HomeMy WebLinkAbout08-13-121505610143
REV-1500 EX (01-10) ~°
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes oEraRTMEMr OF REVEIdIE
Po Box.zsosol INHERITANCE TAX RETURN 21 11 1312
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
181 32 2900 11 22 2011 04 12 1937
Decedent's Last Name Suffix Decedent's First Name MI
WAGNER JOHN M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Retum ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ qa. Future Interest Compromise ~ 5. Federal Estate Tax Retum Required
(date of death after 12-12-82)
g Decedent Died Testate ~
(Attach Copy of Will) T~ ~At acdteCo a~of T ~ a Living Trust ~ 8. Total Number of Safe Deposit Boxes
pY )
9. Litigation Proceeds Received ~ 1 D. Spousal Povert Credit (date of death 11. Election to tax under Sec. 9113(A)
between 12-31 ~J1 and t-1-95)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Numbed
MARK A MATEYA a
717 24~~500 ~'T3
REGISTERItt IL•~S USEZNLYe:i -+~
~' _ -, ~ ~~
First line of address ;-s
~7 ~-., ~-... "
55 W CHURCH AVENUE 7
p~-: -
Second line of address ~ t~ r r-T-t
A
.
~• p
~
~
(~T
DATE FILED
City or Post Office State ZIP Code
CARLISLE PA
Correspondent's a-mail address: mam@mateyalaw.com
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETU
- RN DATE
~..~..,~ ~l~ Mark A Mateya g(4' ~1
ADDRESS
55 W. Church Avenue, Carlisle, PA 17013
SIGNATURE OF PREP ER OTHE THAN R E DATE
Mark A. Mateya ~ Q 12
ADDRESS
55 W. Church Avenue, Carlisle, PA
1505610143
Side 1
1505610143
REV-1500 EX
Decedent's Name: Wagner, John Mark
Decedent's Social Security Number
181 32 2900
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
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. 33 , 4 63.71
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous ton; Probate Property
(Schedule G) u Separate Billing Requested............ 7,
8. Total Gross Assets (total Lines 1-7) .................................................................... . 8. 33 , 4 63.71
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 21 , 82 6.32
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 8 , 161.6 9
11. Total Deductions (total Lines 9 & 10) .................................................................. . 11. 2 9 , 98 8.01
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12, 3 , 4 7 5. 7 0
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 13. 3 , 4 7 5. 7 0
14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14, 0 . O 0
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15 O
OO
(a)(1.2) X .00 . .
16. Amount of Line 14 taxable
0
00
16
0
OO
.
at lineal rate X .045 . .
17. Amount of Line 14 taxable
17
0
0 0
at sibling rate X .12 . .
18. Amount of Line 14 taxable
18
0
0 0
at collateral rate X .15 . .
19. Tax Due ................................................................................................................. . 19. 0 . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1505610243
Side 2
1505610243 1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-11-1312
DECEDENT'S NAME
Wagner, John Mark
STREET ADDRESS
111 Conodoguinet
CITY
Newville STATE
PA ZIP
17241
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
0.00
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1)
Total Credits (A + B) (2)
(3)
(4)
(5)
0.00
0.00
~.~0
Make Check Payable to: REGISTER OF WILLS, AGENT.
. . $, y e
"- 3~3 .I } i4 7
~: S ~ ~1: is ~~i~~~~C~.9 h ritv~~
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 :............................................................................... ^ ^x
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? ............................................................ ^ 0
2. If death occurred after December 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?....... ^ ^x
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.
Rev-1508 FJ(+~6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8t MISC.
