HomeMy WebLinkAbout03-12-14 -� REV-1500 EX(02-11) 1505610143
PA Department of Revenue OFFICIAL USE ONLY
P pennsylvanNU County code Year File Number
Bureau of Individual Taxes DEPARTMENT Of REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 11 01203
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 17 2011 08 12 1930
Decedent's Last Name Suffix Decedent's First Name MI
MILLER SR . RICHARD B
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
MILLER DELORES J
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 Return ❑ 3.Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12.12.82)
® g Decedent Died Testate ❑ 7 Decedent Malntalned a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death ❑ 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
HAMILTON C DAVIS ESQUIRE 717 532 5713
r�
REGISTER OF ILLS USE ONkYY
First Line of Address
PO BOX 40
CD
Second Line of Address
20 EAST BURD STREET o `Q
DATE F D n
City or Post Office State ZIP Code
SHIPPENSBURG PA 17257
Correspondent's e-mail address: hdavis @zullinger-davis.com
Under papalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledgp and belief,
it is true correct and complete.Declaration of eparer other than the personal representative is based on all information of which preparer has any kno edge.
SIG RE O PERSON ONSIBLE FO ILI RETURN � D E
Richard B. Miller,Jr.
ADDRESS
330 Elmont Circle, Shippensburg, PA 17257
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
Hamilton C Davis Esquire
ADDRESS
Zullinger-Davis, P.C.
P.O. Box 40, Shippensburg, PA 17257
Side 1
1505610143 1505610143 J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: MILLER, RICHARD B. SR.
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1. 100 , 0 0 0 00
2. Stocks and Bonds(Schedule B)............................................................................... 2. 4 , 769 00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......,... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5• Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 14 , 860 . 28
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 570 . 5 0
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8, Total Gross Assets(total Lines 1 through 7).......................................................... 8. 120 , 199 . 78
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 16 , 7 1 8 . 20
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 61 , 4 4 1 . 1 6
11. Total Deductions(total Lines 9 and 10).................................................................. 11, 78 , 15 9 . 3 6
12• Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 42 , 0 4 0 . 42
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. 42 , 040 . 42
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 14 , 013 . 47 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 28 , 026 . 9 5 16. 1 , 261 . 21
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE................................................................................................................... 19.
1 , 261 . 21
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Q
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 - 11 - 01203
Decedent's Complete Address:
DECEDENT'S NAME
Miller, Richard B. Sr.
601 Walnut Bottom Road
CITY --- ---- -------------- STATE zIP —i
Shippensburg i PA f 17257
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 1,261.21
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest (3) 0.0 0
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
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. (5) 1 ,261 .21
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;.................................................................................. ❑ x❑
b, retain the right to designate who shall use the property transferred or its income;.................................... ❑ ❑
c. retain a reversionary interest;or.................................................................................................................. ❑
d. receive the promise for life of either payments,benefits or care?.............................................................. ❑ ❑
2. If death 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?......... ❑ ❑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)((n)]. 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(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)1. A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether y blood or adoption.
pennsylvania j I
}� DEPARTMENT OF REVENUE I SCHEDULE A
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
BER
ESTATE OF Miller, Richard B. Sr. 21 -FILE NUM- BER
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 wilting seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which 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.
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 601 Walnut Bottom Road, Shippensburg, PA 17257 - See attached settlement sheet; Property 100,000.00
sold 11/19/13
TOTAL(Also enter on Line 1, Recapitulation) 100,000.00
REV-1603 EX+(6-98)
SCHEDULE B
CO!l.MONYMALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Miller, Richard B. Sr. 21 - 11 -01203
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 Series E Savings Bonds-See attached valuation 25.00 4,192.92
2 Series EE Savings Bonds-See attached valuation 100 576.08
TOTAL(Also enter on line 2, Recapitulation) 4,769.00
pennsylvania SCHEDULE E
�} DEPARTMENT OF REVENUE CASH,INHERITANCE TAX RETURN , BANK DEPOSITS AND MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
ESTATE OF Miller, Richard B. Sr. 21 - 11 -01203
Include the proceeds of litigation and the date the proceeds were received by the estate.All property Jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 Orrstown Bank Checking Account 1,767.78
2 1999 Chevrolet Truck 5,000.00
3 Personal Property 8,092.50
TOTAL(Also enter on Line 5, Recapitulation) 14,860.28
REV-1509 EX+(01.10)
pennsylvania
1' DEPARTMENT OF REVENUE SCHEDULE F j
INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF Miller, Richard B. Sr. I FILE NUMBER
-------- ------ ---- — I 21 - 11 -01203
If an asset was made Joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Richard B. Miller, Jr. 330 Elmont Circle Son
A Shippensburg, PA 17257
Delores J. Miller Shippensburg Health Center Wife
B Shippensburg, PA 17257
JOINTLY OWNED PROPERTY: E� �pp P
ITEM LETTER DATE Include name ffi,S R al InOstitutlon anOd bank account numbe DATE OF DEATH %OF DATE OF DEATH
NUMBER FOR JOINT MADE or similar identifying number.Attach deed for jointly-held real VALUE OF ASSET DECD'S VALUE OF
TENANT JOINT 9 ) y INTEREST DECEDENT'S INTEREST
estate.
