HomeMy WebLinkAbout10-10-13 (2) 1505610140
REVA 500 EX (02-11)(FI)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisbur PA 17128-0601 RESIDENT DECEDENT 2 1 1 3 0 3 8 8
ENTER DECEDENT INFORMATION BELOW
0 7 2 8 2 0 1 2 0 6 0 2 1 9 1 8
Decedent's Last Name Suffix Decedent's First Name
MI
C 0 C K L I N A D A G R A C E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS
Q 1.Original Return 2.Supplemental Return 3.Remainder Return(Date of Death
❑ Prior to 12-13-82)
4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12-12-82)
QX 6.Decedent Died Testate Cj 7.Decedent Maintained a Living Trust 8.Total Number of Safe De osit Boxes
(Attach Copy of Will) (Attach Copy of Trust.) p
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 Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
Daytime Telephone Number
D A V I D H S T O N E E S Q U I R E 7 ,1 7 7 7 4 7 4 3 5
CGISTER OF WI[L$USFI',N!
C> c G p
First Line of Address ro
t'rt S C-� --{ cJ
4 1 4 B R I D G E S T R E E T �_ r-
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Second Line of Address 3> Cf> ,=1
G Cn p -� -n
City or Post Office '� C -r;
Stale ZIP Code O DA7E FILFEd q— M iTY
N E W C U M B E R L A N D P A 1 7 0 7 0 w U o
Correspondent's e-mail address: DSTONE@STONELAW•NET
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules an 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.
SIGNATUREOFPERSONRES N ILING REf(i&YStOrle Uar tans Ip ervlces ATE/I�
ADD SS 10�� `L3
PO BOX 804 ELIZABETHVILLE PA 17023
SIGNATU ER HA EPRESENTATIVE
�. DATE
ADDRESS 19-
414 BRID TREET , NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J
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1505610240
REV-1500 EX(FI)
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 8 2 0 0 0 . 0
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 1 0 0 2 , 2 3
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3.
4. Mortgages and Notes Receivable(Schedule D) 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 4 1 9 5 5 , 8 0
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous N -Probate Property
(Schedule G) Separate Billing Requested . . . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . I . I . . 8. 1 2 4 9 5 8 , 0 3
9. Funeral Expenses and Administrative Costs(Schedule H) 9. 3 1 7 1 4 . 4 2
. . . . . . . . . . . . . . . . . .
10. Debts of Decedent,Mortgage Liabilities, and Liens(Schedule 1) . . . . . . . . . . . . . 10. 6 7 6 8 5 . 8 4
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 9 9 4 0 0 . 2 6
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 5 5 5 7 . 7 7
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. 2 5 5 5 7 • 7 7
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 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X - 0 0 . 0 0 16. 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate x.15 2 5 5 5 7 . 7 7 18. 3 8 3 3 . 6 7
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 3 8 3 3 . 6 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
REV-1500 Ex(FI) Page 3 File Number
Decedent's Complete Address: 21 13 0388
DECEDENT'S NAME
ADA GRACE COCKLIN
STREETADDRESS
1000 CLAREMONT ROAD
CITY STATE ZIP
CARLISLE PA 17013-
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 3,833 .67
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+8) (2) 0 . 00
3. Interest
(3) 0. 00
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. (4) 0 .00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 31833 -67
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 ...................................................................... ID b. retain the right to designate who shall use the property transferred or its income ........I...................... 0 121
c. retain a reversionary interest ..................................................................................................... ❑ IR
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? ....................................................................................... ❑
3. Did decedent own an'in trust for or payable-upon-death bank account or security at his or her death? ......... ❑ 0
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑ IZI
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
is 3 percent[72 P.S.§9116(a)(1.1)(1)].
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)(it)].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 p2 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-1502 EX-(12-12)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ADA GRACE COCKLIN 21 13 0388
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1 Property located at 802 Fairfield St . , Mechanicsburg, 821000 . 00
Middlesex Twp - , Cumberland County, PA sold to
Mark S . Seltzer , married man on August 9 , 2013
TOTAL(Also enter on Line 1,Recapitulation.) $ 821000 - 00
If more space is needed,use additional sheets of paper of the same size.
