Loading...
HomeMy WebLinkAbout09-09-14 1505610105 REV-1500 Ex(a2-,)(Fns OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes """`" County Code Year File Number PO BOX 28o6o1 INHERITANCE TAX RETURN / /� f V l � Harrisburg PA 19128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 04/09/2012 10/31/1919 Decedent's Last Name Suffix Decedent's First Name MI Whisler Vera L (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 p 1.Original Return GOD 2.Supplemental Return O 3. Remainder Return(Dale 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 t= 7. Decedent Maintained a Living Trust B. 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 TO: Name Daytime Telephone Number Andrew C. Sheely, Esquire 717-697-7050 REGISTER OF WILLS USE ONLY _6 C First Line of Address __0 M rrJ 127 South Market Street S r— xn r f .. . Second Line of Address rri C.0 .4 Ca P.O. Box 95 C� c 0 0 City or Post Office State ZIP Code bATIE FIL Mechanicsburg PA 17055 y O r- rrrf Correspondent's e-mail address:andrewc.sheely @verizon.net Under penalties of perjury,1 declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,Ncorrect and complete.Declaration of preparer other than the personal representative is based on all information of which prepamr has any knowledge. Sv 2E OF P RSON R S LE FAR FII� � PE ATE ADDRESS Edward J. hisler, Executor, 887 King Street, Lewisberry, PA 17339 SIGNAT,yRE OF�PREPr!R OU I � EPRESENTATiVE r I _?ATE2 u, ADDRESS Andrew C. Sheely, Esquire, 12 outh Market Street, P.O. Box 95, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 �a V I 1505610205 REV-1500 EX(Fl) RECAPITULATION .„_._._..._.__...._...,..__._._„_.,.,__.._..___.__._....___.,......., : 1 1. Real Estate(Schedule A). ..___.... - m .._ „¢. -m, P -...$72,000.00 .-.. `00 ............................... t ! 72,000. 2. Stocks and Bonds(Schedule B) .. . .. . . .. . .... . ... . . . . . .. . . . .... . ... . .. 2, , 3. -Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .,.._ 3. r E 4. Mortgages and Notes Receivable(Schedule D) .. . . . . . .. . . .. .... . .... 4 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)..... .. 5. $86,053.08 I 6. Jointly Owned Property(Schedule F) O Separate Billing Requested , , . . ... 6, $71,459.47 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property , ,._..__._.._.___.-.. ._.__.. .____, i .(Schedule G) CM Separate Billing Requested........ 7. $20,388.90 8. Total Gross Assets(total Lines 1 through 7).. . . .... . ... . . .. . .... . . ... . .. 8. $249,901.45 9. Funeral Expenses and Administrative Costs(Schedule H)............. ...... 9. $15,211.30 1 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). ... . . ... ... . .. 10. $10,182.45 I v 11. Total Deductions(total lines 9 and 10 $25,393.75................ ................. 11. ' .._.._-..w..W._.........-.__.......n........._._.,.,............_.._-....1 12. Net Value of Estate(Line 8 minus Line 11) .... . .... .... ... . . .......... .. 12, i 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. $224,507.70 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 .......... _..,.. .. ......... ........ .. i ....__ _ ... _ ........... .. ,.._. .. ..___.. _.... (a)(1,2)X.0__ 16. Amount of Line 14 taxable - -�.W.v...... . wm..W.,...._. ,W..„_...� _,-....,.„... , ..�,.»,.,,_..,,e...,....._.._,_..._..,...,..- _,.__.._ at lineal rate X.0 45 $224,507.70 16.; � $10,102.84 17. Amount of line 14 taxable at sibling rate X A2 17. 18. Amount of Line 14 taxable - at collateral rate X .15 18 19. TAX DUE ... . . . .......... ............... . .. .. .... .... ......mm...... 19. ,,.,�,-._..._.._..,.,...,....