HomeMy WebLinkAbout05-11-15 1505610143
REV-1500 EX(02-11) IR OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes MEPARTMENT OF REV&=
PO 60X.280601 INHERITANCE TAX RETURN 21 14 0821
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
08 15 2014 01 19 1920
Decedent's Last Name Suffix Decedent's First Name MI
BLOSSER SR. ROSS C
(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
1, Original Return 2, Supplemental Return 3, Remainder Return(Date of Death
Prior to 12-13-82)
(date of death after 12-12-82)
4. Limited Estate El 4a.Future Interest Compromise 5. Federal Estate Tax Return Required
6. Decedent Died Testate pk
(Attach Copy of Will) El 7. teed &M
tag aionjVneda Living Trust
py rust 8. Total Number of Safe Deposit Boxes
F� 9. Litigation Proceeds Received E] 10,gaseani P?ver 11 Election to tax under Sec.9113(A)
8 31- and -1-95) (Attach Schedule 0)
Vredit4ate of Death
I - F
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL L BANGS 717 730 7310
1-1 71 rTj
REGISTER OF WILLS USE
First Line of Address TA
� I'T1
7,J
429 SOUTH 18TH STREET A C:)
7r, -ri
Second Line of Address
rTj
DATE FILED jrI > 01
City or Post Office State ZIP Code
CAMP HILL PA 17011
Correspondent's e-mail address: M ikebangsgverizon.net
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 ERSON RE,-qPONSIBLE FOR FILING RETURN DATE
J Terry L. Blosser 4-- X<�
7ss
65 Bunker Lane,Etters,PA 17319
SIG TURE OF PREPARER,OTHER=TSENTATIVE
DATE
Michael L. Bangs 2 -11
ADDRESS 0
429 South 18th Street,Camp Hill, PA 17011
Side 1
1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Blosser, Ross C. Sr.
RECAPITULATION
1. Real Estate(Schedule A).................................................................................. 148 ,737 . 88
2. Stocks and Bonds(Schedule 8)...... ........................................................... ........ 2. 23, 028 . 50
3, Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 1
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4,
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)......... 5. 12 ,533 . 96
6. Jointly Owned Property(Schedule F) D separate Billing Requested............ 6. 56, 890 . 85
7. Inter-Vivos Transfers&Miscellaneous Probate Property
(Schedule G) In Separate Billing Requested........,... 7. 448, 186. 97
& Total Gross Assets(total Lines 1 through 7)........................................................ & 689, 378 . 16
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 32 , 876. 33
10, Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 2 ,255 . 19
11. Total Deductions(total Lines 9 and 10)...... ........................................................ 11. 35, 131 . 52
12. Net Value of Estate(Line 8 minus Line 11)...... ......_............. .... 12. 654,246. 64
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. 654 ,246. 64
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 15. 0 . 00
16, Amount of Line 14 taxable
at lineal rate X .045 654 ,246. 64 16. 29,441 . 10
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18, Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0. 00
19. TAX DUE............................................. .........__..........-..... 19, 29,441 . 10
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-14-0821
Decedent's Complete Address:
DECEDENT'S NAME
Blosser, Ross C. Sr.
STREET ADDRESS
926 Valley Street
CITY Enola STATE PA ZIP 17025
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 29,441.10
Z Credits/Payments
A. Prior Payments 26,500.00
B. Discount 1,394.74
Total Credits(A +B) (2) 27,894.74
3. Interest (3)
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) 1,546.36
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;.............................................................................. D 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?................................................................................. ............ .................... 0 X
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 ❑
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 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)(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
[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)]. 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+(01-10)
SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
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 fads.
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
Include a copy of the deed showing decedent's Interest if owned as tenant In common.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Real Estate-926 Valley Street, Enola. Tax Parcel#09-13-0999-030. Property sold to Terry 148,737.88
and Linda Blosser on 4/10/15;see settlement sheet attached.
