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HomeMy WebLinkAbout04-27-12 (3)5^56~,~1?,C5 REV-1500 °` `°~-11' `~' PA Department of Revenue pennsytvartia OFFICIAL USE ONLY Bureau of Individual Taxes °"""TM`«'°""`~`««` County Code Year File Number PO BOX z8o6o1 INHERIT~-NCE 'I'AJC RETURN /~~ " Harrisburg, PA 1YU8-o6oi RESIDENT DECEIDENT ~ ` ~ ~ ~ vU ENTER DECEDENT INFORMATION BELOW r~ Social Security Number Date of Death MMODYYW Date of Birth MMDDYYW 07/14/2011 07/26/1948 Decedent's Last Name Suffix Decedent's First Name MI Sporg Kathleen M (If Applicable) Enter Surviving Spouse's Irtformatlon 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 Q)b 'I. Original Retum O 2. Supplemental Retum O 3. Remainder Retum {Date of Death Prior to 12-13-82) O 4'~. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate lax Retum Required death after 12-12-82) O E.. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 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 T0: Name Daytime Telephone Number Paul D. Daggs, Esquire (717) 884-4963 First Line of Address 130 W. Church Street Second Line of Address Suite 100 City or Post Office State ZIP Code REGISTER OF WILt_S USE 0~1~ ~ _ ., ~ ~ r-.~ -~ - :T C~ -~:~ . ~-- -';; .~ ,~ - . ., -a - -,~ ' ~-~ . 7 DAT _ it_HD 4.J is ~"• Dillsburg PA 17019 71 f"i~ ~ 'l f ~ ~ ~- i _, =r =_ c , '.--, ~.., l.' J ~l "T~ Conrespondent's e-mail address: paul(~daggslaw.COm Under penaRies of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all informatbn of which preparer has any knowledge. RESPONSIBLE FOR FILING RETURN 'Z~ ADDRESS 3510 Beech Run Road, Mechanit~burA, PA 17050 THAN REPRESENTATIVE ADDRESS 130 W. Church Street, uite 100, Dillsburg, PA 17019 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: Kathleen M Spong RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 137,600.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mort a es and Notes Receivable Schedule D 9 9 ( ) ......................... 4. .. 10,000.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 50,970.62 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 135,062.46 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 333,633.08 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 21,670.67 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 9,899.64 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 31,570.31 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 302,062.77 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. 302,062.77 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 rate X .0 45 302,062.77 16. 13,592.82 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 OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1505610205 13,592.82 O REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Kathleen M. Spong STREETADDRESS 210 Brian Drive CITY - -_ - - ---- ---------- STATE ZIP Enola PA 17025 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 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. (1) 13, 592.82 Total Credits (A + B) (2) (3) (4) 14.48 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 13,607.30 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 occurced 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 QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)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 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)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (11-08) j ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Kathleen M Spong 2211-0806 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. It more space is needed, insert additional sheets of the same size. REV-1507 EX+ (6-98) SCI~IEDI~LE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECENABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Kathleen M Spong 2211-0806 Ali property jointlyowned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-i5o8 EX+ (11-10) Pennsylvania SCEIEDIILE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Kathleen M Spong 2211-0806 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PNC Bank Savings Acct #5004058413 50.00 2. PNC Bank Checking Acct #5004054519 368.24 3. CUNA Mutual Group Credit Insurance on home equity loan held by Susquehanna Valley Fed. Credit Union; 15,000.00 (Death benefit in excess of loan payoff (no beneficiary designated)] 4. Susquehanna Valley Fed. Credit Union Account 34,052.38 5, Misc. personal property & household items 1, 500.00 TOTAL (Also enter on Line S, Recapitulation) $ ~ 50,970.62 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) ~ Pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Kathleen M Spong 2211-0806 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (1F APPLICABLE) TAXABLE VALUE I~ SERS IRA; Beneficiary: Michelle Gouse (daughter) 135,062.46 100 135,062.4E TOTAL (Also enter on Line 7, Recapitulation) $ I 135,062.46 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) j i~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Kathleen M Spong 2211-0806 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hollinger Funeral Home & Crematory 3,000.00 2. food/refreshments 175.