HomeMy WebLinkAbout08-11-14 (2) � 15056101�5
REV-1500 EX�oz_��,�F�, .�
enns lvania OFFICIAL USE ONLY
PA Department of Revenue P,pqNrME Y County Code Year File Number
Bureau of Individual Taxes ` �pE�E��E
Po Boxzsosoi INHERITANCE TAX RETURN n j
Harrisburg,PA 1�128-o6oi RESIDENT DECEDENT G� I 3 ( ��� '
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
! ' 11/24/2013 : ' 01/17/1929 '
_ . , _. ..... ..., . . .
Decedent's Last Name Suffix DecedenYs First Name MI
__ __ __ _ _
_ _ _
Yohn ' John W '
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Su�x Spouse's First Name MI
'n/a ' ' '
__ __ __ __ _ _
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 O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
p 4.Limited Estate O 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required
death after 12-12-82)
C� 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust _ S. 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 Teiephone Number �--a
_ _ _ _ _ _ � ��
Adam R. Deluca, Esq. (717) 249-11;��-, � �"'F r�.
_ _ ��x�� ..- ,�- --�,
� �';
REGISTER��`�S SJSE Ofi1.�' t :
�J'�?�:, _ .� i
J CJ 1i rr _
FirstLineofAddress ���; -, ...� � -i'�
_ __ ,_
61 West Louther Street n� `�` `
1
{"'J�. ,^rTt
�
_. ... .. ., __ _.. . .
: � �-� L�.7 f_.,.,
Second Line of Address D ' �� `-���
__ _ _ ...... -°rt
�
City or Post Office State ZIP Code DATE FILED
'Carlisle ", PA ' '17013
CorrespondenYs e-maii address:ade►uca@keystonehearings.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F PERSON PONSIB FILING E�URN DATE
-� i
ADDRESS
329 Sherwood Dri , Carlisl PA 17 15
SIGNAT OF REPAR E TH N EP ENTATIVE �E _/ ��
O
ADDRESS
61 West Louther Street, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610105 1505610105 J
� 1505610205
REV-1500 EX(FI)
DecedenYs Social Security Number
�ecedent's Name: John W. Yohn ! '
RECAPITULATION
1. Real Estate(Schedule A). . . ..... . .... .. . .......... .. . .. .. .... .... . ... 1. ', 65,000.00
2. Stocksand 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 Personal PropeRy(Schedule E). ..... . 5. ', 8,184.08 ',
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... . ... 6. I
_ ... .. _........ .
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Biliing Requested... . . . .. 7. i ;
8. Totai Gross Assets total Lines 1 throu h 7 8. ' 73,184.08 ',
� 9 ). ......... ... ..... . .... . .... .
9. Funeral Expenses and Administrative Costs(Schedule H)... ..... ... ..... . . . 9. ', 21,693.54 !
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . ... . .... . .... 10. ! 1,202.63
11. Total Deductions(total Lines 9 and 10)... . ......... ... . .... . .. .. . ... ... 11. ',. 22,896.17 ',
12. Net Value of Estate(Line 8 minus Line 11) . . ... ....... ........ ..... ..... 12. ' 50,287.91
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. ! 50,287.91 ,
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�ineal rate X.0 45 50,287.91 �g, ' 2,262.96 '
17. Amount of Line 14 taxable '
at sibling rate X.12 17. ' '
....._.. . . _ ,r____..: ....._,... .. __ .�__._.
18. Amount of Line 14 taxable '
at collaterai rate X.15 : ��I 18. ! '
19. TAX DUE . ...... .. .. ..... ........ ..... .. . .... ... . .. ..... ..... ..... 19. 2,262.96 ',
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 15�5610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
John W. Yohn
STREETADDRESS
331 Sherwood Drive
CITY STATE ZIP
Carlisle PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,262.96
2. Credits(Payments
A.Prior Payments 0.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. I nterest
(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) 2,262.96
Make check payable to: REGISTER OF WILLS, AGENT.