TOTAL(Also enter on Line 1, Recapitulation) 148,737.88
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule A(Rev. 01-10)
Rev-1503 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 1,166 shares of Manulife Financial Corporation 19.75 23,028.50
TOTAL(Also enter on Line 2, Recapitulation) 23,028.50
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule 8(Rev.6-98)
Rev-1508 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
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
NUMBER DESCRIPTION OF DEATH
1 Commonwealth of Pennsylvania-State retirement payment 578.86
2 M&T Retirement Account distribution 238.32
3 Manulife Financial Corp.-dividend 139.91
4 MetLife-straight life benefit payment 178.00
5 Miscellaneous personal property 2,000.00
6 Refund from Liberty Mutual Insurance 49.44
7 Refund from Teachers Protective Mutual Life Insurance 2,423.43
8 Teachers Protective Mutual Life Insurance Refund 6,900.00
9 US Treasury-2014 income tax refund 26.00
TOTAL(Also enter on Line 5, Recapitulation) 12,533.96
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
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
A. Terry L. Blosser 65 Bunker Lane Son
Etters, PA 17319
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S DECE EVALUE OF
NTS NTEREST
NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR VALUEOFASSE1 INTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE.
1 A 11/28/1976 M&T Bank-Checking Account 20,738.75 50.000% 10,369.38
2 A 07/01/2008 M&T Bank-Savings Account 93,042.94 50.000% 46,521.47
TOTAL(Also enter on Line 6, Recapitulation) 56,890.85
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1510 EX+(08-09)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY ENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THINCLUDE
DATE OF TRNAME OANSFER TRANSFEREE THEIR
COPY OF THE DEEHIPD OR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 American General Life Insurance Company-Annuity 81,196.77 81,196.77
Contract No.AN205354. The decedent's son Terry L.
Blosser is the sole beneficiary.
2 Athene Annuity and Life Company-Annuity Contract 210,048.90 210,048.90
475128AAI;the decedent's sons Jack I. Blosser and
Terry L. Blosser are the beneficiaries.
3 Athene Annuity and Life Company-Annuity No. 67,547.17 67,547.17
466367;the decedent's son Terry L. Blosser is the
beneficiary of this annuity.
4 M&T Bank-IRA;the decedents sons Terry L. Blosser 2,418.99 2,418.99
and Jack I. Blosser are the beneficiaries of this IRA.
5 Midland National -Annuity Contract 8500334581. The 86,975.14 86,975.14
decedent's two sons Terry L. Blosser and Jack I.
Blosser are the beneficiaries of this annuity.
TOTAL(Also enter on Line 7, Recapitulation) 448,186.97
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 Ex+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAXRETURN
RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NWMQER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 7,162.05
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Terry L. Blosser
Street Address 65 Bunker Lane
City Etters State PA zio 17319
Year(s)Commission Paid 12,000.00
2. Attornev's Fees Michael L. Bangs 12,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees 425.50
5. Accountant's Fees 665.00
6. Tax Return Preparers Fees
7. Other Administrative Costs 623.78
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 32,876.33
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
'I Sullivan Funeral Home 7,162.05
H-A 7,162.05
Other Adm*nistrative C12sts
2 Cumberland Law Journal -estate advertisement 75.00
3 Pamela Reitenbach-real estate appraisal fee 375.00
4 The Patriot News Co.-estate advertisement 173.78
1-1-137 623.78
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1600 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
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 Alixa, RX 153.84
2 East Pennsboro Township-sewer/trash 10/1/14 to 12/31/14 128.70
3 East Pennsboro Township-sewer/trash 1/23/15
128.70
4 Inogen,Inc. 45.96
