HomeMy WebLinkAbout11-15-05
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REV~1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
02-03-05
I DAlE 01 RIRHI IMMDD-YEAR)
08-24-12
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i'F !\PPLlCABL EI SURVI'JII JI; SPOUSl.S NAill!, IlAS r, FIRSl, ANU MIDDI E INIIIAll
[,tIlE OF DFi\TH 'MIII.f)[) iT,\I;,
_~1 O"glll~lli(IIUUl
4 lllnlted Estete
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! (,I L ,11(]r111()fl Pfor,,8Pr!c:: p(H('j',/,.~d
[] 2, Supplemental Retulll
[] 4a, Future Interest Compromise (dele 01 deetll efler 12.1282)
[- -j 7. Decedent Maintained a Living Trust IAiled, copy 01 Tru,11
[: -\1 0, Spl)us~1 Poverty Credit Idele 01 dl'illl' helween 1;.1I~1 ,""1 11 9C"
m F NUMBEH
2.1 0 5
r.:O:JtHY (!JUE tf-,\r~
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SOCIAL SFCUHITY NUMBm
201 18
6 21
THIS RETURN MUST BE FILED IN D PLICATE WIlH THE
REGISTER OF ILLS
SOCIAL SECURI II' NUMBER
CJ 3. Remainder RetlJrtlI11:1!e of d ';lth prior 10 12.1Jfl2l
[J 5, Federal !:state Tax Return Required
o 8, 10tal Number of Safe Dep Sit Boxes
~-111. Electiun to t~x under See 9113(A) ",-"" h S," !'!
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL tAX INFORMAtiON SHOULD B DIRECTED TO:
I JAME COMPLETE MAILING ADDRESS
Stephanie J Baylett
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F II'.M NAME ,'I ^''I'i'' at",,,
TElEPHOI.JE NUMBER
717-763-0355
Real Estate (Schedule AI
Stocks and Bonds (Schedule B)
3810 Chestnut Street
Camp Hill, PA 17011
(1)
(2) ---
(3)
(4)
(5) -+-~~-6--.-42
(6) -----AQ,.15.4 . 46
(7) 84,427.33
-------"
Ctosely Held Corporation, Partnership or Sole-Proprietorship
Mortgages & Notes Receivable (Schedule D)
5 Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
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6 JOintly Owned Properly (Schedule F)
[J Separate Billing Requested
Inter-Vivos Transfers & Miscellaneous Non-Probate Propelty
(Schedule G or l)
8. Total Gross Assets (total Lines 1-7)
9 Funeral Expenses & Admimslralive Costs (Schedule H)
(8)
(9) 9,380.28
(10)_~_________~l 070.57
(11)
(12)
11 Total Deductions Itotal lines 9 & 101
10 Debts of Decedent. Mortgage liabililies, & Liens (Schedule I)
12 Net Value of Estate (line R Illlnus line 11\
13 Chafltable and Governmental Bequests/Ser: 9113 Trusts for which an election to tax has not been
made (Schedule JI
1.1 Net Value Subjpct to Tax lime 12 1Il111US Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15 Arnount of line 14 laxahle al the spuusal tax
ralr, Of I';;n':f'% under 58': 91H) !a)(121
1 G Amount of 1.111e 14 laxilble ;1\ IllIeal rote
17 !ltY10Uflt flf l WH.) 1'~ \CjY.c-ltdp :11 :)ihlllH:.1 :~1t(J
1;~ h,Ir1(jlllll L'!lr~ 1.'t trlt,;ddl' ill [J.lli-1tf:'1;11 r;lIf>
T~x Uur,
t \~ i I! 11\1 I ;'-~I
13_6.,5
(13)
17 450. 5
.1.19..,-103~ 6---------
500. 0
(14) ________lJ,f3J.9.9). .11________________
xO _ ____ (16)
x .0__ (15) _~___
(17)
(1i1) _
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17,790 50
x 12
118,603.36
x 15
(19)
X, ~~:~EJ]~.1Ir~.J~I~;.'I~{crJiJ~i!J~;J.J~~I.~l43ii;J:,Y.l'I':l~11
------------------------ - - - --------'-----------j-- ..-----..---
> :-- BE SURE TO ANSWER ALL qUESTIONS ON REVERSE SIDE AND R.ECHECK MAnl < <
-1--
Decedent's Complete Address:
S1 RE ET NJDRESS
4 West Manor~A\fe
CITY
.. _._._-----------?~~
Enola,
Tax Payments and Credits:
1 Tax Due (Page 1 Line 19)
2 Credits/Payments
A. Spousal Poverty Credit
B Prior Payments
C Discount
T:~;
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(1) __~---1.],
I
(3) -t
(41 =-=~~-f.~3-=--
(5) ___._---!-____._~
i
--17,090.90--.-
. --889.53--..--
Total Credits ( A + B + C )
(2)
3.