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City __-- Year(s) Commission Paid: State ZIP 2. 3. Attorney Fees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant 2,500.00 Street Address _ City _______. State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 218.50 S• Accountant Fees: 6. Tax Return Preparer Fees: ~• estate publication costs 225.00 B. upkeep/maintenancefinsurance/condo fees & utilities for 210 Brian Drive, Enola, PA 3, 042.70 9. real estate dosing costs for 210 Brian Drive, Enola, PA 7, 762.30 ~o. seller's assistance for 210 Brian Drive, Enola, PA 4,747.17 TOTAL (Also enter on Line 9, Recapitulation) I $ 21,670.67 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) j ~ Pennsylvania SCHEDULE I ~ DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Kathleen M Spong 2211-0806 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. 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 ~ BENEFICIARIES ESTATE OF: FILE NUMBER: Kathleen M. Spong 2211-0806 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECENING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Michelle Gouse, 3510 Beach Run Road, Mechanicsburg, PA 17050 daughter 50% 2. Peter J. Brown, Spring Creek Rehab Ctr., Long Term Care son 50% 1205 S. 28th St., Harrisburg, PA 17050 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 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. I ~ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT BE II' REMEMBERED THAT I, KATHLEEN M. SPONG, a resident of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding do make, publish and declare this to be my LAST WILL and TESTAMENT, hereby revoking any and all Wills and Codicils previously made by me. I I declare that I am not married, my beloved husband, Steven L. Spong, having predeceased me, and that I have two (~) children, namely MICHELLE L GOUSE and PETER J. BROWN. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable a$er my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense ofthe administration ofmy estate. IV I give, devise and bequeath all my property, whether real or personal, wherever situate, including any property over which I may have a power of appointmient to my children, MICHELLE I. GOUSE and PETER J. BROWN, in equal shares, pursuant to the hereina$er instructions: A. To my daughter, MICHELLE L GOUSE, I leave her share of my estate to her outright, per stirpes; and B_ To my son, PETER J. BROWN, who is phSsically disabled with sevee impairments consisting of paralysis, diabetes, and heart disease, shall be held in Trust with my daughter, NIICHELLE I. GOUSE, as Trustee, nevertheless, underthe fallowing terms: 1. In providing for the establishment of this trust for the benefit of my said son, I am aware of the special circumstances and disabilities affecting PETER J. BROWN; which may cause or will cause him to be eligible for various local, state and Federal benefits and entitlements, as well as possible assistance provided by various private agencies and organizations. The primary purpose of this trust is to assure that PETER J. BROWN achieves his maximum potential and leads as full, independent and normal life as possible. To that end it is my wish that the Trustee view herself not only as trustee in the traditional sense, but also as protector, guardian and advocate for my said son. Correspondingly, the Trustee shall expend the income and principal of the trust in ways that best further these goals, and under the following terms and conditions: a. The Trustee, within her complete and unfettered discretion, shalt apply the income and principal of the trust in furtherance of the purposes of the trust as set forth in paragraph 1 above and generally to enhance the life of my son, PETER J. BROWN, if living, but only to the extent not provided for by insurance or by Federal, state, local or any other assistance programs of any nature whatsoever, including Supplemental Security Income benefits under the Federal Income Maintenance Program as then existing. The Trustee shall have foil powers of choice and discretion over the expenditure of payments of the trust. The Trustee shall provide trust payments of such an amount as not to preclude payment of the maximum amounts of any Federal, state, local or other assistance programs, as noted above. The income and principal of this trust may therefore be used as judged necessary and appropriate as a supplement to, but not to supplant, such Federal, state, local or other assistance, and to the extant the income of this trust is not used, the Trustee may accumulate the income and add it to the principal of the trust. b. The Trustee is empowered to collect and expend on behalf of my said son, PETER J. BROWN, all governmental financial assistance benefits to which he is other wise entitled; provided that such funds shall not be co-mingled with the other funds ofthis trust. c. In the exercise