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HomeMy WebLinkAbout07-30-121505610143 REV-1500 Ex `°'-'°' OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes UEiFRTMENT OF REVENUE Po Box.2aoso~ INHERITANCE TAX RETURN 21 11 1280 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 11 15 2011 04 20 1923 Decedent's Last Name RODGERS Suffix Decedent's First Name MARJORIE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. Future Interest Compromise lrloln of rlcnlh nHcr 17_1 ~_R~\ 8 Decedent Died Testate ^ ~ Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 1 °. spousal Povenvv Credit (date of death between 12-31 91 and T-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number WM D SCHRACK III ESQ 717 432 9733 First line of address 124 W HARRISBURG STREET Second line of address City or Post Office DILLSBURG State ZIP Code PA 170191268 :7'1 '~ ~ `"t t-r1 !'-7 tt~ G~ ~~~ !'''a r-i ; _;~ ~ C~"i~n _- -r-I f' ~, ~~ Correspondent's a-mail address: SChracklaW@COmCaSt.rtet Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Denise H. Koser ADDRESS 111 Mel SIGNATURE S REPRESENTATIVE 3. Remainder Return (date of death 11. Election to tax under Sec. 9113(A) (Attach Sch. O) MI MI prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes DATE PA 1 Wm. D. Schrack Ilt Esq. DATE ADDRESS ~ ~/' 124 W. Harrisburg Street, Dillsburg, PA 17019-1268 Side 1 1505610143 1505610143 J REGISTER OF ~ USE Of~tf .=~'• ~ C_ rn c-ti 77 ~ ,-_ ~ ~~'~_' c,~-, - - O C'~L~~i ~ DAT~ILED ~~ 1505610243 REV-1500 EX Decedent's Social Security Number °eceae"~'SName Rodgers, Marjorie RE CAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 164 , 000.00 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5~ Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... 5. 8 , 752.81 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous Non; Probate Property (Schedule G) u Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 172 , 752.81 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 2 8 , 8 4 0 . 8 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 1 , 717.23 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 30 , 558.09 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 142 , 194.72 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. 142 , 194.72 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .o0 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rateX .045 142 ,194.72 16. 6, 398.76 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17. 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. O, O Q 19. Tax Due .................................................................................................................. 19. 6 , 3 98.7 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ L 1505610243 Side 2 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-01280 DECEDENT'S NAME Rodgers, Marjorie STREET ADDRESS 916 Apple Drive CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 6,000.00 315.79 (1) Total Credits (A + B) (2) 6,398.76 6,315.79 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $2.97 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 :.................................. ^ ^x c. retain a reversionary interest; or ............................................................................................................... ^ ^x d. receive the promise for life of either payments, benefits or care? ............................................................ ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... ^ ^x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ^ ^x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [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 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 under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Rodgers, Marjorie 21-11-01280 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex ep nses 1 Malpezzi Funeral Home 7,422.67 H-A 7,422.67 Other Administrative Costs 2 Barry Heckard, T.C. (municipal/county taxes) 734.08 3 Clerk of Orphans' Court -Fiduciary Release filing fee 5.00 4 Costs of sale of decedent's residence (see attached HUD-1) 11,885.00 5 Cumberland Law Journal -estate advertisement 75.00 6 Don Lenk -tree removal at property 100.00 7 John Potteiger -repairs to property before listing for sale 816.00 8 Liberty Mutual -homeowners premium during adminstration 474.00 9 Mechanicsburg Borough -trash collection during administration 269.47 10 Miscellaneous expenses -photocopies, postage, etc. 15.00 11 Patriot News -estate advertisement 120.45 12 PP&L -electric during administration 223.99 13 Register of Wills -Inheritance Tax Return filing fee 15.00 14 Reserve for future administrative expenses 100.