InteresUPenalty if applicable
D. Interest
E Penalty
4
TotallnteresUPenalty ( 0 + E )
If Line 2 IS greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A Enter the interest on the tax due.
(5A)
(58)
B Enter the total of Line 5 + 5A This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
.50-----
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;................. .
b retain the right to designate who shall use the property transferred or its income;
c retain a reversionary interest; or ......................................................... ......_.........
d. receive the promise for life of either payments, benefits or care? .......... ................
If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?.. ......................
Old decedent own an "in trust for" or payable upon death bank account or security at his or her death?.
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ... ............ .. .. ..... ......_................
Yes
... [Xl
........... ..... IX]
[]
....... [J
2
.... []
[]
3
4
No
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[]
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. .10' I ,;c.,i"", 'i V;I!'I'" I ~e'.I;1le Ihill ! "0'''' PYilITII""rJ IhlS relllrn. including a<:compilnying schedllles and statemenls. and to Ihe best of my knowledge and belief. it is true, cOllect onr) complel
:j'a:'(lr1 ~:I prprl:jlpr (ltrler tlla:l the person~~lHese!llatlv.::.,is based on all information of which preparer has any knowledge.
PA 17011
ADDRESS
POBOx 326 Port Royal, PA 17082
rC'1 d8te', of death 011 or after July 1 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving s
i72 PS s91161a) 111) (iil
rC'i dates uf ,jeath 'JII or aftel January 1. I'J%. the tax rate imposed Oil the lIet
The, st81ute (,iQe'i.QfJLejj;llwJ a transfer t" ,1 S'II \lIving spollse fro III tax, and the s
the ,ur'Jl/lng spollse IS \he only benefiCiary
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Pei dO G'lJ
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viving spouse is 0% [72 P.S. ~9116 (a) (1.1) (il)].
and filing a tax return ar still applicable even if
r", da\i.,s 'jf (je,Jlh on ell alter ,Iuly 1. ,'(11)11
"7u~ 1;:1. ';it~'J :"l!'I.;'J'll r}II U10 ne1 "';11111-' (If lr.-1W_,[flli; fl:1I!1;1 :\Pf'f~;)'_:crl t,11ild Lvellly.,
"", ,I"II),!IPI': 111' (h:l<I j, (I'" Ii.' f": ij"11r,[;I)1 \ '))1
r tile use of a lIalul all'arelll, all adoptive parent
, I
1(1 I: [("II lid, q.;(1I)f 11:11 dF'-~(If-.;'!lt"
in It' f'.S.SC111fi( I)) [T,! f' ,; s!ll1G(:l'( 1)\
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:\' 'I(,~, :1;,1: jll', It) fit fnr 1I1P lIS(~ {If lhp. deC8\
" ",1,,'1 :.1", I'T 'I! ;",!',II:"'" 1"''''''1 'i '1'11'1111111 Will! the (!f:rl)denl. whether by hlood or adoption
"-IJ A silJliny IS defil!rrJ, !lIulfir Secltun 91()2. il'; ;111
Pj "/P,ff. ,1 971
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
!1:>!,IW)NWEAl TH OF PUJNSYI 'JAIII!I
INHERIT AI Jel: TAX I,UlJmJ
RESIDENT DECEDFtH
ESTATE OF
INEZ 0 ERE
FILE NUMBER
21-05-00146
I
I
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 disclos d on Schedule F.
ITEM
I~UM8ER
1
2.
3.
4.
5.
6.
DESCRIPTION
Miscellaneous Cash On Hand
First National Bank of Marysville
Certificate of Deposit #3062492
Irrivocable Burial Fund DOD Value
Metropolitan Insurance Company
Proceeds for Water Damage to Home
Received after Death
state Retirement
Rece~ved after Death
2004 Federal Income Tax Refund
Received after Death
Money received from miscellaneous refunds after Death
_J
TOTAL (Also enter online 5. r~ecapitlllalion) $
. ___._.._____________,_______ .n __..._,,_._.___..__-.._____._,_____.____~.____.__._
(II rl1un~ SP:1IP is neednd. insel1 additional shE'pls of the same size)
VAl UE AT DATE
( F DEATH
65.00
Sf415.S9
2 768.34
843.79
1,080.00
11,199.70
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11,372.42
PFJ.''3f'flf:.:. p ~T;
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMOt~WEAL TH OF fJENNSYI 'JMM
I~JHERITANCE TAX RETUfU,
RESIDENT DECEDEtJT
INEZ D ERE
FILE NUMBER
21-05-00146
ESTATE OF
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
Sc!f,'jIJING JOII~T fHJAIJT(S) NAME
ADDRESS
RElA IONSHIP 10 DECEDENT
A
stephanie J Baylett
3810 Chestnut street, Camp Hill, PA 17011
Gra d Niece
B.