of the Trustee's discretion to expend income and principal for PETER J. BROWN, the Trustee is directed that consideration should be given to any Letters of Instruction which I may, from time to time, direct to the Trustee. Such Letters of Instruction, if any, shall be interpreted based on the express purposes stated herein, and shall not be interpreted to expand the powers and limitations ofthe Tnastee hereof d. In the exercise of discretion with respect to income and principal distributions for PETER J. BROWN, if any, the Trustee shall bear in mind my express desire to preserve, to the greatest extent possible, this trust's assets for the eventual distribution to the beneficiaries named hereinafter, whether outright or in mist. The foregoing sentence is in no way intended to limit the sole and absolute discretion of the Trustee with respect to such distributions or to give any remaindennan any right to challenge any distribution made by the Trustee in the proper exercise of such discretion. Rather, said sentence is intended to aid the Trustee and any Court or administrative agency in properly interpreting my intent in establishing this trust, namely, that the needs of my son, PETER J. BROWN, be provided for only to the extent that governmental benefits and entitlements and other resources are either unavailable, inadequate, or have been exhausted. e_ If any govemmeantal agency deteirnines that this Trust is an "available ressoucee" to be utilized and exhausted to pay for services for PETER J. BROWN, otherwise provided by public funding then the Trustee may, at her complete discretion, elect to terminate this trust, in which case the total assets may be distnbuted in accordance with Paragraph 6 below as if my said son, PETER J. BROWN, was then deceased. f. Upon the death of my said son, PETER J. BROWN, or in the event he should predecease me, the principal of this trust as then constituted, together with any accrued and undistributed income thereon, shall be distributed in the following manner: my daughter, MICHELLE I. DOUSE, is to receive this entiE amount. V I nominate, constitute and appoint my daughter, MICHELLE I. DOUSE, as Executrix of this LAST WILL, to serve without bond IN WITNESS WHEREOF, I, KATHLEEN M. SPONG, have set my hand to this LAST WILL this 21 ~` day of June, 2011. KATHLEEN M. SPONG We, R Mark Thomas and Jessica. Leigh Wray, hereby acknowled~ and attest that we witnessed the above~azned KATHLEEN M. SPONG place her marls on the signature line declaring this to be her last Will and Testament, and in the presence of us, who, at her request and in herpresence, and in the presence ofeach otherhereunto subscribe ournames as witnesses. ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CEJMBERLAND ss I, KATHLEEN M. SPONG, Testatrix, whose name is signed to the attached orforegoing instrument, having been duly qualified acconling to law, do hereby acknowled~ that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. ~i THLEEN M SPONG Sworn or a#Ermed to and acknowled~d before me by KATHLEEN M. SPONG, Testatrix, this 21 ~` day of June, 2011. Norte SEK .IOETTE 1 Ai>C601MEN Notary Publk AIMCSBURG 9080, C<iNp CNt1f Mp Commission Expire JW 7.20f~ AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss We, R Mark Thomas and Jessica Leigh Wray, the witnesses whose names are signed to the attached or foregoing instnunent being duly qualified accotYiing to law, do depose and say that we were present and saw Testatrix sign, who was unable to sign her name, place her mark for the purpose of executing the instrument as her LAST WILL; that KATHLEEN M. SPONG 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 sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at the time 18 years of age or more, of sound mind and under no constraint or undue in~uence. ~acrc W Sworn or affrmed~ to and ~'Es~~~,q, l~sF1s k U /~'.A~ this lpTAR1Al SEAL JOETTE L MC60YVEil Notary Punk ~CHANiCSBURG 8pH0, Ci~MtB~E CKTY IAy Co+nmissioe Ezplras acknowledged before me by R Mark Thomas and 21~` dayof June, 2011. ~~ tary Pu lic -~~ - l H. B. TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.aFHA 2.^FmHA 3. ^X CONV. UNINS. 4. QVA 5. QCONV. INS. SETTLEMENT STATEMENT 6. FILE NUMBER: 7. LOAN NUMBER: g. MORTGAGE INS CASE NUMBER: C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked `(POCj" were paid outside the closing; They are shown here for informational purposes and are not included in the totals. 7.0 3/98 (CAD12017 PFD/CAD12011/8y D. NAME AND ADDRESS OF BORROWER: ROBERT L. SMELTZ, JR. E. NAME AND ADDRESS OF SELLER: ESTATE OF JOAN I. SMELTZ F. NAME AND ADDRESS OF LENDER: G. PROPERTY LOCATION: 601 WAYNE STREET ENOLA, PA 17025 H. SETTLEMENT AGENT: 25-1638737 CRAIG A. DIEHL, ESQUIRE I. SETTLEMENT DATE: F b 28 2 CUMBERLAND County, Pennsylvania "'PURCHASE OF 50% INTEREST FROM ESTATE OF KATHLEEN M. SPONG'• PLACE OF SETTLEMENT 3464 TRINDLE ROAD CAMP HILL, PA 17011 e ruary , 012 J. SUMMARY OF BORROWER'S TRAN SACTION K. UMMARY OF SELLER'S TRANSACTION 101. Contract Sales Price 38,100.00 401. Contract Sales Price 38,100.00 102. Personal Pro e i 402. Personal Pro ert 103. Settlement Char es to Borrower Line 1400) 673.00 403. 