-,......-...,..,..,,�...$10._.-..._--...... 102.84 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1505610205 J I REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Vera L. Whisler STREET ADDRESS 13 East Main Street CITY STATE ZIP Shiremanstown PA 17011 Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) $10,102.84 2. Credits/Payments A.Prior Payments --1----.----------12,501.1 6 B,Discount Total Credits(A+8 (2) $12,501.16 3. Interest 4. If Line 2 is greater than Line I+Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) $2,398.32 5, If Line I +Lne 3 is greater than Line 2,enter the difference.This is the TAX OLIE. (5) 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..........-.................-..................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income ......--............---............. ❑ 0 o. retain a reversionary interest .....—....................................... ......................................................................... ❑ E d. receive the promise for life of either payments,benefits or care?...........--....................................--............. ❑ ■ 2, If death occurred after Dec.12.1982,did decedent transfer property wirthin one year of death without receiving adequate consideration?................................................ ..................................-...........-- ❑ 0 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?......... ❑ N 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a 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 172 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in V2 P.S.§9116(a)(1)j- • 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+ (11-08) pennsytvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Vera L. Whisler 21-12-0502 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 t Decedent's real estate located at 13 East Main Street,Shiremanstown.PA 17011 $72,000.00 Tax Parcel No.37.23-0555-082A. See attached settlement sheet. TOTAL(Also enter on Line 1, Recapitulation.) $ $72,000.00 If more space is needed, insert additional sheets of the same size. OM8 Approval No,2502.0265 II- A. Settlement Statement (HUD-1) 1,©FHA 2.Q RHS 3.Q Conv.Unins. o Pilo Number 17.Loan N=bm*ber: 8.Mortgage Insurance Case Number: 14269 30037564 446-2i43883-703 4,0 VA 6,E]Cow Ins. G.Nom:Iris farm is frxnished W give you a Statement of actual aadle"m=M Amounts paid to and by the Settlement egents are sixiwr.items marked 'fp.o,ej wee and outside the Uastng;they are Shawn here for informational purpoxez and are not included in the totals D.Name&Address of Borrower: E.Name&Address of Seller: F.Name&Address of tender: Peter M.Gcda,Jr. Estate Ovens L ViNslar Manurial Mortgage Company,Inn 828 BCds"gd Court Mechiavabu:c,PA 1705) 887 Wag Steel,Cesisbery,PA 17334 1045EIm Street,Suite 601.Merohaster,k8 03`01 G.Property Location: H.Settlement Agent t.Settlement Date:08x14(2014 13 East Main Street Is!Advantage Settlement 5err„es r18. Disbursement Date:08x1472)14 Shiremanstown,PA 17015 6375 Mercury Dive,StiVe 102,Mechanicsburg,PA 17050 Shiremanstown Borough 717,591-7755 Place of SettlemarlC by VW press alb tdarcvry D(nre,Suite 102,Mw.hard�burg,PA 17055 Printed 0&13t2014 at 4:4T pm by VW , 100. Gross Amount Due from 8omwar 400. Gross unt Amo Dueto S0 101, Can`SaC.solos price _ 72,0000 4M. COnRecfa2iapnce 72,006,00 102, Personal property 402. Perstmal 2rMtq 1013. $dI emsal charges to brnrnanir(lice 1400) 5226.76 d03, 10». 