HomeMy WebLinkAbout01-23-121505610140
REV-1500 EX (01-10)
PA Department of Revenue ~ '~~~ ~'~~'
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 1712&0601 RESIDENT DECEDENT 2 1 1 1 0 5 4 2
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 8 4 1 2 4 8 3 0 0 4 2 4 2 0 1 1 1 2 2 3 1 9 2 2
Decedent's Last Name Suffix Decedent's First Name MI
C L E M E N T S H L O U I S E
(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 WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
0 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required
death after 12-12-82)
^X 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. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
D A V I D H S T O N E E S Q U I R E 7 1 7 7 7 4 7 4 3 5
First line of address
4 1 4 B R I D G E S T R E E T
Second line of address
City or Post Office
N E W C U M B E RL A N D
State ZIP Code
REGISTER O~ ILLS USE OAH.Y
r.-r„y
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P A 1 7 0 7 0
Correspondent's a-mail address: D S T O N E a~ S T O N E L A W. N E T
.fi'
Under penalties of perjury, I declare that 1 have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG URE OF PERSON RESP NSIBL OR FILING R RN DATE
ADDRESS _ '
1350 MA LE COURT NEW CUMBERLAND PA 17070
SI UR F P RE THER THAN REPRESENTATIVE DATE
414 BRIDGE STREET NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
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REV 1500 INHERITANCE TAX RETURN RESIDENT DECEDENT
Estate of: H. Louise Clements File No. 21-11-0542
Additional Signature and Address of Co
l~t-cl
1476 Maplewood Dr. , New Cumb'erlar3tY, PA 17070
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: H LOl1ISE CLEMENTS 1 8 4 1 2 4 8 3 0
RECAPITULATION
1. Real Estate (Schedule A) ......................................... .. 1. 1 4 3 0 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. 3 3 2 8 . 5 5
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... , . 6. 1 7 4 6 7 1 • 0 3
7. Inter-Vivos Transfers 8 Miscellaneous N
Probate Property
~
(Schedule G) Separate Billing Requested ..... .. 7. 0 . 0 0
8. Total Gross Assets (total lines 1 through 7) ......................... .. 8. 3 2 0 9 9 9 • 5 8
9. Funeral Expenses and Administrative Costs (Schedule H) ................. . 9• 3 9 5 1 6 . 2 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ . 10. 6 0 8 5 • 9 5
11. Total Deductions (total Lines 9 and 10) .............................. . 11. 4 5 6 0 2 . 2 3
12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 2 7 5 3 9 7. 3 5
13. Charitable and Governmental BequestslSec 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. 2 ~ 5 3 9 7. 3 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)(t.2) x• 4 D. 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate x• 0 4 5 2 7 5 3 9 7. 3 5 16. 1 2 3 9 2. 8 8
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 18. 0. 0 0
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
1 2 3 9 2. 8 8
1505610240
J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 11 0542
DECEDENT'S NAME
_H_ L O U I S E___C L E M E N T_S ________..-___-_.___ __._____ __
STREETADDRESS
525 GRANDVIEW AVE_
CITY-~ ------ --J- --~-'- STATE ZIP
CAMP HILL ~ PA ~17011-
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments 12 , 0 0 0.0 0
B. Discount 619.6 4
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
12,392.88
Total Credits (A + B) (2) 12 , 619.6 4
(3)
0.00
(4} 226.76
(5) 0.00
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 Na
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 ................................................................................................ ^ 0
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ Q
3. Did decedent own an 'in trust for' orpayable-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? .................................................................................................. ^
tF 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
3 percent [72 P.S. §9116 (a) (1.1) (i)j.
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)j. 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)}.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneftciaries 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, unde
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
H LOUISE CLEMENTS 21 11 0542
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 OF DEATH
DESCRIPTION
1 Property located at 525 Grandview Ave Camp Hill, 143,000.00
Wormleysburg Borough, Cumberland County, PA sold
to Shane Norford, single individual and Maja Bozic,
single individual, as j/t/w/r/o/s on October 28,
2011
TOTAL (Also enter on Line 1, Recapitulation.) I $ 14 3 , 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 PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
~N RESIDE TEDECEDE TRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
H LOUISE CLEMENTS 21 11 0542
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of su-vivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Household goods sold by Rowes Auction 1,711.55
2- Personal property sold by Cordier Antiques & 1,252.00
Auctions on September 23, 2011 and September 30, 2011
3• Silver coins sold by R• Cooper Coins 3b5.OD
TOTAL (Also enter on line 5, Recapitulation} 13 3 , 3 2 8 • 5
(If more space is needed, insert additional sheets 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:
H LOUISE CLEMENTS 21 11 0542
If an asset was made 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. DONNA LOUISE NISSEL 1350 SUGAR MAPLE COURT Daughter
