HomeMy WebLinkAbout12-23-13 J 1505610105
REV-1500�``O2_ll„�, �
OFFICIAL USE ONLY
PA Department of Revenue P���� County Code Year File Number
Bureau of Individual Taxes "�"�'EM���E
Po sox z8o6oi INHERITANCE TAX RETURN �,�Z
Harrisburq,PA i�i28-o6oi RESIDENT DECEDENT 21 �t9 '�#£�01309
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
170362721 12022012 12081947
Decedent's Last Name Suffix DecedenYs First Name MI
Blust Sandra D
(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
4'j 1.Original Return O 2.Supplemental Return Q 3. Remainder Retum(Date of Death
Prior to 12-13-82)
p 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Allison A Blust-Zang 7175852592 �::;
�
� u:� � ��
� TER OF 1(YtyLS U$5 Y
C�7 • •-•� —_
ty� ��� � c-� C/? �
...�
First Line of Address � ?' � W :.�.M P
..__ ,.,.,
�� ��»� ;r': C.s C=`
143 Walden Way .«=-
c.;� r--, �>> � . _,,
SecondLineofAddress <�> "" � t
, _, _� .,_
<_., ,
.-, a :-: ' .:..�, �'a
� ;•:7 C.> I,_.. t'"9
�� ~� DATE�ED �', ��
City or Post Office State ZIP Code ,
Mechanicsburg PA 17050
Correspondent's e-mail address:alli.blust@gmail.COm
Under penalties of perjury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG RE OF PERSO RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610105 1505610105 J
�
� 1505610205
REV-1500 EX(FI)
DecedenYs Social Security Number
DecedenYs Name: 170362721
RECAPITULATION
1. Real Estate(Schedule A). ...................... ..... ......... ..... ... 1. 267000
2. Stocks and Bonds(Schedule B) .. ... ...... ........... ........ ....... .. 2. �
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 Personai Property(Schedule E)....... 5. 13139.02
6. Jointly Owned Property(Schedule F) O Separate Biliing Requested ... .... 6. �
7. Inter-Vivos Transfers&Miscelianeous Non-Probate Property �
(Schedule G) O Separate Biliing Requested.... . ... 7.
8. Total Gross Assets total Lines 1 throu h 7 a. 280139.02
( 9 ). ........... .................
9. Funeral Expenses and Administrative Costs(Scheduie H). .. .. .............. 9. 25202
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). .............. 10. 6598.63
11. Total Deductions(totai Lines 9 and 10)..... ...... ....... . .......... .... 11. 31800.63
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. , 248338.39
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ..... ... .. ....... ..... .. 13. �
14. Net Value Sub'ect to Tax Line 12 minus Line 13 �a. 248338.39
1 ( ) .......... ... ...........
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at Iineal rate X.o_ .045 �g. 11175.23
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 1$•
19. TAX DUE ...................... ........... ........... .... ......... 19. �
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505610205 1505610205 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Allison A Blust-Zang
STREETADDRESS
143 Waiden Way
��n STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 11175.23
2. Credits/Payments
A.Prior Payments 12523.75
B.Discount 0
Total Credits(A+B) (2) 12523.75
3. Interest
(3) 0
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) 1348.52
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUE5TIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Oid decedent make a transfer and: Yes No
a. retain the use or income of the property transferced.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ �
c. retain a reversionary interest .............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
containsa beneficiary designation? ........................................................................................................................ ❑ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent(72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the suroiving 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 applicabie 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 chiltl is 0 percent�72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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 OP REVENUE
INHERITANCE TAX REfURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Sandra D Blust
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 selier,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 Inciude a copy of the deed showing decedenYs interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• 2 story single family home 5265 Joshua Road Mechanicsburg PA 17050 267000
TOTAL(Also enter on Line 1, Recapitulation.) $ 267000
If more space is needed,use additional sheets of paper of the same size,
N�ne of Barower: N�ne of Seder: Flie Number:
Shawn S.Nidx�lson Allisai Zang,Executrix of the Estate of S�a D.Blust 13-1521 GC
Rebekah E.Nididson
Pr ared QBl29/2013 at 5:2&pm
Note:7his page displays an itemization of the charges shown on iine 1101 of the HUD-1 Setqement Statsment This page
accompaniss but is not a part of the HUD-1 Settlement Statement If a discrepancy exlsts,the information on the HU0.1 Setdement
Statement applies.