104. Pa off 1st Mort a e 404. 105. 405. n r r n n r/ P r n n 106. C !Town Taxes to 406. Ci /Town Taxes to 107. Count Taxes to 407. Count Taxes to 108. School Taxes to 408. School Taxes to 109. 409_ 110. 410. 111. i 411. 112. 412. i 20. GROSS AMOUNT DUE FROM BORROWER ! 38,773.00 420. GROSS AMOUNT DUE TO SELLER 38,100.00 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest mone 501. Excess De osit See Instructions 202. Princi al Amount of New Loans 502. Settlement Char es to Seller Line 1400 203. Existin loans taken sub'ect to j 503. Existin loans taken sub ect to 204. ! 504. Payoff of first Mortgage 205. 505. Pa off of second Mort a e 206. 506. 207. ~ 507. 208. 508. 209. Closin Costs Paid B Seller 509. Closin Costs Paid B Seller j Ad~ustments Forltems Un aid B Seller Ad ustments r terns Un aid B Seller 210. Cit flown Taxes to 510. Ci flown Taxes to 211. Coun Taxes to 511. Coun Taxes to 212. School Taxes to 512. School Taxes to 213. ! 513. i 214. 514. 215. 515. 216. 516. 217. 218. I 517. Purchase of 50% Interest to KATHLEEN M. SPONG ES 38,10D.00 518. 219. 519. ! 220. TOTAL PA1D BY/FOR BORROWER 520. TOTAL REDUCTION AMOUNT DUE SELLER 38,100.00 300. CASH AT SETTLEMENT FROMffO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 301. 302. Gross Amount Due From Borrower (Line 120) Less Amount Paid ByfFor Borrower (Line 220) 38,773.00 ~ ( } 601. Gross Amount Due To Seller Line 420 38.100.00 602. Less Reductions Due Seller (Line 520) ;( 38,100.00 303. CASH (X FROM) ( TO) BORROWER 38,773.00 603. CASH ( TO) ( FROM) SELLER 0.00 ,~ unuc~a~yncu ncicvy ac~ a recei or a ~etea copy of pages 1ts<z of this statement & any attachments fe ed to herein. Borrower ~~~ Seller L ~,:. P..F~: L4~~~ . ~~_ ~ ~1 'V. i.. ~ ~ /~.. OBER L. S LTZ, Jf~. ESTATE OF JOAN 1. SMELTZ ' NL'D-7 (3-86) RESPA, HE34305.2 70 . TIC ..„.• ,MISSION Based on Price ° PAID FROM pAIOFROM Division of Commasron ('hn= 700 aS FO/LOWS: nORROWER'S SEL ' 7D1. $ t0 -- FUNDS AT LER S 'O2 S tG '03 Commission Paid at Settlernert --- SETTLEMENT FUNDS A7 SETTLEMENT 704. t0 00. tTEM AYABLE IN CONNECTI N WITH L N 801. Loan Ori ination Fee _____ % to 8D2. Loan Discount _ % to 803. Appraisal Fee _ to 804. Credit Report _ t0 805. Lender's Inspection Fee to 806. Mort a e Ins. A .Fee to 807. Assumption Fee to 808. 809. 81 D. 811. 9 0. ITEMS RE I D BY LEN O E P I V NC 901. Interest From to @ $ Iday ( days %) 902. M!P Tottns_ for LifeOfLoan for months to 903. Hazard Insurance Premium for 1.0 ears to 904. 905. 1000. RESERVE DE OSITED WITH LENDER 1001. Hazard Insurance months $ r month 1002. Mort a e Insurance months $ er month 1003. Cit /Town Taxes months $ er month 1004. Coun Taxes months $ er month 1005. School Taxes months @ $ per month 1006. months $ er month 1007. months @ $ per month 1008. months $ er month 1100. TITL H GES 1101. Attorne Fees to CRAIG A. DIEHL, ESQUIRE 1102. Abstract or Title Search to 475.00 1103. Wire Fee to 1104. Courier Fee to 1105. Deed Pre aration to CRAIG A. DIEHL. ESQUIRE 1106. Nota Fees to CASH 1107, Electronic Document Prep to 120.00 5.00 includes above item numbers: 1108. Title Insurance to includes above item numbers: 1109. Lender's Coverage $ 1110. Owners Coverage $ 1111. 11 i2. 1113. 1 G VERNM DIN A F R 1201. Recording Fees: Deed $ 63.00; Mortgage $ Releases $ 1202. Cit /Count Tax/Stam s: Deed • Mort a e 63.00 1203. State Tax/Stam s: Revenue Stam s ; Mort a e 1204. 1205. 1 . AD ITl N L CEMENT GE 1301. Surve to 1302. Pest Ins ection to 1303. Tax Certification Fee to CRAIG A. DIEHL, ESQUIRE 1304. 10.00 1305. 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K BV SlOnlnO Daae 1 of this statPmonf thn cin~~+.,.:e~ ~..~.......,,.a..,. ____:_. _~ _ _ 673.00 -~- •~~-•r• ~• ~ ==•••N•=.== ==Ny ~~ Kaye c u~ rnls cwo page statement Certified to be a true copy. 4 ~ CRAI A. DI L, ESQUIR~a Settlement ent ~cAD,aoti~CAD1207tf8) 109, fi~toaaAerourrtDwfismtlonower 400, fioes~AraorertDrMto~ller 1 aalea 102. Personal ~ Penorral 103. Se0lenxritdxtgea b barawer (ino 1400} 6,337.90 403. i 104. - 404, j 105. ' 405. ~ for>~ adr Yr advance for Oenre seer in sdvanaa 106. C.it7llDwn tapes to 406. City/bDim taxes i to 107. raxa ro 4or. taxes I b 106. A:eeeamene m 406. AaaemaMs I to 108. SeJr0c1 Faroe 02129012 b 013~0l1IFt2 818.31 40$. SGr0o1 Taxa j QZf19r201210 06J3Q12012 316 57 110. SwvedRefuee 0212g12012t003131C2012 483 . 410. Sewerfitefuse ; 02+~9120t2b03R111T012 4$.53 111._ Aseodatlon tee 0202812012 to 021292012 4.14 411. AssodMion tee 021192012 b 02/19/1012 4.14 112 ~ 412 120. Gross Aororart Dw fian Boeowx 105y7A7.17 420. MrouM Duebe SrYer 99,69924 200. Mtoaub Paid a 6r BelraM d9arower 500. Redadbos b Mrwnt Dw b.Sellir 201. Deposit ar eamat money 1, ) 202 Pdrlapei amount d new loan(s) 96,917,00 502 3el0emetrt Charges to salver 0~ 140Q) 14,478.55 203. s takari b 503. ' su ' b 204. 