1 A 1972 Chevrolet 1,000.00 50% 500.00
2 B Citizens National Bank, Checking Account No. 141.00 50% 70.50
6223759391
I
I I
i
i
I
I
TOTAL(Also enter on line 6, Recapitulation) i 570.50
REV-1611 EX+(10-09)
Pennsylvania i SCHEDULEH
DEPARTMENT OF REVENUE FUNl=1RAL EG I NSM AND
INHERITANCE TAX
RESIDENT DECEDENTY URN w Miw ISTR wTIVE WSTS
ESTATE OF Miller, Richard B. Sr. FILE NUMBER
_ 21 - 11 - 012_0_3__
Decedent's_debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A. 1 Fogelsanger- Bricker Funeral Home 7,704.20
2 Wagoner's Memorials 925.00
3 After-funeral meal 193.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Hamilton C. Davis, Esquire i 6,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County Register of Wills 385.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
Diversified Appraisal Service- Real Estate Appraisal Fee 350.00
See attached 660.50
TOTAL(Also enter on line 9, Recapitulation) 16,718.20
F Schedule H
COMMONWEALTH OF PENNSYLVANIA Funeral Expenses&
INHERITANCE TAX RETURN Administrative Costs c onfinued
RESIDENT DECEDENT
ESTATE OF Miller, Richard B. Sr. FILE NUMBER
21 - 11 -01203
2 Reserve for Filing Fees i` 100.00
3 Gateway Gallery Auction 372.50
4 Legal Advertising -The News Chronicle 113.00
5 Legal Advertising-Cumberland County Legal Journal 75.00
1
i
I
Page 2 of Schedule H
pennsylvania
DEPARTMENT OF REVENUE SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
LIABILITIES & LIENS .
ESTATE OF Miller, Richard B. Sr. ]FILE NUMBER
21 - 11 -01203
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
I Rowe's Auction Service-Commission - Personal Property Sale 4,357.50
2 Carlisle Regional Medical Center 1,320.00
3 Tanner Home & Energy- Fuel Oil 1,315.15
4 CFJMA- Sewer Bill 701.28
5 Penelec- Electric Bill 700.55
6 R& R Roofing -Trash 750.00
7 IESI -Trash 157.58
8 Vivian Coy, Tax Collector-2012-13 County/Township Real Estate Taxes 338.10
9 Vivian Coy, Tax Collector-2012/13 School Real Estate Taxes 1,727.18
10 Goodville Mutual Casualty Company- Homeowner's Insurance 1,021.00
11 Sollenbergers-Transfer Truck Title 52.50
12 Labor for Cleaning out house to sell 1,442.00
13 Mowing expenses 515.00
14 Vivian Coy, Tax Collector-2013 County/Township Real Estate Taxes 422.75
15 Vivian Coy, Tax Collector-2013/14 School Real Estate Taxes 1,933.36
16 Realty Transfer Tax- Paid on Sale of Real Estate 1,000.00
TOTAL(Also enter on Line 10, Recapitulation) 61,441.16
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT continued
NUMBER
BER
N --� T-
ESTATE OF Miller, Richard B. Sr. FILE- N - BER
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
17 Orrstown Bank- Mortgage Payoff 9,263.73
18 Timmons Oil - Fuel Oil 883.50
19 Tim Gruver's Plumbing -Winterize House 124.00
20 Southampton Township-Trash Service 167.62
21 Repayment of Personal Loan from Richard B. Miller, Jr. and Marilyn Miller 29,900.00
22 Orrstown Bank- Mortgage Payments 3/2012-2/2013 3,348.36
Page 2 of Schedule I
REVA 613 EX+(01.10)
Qp"L7 pennsylvania I SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF Miller, Richard B. Sr. `FILE NUMBER
Ii 21 - 11 -01203
NAME AND ADDRESS OF PERSONS RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER ^v —— ( ) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not Llst Trustee(s)
I. TAXABLE DISTRIBUTIONS[include outright spousal
distributions and transfers
under Sec.6116(a)(1.2)]
1 Richard B. Miller, Jr. Son REMAINING 14,013.47
330 Elmont Circle RESIDUE
Shippensburg, PA 17257
2 Marilyn A. Miller Daughter-in-Law REMAINING 14,013.48
330 Elmont Circle RESIDUE
Shippensburg, PA 17257
3 Delores J. Miller Wife 1/3 RESIDUE 14,013.47
Shippensburg Health Care Center
Shippensburg, PA 17257
Enter dollar amounts for distributions shown above on lines 15 through 18 on 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
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
LAST WILL AND TESTAMENT
of
RICHARD B.MILLER, SR.