1100.Ta)e Ciiaiges . . . Total Ch�ge 8o�rowei Seiler
t 101.Title services a�lender's title insurance to
4YKe In �Guardan Transfer $ 12•00 12•00
Nocary Fee-Purchasers ro Guaidian Transfer 'on $ 35.OQ 35.�
Courier Fee-Purch�e to Guardfan Tr�sf� ; t5.00 15.00
Etedromc Document Fee to Guardian Trdnsfer 35.00 35.00
Notary Fefl-Sell�s to Amanda Li j 15.00 15.
Courier Fee-Selle.rs lo Guardian Transfec ; 15.00 15.00
Tan Cert Reirr�bursement Fee to Guardian Tr�sfer C ation 3 10.00 10.00
1702.Settlement or dosirg tee � E 0.00
1104.Lenders title insurance-Title Resources Gto Fitle Resources GuaratH C •E 1.695.00 1,695.00
1109.100 No Vio11100 to Tflle Resources Guazan Can •S �.� ��
1110.300 Surveyt300 to Title Resaurces Guarant Com :� �.� �.�
111 t.900 EPL-Res18.1 to TiUe Resources Guaran Com'S �.� �.�
t 112.ClosingSvcLtrlCl to Tide Resources Guaran Com •S 75.00 75.00
Totals: S 2,05T.� 0.00 2,017.00 40.
SeileHLendercredrtssfiawn on 1 . ' _ ` POG�Pald.autside Cbsf' CR=Lender Credk
Previous editions are obsolete Page 1 of 1 HUD-1
�µ�� A. Settiement Statement (HUD-1) v � ~~v Y v FINAL
,�
1. FHA 2.Q RHS 3.Q Cdnv.Unins. •File Number: �7.Loan Number. 8.Mortgage Insurance Case Number.
❑ 13-1521GC 5701368740
4.Q VA 5.�Conv.ins.
C.Note:This fortn is fumished to give you a statemeM of actual settlement costs.Amounts paid ro and 6y the settiament agents are shown Items marked
"(p.o.c)"wero paid outside the cbsing;they are shown here for informational purposes and are not included in the totals.
D.Name&Rddress of Borrower: E.Name&Address of Seller: F.Name 8 Address of Lender.
Shavn S.Nidiolson,Re6ekah E Nicholson Allison Z�g,Executrix of the Estate of Sandra D.Blust Fulton B�k,N.A.
105 Oneida Road,Camp Hill,PA 17011 5265 Joshua Road,Mech�icsburg,PA 17050 One Penn Square,Suite 304,Lancaster,PA
17602
G.Property Location: ti.Settlement Agent: I.Settlement Date:08/3Q2013
5265 Joshua Road Guardian Transfer Carporation Disbursemenl Date:08/30/2013
Mechanicsburg,PA 17050 4075 Maricet St.,Camp Hill,PA 17011
Hampden Township
717-9Q9-4700
Place of Settlemerrt: TitteExpress
555.E Chocotate Avenue,Suite 2p3,Hershey,PA 17033 Printed 08/29V2013 at 5:26 pm
by JMG
. :. . . . �
100. Gross Amcimt.Due from Bori'ower ` i ` d00::Gro�s AmouM Due 4o SeBer •
101. Conuacl sales prioe 267, .00 401. CoMract sales Price 267,000.00
102. Personal 402. Person�
903. Settlement chatges to borrower(iine 1400j 7,853.25 403.
1Q4. 404.
105. 405.
Ad'usbne�for items ' b seller In advance Ad strnenb for items Id b seller in advance
�os. c+rynowm t�ces to 406. Ciry/town tax� ro
107. County t�ces 08130Y2013 to 12I31f2013 243.62 407. County taxes 08/30/'1013101213112013 243.62
1d8. 5chool taxes 08J3ol2013 W O6t30/1014 2,100.82 408. Schod taxes OS/.i012013 to Q6f30C2014 2,100.82
1 Q9. Seww JtAfS 08130I2013 to 09l30/2013 53.93 409. Sewer JINS 0813(N2D13 ro 09/30t1013 53.93
110. 410.