5 Leffler Energy-11/24/14
136.28
6 Leffler Energy-12/8/14 125.12
7 Leffler Energy-12/30/14 56.98
8 Leffler Energy-4/10/15 378.54
9 Liberty.Mutual-monthly homeowners premium installment 72.85
10 Liberty Mutual Insurance-10/8/14 monthly homeowners insurance payment 68.85
11 Liberty Mutual Insurance-11/2014 monthly homeowners premium 72.85
12 Liberty Mutual Insurance-12/2014 monthly homeowners insurance premium 72.85
13 Liberty Mutual Insurance-1/2015 monthly homeowners premium 72.85
14 Liberty Mutual Insurance-2/2015 monthly homeowners premium 72.86
15 PP&L Electric-7/22/14 to 8/20/14 66.41
16 PP&L Electric-August, 2014 to September 2014 74.45
17 PP&L Electric-9/19/14 to 10/21/14 50.75
Total of Continuation Schedule See attached page
TOTAL(Also enter on Line 10, Recapitulation) 2,255.19
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
Rev-1512 EX+(12-08)
SCHEDULE I
pennsylvania DEBTS OF DECEDENT
DEPARTMENT OF REVENUE
INHERI ANCECEDENTE TAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDcontinued
ESTATE OF FILE NUMBER
Blosser, Ross C. Sr. 21-14-0821
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
18 PP&L Electric-10/21/14 to 11/19/14 33.79
19 PP&L Electric -11/19/14 to 12/19/14 37.27
20 PP&L Electric -12/19/14 to 1/21/15 34.93
21 PP&L Electric-1/21/15 to 2/19/15 31.97
22 PP&L Electric-2/19/15 to 3/20/15 30.16
23 PP&L Electric-final bill 18.80
24 State Employees Retirement System -return of unearned retirement payment 289.43
TOTAL(Also enter on Line 10, Recapitulation) 2,255.19
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Blosser, Ross C.Sr. 21-14-0821
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSONIS)RECEIVING PROPERTY DECEDENT (Words)
Do Not List Trustee(s) ($$$)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Jack Blosser Son 327,123.32
98 Howard Street
Enola, PA 17025
Ross C. Blosser, Jr. Son
304 South Enola Drive
Enola, PA 17025
Terry L. Blosser Son 327,123.32
65 Bunker Lane
Etters, PA 17319
Total 664,246.64
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appopriate.
NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
TOTAL OF PART 11 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
4 OMB Na.2502-0265
B. TYPE OF LOAN
A. SETTLEMENT STATEMENT (HUD-1) 1. ❑ FMA 1 ❑ FHMA 3. ❑ CONV.UNfNS.
4. ❑ VA 5. ❑ Cow INS,
6.FILE NUMBER: 7,LOAN NUMBER
.r 15-00046-ALT
8.MORTGAGE INS.CASE NO.:
C.NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items
marked"(p.o.c.)"were paid outside the closing!hey arc shown here for informational purposes and are not included in the totals
D.NAME&ADDRESS Terry L.Blosser and Linda J.Blosser
OF BORROWER: 65 Bunker Lane,Etter$ PA 17319
E. NAME&ADDRESS Terry L.Blosser,Executor of The Estate of Ross C.Blossor,Sr.
OF SELLER: 65 Bunker Lane Etters,PA 17319
F. NAME&ADDRESS ^-
OF LENDER:
G.PROPERTY LOCATION: 926 Valley Road,Enola,PA 1704.3 _
K SETTLEMENT AGENT: Assured Land Transfers,Inc.301 Market Street,Lemoyne,PA 17043(717)761-4720
PLACE OF SETTLEMENT: Michael L.Bangs Esquire 429 South 18th Street,Camp Hill PA,17011(717)761-4720
1. SETTLEMENT DATE: 4/10!2015
J. Summary of Borrower's Transaction K Summary of Seller's Transaction
100.Gross Amount Due From Borrower: 400.Gross Amount Due To Seller:
101.Contract sale price 150 000.00 401.Contract sales price
150 000.00
102.Personal property 402.Persona!pro rry
103.Senitment charges to borrower(line 1400) 2 739.00 403.
104. 404.
105. 405.
Ad'ustments For Items Paid By Seller In Advance: Adjustments For Items Paid By Seller In Advance:
106.Ci /town taxes to 406.Ci /town taxes to
107.County taxes to 407.County taxes to
108.Assessments to 408.Assessments to
109.2015 County/Township Taxes 4/10/2015 to 12/31/2015 399.73 409.2015 Coun /fownshi Taxes 4/102015 to 12/31/201 399,73
110.School Taxes 4/102015 to 6/302015 413.21 410.School Taxes 4/10/2015 to 6/30/2015 413.21
11 L 2nd QtT Sewer/Trash 4/102015 to 6/302015 122.50 411.2nd Qtr Sewer/rash 4/102015 to 6/302015 122.50
112. 412,
113. 413.
114, 414.
115. 415.
116, 416.