:
�. .
, :. . . ,
:
,
, .. .r .,
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ �
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 properry,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 surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
. The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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-isoz ex+taz-iz)
� pennsylvania SCHEDULE A
DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
John W. Yohn 21-13-1308
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 refevant facts.
Reai 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 decedenYs interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• 331 Sherwood Drive,Carlisle,PA 17015 65,000.00
(settlement sheet attached)
TOTAL(Also enter on Line 1, Recapitulation.) $ 65,000.00
If more space is needed,use additional sheets of paper of the same size.
REV-i5o8 EX+(o8-iz)
� pennsylvania SCNEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX REfURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
JOHN W. YOHN 21-13-1308
Include the proceeds of litigation and the date the proceeds were received by the estate.
Ali property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M&T Bank 6560 Carlisle Pike,#500, Mechanicsburg, PA 17050 Classic Checking Acct#1113267 356.19 '
2. Cash on hand 100.00
3, Cash in loose change 11.15
; 4. sale of Refrigerator 150.00 ,
5, sale of Clothes Dryer 50.00
g. Refund from Shipley Oil/Energy Group 644.61
7. Refund from Bankers Life and Casualty Company 413.92
g, sale of 1994 Ford Taurus(111,956 miles)sold AS-IS in fair condition 600.00
g. County and School tax refund 441.71
10. All personal property sold at on-site auction(Fahnestock's Auction Seroices-Auctioneer ID#1909) 5,315.50
11. Refund from Erie Insurance Homeowner's policy 101.00
TOTAL(Also enter on Line 5, Recapitulation) $ 8,184.08
If more space is needed,use additional sheets of paper of the same size.
� REV-1511 EX+ (08-13)
� pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX REfURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
John W. Yohn 21-13-1308
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Hoffman-Roth Funeral Home and Crematory, Inc."Traditional Funeral Service Package" 5,502.56
B. ADMINISTRATIVE COSTS:
i. Personal Representative Commissions: 2,000.00
Name(s)of Personal Representative(s) Mary J. ChurliCk(SSN 196-48-4248)
street address 329 Sherwood Drive
City Carlisle state PA Zip 17015
Year(s)Commission Paid: 2014
4,392.00
2. Attorney fees
3. Family Exemption: (If decedent's address is not the same as ciaimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees, 313.50
5. Accountant Fees:
6. Tax Return Preparer Fees:
�� Miscellaneous Expenses 9,485.48
(SEE ATTACHED ITEMIZATION)
TOTAL(Also enter on Line 9, Recapitulation) $ 21,693.54
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
� pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
INHERITANCE TAX REfURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
John W. Yohn 21-13-1308
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• Shipley Oil/Energy Group 586.90
2. Watershed Urology, PC ' 20.00
3. Frank Roberto,Tax Collector 595.73
TOTAL(Also enter on Line 10, Recapitulation) $` 1,202.63
If more space is needed,insert additiona�sheets of the same size.
REV-1513 EX+(01-10)
-� pennsylvania SCHEDULE �
DEPARTMENT OFREVENUE
INHERITANCE TAX REfURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
JOHN W. YOHN 21-13-1308
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. Mary J.Churlick 329 Sherwood Dr.,Carlisle,PA 17015 daughter 12.5%
2. Gretchen Deel 464A Henry Cowgill Rd.,Camden-Wyoming,DE 19934 grandchild 12.5% '
3.' Judy A.Yohn 110 E.North St.,Carlisle,PA 17013 daughter 6.25%
4. John Thoman 110 E.North St.,Carlisle,PA 17013 grandchild 6.25%0
5. Terrance Thorne 222 Old Ferry Rd.,Millerstown,PA 17062 grandchiid 6.25%
6.' Denise M.Doherty 438 Fairground Ave.,Carlisle,PA 17013 grandchild 6.25%
7. Betsy J.Herron 59 Twin Church Rd.,Berwick,PA 18603 daughter 8.34%
8. Carolyn Kimsey 4565 Marie Circle N.W.,Cleveland,TN 37312 ' grandchild 8.33%
9.' Chasity Quick 322 Kramer Hill Rd., Orangeville,PA 17859 grandchild 8.33% ''
10.' Juanita G.Zeigler 119 Juniata Prkwy East, Newport, PA 17074 daughter 25%
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:
L
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
L
TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use adtlitional sheets of paper of the same size.