11 t. 411.
112. 412.
�Z4• Grosa Amount Oue trom Bortower 277,251.62 420. Groas MauM Due to Seiler 269,398.37
200. MwuMs P�i b M M 8ehelfof Borrower -;-,. , . - 500. "Reduetldns In AmouM Due to 5eller
2Q1. Oeposit a earnest money 5,000.00 501. E�ccess deposk(see instrudions)
202. Pri�cipal�rount of new ban(s) 258,990.� 502. Seltle�nenl d�arges to seiter(line 14007 15,394.1 Q
203. Exisfi s taken sub'ed ro 503. Exisli I s taken su ecl to
204. 504. Pa �frcst mort ban
205. 505. Payoff of secotrci matgage loan
206. SeNers Assistance 5,000.00 506. Sellers Assistance 5,OOD.00
207. �7.
208. �.
209. `�.
Ad ustmeMs for iEems un akf b seller Ad ushrrents for items un aid seller
210. CityHaan taxes to 510. Cityltown tazes to
211. Countytaxes to 511. Countylaxes to
212. School taxes to 512. School ta�ces to
213. 513.
214. 5t4.
215. 515.
21&. 516.
y�7. 517.
218. 518.
y�g, 519.
220. Total Paid b lfor Bonower
288,990.00 520. Total ReduMion Amount Due Seller 20,384.10
�00. .-CashatSettlementFromlto'Borrowerr; . 600. GashaCSellkmeMtolf�omSelier
3p1. Gross amouM due from barower(line 120) 277,251.62 gqt. Gross artwunt due to seller(tine 420} 269,398.37
3p2. Le.ss�aunts paid bylfa borrower(I"u�e 220) 268,990.00 602. Less reductions in amaunt due selier(tine 520) 2Q,394.10
303. Cash QX From ❑ To Bortower $�26�•6Z 603. Cash QX To ❑ From Seller 2���•��
. v�
uwseam.wasseaWrs�aamurrawouBcawwn�x�oei.raom✓aa�orprbaw�a:uriaadwwsw�:a�aaeon.iuuuuero�rov�viaeneww%m.rsesvaaovaeanns.r,xa��waw�omu�onamnuu+s
mw.menc aacex
Previous editions are obsolete Page i of 4 HUD-i
_ _
._ _ _
�w�.iau�anwu�.i�rnu-
700. TotalReatEat�BrokerFees� : i,-t0,170.00- ,, - . . : `Pa�d From Paid From
>oivisiqndcanmfasion Iine7700 asfdbws:� . BOrrower's Seller's
n .
70t. $3,su}.op ro ForSaleByOwner-PlusRealtors `Funds at : FUnds at
7p2. �,�5p,pp �a Coldweil Banker SeleG Pr�essionals ' Settiement .Settlement
703. Canmission paid at settlement 10,170.00
800. Items, bk in GonneeHon with F.oan ` - ' . : :
&l1. Our axigitwtfon charge (Indudes Originadion Pant 0.000%or 30.00) 5695.00 (fran GFE#1)
802. Your credit w charge(pants�for the speaBc interest rate chosen $ (from GFE#2j
803. Your adjusted originatian charges (from GFE A) 695.00
804. Apprais�fee to A ais�Sdutions (from GfE�3} 375.00
805. C�edit�eport (p Credstar (from GFE f3) 72.63
806. Tax service ta from GFE#3
807. Flood certfication ta C ' Flood Services (from GFE#3) 11.50
H08. to
900. kems:R uired Le�tol�PaidinAWvanee' ' ,. - ;
901. Daity interest charges from fran 08/30/10 3 to 09I0112013�$34.5911tday {from GfE#10) 69.t8
902. Matgage insurance premium for months to Futton BA LNe of Ln 57148.72 P.O.C.L (from FE#3)
903. Flomeowners insWance for t ears to Penn Nadon� (irom FE#11) 740.00
gp4. months to from GFE#11
� _
1001. tni6al deposA fa your escrav aawunt (from 6FE#9) 992.74
1002.Haneowner's i�surance 3 rt�ihs S 61.671monih $185.01
1003.Mortgage i�urance months $ O.00tmonth S
10Q4.Property taxes monihs 3 0.00/month a
1005.County faxes 7 months $ 5976fmonth 5418.32