40C 105. 405, Adjustments for items Paid by aster in advance Adushnerds for paid b Seiler in advance 106, CIty.4cvmtnxes to 406, Gtyfloxnumal to IV, Counybusis Cr8?74t2014to123112014 193.,-5 407. Co rvtaxas 0&114{2014ta12131r20t4 193.55 105. School Taxes C;?74t2014mn13 .015 1,28324 408, Schaal Taxes 0871472014 to 06,30120115 1283.24 109, 3M Q11 Saver 08l1412014wO9rWO14 35.52 b0&, 3rd Qtr Sewn W14010009430014 38.52 110. 3rd Qtr.Trash C611U23141a 09/3012014 21.93 410. 3rd0fr.Trash 08/1412014to09,902014 21A7 tit- 4t?. 2. 412, 120. Gross Amount Due from Borower 78,762.04 426, Gross Amount Due to Seller 73,536,28 200. Amounts Paid b or in Behalf of Borrower 500. Reductions In Amount Due to Seller 201. DeposftOCeatnestmoray ZSCUO Sn. Excess deiausk iseoinsinrCum 202. Paflcids arraantof rea,I an(a; 7,0,695.CYJ 502. SelitenNm di rps to se6erlime 140 6,596A5 203, Eusfin logs)taken subject l0 503. Exlstl loads taken sub ea to 204, Apia„cation Credit 460.0q 504. PayoO of firm mortgage iaan 205. 505. Paydi o'seOCOd margageloan 2�. j509.�, Seller Assist 4,323.00 Seller Ass:s 4,320.00 tut usorrents[pr hetus un saber Ad'stmerds for lE&a0 un I'd Wier 210. 'Linp1own taxes to 510. Cuy,4srem taxes to 211, County Was to 5N. Ccuntytaxes to 212. Schaal Taxes 10 511 Schod 7axa to 213. 5;y 214, 514. 216, 515, 216, 516. 217, 517, 218, 518. 219, 819, 220,Total Pald WforSorralver 1 77,475,00 520. Total Reduction Amount Due Seiier l0,9!&O6 300" Cash at SeR @mentiromlto Ratan 600. Cash at Sa6knotttttolfram saw 301, Gross amount 8le front rox=ar{pne 120) 78-,7,;T 0-4 601. Gras artm�mtdue to se8erymo 420) 73,5?5-2A 302, Less arrounq paid byr*pr bo^pker(line 226) 77,475.00 &72 Lasredugia,7s in amount due seller(line 529f , i0,4l6.0S 361 Cash [X From ❑ To Borrower 787.04 603. Cash Q% To [� From Seiler 62:61913 aMM:hMwnMC#;mAYTS4ww'Pf M4 CYS aa:M masOV.4+m,r4u4s°Y iW¢':NSdzk¢mAC¢Yywrxi,nahvu'°i^�hvAr<t'FtYS"iesg.RFMANUN}tixx9arvl M'mmQ3Ttr9 M: Previous editions are obsolete HUD-1 700. Total Real Estate Broker Pees $4,380,80 Paid From Paid From Drvxian of ccnsmissiaa rm700 as farms: Borrower's Seller's 707. $23x0.40 to i 8anser HOmotaad a%?sm(a Funds at Funds at 7C . S2.Q30.40 10 RaTdax istFdvantaga Settlement Settlement 703. Commission paid at mo lemeni 704. Commission to Re,NaxVAdvmdage 395,00 500. items pavaldle in Comedian W b Loan 801. Ouo oirstimcharga (IrlcWdes Gdginatbn?aint0.000. a5C.00} $1,590,64 (fmm GFE#1) Sat. Youraaiit w Marge(W;rRS,V00 speriflo interest roe chosen 5-1,500.15 (from GFE#2) Yajr adjvsted origination chages (from GFE A) 90.49 604_ Ap;xa*4,!ee IsThe LerderxTeam prom GFE" 455. Pas. Credit-ow b U M n(Yasei Credit Servixs icc. (from GFE#3j 34.03 806. Tax service to from GFE 93 807. Flood renification to Cores is-food&ngaes (from GFE 93) 19.55 808. Finalctspocum to The Lerdarx Team ;!from GFE S3; 900. Hems Required by Lender to be Paid In Advance g01, Daily interest charges from m, 06314120141009*1, 014 @582Maitq "GFE#10) 148.17 902. Montage Ins.Premium for months to Federal Housing Author -FHA (from GFE h3) 1,215.90 903. Homeowners insurance fat ears taHomesde lnsuranceC 5994,00 P.O.CiB (from FE Ati) 9(,4, mass to Pram GFE57}7 1000.Resenres Pgpoaited with Lender i?Ct.trait depcs;;fo,youremwaaount UWGFE#9) 7339.25 02.Hom- mees:msurance 2 mrgMa S 62.811mcn1h $165.66 to Merrimack MM20 Gommen 1 't Mortgage insurance momma 0$ 77.F,6tammh $ toMetrr�mOrt 1(,614.City P•oparty Ta mon'hs 0$ 0,0month $ to 1005.County Propane Tax 8momhs $ 42176'mmrtr $336,40 to Merrimack Momage Cpm X6.ScnW Taxes 2 mantis R S 121.5itmmdh $243.02 to Merrimack Mortgage Corn 1007 A.WNe.Adyashnent $-15.83 !oA ry kM e 1100.1i6e Cho es 4101. Tipe ser!icas and iandets We insurara rom GFE 94) 1A57.S0 1102.Sediernentodasingfee, to $ 110-1 NTxYS title Insurance-PvAmencan Title lirsuaice Carparg 'a from GFE 550 1104.Lmdors.