HomeMy WebLinkAbout01-20-06 (4)
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~I,' S~~;~~~~U~~~;~MBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
--- --t ~ SOCIAL SEC~~~I:U:~~ OF~ILLS__
I
-~ ~" ~ 1 ~n()rigi;;;;lR~tur~- -U-2. Suppl~~ental R~t~-- -0 3. Remainder Return [dite of deaif,pnor to 1:2-= 13-82) ---
" :! III '0 4. Limited Estate 0 4a. Future Interest Compromise (date of death ~ 5. Federal Estate Tax Return Required
o g:: 5 after 12-12-82)
~ :i1 g ,0 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach 0 8. Total Number of Safe Deposit Boxes
o ~ m~_ 9. ~~t:~iion Proceeds Received 0 10. ~fE~~rE~v1~~~~redit (date of death behveen ___0 11.Election to tax und~~sec 91~=(A) (Attach Soh 0)
l!.H~~~Tl(:?!'Lt.1~ST ~.5=OMPL~~!l:I). AU...~ESP()NDENCeAND.CONFl~ 'tAXIN~!1Ql'! _Q!.D BEDI~~tO: ~
~AME I COMPLETE MAILING ADDRESS
I Julie M. Cooper I
t--rIRMNAME (If appllcablej- ~--I
. Gingrich, Smith, Klingensmith & Dolan I 222 South Market Street, Suite 20 I
~ELEPHONE NUMBER --- '- ----- Elizabethtown, P A 17022
I 717/367-1370
REV -1500 EX + (6'{)())
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17121l-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'I FILE NUMBER
21
, COUNTY CODE
05
YEAR
0513
NUMBER
~~ECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) .
, SHIPE, LESTER K.
~ ~()F DEATH (MM-DD:VEAR)-i DATE OF BIRTH (MM-DO:YEAR) -
o '
M ~127/2205 _____ 12/29/1917_____
o (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
'1-
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00-
--I
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
88,805.70
None
3. Closely Held Corporation, Partnership or Sole-Proprietorship
None
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(9) 24,86~U4
None
-.,
(5) I 9, I 07. ()]
... ",
',:\./
(6) None
1".)
c~:
(7) None
(8)
107,912.71
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(10)
43,403.72
11. Total Deductions (total Lines 9 & 10)
(11)
68,272.06
! 12. Net Value of Estate (Line 8 minus Line 11)
(12)
39,640.65
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
, made (Schedule J)
I
--1. ~et VaIUe~Ubj~ct to Tax (Line 12 minus Line 1 ~_ _ _ _ __~~~_____ (14) ~ ___39,640.65
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15 Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec 9116(a)(1.2) - - -- _ ___ ___
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39,64065
(16)
16. Amount of Line 14 taxable at lineal rate
x .045
1,783.83
17. Amount of Line 14 taxable at sibling rate
x .12
(17)
18. Amount of Line 14 taxable at collateral rate
x .15
(18)
19. Tax Due
(19)
1,783.83
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
I 20. ~
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>> BE SURE TO ANSWER AU... QUESTIONS ON REVERSE SlOE AND RECHECK MATH <<
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
24 Palmer Drive
CITY
Camp Hill
STATE PA
ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
] .783.83
2,00000
Total Credits (A + 8 + C)
(2) 2,000.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
4.
Total Interest/Penalty (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
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.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
0.00
--_._-"---
216.17
5.