NEW CUMBERLAND, PA 17070-
B. DIANE MARIE WAY 1476 MAPLEWOOD DRIVE Daughter
NEW CUMBERLAND, PA 17070
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 % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1• A,B 1/23/10 Members 1st FCU-Cert of Deposit 173,044.32 33.33 57,675.67
#82663-43 joint w/Donna Nissel
and Diane Way dtd 1-23-2010
Princ• $172,817.81, Int• $226.51
2 A,B >,/9/Ln Members 1st FCU-Cert of Deposit 133,620.29 33.33 44,535.64
#82663-51 joint w/Donna Nissel and
Diane Way dtd 8-9-2D10 from roll-
over cd dtd 1-9-2010 Princ•
$133,486.55, Int• $133.74
3 A,B 9/27/1D Members 1st FCU-Cert of Deposit 140,410.61 33.33 46,798.86
#82663-53 joint w/Donna Nissel
and Diane Way dtd 9-27-2010 from
rollover of 2 jointly held cd's
Princ• $140,265.66, Int• $144.95
4 A,B LD/6/oz Members 1st FCU-Cert of Deposit 19,749.85 33.33 6,582.63
#82663-60 joint w/Donna Nissel
and Diane Way, dtd 10-6-2007
Princ• $19,735.55, Int• $14.30
5 A,B ~/26/DS Members 1st FCU-Money Management 3,419.45 33.33 1,139.70
Acct #82663.05 joint w/Donna
Nissel and Diane Way dtd 7-26-2005
Princ• $3,418.70, Int• $•75
TOTAL (Also enter on Line 6, Recapitulation) I $ 17 4 , 6 71 D 3
If more space is needed, use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
H LOUISE CLEMENTS 21 11 0542
Decedent's Name Page 1 File Number
Schedule F-Z -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 % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
6 A,B 4/Z6/05 Members 1st FCU-Life Savings Acct 2,000.32 33.33 666.71
#82663-04 joint w/Donna Nissel and
Diane Way dtd 4-26-2005, Princ
$2,D00.00, Int• $•32
7 A,B 4/26/05 Members 1st FCU-Savings Acct 49.99 33.33 16.66
#82663-00 joint w/Donna Nissel and
Diane Way dtd 4-26-2005
8 A 11/29/05 PNC Bank-Checking Acct #5140011978 34,510.31 50. 17,255.16
joint w/Donna L• Nissel dtd
11-29-2005 Princ• $34,509.97, Int
$•34
SUBTOTAL SCHEDULE F-2 17 , 9 3 8 • 5 3
GRAND TOTAL SCHEDULE F•2 S 174,671.03
REV-151 1 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMiNiSTRATIVE COSTS
E5 r A t t ~r FILE NUMBER
H LOUISE CLEMENTS 21 11 D542
Decedent's debts must be reported on Schedule i.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 St Johns Cemetery-stone and engraving 700.00
Gerry Eckert-work done at cemetery 300.00
St Paul's United Methodist Church-services rend 100.00
Myers-Harper Funeral Home-funeral expenses 10,038.00
Gingerich Memorials-engraving and repair marker 160.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. AttomeyFees: David H Stone, Esquire
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
4-
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees: See # 5 b e l o w
5 • Accountant Fees:
6 • Tax Return Preparer Fees:
12,500.00
1 Donegal Insurance Group-homeowners insurance 137.75
2 Donegal Insurance Group-homeowners insurance 20.25
3 Checks and printing fee 54.00
4 Stone LaFaver & Shekletski-Reimb for advertising 307.02
5 Register of Wills-probate costs 419.50
6 US Treasury-add'1 tax due on 2010 1040 Return 83.56
7 PNC Bank-service charge 2.00
8 PNC Bank-service charge 2.00
9 Diane Way-Reimb for trash hauling by Derrrs 285.00
1D PNC Bank-check printing fee 40.24
11 TruGreen-lawn service at property 54.54
12 Dan Gilham-lawn mowing at pro erty for Ma 140.00
TOTAL (Also enter on Line 9, Recapitulation) $
ZIP
39,516.28
ff more space is needed, use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
H LOUISE CLEMENTS 21 11 0542
Decedent's Name Page 2 File Number
Schedule H -Funeral Expenses 8 Administrative Costs - B7.
ITEM
NUMBER DESCRIPTION AMOUNT
13 Dan Gilham-lawn service from 4-12 to 5-3-11 140.00
14 TruGreen-lawn care at property 163.61
15 Dan Gilham-lawn mowing at property for June 140.00
16 Dan Gilham-lawn mowing at property for July 140.00
17 TruGreen-lawn care at property 57,72
18 Dan Gilham-lawn mowing at property for August 175•DO
19 Stanley Steemer-carpet cleaning 252.28
20 TruGreen-lawn care at property 57.72
21 Dan Gilham-lawn mowing at property for Sept 140.00
22 Dan Gilham-lawn mowing at property for Oct 105.00
23 Shane Norford-repairs done at property 300.00
24 Alma Berresford-real estate taxes on property 894.16
25 Selling costs ($11,041.09) less reimb ($1,242.43) 9,798.66
26 Verizon-service at property 62.68
27 PAWC-water service at property 19.81
28 UGI-gas service at property 185.00
29 PAWC-water service at property 22.28
30 PPL-electric service at property 42.77
31 UGI-gas service at property 81.00
32 UGI-gas service at property 127•DO
33 PPL Corp-electric service at property 74.66
34 PAWC-water service at property 19.81
35 PPL Corp-electric service at property 42.01
36 Comcast-cable service at property 62.85
37 UGI-gas service at property 81.00
38 Borough of Wormleysburg-trash and sewer at prop 122.50
39 PPL Corp-electric service at property 117.87
40 PAWC-water service at property 22.33
41 UGI-gas service at property 57.95
42 PPL Corp-electric service at property 142.53
43 PAWC-water service at property 20.69
44 UGI-gas service at property 12.15
45 PPL Corp-electric service at property 62.12
46 PAWC-water service at property 21.51
47 UGI-gas service at property 20.57
48 PPL Corp-electric service at property 43.33
49 PPL Corp-electric service at property 33.28
50 PAWC-water service at property 25.41
51 UGI-gas service at property 55.16
52 Register of Wills-filing Inh Tax Ret & Inventory 30.00
53 Reserve for closing expenses 200.OD
SUBTOTAL SCHEDULE H-B7 14 ,17 2. 4 2
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE!