1006.Schaol taxes 3 mpnths 5 209.511moMh 5628.53
1007.Aggregate Adjustment 5-239.12
1100.TMIe:Ch
1101. Tide servic�s and lender's Gtle insurance � from GFE�i4 2.017.00 4D.00
1102.Setllement a dosing fee io $
1103.Ow�s tNe insurance-Title Resources Guaranty Company $ (ran GFE#5 `�•�
1104.Lender's title insurarKe-Title Resources Guaranty Company $1,695.00
1105.Lenders 6tle po�cy limit 5258,990.00 Lenders Poticy
1 tp6.Owners title poticy limit�267,OOO.QO Owne�'s Pdicy
1107.Agenl's portion of the totai 6tle insurance premiurtt $1,47475
to Guardi�Tr�sfer Co 'on
1108.Un�writer's portion of the tWal Mle insura�e p►�nium 5260.25
to Title Resources Guaran Can an
1109.100 No�dN 00 to TiUe Resources Gu�ty �.�
1110.3fl0 Survey1300 to Title Resources Guazanly 550•00
Com •
11 t 1.900 EPL-Res18.1 to Title Resources Guaranty 550.00
Com
1112.ClosingSvcLtrlCL to Trtle Resources Guararity S�5•00
Com
1200.GowmmwrtR�ccrtli and'Transfer es_ c-'
1201.Govemment recading charges S (from 6FE#7) 170.00
1202.Dyed$67.pp Nbrt $103.� Release S
1203.Transfertaues 5 (fromGFE�fB) 2,670.�0
12D4.CitylCounry taxlstamps peed .670.00 S
1205.State Ta�dstanps peed E2 670.pp g 2,67D.00
1206. peed S Mort $
1207. S
1300./tddidonal SeidemeM Ch' ; ,
1301.Required services ihat you can shop for (from GFE�6)
1302.2013 School Taxes Due to Michael an 2,514.1
1303.Pest Inspection to b
1304. to
1305. to
.�� . . - . .::: • . • . . . + - . 7,853.25 15,394.10
'Paid aitside of cbsing by(B)orrawer,(S�Iler,(L�nder,(I)nvestor,Bro(K�r."Cre�t by lender shown on page 1."'Credii by s8ller shown on page 1.
Previous editions are obsolete Page 2 of 4 HUD-1
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Ydur�tll��'������s�,r�`:t�.�".,..."`s u�.�:.��_'.�r;" ,�..aF.`.�'af f�.;�t ,' 695.06 695.00
f ranSf�r'lax2s t�,�,� �.� 7,.,. nµ<��F�..,.. .''C�3 ;��� :, Li�a.. Zrb7O.OQ 2,670.00
Cha es Ikat i�'#ot�„`1,_��,n 'l1b� '�9L ��'�' �`���-��.���� ��:
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APD��i ..��' �'
GredfE,tep�rt�+.�,�._ �"fi..�.`�:'���i"y�`'' � �F`�. �: �:s� '::# ��.�«,ta�� =" _-I'i 55.00 72.83
'FlaOdt�tU1�01��' .;a* :�':�a�(�"+�'`�"_"s+`�,�;k , ..0..�. i:"ry�,L." .II=;a�"& 1=� 11.50 11.50
htort ins['Ir�. �:_, ,. -,.�a x��� ��. .��,..'�if�,;'�: . � ��� i�.�.,�'..: ...;:;- 7,tA8.12 7,148_72
Titl��fcescdrtdi._: .0 r,r_�.. .�,�-,�R„E z ,.u`" ''�#�Q33*:,e� ; , . 2,055.� 2.017.00
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10,019.62 9,834.45
. � -185.17 -1.&481%
Cha Tliaf� : � s" r �� ' �' ��.a+t����t�M�,k� .`r � a y,�� ;�,GQpd,Fi�11t�11N1�9�r . .=FIUD�1 - ;
Intt�ahdepOS��t �1n, �.,�::�;�*���`'it'`��F i� � �5���+�wr.« '� 3,150.00 i 992.74
D2Ay�[If@t�#�at�lg3 ,,. �" �,; .�.t� *x:�`��'.�C'`.!'�`',ar,?>;:�� �e#u �.��*t.`�+f�' . .`�t.1 - 69.18 69.18
HOfI180NViierS�1180C�' `a, ,���,�_�, �'i'i'�;.�4'zi,i� `�'1,r.--�_-'� x.z:��� ., -�� na'ic; &00.00 T40.00
�;;� es �..._;:�"�'�.�r"� n.�...r��� ':s :'.,^.'..�`��:�.�.�.��'a::?'v_�
�_ � 5� ,si::k:'�3��'°'.�,!.�'�i;:'iffi�z���:,Js'� "w�'�"���_��� ti a��'u,ti-`•i?.. ��.�,.�k.-'. . -