504. otfaat morTdapeben 1pAcrdnelt B. Parr 8.339.36 205. ~. Peydfofascaxlrrdrgagelo~n;iRaf#130655b 1,729.78 Wells F ': 206. 50B, ~ 20T• ~ 4,747.17 507. SeOerasrast 4,747.17 208. ~ ~. 509. I 'wbaerrlsforttearsu eeper ~ forl6sas estMr teData b 12 0• 50 510. trrass t0 rte. 211. Caurrty taxes >D 511. taxes b 212 ~ b 512 Assessmertffi i to 213. ~ Sdt001 Talc 1D 519. Sdgd Tax pp ~4• 514. 215. 515. j ' 216. 516. i .217. 517. I 218. 518. 219. 519. I ~. Tolal Paid lisnorear 1e1,774;21 lt20. Tobll tteduc'don Mirount Due Sayer 27,14/.90 300. Cah at SaltlasenRfkealtp Borrower e00. Cash atSeWementllollrom SNMr 301. Qross asacatt dueUcm borderer ne 1 ) 1 .17 601. Qoss amdad due b seller (one 420) 99,86924 302 Lao amounh paid byffor ne 220) 101.77421 602 Lae rsotxlicns b ainarrt due'edler 520) 21 .90 303. Cash ®Frae- ^ To Bortower 3,0.5299 907. Cash ®To ~ [~ From Barer 72,324.34 wronn.r..irww..m..u.~..iae.~..i...~.._,.~.~......~~ ....~..___Y._._. ~~._ .. .. - - -- editions are obsofebe stage i of a ~ HUD-1 MAR-01-2012 12:26 LIFT INC 717 691 8850 P.001 -- A. Settlement Statement (HUD-1) °A"B''ppr°~' "~• 2soz-o2ss FINAL MAR-01-2012 12:26 LIFT INC 717 691 8850 P.002 ""` 1pj1C1"~~ ~o.am•w Paid From Paid From " Divi>iicndoaronission ~ astollows: Borrower's Seller's • ~x! 184.10 to WdekAtsa#ates Funds at F nd t ~' •~ ~ ~'tl1r C paid 8t SOlOarnerrt Settlement u s a Settlement 5 ertee to W eltz I ~ ~ 175. . 1 100. Ihmrs in COnrrasttion wNh Loin eat. our Pantaa009ior .i7 (ircmGFE ~ our or Braga (pohKs} tlfe kdarest rye chosen .77 Oran Youredjeahad arigit~ion (~ 985 ~ ~ AMG ~nin 345x.00 P.O.C } Cred'R mport ~ ~ 17 eos. r>ix s~~ to GFE ~ 807. Food oa5ficatbn to F,4PDS OFE tli) 9.00 808. ~ ; 900. kieK Ind LendertD brPaid (n Adwnca . ~h' ~ from rfl 12012 ~ t . 1 m 1 .63 902. Mortgaoe Ins. m. mordhs to HUD ,1 Harrecxrtrers insunrroe tar 1 ~ V bkAual 3434.00 P,O.C 904. rrranOfa t0 floor GFE X11 1000. 1001. [nilid 'tfaryourescrowaooowrt (tromGFE~ 520.35 1402. Homeowners insurerx:e 3 mordhs S 3&17rmorAh 3108.51 1003. M Insurdncs months 3 91.28hnanOr 10D4. City Property Tax 2 g $ ~,87~yr x51.74 10D5. County Property Tax marffia S O.OOAfrontlf 3 1006.. SrhaW Properly Tart B apdryg 3 78,~p~ 362&00 1007. AdjtuUrrant ~7,9D 1100. TlOe q+ t services and a irrarxanoe tivm GFE #4 1, 1102 Settlement or dosing fee ~ 3 1103. Owners Otle trrsurence - FbNily N~icnal Title Insradrrce Compay GfE 1620 1 t04. Ler>dera title irarxarrw - F1de0ly Hatlcnil Title Inarrarce Company 11,031.68 110$. Lenda's title Nmit;98,977A0 Lender's Pdky I t 106.. Ownet'a ttlle limit ~9,600A0 Owner's Paticy I 1107. AgerU's portion d Ore toCd title irptrrartw premium Slf26.95 t 108. tindenvrf~ra patios d the total tine insurarw pren~m 322D.93 1109. E-Dac DdherY Fee to Select Lard Trdrrefers 125A0 1110. GouderltKre Fee tp Seled land Transfers ;15.00 Zp,00 1111. Not~y Fee to Vaiede Priest 325.Oa 20,00 1112 Reimburse fa lax Certdicatlon to Sated Land Transfers 3 I 10.00 1200. Ciorartnrerk ind Trralder 1201. Governmerd reedding dlarges 3 {from GFE tA) 15200 1202 DeedS8200 .00 Rel~se3 I 1203. Transfrr texos 1 (from GFE 38) t;95.oD 1204. ~!'FCarmtY Oeadia395.00 S 1205. 5tee Taxlstamps Deed 1996.00 i 995.OD 1208. Deed S $ 1207. idcr~aga 3atisfacbm ' ~~ 1300. Addmonil Settlerierrt 13x1. Requ services yeu can shop (from t16} ^mY to 1303. to , 1304. Irdrerifance tax escrow to Seied lard Tai, LLC I t~• to East Perxahorp Canwrrrer OIOce 6,71 1 1 1 ~ 1 preparation t0 Law LLC ! t 1 2 wp taxes to Escrowed 8dect Land Trarraters, LLC 00 1 .. February Ass00;i5on ~ r Cardomirrran A-sex .d:.-~_.._ . 6,337 1 . .~ w~ a evens q lapnawer. (ate, tyaxrer, (r]te'e~', eml~ "~ hY teed8r sham m page 1. "',Cry by sekr shown oe page 1. Previous nS are ObsiDlehe e 2 4 ~ HUD-1 MAR-O1-201?. 12:26 LIFT INC 717 691 8850 P.003 Conf : .Good Faph.•Eglmaoe ~md FIUO-1' '~JfatrCannot~nar~ea M!a] lafifi~abffr , . a. `. ~YOf,•iha' „Sd~l6TdfBChOS6fNR'. :#:° ~ •+'` . euradjnstad'fxigif.dfarges'• - ,.5:'.8031:" Tom... .•4 , . . at+1n Folil~nnot'8icwan.Mora~han'16%. ' C~ovgnmeaCaecading'diorgri:'. _ ,~.1,. . • .. lea.. ,:#;.~,; ~'OrediNreporC^~ 7.:;.,'St~81i5`,M1.`,ti . Imo: ..a;. .'r; ;.$•:!1 >owners. •'r~iranc'e.- pri:~ns 1 :~•aios. ;'~' Ch ' Tom: in reec+owaccoufd ... .. - '#'tAOf - ~.'F]orneowriedsioearance~=" - ",;•. ..{~, --,;'; . ,.*, ... lean Temnc tiOad~FaMh 6tlngle tg1D~1 1,85b.17 1, .17 .n 9e5.4o I ' Good`~Ea11-1Eginieaa ~ ..:; fAla9 ' 150.00 1 460A 450A0 17.50 17.50 9. g, i .17 ' 1,193.75 1, io.5o 16.20 I ' 2,790.92 1.SS 3 Ygriniflefl08n'8et0uM:is:' ' S969,770.~ . .. .. .. ., Xcur, loan ~mffn is,: 30. ysaa 'Maur'ttiitial`InliBfaet;rdtei9~ 4.0000% Your-IeI11~f,~i~or~1Y~,~:~P!~~Pg.g!4%and~y:n!Q! 5554.26indidas lnsarance'is:' ~ ~~ ' i X^ tMereet ~ ~Cen yourJtilefeet'rale dse9 , ~ ~ ~ . ~ , ~ Q No. ^ Yes, K can rise to a ~ mum at %. The flat change ' ~ Wpl be on ! I and can again ~' years aPoer ! f . Every drags _ ' date, Your intareat ra0e an inort~e a dtxxeeee by %. Over the lfle aF the fan, your :::~''"' ' Nterest cafe is guaranteed m never be lorefr than % a Idgherthen ~. ,_ . . '.J.