HomeMy WebLinkAbout08-24-15 (2) ,
• � ,:`a pennsylvania 15D56184D3
{yi� DEPARTMENTOFREVEN�X(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes CounryCode Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburq, PA 17128-0601 RESIDENT DECEDENT 21 15 0626
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY
a5 15 2015 07 08 1939
DecedenYs Last Name Suffix Decedent's First Name MI
HILL JUNE A
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Retum � 2. Supplemental Retum � 3. Remainder Return(date of death
prior to 12-13-82)
� 4. Agricultural Exemption(date of � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
� 10. Litigation Proceeds Received � 11. Non-Probate Transferee Return � 12. Defercal/Election of Spousal Trusts
(Schedule F and G Assets Only)
� 13. Business Assets � 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT•iHIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DAVID J LENOX 717 271 7175
First Line of Address
8 TRISTAN DRIVE SUITE 3
Second Line of Address
City or Post Office State ZIP Code
DILLSBURG PA 17019 ,�,
« �
e� � ::� rr'
CorrespondenYs email address: law davidjlenox.comcastbiz.net � 8 t� 7
REGIS Z5R V�111�LS U84 ONLSE'? C�
. r� N i _,t
REGISTER OF W ILLS USE ONLY � "
. . � � � C:-7
DATE FILED MMDDYYYY �''
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D�'fE FI�LED STAry�RJ 'n �
Side 1
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15�5618403 15�5618403 �
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J 15�5618411
REV-1500 EX
DecedenYs Social Security Number
�ecedent's Name: H i I I, J u ne A.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1. 15 9,7 4 6 •8 5
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivabie(Schedule D).................................................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 3,512•0 6
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 16 3,2 5 8 •91
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 51,6 8 4 .11
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 9 7,13 0 •3 8
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 14 8,814 -4 9
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 14,4 4 4 •4 2
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. 14,4 4 4 -4 2
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.00 15. 0-00
16. Amount of Line 14 taxable
at�ineal rate X .045 14,4 4 4 • 4 2 �s. 6 5 0 •0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 •0 0 17• 0 -0 0
18. Amount of Line 14 taxable
at collateral rate X.15 � • 0 0 1$• 0 •0 0
19. TAX DUE................................................................................................................ 19. 6 5� •0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on ali information of which preparer has
any knowledge.
I$GNPTURE OF PER O�PON�OR FILING RETURN Terri L. Polinka �TE �
`�,,.� l � I S
6 AD RESS
829 Fairfield Street, Mechanicsburg, PA 17055
SIG TU OF E THERTHA REPRESENTATIVE David J. Lenox �Ar .e
�
ADDRE S �
8 Tristan Drive, Suite 3, Dillsburg, PA
� I I�I' (I�' IIIII I"I I III IIII)II'� II II I II (IIII IIII IIII Side 2
15�5618411 1505618411 �
REV-1500 EX Page 3 File Number 21-15-0626
Decedent's Complete Address:
DECEDENT'S NAME
Hill,June A.
STREET ADDRESS
930 S. 28th Street
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 650.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
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
g. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) s�'jQ.QQ
Make Check Payable to REGISTER OF WILLS, AGENT
� ;" � � :.� .� "�ssa �v�7r'."'�: x�* ., _�"°r'+'�"�s���'�.`t�"�`"r"1"�� '�'y ,i"�"�, �o M1e�+�''�,�'��c�.. ',�a, :, �. �":o'
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t�....., o,��.,n., .-�.�.�.�P,�.�,.:,�°,.,.,��7�.���. ,�aa�,`�`�.a.Ha .��:��.,.,�i;.�'�, ��-` .,��4:.�.�.R.�=�. s�,.�,e»,�..s�,���....m�.:���,.w.,�:.��.�,...h.,w..a,.w..a.�:.�,.,.�..a..a:5�.�..,..,.cr.; ,�..m�,„.�2'.,
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:.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ �
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ �x
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.
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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 retum 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 step-parent 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.