�,.r cr?�t-i r x€'���`�..,�. �,._= >Y.,:Y'S;.M:' �'t,s _ �
Loan Terms
1'ourini��1loea,�i���&Y',�..��i yn��.E�"`�"�'*i�,��''�.�`,�",'�:; 5258,990.00
`fdU[�G�t18I111i5,��`�``�.��� ��,`��,.-��'��'�� �`��s`�E"� �:' 3Q.y¢8ts
Yourin�a�, �.�a� ��,��,'����;��,�,���`"�,` �����a"`�Yn a.8750%
x � � f �..� ���y M �.'. «�u y
Y¢w'�n�iaf fixxrthfy��iint o��rG���t,�Sd��y�q"5ge; $1,370.60 indudes
insuranee�s ��'��� ' } -�'-`���'��."�`�, ,�-�� ��,�� ,�' D �
� Z� r�. fr�, a .s�' '�� a��* x� X Pfl I
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Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender.
Previous editions are obsolete Page 3 of 4 HUD-1
HUD CERTIPICATION OF BUYER AND SELLER
I have carefuiry reviewed the HUDt Settiement Statement and to the best of my knowledge and betie(,R is a true and accurate statement of ali receipts and
disbursemenfs tnade on my acoount or by me in this trensad'an 1 turther certlfy that t have re�ived a copy of the HUD-1 Settlement Sfatement.
�
/
/
Shaw ' olson
.---_._-�
, C ---_.--___---.__.�
Rebekah E.Nichdson
i �. �� . �, a,�. � s�.l��
AAison Zar�g,Execu ' of the Es of Sand .
The HUD�1 Settlement Statement wfiich I have preparcd is a Vue and accurata acwunt of this transadion.I have caused or will cause the tunds to be
disbursed in aa;ordance with this statement
�-?���� �
SE ENT DATE
WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SlMILAR FORM.PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 100t AND SECTION 1010.
Previous ediYions are obsolete Page 4 of 4 HUD-1
PRE-SEfTLEMENT WALK-THROUGH INSPECTlON �SW
Date: Aug 30,2013 Properry Address 5265 Joshua Rd.Mechanicsburg,Pa.17050
Buyer 1 Shawn S.Nichoison Buyer 2 Rebekah E Nichoison
The undersigned purchaser(s)have compietely i�spected the above property on Aug 30,20i 3 and were accompanied by
Steven A.Nitholson Realtor and have determinecf to their satisfaction that the properiy was in
substantiaily the same condition as ii was at the time of execution of the agreement of sale.
The purchaser(s)acknowledge ihat a11 non-real estate extras as out�ined in the agreernent of sale were on the premises at the time of inspeccion and
afi fixtures were in place and functioning except those specified below.The purchaser(s)had the opportunity to test ait piumbing,heatiny,electricat
systems and appliances artd found them to be in a satisfacEory manner,except ihose specified below.
�
The items iis#ed below were noted as NOT being in satisfactory tondition but were accepted in'A515"condition.(Mark if"NONE";:���
The followiag items were noted as NOT being in satisfactory condition a�d are NOT ACCEPTED by Purchaser(s).
item • �c- � Remedy _2.�i��i 'l/� ���.rr//rU9��
Item �j��G �- Remedy .
Item Remecly
Item Remedy
ttem Remedy
At time of acceptabie inspection o�agreement for resalution for unsatisfactory items by both parties, purch er{s)and Seiler(s)agree to hold
harmless Listing A nt,Sub-AgentBuye�'s Age�t,from any and alt liability which may arise due to onditi f suBject property.