PERSONAL PROPERTY
ESTATE OF (FILE NUMBER
Wagner, John Mark 21-11-1312
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with the right of survivorship must tre disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Adams Electric Cooperative -Patronage Capital Retirement Ck #21135533 45.25
2 Cash in hand 219.00
3 M 8r T Bank -Classic Checking Account w/interest Account No. xxxxx5735 697.23
4 M 8: T Bank -Checking Account No. 523335735 2,093.53
5 M 8 T Bank -Savings Account No. 15004221762104 0.71
6 Automobile - 2004 Chevy Aveo (sold at auction. See attached Settlement Sheet) 4,100.00
7 Mobile Home -1986 Redman 14x70 -See attached settlement sheet 10,000.00
8 Rowe's Auction Service -Proceeds from sale of personal/household effects 15,189.00
9 Rowe's Auction Service -Proceeds from sale of five Silver dollars 100.00
10 Adams Electric -Refund on Account No. 205411102 25.00
11 Adams Electric Cooperative, Inc. -Refund of Capital 429.99
12 Conodoguinet Mobile Estates -Refund of rent for February 2012 185.00
13 Erie Insurance -Refund on insurance policy for mobile home 291.00
14 Millville Mutual Insurance Co -Refund on premium on Policy 1071633 88.00
TOTAL (Also enter on Line 5, Recapitulation) I 33,463.71
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 EX+(10-os) gCHEDULE H
COMINHERITANTCETAXRETU RLNANIA FUNERAL EXPENSES &
RE3IITDEEEN DE DENT ADMINISTRATIVE COSTS
ESTATE OF I FILE NUMBER
Wagner, John Mark 21-11-1312
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 7,233.82
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(sl Commission paid
2. Attorney's Fees Mark A. Mateya
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
2,000.00
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 12,592.50
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 21,826.32
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Wagner, John Mark 21-11-1312
ITEM
NUMBER DESCRIPTION AMOUNT
1 Funeral Expenses
Egger Funeral Home -Funeral Expense
6,506.87
2 Reverend Robert L. Hoover, Jr. -Funeral Service Honorarium and expenses related to after 399.45
funeral meal
3 Robert L. Hoover, Jr. -Reimburse for expenses and Honorarium Service 327.50
H-A 7,233.82
4 Other Administrative Costs
Cumberland County Register of Wills -Probate Fee
123.50
5 Cumberland County Register of Wills -Filing fee for Inheritance Tax 8< Inventory 30.00
6 Eby Granite Works -Memorial Marker 1,674.00
7 Glass Lock & Key -Expense to change locks on decedent's residence 176.00
8 H.R. Williams -Glass repair 175.00
9 Hilton's Lock Service -Service Charge to open safe 156.00
10 Kough's Oil Service -Heating fuel for residence 268.00
11 Lil Wonders Cleaning -Cleaning of decedent's residence in preparation for sale 200.00
12 Midway Self Storage -Secure Storage for automobile 35.00
13 Prudential Homesale Service Group -Real Estate Commission paid for sale of mobile home 3,000.00
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
Wagner, John Mark 21-11-1312
ITEM
NUMBER DESCRIPTION AMOUNT
14 Robert L. Hoover, Jr. -Reimbursement for after funeral dinner 71.95
15 Rowe's Auction Service -Commission for sale of tangible personal property 5,316.15
16 Rowe's Auction Service -Expense for Trash Removal in preparation for auction of tangible 165.00
personal items
17 Rowe's Auction Service -Commission for sale of tangible personal personal property 855.00
18 The Sentinel -Legal Advertisement for Estate 157.68
19 The Sentinel -Legal Advertisement for Estate 189.22
H-B7 12,592.50
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 FJ(+ (12A8)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF (FILE NUMBER
Wagner, John Mark 1 21-11-1312
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbunsed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Adams Electric -Electric Service Acct. # 2054111102 54.61
2 Adams Electric -Utility bill for December 2011 33.27
3 Adams Electric -Electric Service Acct. # 2054111102 Final Bill 95.56
4 Adams Electric -Electric Service Acct. # 2054111102 9.25
5 Cumberland County Taxes -Mobile Home tax due from 01/01/12 to 02/08/12 2.48
6 M 8: T Bank -Personal Installment Loan -Account No. 10000135098390001 4,036.33
7 M8~T Bank -Signature Loan No. 10000135098390001 3,813.78
8 QVC Studio Park -Home Shopping Order No. 4011455628 18.16
9 Sprint -Telephone Service -Acct No. 683771246 98.25
TOTAL (Also enter on Line 10, Recapitulation) I 8,161.69
(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-7513 EX+(11-OS)
SCHEDULE J
COMM_Q~~EA~LT OF PEy[1N$_RNANIA BENEFICIARIES
ESTATE OF
FILE NUMBER
wa ner, Bonn marK ~ 21-11-1 312
NAME AND ADDRESS OF RELATIONSHIP TO
SHARE OF ESTATE
AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
~ distributions, and transfers
under Sec. 9116 a 1.2
[Name]
PA
1 [Name]
PA
Total
Enter dollar amounts for distributions shown above on lines 15 throw 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
1 [Please enter a charity into the Beneficiary field in Transact] 3,a75.7o
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 3,475.70
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
LAST WILL AND TESTAMENT
OF
JOHN MARK WAGNER ~~ ~ = -
- r~ `:-
`~'"1
I, John Mark Wagner, of CME 111, Newville, Cumberland County, Penns}~t~a~ia mafi<ce
this my Will. I revoke any other Wills or Codicils to Wills made by me. - = ~-~ -, _ ....