`ac Insurance,Rre.Amedcan-die insurance Company 5955.50 105. LorMers titre pal cy limit$70,695.00 Lenders Poky 1166.Owners ti0e policy sir t 872,000.05 Owners Policy 11077.Agan's permm of ihefoW Otte f; anceprnnkan $76159 to 1sftA6xMmaqe Serfamarl services Inc. 1108.Umderwdtors portion Mahe total no insurance premium $209,41 10 F ins l AT&".Vn T I W 1asurance Can par 1109, 7110.Tax Gems&cxNa,Pee fiis?Advantage Seitlzment - t 5 411 Smites Inc. 1200.Government Recording and Transfer Viarges 1201.Govemmem recanting charges $ (from GFE 9r) 2095x0 1202.peed b79.30 Me e$95.00 Pei-- ,o GnmbadarW C<iumitRecorcer 1203 Transfer taxer $ (nor GFE AS) 720.047 1204.Cityffamty t3c'stamps Deed$720.00 Mat aoe5 to CUmbedand Count Reoxder 1208.State Taximampe peed$720,00 mnam,s 724.60 1206. DedS aoe$ !a 1207.Reard Maintenace Agreertxmt 532.00 to Cumberland Couniq 1300.Addittonal$etdemedt Chargaoi 1301.Required Sw4ces trztmu can slmp for t7;mn GFE#6) 1362•Suaev to $ 363. to 1394.0310.'15 SOhcol Tax to Beill A,Mori han 1,458.1 1363.sc QbNO(LCM79) taAdvanced Dismal 4211 NEW r 5,226.76 6,596.05 `Pa(d outside of Closing by(S)our r,(S)eiler,(L)ender,(Qnvastmr,BM(K)er.^Credit by lender i mwn an Page 1,""Cretlit by seller Shown en page 1. Previous editions are ObS0lete HUCS^i r Cam arisen of Good Faith Estimate iGFEI and HU0.1 Charges __good Faith Estimate Cha es That Cannot Incmasa HU0.t Line Humber purr Onginatiel Cha'9e : 307 64 1 Ywrtz 5orchzega(po'mis',for tpe spedficlntcs25t rate Posen.- 5802' -UMA5 -1'ro ti YWrad�t.'ced WitJinaC-0.i charges # 803 9049 ,- 90,49 Trans'er nixes i203 779,40 7e7.00 EOS es That in totatCanhe�fnm!m Akm Than tB% Good Fab Estimate HU0.t ment fec"ming dog #4231 5 3.50 206.00 sa rag #804 487.00 455.00 rapM ...., # 805 70.00 ;!4.OG ert7!igfieo § 607 1900 19.95 speaian # tA73 t00.00 1Q7.{; ge Ins,OW.W m # 902 1,218.90 1,215.90 rvices and lenders title Insurance # 1101 1,054,50 1,0:7.50 title insurance-First Amenean Title Insurance Compaq a 7703 20,00 5.5c 3 3AZ3 p 03.,1193G328% Cher e;That Can Chance Good Faith Estimate HU0.1 Initial dePPSit fqi yeurasprrnaaxawt #3001 1,537.15 ?33.25 Daily lnmaencrames from -- g 503 $fi231E«k1a 20G.30 148.'7 Hamernmers insu�ana $903 ,493.98 9^J4,00 5 i Loan Terms Your!nifial loan amount is 370,89500 Yom pmn Mrs'Is 3G,years Yen€rilbai irhst rate is 42500% You';mi5ial monthly mount mod formindpaL!ntarest,and any mortgage $425.34 includes insurance is ®Rrinppa! Q interest Q Fdortgage Insurance Cwt your interest raterse? Quo. rYes,itcanriset4amadmumof °,S. The Hstchangn wily be on ' artdran change again every yeissfor ? r , ea y chengedate,yourtntersst rite gnincroase orderreasc by %. Over the life of the loan,your interest rate is guaranteed to never be low than %cif higher than Even<"YOU make payments on 5mo,can yourloah became rise? Qtde. QYes,it can dse t7amaximumd3 Even H you makepayments on Gm&an you Mainly anKKnt owed for ONO, Q Yes the find increase can be on 1 I and the monthly prncipal,inraasL and mortgge nsur eice naP amount owed an rise to$ The maximum it can everrrse to is$ Does your ban have a prepaymentpsnafty7 Q No. Q Yes,ywrmaximam prepayment penalty is$ Dues your loan ha`m a balloon payment? QX Mo. Q Yes,you have a ballocn paymast a$ Cue in years on r Total mxdhly amnuntOwed incuam esci account payments ❑You do not haven mommy esex.payment is,'rental,such as puts" xea and hommuchWs insurance, You Imetpaytheseitens dimcdymirsdr. 