c
JOINTLY.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM fOR JOINT M~.DE Include name of finanCial institution and bank account number 01 similar identifying number Ailach DATE OF DEATH DECDS VALUE OF
: 'UMBER TENANT JOINT deed for jomtly-held real estate. VALUE OF ASSET INTERES r DECEDENT'S INTERES r
A. 2/17 /
96 M&TBank
Checking Account #31008038 13,758.73 50 6,879.37
2. A 4/01 M&TBank
Certificate of Deposit #31003913939400 67,750.17 50 33,875.09
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
40,754.46
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VJMMOIJWEAL 1 H OF PENNSl'l 'JAtII"
ItJHERIl At~CE TAX RETURIJ
RESllJEl1T DECEDENT
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
ESTATE OF
INEZ D EB1L-~_________________
FILE NUMBER
21-05-00146
TillS schedule must be completed and flied if the answer to any of questions 1 through 4 on Ule reverse side of the REV -1500 COVER SHEET is yes.
-~------r------------DESCRIPTlONiJFPR6PERTY --------- ------ % OF ----
ITEM 'c';. TII! rJM.1r ,r~r:~;~:'~fH~: ~C:~_I; ~~~~I~:;I\lr~g~1:~~[;;~:i.~tl~!~~~~; MW [liE P"~T OF IRNJSf[H DATE OF DEATH DECO'S EXCLUSION
tIUr~8EP _______________ VALUE OF ASSET _INTEREST (If APPIICABLE)
1
Residence located at
4 West Manor Avenue
Enola, Cumberland Co, PA
17025
Transferred by decedent to ni(~ce.
Decedent retained life interest in real
estate which was noted in will.
Real Estate sold 8/12/05 as per settlement
I attached
ooD Value based on selling of home price
87,427.33
100%
3,000.0
TOTAL (Also enter on line 7, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
I
TAXABLE VALUE
84,427.33
84,427.33
Pf'.i\I)I\O .(1-':<,\
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEAL TH 0, PEtlW;Y\ VM-IIA
INHERITAr.CE T^X REIUPN
RESIDENT DECEDEtIT
ESTATE OF
INEZ D ERB
Debts of decedent must be reported on Schedule I.
~ ----....---_...... -. ._.-.._----,~._-~------._- --.,,----_...__.._-~---+-_._-----_._----
ITEM
NUMBER DESCRIPTION
-_._~---- -FUiJ-ERAL"6(PENS-ES:-----------------
B.
1.
Funeral - Michael J Shalonis Funeral Hane
2.
Engraving of Memorial - Frank Snyder & Son
1.
ADMINISTRA liVE COSTS
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City--
State
Year(s} Commission Paid:
2.
3.
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City__
Relationship of Claimant to Decedent
State
4.
Probate Fees
5
Accountant's Fees Preparation of Estate Return
6
7.
8.
9.
10.
II.
12.
13.
14.
15.
16.
17.
T ax Return Preparer's Fees
Estate Notice - Patriot News
Cost to have water damage repaired in home
Cost of Electricity to shut off
Cost of Telephone to shut off
Cost of Gas to shut off
Cost of Water until shut off
Cost of Oil
Cost of Sewer & Disposal - final bill
Real Estate Taxes Paid (Refund inc. in sale)
Refund of State Retirement payment
Cost of Home Insurance until sold
-.- . - -
FILE NUMBER
21-05-00146
lip
lip
--_._--. .._.-~---_.._-- .----.--.-...- -----. -.. ---- ----.-- ...--....- ---.-' - --~_...__._-_. ---~
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
4,254.00
114.00
58.00
500.00
1 94. 1 0
2,451.25
51.25
33.87
39.69
44.20
422.95
115.00
184.99
856.98
60.00
,9 ,J 00 .28
D' r.} Q'
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!,!t~__\1' ,
!f{l't{}l) ,\'~
"r, ';,?~~'.?;r,'.,
:, :,' ,'[ P' F'cIH:',,'1
,',.11 ':I;!,JVl 1/1/ f'>f TUf.:~:
SCHEDULE I
DEBTS OF DECEDENT,
U'7. ,,~Q~TG,A~E LIABILITIES, & L1EN?_,n'=~=7~~___-_'~
FILE NUMBER
21-05-00146
EST ATE OF
___n _, ,IJ'U~:~_lLEEill
Include unreimbursed medical expenses,
I r:=M'-'--r'--- 'u,"
I IIH,IBty I
DESCfWTlmj
.-.--.------ _._."~_._---~-----_._-_._---~---,----_._-----_._..-
Telephone Bill Paid 2/9/05 Verizon
2.