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
H LOUISE CLEMENTS 21 11 0542
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 Heartland Pharmacy of PA-perscriptions 30.85
2 Manor Care-nursing home services ~ 6,055.10
TOTAL (Also enter on Line 10, Recapitulation) I S 6 0 8 5
If more space is needed, insert additional sheets of the same size.
REV-1513 EX + (9-00)
SCHEDULE)
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
N I OIITC~ ~I ~M~NTC ~1, 1, 1, f154~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustees) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2))
1 DIANE MARIE WAY Lineal 91,799.11
1476 MAPLEWOOD DRIVE
NEW CUMBERLAND, PA 17070
2 DONNA LOUISE NISSEL Lineal 91,799.12
1350 SUGAR MAPLE COURT
NEW CUMBERLAND PA 17070-
3 JAMES D CLEMENTS Lineal 91,799.12
105197 S• HIDDEN VALLEY DRIVE
McLOUD OK 74851-
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
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, insert additional sheets of the same size)
STONE, LAFAVER & SHERLETSKI
ATTORNEYS AT lAW
" 414 BRIDGE STREET
l
NEW CUMBERLAND, PA lT070
ii
!I
LAST WILL AND TESTAMENT
i~
OF
H. LOUISE CLEMENTS
I, H. LOUISE CLEMENTS, of the Borough of Wormleysburg, Cumberland
County, Pennsylvania, declare this to be my last will and revoke any
will previously made by me.
ITEM I: I direct that my Executor hereinafter named shall pay
all my just debts and funeral expenses as soon as conveniently may be
done after my decease from the residue of my estate.
ITEM II: I devise and bequeath all the rest, residue and remain-
der of my estate, of every nature and wherever situate to my husband,
CHARLES D. CLEMENTS, if he survives me.
ITEM III: Should my husband, CHARLES D. CLEMENTS, fail to
survive me, I devise and bequeath all the rest, residue and remainder
of my estate, of every nature and wherever situate, in equal shares to
my children, JAMES D. CLEMENTS, DONNA LOUISE NISSEL, and DIANE MARIE
WAY, as survive me. Should any of my children predecease me, I devise
and bequeath the share of such child to his or her issue, per stirpes;
and should any such child of mine leave no such issue living following
my death, I devise and bequeath the share of such child to my issue,
per stirpes.
Page 1 of 5
ITEM IV: I appoint my Executor and his successors guardian of
any property which passes, either under this will or otherwise, to a
minor and with respect to which I am authorized to appoint a guardian
and have not otherwise specifically done so, provided that this ap-
pointment of a guardian shall not supersede the right of any fiduciary
in its discretion to distribute a share where possible to the minor or
to another for the minor's benefit. Such guardian shall have the
power to use principal as well as income from time to time for the
minor's support and education (including college education, both
graduate and undergraduate) without regard to his or her parent's
ability to provide for such support and education, or to make payment
for these purposes, without further responsibility, to the minor or to
the minor's parent or to any person taking care of the minor.
ITEM IV: I appoint my husband, CHARLES D. CLEMENTS, Executor of
this my last will. Should my husband, CHARLES D. CLEMENTS, fail to
qualify or cease to act as Executor, I appoint my daughters, DONNA
LOUISE NISSEL and DIANE MARIE WAY, Co-Executrices of this my last
will.
ITEM V: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of hislher duties
in any jurisdiction.
Page 2 of 5
IN WITNESS WHEREOF, I, H. LOUISCE CLEMENTS, have hereunto set my
hand and seal this ~ day of ~~c,.b~Z` 2002.
~~~~
H. LOUISE CLEMENTS
SIGNED, SEALED, PtJBLISSED and DECLARED by H. LOUISE CLEMENTS, the.
Testatrix above named, as and for her Last Will and Testament, and in
the presence of us, who at her request, in her presence and in the
presence of ea h other, have subscribed our names as witnesses.
Witne Address
,' -; ~~
L}" ~~~~~G~~~c~:,~~~~Z~f
Address
COMMONWEALTH OF PENNSYLVANIA:
. SS:
COUNTY OF CUMBERLAND .
I, H. LOUISE CLEMENTS, the Testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law do hereby acknowledge that I,signed and executed this instru-
Page 3 of 5
ment as my last will; that I signed it willingly and that I signed it
as my free and voluntary act for the purposes herein contained.