(5)
(5A)
(58)
0.00
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 ~
b. retain the right to designate who shall use the property transferred or its income;... D ~
~: ~:~~~: ;;;~~~~:~f:rt~;:~~ ~~;~.~; .~~.~~~~;~:. b~~~~;~ ~; .~~.;~;......................................... ............. ................................ B ~
2. ~:~~~~~g Oacdce~~:~e ac~~s~:~~:~~r.1~....1~~~...~i~.~~cedent transfer pr~~~~..~it~i~.~~~ year .~f..de~t~..~ithout D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... D ~
4. ~~~t~~nc~e:~~~i:~I~~~~~::iO~~ir~~~~t.~.c.c~~~t:. annuity. .o.r.ot.h.e.r .n.on.~~r~~~t~ .~r~r>e~ .~~i~~......... D ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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
peclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. _ ~__~
SIGNA.TURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS 222 S Market St., Suite 201 DATE
Julie Cooper, ~;~~ P O. Box 267 )
ill. ',f) (.J-Vt Elizabethtown, P A 17022 - /R- 06
SIGNATURE R ON RES ON~ORFILlNGRETURN--ADDRESS-- -- - - - - - DATE
----..---.-.----..-..---.-.-...---.----........--------
ADDRESS
DATE
222 South Market Street. Suite 201
Elizabethtown. PA 17022
For dates of death on 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 spouse is 3% [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%
[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 twenty-one 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% [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%. except as noted in 72 P.S. 39116
1.2) [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% [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.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-'1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
COOPER JULIE M
222 SOUTH MARKET STREET
ELlZABETHTOWN, PA 17022
nnnn fold
ESTATE INFORMATION: SSN: 031-22-7804
FILE NUMBER: 2105-0513
DECEDENT NAME: SHIPE LESTER K
DATE OF PAYMENT: 10/21/2005
POSTMARK DATE: 10/20/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/27/2005
NO. CD 005919
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,000.00
I
I
I
I
I
I
I
I
-
- I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 1010
SEAL
INITIALS: JA
RECEIVED BY:
TAXPAYER
$2,000.00
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
.
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
--~----
ESTATE OF
II FILE NUMBER
21-05-0513
----- - -- ---- -- ---- ----------.------------- ----_..,._-~
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 excnanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
SHIPE, LESTER K.
ITEM
NUMBER
1
Real estate located at 24 Palmer Drive, Camp Hill, P A 170 II, sale price
VALUE AT DATE
OF DEATH
88,000.00
DESCRIPTION
2
Prorated taxes at settlement
805.70
TOTAL (Also enter on Line 1, Recapitulation)
88,805.70
,r
A. B. TYPE OF lOAN:
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT l.oFHA 2.0FmHA 3. I!]CONV. UNINS. 4.oVA 5.0CONV.INS.
6. FilE NUMBER: 17. LOAN NUMBER:
SETTLEMENT STATEMENT ASA-050368 77775692SMITH
8. MORTGAGE INS CASE NUMBER:
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid 10 and by Ihe seltlemen/ agent are shown.
Items marked "{pac]" were paid outside the closing; they are shown here for informalional purposes and are not included in the totals.
10 3/98 (ASA.050368 PFO/ASA-050368127)
0 NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF lENDER:
Jaye lynn Smith and Julie M. Cooper, Executrix for and Commerce Bank
Brian Hoffman the Estate of Lester K. Shipe P.O. Box 8599
24 Palmer Drive Camp Hill. PA 17011
Camp Hill, PA 17011
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 02-0640071 I. SETTLEMENT DATE:
24 Palmer Drive Appalachian Settlement Agency, LlC.
Camp Hill, PA 17011 October 28, 2005
Cumberland County. Pennsylvania PLACE OF SETTLEMENT
1229 East Chocolate Avenue
Hershey, PA 17033
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 Sales Price , 88.000.00 401. Contract Sales Price 88.000.00
102. Personal Property 402. Personal Prooertv
103. Settlement CharQes to Borrower (Line 1400) 4,085.27 403. I
104. 404. I
105. 405.