• ... '~: ;.;,..j.. ~ ':''' ' ~ : '~.R. ...,..: ~~ :: , ~ ,_ , ., . .. . ..^5,` :Even;i~'j~odfiake~:p~liYi-ieiil&~Cil~fn9ean'YOUf~t.bel8r~oaips~'"~w ~' QX Na ^YetdoenrioetiDama>mmwnofS , Evon:rf~ . , ti .,. )I'OCIr!ake,~ij'mCatS'aiWr~ cen:l!ouF?1y'arrgiriCOwed~for^`~ ®N0. ^ Yp, the first NcaeaSe can be an 1 ! and the madhly ;II~Of~iiI1MY[8gf~.1AB~;',','~ ~' ,„.~ •,~ 8i11W11tON9d(~IdeBl05 S ~ . ~~:, '~c_w :.` ,:~'ti:~~ '':i~'~;;:'+. ;'>' ~:V A ThenfmdrnurnnCaneverdserotaSl . . •p?!!:' ,'r,..'~ " L^! No. ^ Ye9, ydr meodmlm prepaynferd Penalty is S Does yow':.lo®n'(i~e;Ytialboa.Payrt~iit7': Q No. ^ Yea 1'a have a baNooh paymad of 5 d~ in :~. ~' ~ ' years a, / / . Total; monlhlyfiirigcnE . . R . ,tpaynieita;' ~ .`.: [] Yea do not have a monthly eeaow Payment to itdwi, each es proptAy traces ~,, and homeownef's irreurance. You mu'et pay thane ittmK dicOCtly youreelF. $ '. ^X Ycu have 8n addtlbnal monthy esaow peymeM of S]40.64 ' that re;auip in a tOgtl inflict mantltty ergpunt owed of 1694.80. This indudes pAndpel, IrrDerest, arty ' mof~age irraaance and any iDdns o'.tiedced Oebw: , ;' ' ©~ti telaes ~ Q Home0Mnler's Insurance ;a ,.:.• ~. s . , ~ ^ Fbod irti;uranw I ^ . ^ ~ ^ nvu~ n yw nave arty queaeorla aa0u[ me 5el0arn9nt (:tlafg6s antl Loan T9ftrls Rioted Oft this f01rt1, PI6816 OOItidCt yOt,r lehdPJ. i MAR-01-2012 12:26 LIFT INC 717 691 8850 P.004 fiUD CE1tTiFICA770N QF QUYER AND SELLER ~~rssmenl~m the HUD-1 Settlement Staterrmrk and to the bast Ct my Iplowkdae yid belief, it s a tore and aoarrate stalsmeM d all and my aarorart a by me in thta orarmaction I iurtlnr certify ttrat 1 haw noeMed a acP!' of the NUQt Setllerr~eed StaNmarrt Easne ottcan>bee rw. socllg The MUD-1 BefNemant Sta~srrunt arhidt I have pypatgd is a true and eoourame dl;buraed in aocorQance rvbll thls afalenrML ~~ P.ru.ea~ sErn~rrACerrr cause the a~d.9 /z. ~~ WARNtNQ R IS A CROrE TO IOrOWINIGLY MAID FALSE STA773tlENT'$ TO'RIE UNfiED STAT$S ON CONV1CT1ON GW INCLUDE A FINE AND I>VPRl~1MEN7; FOR DETAILS SEE 1177E 1& U.S. CODE 31 OR ANY SIMILAR FORM. PENALTIES UPON )N toot AND SECnoN,tno. are MAR-01-2012 12:26 LIFT INC 717 691 8850 P.005 .. • .. Narne~f Bonvwer: Name of Geller. ; F1e Numba: ~^ ~ v Estate of Kalbksn M. Spwp i SL12279 r Name of eonov+er: Nana cf 5elbr. Fee Number: 8rfan Alspau~ Estate of Kallieerl M. SpOng SL12279 ~P~d 0?l1812012 at 5:42 pm Note: This page displays ttn ibmisatian o/ the rd7argvs shown on Iir1e 1101 d ttte iiUD-1 ~tiemene 9tabe~nent Thin pope panlas but is not a paR of the }100.1 Semement 8tatonrsnt It a discrepancy exis , the infotmadon on the NUD•t SettJonfent Statement appiias, t 1100.11tle t 1101. ~tla services lerxler~ ' esura~ce to ~~ Sdhr i Subbolal S 1102. Sa9tlert~erd ordosirg fee ~ S 0.00 8orrowjer 1t04. lerder'a ti8e insranoe-F+del~llr Naticrcal lto Select land Transfers for Eii 1.031.68 Banoaer 1109. E-Doo AeBveyy Fee to Sdea Laid Tra>sfers fOr I$ 26.00 B0rn7eer 1110. CourierllAflre Fee Bo ~ cot land T for' fi 13.00 Marual 20 00 1111. Nday Fee p Y~ p s . 25.00 Manua{ 20 00 1112. Rxbiibase torTax CarGfigtion to Seixt land Trtansfers for FS . OAO SeSer , 10 00 8elatlenderdedlts allonrr On 7 pOC s pald Cubide . i~~Ra-ed 07118!'1012 at 5:42 pm Note: Thla papa dlaplays an itemastian of the adjusted oryirrartlon ehargss shown in sidion 800 of the HUD-1 9e~orrt Stabmen ~~ apPl~ not s part of the HUO-1 SsltlemerrtSbtement ff a dbcrepancy exists, tfte Information on the HUQ1 MAR-O1-2012 12:26 LIFT INC 717 691 8850 P.006 CERTIFICATION ItORNp INFORMATION REPORTING pN THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENC& This tarttr may 1!ae completed by the seller of a principal rasldeaee. This information is nexasary m detetinime whether the sale ar exchange should be reported to the teller, aced to the Iaberasl R~evenuc Service on ~Fomx 1099-S, Proceeds From Brat F,arate Tronsadlora'. If the soils' pevperly caanpletes Parts I and 1TI, aced malxs a "true" rasporxse to assvranxs (l) tlaotrgh (6) 6e Part II ar a "not applicable" mpoase to assurance (~}, ao information tepor4ng to the sutler ar to the Service will be required fur that scllcr. The team "`roller" includes each owner of the resideafee that is sold ar exchanged. Thus, if ~ residcece has more rhea one owns, a reaE estate ruing person must eithar obtain a oartificeti~ >tnm each owner (whe:dfer mmtiod or not) err 51e an information return and furnish a payee statetnerrt lbr any owner that does not make the certifladoo, Part I. Solkr Information 1. Name: R of n 2. A+ddreas air legal descriptim (utdodmg city, se>ce, and ~ cook) of rasidevaoo bolog sold Q exchnged: l10 Brla^ PA 27025 ..~.w,.. 