Rev1502 EX+(12-12)
� SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OFREVENUE �
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF IFILE NUMBER
Hill, June A. 21-15-0626
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 wiiling 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 6een 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 HUD Allocation- Sewer/Trash/Water 60.33
2 HUD Allocation- Local Tax 302.02
3 HUD Allocation-Schooi Tax 1,384.50
4 Real Estate Situate at 930 S.28th Street,Camp Hill, PA- 158,000.00
TOTAL(Also enter on Line 1, Recapitulation) 159,746.85
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, inc. Form PA-1500 Schedule A(Rev. 12-12)
Rev-9508 EX+(08-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENTOFREVENUE pERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Hill, June A. 21-15-0626
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 schedu�e F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Accrued Retirement Pay 573.00
2 M&T Bank acct#40813 16.75
3 M&T Bank acct#63234 2,060.71
4 Miscellaneous property and furnishings 861.60
TOTAL(Also enter on Line 5,Recapitulation) 3,512.06
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12)
REV=1571 EX+(08-13)
' pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
R SEDENTDECEDENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hill, June A. 21-15-0626
DecedenYs debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
q, FUNERAL EXPENSES:
See continuation schedule(s)attached 13,692.60
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Terri L. Polinka
Street Address 829 FairField Street
city Mechanicsburg state PA zio 17055
Year(s)Commission Paid $��2$•72
2. Attorney's Fees David J. Lenox 5,354.25
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zio
Relationshi�of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 24,508.54
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 51,684.11
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 08-13)
' SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hill, June A. 21-15-0626
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Head Stone 2,500.00
2 Malpezzi Funeral Home 9,697.60
3 Rolling Green Cemetery Grave Opening and Preparation 1,495.00
H-A 13,692.60
Other Administrative Costs
4 Additional Commission sale of real estate 200.00
5 Annual Real Estate Tax 1,598.51
6 Cleaning,Painting,Stamps,Trash Removal,Misc. repair 1,000.00
7 Comcast 400.00
8 Handyside Inc.electric box replacement 898.00
9 PP&L 160.00
10 Real Estate Transfer Tax 1,580.00
11 Realtor Commission 6% 8,923.21
12 Sellers Help at RE Closing 9,279.91
13 Sewer,Water,trash 283.96
14 Talley Petrolium 99.95
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
� SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hill, June A. 21-15-0626
ITEM
NUMBER DESCRIPTION AMOUNT
15 Various HUD service charges 85.00
H-B7 24,508.54
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev=1512 EX+(12-12)
� SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF IFILE NUMBER
Hill, June A. 21-15-0626
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 HCR Manor Care 3,879.46
2 M &T Bank Monthly Mortgage(3 months) 2,115.00
3 M &T Bank Visa Card 3,454.58
4 Pa. Dept.of Welfare Estate Recovery Claim 542.78
5 Pay off M &T Bank Mortgage 84,755.36
6 Repayment Railroad f2etirement Check 2,383.20
TOTAL(Aiso enter on Line 10,Recapitulation) 97,130.38
(if more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-12)
REV-1513 EX+(01-10) .
� pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN B E N E F I C IARI E S
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hill, June A. 21-15-0626
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(Sl RECEIVING PROPERTY (Words) ($$$)
Do Not List Trustee s
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Heather J. Donlevy Daughter 7,222.21
31 Tavern House Hill
Mechanicsburg, PA 17050
Terri L. Polinka Daughter 7,222.21
829 Fairfield Street
Mechanicsburg, PA 17055
Total 14,444.42
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. 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
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev.01-10)
LAST IdILL AT��TD TESTAI��'IEI�TT OF JUI�TE A. HTLL
T, JUNE A. H�LL, of the Township of Lower Allen, County
of Cumberland and S�ate of Pennsyl.vania, being of sound and
dispoaing mind, memory and undexstanding, do make, publish and
declare this my Last l�Ji11 and Tes�ament.
l.
T direct �he paymen� of a11 my �ust deb�s and funeral
expenses as soon after my decease as the same can be conveniently
done «
2.
I give, devise and bequeath all the res�, residue and
remainder of my estate, real, personal and mixed, whatsoe�er
and wheresoever the same may be situa�e, zo m�r husband, L� �1.
�IILL, absolutely and uncondi�ionally.