Ad'ustments For Items Paid Bv Seller in advance Ad'ustments For Items Paid Bv Seller in advance
106. Library/LiQht'Debt 10/28/05 to 01101/06 , 17.65 406. Library/Light'Debl 10/28/05 to 01101/06 : 17.65
107. Countv Taxes 10/28/05 to 01/01/06 I 69.69 407. County Taxes 10/28/05 to 01/01/06 I 69.69
108. School Taxes 10/28/05 to 07/01/06 I 662.29 408. School Taxes 10/28/05 10 07/01106 I 662.29
109. Sewer Proration 10/28/05 to 01/01106 I 21.20 409. Sewer Proration 10/28/05 to 01101106 I 21.20
110. Trash Proration 10/28/051001/01106 I 34.87 410. Trash Proration 10/28/05 to 01/01106 : 3487
11,. I 411. I
112. 412. I
120. GROSS AMOUNT DUE FROM BORROWER I 92,890.97 420. GROSS AMOUNT DUE TO SELLER i 88,805.70
,
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deposit or earnesl rnonev 8,800.00 501. Excess Deposit (See Instructions) I
202. Principal Amount of New Loan(s) 70.400.00 502. Selllement CharQes to Seller (Line 1400) ! 50.00
203. ExistinQ loanlsltaken subject to 503. Existing loan(sltaken subjeclto I
204. 504. Payoff of first Mortgage I
205. 505. Payoff of second MortQaQe I
206. 506. Deposit retained by broker : 8.800.00
207. I 507.
208. i 508. i
209. I 509.
Adjustments For Items Unpaid By Seller Adjustments For /Iems Unpaid By Seller
210. Library/LiQht'Debt to : 510. Library/LiQht'Debt to I
211. County Taxes to 511. County Taxes to
212. School Taxes to 512. School Taxes 10 :
213. 513. I
214. 514. :
215. 515. I
216. I 516. I
217. 517. i
218. 518. !
219. 519. I
220. TOTAL PAID BYIFOR BORROWER I 79,200.00 520. TOTAL REDUCTION AMOUNT DUE SELLER I 8.850.00
300. CASH AT SETTLEMENT FROMITO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Borrower Line 120 92,890.97 601. Gross Amount Due To Seller (Line 420) I 88,805.70
302. Less Amount Paid By/For Borrower (Line 220) I( 79,200.00) 602. Less Reductions Due Seller (Line 520) I( 8,850.00
303. CASH ( X FROM) ( TO) BORROWER I 13.690.97 603. CASH ( X TO) ( FROM) SELLER I 79,955.70
OMS NO 2502-0265 ho,
The undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement & any attachments referred to herein.
Jaye L~npmlr.!';: /'/
~ ~<: _' //tf ~r
Brian HOffm;n/....
. -"" . \-
Seller
Borrower
~
L. SETTLEMENT CHARGES
700. TOT A;. COMMISSION Based on Price $ @ % PAID FROM PAID FROM
Division of Commission line lOO! as Follows: BORROWER'S SELLER'S
701. $ to FUNDS AT FUf-JOS AT
702. $ to SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement
704. to
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Oriqination Fee % to
802. Loan Discount % to
803. Appraisal Fee to The Appraisal Firm. Inc. POC $325.00
804. Administration Fee to Commerce Bank 575.00
805. Operating Income Slmt tq The Appraisal Firm. Inc. 75.00
806. Mortoaqe Ins. App. Fee to
807. Assumption Fee to
808.
809.
810.
811.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From 10/28/05 to 11/01/05 @ $ 12.295900/day ( 4 days %) 4918
902. Mortqaqe Insurance Premium for months to
903. Hazard Insurance Premium for 1.0 years to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard Insurance 3.000 months $ 29.25 oer month 87.75
1002. Mortoaoe Insurance months $ oer month
, 003. Library/LiqhVDebt months $ oer month
1004. Countv Taxes 9.000 months $ 37.32 oer month 335.88
1005. School Taxes 5.000 months @ $ 83.56 per month 417.80
1006. months (1j) $ er month
1007. months IGJ $ oer month
1008. Aaoreoate Ad'ustment months (cj) $ oer month .391.09
1100. TITLE CHARGES
1101. Settlement or Closina Fee to
1102. Courier Fee to Aooalachian Settlement Aaencv. LLC. 40.00
1103. Tax Certification Fee to Aooalachian Settlement Aoencv, LLC. 10.00
1104. Wire Fee to
1105. Document Preparation to Apoalachian Settlement Aoencv. LLC. 25.00
1106. Notary Fees to Aooalachian Settiement Aoencv. LLC. 10.00
1107. Attorney's Fees to
(includes above item numbers:
1108. Title Insurance to Aooalachian Settlement Anencv LLC. 786.75
{includes above item numbers: J
1109. Lender's Coverage $ 70.400.00
1110. Owner's Coverage $ 88.000.00 786.75
1111. Endorsements to Appalachian Settlement Agency. LLC. 100/300/8.1 150.00
1112. Closing Protection Letter to Old Republic National Title Insurance Company 35.00
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 38.50; Mortgage $ 80.50; Releases $ 119.00
1202. CitY/County TaxlStamos: Deed 880.00' Mortoaoe 880.00
1203. State TaxlStamps: Deed 880.00; Mortqaqe 880.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest Insoection to
1303. Final Water to PA American Water Co. Held in Escrow 50.00
1304.