I, RICHARD B. MILLER, SR., of Southampton Township, Cumberland County,
Pennsylvania, declare this to be my Last Will and Testament and revoke any Will or Codicil
previously made by me.
ITEM I: I direct that all my just debts (except as maybe barred by a Statute of Limitations)
and my fiuleral expenses (including my gravemarker and expenses of my last illness) shall be paid
from my residuary estate as soon as practicable after my decease as a part of the administration of
my estate.
ITEM U: I bequeath those articles of my household fin-niture and furnishings and those
articles of my personal effects and personal property as I have or may set forth in a separate
memorandum (which is or will be signed by me, dated and make specific reference to this Will and
memorandum, which I shall place with my Will or deposit with my attorney), to the persons therein
designated.
ITEM III: I devise and bequeath all the residue of my estate of every nature and wherever
situate as follows:
A. One-third(1/3)thereof to my wife,DELORES J. MILLER, if she survives me.
B. The residue and remainder thereof to my son, RICHARD B. MILLER, JR. and his
Wife, MARILYN A. MILLER, or the survivor of them.
ITEM VI: If any property passes outright (either under this Will or otherwise) to a minor
� 1
(which shall be defined as anyone under twenty-five (25) years of age) and with respect to which I
am authorized to appoint a guardian and have not otherwise specifically done so, I decline to
appoint a guardian but instead authorize my Executor to distribute such property to a Custodian
selected by my Executor (and my Executor may act as such Custodian) as Custodian for the minor
under the Pennsylvania Uniform Transfers to Minors Act. Provided, however, that this
appointment shall not supersede the right of any fiduciary to distribute a share where possible to the
minor or to another for the minor's benefit.
ITEM IV: I direct that all taxes that may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as
part of the expenses of the administration of my estate.
ITEM V: I appoint my son, RICHARD B. MILLER, JR., Executor of this my Last Will.
Should he fail to qualify or cease to act as Executor, I appoint my daughter-in-law, MARILYN A.
MILLER, Substitute Executor of this my Last Will.
ITEM VI: I direct that my Executor, custodian, or their successors, shall not be required to
give bond for the faithful performance of their duties in any jurisdiction.
ITEM VII: The interests of the beneficiaries hereunder shall not be subject to anticipation
� � rV\
2
or to voluntary or involuntary alienation.
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and
Testament, written on four(4) sheets of paper, dated this ily day of , 2009.
(SEAL)
RICHARD B. MILLER, SR., TESTATOR
The preceding instrument, consisting of this and three (3) other typewritten pages, each
identified by the signature or initials of the Testator, was on the day and date thereof signed,
published and declared by the Testator therein named, as and for his Last Will, in the presence of
us, who, at his request, in his presence, and in the presence of each other have subscribed our naives
as witnesses hereto.
1
residing at 1U6)6V-n-,
residing at arm �l`1
3
COMMONWEALTH OF PENNSYLVANIA
: ss.
COUNTY OF CUMBERLAND
I, RICHARD B. MILLER, SR., 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.
l ✓ � � SEAL
RICHARD B. MILLER, SR.
