Loading...
HomeMy WebLinkAbout06-04-12 (2)1 1505610140 _ REV-1500 ~` `°'-'°' OFFICIAL USE ONLY PA Department Of Revenue Bureau of Individual Taxes County Code Y~r Flle Number Po BoX 280501 INHERITANCE TAX RETURN 2 1 1 1 0 7 2 2 Harrisburg, PA 17128-0801 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 5 2 6 2 0 1 1 0 2 2 5 1 9 3 2 Decedent's Last Name Suffix Decedent's First Name MI M I L L E R BARB ARA A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffx Spouse's First Name MI Spouse's Social Secudty Number THIS RETURN MUST BE FILED I N DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW © 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Retum (date of death poor to 12.13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) © 6. Decedent Died Testate [] 7. Decedent Maintained a Living Trust ~ 8. Total Numtrer 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 . O) !`~ a CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTUIL TAXINFOR HOULD BEDIRECTt~ Name Daytime Telep umber C ~ d J OEL R. ZUL L I NGER 71 7 6`~0~'~~? r REGIS S USft. f1NLY j f-r , First line of address I ~"'r N ~ ' '.' ~ ~ 1 4 NORTH MAI N STREET Second line of address S U I T E 2 0 0 City Or Post Office State ZIP Code DATE FILED C H A M B E R S B U R G P A 1 7 2 0 1 Correspondents e-mail address: Untler penalties of perjury, I dedare that I have examined this return, inducting acmmpanying schedules and statements, and to the beat of my knowledge and belief, it is true, mrred and complete. Dedaretion of preparer other than the personal representative is basetl on all iMOnnatlon of which preparer hae arty knowledge. 126 CE 200 PLEASE USE L 1505610140 Slde 7 SHIPPE 17201 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number oecedenfs Name: BARBARA A. MILLER RECAPITULATION 1 1 7 7 8 3 4 1 1. Real Estate (Schedule A) ......................................... .. 1. , 2. Stocks and Bonds (Schedule B) .................................... .. 2. 3. Closely Hekl Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4. 3 1 8 7 7 . 5 3 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-~lnos Transfers & Miscellaneous N -Probate Property ~ ] 4 7 5 0 1 5 Separate Billing Requested ..... (Schedule G) .. 7. , 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 2 2 4 4 1 1 0 9 9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9. 4 5 9 5 6 • 9 6 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... .. 10. 3 0 1 4 • 2 4 11. Total Deductions (total Lines 9 and 10) ............................. .. 11. 4 8 9 7 1 • 2 0 12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. 1 7 5 4 3 9. 8 9 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. 1 7 5 4 3 9. 8 9 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.z>x.o _ 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable 0 0 0 o 0 0 0 . _ at lineal rate x . 16. . 17. Amount of Line 14 taxable 1 3 1 5 7 9 9 2 1 1 5 7 8 9 5 9 . at sibling rate x .12 7. . 18. Amount of Line 14 taxable 4 3 8 5 9 9 7 6 5 7 9 0 0 . at collateral rate x .15 16, . 19. TAX DUE .................................................... ..19. 2 2 3 6 8. 5 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Pape 3 File Number Decedent's Complete Address: G ~ ~ ~ U! GG DECEDENTS NAME BARBARA A. MILLER STREET ADDRESS -- _-_-- _- - - ~- 1051 County Club Road _ __ CITY STATE IZIP Cam Hill PA 17011 Tax Payments and Credits: f Tax Due (Page 2, Une 19) 2. Credits/Payments A. Prior Payments - B. Discount 3. Interest 4. If Line 2 is greater than Line 1 +Line 3, enterthe difference. This is the OVERPAYMENT. Fill In oval on Page 2, Line 20 to request a refund. (1) 22,368.59 Total Credits (A+H) (2) 0.00 (3) (4) 0.00 5. If Line 1 +Une 3 is greater than Line 2, enterthe difference. This is the