. ^Conv. Uruns. 6. File Number 7. Loan Ntunber 8. Mortgage Insurance Case Number
4 ov o ~ 011-129
This form is fumished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. TitleEx ress Settlement S stem
C. Note: Items marked "(p.o.c.)" were paid outside the closing; they are shown here for Information purposes and are not included in the totals. P y
WARNING: Il is a crime to knowingly make false statements to the United States on this or an other similar tone. Penalties upon 117/26/2011 at 16' 18 KSC
D. NAME OF BORROWER: Douglas Fornwalt and Darlene C. Fornwalt
E. NAME OF SELLER: Estate of Patricia K. Campbell
F. NAME OF LENDER: N/A
G. PROPERTY ADDRESS: 112 Touchstone Drive, Carlisle, PA 17013
S tit iddleton Towns '
H. sET-rCEMENT AGENT: PA Real Estate Settlement Services, LLC, Telephone: 717-249-6333 Fax: 717-249-7334
4 e a
07/2 /
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY O ELLER' TRANSACTION:
F
121 000.00 121,000.00
2 439.13
r. i ' ladvance
y
07 26 11 12 31 11 123.30 07 26 11 12 31 11 123.30
07 26 11 06 30 12 954.19 07 26 11 06 30 12 954.19
1 124 516.62 122,077.49
R
9,559.15
67,320.03
Citimort a e
1
I
I 76,879.18
f
124 516.62 122 077.49
76 879.18
sns cases FROM BORROWER _ 124 516.62 45 198.31
SUBSTITUTE FORM 1099 SELLER STATEMENT: The information contained herein is important tax Intonnation and is being fumished to the Internal Revenue Service. If you are required to file a return,
a negligence penalty or other sanction will be Imposed on you if this item is required to be reported and the IRS delennines that It has not been reported. The Contract Sales Price described on
line 01 above constitutes the Gross Proceeds of this transaction.
You are required bylaw to provide the settlement agent (Fed. Tax ID No: )with your correct taxpayer identification number. If you do not provide your correct taxpayer identiflwlion
number, you maybe sublecl to civil or criminal penalties imposed bylaw. n ar pens ties o penury, I certify that the number shown on this statement is my correct taxpayer Identification number.
TIN: / - SELLER(S) SIGNATURE(S): /
noccc
SELLER(S) PHONE NUMBERS: (H) (W)
TOfRI HUU-l t:5/L'ti) reT HanODOOK 4:SU~.L
rrewous saloons are oosoiete
U.S. DEPARTMENT OF HOUSMG AND URBAN DEVELOPMENT File Number: 2011-129 PAGE 2
~c.~u ver•
SETT EMENT STATEMEN I
PAID FROM
PAID FROM
121 000.00 6.000 = 7 260.00 BORROWER'S SELLER'S
FUNDS AT FUNDS AT
3 630.00 Wolf & Com an SETTLEMENT SETTLEMENT
3 630.00 Prudential Homesale Services Grou
7 260.00
0
0
T F
0.00 0.00
Note Clerk 5.00
Old Re ublic Central Penn SH 1 060.13
121 000.00 - 1 060.13
T R N A
64.00 64.00
1 210.00 1 210.00
1 210.00 1 210.00
South Middleton Townshi 40.00
Salzmann Hu hes P.C. 20.00
Title Ins actions P.O.C. 325.00 Bu er
Robert Cairns Tax Collector 1 024.15
_
Robert Cairns Tax Collector 5.00
Summerfield HOA 100.00
T nu wor+cc r....~.,...., r..e~ Ana Ca~finn .I and Fro Swctinn Kl _ 2 439.13 9 559.15
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUD- Settlement Slate n d to the bast of my knowledge and belief, it Is a true and accurate statement of all receipts nd disbursements made on my account or by me
irythis tra section. I fyrther certif at I have receive he HUD-1 Settlement Statement. ~ yr -
D as Fomw ~ II .. OarteDe~: Fornwalt """
Estate of Patricia K. Campbell
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction.
UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION I have caused or will cause the funds to be disbursed in accordance with this statement.
CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18:
U.S. CODE SECTION 1001 AND SECTION 1010. ~'