120,Gross Amount Due From Borrower: 153,674.44 420.Gross Amount Due To Seller: 150,935.44
200,Amounts Paid By Or In Behalf f n Amount Due To Seller:
201.Deposit or tamest money 501.Excess deposit(see instructions)
202.Principal amount of new loan(s) 502.Scraement char es to seller(line 1400) 2,19T56
203,Existing loan($)taken subject to 503.Existing loan(s)taken subject to
204. 504.Pa ff 1st M Ln.
205. 505.Payoff2nd Mtg,I.A.
206. 506.
207, 507.
208, 508.
209. 509.
Adjustments For Items Unpaid By Seller: Adjustments For Items Unpaid By Seller:
210.Ci /town taxes to 510.Ci flown taxes to
211.County taxes to 51L Countytares to
212.Assessments to 512.Assessments to
213, 513.
214. 514.
215. 515.
216. $16.
217. 517.
218, 518-
219. 519.
220.Total Paid By/For 520.Total Reductions 2,197.56
Borrower: In Amount Due Seller:
300. Seller:
301.Gross amount due fmm borrower(lune 124) 153,674A 601.Gross amount due to seller(line 420) 150 935.44
302.Less amount paid by/for borrower(line 220) 602.Less reductions in amount due seller(line 520) 2,197.56
303.Cash(®FROM) Gro) Borrower: 153,674.44 603.Cash(rXX}r0) (OFROM) Seller: 148,737.88
Previous Edition Is Obsolete SB-4-3538-000-1
Form No.1581 HUD-1(3-86)
3/86 XPage!of 3 X RESPA,HB 4305.2
X X
L SETTLEMENT CHARGES Escrow: 15-00046-ALT
700.Total Sales/Broker's Commission:
Paid From Paid From
Based On Price S %= Borrower's Seller's
Division of Commission(lone 700)As Follows@ Funds Funds
201 t At At
702,$ Settlement Settlement
703,CommiasimpAid at settleme
704.
800, ltpmq Payable In Crmneption Wwth Loan-
1.Loan Originationu
802.Loan Discount o
803.Appraisill fee to,
804,Credit report to
Lend inspection fee
806,Mortesee insurance application fee to
7.Assumntion fee
808,
809.
810.
I .
812
813.
814.
815.
816.
7
818.
1
2 .
821.
900, Iterns Required RX T&Gder To Re Paid In Ad-n-
0 1.Interest ftom t /day
902,Mortgage insurance premiumt
insurance903.Hazard i r Y11,to
04 insurance
905,
906.
0 r month
1002. Morteage insurance 0 months Q,S 0.00 per month
03. City propoM taxes 0 months(@,S 0.00 Ror month
1004. County propertynthmonth
1005. Annual assessments 0 months a$ 0.00 per month
1006, Flood
1007. per n
1008. A2ereggteu t
1009.
1101. Settlt or closing fee to
1102. Abstract or title search to
1103. Titlexamination
1104,
1105. Document
1106. fees to
1107. Attorney's fees to To Be Determined
(includes above item Numbers: )
1108. Title insurance to.Assured Land Transfers,Inc.(Sale)
(includes above item Numbers: ) 1,150.
1109. Lendces roverape
1110. Owner's v 150.000.00 Premium: V.I 50.00
111L
1112.
1113.
1114. Notary Fee to Wendy K.Straub lo.001 10.
00
1200, G�Yernment Record'
1201. Rocording
12 / 0
12 0 lZage S 0,00 I
1204.
1205.
1300, Additormal Settlement Ch-es-
1301. Survey to
1302. Pest innoction to
133. Reimbursement r Tax Certification to Johnson.Duffic.StewartWeidner 0
1304, w nhiCollector 5395
1305, 2nd Otr Sewor/TrashPennsboro Township
1306.
1307,
1308.1400 Tntal Settlement Charpe (Entero i i i 7 6
Form No.1582 Page 2 of 3 SB4-3536-000.1
X X X X
SELLER'S AND/OR BORROWER'S STATEMENT Escrow: 15-00046-ALT
I have carefully reviewed the HUD-I Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction.I further certify that I have received a copy of the HUD-I Settlement Statement.
Borrowers/Purchasers Sellers
Terry L.Blosser,Executor of The Estate
L.BI ser of Ross C.Blosser,Sr.
inda J.Blosser erry L�, S-r,
xecutor
The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction.I have caused or will cause the funds to be
disbursed in accordance with this statement. L�
Settlement Agent: ` v( Date:
Title Officer,.Assured Land sfers,Inc.