/~. C7~I `yKo.tJ
H. LOUISE CLEMENTS
Sworn to or affirmed to and acknowledged before me by H. LOUISE
CLEMENTS, the Testatrix, this ~ day of P , 2002.
~~
Notary Public
__..
NOTARIAL SEAL
CAROL. L TROXELL, Y PubltC
flew Cumberland Sao. Cumber~nd Ca
My Comml~lon F.xpbes Dea 27, 2006
COMMONWEALTH OF PENNSYLVANIA
. SS:
COUNTY OF CUMBERLAND ,~
/.
we, Q. f and Z ~ ,
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign and execute the instrument as
her last will; that Testatrix signed willingly and that she executed
it as her free and voluntary act for the purposes therein expressed;
Page 4 of 5
~., that_:each of'~~s in tha~hearing and sight of the Testatrix signed the
WiY3 a~ witnesses; that to the best of our knowledge, the Testatrix
was at that time eighteen or more years of age, of sound mind and
under no constraint or undue influe
Sworn to or affirmed to and acknowle ed before me b
~~ ~_''t ~~~ and
.witnesses, this _~ day of ~A 2002.
...
Notary Public
NOTARIAL SEAL
CMOL L 1~~ Noh~ry Pudic
t~kw t~etisnd Bono. aumberland C~.
My Gommhalon ExpN~ QeQ 27, 2006
Page 5 of 5
4
~c~~~~~
Z:\REIDEDIC'Iements.Louise - 525 Grendvicw Avenue.wpd
~iii~~~
Tax Parcel #: 47-18-1302-103.
Address: S25 Grandview Avenue
Camp Hill, PA 17011
DEED
THIS INDENTURE made the ~~ day of tYGN ~ ~~ , in the year 2011, between
DONNA L. NISSEL and DIANE M. WAY, Co-Executrices of the Last Will and Testament of H. LOUISE
CLEMENTS, late of Wonmleysburg Borough, County of Cumberland ,and Commonwealth of Pennsylvania,
of the first part, hereinafter called the Grantors,
-AND-
SHANE NORFORD, single individual, and MAJA BOZIC, single individual, as joint tenants with
the right of survivorship, of the second part, hereinafter called the Grantees;
WHEREAS, the said H. LOUISE CLEMENTS became in her lifetime seised, as of fee, of and in
a certain tract of land, together with the improvements thereon erected, situate in Wormleysburg Borough,
County of Cumberland, and Commonwealth of Pennsylvania, and more particularly described hereinafter;
and being so thereof seised, died on Apri124, 2011, having first made her Last Will and Testament in writing
dated September 4, 2002, duly probated and registered in the Office of the Register of Wills of Cumberland
County on May 4, 2011, wherein and whereby she appointed as Co-Executrices, the said DONNA L.
NISSEL and DIANE M. WAY, to whom Letters Testamentary were duly issued by said Register of Wills
on May 4, 2011, wherein and whereby said premises hereinafter described were not specifically devised, all
as in and by said Will and the records of said Register of Wills, recourse thereunto being had, appears:
NOW THIS INDENTURE WITNESSETH, that the said Grantors, for and in consideration of the
sum of ONE HUNDRED FORTY-THREE THOUSAND and NO/100------------($143,000.00)------------
Dollars,which has been paid to they by the said Grantees at or before the sealing and delivery hereof, receipt
whereof is hereby acknowledged, has granted, bargained, sold, aliened, released and confirmed, and by these
presents does grant, bargain, sell, alien, release and confirm unto the said Grantees,
ALL THAT CERTAIN piece or parcel of land situate in the Borough of Wormleysburg,
Cumberland County, Pennsylvania, more particularly bounded and described as follows, to wit:
BEGINNING at a point on the northerly line of Grandview Avenue, which point is two hundred
seventy (270) feet Fast of the northeasterly corner of Grandview Avenue and West Foxcroft Drive extended,
and at dividing line between Lots Nos, 18 and 19, Section "A" on the hereinafter mentioned Plan of Lots;
thence along the northerly line of Grandview Avenue South fifty-three (53°) degrees eighteen (18') minutes
thirty-three (33") seconds West seventy-five (75) feet to a point; thence North thirty-six (36°) degrees thirty
(30') minutes West one hundred twenty (120} feet to a point; thence North fifty-three (53°) degrees eighteen
(18') minutes thirty-three (33") seconds East seventy-five (75} feet to a point at the dividing line between
Lots Nos.18 and 19, Section "A", on said plan; thence along said dividing line South thirty-six (36°) degrees
thirty (30') minutes East one hundred twenty (120) feet to a point, the place of BEGINNING.
-1-
BEING the eastern most 75 feet throughout of Lot No. 18, Section "A", in the Plan of Riverview,
which Plan is recorded in the Office of the Recorder of Deeds in and for Cumberland County, Pennsylvania,
in Plan Book 12, Page 12.
BEING the same premises which Edward T. Durkin and Jean C. Durkin, his wife, by Deed dated
November 22, 197F, and recorded December 3, 1976, in the Office of the Recorder of Deeds of Cumberland
County in Deed Book X, Volume 26, Page 643, granted and conveyed unto Charier D. Clements and H.
Louise Clements, his wife. Charles D. Clements died on March 8, 2005, thus by operation of law vesting
title in H. Louise Clements, deceased.