3•
In the event that my husband, LEE Id. H2LL, ahould predecease
me, or should he die within �hir�y ( 30) days from �he da�Le of my
death, then in ei�her of such events , Z �;ive � devise and bequeath
my entire es�ate, of wha�soever nature and wheresoever the same
may be situate, . to my �tiao ( 2) ch3.ldren, to wi�, my dau�;hter,
T�RRI L. �OLINKA, and my daugh�er, HEATH�t J. HTLL, share and
share alike .
, _1.,
( a) In the event that my daughter� i�EATHER J. HILL� has
no� a-�tained �he age of twenty-one ( 2l) years a� the time of my
decease, then i.n such event, I give and bequeath her share in
my estate �o my dau�hter, TERR2 L. POLINKA, in �rust, nevertheless,
to ho1d, manage , inves� and reinvest the same, and to use and
apply the income and principal, or so much thereof, as in my said
Trusteets discretion, she rnay deem necessary or appropria�e for
the care, maintenance and educ�tion Qf my daughter, HE.A.THER J.
H2LL, including her colle�e education, or o�her professional or
�echnical training af�er she �raduates from Hi�h School, wi�hou�
further responsibility to auch beneficiary or to her guardian, if
any, or to any person who may be taking care of her.
Any income not so used or applied shall be accumulated and
added �o and thereaf�er be treated as part of' the principal of
said trust fund. When my said daughter, HEATHER J. HTLL, a�tains
the age of twen�y-one ( 21) years, her truat shall �terminate and
the principal of the trust fund, �ogether with any income which
may have accumulated �hereon� shall be paid over and dis�ributed
to her, absolu�el�T and uncondi�ional].y.
Z direct that zny dau�hter, TERRT L. POLIPZKA, be permi�ted
�o serve as Trustee of the Estate of my daughter! �iEATHER J.
IiILL, without being required to post bond or other securi�y and
�ha� she be excused from f31in� a formal accounting of her
Trus�eeship in all instances.
(b) I nominate, cons�itute and appoint my daugh�er,,
_Z_
TE'RRI L. POLTNI'�., guardian of the person of my daughter,
HEATHgi. J. HILL, for atzd during the term �f her zninority and
direct tha� she be paid a reasonable compensatio.n for the care
and maintenance of my said daugh�ter, so long as she is under
her personal care and custody and is a znember of her immedia�e
household.
LASTLY, I nominate, consti�ute and appo3nt my husband, LEE
N. HILL, Executor of this my Las� Will and Testament, and in
the event that my said husband should predecease me� or should
he be unable or unwillin� ta serve in such capacity for any reason,
then in such even�, I nominate, constitu�e and appoint my daughter�
TERRI L. POLINKA., Executrix of this my Last Wil1 and Testament, in
his place and stead, and in either instance, I direc� �Yia� my said
personal represen�atives be exeused from pos�ing bond or othar
security for the faithful performance of their duties in any
jurisdietion.
ITd �;JITTu�,SS t�TH�EOF, I have �GI'BU.x'1 V O s e� my har.d ar�d s e al
�hia day of June, A. D. , 199t�.
i` � �j
'� ;' ^ � (SEAL)
�June A . Hi,11
..3..
Signed, s�aled, publi9hed and declared by �he above
named, JUIdT A. IIILL, as and for her Last U1i1.1 and Testament,
in �he presence of us, who have subscribed our names hereto as
witnosses, at the reques� of said testatrix, in her presenee
and in the presence of each other.
.
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CQMMONWEALTH OF PENNSYLVANIA )
. SS.
COUNTY OF CUMBERLAND )
I, J�UirE A. ri�_LL , the testat rj.:�,
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 Testament;
that I signed it willingly; and that I signed it as my free and volun-
tary act and deed, for the purposes therein contained.
Sworn and affirmed to and acknowledged before m� byf �---
JU'1'�T�`�; A. 't?ZLL , the testat��� , this � /� '' �
day oF �rt�n� � A. D. � � 0�9��
,�',� t �f.t� �' ���.
� �
, r........��#}f f 1�..�y`E' .!3 i\�!�,,..7; "-('V.. ._...3
, : �
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A+6Y CcSmro��:�'!Ea.pBL-u r"�.�.i�'J
COMMONWEALTH OF PENNSYLVANIA ) �
. SS.