0 You have an additional M=tly asarrw payment of$246,39 tRatresulm in a fetal;ild..W motthly amwrn'a zd of§871.73.Tris irietuare principal,ictans;any mortgage ibr a m and any dears checked bscw,, Q Property laces Q Hemememei s insurance Flood tnsurancer p School Tax O Noce; If you have any questions about the Settlement Charges and loan Terms listed on this form,please contact your lender. Prevbus MlSOns are obsolete HuD-z HUD CERTIFICATION OF BUYER AND SELLER I have carefa!ly reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement Vail receipts and disbursements made on my amount or by me in this transaction.1 further certify that I have received a copy Vine HUD-/Settlement Statement. Peter M.Geda,jr, ESTATE OF VERA L.WHIELER The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction.I have caused orwill cause the funds to be disbursed in zmerdance.1h tMS statement 4�Ll41' iii SETTLEMENT AGENT DATE WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT,FOR DETAILS SEE TITLE IS:U.S.CODE SECTION 1001 AND SECTION 10% fimvlous edltlods are obsolete HUD-1 1 i ! apt Seller; rile NSrbar { Peter 6d.Goda,Jr. Estate of Vera L.Whisfer 14259 I 3 TiftEapress Prepared 0771772014 at 12:30 pm i Note: This page is furnished to give you an itemization of the amounts shown on paid From Paid From Lines 1101, 1103 and 1104 of the Settlement Statement(HUD-1).This page ' Borrower's Sellers accompanies but is not a part of the settlement statement.if a discrepancy ! Funds at Funds at exists,the information shown on the Settlement Statement(HUD-1)applies. S Settlement Settlement !. 11100. Title Charges knee;*Included InUflollol 11Q1. Tne servim and lenders title Insurance _ 1,697.50 a'Alm!nFee b.E.mafltDoc Copy Fee 50.00 —__- 1 � a.^,vem 9Jlvery Fee-Pade��p,; _ _ _ PSAO d Notary Fee 45.60 S 122.60 _ ;1162. Seidemerl a'desin�P fee ': i 1165. OmesMleirsurancc —Ant cyr 7 5.50 1104. iw^ntler<.,li0e insurance (policy) 740.50 S 969.50 _ a. Endersemeif 90 EPL-Residential _ W.00 b_Emtoraament106(NO Uofafrxp � 50_410 c.Enaoteootrcnl 30 Survey 510 d.C,csia Servi:a,e0u ��T.' 75.00 ..... .—_ _ (Tota11103 1164) x. st71 nn vry W 1165. Lendafs I'll'_PcBic;litrul570;698.Op - t'0 Ormer'S lde cy Gant$72,000130 1'07. .4 enrsIcn of;he total6He`nsura^,ce prermum $ 76159 1108. Undensrder Po4anof lha totai'.Hiemsuranoe Prem 209.41 , (Tonn 1167.1168) 41109. t Tout .Borrower' Borrower _ Seiler Jim Idle Charges wide aayea CAarpc -FOC ar C' t Lane 1101 Paid 1101. Tifie mires end leldoes bile insurance $ i ---i a.VOT In Fee to tst Advanta SeOiement Services mC 12.00 1200. + .�__. In.ErrWoc Copy Ferro lst A.dvamaie Setiiemer semces Inc. 50.0! -- --'� _ 4vwnlBl?ttsety Fee-PkatclstAdvattSeHkvneat_Savtcestm. 25.k! . 2503 w _y d. 46.0 45100 L(f04. Lorde!s Htte lnsurznce to 1st Advarrtage Setdement SeNlm Inc. 965,50 055.s0 I S 1.097.50 '1,19750 1 r REV-1512 EX+ (12-08) pennsylvania SCHEDULE I __ DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Vera L. Whisler 21-12-0502 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 71East DESCRIPTION OF DEATH 1. $3,586.40 2. Main Street,Shiremanstown, PA 17011. See attached settlement $6,596.05 TOTAL(Also enter on Line 10, Recapitulation) $ 10,182.45 If more space is needed, insert additional sheets of the same size.