Sworn to or affirmed and acknowledged
before me by RICHP.D B. MILLER, SR.,the
Testator,this day of
&IJEM��2009• COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Angela M.Schaeffer,Notary Public
�l Shippensburg Boro,Cumberland County
Rotary Public My Commission Expires May 15,2011
Member,Pennsylvania Association of Notaries
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
We, r ( 1 eV and j(l7 j� /�Ot� the witnesses
whose names are signed to the att hed 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 flee 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 the
time eighteen (18) or more years of age and of sound maid and Linder no constraint or undue
irnfluence.
CLc�
O-H—
Sworn to or affirmed ands crib d to
�fore me by I P,I,C 6L Q t P l and
witnesses,this
0' day of A/n(/ ,f(1,- , 2009. COMMONWEALTH OF PENNSYLVANIA
Notarial Scat
Angela M.Schaeffer,Notary Public
Shippensburg Boro,Cumberland County
NOtary PU My Commission Expires May 15,2011
Member,Pennsylvania Association of Notaries
4
U.S.Department of Housing -Ir
A. Settlement Statement
and Urban Development OMB No.2502-0265(Page 1)
B.Type of Loan
1. J FHA 2. U FmHA 3. ❑Conv.Unins. 6.File Number 7.Loan Number 8.Mortgage Insurance Case Number
4. _;VA 5. Conv.Ins. 1 3735
C.Note: t*eramora r,,anmtaLi"yoa„themeatarlless! tdeteesteoaaAroauor,pi dto,ndbyu1settrtment.gentImsho. Ittee,-kd-(p.o.r.)^werep,id outside madesing;wey-sha..nh-1-
ororm,tioaal parposes,ad are one ieeruded ie dm I.W.
D.Name and Address of Borrower E.Name,Address,and Taxpayer identification#of Seller F.Name and Address of Lender
Jeremy C.Boothe& Estate of Richard B.Miller,Sr. N/A-CASH
Julie S.Boothe
154 Kline Road
Shippensburg,PA 17257
G.Property Location H.Settlement Agent Name,Address and Taxpayer Identification Number
601 Walnut Bottom Road,Shippensburg,PA 17257 Zullinger-Davis,Professional Corporation
Southampton Township,Cumberland County 20 E.Burd St.,Ste.6,P.O.Box 40
Tax Parcel#39-33-1883-016&39-33-1883-015 Shippensburg,PA 17257
Place of Settlement I.Settlement Date
Hamilton C.Davis,Esquire 11/19/2013
I Summary of Borrower's Transactions K.Summary of Seller's Transaction
100. Gross Amount Due From Borrower 400. Gross Amount Due To Seller
101. Contract sales price 1 100,000.00 401. Contract sales price 100,000.00
102. Personal Property 402. Personal Property
103. Settlement charges to borrower(line 1400)
1,082.00 403.
104. 404.
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. City/town taxes to 406. City/town taxes to
107. County taxes 11/19/13 to 12/31/13 44.22 407. County taxes 11/19/13 to 12/31/13 44.22
108. Assessments to 408. Assessments to
109. School Tax 11/19/13 to 06/30/14 1,073.82 409. School Tax 11/19/13 to 06/30/14 1,073.82
110. Garbage Fee 410. Garbage Fee
Ill. 411.
112. Reimburse Seller for Atty Fee(settlement sheet) 250.00 412. Reimburse Seller for Atty Fee(settlement sheet) 250.00
i
120. Gross Amount Due From Borrower I 102,450.04 420. Gross Amount Due To Seller 101,368.04
200. Amounts Paid By Or in Behalf Of Borrower 500. Reductions in Amount Due To Seller
201. Deposits or earnest money 501. Excess deposit(see instructions)
202. Principal amount of new loan(s) 502. Settlement charges to seller(line 1400) 7,057.39
203. Existing loan(s)taken subject to ' 503. Existing loan(s)taken subject to
204. 504. Payoff of first mortgage loan Orrstown Bank 9,263.73
205. 505. Payoff of second mortgage loan
206. 506.
207. 507.
208. 508.
209. 509.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. City/town taxes to 510. City/town taxes to
211. County tares to 511. County taxes to
212. Assessments to 512. Assessments to
213. School Tax to 513. School Tax to
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. Total Paid By/For Borrower 520. Total Reduction Amount Due Seller 16,321.12
300. Cash At Settlement From/To Borrower 600. Cash At Settlement To/From Seller
301. Gross Amount due from borrower(line 120) 1 102,450.04 601. Gross Amount due to seller(line 420) 1 101,368.04
302. Less amounts paid by/for borrower(line 220) ( 602. Less reductions in amt due seller(line 520) ( 16,321.12)
303. Cash l X 1 From To Borrower i $102,450.04 603 Cash EX!To
J From Seller $85,046.92
1 have carefidly reviewed the HUD-I Settlement Statement and to the best of my knowledge and beheC it is a true and curate statement of all receipts and disbursements made on my
account or by me in this trans ction,1 further certify cived a completed copy of pages I and 2 of this I Sc lement S ement-
Borrower J emy .B 1 n Se 6r Estate of .