COUNTY OF CUMBERLAND )
We, the undersigned, J. �Q�'�2' �T4UFr��
and '�Rl'1�� L. LEV i I?�AG�T� , the witnesses whose names are
signed to the attached or foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the
testat �ix , JUi<i�' .�'.. I-iIT.,L , sign and exe-
cute the instrument as �her Last Will and Testament; that the
said testat-�,�X , JUT+TF A. i�,TLL , executed it as
}�/her free and voluntary act for the purposes therein expressed;
that each of us, in the hearing and sight of the testatY��.y , signed
the Will as witnesses; and that to the best of our knowledge, the
testatT'iX was, at the time, eighteen (18) or more years of age,
of sound mind, and under no constraint, duress or undue influence.
�� � ,
L
Sworn and subscribed to before i'�l;f' ; -._-��- �� � ����' '' �
me this ,� � �' day of � %
Ju.ne , I99�.. �
f � � � `y
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`� j I01 A DE�-9wt fr� :.. . . ' 7�`2 . ' � ��la�wNw S�M� •.lf � ..�� � ' _
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Made the'•i ; �S'�`'� day of �ar��� ;in the year ��
,� .N�neteen hundred and Sixty-Seven (1967) : u
:�
ii ���dtsit. HOBERT C. oANDERBILT and $EATRICE L. VANDERBILT. h16 wifa, of
�� � Lover Alien Townahip. C�berland County, Pennsylvania
�,�
:� � ' Orantora
I �
tl . i LEE NET.SON BILL and JD2.E A. HILL, hie wife. of tha sama place , , .
� • 1 . •
i T:t'
��� ' . Grante�
y ' �litstessefh�that in consuderatianoJ ($14,500.00)
,:! � Sixteen Thousand Five Hundred --- --.-------_�-....Dollats, �
�} in h.and paid,tlae receipt wTcereof is heseb�acknowZedaed,the said Grantors do ' � ' ��
�; herebJ grant and eonveJ to,the said Gra�atee s their heirs and asai,e�is,
4: .! ._.._..... .... : • .
;� � ; ALL THAT CEFcTAIN piece or parcel.of la.ad eituate ia the Toxaehip of Lover Allan, �
�;� • � County of C�mberland and State of Pennsylvaaia, more particularly bouwied and
�,: ! described in aceocdaace with susvey of Ernest J.�Walker. Ragistered Profesafoaal '
s�: t � Engineer, dated June 22, 1967. as follovs, to wit:
!ia j ._ .. _ ,
i:� { � BEGINNING at a point on the westezn line of 28th Street. which poiut is one hundred �
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>'s ; line of South 28th Street south one (1) degrea eset one.hundred (100) feet to a � °
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� pipe; thence south eighty-three (83) degrees twenty-three (23) minutee+ uest oua � �
�a ' hundred fiftq-one (151) feet to a pofat oa tha eastern 21ne of lands aow or formerl �
r� I � of Clayton 1�. Russ; thence along the same aorth three (3) degrees saventeea (17) ` Y,�
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�� minutes vest ninety-nine and eixty-four one-bundredths (99.4b) feet ta tha southern �'q,
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Having'Eherenn e�BCtBd a one atory brick a.nd frame daelling house knowa and u�bere �.j
�; ae 930 South 28ih�iseet.. _ EI
BEZNG the eame premises which Paul L. Creasman. Jr. et al by their deed dated
y August 5, 1957 and recorded ia the C�berland Couaty Recorder's office in Deed
; � I Book "D", Vol. 18, page 24� granted and coaveyed unto Robert C. Vauderbilt aad
i'? � Beatrice L. Vanderbilt, his vife, grantors herein.
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A Notary Pub11c � � P ,7,AP....::'•--
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Robert C. Vanderbilt and 8eatrice L. Vanderbilt, his vife i
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known to mi(w aatis�adorilr prooenJ to be tht persons rchose namee are su6scriGe ,�ed K.�•k�t�9+.;•?��
instrument,and acknowledged that t/u y txecuted the same for the purpose:_theTeia.�o�teirted� '':M �
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IN IYITNESS WHEREOF,1 have her�o aet my hand and notarial ���__u'�y s . '•.7, �
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� ,µ'������ N OMB No.2502-0265
� ���,���� ��' A. Settlement Statement (HUD-1)
B.Type of Loan �
I. ❑O FHA 2. ❑RHS 3. ❑Conv Unins 6.File Number 7.L.oan Number 8.Mort�age Lis Case Number
4. ❑VA 5. ❑Convins. 6. ❑SellerFin 154-001239 3804045057 446-25gg043-703
7. ❑Cash Sale.