REV-1503 EX+(8-12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ADA GRACE COCKLIN 21 13 0388
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 • 35 shares Vodafone Group Plc stock a $28 . 635 each 11002 . 23
7-27-12 High $28 . 77, Low $28 . 40 average $28 . 585 and
7-30-12 High $28 . 84 , Low $28 . 53 average $28 . 685 with
average of $28 . 635 per share
TOTAL(Also enter on Line 2,Recapitulation) $ 1,002 - 23
If more space is needed, insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
ADA GRACE COCKLIN 21 13 0388
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 • Claremont Nursing Home-refund due 88 . 37
2 M&T Bank-Cert of Deposit #4192-44 507. 38
Princ $507 . 38, Int $ . 17
3 M&T Bank-Cert of Deposit #4192-44 - Accrued Int 0 . 17
4 M&T Bank-Savings Acct #4192-00 119 . 93
Princ $119 . 93, Int 5 . 03
5 M&T Bank-Savings Acct #4192-00 - Accrued Int 0 . 03
6 Riverview Bank-Checking Acct #36288310 34,973 . 15
Princ $34 ,973 . 15, Int $2 . 59
7 Riverview Bank-Checking Acct #36288310 - Accrued Int 2 . 59
8 The Forethought Trust-Prearranged burial account 6,264 . 18
TOTAL(Also enter on Line 5,Recapitulation) $ 411955 - 80
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX-(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ADA GRACE COCKLIN 21 13 0388
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 • Cocklin Funeral Home-funeral expenses 8,351 . 17
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representatives) Keystone Guardianship Services 6,247. 00
Street Address PO Box 804
D;ryElizabethville state PA ZIP 17023
Years)Commission Paid: 2013/2014
2 , AttomeyFees: David H Stone, Esquire 6,247 . 00
1 Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
city State ZIP
Relationship of Claimant to Decedent
4 • Probate Fees: Cumberland County, Reg of Wills 268 . 50
5 . Accountant Fees:
6 • Tax Return Preparer Fees:
7 . Penn Waste-services at property 93 . 98
2 Selling costs (911,141 . 54 less reimb $1,299 . 22) 91842 . 32
3 PPL-electric service at property 169 . 91
4 Cumberland Law Journal-adv grant of letters 75. 00
5 The Sentinel-advertising grant of letters 189 . 54
6 Register of Wills-filing Inh tax ret and Inventory 30 .00
7 Reserve for closing expenses 200 . 00
TOTAL(Also enter on Line 9,Recapitulation) $ 31,714 - 42
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX-(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ADA GRACE COCKLIN 21 13 0388
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 • Stone LaFaver & Shekletski-fees prior to death 300 .00
on guardianship
2 Keystone Guardianship Sery-fees and costs on 614 .10
guardianship
3 Claremont Nursing Home-services rendered in 2012 2,000 .00
4 PA Dept of Public Welfare-claim 64 ,771 .74
TOTAL(Also enter on Line 10,Recapitulation) $ 67,685 - 84
If more space is needed, insert additional sheets of the same size.
REV-1513 EX,(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ADA GRACE COCKLIN 21 13 0388
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
1 CAROLYNN STUART Collateral 251557 . 77
4708 FLORENCE AVENUE
MECHANICSBURG PA 17055-
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 TT-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
OF
GRACE A. COCKLIN
I, Grace A. Cocklin, now or formerly of 802 Fairfield Street, Mechanicsburg,
Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do
make, publish and declare this my Last Will and Testament, hereby revoking all Wills and
Codicils by me at any time made.
ITEM I: 1 direct that all inheritance and estate taxes becoming due by
reason of my death, whether such taxes may be payable by my Estate or by my Executor
out of the property passing under this Will, which is not specifically devised or
bequeathed, be paid as an expense and cost of administration of my Estate. My
Executor shall have no duty or obligation to obtain reimbursement for any such tax paid
by my Executor even though on proceeds of insurance or other property not passing
under this Will.
ITEM II: 1 direct that before any distribution of assets is made to my
beneficiary as set forth below, that, in the event that I have any pets at the time my death,
that the first $4000.00 of the assets of my estate be set aside for the care and
maintenance of such pet, including end of life or burial costs. Set funds may be provided
to any individual or agency who shall care for my pet or pets.