TOGETHER with alt and singular the buildings, improvements, ways, streets, alleys, passages,
waters, water-courses, rights, liberties, privileges, hereditaznents and appurtenances whatsoever, thereunto
belonging or in any wise appertaining and the reversions and remainders, rents, issues and profits thereof,
and all the estate, right, title, interest, property, claim and demand whatsoever of her, the said H. LOUISE
CLEMENTS, at and immediately before the time of her decease, in law, equity, or otherwise howsoever,
of, in, to or out of the same.
TO HAVE AND TO HOLD the said lot or piece of ground above described, with the buildings and
improvements thereon erected, hereditaments and premises hereby granted or mentioned, and intended so
to be, with the appurtenances unto the said Grantees, to and for the only proper use and behoof of the said
Grantees, forever:
AND the said Grantors, for themselves and their respective heirs, executors and administrators, does
covenant, promise and agree to and with the said Grantees, their heirs and assigns, that they, the said
Grantors, have not heretofore done or committed any act, matter or thing whatsoever whereby the premises
hereby granted, or any part thereof, is, are, shall or may be impeached, chazged, or encumbered in title,
charge, estate or otherwise howsoever.
(SIGNATURES ON NEXT PAGE)
-2-
IN WI E WHEREOF, the said Grantors have hereunto set their hands and seals the day and
y e 't en.
- (SEAL)
"'~~ DONNA L. NISSEL, Co- xecutrix of the Last
Will and Testament of H. LOUISE CLEMENTS
(SEAL)
DIANE M. WAY, Co-Executrix he Last
Will and Testament of H. LOUISE CLEMENTS
COMMONWEAL'T'H OF PENNSYLVANIA
~Q'N ~ SS:
COUNTY OF C L~C~r~.~~ .
On this, the~~s~day of ~~'~-~`'v "''~" , 2011, before me a Notary Public, the undersigned
officer, personally appeared DONNA L. NISSEL and DIANE M. WAY, Co-Executrices of the Last Will
and Testament of H. LOUISE CLEMENTS, known to me or satisfactorily proven to be the person whose
name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes
therein contained.
IN WITNESS WHEREOF, I have hereto set my hand and notarial seal.
~~~1L'TN OF PENNfY~.VAWA
N07ARIAt SEAL ~
yICKIE R. WELKER, Notary 5 /,
Camp HCo".E ~ a~Mard+ 4Coun ~/~ ~(..~2~ ~J
Notary Public
COMMONWEALTH OF PENNSYLVANIA .
(~~r-~e~.QC~--n ~ : ss:
COUNTY OF _
On this, thaOt~~day of ~~~~ "` , 2011, before me a Notary Public, the undersigned
officer, personally appeared DONNA L. NISSEL and DIANE M. WAY, Co-Executrices of the Last Will
and Testament of H. LOUISE CLEMENTS, known to me or satisfactorily proven to be the person whose
name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes
therein contained.
IN WITNESS WHEREOF, I have hereto set my hand and notarial seal.
TH OF PENNiK-V~~ ~
~ R1AL SEAL ~ ~/, /
ylClClE R. WELKER. Notary Pubs ~ j(J
Cumberland -~°
CamP~'Mard+4,~ 6 Notary Public
-3-
I hereby certify that the precise address of the Grantees is .5.~ S~r told!// Fib t~d.~f~lG~
~.~-~t~ t~~GL i4fr ~~6t ~
DATE: ~ ~ 7- , •l~
Attorney for
-4-
ROBERT P. ZIEGLER
RECORDER OF DEEDS
CUMBERLAND COUNTY
1 COURTHOUSE SQUARE
CARLISLE, PA 17013
717-240-6370
Instrument Number - 201130724
Recorded On 11/4/2011 At 12:52:04 PM
* Instrument Type -DEED
Invoice Number - 96255 User ID - MSW
* Grantor - CLEMENTS, H LOUISE
* Grantee - NORFORD, SHANE
* Customer - 1ST ADVANTAGE
* FEES
STATE TRANSFER TAX $1,430.00
STATE WRIT TAX $0.50
STATE JCS/ACCESS TO $23.50
JUSTICE
RECORDING FEES - $11.50
RECORDER OF DEEDS
PARCEL CERTIFICATION $10.00
FEES
AFFORDABLE HOUSING $11.50
GOUNTY ARCHIVES FEE $2.00
ROD ARCHIVES FEE $3.00
WEST SHORE SCHOOL $715.00
DI5TRICT
WORIYII,EYSBURG BOROUGH $ 715.0 0
TOTAL PAID $2,922.00
* Total Pages - 5
Certification Page
DO NOT DETACH
This page is now part
of this legal document.
I Certify this to be recorded
in Cumberland County PA
0
o
RECORDER O
~' -Information denoted by an aaterisk may change during
the verification process and may not be refleMed on this page.