C.Note: This form is fumished to give you a statement of actual settlement costs. Amounts paid m and by the settlement agent are shown. Items marked
"(p.o.c.)"were paid outside the closing;they are shown here for informational purposes and are not included in the rotals.
D.Name&Address of Bon�ower E.Name&Address of Seller F.Name&Address of[,ender
Jared R.Mummert and Saman[ha Jo Mummert The Estate of June A.Hill Home Poinf Financial Corporation
1$12 Montfort Drive 930 S.28th Street 9 Entin Road,Suite 200
Harrisburg,PA 17110 Cnmp Hill PA 17011 Parsippany,NJ 070$4
G.PropeiTy Location H.Settleme�t Age�t Name C Settlement Date
T.A.of Central PA,L[.0 8/1S/2015
930 S.28Ih Street,Camp Hill,PA,17011,Lower 530 N.Lockwillow Avenue Fund:8/18/2015
Allen Township Harrisburg,PA 17112
717-7243724
Underwritten By:First American-NJ/PA
Place of Settlement
Keller Williams of Central PA
4242 Carlisle Pike
Cnm Hill PA 17011
J.Summary of Borrower's Trnnsaction K.Summary of Seller's Transaction
100.Gross Amount Due from Borrower 400.Gross Amount Due to Seller
101. Contraci sales price $I58,000.00 401. Contract sales price $I58,000.00
102. Personal property 402. Personal property
103. Settlement charges to bonower $10,201.06 403.
104. 404.
]O5. 405.
Adjustments for items paid by seller in advance Adjustmen[s(or items paid by seller in advance
106. 2015 Counry& OS/19/15 thru 12/31/IS $302.02 406. 2015 Counry& 08/19/15 thru 12/31/15 $302.02
Township Taaes 'I�ownship Taxes
107. 2015-16 SchoolTaxes OS/19/15thru 06/30/16 $1,384.50 407. 2015-16 School Taxes 08/19/15thru 06/30/16 $1,384.50
108. 3rd qtr 08/19/I S Uuu 09/30/15 $60.33 408. 3rd qtr 08/l9/15 thru 09/30/I S $60.33
SewerlCrash/Recycling Sewer/Crash/Recycling
]09. 409.
I I0. 410.
1��. 411.
]I2. 412.
I13. 413.
114. 414.
I I5. 415.
116. 416.
120.Gross Amount Due From Borrower $169,947.91 420. Gross Amount Due to Seller $1g9,746.85
200.Amounts Paid By Or in Behalf Of Borrower 500.Reductions in Amount Due to Seller
201. Deposit or earnes[money $2,000.00 501. Excess deposit(see instructions)
202. Pnncipal amount of new loan(s) $155,138.00 502. Settlement charges to seller Qine 1400) $15,168.63
203. Existing loan(s)[aken subject to 503. Existing loan(s)taken subject to
2p4, 504. ]st Mte PayoffM&T Bank $84,755.36
205. 505. Payoffofsecond mortgageloan n/a
206. Seller Assist $9,279.91 506. Seller Assist $9,279.91
20Z SOZ (EMD$2,000 Disbursed as Proceeds)
2p8. 508.
209. 509.
Adjustments for items unpaid by seller Adjuscmen[s for items unpaid by seller
210. 2015 County& 510. 2015 Counry&
Townshi Tases Township Taxes
21 L 2015-16 School Taxes 511. 2015-I6 School Taxes
212. 3rd qtr 512. 3rd qtr
Sewer/Trash/Recycling Sewer/Trash/Recycling
213 513.
Z�q. 514.
215 515.
216. 516.
217. 517.
218 518.
219. 519.