3. Taxpayer IdaRti~tfom Ntunbcr (T1N) i Part IL Scllor Assurances i Cheek "Cve" ar "false" for assmmtee.4 (I) thruugh (S), and "true", "false", or'bot applicable" for assnraoco (fi}. True False !. (] (I) T owned and used fife residence as my principal residerce for peiiods agga+egating 2 years or morn durlag the S-Yem p~ endiog Cox the date of the salC cr Wcchaoge ofthe rrside>~oe. ~. ^ t:2) I have mot sold ar CxChmosed smother psincipai reaidesfce dur;n~ the 2-Y'~ Pmt ~duag on the datc of the sate ar ekclaange of the t+ardgfco. '~ ^ (3) I Cos' my spouse or formes spouse, if I was mottled at any tune dxtr¢ag fire period begirmeng at3er May 6, 1997, and ending today) have sot used ivy portion of the rtaidcrxce for busitsess ar rerr~I purposes aiD:x May 6, 1997. ~-. ^ (4} At least one of the EoDawing three statdgteratg applies; The sale or dccstaage is of rho enure residence for 5250,000 or less. OR I am mmied, the oak of exchange » of the affime residence for 5500,000 ar lcas, and the gain on the sak or exc~eoge of rise entire resirleace is 5250„000 err less, i OR i . I am maaied, the sale or eAehange is of the emirs reaidemee for 5500,000 Cr leress„ and (a) I iff~rad to t31e a joint retttm far the year of the sak ar exchange, (b) my spouse also used tiie residence as his or het principal residence far 1~~ 88r'p'egRting 2 years ar more duringthe s-yar period eodafg on the dabs of the sale err exchange of the restde~e, aced (c) roy spouse also has sot sold a>r exchanged ataother;principal resideaa during the 2-year period Boding oa the date of the sale ar exchange of the painaipal residence. ~. ^ (5) 1Duriag the 5-year period ending oa the date of the sale or exch'sage: of the tosidaua, I did not acquire the residence in as exchange tb which sexxion 1031 of the Iuteraal Revax$e Code applied True Faire N/A ^ ^ ~ (~ If ray ba.4is in the residence is date~ined by refm~cnce to the bases is the hands of a person who acquired the residence itt m exchange to which section 1031 of the Internal Ravanue Code applied, the exchange to which serxion 1031 applied occurred mode Bran S years prlar to the dace 1 sold or exchanged the residetme. Part itlL Se,fkr Certification , Under pafalties of parjmy, I cerdfy that all above information is true as of the aced of the day of the sale or axchaoge. Sfgoenua of Seller ~/'7+~ 2012 Ihte • This certll5mtioa mast be retaisfed by rho d~8 a~at flat 4 vats asibcr ~e year of the sale or ettc6ange. • Se11a's Forwarding Add: Scttlanent date: ~ Sales Price: 599,500.00 Portion etsxa'butabk m this Seller. % ! File Number: SL12279 Ballet Names: Estau of ICadflam M. Spong TOTAL P.006 U I,IICGt~ if NvaGCV vn ..w.. ~..y ..,... _ r.,....._ -_ ...--'-_-' ----- -..._ ® CIOSed aCCOUnt 5004058413 ^ Branch adjustment (branch name) ^ Service charge error ^ Other: Account Number File ID AMOUNT $ so . o0 5004058413 040 PNC Bask, National Associa RATHLSSN M SPONG FOR BANK USE ONLY p E 3510 BSSCH RUN LN Branch #/Dept. # Date B 1~CHANICSBURG, PA 17050-2206 0000108 09/07/2011 I T Prepared By (PRINT Name) Authori~z By I NATHAN L COOK / /~, Customer's Advice of Charge EFORM100472-0900 PNCBANC Your account was DEBITED for the following reason: ^ Check # posted on encoding error ,_ posted to incorrect account ® Closed account 5004054519 ^ Branch adjustment (branch name) ^ Service charge error n Other. 5004054519 D ' RATSLSSN DS SPONG E MICHSLLS I GOUSS i3 3510 BSSCH RUN LN I I48CHANICSBURG, PA 17050-2206 T AMOUNT $ 1368.24 040 PNC Bask, Na FOR BANK USE ONLY Branch #/Dept. # 0000108 Prepared By (PRINT Name) Autho~riz/ NATHAN L COOK / _ . By a Date 09/07/2011 Customer's Advice of Charge r r.: f7 -i r. L C: fl L J i f t~ N t (7 N ~~.a~cZ~~:~ Iir.;dr AHI ~(li) i3~i-1711 1k +;i0fi? _ .~ i'iSIi Ui Af: www.svr u.,,k;: !!:ilc.~~:_t~~~~i~~ !i~te! in;": 1:~; lr;j~i)11 ~. !; brni: -.: Mai n lel;e~ 'f~~: !~ljl :e• ~~• .. c:6tAr15 Meia;;e Ninnt;er : 3A45 KF'tNt.FFPi ~!'UN;~ .. i i : ~ :. I .l u,;a. f~yac:: P!; ~IEi I E ; iCll~ E Amrnint ,y, `i ,.1. ~~ WI i ~draw<.l . `. i(;': i)(i-~ey;l?a~f 5!tiir a ~: 'ail L~:J...,. i •t: qi. ..c.. 111:. ,..A~.!lir~ :~ : ~ 1 Fi eVl JIiS Ii&Iul i! d: 3Ql~i: „[I ~IaCr'e11 [i;ilaf:CE .,c .~i~~ MBI!IIJF'" Jlutla:~CB COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM 30 NORTH THIRD ST STE 150 HARRISBURG, PA 17101-1716 t-800-633-5461 www.sers.state.pa.us September 15, 2011 MICHELLE I GOUSE 3510 BEECH RUN LN MECHANICSBURG PA 17050 Re: KATHLEEN M SPONG SSN: 199-36-5996 Dear Beneficiary: We are writing to you regarding the above named account. The enclosed forms must be completed by you, according to the printed instructions, before we can proceed with the processing of this account for payment. Please note: The Retirement Code does not provide for the payment of interest on the principal sum of a death benefit. Please read the enclosed information pertaining to the recent change in the Federal tax law. Also, please complete and return all applicable forms to our office as soon as possible. To aid you in making selection decisions, the following information is provided: Death Benefit Payable to you: Taxable Portion: Non Taxable Portion: $135,062.46 $135,033.46 $29.00 If you have any questions or need assistance, please contact the field office nearest you at 1-800-633-5461. Sincerely, t~,Gvrc. J`77~c~~ Debra G. Murphy, Director Benefits Determination Division Enclosures BEN65 I IIIIII VIII I'll' Illll 11111 VIII 