` 00`3HElP``
(I I I II N N IN ~ ~ Il ~6~I I P ~~)
DEC-16-2011 14:24 From:M15T I~ND~INS SUPRT 717795517$ To:717 774 3$69 P.1~1
SAVINQS ACCOUNT:
Account NumbeNSuffuc
Data Account EatabBshed
Principal tialanoe at Date of Death
Accrued Interest to pate of Death
Total Principal end Accrued interest
Name of Joint Owner
Date Joint Ownership Established
LIFE $AVINGS AGC UNT:
Account Number/Suftix
Dat® Account !^stabNshad
Principal Balance at Date of Death
Accrued Intanst to Date of Death
Total Principal and Accrued lntertst
Name of Joint Owner
Date Joint Ownership Established
e
NfEMBERS 1'~
t'LDIDtAL CaIDIT UNlUDi
e2~6a-oo
0181/1987
ti49.99
s.oo
:49.98
Donna Nissel & Diane Way
04/28/2005
a2663•aa•
02/018001
12,000.00
1.3~
52,000.32
Dorms Nis¢s1$, Diana Way
oan6noos
"Oparssd by transfer of shares from 82663.00.
M4l~i~Y MANAGEMENT accouNT:
AcCOUnt NumbeNSuffix
82663-06
Date Account Established 01/0$/1p01
Principal i3alanoe at Date of Death 53,418.70
Accrued Interest to Date of Death 1.76
total Prindpal and Accrued lntereat 53.419.45
Name of Joint Owner Donna Nirasl 8 Diana Way
Date Joint Ownership Eatabliahed 07868005
CERTiFlCATE$ OF DEP0317:
Account NumberlSuffix
$2aa3~3
82865.51
Date Aooount Established 01/23/2010 081098010'
Principal Balance st Date of Death 1172,817,81 1133,486.55
Accrued Irtenest to Date of path 1226.61 5133.74
Total Principal and Accrued interest 1173,W4.32 5133,820.29
Nartrr of Joint U~vner Donna Nissel Donna Nissei
Diane Way plane Way
Date Joint Ownership Establtshed 0183/2010 08/098070
'Rollover from certificate 82683-68, originally established 01/08/201 p.
``OptrnMd by hara-f»~ of funds Uom 82663-05.
`'Opened by transfer of funds from certificate 132863-49.
E~arFl~!-I~~ OF DEPOSIT:
ACCOUrft NumbaNt3uffix
82663.60
Date Account Established 10/08/2007^
Princpal Balance al Date of peath 119,735.55
Accrued Interest to Date of Death 514.30
Total Principal and Accrued Interest 116,740.85
Nama oiJoint Owner Donna Nisael 10iane Way
Date Joint Ownership Established 1000/2007
'Opened by transfer of funds from 82883-00,
Esttto of H. LOUSE CLEMENTS
Daea of Doath: 04/24/2011
Sodal Security Number: 184.12-0830
8Y663.53
o9n7no1o••
1140,265.6ti
6144.05
5140,410.61
Oonna Nissei
Diane Way
09/17/2010
E ERS 1~ FEDERAL CREO U N
A ~~~~
Daniel A Kline
Lending Insurance Support Speolalitt
April za,1a11
5000 Jauise l7zave }?(:). 13ox 40 Mechatucsl~ux~,1'enusylvatua 17U55 (~3UU) 2H3-2323 wwwmernberslst.orb
~~~
LBADINO THit MtAY
May 1 i, 2011
David H Stone
Stone, Lafavez~ & Shekletslai
414 Bridge St PO Box E
New Cumberland, PA 17070
ltE: H Louse Clements
SSN: 184-12-4830
DOD: 04/24/2011
Dear Mr. Stone:
Izt response to your request far Date of Death (DOD} balances far the customer noted above, our
records show the following:
Checking Account
Account # 5140011978 Established: 11/29/2005
~I LOC7ISE CLEMENTS
DbNNA L NISSEL
DOD balance: $ 34,509.97 + 0.34 accrued interest
Interest paid 01/01/2011 tliru 04/24/2011 - $0.43
Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and
Savings). We do not process any financial transactions or provide statamc~. )f you Head assistance with
any of these Items. please ca111-888-PNC-BANK (1.888-762-2265) or stop by your local PNC Hanle branch
office.
Sincerely,
National Financial Services Center
PNC Bank, N.A.
Member FDIC
This message is intended for the wse of the individual or entity to which ft is addressed and may
contain information that is privileged, confidential and exempt from disclosrere under applicable law.
If the reader of this message is not the intended recipient yr the employee or agent responsible for
delivering this message to the intended recipient, you are hereby nott, fled that arty dissemination,
distribution or copying of this commiazications is strictly prohibited Ifyrou have received this
communication in error, please notify me immediately by reply or by telephone at 800-762-1775 and
immediately destroy this fazed document.
Page 1 of 1
~ A. Settlement Settement (HUD-1) 0A7B~¢rov:~r~o.zsD2-o2a~
~~~'
1. ~] FHA 2. Q RHS 3. ^ Conv. Unins. g1~ Number: 7. Loan Number. 8. Mortgage {tusurartce Case Number:
5791275490
3. [] VA 5. ®Com. iris.
:. Note: This form Is fumkhed b give you a statement o1 aetutl ssttlernent wets, Amount paW to and by the settlement agerns are shown (terns marked
"
•
(p.o.c)
were pekl outside the dosing; they ate shown hero for Iniortnatlonai purposes end ere not Inducted N the tdals.