220.Total Paid By/For Borrower $166,417.91 520.Total Reduction Amount Due Seller $109,203.90
300.Cash At SetUement From/To Borrower � 600.Cash At Settlement To/From Seller
301.Gross Amount due fi�om borrower(line 120) $169,947.91 601.Goss Amount due to seller(line 420) $159,746.85
302.Less amounts paid by/for borrower(line 220) $166,417.91 602.Less�eductions in amt.due seller Qine 520) $109,203.90
303.Cash From Borrower $3>530.00 603.Cash To Seller $50,542.95
The Pul lic Aepoitin�,Burden forthis collection of info�mation is estimated at 35 minufes per response for rnllectin�„rea�iewing and repoRing the data_'Ihis xaency
rnay nu[.ollect this inionnauon,and yuu are not required to complete this fuim,unless it Jisptays u currantly valid O\46 mutrol number.Ne contidentiality is
assured;this disolosure is rt�andamry.This is dcsigned[o�rovid�the partias[o a FESPA covered cransactinn with informntion during tl�e settlement proeess-
POC(B)-Paid Outside of Closing by Borrower. POC(S)-Peid Outside of Closing by Seller. POC(L)-Paid Outside of Closing by Lender.
Previous editions are obsolete Page 1 of 5 HUAI
L. Settlement Charges
700. Total Real Estate Broker Fees $8,923.21 Paid From Paid From
Division of Commission(line 700)as follows: Bon-ower's Sellers
701. $4,461.61 to Re/Max Realty Professionxis Funds at Funds at
702.54,461.60 to Keller Williams of Cen[ral PA Settlement Settlemen[
703. Commission Paid at SetHement $0.00 $8,923.21
704. Additional Commission to Keller Williams of Central PA $175.00
705.Additional Commission to Re/Max Realty Professionals $200.00
706. Reimbursement for Talley Petrolium to Tracy IJinger $99.95
800. Items Payable in Connection with Loan
801. Our ori�ination char�e S1,2a5.uu (from GFE#1)
802. Your credit or char�e(oints)for the specific rate chosen 50.00 (from GFE#2)
803. Your ad�usted ori�ination char�es to Home Point Financial
� b �' Cor oration (from GFE A) $1,245.00
504. Appraisal Fee to Appraisal Nation (from GFE#3) $450.00
805. Credit report to Credit Plus (from GFE#3) $36.50
806.Ta�c service to CoreLogic POC��� (from GFE#3)
sx�.nn
807.Flood certification to CoreLogic Credw (from GFE#3) $9.00
900. Items Required by Lender To Be Paid in Advance
901. Daily interest charges from 8/I8/2015 to 9/1/2015 �$15.94/day (from GFE#10) $22316
902. MIP for Life of Loan for months to (from GFE#3) $2,668.23
903. Homeowner's insurance for 1 years to State Farm Insurance (from GFE#1 I
Com anies 1 $682.00
1000.Reserves Deposited With Lender
1001.Initial Deposit for your escrow account (from GFE#9) 5774.27
1002.Homeowner's insurance 3 months� $56.83 per month $170.49
1003.MoRgage insurance months(td $107.10 per month
1004.City property taxes months(a� per month
1005.2015 County&Township Tarzes 7 months� $68.05 per month $476.35
1006.Assessment Taues months� per month
]007.2015-16 School Taxes 3 months(u� $13311 per month $399.63
1008.MUD taxes months(r� per month
1009. Other taxes 0 months(�
1D10. Othertaxes 0 months(�
1011.Aggregate Adjustment -$272.20
1100. Title Char es
i lOL Title services and lendei's tide insurance to T.A.of Central PA,LLC (from GFE#4) $1,700.90
]102.Settlement or closing fee to T.A.of Central PA,
LLC
1103.Owne�s title insurance to T.A.o(Central PA,LLC (from GFE#5) $129.00
1104.Lende�'s tide insurance to T.A.of Central PA,LLC $1,150.00
1105.Lenders title policy limit$ $155,138.00/$405.90.