TAX DUE. (5) 22,368.59 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 hansfer and: Yes No a. retain the use or income of the properly transferred : ................................................................. ..... ^ b. retain the right to designate who shall use the properly transferred or its income : .......................... ..... ^ c. retain a reversionary interest; or ........................................................................................... ..... ^ d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ 2. If death occurted after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................. ..... ^ 3. Did decedent own an 'in Wst for" or payable~upon~death bank account or security al his or her death? .... ..... ^ ^JC 4. Did decedent own an individual retirement account, annuity or other non-probate properly, 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 far the use of the surviving spouse is 0 percent p2 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 fling 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 adopfive 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 decedents lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent 172 P.S. §9118(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common vtlth the decedent, whether by blood or adoption. REV-1502 EX+ (01-1 O) Pennsylvania ~ SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT OF: BARBARA A. MILLER 21 11 0722 All real property ovmed solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the pdce 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 Jolntlyowned 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 awned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. Decedent owned aone-half interest as a tenant in common in real estate, together with improvements thereon erected, situate at 1051 Country Club Road, Camp hNill, PA, said real estate was sold for a gross purchase price of $234,000.00, one half of which is being 117,000.00 ;edent's one-half share of proration of real estate estate taxes from the sale of I 783.41 above real estate TOTAL (Also enter on Line'l, Recapitulation.) ~ S 117, If more space is needed, use additional sheeb of paper of fhe same size. REV-1508 Ex+ (11-10) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS, & MISC. INHEPoTANCE TAx RETURN RESiCENT DECEDENT PERSONAL PROPERTY e57arE uF: FILE NUMBER: BARBARA A. MILLER 21 11 0722 Include the proceeds of litigatlon and the date the proceeds were reraived by the estate. All property jointly ovmed with ripM of survNOrshlp must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Checking Account #97402036, M&T Bank, including interest accrued to date of death, 7,496.42 copy of verification letter attached 2. Proceeds from sale of decedent's automobile 6,250.00 3. Proceeds from private sale of miscellaneous personal 1,843.50 property 4. Refund of Medicare premium 737.30 5. Annuity Contract #AO200329, Western National Life Insurance Company, with named 14,469.31 beneficiary of "Estate of Barbara Ann Miller", which makes the asset part of the probate estate 6. U.S. Treasury, tax refund for 2011 972.00 7. ~ PA Department of Revenue, tax refund for 2011 ~ 109.00 TOTAL (Also enter on Line 5, Recapitulation) I S If more space is needed, insert additional sheets of paper of the same size REV-1510 FJ(+ (0a-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON•PROBATE PROPERTY FILE NUMBER BARBARA A. MILLER 21 11 0722 This schedule must be completed and filed if the answer to any of questions i through 4 on page three of the REV-1500 rs yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAMEOF TI¢TPANSFFREE, THEIR RELATIONSHIPTO DECEDENTAND THE DATE OFTRANSFER. ATTACHACOPY OFTHE