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Rodgers, Marjorie 21-11-01280 ITEM NUMBER DESCRIPTION AMOUNT 15 Shipley Energy -fuel oil during administration 16 United Water -water/sewer during administration 1,182.57 78.13 H-B7 16,093.69 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+(12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Rod ers, Mar'orie 21-11-01280 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 AT&T -balance due on decedent's landline phone service 46.16 2 Comcast -balance due on decedent's cable service 1.37 3 Discover card balance 376.23 4 Dr. Armesto 15.63 5 Liberty Mutual -car insurance premium 73.90 6 PA Retina Associates 31.41 7 Pinnacle Health 1,129.68 8 Quantum Imaging 9.71 9 Verizon -balance due on decedent's cell phone 33.14 TOTAL (Also enter on Line 10, Recapitulation) I 1,717.23 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+111-08) V SCHEDULE J COMMNHE IRTANCETgFXRETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER rcoa ers, mar orle 21-11-01 280 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) No i I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 Denise H. Koser Child 50% of residuary 111 Melbourne Lane estate Mechanicsburg, PA 17055 Norma F. Strothers Child 50% of residuary 2645 Hill Road estate Sellersville, PA 18960 Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) ~~ts# tC[ ~x~ C`~ESt~tme~# OF MARJORIE RODGERS BE IT REMEMBERED, that I, MARJORIE RODGERS, an tlnremarried widow, presently of 9"16 Apple Drive, Mechanicsburg, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will rind Testament, :hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that my hereinafter named Co-Executors pay all my just debts, my funeral expenses, and the expenses of the administration of my estate. With this direction, I authorize and empower my Co-Executors to expend for my funeral expenses and interment such amounts as they may consider necessary and proper, without regard to any limit tha t may be prescribed by a court of law. ITEM 2 Idirect my Co-Executors to pay ail inheritance, estate, s~iccession, and legacy taxes of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject, and to charge such taxes against my residuary estate. It is my intention that none of the aforesaid taxes; c i ther federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property may be transferred or to whom any benefit accrues. ITEM 3: I give and bequeath certain items of tangible personal property are solely owned by me at the time of my death and that are identified in a separate writing or writings, titled "Specific Bequests of Marjorie Rodgers,"directing distribution thereof after my death which is dated and is signed by me at the end thereof, to those persons designated in such separate writing. If any item of tangible personal property is identified j I in more than one separate writing, I direct that, unless stated to the contrary, the separate I writing bearing the last date shall govern the disposition of such item. If no such writing i is found within thirty (30) days of my death, it shall be re p sumed not to exist or that I i destroyed it. If I do not own the item at the time of my death, the gift shall be considered ' adeeined. .I ITEM 4: All the rest, residue and remainder of my estate, of whatsoever nature -~ and wheresoever situate, whether it be real, personal or mixed, including property over ~l I .`~ which I have ~ power of appointment, I give, devise and bequeath to my daughters, i~~` I~ DENISE H. KOSER and NORMA F. STROTHERS, in equal shares, per stirpes, .,, ii n-~ ,, 1~~ . ITEM 5: In the event that either of my daughters should predecease me leaving ~` N issue surviving, I direct that the share of such deceased child shall be passed to my ~ ~~ ~Trandchildren, SHANA L. STROTHERS DOTTERER and CHAD M. STLROT_1`-I_E_I2;z,_in Page -2- equal shares. In file event that either of my daughters should predecease me without leaving issue surviving, I direct that the bequest to that deceased daughter lapse, and that my residuary estate be distributed to my surviving daughter. ITEM 6: I nominate, constitute and appoint my daughters, DENISE H. KOSER and NORMA F. STROTHERS, to serve as