......
G.;
ARTICLE I. DISTRIBUTION OF MY ESTATE
A. I give my tangible personal property to Dickinson Presbyterian Church, located
on Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania. Tangible personal
property includes stamp or coin collections but does not include other money or stock certificates
or other evidences of intangible rights or interests. Tangible personal property does not include
any property that is held primarily for investment purposes or used in connection with any
business in which I may be engaged or in which I may have any interest at the time of my death.
B. I give the residue of my estate to include my trailer and all contents to Dickinson
Presbyterian Church.
ARTICLE II. PAYMENT OF EXPENSES AND OTHER CHARGES
I desire to have a traditional rziodest Christian funeral and burial to be held and conducted
by Dickinson Presbyterian Church. I do NOT desire to be cremated. I direct that I be buried at
Prospect Hill Cemetery in a plot beside my mother and father. I direct my Executor to pay for
my burial expenses (including the cost of a monument or marker). The estate, inheritance and
similar taxes assessable on my death (including taxes on assets not passing under this Will) shall
also be paid as a cost of administering my estate and my Executor shall not request any
beneficiary to pay any part of such tax.
-,,
-~-, ;=~
T" .,
_ ~,,
~_.. :T';
G~ C,_'?
..~..
Page 1 of 4 C~~' J.M.W.
ARTICLE III. MISCELLANEOUS PROVISIONS
Matters of Interpretation. For simplicity, I have expressed pronouns and other terms in
one number and gender, but where appropriate to the context these terms shall be deemed to
include the other number and genders. The bold headings are .for convenience and shall not
affect interpretation.
ARTICLE IV. APPOINTMENT OF FIDUCIARIES AND POWERS
I name my Mark A. Mateya, Esquire of Mateya Law Firm to be my Executor. It is my
desire for the Executor to be remunerated according to local custom. If administration of my
estate or trust should be necessary in any jurisdiction where my Executor or my Trustee is unable
to qualify, or if my Executor or my Trustee deems it necessary for any other reason, I give to my
Executor or my Trustee power to designate any individual or corporation with trust powers to
serve with my Executor or my Trustee or in my Executor's or my Trustee's stead. I request that
no security be required of any Executor or Trustee, including an Executor or Trustee named
pursuant to the preceding sentence. References in my Will to my "Executor" and my "Trustee"
are to the one or ones acting at the time, except where otherwise specifically provided.
B. Any individual who serves as Executor or Trustee shall be entitled to receive
reasonable compensation for his or her services and, whether or not such individual receives
compensation, shall be entitled to be reimbursed for expenses incurred for such services.
C. I grant my Executor and my Trustee the powers set forth in 20 Pa. C.S. §§ 3311-
3332 and 20 Pa. C.S. §§7771-7780 respectively. In addition, my Trustee may merge any trust
under this Will with any trust having the same trustee and substantially the same diapositive
provisions. If at any time after my death the size of any trust under this Will is so small that, in
the opinion of my Trustee, the trust is uneconomical to administer, my Trustee may terminate the
trust and distribute the assets to the person or persons authorized to receive the trust income in
such shazes as my Trustee may deem appropriate. No Trustee who is also an income beneficiary
of the trust at issue shall exercise any discretion granted in the preceding sentence. My Executor
and my Trustee may distribute tangible personal property passing to a minor to any adult perscn
with whom the minor resides, and that person's receipt shall be a sufficient voucher in the
accounts of my Executrix and my Trustee.