Electric Bill Paid 2/9/05 PPL
3.
Sewer & Disposal Paid 2/9/05 Pa Am Water Co
4.
Gas Paid 2/9/05 UGr
5.
Oil Paid 2/9/05 Shipley Oil
6.
Nucsing Home Paid 2/9/05 Manor Care of Camp HIll
7.
Perscriptions Paid 3/8/05 Neighborhood Care
8.
Preparation of 2004 Taxes Paid 3/9/05 Sylvia Kepner
9.
Physician Paid 3/10/05 PhilHaven
10.
Nursing Home Paid 5/24/05 Final Payment Manor Care
11.
Physician Paid 4/18/05 PhilHaven
12.
East Pennsboro Anmulance Paid 5/26/05
(If 111018 SUiJl;e IS Ilc<.:ded, insert additional sllPets of the same size)
TOTAL (Also enter un line 10, Recapitulation)
,"'.MOUNT
41.07
53.60
11 .81
9.80
387.58
5,000.00
676.16
40.00
18.73
1,693.09
18.73
120.00
$ ~,070.57
--------1
:lfYF,n lX. I'HJUj
,V:.l~.1l: 9...
1-". \\-ili', '
."",~.-,~$fl
SCHEDULE J
BENEFICIARIES
u J~.~r.1UNWI.1\1 "11101 I'll nJ';(1 VMIII\
ItlllFHI r I\~JCf: 1l\X Ill' 11'1 ilj
Rr';lfJEI,r [IF:CFI)FlJ1
ESTATE OF
IIlJl.IIH:H
,
INEZ 0 ERB
IJAlvlE 1'1-.111 III.1UHLSS OF PERSON(S) RECEIVING PROPEHTV
T llYN\[ [ [)IS rl11R1 iTl()IIS [inclildp outright spousal cilslrihlltiollS. ,Hid transfers lllldpr
~-;P( ql16 (il) II?)]
stephanie J Baylett
3810 Chestnut street
Camp Hill, PA 17011
2.
Dorothy E Heller
3810 Chestnut street
Camp Hill, PA 17011
FILE NUMBER
21-05-00146
RELA110NSHIP TO DECEDENT AMOUNT R SHARE
Do Not LislTrustee(s) OF ES ATE
_n.. __._____._ __________.______~_..~. _~_._.__..__n_"_______
Grand Niece
Neice
--'.
II NON-TAXABLE DISTRIBUTIONS
A. Sf'OUSAL DIS TfW.3IJIICmS UNUE~l SECTION 911:1 FOR WHICH AN El ECTION TO 1 AX IS NOT BEING MADE
1wo-Thir s (2/3)
Residue f Estate
One-Thir
Residue
( 1 /3)
f Estate
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18. AS APPROPRIATE, ON REV-1500 COV R SHEET
, I! Ill/If' (:Iq{ r, I'~ rp)nf!(ld. il1sptl dddiliOIl\l.1 sl)(~p!s of 1I1P ~;;-H1H) ~~izr)
500 00
[(Hi" I \IF I'MlT II i II i I II I'll/II 11111.j I fIX AHII I!I'; rl11111 JIIONS ON LINE i:lor nEV 1 SOD COVEll SH[ET $
50 .00
G CHI\RITABLE A~II) GOVEF1NMENTAL DISTRIBUTIONS
1 I
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Enola Ernrnanuel United Methodist Church
j".A:J/ WILL AND TESTAMENT
OF
!NEZ D. ERB
I, INEZ D. ERB, widow woman, of Enola, East Pennsboro
Township, Cumberland County, Pennsylvania, being of sound and d sposing
mind, memory and understanding, do Ilereby make, publish and declare this to be my
Last Will and Testament, hereby revoking any and all Wills and Codicils previ usly
made by me at any Jime I-leretofore, specifically my Will dated 27 June 1990_
FIRST: I tlereby direct that my personal representalive(s), tlereinafter named,
H
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N~
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to pay all of my just debts, not barred by any statute of limitations, as well as m funeral )
),. )
and testamentary expenses, including Pennsylvania Inlleritance Taxes, as so n after
my demise as may be practicable.