ITEM III: I give and bequeath all of my household furniture and
furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing
apparel and all other like articles of household or personal use and adornment to
Carolynn Stuart, now or formerly of 2722 Walnut Street, Apt. A, Camp hill, PA 17011.
ITEM IV: I give, devise and bequeath all of the rest, residue and
remainder of my property, real, personal and mixed unto the aforementioned Carolynn
Stuart.
ITEM V: Any person who shall have died at the same time as Testator,
or in a common disaster with him, or under such circumstances that it is difficult or
impossible to determine who died first, or who shall fail to survive Testator by ninety (90)
days, shall be deemed to have predeceased him.
ITEM VI: I hereby nominate, constitute and appoint the aforementioned
Carolynn Stuart to be my Executor (hereinafter "Executor'). My Executor and Trustee are
specifically relieved from the duty or obligation of filing any bond or other security.
ITEM VII: In all references herein to any Spouse, Executor, Beneficiary
or Child, the use of any particular gender or the plural or singular number is intended to
include the appropriate gender or number as the text of this my Last Will and Testament
may require.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last
Will and Testament, consisting of this and the preceding one (1) page, this 30 day of
September, 2009.
Grace A. Cocklin
"J COHIION`"'rAITH OF PENNSYLVANIA
Page 2 of 4 " ilOi iroAL SEAL
AQARK K. EMERY, Notary Public
City of Flarrisburg, Dauphin County
My Commission Expires Jan. 10, 2011
SIGNED, SEALED, PUBLISHED AND DECLARED by the above named
Testator, Grace A. Cocklin as and for her Will, in the presence of us, who, at her
request, in her presence and in the presence of each other, have hereunto subscribed
our names as witnesses in attestation thereof.
ler
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS.:
COUNTY OF DAUPHIN
I, Grace A. Cocklin, the Testator whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will; and that I
signed it willingly and as my free and voluntary act for the purposes therein expressed.
Sworn to or affirmed and acknowledged before me by Grace A. Cocklin,
the Testator, this 30 day of September, 2009.
AA A (�
I Grace A. Cocklin/
l
Notary Public �-
My Commission Expires:
(SEAL)
COMMONWEALTH Of PENNSYLVAMA
MARK KNEMERA' YL— NS A y public
City of Harrisburg, Dauphin County
My Commission Expires Jan. 10, 2011
Page 3 of 4
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.:
COUNTY OF DAUPHIN
We, tli ry, ,ry l7a S�r� 4 t4c. rte/ C,
the witnesses whose names are signed to the attached or foregoing instrument, being
duly qualified according to law, do depose and say that we were present and saw the
Testator sign and execute the instrument as his Last Will; that the Testator signed
willingly and executed it as his free and voluntary act for the purposes therein
expressed; that each subscribing witness, in the hearing and sight of the Testator,
signed the Will as a witness; and that to the best of our knowledge, the Testator was at
that time 18 or more years of age, of sound mind and under no constraint or undue
influence.
Sworn to or affirmed end subscribed to before me by
V1 r5'." / ',S',} and this 369 day of
September, 2009.
Witn
e
j &— 6, _
,
Witness � . %
Nota
My Commission Expires:
(SEAL)
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
MARK K. EMERY, Notary puNttc
City of Harrisburg, Dauphin County
My Commission Expires Jan. 30, 2011
Page 4 of 4
3
49t"1 DW,Mk ne Guardianship services.ADA GRACE CGCKLUt-802 Fairfield Sbeet I I II I I I�I I lfl
Q 1�B
Tax Parcel#:22-24-0783-045
Address: 801 Fairfield Street
Mechanicsburg,PA 17055
DEED
THIS INDENTURE made the Q day of in�jr in the year 2013,
between KEYSTONE GUARDIANSHIP SERVICES, Admini strator C.T.A., of the Last Will
and Testament of ADA GRACE COCKLIN a/k/a A. GRACE COCKLIN, late of Middlesex
Township, County of Cumberland and Commonwealth of Pennsylvania, of the first part,
hereinafter called the Grantor,
-AND-
MARK S. SELTZER, married man, hereinafter called the Grantee;
WHEREAS, the said ADA GRACE COCKLIN became in her lifetime seised, as of
fee, of and in to a certain tract of land, together with the improvements thereon erected, situate
in the Middlesex Township, County of Cumberland, and Commonwealth of Pennsylvania, and
more particularly described hereinafter; and being so thereof seised, died on July 28, 2012,
intestate;and
Letters of Administration C.T.A. upon her estate have been duly issued by said Register
of Wills on April 8, 2013 to said KEYSTONE GUARDIANSHIP SERVICES (File No.