WARNING:It is a crime to knowingly make false statements to the United States on this or any other similar form.Penalties upon conviction can include a
fine or imprisonment.For details see: Title 18 U.S.Code Section 1001 and Section 1010.
Page 3 of 3
IMM&TBank
499 Mitchell Road,Millsboro,DE 19966 Records Management
Phone 888-502-4349
Fax (302)934-2955
Bangs Law Office, LLC September 18,2014
429 South 18th Street
Camp Hill,PA 17011
Re: Estate of Ross C. Blosser, Sr.
Social Security: 164-14-4955
Date of Death: August 15 2014
Dear Sir or Madam:
Per your inquiry on September 09, 2014, please be advised that at the time of death,the above-named decedent
had on deposit with this bank the following:
I. Type of Account Checking Account
Account Number 16034759
Ownership(Names ofi Ross C. Blosser
Terry L.Blosser
Opening Date 11128/1976
Balance on Date of Death $ 20,738 75
Accrued Interest $ .17
Total $ 20,738.92
2. Type of Account Savings Account
Account Number 15004215200144
Ownership(Names ofi Ross C. Blosser
Terry L.Blosser
Opening Date 0710112008
Balance on Date of Death $ 93,042.94
Accrued Interest $ 2.04
Total $ 93,644-98
3. Type of Account Individual Retirement Account
Account Number 35004201721435
Ownership(Names ofi Ross C Blosser
Opening Date 04/08/1985
Balance on Dare of Death $ 2,41&99
Accrued Interest $ 1.70
Total $2,420.69
For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds,
please call the Sumumihtle Plaza at 717-255-2261.
We were unable to locate any safe deposit box for the above-mentioned decedent.
This letter does not include any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers,
Representative Payee,or Trustee under a Written Agreement
Sincerely,
Valarie Mercer
Adjustment Services
TAT H E N E Athene Annuity and Life Company
Athene life insurance Company of New York
Mail correspondence to:P.O.Bax 1555,Des Moines,IA 50306-1 55 5
Customer Contact Center Tel:888 266 8489 Fax:866 709 3922
November 19, 2014 .
Terry L Blosser Contract Number: 466367AAI
c/o Michael L Bangs,Esquire Deceased: Ross Blosser
429 South 181h St
Camp Hill,PA 17011
RE: Annuity Death Benefit Claim
Dear Mr. Bangs,
Thank you for your recent request for information regarding the contract listed above. The date of
death value is noted below.
Date of Death: August 15,2014
Principal Amount: $52,587.46
Interest Amount: $15,697.18
Account Value: $68,284.64
Surrender Charges: $737.47
Cash Surrender Value: $67,547.17
The Death Benefit on this contract is the Account Value taken in the form of a settlement option
payout of 5 years or greater. If you wish to receive a lump sum in lieu of the settlement option
payout,the value you receive will be the Cash Surrender Value.
Athene Annuity and Life and its representatives continue to welcome any opportunity to be of
service. Should you have additional questions,please do not hesitate to contact our Customer
Contact Center at 1-888-266-8489.
Sincerely,
Customer Service
7700 Mills Civic Parkway,West Des Moines,to 50266-3862
www.athene.corn
18007 7n3
Athene Annuity and Life Company
Life AT
H �- N �- A�en /nmm"ocompao '*we°m�-- -- Mail cvrre-spv"ue"c~*:r0Box /ss.Des wwn=m 50306,/555
Customer Contact Center Tel:oox2a6owv Fax:x66,cn/vo
. .
November 19,2014
Terry L8|osser Contract Number: 475128AA|
c/o Michael LBangs, Esquire Deceased: Ross8hosser
428South 18thSt
Camp Hill,PA 17012
RE: Annuity Death Benefit Claim
Dear Mr. Bangs,
Thank you for your recent request for information regarding the contract listed above. The date of
death value isnoted below.
Date ofDeath: August 1E'2O14
Principal Amount: $185,952.41
Interest Amount: $29'925.18
Account Value: $215,877.59
Surrender Charges: $5,828.69
Cash Surrender Value. $210'048.90
The Death Benefit on this contract is the Account Value taken in the form of a settlement option
payout of 5 years or greater. If you wish to receive a lump sum in lieu of the settlement option
payout,the value you receive will bethe Cash Surrender Value.