SECOND: I hereby specifically bequeath FIVE HUNDRED ($500.00)
DOLLARS to the Enota Emmanuel United Methodist Church on Salt Road, Eno a,
Pennsylvania and FIVE HUNDRED ($500.00) DOLLARS to each of tile followil g if
they survive me:
A. to Iny grand niece, STEPHANIE J. SA YLETT;
B. to my grand niece, RUTH POTTEIGER;
C. to my grand nephew, WALTER WHITE;
D. to my niece, PEGGY HA YMAN;
E. to my brother, SAMUEL WILLIAM DILL; and
F. to my brother, HERBERT DILL.
x----
. ,\
. .
T H I R 0: All tt1e rest, residue and remainder of my estate, I hereby give,
devise and bequeath as follows:
A. TWO-THIF~DS (2/3d's) to my grand niece, STEPHANIE J. BAYLETT;
and
B. ONE-THIRD (1/3d) to my niece, DOROTHY E. HALLER
BE IT KNOWN THAT, as of this same date, I have
conveyed my residence known as 4 West Manor A venue, Enola,
East Pennsboro Township, Cumberland County, Pennsylvania, to my
niece, DOROTHY E. HALLER, reserving a "life estate interest" for
myself.
FOURTH: I hereby nominate, constitute and appoint my grand niece,
STEPHANIE J BA YLETT, as Executrix of this my, Last Will and Testament. In the
event that my grand niece, STEPHANIE J. BA YLETT, predeceases me, fails to qualify
ceases to act, or for some reason is incapable of performing such task, I then
nominate, constitute and appoint my niece, DOROTHY E. HALLER, to act as
alternate Executrix of this my, Last Will and Testament.
,,1 ( -
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F 1FT H: None of the above named persons sllall be required to post bond or
surety in this or any other jurisdiction for faithful compliance of the office of Executrix.
IN WITNESS WHEREOF, I hereby set my Iland and seal and
declare this to be my, LAST WILL AND TEST AMENT, consisting of t1lis and two (2)
other typewritten pages, identified by my signature, dated on this,
tile '1~ay Of~J~____,19_<{0_
~~5-lJ_&'--J-.
INEZ GO. ERB
(T estatrix)
The preceding instrument, consisting of this and two (2) other typewritten pages,
identified by the signature of the Testatrix, INEZ D. ERB, as Iler Last Will; WllO at her
request, in her presence and in tile presence of eacll other Ilave subscribed ur
names as WITNESSES hereto.
jJ~~L.._/~_ReSiding At Y i(/~~~l~~e.L'~'-1fgp<<-
_1{( V?l _~~~~___ReSiding At i/-cLd'L____
-
COMMONWEALTH OF PENNSYLVANIA)
)
COUNTY OF CUMBEnLAND )
~-- ~. (2)
~- ~C.?__ .___C~b________, __81~~J Gc~~__________, AND
~___ ":U~t~_ :-:1~~l.11e Testatrix, and the witnesses, respectively,
Wh nallleslar - signed to tile attached and foregoing instrument, being first duly
sworn, do here y declare to the undersigned authority that the Testatrix, INEZ D_ EF1- ,
signed and executed tile instrument as Iler Last Will, and tllat she signed and
executed it willingly, and that she executed it as fler free and voluntary act for the
purposes tile rein expressed, that eacfl of the Witnesses, in tile presence and hearing
of tile Testatrix, INEZ D. ERB, signed the Will as witnesses, and tllat to the best of au
knowledge and sight. INEZ D. ERB was at the time eighteen (18) or more years of
age, of sound and disposing mind, memory and under no constraint or undue
influence
iNr&2t::iJt~EdL --~----
(Testatrix)
[)2~~r-~~.j~-
WITNESS {
J.J <;' /J
/L~~ ~ (It-v..-Z----
WITNESS
Subscribed, sworn to and acknowledged before me by INEZ D. ERB, the
Testatrix, who personally appeared before me, tllft.~r ndersigned officer, and
sUb~~.rib8(j to a~ swO{n to by tile WfTNESSESc:iiili.\~~ and
__:~j C.(.tL":\J _, on this, 0 .,
the '(- day of 2:7 \. 'A(:, .