DEED FDR REAL ESTATE. DATE OF DEATH VALUE OF ASSET 'YO OF DECD'S INTEREST EXCLUSION nF.sPUCra~D TAXABLE VALUE 1. Mutual Fund Acct. #02131387368 5 002, Ameriprise Financial 1,639.09 100.00 1,639.09 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent 2. Annuity Acct. #93007684781 1 004, Ameriprise Financial, 23,162.99 100.00 23,162.99 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent 3. Annuity Acct. #93101839019 1 004, Ameriprise Financial, 9,172.94 100.00 9,172.94 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent 4. IRA Acct. #93107506029 9 004, Ameriprise Financial, 3,237.25 100.00 3,237.25 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent 5. IRA Acct. #93108255643 8 004, Ameriprise Financial, 4,356.88 100.00 4,356.88 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent 6. Premier Acct. #00049836364 7 021, Ameriprise Financial 33,181.00 100.00 33,181.00 named beneficiaries, Dorothy Daniels, Rachel O'Donnell, Mary Showvaker, Vivian Peters, all sisters of the decedent TOTAL(AlsoenteronLine7Recapitulation)I $ 74,750.15 If more space is needed, use additlonal sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF BARBARA A. MILLER 21 11 0722 DeeedeM's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, funeral services 10,394.35 2. Grave opening 600.00 3. Flowers 200.00 4. Eby Granite Works, gravemarker 4,832.00 8. I ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Addles5 1Zb MIIKy VVay City Shippensburg state PA zip veer(s) Commission Paid: 2012 7,500.00 Attorney Fees: Joel R. Zullinger 7,500.00 Famiy Exemption: (If decedenCs address is not the same as daimanrs, adach explanation.) Claimant Street Address City Stale ZIP _ Relationship of Claimant to Decedent Prebate Fees: Register -JCS fee 23.50; automation 5.00; short certificates 20.00; renun- 343.50 ciation 5.00; will 15.00; letters 260.00; filing return 15.00 Acceuntant Fees: Tax Return Preparer Fees: 7. Cleadis Peters, labor for cleaning house prior to sale 150.00 8. Stephanie Hoch, labor for cleaning house prior to sale 200.00 9. Brad Shover, labor for cleaning house prior to sale 300.00 10. Pennsylvania American Water, water service to residence prior to sale 270.80 11. PPL Electric, utilities to residence prior to sale 264.57 12. East Pennsboro Township, trash 8 sewer to residence prior to sale 414.00 13. Hambright & Vorkapich, lawn mowing prior to sale 120.00 14. Stanley Steamer, carpet cleaning prior to sale 306.34 15. Nationwide Insurance, homeowner's insurance 514.50 16. Don Eberly, installation of garbage disposal 75.00 17. UGI Gas, gas service to residence prior to sale 340.78 18. Pat Ha ood, reimbursement for dumpster, haulin and advertisement 570.89 TOTAL (Also enter on Line 9, Recapitulation) S 45.956.96 If more space is needed, use additlonal sheeb of paper of the same size REV-1512 EX+ (12-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER BARBARA A. MILLER 21 11 0722 Report debts incurred by the decedent prlorto death that remained unpaid at the date of death, Including unrelmbureed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PPL Electric, utilities due at death 69.43 2. Pennsylvania American Water, water service due at death 3. UGI Gas, gas service due at death 4. Terminex, service contract due at death 5. J.C. Penney, credit card balance due at death 6. Comcast, cable service due at death 7. Verizon, telephone service due at death 8. WSEMS Chambersburg, ambulance service due at death 9. PSERS, return of teacher retirement received after death 10. Menno Haven Physician Services, medical services due at death 11. WSEMS Chambersburg, ambulance service 52.01 29.11 59.63 2.06 27.22 33.95 78.87 1,566.58 10.00 1,085.38 TOTAL (Also enter on Line 10, Recapitulation) 15 If more space is needed, insen addN'onal sheeb of the same size. REV-1513 E%+(01-10) pennsylvania ~ SCHEDULE J OEPARTMENTOF REVENUE I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: BARBARA A MILLER 21 11 0722 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [IndudeoutUr~1'pphtsousaldlsMbutionsandtransfersunder Sec. 97f6 (a~(1.2).] 