Athene Annuity and Life and its representatives continue to welcome any opportunity to be of
sen/ice. Should you have additional questions,pleayadonot hesitate tocontact our Customer
Contact Center at1'88O'266-D489.
Sincerely,
Customer Service
rwaMills Civic ma°^ West Des Moines.m e026+386
��thene.uom
.°m,n.3
American General Life Insurance Company
The United States Life Insurance Company in the City of New York
September 19, 2014
MICHAEL L BANGS
429S 18TH ST
CAMP HILL PA 17011
Re: Annuity Contract: AN205354
Deceased: ROSS BLOSSER
Dear Mr. Bangs:
Thank you for your recent inquiry regarding the above referenced annuity contract. We
would like to take this opportunity to respond to your request.
The accumulated value of this contract as of August 15, 2014, the date of death, is
$81,196.77.
Mr. Bangs, we appreciate the opportunity to assist you. Should you have any questions,
please contact our Client Care Center at 1-800-424-4990.
Sincerely,
Brittani Jordan
Annuity Claims Department
Annuity Service Center-P.O. Box 871 •Amarillo, TX 79105-0871
Administrator for Renaissance Life&Health Insurance Company of America • Administrator for John Alden Life Insurance Company
Did you know? Most shareholders can manage their holdings online with freeomputershare
access to Computershare`s investor CentreT``website. Use this simple tool to
quickly and easily update account information, sign up for electronic delivery of
documents and more. Enroll FREE today at www.computershare.com/investor. Computershare Investor Services
250 Royall Street
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www.computershare.com
BANGS LAW OFFICE LLC
ATTN MICHAEL L BANGS
429 S 18TH STREET
CAMP HILL PA 17011
October 16, 2014 -- --- ------
Company: MANULIFE FINANCIAL CORPORATION
Registration: ROSS C BLOSSER
Holder Account Number: C0000513661
Document I.D.: 14287WF00585003
Our Reference: MFC/0011842364/4/
Dear Sir/Madam:
Thank you for contacting Computershare, the transfer agent for MANULIFE FINANCIAL CORPORATION. We
appreciate the opportunity to be of service to you.
Below is the account balance information you requested as of August 15, 2014 for the above account.
Shares Held by Agent: 1166
Shares Held in Certificate Form by Holder: 0
Total Shares: 1166
Closing Price Per Share: $19.75
Should you have other account related questions, please call us at (800) 249 7702 during regular business
hours. Please note that any available representative can assist you.
Sincerely,
00
Service Representative
Enclosure: None
Bangs Law Office, LLC
From: Gregadams <grpg.ada iicnnn^
Sent: Thursday, October 3[\ 2Ol4Il:37AK4
To: Bangs Law Office, LLC
Subjdct: Re: Ross C. B|osser, Sr.
Wendy,
Our records indicate that Terry L Blosser%50, and Jack I Blosser%50 are the beneficiaries.
The balance ofthe account a\time ofdeath was$O6'975.I4.
You can contact Midland directly at 1-800-586-0244 with any questions.
Gregory R.Adams
Adams &Associates
Your Financial Community ofPA, Inc.
200 Main Street
Palmyra, PA1707O
Toll Free: 1'8OO'922-19O4
Office: 717-838-9009
Mobile: 717-514-6173
---Original Message---
From: "Bangs Law Office, LL['' < >
To:
Date: 10/30/1408:4K8AM
Subject: Ross C. Bkosser Sc
Good morning.
We wrote toyou on September 9, I014 /see attached letter) concerning the death of Mr. B(ouser.
Tndate,wehave not received aresponse.
Could you let us know when we can expect to receive a response and how to proceed in this matter.
Thank you.
Wendy Straub, Paralegal
Bangs Law Office, LLC
Michael L.Bangs, Esquire
(717)730-7310V-`ofk
429 South 18th StreetCamp Hill,PA 17011
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1. ROSS C. BLOSSER, SR., of Enola, Cumberland County, PennsyE�ana, dec4= thg
co
to be my last will and revoke any will previously made by me.