21-13-0388)all as in and by the records of said Register of Wills,recourse thereunto being had,
appears:
NOW THIS INDENTURE WITNESSETH, that the said Grantor, for and in
consideration of the sum of EIGHTY-TWO THOUSAND and NO/100 ($82,000.00) Dollars,
which has been paid to them by the said Grantee at or before the sealing and delivery hereof,
receipt whereof is hereby acknowledged, has granted, bargained, sold, aliened, released and
confirmed, and by these presents does grant, bargain, sell, alien, release and confirm unto the
said Grantee,
ALL THOSE TWO CERTAIN adjacent lots of ground situate in the Township of
Monroe, (formerly referred to as Silver Spring), County of Cumberland and State of
Pennsylvania, bounded and described as follows:
ALL THOSE TWO CERTAIN adjacent lots of ground situate on the North side of
Fairfield Street in the Township of Monroe,(formerly referred to as Silver Spring),County of
Cumberland and State of Pennsylvania,and being Lots Nos. 83 and 84 in a certain plan of lots
known as Point Comfort, laid out for George B. Vogelsong and Minnie C. Vogelsong, his wife,
which said plan of lots remains of record in the Cumberland County Recorder's Office in Plan
Book 2,at Page 36,more particularly bounded and described as follows,to wit:
�1 '
BEGINNING at a point in the northside of Fairfield Street at the division line between
Lots Nos. 82 and 83 in the aforementioned plan of lots; thence along the northside of Fairfield
Street in a westerly direction one hundred(100)feet to a point in the division line between Lots
Nos. 84 and 85 in said plan; thence along the division line between Lots Nos. 84 and 85 in a
northerly directions, one hundred forty-one and five tenths (141.5) feet to a point in the
southern line of a five(5)foot wide right-of-way; thence along the southern line of said five(5)
foot wide right-of-way in an easterly direction one hundred (100) feet to a point in the division
line between Lots Nos. 82 and 83 in said plan, aforesaid;thence along the division line between
Lots Nos. 82 and 83 in a southerly direction one hundred forty-one and five-tenths(1415) feet
to a point in the northern line of Fairfield Strect,aforesaid,at the place of BEGINNING.
BEING THE SAME PREMISES WHICH Frank Barton Miller and Mary Virginia
Miller, his wife, by Deed dated November 18, 1960, and recorded November 21, 1960, in the
Office of the Recorder of Deeds in and for Cumberland County, in Deed Book B,Vol.20,Page
383, granted and conveyed unto A. Grace Cocklin, also known as Ada Grace Cocklin, single
woman,the deceased.
TO HAVE AND TO HOLD the said lot or piece of ground above described, with the
buildings and improvements thereon erected, hereditaments and premises hereby granted or
mentioned, and intended so to be, with the appurtenances unto the said Grantee, to and for the
only proper use and behoof of the said Grantee, forever.
And the said Grantor,for itself and its respective heirs,executors and administrators,do
covenant, promise and agree to and with the said Grantee, his heirs and assigns,that it, the said
Grantor,has not heretofore done or committed any act, matter or thing whatsoever whereby the
premises hereby granted, or any part thereof, is, are, shall or may be impeached, charged, or
encumbered in title,charge,estate or otherwise howsoever.
IN WITNESS WHEREOF,said Grantor has caused this Indenture to be executed by its
President who has hereunto set her hand and seal the day and year fast above written.
Signed, Sealed,and Delivered
in the Presence of
VX4__�Che)sCOC_ (SEAL)
:CONSTANCESTONEROADofKEYSTONE
GUARDIANSHIP SERVICES,
Administrator-CTA of the Last Will and
Testament of ADA GRACE COCKLIN
afk/a A.GRACE COCKLIN
"z`
COMMONWEALTH OF PENNSYLVANIA:
COUNTY of
�U tn.�Jet lGunrX SS:
On this, the day of 2013, before me a Notary Public, the
undersigned officer, personally appcar CONSTANCE STONEROAD, President of
KEYSTONE GUARDIANSHIP SERVICES, Administrator C.T.A., of the Last Will and
Testament of ADA GRACE COCKLIN, known to me or satisfactorily proven to be the person
whose name is subscribed to the within instrument, and acknowledged that she executed the
same for the purposes therein contained,
IN WITNESS WHEREOF,I have hereto set my hand and notarial seal.