1. Dorothy Daniels Sibling Menno Haven, 2075 Scotland Avenue 1/4 of residue Chambersburg, PA 17201 2. Rachel O'Donnell Sibling Menno Haven, 2075 Scotland Avenue 1/4 of residue Chambersburg, PA 17201 3. Vivian J. Peters Sibling 5 Robin Drive 1/4 of residue Shippensburg, PA 17257 4. Elizabeth A. Shover, issue per stirpes of Mary E. Showvaker Collateral 4/16 of residue Carlisle, PA 17013 5. Joyce C. Showvaker, issue per stirpes of Mary E. Showvaker Collateral 4/16 of residue Shippensburg, PA 17257 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH i6 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COWER SHEET. S If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAME OF BARBARA A. MILLER I, BARBARA A. MILLER, of Cumberland County, be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES ~~ 7 ~R {. T _7 r- _;-~ ~; -- N ('~ ~ _"_ _.. ~- ~ ' ,, ~: ~' - = =,; tl~u's to ~'~ FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon as maybe convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that maybe 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 of administration of my estate. PERSONAL PROPERTY THIRD: I bequeath all personal effects and personal property as I may set forth in a separate signed memorandum to the persons named in that memorandum. Any household furnishings not previously distributed by memo I bequeath to Matilda Shaub, if she shall survive me for a period of thirty (30) days. If she shall not so survive me, my household furnishings shall be added to the residue of my estate. DISTRIBUTION OF RESIDUE FOURTH: I give the entire residue of my estate to my sisters, Dorothy Daniels, Rachael O'Donald, Mary Showvaker, per stirpes and Vivian Peters, per stirpes, equally, provided that the share of any sister who does not receive her share per stirpes and who predeceases me or dies on or before the thirtieth day following my death, such share or shares shall be added to the share or shares for my remaining sisters. If none of my sisters shall survive me for a period of thirty (30) days, the entire residue shall be distributed as follows: one-half to the Shippensburg First Church of God, one-fourth to the Humane Society of Hamsburg, Inc., and one-fourth to the Humane Society of Franklin County. PROTECTION OF BENEFICIARIES (Spendthrift Provision) FIFTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. TRUSTEE OF ESTATE OF MINORS AND INCAPACITATED BENEFICIARIES SIXTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor, as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support an~9 education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated pF;rson, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Trustee may, in discharge of all the Trustee's duties, pay any minor's share deemed impractical of administration to the parent or other person in charge of the minor or to his or her guardian or to a custodian for the minor under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon such person reaching the age of 18. My Trustee shall have the same powers as my executor and shall serve without bond. POWERS OF EXECUTOR SEVENTH: I confer upon my executor the right to sell o:r otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and upon such terms and conditions .as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers thereof, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments;" to make distribution in cash or in kind; and