ATTACHMENT TO SCHEDULE H
ITEM NUMBER 7—MISCELLANEOUS EXPENSES
a. Deluxe Check-checks for Estate Account $25.20
b. Estate Advertisement in Cumberland Law lournal $75.00
c. Estate Advertisement in Patriot News $99.66
d.Auctioneer commission/fees(Fahnestock's Auction Service-Auctioneer ID# 1909) $2,059.50
e. Real Estate settlement charges (commission, deed/notary,transfer tax, septic inspection) $5,555.00
f. Real Estate settlement Septic Credit $500.00
g. PP&L Electric(electric bills for Decedent's home pending sale/transfer) $225.73
h. Erie Insurance Group (Homeowner's Insurance for Decedent's home pending sale/transfer) $53.00
i. Carlisle Petroleum Inc. (heating oil for Decedent's home pending sale/transfer) $439.90
j.Carlisle Propane Company(heating gas for Decedent's home pending sale/transfer) $67.19
k. D & D Septic Service (Toilet Rental for on-site auction) $80.30
I. Middlesex Township On-Lot Septage Pumping Permit $5.00
m. Spotlight Enterprises(private detective services to locate heir) $300.00
$9,485.48
. � ` � '�� U� � ��
J �
LAST WILL AND TESTAMENT
OF
JOHN YOHI�II
I, JOHI1 YOHN, Ct�mberland County, Pennsylvania, being of sound and
disposing mind, memory and understanding, do hereby make, publish and declare
this as and for my Last Will and Testament, hereby revoking all other wills I
and codicils heretofore made by me.
FIRST
I direct the payment of my debts and the expenses of my last
� illness and funeral froQn my estate as soon after my death as conveniently may
� . be done.
� Ftiirther, in this connection, I authorize my personal
� .
��
representative to expend funds from my estate, in such amount as my personal
representative shall consider necessary and desirable for the purchase,
erection and inscription of a suitable marker for my grave.
SECOND
I give, devise, and bequeath my entire estate, real, personal or
mixed wherever situate, I give, devise and bequeath unto my beloved wife, N�RY
YOHI�t, should she survive me by a period of thi.rty (30) days. Should my wife
predecease me or fail to survive me by thirty (30) days, then I give, devise
and bequeath all the rest, residue and remainder of my estate, to my children
as follows:
A. One fourth (1/4) to be divided equally among my daughter
Judy Meyers and such of her children as survive me.
L
B. One fourth (1/4) to be divided equally among ray daughter
Betsy Roush and such of her children as survive me.
C. One fourth (1/4) to be divided equally among my daughter
Mazy Jo Churlick and such of her children as su=vive me.
= D. One fourth (1/4) to be divided equally ampng my daughter
, z.:,,..,_�_
Juanita Cauffinan and such of her children as survive me.
THIRD
I naminate, constitute and appoint my wife, N�,RY YOHN, as
Executrix of this my Last Will and Testament. Should my wife predecease me,
fail to qualify or cease to act as E�ecutor, I appoint and MARY JO CHURLICK as
Executrix of this my Last Will and Testament. I relieve my personal
,� representative fram the necessity of posting security in connection with her
�,`�.
1� �` '` duties as such in any jurisdiction in which she may be called upon to act
, ��
�., "`� i.nsofar as I am able by law to do so. I direct my Executr� to make available
,
`-� for possession any and all property that a child may have stored at my home as
soon after my death as possible.
F'OURZ�i
In addition to the powers conferred by law, I authorize my
E�ecutrix in her absolute discretion:
A. To retain i.n the fonn received, and to sell either at public
or private sale any real or personal property.