Page 2 of 4 LLB, J.M.W.
ARTICLE V. DEFINITIONS
The following definitions shall be applicable to all of the provisions of my Will except
where otherwise specifically stated:
1. The use of the masculine shall include the feminine or neuter and the use of the
singular shall include the plural, and vice versa.
2. The term "estate" where appropriate, shall include any trust hereunder.
3. The term "minor" shall mean an individual who has. not attained the age of
twenty-one years.
Executed this ~~ ~ day of , 2010.
" C1 C ~~-~" SEAL
Jo Mark Wagner
.Signed, sealed, published and declared for and as his Last Will and Testament by
the testator in our presence, we all being present at the same time; and we, in his presence and at
his request and in the presence of each other, have subscribed our names as witnesses whereof,
all on the date last above written.
J
:,
of :~)S_11~C'(~~~~CtI~•~/~(~'- ll~l~~~~t~~~~, ;'-~ I'r`i•`-(
,.
Page 3 of 4
~ Cti~ J.M.W.
COMMONWEALTH OF PENNSYLVANIA
CUMBERLAND COUNTY
to wit:
Before me, the undersi ned authority, on this date personally appeared John Mark
Wagner, and711 ~ -~ K ~ A , and~'l1 AR v ~ Zv~,PA ~lA.r~ ,known to me
to be the testator and witnesses, respectively, whose names are signed to the foregoing
instrument and, all of these persons being by me first duly sworn, John Mark Wagner, the
testator, declared to me and to the witnesses in my presence that said instrument is his Last Will
and Testament and that he had willingly signed and executed it in the presence of said witnesses
as his free and voluntary act for the purposes therein expressed, that said witnesses stated before
me that the foregoing Will was executed and acknowledged by the testator as his Last Will and
Testament in the presence of said witnesses who in his presence and at his request and in the
presence of each other did subscribe their names thereto as attesting witnesses on the day of the
date of said Will and that the testator, at the time of the execution of said Will, was over the age
of eighteen years and of sound and disposing mind and memory.
Sworn and acknowledged before me by JOHN MARK WAGNER, the testator,
witness, this / I .fib day of
witness, and ~ A~~~ ~ • -~~U~R~1~A ~J ,
rc.<,Cc,~4,c.~ , 2010.
;~
,. ~'
JO MARK WAGNER -~
~ ~
Witness
~,
~` 1
)~, r~ j.
Wit~i~ess
My commission expires:
Page 4 of 4
Notary Public
COMNI~NV+I~F! Tf•-1 C}~ P_~~~JBYLVANIA
Nvtriat S at
~f3t'~C~ /1. t'~li'T3?I;tif, id JtEll'y f Ut`rflC
aauth IvS:da'l~terl ~~:~~., ~'s±rrtt~rtand County
! A.<.yCommi<>c~• ~s<i.;; = n; ; c` ib ''JiQ
~.
C.i~• J.M.W.
Previous editlona are absobre
form HUD-i (yam) ral Handbodc 4305.2
A. SettlerileIIt Stat0rilerit U.S. Department of Housing and Urban Development
R Tuna of I nnn CIMR Ammval Nn p5np-n~RS
1. ^FHA 2. ^FmHA 3. ^Conv. Unins. 6. File Number
4. VA 5. Conv. ins. 12.12 7. Loan Number 6. Mortgage Insurance Case Number
q rrn q mq 9 ve you a s en a s me co noun p a e n are
C. Note: Itama madred'(p.o.a)' ware pale outside me aoainrqp~~ may are ahovm here for Information purpcees era era not bcfuded m me totals.