C0MMMWMT)j OF a11 Nsw PENWYLKMA
R '
UrdA N.ftWA,W ftyP+ubk Notary Public
HWW ftT#*MOffi* rftWCwMY
n ammomtme m 2@13
Member,Kmmlvanib knwaoon M wftlus
I hereby certify that the precise address of the Grantee is
iG St .
DATE: � �
"3"
ROBERT P. ZIEGLER
RECORDER OF DEEDS
CUMBERLAND COUNTY
I COURTHOUSE SQUARE
CARLISLE, PA 17013
717-240-6370
Instrument Number-201326656
Recorded On 5/12!2013 At 12:09:23 PM *Total Pages-4
•instrument Type-DEED
Invoice Number- 144403 User ID-MSW
•Grantor-COCKLIN,A GRACE
•Grantee-SELTZER,MARK S
•Customer-KEYSTONE SETTLE
*FEES
STATE TRANSFER TAX $820.00 Certification Page
STATE WRIT TAX $0.50
STATE JCS/ACCESS TO $23.50 DO NOT DETACH
JUSTICE
RECORDING FEES — $11.50 P
now This page IS art
RECORDER OF DEEDS p g
PARCEL CERTIFICATION $15.00 of this legal document.
FEES
AFFORDABLE HOUSING $11.50
COUNTY ARCHIVES FEE $2.00
ROD ARCHIVES FEE $3.00
CUMBERLAND VALLEY $410.00
SCHOOL DISTRICT
MONROE TOWNSHIP $410.00
TOTAL PAID $1,707.00
I Certify this to be recorded
in Cumberland County PA
RECORDER RDER ON D D
*-Information denoted by an asterisk may change daring
the verification process and may not be reflected on this page.
1031B9 t(t( J(J(
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I'S t
MEMBERS Pt
FEDERAL CREDrr UNION
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 4192-00
Date Account Established 07/19/1957
Principal Balance at Date of Death $119.93
Accrued Interest to Date of Death $0.03
Total Principal and Accrued Interest $119.96
Name of Joint Owner None
CERTIFICATE OF DEPOSIT:
Account Number/Suffix 4192-44
Date Account Established 11/05/2010
Principal Balance at Date of Death $507.38
Accrued Interest to Date of Death $0.17
Total Principal and Accrued Interest $507.55
Name of Joint Owner None
MEMBERS 1sT FEDERAL CREDIT UNION
V
Tessa L Klugh
Lending Insurance Support Specialist
April 22, 2013
Estate of: ADA GRACE COCKLIN
Date of Death: 07/2812012
Social Security Number: 209-12-5749
5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 • www.memberslst.org
RIVE RW BANK
AVIENG
Div IsIONS
200 Front Street,PO Box B,Marysville,PA 17053
www.rive"iewbankpa.com
April 23,2013
Stone LaFaver& Shekletski RE: Ada Chace Cocklin
Attorneys At Law DOD: 7/28/2012
414 Bridge Street
Post Office Box E
New Cumberland,PA 17070
Account Number(s) 36288310
Type of Account Checkinu
Date Opened January 27,2012
Principal Balance at date of death $34,973.15
Interest Rate 0.4500%
Accrued Interest not
disbursed as of date of death $159
Maturity Date NIA
Primary Owner of Account Ada Grace Cocklin
Name of Joint Owner(s), if any N/A
Beneficiary, if any N/A
Date Joint Ownership was
Established N/A
If within 1 vear of death of
Decedent could prior Account
Be traced into a prior Joint
Account in existence over
1 year prior to death of
Decedent N/A
N/A
Safe Deposit Box(s) and Location
By: �3�_,\
L.eshe Miller, Operations Support Specialist
Halifax Bank Marysville Bank
300 Market Street 200 Front Street
PO Box A PO Box B
Aa/ifaX Bank Halifax,PA 17032 alysv jje i. Marysville,PA 17053
www.hatifaxbankpa.com www.marysvitlebankpa.com
p Ww.w, GMS Approval N.2502.0266
d
S
A. Settlement Statement (HUD-1J
B.Type of Loan
1.o FHA 2.Q THIS 3.OCanv.lI ns. 6. Fee Number 7. Loan Number, 8 Mortgage Insurance Case Number:
4.[�VA 5.0 Cony.Ins. 2013080001KS
C. NOW This form is furnished to truly you a statement of actual settlement costs. Amounts poitl ro end by Ule setlement agent e7n shown.