B. To manage real estate.
C. To invest and reinvest in all forms of property without being
confined to legal investments, and without regard to the pri.ncipal of
diversification.
D. To exercise any option or rights arising from awnership of
investments.
- E. To compromise claims without court approval, and without the
a -_
consent of any beneficiary.
� ' IN WITNESS WFIEREOF, I have hereunto set my hand and seal to this,
,:
my Last Will and Testament, consisting of three (3) typewritten pages, the
first two (2) pages which bear my signature in the margin for the purpose oi
identification, this the ` � day of �c��-���_ , 1990.
.�
f, I � �5���
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Signed, sealed, published and declared by the above named testator
JOHIJ YOHN, as and for his Last Will and Testament, in the presence of us, who,
at his request, in his sight and presence, and in the sight and presence of
each other, have hereunto subscribed our names as witnesses.
�� J / /� �
�iU? ' �� ✓� ADDRESS �.�''�f�.��/.'/��—� ..r.�`.T�1�c. /�`i/.-�� �--�i1�7
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��L ���.� �D�SS �3� �oc�C.�c-� �Q,�-� Cy��l sl� �
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OCIi`M�R7iNWEALTH OF PENNSYLUANIA:
COLTNr!'Y OF CUMBERLAND
� / � �� J .
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We, JOHI�1 YOHN, �L : and '�--�"
� �' ���`��`r' , the testator and the witnesses, respectively, whose
names are signed to the attached or foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the testator signed
and e�cecuted the instrument of his Last Will, and that he signed willingly and
that he executed as his free and voluntary act for the puzposes therein
expressed, and that each of the witnesses, in the presence and hearing of the
testator, signed the Will as witnesses, and that to the best of their
knawledge, the testator was at the time eighteen (18) years of age or older,
of sound mind and under no constraint or undue influence.
S�vorn to and subscribed bef,�ore me
f� '
this � �� day of ( �,����--�,;-'�"�'..,�
�� '
1990.
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2014-Ob-30 15:59 mary churlick 7177666934 » 7172494514 P 10/11
' A. Seftleinent Statement U.S.DepaAment of Housing a�d Urban Developmanl
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D.NAME OF BORROWER: Clifford A.Karlsen -
_ADDRE55 809 Genevieve Drive.Mechanitsburg,PA 17055
E.NAME OF SELI.ER: Estate of John W.Yohn
ADDRESS
F.NAME OF LENDER: � -"
ADDRESS:
G.PROPERTY ADDRESS: 331 Shanvood Drive,Carlisle,PA 17013 �
Middlesez Townshi
H.SETTLEMENT AGENT: The Law Office of Andrew H.Shaw,PC,Telephone;�17•243-7135
PtACE OF SE7TLEMENT: 200 5,S fin Garden Stree Suite 11 Carlisle PA 17013
I.SE7TLEMENT DATE: 0 610 612 01 4
J.SUMMARY OF BORROWER'S TRANSACTION: K.SUMMARY OF SELLER'S TRANSAC710N:
100.GROSS AMOUNT DUE FROM BORROWER 400.GROSS AMOUNT DUE TO SELLER
t01. Contract sales rice._� �, 65 000.00 401. Conuad sales rice 65,000,00
102. Personal ro e 402. Personal ro e
103. SeltlemeN cha es to 6ortower line 1400 1 549.50 403.
104._. __ . ..._ __
. ..- - �--...... __._.. . ._..__. 404.
105. ___- . 405. ._, .
Ad'ustments tor Rems aid b saller in advance Ad'uatments for items Paid b Seller in advance
106. Cil/town tazes , 406. Ci Rown laxes
t0�. Coun ta�ces 06106114to12131N4 348.07 407. Count taxes 06106114to12131/14 348.07
108. Scnool taxes 06106114to 0613D114 _ _ 93.64 40&. Schooi taxes 06106114 fo 06130114 93.64
109. � 409.