to do all other acts and things :necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENT OF EXECUTOR EIGHTH: I appoint Vivian Peters, executor of my will. If Vivian Peters is unable or unwilling to qualify as executor or having qualified is linable or unwilling to act, I then appoint Patricia Haywood as executor hereof. I direct that my executor shall not be required to furnish security in any jurisdiction. INTERCHANGEABILITY OF LANGUAGE NINTH: Words used in the singular maybe read to include the plural or the plural maybe read as the singular. Similarly, the masculine form maybe read to include the feminine and neuter; the feminine maybe read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine;. HEADINGS TENTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. /d ~ I have signed this will this /3 day of /-a~: ~~y , 2003 Barbara A. Miller / G~ "'_` Thomas J. Ahrens -P~~a;~ Ashley J. Pi c:k ACKNOWLEDGEMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA: SS. COUNTY OF CUMBERLAND I, Barbara A. Miller, the testatrix in, and Thomas J. Ahrens and Ashley J. Pisanick, the witnesses to the last will, the attached or foregoing instrument, who have signed the instrument, having been duly qualified according to law do depose and say: (a) that I, the testatrix, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the testaU-ix sign and execute the instrument as her last will, that she signed it willingly and 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 a witness and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Barbara A. Miller ~` __ Witness, Thomas J. Ahrens UlX- n/JGC~Py~C~ Witness, Ashley J. Pisanick NOTARIAL SEAL JUDD M. AHRENS, NOTARY PUBLIC ~ (~ )/J~ MECHANICSBURB 80R0., CUMBERLAND CO. /~ Y ~ ~ ~ ,~L~ivJ MY COMMISSION EXPIRES MAY 23 2005 N tary Public U. S. DEPARTMENT OF HOUSING antl URBAN DEVELOPMENT OMB No. 25@d2fi5 SETTLEMENT STATEMENT TffLEPRO TM LIBERTY LAND TRANSFER, INC. 13. TYPE OF LOAN 4660 Trindle Road, Suite 201 Camp Hill, PA 17011 1. FIw 2. RHS 3. CONV.UNINS. 4. VA 5. (:ONV. INS. Phone: 717-975-9915 FAX: 717-7637460 8. FILE NUMBER ~% 7. LOAN NUMBER: '373838 MORT. INS. CASE NO.: C. NOTE: This brtn is Punished to give you a stafemerO or actual seOlamad cosh. Amounts peitl b atl M Oie settlement agem me shown. ttns marketl "(P.c.c.)"ware paid cutaitle Oar rbsing; Oiey ere shown here br Odanriation puposes ant era rat'esduded in the totals. D. NAME AND ADDRESS OF BORROWER: Glom L Perayl Martha Jere Penayl E. NAME AND ADDRESS OF SELLER: MaMtle E. Slarb Estate Barbee A MiOa Estate F. NAME AND ~4DDRESS OF LENDER Ameridloice Federal CredR Unbn 2175 Buda Bee Holbw Raetl Medwniredag PA 17055 G. PROPERTY LOCATION: 1051 Cwr4ry Cair Road Camp HiR, PA 77071 N. SETTLEMENT AGENT: Ubarty Laritl Transfer I. SETTLEMENT DATE: Apr 05 2012 Thursday East Pennaboro Towrehip Cumbertad County, PA PLACE OF SETTLEMENT: 2775 Sunda Bea Fbllvx Road Meaureiaburg, PA 17055 J. SUMMARY OF BORROWER'S TRANSACTIO K SUMMARY OF SFILER'S TRANSACTION 100. Gross Amont Oua From Bwmwx 400. Grow Amount DUSb SNIer 101. Contract sales Price 234,OOD.00 401. Cmtrad gabs prior 234.000. 02. Percasal Property 402 Pxawia Prapaty 03. Setlbrrertl CtMrpea (line 1400) 5,492.55 403. 09. 404. 105. 405. AdjusMeMS for Rams paitl h advance by seller(s) Adjusbnema for items peitl in etlvanw by seller(s) ofi. cRyrtown Tar to 40fi. cityrtown lax b 07. Cnuay/GTy tmc O/5RO7z b 7z(d7rz072 700.33 407. Ccuty/Ciy Teat 4/5207z to 1207/N7z 700. O8. Asaeasmada b 403. AscessmaOU b 09. Sdrocl Tes 4/58072 b 6G0'2072 738.08 409. Srlaol Tmr 4/52072 to N3Qr2012 738. 70. Sewer?r4sh 4/5rz012 b 6TJ0'2012 130.42 470. Sewer/Treah 4/512012 to 6T3W2012 130. 