ITEM I. 1 direct that all my just debts and funeral expenses, including my gravernarker
and all expenses of my last illness, and any and all taxes and assessments imposed by any
governmental body as a result of my death, whether on property passing under this will or
otherwise, shall be paid from my residuary estate as soon as practicable after my death as a part
of the expense of the administration of my estate.
ITEM U. I give and bequeath all of my household goods, automobiles,jewelry, and all
otl er articles of household and personal use, equipment and ornament, together with all
insurance thekeon and relating thereto, to my sons TERRY L. BLOSSER and JACK BLOSSER.
or to the survivor of them, who survives my death by thirty (30) days.
ti
ITEM 111. 1 give, devise, and bequeath all the rest, residue, and remainder of my
possessions and estate of every nature and wherever situate to my sons TERRY L. BLOSSER
and JACK BLOSSER, or to the survivor of them, who survives my death by thirty (30)days.
ITEM IV. I have made a conscious and knowing decision not to leave any bequest to
my son, Ross C. Blosser, Jr.
ITEM V. All of the interests of the beneficiaries hereunder shall not be subject to
anticipation or to voluntary or involuntary alienation nor shall they be subject to any execution or
attachment.
ITEM V1. I appoint my sm TERRY UR[jOWM executor this my last will. Should he
predecease me or otherwise fail to qualify or cease to serve as executor of this my last will, I
appoint my son JACK BLOSSER executor of this my last will.
ITEM VII. In addition to the other powers and authorities granted to my personal
representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby
give to my personal representatives the following powers and authorities effective without court
approval and until actual distribution of all property: to compromise any claim or controversy;
to make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as
my personal representatives may determine and at valuations finally to be fixed by them; to
invest in all forms of property, including any stock or other securities in any corporate fiduciary
or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my
personal representatives deem proper, without regard to any principle of risk or diversification;
to retain any or all assets of my estate, real or personal, without regard to any principle of risk or
diversification. to sell at public or private sale, to exchange, or to lease for any period of time,
any real or personal property and to give options for sales, exchanges, or leases, for such prices
and upon such terms or conditions as my personal representatives deem proper; and to allocate
receipts and expenses to principal or income or partly to each as my personal representatives
deemproper in their sole discretion,
ITEM VIII. I direct that my personal representatives and fiduciaries shall not be
required to give bond for the faithful performance of their duties in any jurisdiction.
2
M RTT%M Rte,i ire set tnc hated this day of
?004.
S C. BL ER, SR.
3
The preceding insn ument consisung of dis anti THREE other Rpe written pages,each
identified by the signature of the testator was on the date thereof signed, published, and declared
by ROSS C. BLQSSER, SR., 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
names as witnesses hereto.
4
,f r
CONOAONWEALTM 1J7Fti.7 i i'.r3A
COUNTY OF CUMBERLAND )
The undersigned, being the testator whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law,does hereby acknowledge that I signed and executed the
foregoing instrument as my last will,that I signed it willingly; and that I signed it as my free and
voluntary act for the purposes therein expressed.
ASf. BLOSS SR.
S.w&3 .-Or iffirmed to and acknowledged
befo yhe t e above
this " o , 2009. EhLTH OF PENNSYLVANO
NotwW seas
Vidy K Staub,NOWY R+bk
tz%„I a_ 11c 1„y t" En*w May 10,2011
yhrara<a AssocWon of Notaries
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
E
W ,,�r,r.�t..<�.�.� and ��ngduly
�qu
SSE' the
witnesses whose names are signed to tKe�attached or foregoing ins ent, ified according
to iaw, ¢o 4eeptse and say that we were present and saw the testator sign and execute the instrument as his
last will, that he signed it willingly and that he executed it as his free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the testator signed the will as witnesses;and
that to the best of our knowledge,the testator was at that time 18 or more years of age, f sound mind,
and under no constraint or undue influence. z
Sw r a armed t acknowledged
-_: F` day of
`. , 2009.
No La 11�blit
OF PEMS YL
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wer+ay K sem.Notwy pubk
Lorwr Alen Twp.,Cuntwiar4 Cangr
W OGrtanisekmn EVbw Away 10,2t111
yfil$nla AsSOCl840n Ot Notafte
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