hours marked'in o.c}'wets paid outside the cioctnp,they ere shown ham for inemorumnot purposes and are not included in the totals
D. Name and Address of Borrower E. NumedrMAddrOa$d Softer. F.Name and Address of lender:
Mark S.SeADW Scout,m Ada Grace Cockfin
719 Sindnir Road
MeehanKsberg,PA 17055
G. Pro,"Location: H. Settlement Agent: I. SeNement Date:
802 Fairfield Street Keystone SeftlamenLa,LLC
Mechanicsburg,PA 17055 1104 Fanwood Avenue,Suite 302 August 0.2013
Cumberland County,Pennsylvania Camp Hill,PA 17011 Ph, (717)695-9521
Place of S.Mandnc
4242 Carlisle Pike
Camp Hill,PA 17011
J. Summary of Borrowers transaction K. Summer of Sellerstumsk.thm
100.Gross Amount Due from Borrower: 400. Gross Amount Due 10 Seiler:
101. Contract sales pace 8200008 401. Contract sales price 82AD0.00
12L&Lsonai rp a 402. Personal prep NY
103. Setramant Cringes too eodowe+ Line 1400 2151A0 401 _,,,_ -
7D4. MI Pa off 404.
105. We payoff 405.
WIwil4al for items paid by Seller In advance AdWilments for Items paid by Seller in advance
106.City1County Taxes 08110113 to 0110IM4 133.67 406.CAyfCouray Taxes 68150113 10 OIA)1 114 133.67
107. School Taxes 0WI0113 to 07/01/14 1,032,72 407.School Taxes 01111003 to 07/01114 1,032.72
108. Sewer 0711-0W30 08/10113 t0 70101/13 132.83 408.Sewer 07/1-09130 OW10/13 to 10/01/13 132.83
109. 409.
110. 410.
111. 411.
112. 412.
120. Gross Amount Due from Borrower 65,450.22 420.Gross Amount Due to Seller 83,299.22
200. Amounts Paid by pr in Behalf of Borrower $00. Raduclions to Amount CUe Seller:
101. Deposit or serves[money 80.000.00 501. Excess deposit see instmdions
202. Print at amount ex new han s 502. Seriiemeni ever es to Sector tune 1400 11,141.54
203. Eusbin loan(s)taken Burred 10 503. Exsmig loans taken sobuctW
204. i $04.Payoff Fuel Moa9age
205. 505,Pothell Second lylearl
206. 506.
207, 507.(Decker than as proceeds)
208. 508.
269. SM,
Adjustments for Items un ald tr Geller Ad uslmenta for items unpaid by Seller
210, CRyChourry Taxes to 510.CityiCo.ray Taxes to
211. School Tones to 511. Sdmd Taxes to
212. Sewer 0711-09r3O t0 512. Sewer 0711,Me to
213. 513.
214. 514.
215, -� 515-
216. 516.
217. 517.
218, 518.