]]06.Owne�'s ti[le policy limit$ $158,000.00/$1,309.00
1107.AgenPs portion of the total tiUe insurance to T.A.o(Central PA,LLC $1,351.41
remium
I 108.CJndenvriter s portion of[he total title to First American-NJ/PA $363.49
I 109 Type of Insurance Rate:Enhanced Policy to
Rate
1110. Reimbursement for Tax cenification to T.A.of Central PA,LLC $20.00
1]]L Wire Out Fee(seller payoffl to T.A.of Cen[ral PA,LLC $20.00
1112. Seller Notary Fee to Abby Wendel $20.00
1113. PA Short Fo�m Poliry Premium to T.A.of Central PA,LLC $100.00
11 14. PA 900 Environmental-Res to T.A.o(Central PA,LLC 550.00
l I I5. Cbsing Protection Letter to T.A.of Central PA,LLC 5125.00
1 I 16. PA]030 ALTA 9-REM-L to T.A.of Central PA,LLC EI30.90
1��� Estimated Payment-PA Liheritance to Commonwealth of $650.00
Taaes Pennsvlvania
ll 18. Balance held for PA Inheritance Taxes to Title Alliance L[d. $850.00
1119. EscrowHoldFee to TitleAllianceLtd. $25.00
1200. Gocernment Recording and Transfer Charges
120L Government recording charges (from GFE#7) $178.00
1202. Deed$79.00;Mortgage$99.00,Release$0.00 to Cumberland County
Recorder of Deeda
1203. Transfer tases (from GFE#8) $1,580.00
Deed$1,580.00;Mongage to Cumberland
1204. Ciry/County ta�stamps $0.00 CounTy Recorder of $1,580.00
Deeds
Deed$1,580.00;Mortgage to Cumberland
1205. State ta�c/stamps $0.00 County Recorder of 50.00
Deeds
1300.Additional SetHement Charges
130L Required services you can shop for (from GFE#6)
Previous editions are obsolete Page 2 of 5 aun-i
� . � � File No.154-001239 �
' 1302. 2015 County&Twp Taxes to Bonnie K Miller,Tax poc�s�satesx
Collector
1303. 2015-16 Schooi Taxes(discount) to Bonuie R.Miller,Taz $1,598.51
Collector
1304. Home Inspection to Inspect-A-Home,Inc. $350.00
1305. Sewer/Crash/Recycling(2nd&3rd qtr) to Lower Allen Township $283.96
1306. L�voice to Handyside Ina $895.00
1400.Total Settlement Charges(enter on lines 103,Section J aud 502,Section 6� $]0,201.06 $15,168.63
POC(B)—Paid Outside of Closing by Borrower.POC(S)—Paid Outside of Closing by Seller. POC(L)—Paid Outside of Closing by Lender.
Previous editions are obsolete Page 3 of 5 HUD-1
� ��zs��
499 Mitchell Road,Millsboro,DE 19966 Records Management
Phone 888-502-4349
� Fa�c (302)934-2955
June 29,2015
David J Lenox
Attorney at Law
8 Tristan Drive, Suite 3
Dillsburg,PA 17019
Re: Estate of: June A Hill
Social Security: 198-30-0439
Date of Death: May 15,2015
Dear Sir or Madam:
Per your inquiry on June 16, 2015, please be advised that at the time of death,the above-named decedent
had on deposit this bank the following:
l. Type of Account Savings
Account Number 15004207040813
Ownership(Names o� June Hill
Lee Hill
Opening Date OS/02/00
Balance on Date of Death $16.75
Accrued Interest 0.00
Total $16.75
2. Type of Account Checking
Account Number 950263234
Ownership(Names ofl June Hill
L,ee Hill
Opening Date OS/02/00
Balance on Date of Death $2,060.71
Accrued Interest $ .00
Total $2,060.71
For any additional information on the above accounts, including ownership and any changes, closures
and/or reimbursement of funds, please call Westshore Plaza at 717-731-1730
We were unable to locate any safe deposit box for the above-mentioned decedent.
This letter dces 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,
Tomara Williams
Records Management
- Malpe.Zzi Fune�al Honze
8 Market Plaza Way (717)697-4696
Mechanicsburg,PA 17055 www.MalpezziFuneralHome.com
Michael J.Malpezzi,Owner,FD Jeremy J.Shartzer,FD Kyle C.Knipe,FD Ian J.McCreary,FD
June 4, 2015
Heather ponlevy
31 Tavern House Hill
Mechanicsburg, PA 17050
This is the final statement for the funeral services of June A. Hill
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way.