Co-Executors of this my Last Will and Testament. ITEM 7: I direct that my hereinbefore named Co-Executors shall not be required to give bond for the faithful performance of her duties in this or any jurisdiction. /--- IN ~ ITNESS WHEREOF, I have hereunto set my hand and seal this ~ ~~ day t of ~jy~iG /1'~/ , 200. MARJ0IZIE RODGERS ~ The pr~cc~d ing instrument, consisting of this and two (2) other typewritten pages, was on the day and date thereof signed, sealed, published, and declared by the Testatrix herein named, ~s and for her Last WiII and Testament, in the presence of us, who, at her request, in her }~~resence and in the presence of each other, have subscribed our names as witnesses hereto. _ - - - OFr t~'-~~ -. ;. y s _. , -~ ' ~ •w Page -3- S COMMONWEALTH OF PENNSYLVANIA ~S COUNTY OF YORK ~5 . /! /! / 1 f ~I _ // Tr We, N,LARJORIE R~DGERS, and ~ _ /~~~-1~~ the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament, and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Will as witnesses, and that to the best of their knowledge, the Testatrix was at the time eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence. SWORN TO AND SUBSCRIBED BEFORE HIS ~ ~ DAY /~ ~?~ ~ , 2005. OF ~%~1~`~~ / ~ , i /s,, , f_. .' ;fit „ NO~I'~41~Y PUBLIC s~~ Janet S. Gor , NGary Fup/,,;. Dd!s~burg 8^ro, 'fc~'r. Courtty iwfi~ i,ar,rrission ExprssCa;t. 25, rOc~; Member, Fe^nsYMania ti,ax:i2~nn Of h'ota;i,~ ` _ __ _~ - ~._ __ f~~ "~.~ 1 A. Settlement.,tatement{HUD-1) OMB Approval No. 2502-x265 ,~' 100. Grose Amourd Due from Borrower 4DQ Gross Amount Due in Seiler 101. Contract sales price 164,000.00 401. Contract sales price 164 000 00 102. Personal ro , . 402 Personal 103. Settlement charges to borrower (line 7400) 6,656.58 . 403. 104. 404. 105. 405. Ad ustments for kerns aid seller In advance Ad bnenb for kema id b seller in advance 1 ~. Cityltam taxes to 406. Ckyllown taxes to 107. County texas 06129/2012 to 12131 /2012 368.06 407. County taxes 08129/2012 to 11!31!2012 368 08 108. School Tax 06129/2012 to 06/3012012 9.76 408. School Tax 06129/2012 to 0613012012 . 9 76 109. Credit on Sewer 12.83 409. Credit on Sewer . 12 83 110' 410. . 111. 411. 112. 412 120. Gross Amount Due from Borrower 171,047.25 . 420. Grose Amount Due b Seller 184 390 87 200. Amounts Pa1d w In Behalf of Borrower 201 , . 500. Reductions h Amount Due to Seller . Deposit a earnest money 2A00.00 501, Exrress deposit (see inswctions) 202. Principal amount of new loan(s) 155,800.00 502, Settlement charges to seller (line 1400} 21 034 44 203. Exisiin to s taken su 'ect to , . 503. Exlslln to s taken sub to ~' 504. Pa off of first foan 205. 206 505. Pa oB of second mort a ban . 506. 207. 507. ~ 506. 209. ~ Ad ustments fw items un aid aellsr "L10 Clt ttown taxes Ad ustments for kerns un aid setter . y to 510. C.'Itynawn taxes to 211. County taxes to 511. County taxes to 212, School Tax to 512. School Taz to 213. 513. 214. 514. 215' 515. 216, 516. 217. 517. 218' 518. 219. 519 220. Total Paid or Borrower 157,800A0 , 520. Total Reduction Amourrt Due Seller 21 034 44 300. Cssh at Settlement fromlto Borrower , . 600. Cash at Setlkmern toBtpm SMNr 301. Gross amount due from borrower (line 120} 171,047.25 L 601. Gross amount due to seller (line 420) 164 39067 302. ess amounts paid bylfor borrower (line 220) 157,800.00 602. Less reductions in amount due seller (line 520} 303. Cash Xn From ~ 7o Borrower 13,247.25 21034 44 603. Cash ©To ~ From Seiler 143 356 ~ecw ~.Nn.t wtiw.~vn.mir vua ore cuad,.,,ro.. ra-nne.,n.urn-...a usawxein.sm.,a.,m.. rir , .23 tin....,...,..,._:._..__.~..__._~. .. u~ See attached addendum for additional information Previous editions are obsolete Page 1 of 4 HUD-1 rw, iuwnsares0alalnpaer~eaa ~ iu,[sow _ Pald From Paid From Dvlsionofcommission line700 asfdlow9 B ' ' 701 315 00 orrower s Seller s ' . 1o Re/Max RealtyAssodates, Inc. F d 702 g2D 00 un s at Funds at . , to Re1Max Realty Assaaates, Inc. 703. Commissbn paid at settlement Settlement Settlement 704. Broker Fee to Re1Max Realty Associates, Inc. 395.0 10,235,00 0 800. ftsma Pa k In Connedlon with Loan 801. Our orgination charge (Indudes Originatlon Polnl0.000% or .00) 0.00 {from GFE #1) 802. Your credit or charge {points) for the spodfic Interest rate chosen $ (from GFE #2) 803. Your a~usted origination charges (from GFE A) 650 00 . 