219. 519,
220. TOW PAW by/for Borrower 80.000.00 520. Total Reductbn Asm)WR Due Seiler 11.14154
300. Cash at Seftlement Truman Borrower 600. Cash at settlement tatbpm Sells,
301. Grass amount due from Be.,One 120 85,450.22 601. Gross amount dua to Sher fore 420 83.29912
302. Less amount paidraor Satrower(line 220) ( 80.000.00) 602. Less reductions due Seller nine 520} ( 11.141.54
303. Cash �% From 0 To Borrower 5,450.22 603. Cash I X To 0 From Seller 72,157,68
vne4uuaa ."Wit.a�maomnn
The undersigned hereby,acknowledge receipt of a completed copy of this statement d any attachmentsrfletemaka to",am
Borrower r, „L. 5 �f Seller /''.,,, Y Y6 .. /
Dark S.Sehhar y G6rle7apCE Slonero6ad of Keystone Guardianship
Services,Adminlsaaker C.T,A
of The Laal WN and Tesiement of Me Grace Cockfin
m leek mr.0 wmrn m,un waeeeen d.rvwrmawn neaimnn n Js mmcul er,.et-1 le,e✓eArva,ynr+.np+^a 4uwlinp me ana rxuprKV x,rot mIW IM nfarmr�un,rrw pu r,e nanwuaee m
aupuy.r yree�lyree oMe<MUa numy,Nc cM eeneaNy.atewdt.Nu 0.1UOau,e umanealary rM u Ce./JnaPiC p,w,M Vw O.Nef W sAf$Px Wrum vxrviacam Mnafwmrµn
WaprW MUgmani9eOtcsi
Page 1 of 3 HUD-1
(2013D80001KS PFIWO13080001)(8118)
L.Settlement Char nest
700.Total Real Estaro Broker Fees $4,92000 Past F.ro Pad From
Divi4tdr+ofoommtsenn M.7O0 as hatemrs.' Borrowers Sellars
Foods of Fuak at
70 .$2,d to Keller Williams of Cartel PA SeNemage SelhPP,,g
703,Coon4asion paid at settlemanl 4 920.
O4.Tran adl p F e AX Real4 Aseod a 95.00
705,Transaction Fee W Keller Williams of Central PA 275.01)
800.theme Pa able in Connection wllh Loan
8O1.Ourarl natbn char e 8 from GFE#1
802.Your oredu or charge(points)for the scectfic interest rata chosen S (from GFE#2) r
603.Your atl uatetl on Mation char es Irom GFE#A 0.00.
804,Ammistal lee to from GFE#3
805.Credit Report to Irom GFE 93
We.Tax service to from GFE al
807.Flood cer ificalbn ro imm GFE#3
800. (from GFE 13)
809, thorn GFE#9
$10. fftomGFE#3
811. (from GFE#3)
900.hems Required by Lendor to Be Paid In Advance
901.Caily interest mar es from to @ II/day (hom
902_MHT Tot low.for Fife of Loan mnnPoa to (from GFE#3)
903.Honnowoer a insurance for years to 1 @m GFE#11
004. imm I
905. (from GFE#it
1000.Reserves Deposited with Lender
1001,initial dep4sii fw r escrow acmunt (gam GFE#9)
1002.Homeowndrs msur8nce months @7 S per month S
months (@ S par month
1004.Property Iaxes 5
Sew r0711.09QO months Pr? $ _„ car month
Civlcw wTaxes months 5 oar manor
School Taxes n
1005. $
1008.Counly(Twip.Taxes months 0 S pas month S
1007.School Taxes months @ 5 par month S „
7008. $
1009.Aggroinge Atl uslment $
1100.Title Clxargea
1101.Title services end IeMai S 414e insurancC from GFE 94 178.00
1102.5ehl meni or dosle i to Keystone SelflenneplS,LLC 150.DO
1101 Owners title insurance b F,"Ity Nation i Two Macron"C.,onob. tr m GFE#51 801.00
1104,Lenders Iltle insurance to Fidelity National THIC InSOPRob,CgMPanV
I IQ5.Landers One policy We
1106.Owner's title Doncy limit S 82.000.00
1107, Agent's Powlson qJ00-tgLal 110c,pwran,promosm to Keystone SenlemarlS LLC 680.85
1108_ Underwr'ter's portba,of the total title inswbott rcmium to Fide10 Netbn0i Tithe insurance Gomparn S 120.15
1109.CPL Fidelity National Title Insurance Company S _
1110.
1111, 5
7112,Deed Prep Fee to Stone LaFayer&Shekletakl 5 150.00
1113. S
1200.Government Recording and Tranefar Charges
1201.Griverfluntmenscooding char es to Recorders DfrKe (from GFE#7 79.00
1202.Deed 5 70.00 mcfcfage RMaases S Dthar
12 63.Trdn I rte to Re r rs He ji!om F 8
1204.CO C-oun Voustrove, S 82 .00
1205.State toahtam s S 820.00 S 820.00
1206.County Charged UPI Fee RacaMers Office
7207.