PROFF.SSIONAL SERViC'ES:
Services of Funeral Director/Staff $5,760.00
FUNERAL HOME SERVICE CHARGES $5,760.00
SELECTED MERCHANDISE:
20 Gauge Steel Casket $2,200.00
Guardian Burial Vault $1,150.00
Maroon Register Package $75.00
THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE
THAT YOU HAVE SELECTED $9,185.00
CASH ADVANCES:
At the time funeral arrangements were made, we advanced certain payments to others as an accomodation.
The following is an accounting of those charges.
Certified Death Certificates $36.00
Newspaper Notices-Patriot $326.60
Flowers $150.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES $512.60
CONTRACT PRICE $9,697.60
TOTAL AMOUNT DUE BY June 14,2015 $9,697.60
If you have any questions or concerns regarding this bill,please call our office at(717) 697-4696.
� '
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. . • .- • '� 1 � � � � � • •
_ � � 07/31/2015 UPON RECEIPT . �583-4�689��_�`�:
• .
JUNE HILL t54347403 ��
Dear Terri Polinka,
The employees of HCR ManorCare appreciate the . � � •
opportunity to care for you. Sign up now to pay your bill
online or call your Center's Business Office Managers to
make your payment today, or discuss payment Balance Forward �3,879.46
arrangements.
Your Payments Since Your Last Statement $0.00
You may pay your bill 1 of 3 ways:
'; � Mail in the payment using the coupon below Current Charges $0.00
• • .
, � �'' To payby phone dial 717-737-8551
, ✓� Pay online at https://www.emergetechnology.neU#/CampHill
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� 2. � 'a4A", '."LF''r5F',»mA5.,�'S'.ifivi. ��`T'4v;3'"{u"fi�?�ft?.._?9$+.P'�'J`,+P,„,.,^n.'..�`.':�?^ 'Ts'z3�,5'."a'Y"LYM'�`5:.;...'..R'^P".v�T.T.^3vT'M'."f�'i��R �.- .,.� :�i� T.,
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Estimated Balance Due Fr�m Insurer � $0:00
Phone:
• � � 717-737-8551
• ��: H�R Manor _�.
�k`' Heartland•ManorCare•Arden Courts
��� Please contact us during our regular business hours.
�,� :_..��� If you are interested in receiving - _
, �:.� ,���,�.�;�::� . .�-4..-�:���.�.���,��.
w.._.
. ._ , ..-� . . a monthlystatement ,�,,..4:. w. .��.�� ,._
� � electronically, please contact :; �,.�
your business office at the center �=�� ,; �.� �
� � � If you would like to pay online, ""
• � Balances not paid by Medicaid Pending or please visit the following website: �
�`` Insurance will be the responsibility of the and enter your Account No. and: -
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�,�r' patient. Online ID. -
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Detach and return bottom portion with payment.Please make checks or money orders payable in U.S.funds to HCR Manor Care Services,LLC and
include your account number.Your payment will be applied to the oldest balance on your account.See reverse side for visit details.
Payments received after the statement date will be reflected on the following statement.
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HCR ManorCare�
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MCHS Camp Hill
1700 Market Street 07/31/2015 UPON RECEIPT `583=4689 ">`''
Camp Hill PA 17011-4817 - . . , - e
JUNE HILL $3,879.46
RETURN SERVICE REQUESTED MAKE CHECK PAYABLE AND REMIT TO
❑ Please check box if address below is incorrect or insurance
information has changed,and indicate change(s)on reverse side.
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� � TERRI POLINKA FACILITY 0583
N 829 FAIRFIELD ST P.O. Box 637602
MECHANICSBURG PA 17055-4021 CINCINNATI OH 45263-7602
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DEPARTMENT OF HUMAN SERVICES
August 4, Z015
DAVID ) LENOX ESQUIRE
8 TRISTAN DR
SUITE 3
DILLSBURG PA 17019
Re: June Hill
CIS #: 820158845
SSN: ###-##-0439
Date of Death: 05/15/2015
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Lenox:
Under State and Federal law, the Department of Human Services (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of 542.78 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely 542.78, was incurred during the last six
months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the
Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim,
namely .00, is to be entered as a priority Class 5.1 claim against the estate. You should
refer to Section 3392 for a more complete explanation of the priority rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486