804. Appraisal fee to Annie Mac 450.00 P.O.C. B" (from GFE #3) 805. Credit report to Credit Plus (from GFE #3} 22,84 806. lax service to Annie Mac {from GFE #3) 88,00 807. Flood certificatron to Core is (from GFE #3) 12,00 808. to 800. Items wind b Londe to ba Paid to Advance 901. Dally interest charges from from 06/2 12 to 07 112012 ~ 17.07401day from GF 0) 34 15 , 902, Mortgage insurance premium for nanths to (from GFE #3j 9D3. Homeowner's insurance for ors to Erie Insurance $819.00 P,O.C. B (from GFE #11) ~• months to from GFE #11 1000• Rearvea De oalted with Lender 1001, Initial deposo fa your escrow account {from GFE #9) 260 84 1002. Homeowner's insurance 3 ~~ $ 51.SBJmonth $154.74 , 1003. Mortg~e insurance months S 76.60/month $ 1004. Pro taxes months $ /month 1005. County taxes 6 months $ 60.36Jmonth $362.16 1006. School Tax 2 months $ 148.li01month $297.60 1007. Aggregate Adjustment $553.86 1100. Title Cha a 1101. Title services and lender's tole Insurance from GFE #4 1,468.75 1102. Settlement or closing fee to $ 1103. Owner's title Insurance -First American Title Insurance Company from GFE #5 1104. Lender's title insurance - Frst American T'Ne Insurance Company $1,363.75 40.00 1105. Lender's title poky limit $155,800.00 Lender's Polley 1106. Owner's title policy limit $164,000.00 Owner's Policy 1107 A t' . gen s portion of the total the insurance premium $1,129.44 to Ke stone Land Transfer Ltd 1108. Underwriter's portion of the total title insurance premium $274.31 to Firs! American Title Insurance Com n 1109. 1110. Notary Fee to Kristen D. Shive 1000 1111, Tax Certification Fee to Ka atone Land Transfer La 1200. Govamment Racordi and Transfer Ch a t 201. GovemmeM recording cha.-ges $ (from GFE #7) 144 00 1202. Deed 562.00 Mo a e $82.00 Release $ . 1203. Transfer taxes $ (from GFE #8) 1 640.00 1204. CiryiCouniy taxlstamps Deed $1640.00 Mort e $ , 1205. StateTaxlstamps Oeed$1,640.00 Mort 1206. Deed $ e$ 1,640.00 1300. AddlBonalSetBementChe a ~`-"~---' ___~.~.,_ 1301. Required services that you can shop for (from GFE #6) 1302 . to 1303. to 1304. tc 1305. to 1306. 2012-13 5chooi Texas to Bar Hedcard 1307. Esaaw for Inheritance Texas to Ke stone Land Transfer Ltd 1 y~ ~ , 9,149.44 r ~ 6,858,58 11,034.44 'Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er.'"Gedd bylender shown on page 1. "`Credo by seller shown on page 1. See attached addendum for additional information Previous edi~ons are obsolete Page 2 of 4 HUD-1 HUD C~ftTtFlCgTiON OF 9tfYE12 AND SEtrLEIt 1 have oargtulpy reviewed thsr ItfU(y; gat#kyment $tatemsgrvt end's the best aF my 3rnpwle#p'd and haoias4, i# as a true and accanrat$ statamrirtt of ilt receipts ssad diaburvreents made on my account ar by n+e to this tFa++sadlan t further certify iha# 1 have receNud a copy of tffe HUD-# Sottlernent Statement. ..,+~ ChristopherS Combs Estste of ar,~arje Rodgers X77 c ~~z...c..~..,..'~'- a c~,~-~--".-.,~ The HUD-1 Settlement Statement which I have preperso is a true and accurate account of this trrnsadion. 1 have caused or wIN cause the tootle to De disbursed' ccordance with this statement. -- ~ ~ ~ ~" a SF..TTI.EMENT AGENT DATE WARNING IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO TkE 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. See attached addendum for additional information Previous editions are obsolete Page 4 of 4 HUD-1 ~ A-meriChoice ..~/ FEDERAL C R E D I T U N I O N Building Relationships For Life February 2, 2012 Atto~7~ey William D Schrack, III 124 W Harrisburg Street Dillsburg, PA 17019-1268 Re: Estate of Marjorie Rodgers Attol-~iey Schrack, The decedent had one member number 9098 titled Marjorie Rodgers. This account was an individual account which included: Regular Savings (suffix OOOI) -opened 11/17/1981 Sub Share (suffix 0002) -opened 11 /28/1988 Share Draft (suffix 0011) -opened 07/06/1988 Date of death balances areas follows: Balance Accrued Dividends 0001 - $ 5,772._53 $ 0.45 Cv 0002 - $ 208.94 $ 0.03 0011 - $ 1,1 1 l .75 $ 0.00 The above balances include the accrued dividends. Mrs. Rodgers did not have a safe deposit box with AmeriChoice. I have included Mrs. Rodgers most recent statement. Please feel free to contact n1e directly with any nuestions you may have. Sincerely, f ~ 4`\^\ F Bonnie R. Seagraves Operations Specialist Phone (717) 591-1282 Fax (717) 697-3713 Email bsea~:raves(a!americhoice.org Main Office: ? I ~-5 t>uFnhle Bee Hollow Road • Mechanicsburg, PA 1 7(15; • Phone: (i "I ~) h97-34'4 • Fax: 1~1 71 h97-3713 Website: www.ameridioice orb; Epuel ~EruuFit OPporWniry (ENDER CRFDI~P UNIONS