110. 410. �--....._.__
111,. . 411.
112. 412, --...
120.GROSS AMOUNT DUE FROM BORROWER 66 991.21 420.GROSS AMOUNT DUE TO SELLER 65 441.71
200.AMOUN7S PAID 8Y OR ON BEHALF OF BORROWER 500.REDUCTIONS IN AMOUNT DUE TO SELLER
201. Da osit or eamest mone __ 1 000.00 501. Ercess De s�t see insVucGons
202. Princi al amount of new loans 502. Sel�emeni char es to seller fine t400 8 455.00
203. Exis6n loan s taken sub"ect l0 503. Existin loan s taken sub�ect to
�� _._ 504. Pa off oF First MoRgaqe Loan
205. __. 505.
206. - _. 506.
207;_Credit•Seplic Inspec0on _ 500.00 507, Credi�-Se tic Ins action 500.00
208. ,_. _ . 508.
209. . 509. �- .
Adjustments for items un aid b selier ., Ad'ustments for items un aid b seller
210. Cityltown taxes .. _ 510. Ci Nown lazes
2t7. Count tazes 511. Coun taxes
212. School taxeS 512, School tazes
2i3. 513. -- .
214. 514.
215. 515.
2i6. _ _ 516.
217. _ 517.
218. 518.
219. 519.
210.T07AL PAID BYIFOR BORROWER 1,500.00 520.TOTAL REDUCTION AMOUNT DUE SELLER 8 955.00
300.CASH AT SETTLEMENT FROM OR TO 80RROWER 600.CASH AT SETTLEMENT TO OR FROM SELLER
301. Gross amount due from bortower(Iine 120 . 66,991,21 601. Gross amounl due to seller line 420 65 441.71
302 �ess amounts paid bWfor borrower(line 220 1 500.00 602. Less reduction amount due seller(line 520) B 955.00
303.CAS4 FROM BOnRON'ER 65 491.21 603.CASH TG SELLER I 56 486.71
SUd57ffU7E FORM t079 SELLER STATEMtNT:Tlie in(oimai�n�wnlalne�l hncn¢importsnl ts.inf aUOn enG ia heingfumis�9U lo Na Inkrcul RBVenue St�vice R you 9re requuea to Ille e relurn,
a nepligbnm pa�alry o�ol�tf hsnetqn�nll Da Impo89E on rou tt fllle llem iy iequireU 10 OB repuncd anC tIN IRS A91em�j�py p�Bl��bs nW bsen taportBC.T11e ConV9R 581e5 Pn�p Qg5vip6C on
�ne�Oi BUave�ronsGWb;1�9 GrvB9 Proceed of NI51leneacGOn
Voy�r9 rpqulr2J Ey Inw Io OfOhCS Nz selllnment agbnt(Fxa.7ax ID No:2615dC665)vnGl you/calrecl t.�payer IOBnG/f�6on�I,�tllper.tt you Co rq10lOVWa youl tonoq tN�Deye!i0mldiqpon
numter,yeu may Ce euDjad m dvil or enminai pniwlnez�mO�aC Oy Isw.UnGOr Deneltiea of perjury,I c6N(y Owl Ihe numDerEOOxnt a�wq:telementle mY��G iexDayer fdandfiwYOn mwnEer
'fIN: ___ /_ _- 6ELlER(S�SIGNa7URE(5): �
SELLFH($)NEW MAILING RUORE55' � '-
SELLER(S)Ph10NF NUMBERS. (M� _� � � �
.2014-06-30,.1,5.�59_, „__ ,.. .,mary„churli,ck 7177666934 » 7172494514 P 11/11.