~. Name & Address of eonnwer. E. Name & Address of Seller. F. Name & Addross of Lender.
Shane h~rfmd, Maja Bobc Estate H. COUIae Ckmenis Fulton Bank
301 Ceders Road, Lewdst>erry, PA 17339 One Penn Square 304, l,ar, PA 17602
G. Property Locatlore H. SsttlementAgent I. Settlement Date: 1 012 8/201 1
525 Grandview Avenue tat Advantage Settlsment SeMcea Inc, Disbursement Data 1 Qi2812D11
Camp H81, PA 17011 6375 Mercury Ddve, SuRe 102, Medcankafxrrg, PA 17060
Wonnleysburg Borough
Telephone: 7t7~15555 Fax: 7fl~91-7273
Piaoe of Settlement:
8375 Mercury pdve, Suite 102, Mecfianitalwrg, PA 17050 Title rasa
PAnted 1 U27/2011 at b:40 pm
byVW
. .
100. Gros Amottrd Due from Borrower
sales price ,Op
400. Grog Amount Due bo SsBer
~
102, Personal 402. p~~
103. Settlenrerd charges to bartower (8ne 1400) 5,187.51 4D3.
104. 404.
105.
arm for Hstnt d seller in advents 405.
ettb for items d teller in advance
106, Cityltatn traes to
1D7. Courdy traces 10/2612011 to 12131/2011
167.49 4D6. Cityltovm faxes to
407. Cotrrdytaxes 10/28/2011 tb 12/3111011
157.49
108. School Taxes 10126/1011100613012012 998.39 408. Sdwol Texas 1Q/181I011 to 08130/2012 998.39
109. Sewx/Trash 1012812011 to 12/31/201 t 86.65 409. SewerlTresh 10128/2011 to 121311m11 86.55
110. 410.
111. 411.
112• 412
120. Gross Amourd Due from Bomourer 149x10994 420. Gross Amount Dueto 8s11er i44,242.43
200. Amounts Pdd or in Behalf of Borrower 500. titductlona M Amount Due to Seger
2D1. Deposit or earnest money
202 Principal anramt d riew krari(a) 3, .00
135,850.D0 posit see Inatnic5ans
Settlertrant charges to se8a (1~e 1400)
11,041.E
203. I s fatten act to 503. a taken au to
204. 504. dflrat loam
205• 605. daeoond loan
20fi. 5pg,
207. 507.
208. 508.
209. 5~,
urb for frame un dd ss5er for Items un ~~
taxes fp 51D. l2tyltoemlmaas to
211. County trams W 511. County texas to
212. Sdtooi Taxes to 512 Scholl Taxes to
213. 513.
214. 514,
215. 515.
218. 516.
217. 517.
216. 618.
219. 519.
220. ToW Paid r Borrower 138,650.00 520. Toh1 Reduction Amount Due Seth 11,041.09
500. Cash d Setllement fromlto Borrower R00. Cash at Settkrtiatt tolhom Setler
apt Gross amount due from borrower Nne 120) 149.409.94 801. Grose smamt due to seller {tkie 420) 144,242.43
302. lass atnourds paid bylfor lxxrower (8ne 220) 138,850.D0 602 Less reduc9loris to amount due BaOer {fine 520) 11041.09
903. Cash ®from ~] To Bonvwer 10,559.94 ~, Cath ~] To ^ from Salter 133,201.34
OiY Yin uYrYl "aambwM01l a~alnamr. Ne miWirYY« YnRNiCCM"YnalrlYn Th YYAWeelY SeNMIM aNrb"IeIlM miw,MYMrr/- YYRe~n ~
Previous editions are obsolete age 1 0 4 HUD-1
Borrower's ~ Seller's
Funds at Funds at
800. Remy Pavabie in Connectlon wRh Loan --1
301. Our origlnatlon charge (fndudes Odgina9on Po6d 0, or .DO) .00 )
. Your aedit a (PotMs the spedAc rderest rate dawn S ( )
our adJusbed origination charges GFEA) 6,95.00
. Appraisal fee to Pramler SaNoe .00 P.O.C. -1 .OD
5. CredR report to Ctedstar (Oan ) 13.84
~6. Taxservlce 1fl GFE~3
801. Flood cerdfic~tion to Rood Services (from GFE AKi) 11.50
908. fn
~e111,,'`~ ~r 4te (y3,Ovo.~~~
=~xs li, UPI I .A9'
ass ~.~;„~ ~ ~~ a _~r3
q~~(8~~~
~~~f8.66
PeBe 4 nuo-i
~133aa~.3y
r .. ~ 5,167.51 11,041.09
'Paid outside of dosing by ~)~ (S)eller, (L)ender, (i)nvests, Bro(IQer. " CrerAt tiY IerWer shown on page 1. °'Credit by aeBer shown on page 1.
.~..
tomoarison of Good faHh &6mete fG FE) and HUD•1 C as
C es Ttret Cannot increase HUD~1 Una Numtxr
C)ur odg anon dlarge # 1
our or charge (points the s Interest rape chosen ~
our adueled odgnatlon rllarges g
ra rtaxes
That Cac f~rarl
your aeaow axamt #
aGy char9ea from # 90 5.35
'rrlslsarlce #
services s.title insurance S 1
s fide Insurance ~ 1103
fe
I n n Tnnne
Good f•_.n Fsdmeta HUD-1
695.1)0 f~5.00.