1305.
1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Sedi_~ 4,08527 50.00
B, "gn.ng page 1 allh" statement, the '~nata"es ,ek,awledge 'eee;p' of a compleled cop, of page 2 of IhiS Iwo page 'ta'ye"(-j \Li ~
, 'J=::::~~-
:.-- .qL... .----'
APg=n ~ementAgency. LLC.
Settlem nlAgen!
Page 2
Certified to be a true copy.
( ASA-0503681 ASA-050368 I 21 )
. SCHEDULE E
, . CASH, BANK DEPOSITS, & MISC. ,
I I
COMMONWEALTH OF PENNSYLVANIA I PERSONAL PROPERTY L
INHERITANCE TAX RETURN
RESIDENT DECEDENT
--.-...."--.--..-------- _-------l_~_ _ _ __ ___ _ _~______
--------..-------.---.--.------..----.-- ----------.,.--
ESTATE OF I FILE NUMBER
SHIPE, LESTER K 21 _ 05 _ 0513
----.-------____n_..______________.._____n____..._____ -____.____n____...______.____.._ ______________..._______________________.__
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
NUMBER
1 Neighborhood Services
DESCRIPTION
VALUE AT DATE
OF DEATH
15,794.01
2
Personal property, sale price
3,313.00
------...-----------.--.---------------.----....----
TOTAL (Also enter on Line 5, Recapitulation)
19,107.01
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KAYNE tIQ,
A u c t i on
Company
September 29,2005
ATTN Julie Cooper
Gingrich, Smith, Klingensmith & Dolan
222 South Market Street
Suite 201
P.O. Box 267
Elizabethtown, P A 17022
RE : 24 Palmer Street, Camp Hill, P A 17011
Julie,
I enclosed the check for the contents that were sold as well as the back-up copies of
sheets for the items that were sold. The total was 3,313.00. In addition, I enclosed an
invoice for our services and the expenses outlined in our agreement. I also provided you
copies of our hard cost. Weare simply charging you what we were charged.
Thanks again for the opportunity and we look forward to managing more auctions for you
in the future.
\"
Sin~":i"J,
r ~,..,
je~ Bankes ..~
711;580-6179
\
666 Revere Circle, Lewisberry, Pa 17339 Phone 717-932-2162
www.Kayneauctioncompany.com
'. j SCHEDULE H
COM MONWEA." rn OC e~",,~, FUNERAL EXPENSES &
IN~EE~;D~N~E DTE'tE~~RN ADMINISTRA 11VE COS1S
_.~--.._-- ------
ESTATE OF
SHIPE. LESTER K.
, FILE NUMBER
21-05-0513
Debts of decedent must be reported on Schedule I.
-L_~~OUN~ ---
ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
Neill Funeral Home, funeral services
6.517.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State
Zip
2.
Attorney's Fees
Gingrich, Smith, Klingensmith & Dolan n Julie M. Cooper
5,000.00
3. 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
Zip
4.
Probate Fees
Letters Testamentary
300.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I Central P A Abstract, lien search 50.00
2 The Sentinel - advertising 144.29
~----
Total of Continuation Schedule(s)
-----------1
TOTAL (Also enter on line 9, Recapitulation)
12,857.05
24,868.34
SchecUe H
FlI1eI"aI Expenses &
AdTirlisb alive Cos1s contil'Lled
ESTATE OF
- -- - -- -- - -_..__._----,._...._--._---.._...__.._-._---.__.~--._---"....-.--
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SHIPE, LESTER K.