-cJ~~~____
G6TARY pusLlc-
My Commission Expires:
Notali'll Seal
Donalrj B. Owen, Notary Public
filSI penn~bor.~ Twp., CUIll!Jt;iland Countv
Ill,' CO!llfl1l!lSIOn Expirf.\!1 Nov, 24. 199c;'
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B. TYPE or LUAN.
..__. .._.u...___.__.._______._..___._.___________________
1 UFIIA 2 [JrlIlIlA :I DC\JNV UNINS. 1\ OVA !, lliJ ;mlV IN:>
G~.~~~[;~_~IBi=:~~=_=_==_ _ _t. Wt~~~f3m:.n____r-___'
fl. MUR I (;AGE INS CASE NUMBER:
lJ S. DEPARTMENT OF HOUSING & UlmAN UEVELOPMEN I
SETTLEMENT STATEMENT
r 1')11 1/1/"; (01111/'; illlll1s/I"'( f,) p,ve YOII iI .',(illel1lelll o( f/c1I1<1I.~ell/eI1lCIII cosls. A,lloUllls pAitl to Alld by IIIe sell/emelll Agelll me Sf,OWII.
11"111.'; l11a/A",1 "11'UCr \\('1/: (1:11.1 011 hi"" file c/OS/IIY; flley ille sllowlI (,e/e 101 ill(ollllal;ollal p/llposes alld me 1101 illcluded illllle lolal".
1.0 \(~lD (O~),lG~;:O~dGG.',")
r lid.l[ hll!) !I()[)PF S!; 'IF IIU''',' II/VI"
i!1,L'()ll/.J ~,nlltl1
';tqllrilllie J. Ibylull
L. IJArvlE AND AUOnESS OF Sr-:Ll.F1~:
F. NAME AND AIJUnESS OF l.[hID .n:
" Pf,uPEPTY l.UC!IIIUH
1 '/j'~',f r,,1;lflfll A.;eIItH;
i ",,1:1. PA 11025
, ,l/fIlIH'd;'lrld (>HHlty, pnlll1~;y'lvi-:lltifJ
H. SETrl.EMEtH AGENl:
I\cystolle l.i.1l1d TI<1IIslel, Lid.
Pl.ACE OF SEt fLEMENT
3421 Markel Street
Camp Hill: PA 17011
J SUMMARY OF RORROWFR'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: ----c:---
!!)~ C''''~l Sales f'~___._____ %,000.00
1 r~'_~~Sf')tl(l1 Property ______
"~:' 'i~tll'~""~llt CI1i11g~S II) B()~)'N(:.rJ.l:~le 1 .1~.Q)_._..__. .~.JGI.Ol\
: '.1
~ I \ r ,
n--'~'/sllllP"IS for Items I'alll l3y Sell'll ill il':!.YiJI~~ ._____
1,,1t....~~rO'.'m T,D.es .._t~~______
"17 (;uulllyTaxes 08/12/0~; 10 01/01/06
",/1 'jCh001 T8X 08/12/05 to Ol/OI/OG
---
l'f. Sewer 08/12/05 to 10101105
68.16
613.61
62.50
110
111
112
1/(). (,ecoS:; AMOUNT our FfWM nowwwu?
H9,501.31
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER:
. '11 D'?posit or earnes~.'..'~. L- 1,000.00
.. Pn"Clpal/,".'rJunl of 'Jew L~L___ ____ 7G,000.00
':..... Exl'2!.'.'..'(,J 1'''lll~~ell s\ll>l0':\ to.uu_________ _____
,I PtlTl'.lpal f'!llt vi tJew l.uan(s)______ 1.I,2GO.00
.,
, 'Ir,
.-.---...-..-....--
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"I;
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. .-;;-=~~lll,;r;~'_~21_-==__--=~~=-~=-~=-_~_===-l_~.'suo.OO
;1r~rl1JfJ/)l, rev Itpms fJlljJalrl Ill' Snllf'1
'-r :~I~T,:.1l T~;-,-;,:----.------IO.=_~~~_==l====
~ i.~~!L_~~~__________.__~~__~___._.__L______
,"~~""'=~ ..~__~~~~ 'u ~~nJ -~:=
..--...--- ..- ---t--.------
.~ -=-~.~-~~ r..:~=~~===--=
! (J iN ",\lnI3 t'1 ()f( IlOW,UWffi
97,7:'0.00
,r".1 CASH AT SETTLEMENT FHOMIIO BOIm()W[f~:
(1rrj";' l\fl_~~1~1!~~)~_~:.~!:~'__~~yrrfJ'!./p~.~1 i'lr~ 1){l)
: {'~,'; /'III"ltllf P;lirl H}'Tllr BflrIO'.-\'Pt (I IIIP ))(1)
.. . JHI,~;(!1 ~\7
97,7:,f)f)())
I
"r., fl':"~/', (1)"".'/'(,"'\'''''' 1 li./!"il:Jl
~__.___"___l_.____.__
COllnlrywide II00ne Loans
tI/DO Cnrlisle Pike, SlIitR D-16
Mech<lnicsblll[}, Pa 1"7055
25-lfl7mJIS
. .-.- c-----
I. SElTLE~ENl DAlE:
AlIllllS\ 12,1;100:'
K. SUMMARY OF SELl.ER'S TnANSACTION
400, GROSS AMOUNT DUE TO SELLER:
1\01. Conlract Sales Price
1\02. Personal PlOpelly
1\03.