0.00 0.00
895.
,000.00 1,
Your mitlal foan amount is 5135,850.00
Your loan term is 30. Peers
Your initial interest rate is 4.125056
Your iNtlal marthly amount owed for prirldpat, Interest, and arty mortgage 5734.25 hxirldes
insurance is u prl~
~] Interest
QX tortgage Irlaurance
Can your Interest rate rise? 0 No. ^ Yes, tt c~rr rise to a meldmum d %. The fast dla<Ige
wHl be on / / and can change ~ every Years ~ f ( .Every change
date, your fnteest rata can increase or decease try 96. th~er the Iffe d the ban, your
interest rate is guaranteed to never be braver than 96 a higher than ~.
Even If you make paymecds on time, can your load valence rise? [~X Na ^ Peg it can rise to a maxinxlm d i .
Even ff you make paymecds on tkna, can your mardhiy eurlourlt orwad br Q Na ^ Yes, the first fnaease can be on ! ! end the monddy
pdndpai, intrsast, and mortgage insurdrrce rise? amatnt awed can rise fo S
The trlsodmum h can eve rise to is 5
Does your ban have a prepayment penait7R []X No. ^ Yee, your m®dmum prepeymart penalty Is 5
Does your ban have a baCoon payment? OX No. ^ Yes, you have a belbarr payment d S due fn
years on / ! .
Tote) monthly amourd awed 4lduding escrow accwlmt peymelris ^ Ycu do cwt have a n-on1Hy esAVw payment for items, such as praparty taxes
and haneawnefs itlsurarrce. You must pay drew Items drectlY Yourself.
^X You torus an addltlonal monthly esavw payment d 5251.15
filet results to a total wtld nwnthiy amount awed of ti985.40. This indudes pr6rdpel, Interest, any
mortgage irsurance end any Items checked below:
[]X ProPe1h` farces Q Homeowners insurance
Flood Insurance ^
Note: !f you have any questions about the Settlement Charges and Loan Temp Usbed on this form, please contact your lender.
Page o 4 llD-i
previous editlons are obso ate
~.~•
HL :ERTIFICATION OF BUYER AND SELLER
have carefully reviewed the HUD-9 Settlement Statement and to the best of my knowledge and b~let, tt k a true and aewrale statement of all teonipm and
tisbursements made on my axouM or by me In thk ttansacdan I further certlfy that f have received a Dopy of the HUD~1 Settlement Statement
~'°tGe+rl F~~ Q-- ~~ ~ ~
thane Norford Maja Bo~C
f/)t,~
Mate H. Louise C .x
The HUD-1 Settlement Statement whbh 1 have preparod k e true and accurate aocourd of ttds hanasWon I have cawed or will ease the funds to be
dkbursed In aceordance wkh fhb statement
~~~~~
SETTLEMENT AGENT DATE
WARNINGc 17 IS A CRIME TO KNO1MNCiLY MAKE FALS£ STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18. U.S. CODE SECTION 1001 AND SECTION 1010.
Previous editions are obsolete Page 4 of 4 HUD-1
. ~
Name of Borrower.
Shane Norford
Maja Bozic Marne of Seller,
Estate H. Louise Clements pte Number
11320
TltleExpress
Prepared 10/24@Ot 1 at 1 o:as am
Note: This page is famished to glue you an Itemization of the amounts shown on
Lines 1101, 1108 and 1104 of the Bafflement Statement (MUD-i ). This page
accompanies but is not a part of the settlement statement. ff a discrepancy
exists, the information shown on the Settlement Statement {HUD-t) applies. Paid From
BoROwet's
Funds at
Settlement Paid From
Setle~s
Funds at
Settlement
1100. Title Charges ~o~ ~duded
b Una 1101
1101. TBIe servioea end tender's title hwranos {,188.75
a
b.
c.
1102. Setlfanentardosi fee
1103. Owners 11tle insurance $ 35.00 35.D0
1104. Lender's title kraurance 1,038.75 i 1,188.75
a. Endorsamerrt 900 tPl~tesidentl~ 50.00
b. Endoraemart 100 No Yiotatlon 50.00
G EndarsaneM 30D Sunre 50.00
{Total 1103+1104)
1105. Larders Otle Omit S1 .00 SOt27{2-18821
1106. Owners title 8mk 5143,000.60 501144T 21521
1107. s of me total 8tle Msurance lam S 1,040.18
1108. Undenvdta's of the total title Ineuranoe 183.b6
(Tota11107+1108
1109.
1110.
1111.
1112
Totat Borrower
1100. Title Cha saYh IOC or Credit Borrower
Lk-e 1101 Seller
Paid
1101. Title services and tenders title irreurance S
1104. Lenders tl0e hrsurance to 1 at Advantage Settlertrsnt Services Inc. 1,188.7b 1,188.75
S 1,168.75 1,188.75
ESTATE H. LOUISE CLEMENTS
By ,,/Date 10/28/11
SO
~`~ .
~--.
S~. ~~'+~
Shane Nortord
Maja~~-
Date 10/28/11
pate 10128!11