71. b 411. tc 72. b 412 to 20. Grose Amount Duefrom Borrwwa 241,O6B.88 420. Gross Amount DYeb BNlar 236,588 . Amounb Pad By q In BMY/ q Borrmvar 500. Rsductlona In AmourO Dua To SNlar 1. DepreR w eamea morey 1,500.00 507. Excece tlepoaR (see iMtrvdiana) . PrtnapalAmount of new bat(s) 187,20D.00 502 SeOlement cherpcebsabr(Iire 14011) 18,274. . EzLSBrM bar(s)bken subjactb 503. ExlaRnp ban(e)bken subjectb 504. PayoBOt FUa MartBapa LOen 505. PayoBaf Semtl Mortgepa Loaf . Cloarp Casts by Seller 10,570.00 50fi. Closing Costa fa buys 10,510. 7. 507. Inheritance Tar ESrmw-Babare Miller Estate 28,500. 50B 509. AdjreMer4s for items ur4leitl by saga Adjwtrnenb ku Rams urpei0 by saga 70. CRy/TOwn tez b 510. CRY/TOMItea m 17. CouM//CRy tmr to 577. CoumylCity Imr to 12. Asaesamema b 572 AssesamarM b 13. SCwd Tar b 573. SGiaol Tar b 74. ro 514. b 15. b 515. b 18. to 57fi. b 17. 577. 18. 57B 79. 519. 0. Totes Patl by/for Borrower 799,210.00 520. Total Retluetlon In Amount Due 8NIar 65,284. . CASH AT SETTLEMENT FraMfo BORROWER 800. CASN AT SETTLEMENT TafFrom SELLER 7. Gioce anent due Born bortower (fine 120) 247,059.38 801. Groan Amount due Sabr(IM420) 235,588. Lces amourb pad byrtw borrower (Ilre 220) 799,210.OD 602 Less reduction in emL due cellar (Iire 520) 55,284. . Cash ®FROM ^ TD Borrower 41,849.]8 803. Cash ®TO ^ FROM Selbr 780,28 Buyerw Bortowera SignaWre Sellefs Signature HUD-7 L SETTLEMENT CHARGES Gse #95888 700. Total Real Esbb Broker Fsas S 73,830.40 Pald Fmm Peltl Fmm DHbial Moanmksion (Ise 700) as follows Borrower's Seller's 707. 8,929.70 b Hoxerd Hems Real Esbb (58929.70 Isla $1500 tlapos8) Furrtls At Funtls At 702 8,704.70 to Coldwell Banker Homestead Select Prof. Settlement Settlement 703. Comm'nsim peitl e¢ Set0emeM 13,634. 700. to 800. Items Payable In Conneetlon Wtlll Loan B]i. Orrorgiretion charge 300.00 (from (GFE!`U 802 Yaur aetli a charge (porc4s) for the nbreel rete chosen $ (fiom (GFE ~!) 373. Vare aCfusted argina8pn M1a'9es b Amedtlwlm Federal CredB UrIM (from (GFE A',I 30000 0. 804. ApgakM Fee to AmenCroice Fetlxal CretlB Union (from (GFE #71) 35000 BOS. Cretltl Report to Amedchoice Fetlerel CredB Union (from (GFE fxl) 15.00 806. Tml Servios tc (from (GFE ~I) 807. Flootl ced'dinah'on to Amedchoice Federel Credi UMm (from (GFE 4rp 25.00 808. to 809. b 810. b 811. b B12 m 813. b 814. to 900. Items RagWrW ty Center to Be Paltl in AWarws 907. Deity h4erest charpeafrom 4!52012 b41302012 ®$ 20.8000 May (Rom (GFE iY0) 540.80 902 Mortgage inswance premurr to 0 manta b (Rom (GFE ittq 903. Homeowners Wuanos premium tar 1 years b Stale Fem $754 POC by bortower (firm (GFE #11) 9D4. to 1000. Raaervee DapoaNed will Lantler 1001. InWM tlepoatl fa your eacrov accaaM (from (GFE #fr) 0.00 0. 1002. Homeowners Insurance 0 Montle ~ $ rtaoM 7003. Mortgage msraenra 0 ManNS ~ $ MbMh iW4. Property lazes 0 Mmtlrs~$ M1onN 1005. 0 Months ~ $ RAOnN 1006. 0 Montlls~$ M1oMh 1007. A118epele AdusMenl 1100. Tifb Charges 1101. Tttle aervilTn and !antlers title insuerza (from (GFE #~',) 1,545.75 0. 1102. Sepanentacbshg fee to Liberty lerrtl Transfer 1103. Ownefa pb irmurence to Uberty L>ald Transfer (from (GFE #:i) 230.00 7104. Lenders tille'veurenre 7,448.75 1105. Lentlera itlle poky !entl S t87,200.OD 1108. Owners t8b poliq limit S 234,000.00 11 W. Agent's pa8on of the total plc ineurarlee premium 1,428.94 1108. Urldervnitera portion of the total plc Inwrenoa pemiun 251.67 1109. Tez Cart to Uberty Lentl Trarefer 10. 1110. to 1111. to 1200. Govsmmertl ReeoMnp arM Transfer Charge 1201. GoverrmeM remrdinp charges (from (GFE#7) 148.00 1202. DeetlS 62.OD MartgegeS 84.00 IWlaeirLF Deetls 12IX1. Trensfertazes (from (GFE #F) 2,340.00 1209. City/CaruNy tmJalempe Deetl $ 2,340.00 Mortgage $ RecoNer of Deetls 1205. Stele bz/sbmps Deetl$2,340.0p Mortpepe$ RemrtlerMDeeds 2,340. 