1\01\.
405.
-------~-------
___.Muslmellls Fo/ltems I'aid By Seller ;11 advAllce
,lOG. City/lown Taxes 10 ._._.
1\01. Counll Tnxes 08/12/05 to 01/01/06
1\08. School Tnx 08/12/05 10 OliO IIOG
1\09. Sewer 08/12/05 to 10101105
tll0.
1\ 11.
1\ 12.
-" 1-----.--.-
\_+____~',OOO.OO
. -.. 1----
GB.IG
f-__J!.lJ67
62.50
420. G(?OSS ilMOUNT DUE 10 SEU U?
'l:" l 'I'I:U
500.
501.
S02.
GO~\.
SlJ.1.
505.
REDUCTIONS IN AMOUNT DUE TO SELLER:
Excess Deposil (See Instr!JClions)
SeltleI~1Cn~_Charg~~ Sel~l.ine 14(0)
Existing 10<ln(s) taken sulJjecllo
Pnyorl 01 firsl Mortgnge
Payoff 01 second MOIlyaye
,-f--------.
-f------
G,B 1700
.----
----
._--
50G.
.~Q7:J!2cposit disl>. <IS proceeds~_.__~______.._.____.._u__
GOIl.
SOH. Seller Assist
-.--
____._~'lj(Jslmellls (01 Items UllfJ:J((II}x. Seller
510. Cill!rown Taxes to
5J~~ulllyl nxes to
512. School fnx to
513.
51,1.
-------
1,500.00
] 1-----
_._--_...;~~
.- - ----
S-lS.
!j !G.
!, II.
--.-----.--
!dB.
-_._---------------~-----------_._--
51\!
--
------
-------
520. 70 r/ll. (?FlJllGT/ON ilMOUN r DllE SULU?
B,31700
60U. CASH AT SETTLEMENT TO/mOM SELLER:
~_._----------_._-------+-_.._---
(jQ~,_c;r~~21\~lIf)11l1.I.D.t.!9](I_S~II!C.rn~~1~_'~~(~___.__.. .._u_ __ r-__~!),!~Ll~1
GO/.. Less "eductioll" Due Selic! (Lillc 52il) (n,:\ II.O!)
(;(U 1:/\511 ( X /(l)( IfWM) SFUU~
1\7,'1)1.:\1
------
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I
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ITEMS REQUIRED BY LENDER TO BE "AID IN ADVANCE
1,,1"''',111,,111 (1(\/1//[):, I" n(~~~~l'i ({jl___!.__2LL!.!_~~/d,lY___._L~_(~~__~____._ /J .7ll
-lll~~t_lr;:l'l;'(~ f~lelni(llll rOf 1I1011lhs to
----~------_.._-_.- -~_._------>-_.._~--------~------------ ----,----------
ll,l/~\~~L~'~'_~~~.'.~_~:~,__l~~~_t,\il I!ll f, If _ _~l.~O __Z':!_~l'_~____~~~_~_________~____ ________~_____.~___.______. ._ _____~______
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_____.'~1()2.'111~~_@_~_____.__[)e.r_')lO'~tll____.______.____._.___
mn_ .._---".~21'111!Ln@_.L_____.. __LJfJr--"~')_'_'II~______n_____ .___ ....__m__
_ :',~J_~~_")(_"..llILSm@_ ~_____~'~QIl..I)C_'_'lI~H2'11 . ...__._._.1...!. l~~_____
,IOUU 1111)lIll1s @ $ 51.19 per 111011111 231 lli
..-_m-~..===-='I2\i1.ii[~s-@-$-----I!~!...i~j~lllIl ==---==- = ~--::==--=~
_______"1.IJ!.!jt~~iL $ per.-'I121!111 ___ -- --------
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WANDA BROWN - Re: Prod - Date of Death Request
Page 1
From:
To:
Date:
Subject:
DATE OF DEATH REQUESTS
BROWN, WANDA
3/21/20059:49:19 AM
Re: Prod - Date of Death Request
The balance on the Date of death: 02/03/2005 for deceased customer: INEZ D ERB
TIN # 201-18-6321
Account Number: 31008038