Witness � j � Buyer 1 � �
�
Witness Buyer 2 x � ,f/��
c{/
Maiiing Address CiEy Zip
Phone Numbers: Home Woric
Cetl Email
Seller(s)ha n 'sed i th tts of the Purchaser{s)inspection and agree to exceptions or re utioru not herein.
Witness Seller t � d !'uCt�.
• 4
Witness Seller 2
Mailing Address City Zip
Phone Numbers: Nome Work
CeN Email '�
Waiver
We have been advisett by Coldwell Banker Se4ed Professionals of our right to a pre-settlement irtspection of the home.We hereby decline and
waive our right to said inspeRion and agree to hoid harmless,Coldwell Banke�Sefect?rofessionals and its agents from any and all liability which
may arise due io the tanditions of subjeR property.
Buyer 1 Date Buyer 2 Date
REV-1511 EX+ (08-13)
�� pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INNERITANCE TAX REfURN AD M I N ISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sandra D Blust 2012-01309
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1� Funeral 6113.43
Memorial Stone 600
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: �
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
0
2• Attomey Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimantto Decedent
4. Probate Fees: 373
5. Accountant Fees: 79.58
6. Tax Return Preparer Fees: 40
�. Real Estate Fees 17,996
TOTAL(Also enter on Line 9, Recapitulation) $ 25202
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ (12-12)
�� pennsylvania SC H E DU LE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
1NHERITANCE TAX REfURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sandra D Blust 2012-01309
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• Celtic Health Care 125
2 Erie Insurance 61
3 West Shore Ambulance 1714.94
4 Hampden Township Ambulance 773.5
5 SewerlTrash Hamden Township 150.05
6 PP&L Electric 182.13
7 PA American Water 96.81
8 PSERS Retierment 3495.20
TOTAL(Also enter on Line 10, Recapitulation) $ 6598.63
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
-� pennsylvania SCHEDULE )
�, DEPARTMENT OF REVENUE
INHERITANCE TAX REfURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Sandra D Blust
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).]
i. Allison A Blust-Zang Daughter 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SNOWN 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.
8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—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.
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG,PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
N0. CD 017451
BLUST ALLISON A
5265 JOSHUA ROAD
MECHANICSBURG, PA 17055
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
""____ fold "'____"' "_____'
13106840 � 523.14
ESTATE INFORMATION: Ssrv: �7o-3s-272� 13106841 � 5142.25
FILE NUMBER: 21 1 2-1 309 13106842 � 5358.36
DECEDENT NAME: BLUST SANDRA D �
DATE OF PAYMENT: 04/16/2013 �
POSTMARK DATE: 04/16/2013 �
CourvTY: CUMBERLAND �
DATE OF DEATH: 12/02/2012 �
�
TOTAL AMOUNT PAID: 5523.75
REMARKS:
CHECK# 1436
INITIALS: CJ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX�11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HAFRISBURG,PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 017966
ZANG ALLISON
143 WALDEN WAY
MECHANICSBURG, PA 17050-4145
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
--"--- fold
101 � $12,000.00
ESTATE INFORMATION: sstv: ��0-36-2�2� I
FILE NUMBER: 21 1 2-1 309 I
DECEDENT NAME: BLUST SANDRA D I
DATE OF PAYMENT: 08/01/201 3 I
POSTMARK DATE: 08/01/201 3 �
CoUNTY: CUMBERLAND �
DATE OF DEATH: 12/02/2012 �
�
TOTAL AMOUNT PAID: 512,000.00
REMARKS: `
CHECK# 1437
INITIALS: BAJ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
REV-15o8 EX+(o8-i2)
�� pennsylvania SCNEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS &MISC.
INHERITANCE TAX RENRN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Sandra D Blust 2012-01309
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
� PSECU Savings Bank Account 514.50
2 PSECU Chevking Bank Account 3161.05
3 PSECU Checking Bank Account 7963.47
4 Jewlery 100
5 Furniture 500
6 Artwork and Decora6ons 500
� Electronics 200
8 Clothing 700
TOTAL(Also enter on Line 5, Recapitulation) $ 13139.02
If more space is needed,use additional sheets of paper of the same size.