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SE�LEMENTSTATEMENT , 7itl�ExressSettlemenlSstemPdntedo610612014at08:21AHS
L. SETTLEMENT CNARGES PnID FROM PAID FROM
700.TOTAL SALES/BROKER'S COMMISSION based on price S6S OOO OO=3 900 00 _. BORROWER'S SELLER'S
Division of crommission fline 700a as follows: FUNDS AT FUNDS AT
707. $ 1,95�.�� l0 BHHS Homesale Realty � SEITLEMEN7 SETTLEMENT
702. 1 950.00 Io Wolfe 8 Com an Realtars
703. Commission aid at Setuemem _ 3 900.00
704. Broker Fee to BFiHS Homesale Realtv 695.OD
500.ITEMS PAYABLE IN CONNECTION WITH LOAN "-
BOt. Loan Ori inalion Fee %
802. Loan Discount % �
A03. A raisal Fse �y ^ -
804. CredilRe ort � '-
BO5. Tax gervics � -'-`
806. Flood Certificatipn `
so�. �
aoe. `.
eos,._ _.. _. - __
s,o. -�._ . _.
e�,. _`�_ --- _. .._
900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE �
901. Intzresl From to p$ Idav
902. Mort a e Insurance Przmium for months to �
903. Nazard Insurance Premium for years to
904.
905. '
1000.RESERVES OEPOSITED WITH LENDER FOR ��
1001.Hazard Insurence . 2 mo.C�$ . !mo
1002.Mortaage Insurance ^, 2 ma.na$ /mo
1003.Cil Pro erty Tax 2 mo.@ S /mo .�
_1004.Counry PropertY Tax _, 2 mo,(a S_. Im�
1005,School laxes _ 2 mo.a(1.$ Imo
1009.Aqqreaate Analysis Adiustm2nl 0.00 0.00
1100.TITLE CHARGES -
1101,Seltlement or Closina Fee
1102.Absl2cl or TiUe Search
1103.TiNe Examination r " '
1104.7itle Insurance 8inder -
1105.Oocument Preparation to 7he Law Office of Andrew H.Shaw,PC 100.00
1106.Nofa Feas Io Andrew Shaw � 25.00 10.00
1107.Attomey's fees
(includes above items No � -
1i08.rtie Insurance m AHSWLTIC 707,50
inGudes above items No: � 1
1109.Lendars Policv --
1110.Owner's Polic 65.000.00 •107.50
1111.Dead Preo Fee �o The Law Office of Andrew M.Shaw,PC 100.00
1112. �
1113.
1200.GOVERNMENT RECORDING AND TRANSFER CHARGES
1201.Recordin Fess Deed$67.00 ;Mart a e$ ;Release S 67.00
t202.Cit/Count ta�stam s Oeed$650.00 ;Mortaaqe$ 650.00
1203.State Taxlstamps Deed 650.00 ;Mort a e 650.00
7204.UPI Fee . Deed$ :Mortgaqe$
1 05.Deed$ ;Mortaaae S Releasa$
1300.ADDITIONAL SEttLEMENT CHqRGES
1307.Surve .
1302.Se tic Inspection and PumO to SundaY's Septic Service P.O.C. 660.00 Bu er 200.00
t303.Escrow fpr Initeritance Tax to The Law Office of qndrew H.Shaw PC 2,900.00
�400.TOTAL SEITLEMENT CHARGES enter on lines 103,Secfion J and 502,Section K _ 1 549.50 8 455.00
MUD CERTFICATION OF NUYER ANO SELLER
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WAftNING.IT�IS A CP.iME TO NNUWiNG�v MnkE F��se srn7FMeNrs ro THe me nuo-i Sa�uement smiemant nave pre rea is w a e raie ewo�,n10l ws
11NITED STATES ON THIS Oli nNY SIMII,qN FORM.PENq�I'IES UPON CONVIC710N IranSiGloll.I htvc qyeBO Of will �Vy f�nds
CAN INCWDE A F�ryE FND IAAPR160NMENT.FOF DETAILS SFE TITLE iB. �B 0 �✓�Il B fQ9�1rq W�N Ulla dlbieTanl
�.S.CO�E SECTON 10p�qN0 SECTION ip10_ / /
SE7lLEMEN7AGErvTf ��✓'� - •4�•f-� �L
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