$13,758.73 balance + $ 0.00 accrued interest = $13,758.73
Account Number: 31003913939400
467,723.62 balance + $26.55 accrued interest=$67,750.17
>>> <EBRNG2N> 03/14/05 9:34 AM >>>
Account Information
Date of death: 02/03/2005
Account Number: 31008038
Product Type: Deposit Account
Account Number: 31003913939400
Product Type: Deposit Account
Request Details
Deliver to: Requestor
Delivery Options: E-mail
Delivery Details: EBRNG2N
Current Date:
April 29, 2005
Account Number:
Capture Date:
Item Number:
Posted Date:
Posted Item Number:
Amount:
Record Type:
3062492
February 08, 2 05
30005996864
February 08, 2 05
5996864
$5,415.59
Debit
INEZ l ERB
SHAlONIS FUNERAL HOME
3810 CHESTNUT ST
CAMP Hill, PA 17011-0000
CERTIFICATE OF DEPOSIT
NO!4 TRANSfERABLE
FIRST NATIONAL BANK OF MARYSVILLE
10111NCOlN ST., BOX B. MARYSVlllE, PA 17053
30624
2
551_201-18.6321
(Inez)~2627S
- INTEREST PAYMENT OPTION
PAYEE'S).
o MONTHLY
DOUARTERLY
IXXf:MI-ANNUALL Y
D AT MATURITY
IjCji:APITALlZE
D OEPOSIT TO
o MAIL CHECK
~IJMCf pona"irn; f;Jl P9~lJry. I CEtrtify (1) '~t the nLRf1bt>r ShcWfl 00
Ihis fOf1l1 ffl my COfT8C1 taxpayer tdenftflc..1Mn nUmhm, and (1'1 thi1t I
om not subject to backup WllhholdlnQ. 81lflef because I have not
been notified thai I am sullied to buclc:lJP wlthhokU09 89 a fe9Ut 0' 8
lai1ure 10 fepon an inleresl or dNldencls or the Inll'lmnl Rf!vnn1l9
~I'lNlf.8 has nnttli"d mR that t am 1"0 klOgfllr ~t1bj8d 10 backup
Wllhtl(lkf"19. I also certify lhat mlruclioos regarding re9ponS9 10 It lIS
r.ol1ificallon have bOOn prOVldAd 8M t',.plamed 10 .....9. ~
()
C
en
...
o
s:
m
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rn
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~
_IDE~:;LL_Erh AND
Shalonis FUneral Home
An Irrevocable Trust
3810 Chest!)Ut_St
__'<:<m1f>_J:lULPA 1701L__
Clr(, STATE liP
$\.51 I S.sr
~~I~t:~OUNT O~:'~i:'~~)::5! Q_O 0 en fs 0 Q_9J~ ____ DOl~:~:JrO
PAYAOlf roWF NO.MEn PAYFflS} UPON PRESENTATION OF TlUS CERTIFICATE. PROPERLY ENDURSED, ON lHE MATURITY DATE. INTEREST Will BE PAID AS AGHEEO.
SUBSTANTIAL PENALTY FOR EARLY WITHDRAWAL
CUSTCJ""lA MUS I SllcCl (1111"H UPTlON BEL ow.
Xlll A11l0MA11CAllY RENEWABLE. THIS CEfHIF'CA IE W'lL BE RENEWABLE AllTOMATICAl.l Y fOR
At~ ,AJOlTltl'''AL PE~10D on PERIODS FO\JAt TO THE ORIGINAl Tf:nM or. HiE CERTlFICA1E
"'NO AT THE nHFr1EST q^TE IN FFFECT ON tHE RFNFwAl DAlE UNLESS POESENTE.O Fon
PAYMmT WITHIN TEN (101 DAYS Of THE IJATURITT DATE.
_1-3-03 2:119 ____%_~_-=3-oI:L..._ _ue...ars
15SUE DATE ANNUAL HATE MATUHITY DATE (Jj)
6~":;ytJ'~$ :~l1n1J"'l;l 'uUl
~OOG!BO!LO :~~~a sns
..~
~~
,~
, -".!,
., J,
.'" ;.
Z6tJi:90LOOOOOOOOO- [pI",I])
LCGOO-~OG-1QUO-1000 Lr:cl r,On(!~D!ZO