7208. b 1300. Atlditlonal Settlement Charges 1307. Requiretl services Net you can shop fro' (Rom (GFE #8) 0.00 1302. to 7303. to 1304. Hama Warranty to HSA WarreMy 479.00 1305. Radon Remedietbn to ARS 790. 1306. 2]12 Co/fwPTazes b Debbie Wpokl 929. 1307. Saxerlfresh bEast Pennsbao Twp 751.80 1400. Tofel Sattlamenl Chemea (enter m lines 703. Sectlane J entl 502 Seaione q I 5.492.55 I 18.274.56 - Pertbs spree Mat no lehtlily kassumtl gSepemeM ApenlMNe aoanq ollnformatlon Nmishetlgotlrers es shamm Nn HU0.1 Se1tlemaM SlalameM, HUD CERTIFICATION OF BUYERS ANO SELLERS I have cmefilly reviewed the HUD-1 SepemeM Sbbmxa entl b the best of my Imowledge and belie(tt k a hue entl emaab alelemeM M at receipts entl drsbunemeMS made m my account q me in tlrs transeaiort I fuller certyy that I have reoalved a ocpy Mtl1e HU0.1 SettNrneM Statement Buyers 9ormaefe 6ipneNra Seaefe SiauNrs Buyah Atltlreu b Phone: Sellers NswAtltlrees b Phone: TAe HU613eMSment Statement wfiiGr I hm prepentl k a ws end gimme ecwunt o/Mis wnsectlm. 1 hew nueetl a W uuu are Nntle b b tla6uM1etl In a~MercawlM Mier ekkmenl Settlement Apart Dale WARNING: ttkaaime to knowinpN rmMialse ektemenkb Me Unile45M1ks an Mia or any elmllar fom. Pompee upon wnWNOn wnlnUUMapne entl kgkonrmM FOr dekpa fee Tlpe 1e: U.S. Cotle Satlkn 1001 entl Bectlon iNp. Com son of Good Falm Eatimeb GFE end HU0.1 ehsr9es Good Fallh Estimab HU0.1 Cher0se met Cennol Increase HUD-7 lJne Numbb Loen# TRIe# 88596 Ouran0betlon chage #801 $ BSD.OD S 30D.OD Your cretlixara0e (poims)ror8te reb clrosan #802 $ .W S .OD Your adjuatetl origine0an ampes #803 $ 860.00 S 300.00 Trerwfw fazes #1203 $ 3,340.00 $ 2,340A0 as mat cannot mrxwss more then 70% Good Felth Estimab HU0.1 Govemmarl reradFB ~9es # 1201 S 128.60 $ 14a00 Appraisal Fee #804 $ 500.00 S 350.00 Credt Report #805 $ 15.00 $ 16.00 Fbod certnce0an # BlA $ 25.00 $ 26.00 rNe servkxu end lendane title iwaance # 1101 $ 700.00 $ 1,646.76 Oamefa title insurance # 7103 S 1,62B.7d $ 230.0D # 0 E .00 S .00 # 0 S .00 S .00 a .oo .oo o .oo .oo o .oo .m o .oo .m row $ z,e9s.2s s z,311as Ineraer between GFE entl HU0.1 shapes $ {83,60 OR ,20.16 % met can ehen Geod Fexh Estimeb HU0.1 nil®l deposd roryou esaox account #1007 S 4,s11At $ .00 Deily iritereat aia9va #901 $ 20.8 /day $ 821.00 $ 540.80 HOme0wners ineurence # 903 S 480.00 $ .00 # 0 S .00 $ .W # 0 S .00 S m # O S Oo S W O .00 .OD o .oo .oo o .oo .oo o .oo .oo Loan Terms Your initlel ban amount is f 787,200.00 Yar ban term is >Q ysare Voir iiliel intaaat rate is 40 % Yea Ftlllel manmy anaaa owetl rot pnnapa{ interest eta arty mort0a9e insuarce b: S 89172 'utchrtles 0 Principal 0 Interval Morbepe lrauranre Cat yata mtereal we nee 7 X N aq h can nee ro e meximun of 0 %. The 8re[ chen9e tw7 be on aW can cherpe a9eb every eTa . Every dtanpe date, your interest rate can inveasB or dacre9se by 0 %. over me life of th ben, yov itbrest rate is 9uaanteed b near be lower man0 %a hiphar man 0 % Even peyb0 m thnq sari yaia bdenov rise? X eq 6een rise to a ma<imum a E .00 Even xyw male peymals an ling ran your monmly anaunlowed furprimapal, inbiasl end mortgage itwranov dm7 X as, xw fret inavase rat be on end me manBJy emaart ovred ran rise to S .00 The mezinum dean ever roebis$ .00 Daea yawIoan have a prepaymeN penatly T X N ea, yaw mexhnun gapaymem perelly o S .00 Does yov loan have a be0om payment 7 % N eq you vnll have a balbon payment of $ ,W due n 0 yeas an row mortVYy emouM owed, inaudrq esaox PaY~ X Yau do not have a manmy escrow peymaitror ibme each as taxes end homeowrers baurarke. Yau must pay mesa Eema ycureex. 