---~--_...._-------------._---._._._-_._.._---_..-.__.-"-'--
20
21
22
3 P A American Water
4 P.P. & L., electric bill during administration
5
Lower Allen TOvlmship, sewer/refuse
6
Cumberland Law Journal, estate publication
7
Fissel & Co., personal property appraisal
8
Bonnie K. Miller, tax collector, 2004 county and township taxes
9
Bonnie K. Miller, tax collector, 2005 school tax
10
Neighborhood Management Development, work at the house
II
Neighborhood Management Development, trash removal
12
Vital Records, death certificates
13
Lower Allen Township, sewer/refuse
14
Lower Allen Township, mowing lien
15
Auctioneer commission
16
Neighborhood Services
17
Central Penn Appraisals, real estate appraisal
18
P.P. & L., electric bill
19
U-haul rental
Lower Allen Township
Rea] estate settlement charges
Escrow fix final closing costs
_.._-------'---_..._-_._---..._------._-_.~._--._--_.,_.._--_.',----
I FILE NUMBER
21-05-05]3
----1--_._------
144.22
I
134.63
319.81
75.00
70.00
490.46
982.67
3.807.00
200.61
45.00
79.35
413.60
4,860.13
360.00
300.00
35.30
247.27
42.00
50.00
200.00
Page 2 of Schedule H
/"
~"NEILL
Funeral Home Inc.
Ms. Sheila Shipe
PO Box 263
Medway, MA 04460
Services For: Lester K Shipe
Graveside Service without Visitation ................... $
Concrete Grave Liner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cemetery Tent & Grave Equipment. . . . . . . . . . . . . . . . . . . .
TRITON BROWN ......................... . . . . . . . .
Death Certificates 12 @ $6.00 . . . . . . . . . . . . . . . . . . . . . . .
Woodlawn Memorial Gardens .. . . . . . . . . . . . . . . . . . . . . . .
Total Funeral Charges
Adjustments (Payments)
Balance Due on Account (Due date: 02/08/2005)
'.+111 \I.II'''CI 'ilrCl"1
(.1111[' 1Ii11, P\, lil1ll--H2H
I\.j ili 7IiHi!!)
I.." 7Ii 7~i-IH;l)
R"IWrl J. I'rall1lh. "'lIpcrvi~or
3501 Derrv'itreet
lIarn~bllrg. P.\ - lill t- tH t i
tel 717 56-+-26'33
fax 7t 7 '511 1-991 H
'itephen J Wilsbal'k. 'illper\lSOr
February 15, 2005
Ref No.: 1002829/ C05-012
$
$
3,230.00
895.00
175.00
1, 1 95.00
72.00
950.00
$6,517.00
0.00
$
$6,517.00
Member of
ALDERWOODS
CROUP
- ,r
A. B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT l.oFHA 2-DFmHA 3. [E]CONV. UNINS. 4-DVA 5.0CONV.INS.
6. FILE NUMBER: 17. LOAN NUMBER:
SETTLEMENT STATEMENT ASA-050368 77775692SMITH
8. MORTGAGE INS CASE NUMBER:
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 '1POCr were paid outside the closing; they are shown here for informational purposes and are not included in the totals.
10 3/9B (ASA-050368. PFDI ASA.OS0368/27 )
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Jaye Lynn Smith and Julie M. Cooper, Executrix for and Commerce Bank
Brian HoHman the Estate of Lester K. Shipe P.O. Box 8599
24 Palmer Drive Camp Hill. PA 17011
Camp Hill, PA 17011
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 02-0640071 I. SETTLEMENT DATE:
24 Palmer Drive Appalachian Settiement Agency, LLC.
Camp Hill. PA 17011 October 28. 2005
Cumberland County. Pennsylvania PLACE OF SETTLEMENT
1229 East Chocolate Avenue
Hershey. PA 17033
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 Sales Price 88,000.00 401. Contract Sales Price 1 88.000.00
102. Personal Prooertv 402. Personal Propertv
103. Settlement Charaes to Borrower Line 1400) 4.085.27 403.
104. 404.