Richard B.Miller,S
Borrower Julie S. oothe ! Seller
S TTLEMENT AGENT CERTIFICATION Seller's Taxpayer Identification Number Solicitation and Certification
The HU0.1 Sent t SirtemenI which t b •true and accurate account of this transaction 1 have You are required by law m provide the Settlement Agent named above with your correct taxpayer identifi�oon
nraW due Ponds be disbursed in accortWm wish t),u m emrne ber.r you do not pm,hde the Settlement)p�a t with yo acct t payyer identifi-on number,you may
be subject to mnl or mmuW perWda imposed by law.Und ha of perjury,1 certify that the number
my w to axpayer ideenfi alien nman
•Set ementAgcn� Date� ''-
wARxhxG:It is a aime m lmowinWmake F.I.sutemcnts m the united stag on this ar,ny o na simaa form.
Pamltin u .wnvictive on ent fine,nd imprisonment For deans sec:Tide I8 U.S.Code section 1001 and
S-6-1 0Po. Seller's Signature Date
HUD-1 3/91 RESPA,HB 4305.2
L.Settlement Charges Page
700. Total Sales/Broker's Commission based on S @ %= 0.00 Paid From Paid From
_Division of Commission(line 700)as follows: I Borrower's Seller's
1If Funds at Funds at
701. $ to Settlement Settlement
702. $ to
703. Commission paid at Settlement 0.00
704.
800. Items Payable in Connection With Loan
801. Loan Origination Fee %
802. Loan Discount
803. Appraisal Fee to
804. Credit Report to
805. Lender's Inspection Fee to
806. Mortgage Insurance Application Fee to
807. Flood certification
808.
809. _
810.
811.
900. Items Required By Lender To Be Paid In Advance
901. Interest from to @$ /day
902. Mortgage Insurance Premium for months to
903. Hazard Insurance Premium for years to
904.
905.
1000. Reserves Deposited With Lender
1001. Hazard Insurance s $ per
1002. Mortgage Insurance S@ $ per
1003. City property taxes s @ $ per
1004. County property taxes s @ per
1005. Annual assessments s @ $ per
1006. School Taxes s $ per
1007. s @ $ per '
1008. Aggregate Adjustment I
1100. Title Charges
1101. Settlement or closing fee to
1102. Abstractor title search to
1103. Title examination to
1104. Title insurance binder to
1 105. Document preparation to
1106. Notary's fees to
1107. Attorney's fees to
_ (includes above items numbers: )
1108. Title insurance to
(includes above items numbers: )
1109. Lender's coverage $
1110. Owner's coverage $
1111.
111_2.
1113.
1200. Government Recording and Transfer Charges
1201. Recording fees:Deed$ 82.00;Mortgage$ ;Releases$ 82.00 0.00
1202. City/county tax/stamps:Deed$ 1,000.00 ;Mortgage$, 1,000.00 0.00
1203. State tax/stamps:Deed$ 1,000.00 ;Mortgage$ 0.00 1,000.00
1204.
1205.
_1300. Additional Settlement Charges
1301. Required services you can shop for
1302. 2013 County/township Real Estate Taxes to: Vivian F.Coy,Tax Collector { 422.75
1303. 2013/14 School Real Estate Taxes to: Vivian F.Coy,Tax Collector 1 933 36
1304. Seller Attorney Fee(not related to title insurance)to: Hamilton C.Davis,Esquire(settlement sheet prep/disburse finds) 250.00
1305. Final Scwcr to: CFJMA 701.28
1306. Seller Attorney Fees(not related to title insurance)to:Hamilton C.Davis,Esquire 2,750.00
1307.
1308. I
1309.