WARNING: It is a gime b knowirgly make fate ataterrreraa m me United States on Mis or omer aimiYr form. Penaldee upon
uonvicdon can induda a me am I onment Fw deoslls see: rde to u. s. code seceon tot and seaon t of a
TitleExpmss Settlement System
Printed 0 2/0112 0 1 2 at 11:05 SDC
D. NAME OF BORROWER: Ruthann Frederickson
ADDRESS:
E. NAME OF SELLER: Estate of Mark J. Wagner
ADDRESS:
F. NAME OF LENDER:
ADDRESS:
G. PROPERTY ADDRESS: 111 Conodoguinet Mob. Estates, Newville, PA 17241
H. SETTLEMENT AGENT: The Law Office of Andrew H. Shaw, PC, Telephone: 717.243.7135
PLACE OF SETTLEMENT: 200 S. S rin Garden Street Suite 11 Carlisle PA 17013
I. SETTLEMENT DATE: 01/0612012
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER
101. Contract sales rice 10 000.00 401. Contract sales dce 10 000.00
102. Personal ro 402. Personal ro
103. Settlement cha es to borrower line 1400 350.00 403.
104. 404.
105. 405.
Ad'ustments for hems aid seller i n advance Ad'ustments for items id b seller i n advance
106. Ci Itown taxes 406. Ci rtown taxes
107. Coun faxes 407. Coun taxes
108. School taxes 02108112to06130112 4.03 408. School taxes 02108112to06130112 4.03
109. Februa Lot Rent 02108112to02129112 191.17 409. Februa Lot Rent 02108112to02129112 191.17
110. 410.
111. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 10545.20 420. GROSS AMOUNT DUE TO SELLER 1019520
200. AMOUNTS PAID BY OR ON BEHALF OF BOR ROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER
201. De osit or earnest mone 501. Excess De sit see instructions
202. Princi I amount of rtew loans 502. Settlement cha to seller line 1400 3 000.00
203. Existi bans taken sub'ect to 503. Existin ban s taken sub'ect to
204. 504. Pa if of First Mo a Loan
205. 505.
206. 506.
207. 507.
208. 508.
209. 509.
Ad'ustments for items un id b seller Ad'ustments for items un aid seller
210. Ci /town taxes 510. Ci flown taxes
211. Coun taxes 01101112 to 02108112 2.48 511. Coun taxes 01101112 to 02108112 2.48
212. School taxes 512. School taxes
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
216. 518.
219. 519.
220. TOTAL PAID BYIFOR BORROWER 2.48 520. TOTAL REDUCTION AMOUNT DUE SELLER 3 002.48
300. CASH AT SETTLEMENT FROM OR TO BORR OWER 600. CASH AT SETTLEMENT TO OR FROM SELLER
301. Gross amount due from bortower line 120 10545.20 601. Gross amount due to seller line 420 10 19520
302. Less amounts aid b lfor borrower line 220 2.48 602. Less reduction amount due seller line 520 3 002.48
303. CASH FROM BORROWER 10542.72 603. CASH TO SELLER 7192.72
SUSSTIME FORM 7090 SELLER STATEMENT: The iMormation contained herein is imponant tax inlortnatbn and b bekp fumiahed b me Inremal Revenue Service. If you are requked a file a return,
a rrepl~arae penexy or omer earodon will be imposed on you H mis item is required to t>a reposed end me IRS degrmines met [ hea rat been reported. The Comract Selea Price deecdbed on
line Mi above oorgtltu[ea me Oroea Proceeds of this transaction.
Vou are required by law b provide me aetllemem seppeent Fed. Tax ID No:261544555) wdh your correct Meyer idemificedon number. H you do rat provide your correct tax r idem'ficetion
number, you may he aublea m civP or crkninal penaltles rrgoeed try bw. Under penahiea of pequry, I certry that me number shown on mis slagment ie my correct ta~ayer itlentifxxtlon number.