11111 VIII VIII VIII VIII Illll IIII I'll Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor 501 North Baltimore Avenue Mount Holly Springs, Pennsylvania 17065 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are onl} for those item, that you selected or that are required. [f we are required by law or by a cemetery or crematom to use any items, we will esplaui the reason in writing below. If you selected a funeral that may require embalming, such as a funeral viewing, you may have to pay for enil~alming. You do not have to pay for embalm- ing you did not approve if you. selected arrangements such as direct cremation or immediate burial. If we charged for embalming, «r will explain why below. For the Service of Date of Death Charge to: Name Address City State A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIO_V.gL SER~~ICES Sen~ices of Funeral Director~iraff - ..... S Embalming ..................... 5 Outer preparation of body' ................ ........... S SUB-TOTAL OF PROFESSIONAL SERVICES ..........AI S 3. FACILITIES AND SERVICES Use of facilities and services for vien•ing (\'isiruion;'~~'ake) ...... .. S Ilse of facilities and services for funeral ceremonti ............ S Other clothing Cremation urn .......... S ('Description) ~ ~ ~ ~, OTHEK $_`_- $__ TOTAL MERCHANDLSE SELECTED ..... .....B $ G SPECIAL CHARGES: Fortvarding of remains to S (Funeral home) Receiving of remains From S l,se of facilities and services for (Funeral Homel Memorial Sen-ice ... S Immediate Burial ................ . $ Lice of equipment and aereices Direct Cremation ......:'..,...:-.:.. . S for gracesidc scnice ............. S S .. ' , `~ Other use of facilities SUB-TOTAL OF SPECIAL CHARGES ,,~ .. ................C 5 - ~ `' -- D. CASH ADVANCED ............................. S Opening Grave ................. .5 SUB-TOTAL OF FACILITIES/EQUIPMENT ...........AZ S Cemeten- Equipment ............. _ . S _ i. AL?T'O\iOTTFP f?QLlP\IE\T Lot and Deed .................. . S - vehicle to transfer remains to Funeral Home _. Newspaper Notices-Local ...... .. . -. . S Local ....................... S NewspaFxr Notices--Out-of-town ..... . $-_-----~- Hearse (Casket Coach) Telephone fi "Telegrams $ _ Local ............... ......... b Airfare ....................... ' .5 - CletgyiMass OfFcrin S ramuy ~m Loxal ......................... 5 Flower car or floral disposition Local ......................... S Lead rar%clergy rar Loxal ......................... 5 Car For pallbearers Loxal ......................... 5 Out of town transpoRation .......... $ $ SUB-TOTAL OF AUTOMOTIVE EQitt)PMENT .........A3 S TOTAL OF PROFESSIONAL SERVICES, FACIIITIES AND AUTOMOTIVE EQUIPMENT ..................... ..............A S B. CHARGE FOR MERCHANDLSE SELECTED: Casket .........................$ (Description) Other Receptacle ................. $ (Description) Outer burial container ............. $ Q)escription) Acknowledgement cards ....... ..... S Register book(s) ............. ..... S !vlemory folders ............. ..... S Pravercards ............... .....S Temporary grave marker ....... .. , .. 5 Butial clothing .............. ..... S Certificate .............. ........ S --- Policu Iiscort ............ ........ S Flowers ................ ....... . t Vault Service Charge ....... ........ 5_ 5 S S S _ SUB-TOTAL OF ADVANCES .......................D S f '" .'', We charge you for our services in obtaining: (specify crib advances that are marked-up) SUMMARY OF CHARGES A. Professional Services, Facilities and Equipment, and Automotive Equipment ..................... S _ B. Merchandise .................... S C. Special Charges .................. S~=;~ D. Cash Advances .................. S TOTAL OF AIL SECTIONS ................ -....... $ , `.~ ( ' PAID AT TEHE OF OR PRIOR TO ARRANGEMENTS .............................'.. 5 . BALANCE DUE ................................ $ . REASON FOR EMBALMING If any law, cemetery, or crematory reyuiremenls have required the purchase of any of the items lifted above, the law or requirement is explained below. I agree that [have examined the items of goods and services selected above and found them to be correct and according to the arrangements 1 have requested. I acknowledge remipt of a copy of this Statement of Funeral Goods and Services Selected. I represent that I have sufficient funds available for pa}mtent of the cash price for the goods and services selected. I also agree to make payment of S within days. I agree to be jointly and severally fiable with anyone else who signs below. A late charge of per month amounting to per year will be applied to the unpaid balance beginning days from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will he considered part of this agreement and the mst thereof will be reflected on the final bill or statement. (Seal) (Purchaser) (Seal ) D Pennsylvania Funceul Dirtrtors association form - 600 Revised 1/04 (Purchaser) t '~, (Licensed Funeral Director) WHI'ft: Furn~ral Uircctor Y'FlLOtt' Furk:cd Dircr.~tor PINK Custaner