1400. Total Settlement Charges(enter on lines 103,Section J and 502,Section I) 1,082.00 7,057.39
Initial Escrow Account Statement Required by Section 10(c)(1)of the Real Estate Settlement Procedures Act(RESPA)
If checked, the terms of your loan require you to have an escrow account to assure that the certain obligations relating to the mortgaged property,such as taxes,insurance
premiums and other charges are paid.The amount specified below will be collected,along with your mortgage principal and interest payments,during the first 12 months after
your account is opened to pay these anticipated expenses: FsertmAtrmmt
Beginning Date: Your escrow account payment will be S per
Payee Purpose Anticipated Due Date Estimated Amount
HUD-1 3/91 RESPA,HB 4305.2
,
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12/21/2011 Orrstown Bank Page: 1
Branch: 3 Savings Bond List Teller: 46
Serial Number Denomination Issue Date Value Interest
C20153491 EE $100 06/1982 $288.04 $238.04
C8467267EE $100 01/1982 $288.04 $238.04
Q6362834115E $25 09/1979 $109.59 $90.84
Q6362159399E $25 09/1979 $109.59 $90.84
Q6362164783E $25 10/1979 $109.59 $90.84
Q6301197366E $25 01/1979 $108.28 $89.53
Q6301198586E $25 02/1979 $108.28 $89.53
Q6389155576E $25 12/1979 $110.62 $91.87
Q6379801419E` $25 12/1979 $110.62 $91.87
Q6301199791E $25 03/1979 $108.28 $89.53
Q6333489126E $25 05/1979 $109.33 $90.58
Q26333488255E $25 03/1979 $108.28 $89.53
Q6351155293E $25 06/1979 $109.59 $90.84
Q63 5 1 1 56978E $25 07/1979 $109.59 $90.84
Q6362833259E $25 08/1979 $109.59 $90.84
QQ6379800425E $25 11/1979 $110.62 $91.87
Q63183211.486E $25 07/1977 $139.67 $120.92
Q618321.0542E $25 06/1977 $139.70 $120.95
Q6162146397E $25 05/1977 $139.40 $120.65
Q6216176651 E $25 12/1977 $128.45 $109.70
Q6191240761 E $25 1 1/1977 $128.09 $109.34
Q6216175524E $25 11/1977 $128.09 $109.34
Q6154929687E $25 10/1977 $139.67 $120.92
Q6191251.611 E $25 09/1977 $139.67 $120.92
Q6191250566E $25 08/1977 $139.67 $120.92
Q6224542745E $25 01/1978 $128.45 $109.70
Q6238199385E $25 05/1978 $106.67 $87.92
Q6162164225E $25 04/1978 $108.54 $89.79
Q6238195057E $25 03/1978 $108.54 $89.79
Q6238195167E $25 02/1978 $128.45 $109.70
Q6264514655E $25 07/1978 $106.97 $88.22
Q6255246234E $25 06/1978 $106.94 $88.19
Q6264513260E $25 06/1.978 $106.94 $88.19
Q6301203164E $25 12/1978 $108.27 $89.52
Q6301201798E $25 11/1978 $107.98 $89.23
Q6286071256E $25 10/1978 $106.97 $88.22
Q6286072548E $25 10/1978 $106.97 $88.22
Q6286075968E $25 08/1978 $106.97 $88.22
Pre-January 1990 Bonds: 38 $4769.00 $3994.00
January 1990 and Later Bonds: 0 $0.00 $0.00
---------- ----------
Total Bonds: 38 $4769.00 $3994.00
N/E = Not yet eligible for redemption
11/28/11
Received this 28th day of November, 2011, the sum of$5,000 cash from Marilyn Miller as payment
received for the sale of pick up truck of Richard Miller.
Tricia L. Bailey
Zullinger-Davis, P.C.
ROWE'S .AUC TION SERVICE (RH 79L)
2505 Ritner Highway • Carlisle, PA 17015
Bill Rowe (AU L538L) 249-1978 215-1044 574-1008 Dave Rowe (AU 2295L)
Auction Is Action Call "Rowe" For Satisfaction
SELLERS NAME
J/`t DATE �'! ?Z / i
ADDRESS 3-3U j" PHONE
OTHER 7 AUCTIONEER % �
AUCTION DATE/LOCATION CLERK oX
DESCRIPTION OF MERCHANDISE
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 ain 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 titles and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the future referred to in
this agreement.
AUCTION SIGNATURE SE SiGNAYLIRE
Total Sales (Clerking Tickets Attached) $
Less Sale Expense:
Commission Auctioneer $
% Commission Clerks $_
�v
OTHER:
TOTAL. SALE EXPENSE DEDUCTED $
SELLERS NET $ ��