TIN: / SELLER(S) SKiNATURE(S):
SELLER(S) NEW MAILING ADDRESS:
SELLER(S) PHONE NUMBERS: _
Previous editlona are abaobte
form HUD-1 (3/SB) ref Hertdhocft 4305.2
U.S. DEPARTMENT OF HOUSINGAND URBAN DEVELOPMENT File Number. 12-12 PAGE 2
SETTLEMENT STATEMENT TitleExoress Settlement Svstem Printed 0?/(11/701? Rf 11'05 SDC
L. SETTLEMENT CHARGES PAID FROM PAID FROM
700. TOTAL SALES/BROKER'S COMMISSION based on rice 10 000.00 = 3 000.00 BORROWER'S SELLER'S
Division of commission line 700 aS folbWS: FUNDS AT FUNDS AT
701. t0 SETTLEMENT SETTLEMENT
702. 3 000.00 to Prudential Homesale Services Grou
703. Commission aid at Settbment 3 000.00
BOO. ITEMS PAYABLE IN CONNECTION WRH LOAN
801. Loan Ori inatbn Fee %
802. Loan Discount
803. sisal Fee
804. Credtl Re rt
805.
806.
807.
808.
809.
810.
811.
900. ITEMS RE UIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to $ Ida
902. Mo a Insurance Premium for months to
903. Hazard Insurance Premium for ears to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER FOR
1001. Hazard Insurance 2 mo. Imo
1002. Mo a Insurance 2 mo. /mo
1003. Ci Pro Tax 2 mo. /mo
1004. Coon Pro Tax 2 mo. $ Imo
1005. School taxes 2 mo. Imo
1009. r ate Ana sis Ad'ustment 0.00 0.00
1100. TITLE CHARGES
1101. Settlement or Cbsin Fee
1102. Abstract or Title Searoh
1103. Title Examinatbn
1104. Title Insurance Binder
1105. Document Pre station
1106. Note Fees
1107. Atforne 's fees to The Law Office of Andrew H. Shaw PC 350.00
includes above items No:
1108. Tide Insurance to NON TRLE
incudes above items No:
1109. Lender's PDlic
1110. Owner's Polb 10 000.00 -
1111.
1112.
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordi Fees Deed $ ~ Mort e $ ~ Release $
1202. Ci ICoun tax/stam s Deed $ • Mort a $
1203. State Taxlstam s Deed $ • Mort a $
1204. UPI Fee Deed $ ~ Mort a e
1205. Deed $ ~ Mort a e • Release $
1300. ADDRIONAL SETTLEMENT CHARGES
1301. Surve
1400. TOTAL SETTLEMENT CHARGES enter on ones 103 Section J and 502 Section K 350.00 3 000.00
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HU0.7 Settlement Statement and b the !rest of my krwwledge and !relief, k Is a true end accurate statement of all receipts end disbursements made on my account
w by me kr th®trereaction. I k/rther certify that I have received a Dopy of the HUD-1 Settlement S~remeM.
enn n n
o e 89ner
WARNING: R IS A CRIME TO IWOWINOLV MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Slatemen[which I have prepared ie a true and accurate swoon[ of this
UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTK)N transaction. I have caused or wiN cause the lunde to ba disbursed in acwrdance with tNs statement.
CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 1 B:
U.S. CODE SECTION 1001 AND SECTION 1010.
SETTLEMENT AGENT: DATE:
ROWE'S AUCTION S
ERVICE (RH 79L)
Bill Rowe (AU 1538L) 2505 Ritner Highway Carlisle, PA 17015
249-1978 215-1044 574-1008
Auction fs Action Call "Rowe" For Satisfaction
Dave Rowe (AU 2295L)
SELLERS NAME 1'~ti'~.fe ~'~.~.i~.~-v. ~ R:4 ~,:.
- ,,., ~-~.,,~, Q-. --y ':.~ ~~ ~ ~..... DATE _ ~ ~, ~ ~ ~ ~.
ADDRESS
PHONE
OTHER
AUCTIONEER %
AUCTION DATE/LOCATION
DESCRIPTION OF MERCHANDISE
.~.
_ ~, .~
CLERK %
I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement.
...-.--c........~......_~_,____,.._..._...,~._._. ,,.~
AUCTION SIGNATURE
SELLERS SIGNATURE
Total Sales (Clerking Tickets Attached) $ ~ 2 ~ ~=
Less Sale Expense:
-------____ % Commission Auctioneer $
-----_--~ % Commission Clerks $
OTHER:
TOTAL SALE EXPENSE DEDUCTED $
SELLERS NET $ ~~ ~~ ~-} S__ '~--.:._~......_
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