1300.Additional Sanloment Charges
1301.Re uTed orvices ihffi u css,soup for -_ (from GFE#6
1302. S
1303. $
1304.
1305.2013 School Tar 22-24-0783-045 to Mary A Murray S 22-240783-045 All
1306.2613 Crdylrwp 22244)78&D45 to Mary A.Money 5 22-24.0783.045
1307.2012 OC9neuent 22-240783-045 to Cumberland County Tax Claim i $ 22-24-0783-046
1308.Munleipal Lien Account 607 to Monroe Township Authority S Account 6O7
1309,Sewer Due Account 607 Io Monrae Township S Account 607
1310.Roimbursemem for Pad t.ocic to John Ease, S
1450.Total Settlement Charges(enter on IIMS 103, action and 502, eetibn K) 2151
Pm MWed 1.11cymvaaa.te:1nMi5I.rnMNL}aML'anrylti r
ell rpny ai r ala tnf[p,alWYaa[1nWYOaf rfYXOt ora[art4Nna ttlEr Cba9a]d]alVxin.el,oaae a#amara.
Napstona SeiNentanm,tLC.BatOa eN-Agent
Cent0ed to be a true copy.
Page 2 of 3 Ht1O-1
(2(f1 3080001 KS.PFD120130.90001 KSl18)
HUD-1 Attachment
Borrower(s):Mark S.Seltzer Sellal(s): Estate of Ada Grace Cocklin
719 Slnclair Road
Mechanicsburg,PA 17DSS
Settlement Agent:Keystone Settlements,LLC
(717)695-9521
Piece or Beeloment:4242 Carlisle Pike
Camp Hill,PA 17011
Sentetnent Data:August 9,2013
Property Location:802 Fairfield Street
Mechanicsburg,PA 17055
Cumberland County,Pennsylvania
Title Services and Lender's Title insurance Details BORROWER SELLER
Wire Fee 20.00
to Keystone Settlements,LLC
Tax Carl Fee 6.40
to Keystone Settlements,LLC
Closing Fee 150.00
to Keystone Settlements,LLC
Total $ 176.00 $ 0.00
Owner's Title insurance BORROWER SELLER
Owner's Policy Premium 801.04
to Fidelity National Title Insurance Company
Total $ 801.00 <$ 0.00
Sok r GOV.t1'p
its
LeSS ACS i
Sett-e.r
q$ va .3a
Pls �� ,� s7.
WARNING: His a Grime to knowingly make false statement.to the United States on this or any elmitar form. Penalties upon to n notion can
Include a fine and imprisonment, Par 0etalls aac Title 18 U.B.Code Section 1001 and Section 1010.
(2013080801 KS.PF02d13be W 0 t K V 1 8)
pennsytvania
DEPARTMENT OF PUBLIC WELFARE
August 7, 2013
STONE LAFAVER & SHEKLETSKI
DAVID H STONE ESQUIRE
P0 BOX E
414 BRIDGE ST
NEW CUMBERLAND PA 17070
Re: Grace Cocklin
CIS #: 100257350
SSN: ###-##-5749
Date of Death: 07/28/2012
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Stone:
Under State and Federal law, the Department of Public Welfare (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of $64.771.74 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $26.841.81, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $37.929.93, is to be entered as a priority Class 5.1 claim against the estate.
You should refer to Section 3392 for a more complete explanation of the priority rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
�� pennsylvania
DEPARTMENT OF PUBLIC WELFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate all deductions from the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to document computation of the amount due the Department, the following
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
S. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
pennsylvania
DEPARTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
�
Elvetta E. Knox
Claims Investigation Agent
717-772-6613
717-772-6553 FAX
Enclosure
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
OMSION OF THIRD PARTY LIABILITY
RECOVERYSECTION
PO BOX 8488
HARRISBURG,PA 17105-8486
September 19,2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of COCKLIN,GRACE
ID 100 257 350
MEDICAL CLASS 3
CLASS 5.1 TOTAL
INPATIENT .00
.00 .00
OUTPATIENT .00
00 .00
LONG TERM CARE 26,833.53
37,695.50 64,529.03
DRUG 8.28
234.43 242.71
REIMBURSEMENT TO DPW 26,841.81
37,929.93 64,771.74
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE-
EIN- 23-6003113
Page 1 of 7