0 you here en etlalbral mon04y escrow peymem ol$ .00 Thal reailb it a total hiliel maahly einoura otS 0 .This ineludes pnrtapel, idaeal, any matpaga insuranw, antl hems drecked below. O Property mzres ~HomeoHStas Insurance O Flood lnsuance 0 0 Hob: Myau have ary queellons ebai the settlement Chapas end lxien Terms on this brm. please mnlad roar gentler Prevbw etlhbna era obsolete Page 3 d 3 HU -7 Closing Statement Continuation -Line 1100 Section TRIe Fees Detail eortower. Perrsyl, Gbrn L Seller Sheub Estate, Matilda E. Plvperty CarNy Club Rd, E Penrlsbao Twp Insurer Fideky National TRIe I Cbdrlp Dale 4/9'12 1700. TNe Charges Detail Icr Hutl form, lines 1107 - 7170 konvAer Seller 1101. Tltls Services antl LentleYa 7ltle lnauranes (From GFE 84) 57,516.76 .00 a) Fx Mail 57.00 to Liberty Lantl 7renafx .00 b> wlreFee 51s.oo to Libxly Land Tmafer .oo c) CPL 57100 to Fldelky Natlonal Ttle .00 tl) 5.00 [o .00 e) E.6o m .06 f) 5.00 to .00 a) S.ap to .m N Loo to .oo it Tdalfran Line 1102 (below) L00 j) Talalfian Ling 7104 (babes) 57,416.76 1102 SslOamsnt or dosing /sa to {SeltlemaM Or rAOalnpM Pryes) SAa .00 1103. OwrrsYa tltla fmurarree to Liberty Lerrd Transfer (From GFE 9 6) 5230.00 .00 1106. Lender's 1Rla iruuranee L7,/48.76 .00 a) Loerr Pofiry 51,266.75 to Liberty Land Tnmafer .00 b) Entlasemertle 5160.00 [o Liberty Lend Transfer .00 q L00 m .00 m Lao to w e) L00 ro .00 1106. Landsfa lkN pdicy 6mk 5767,200 1106. Ownefs lkle papry Bmk 5230,000 1107. ApanYS Portion of lM 1ota1 tltls Inevenee premium 51,426.94 1108. Undsm~itefa portlon of tlr toW tltls Imuranu premium 5267.61 1108. Tax Dart. m Liberty LaM Transfer 5•ao 10.00 1110. to 5,00 .W 1111. to L00 .OD 08-10-'11 14:27 FBOM- ,~"' - © lrl~l DCLllll 499 Mitchell Road, Millsboro, AE 19966 Adjustment Servicra Zullinger-Davis 14 North Main Street Suite 200 Chambersburg, YA 17201 ,1RE: Esrate ofBarb~aAMf7ler Social Stcurity .Number I68.26-7349 Date of Deadh: ,May 26, 2011 T-465 P0001/0001 F-627 Yhoae 888-5024349 F u (302) 9342955 August 10, 2011 Dear Sir or Madam,: Per your inquiry on August 8, 2011, please be advised that at the tune of death, the above-named decedent had on deposit with this bank the following: 1. Type ofAccoura Account Number Ownership (Names ofl Opening Date Balance on Aare of Death Accruet!lraerest Tonal CfuckingAccotuu 97402036 Barbara Ann MiIIer 01/1&D8 $7,496.39 $ .03 $7,496.42 For nay addttiooal Informatloa on the above accounts, iadodiag ovrnesship and auy changes, closures and/or re®hn.sement of funds, please as the WestShorc PLm OSa tt 71717•?31.1Tdd. We were unable to ]Dote any rife deposit ~ for the above•men8oued deudent- Ihis letter does not iadode any atxovAda iA which the deuesed mey have bcea As1ed as kows of Attorney, C d tlot[orm iraosfeis, 1RepnesmgtiveAyq alYuslee ender a Written Agreement Sincerely, Tammy Spencer Adjustment Services Received Time Aug. 10. 2:39PM WESTERN ~ NATIONAL Life Insurance C o m p a n y PO-Box 871 Amarillo, Texas 79105-OS71 t800R24.4990 August 29, 2011. JOEL E ZULLINGER ZULLIGER-DAMS PROFESSIONAL CORP 14 ITT MAIN ST STE 200 CHAMBERSBURG PA 17201 Re: Annuity Contract: A0200329 Contract Owner Barbara Ann Miller, Deceased Dear Mr. Zullinger: Thank you for your recent inquiry regazding this annuity contract. We would like to take this opportunity to respond to your request. The accumulated value of contract A0200329 as of May 26, 2011, the date of death is $14,469.31. The accrued interest as of May 26, 2011, the date of death is $3,469.31. This was a non-qualified tax deferred annuity that was solely owned by Barbara Ann Miller. The Bazbara Ann Miller Estate was the named primary beneficiary. The death claim ;proceeds have been paid to the named beneficiary thereby terminating the policy as of July 26, 2011. We appreciate the opportunity to assist you. Should you have any questions, please contact our Client Caze Center at 1-800-424-4990. Sincerely, Angela urlong Annuity Claims Department