105. 405.
Ad'ustmen!s For Items Paid Bv Seller in advance Adiustments For Items Paid Bv Seller in advance
106. Library/Lioht/Debt 10/28/05 to 01/01/06 17.65 406. Library/Light/Debt 10/28/05 to 01/01/06 17.65
107. Countv Taxes 10/28/05 to 01/01/06 69.69 407. County Taxes 10/28/05 to 01/01/06 69.69
108. School Taxes 10/28/05 to 07/01/06 662.29 408. School Taxes 10/28/05 to 07/01/06 662.29
109. Sewer Proration 10/28/05 to 01/01/06 21.20 409. Sewer Proration 10/28/05 to 01/01106 21.20
110. Trash Proration 10/28/05 to 01101/06 34.87 410. Trash Proration 10/28/05 to 01/01/06 34.87
111. 411. ,
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 92,890.97 420. GROSS AMOUNT DUE TO SELLER i 88.805.70
i
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deposit or earnest money 8.800.00 501. Excess Deposit (See Instructions) I
202. Princioal Amount of New Loan(s 70,400.00 502. Settlement Charges to Seller (Line 1400) I 50.00
203. Existina loan s taken subject to 503. Existing loan(s) taken subiect to
204. 504. Payoff of first Mortgage
205. 505. Pavoff of second Mortaaae
206. 506. Deposit retained by broker I 8.800.00
207. 507. I
208. 508. I
209. I 509. I
Adiusfments For Items Unpaid Bv Seller Adjustments For Items Unpaid By Seller
210. LibraryiLiaht/Debt to 510. Library/Light/Debt to I
211. CountvTaxes to 511. County Taxes to
212. School Taxes to 512. School Taxes to :
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. T07AL PAID BY/FOR BORROWER 79,200.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 8.850.00
300. CASH AT SETTLEMENT FROMfTO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Borrower lLine 120\ 92,890.97 601. Gross Amount Due To Seller (Line 420 88.805.70
302. Less Amount Paid By/For Borrower (Line 220) ( 79.200.00 602. Less Reductions Due Seller (Line 520) ( 8,850.00
303. CASH! X FROM)! TO) BORROWER 13,690.97 603. CASH! X TO)! FROM) SELLER I 79.955.70
OMB NO 2502 0265 .....
The undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement & any attachments referred to herein.
.,+
".
Seller
"""'"
700. TOTA;' COMMISSION Based on Price
Division of Commission (line 700 as Follows:
$ to
$ to
Commission Paid at Settlement
L. SETTLEMENT CHARGES
(GJ
$
%
701.
702.
703.
704.
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Ori ination Fee % to
802. Loan Discount % to
803. Appraisal Fee to
804. Administration Fee to
805. Operating Income Stmt to
806. Mortnaoe Ins. App. Fee 10
807. Assumption Fee to
808.
809.
810.
811.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From 10/28/05 to 11/01/05 @ $ 12.295900/day
902. Mortaaae Insurance Premium for months to
903. Hazard Insurance Premium for 1.0 years to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard Insurance 3.000
1002. Mortoaoe Insurance
1003. Librarv/LiohVDebt
1004. Countv Taxes
1005. School Taxes
1006.
1007.
1008. Annrenate Adiustment
1100. TITLE CHARGES
to
The Appraisal Firm, Inc.
Commerce Bank
The Appraisal Firm, Inc.
POC $325.00
4 days
%)
9.000
5.000
months $
months $
months $
months $
months @ $
months @ $
months CW $
months CW $
29.25 per
per
per
37.32 oer
83.56 per
oer
oer
ner
month
month
month
month
month
month
month
month
1101. Settlement or Closing Fee
1102. Courier Fee
1103. Tax Certification Fee
1104. Wire Fee
1105. Document Preoaration
1106. Notarv Fees
1107. Attorney's Fees
{includes above item numbers:
1108. Title Insurance
{includes above item numbers:
1109. Lender's Coverage
1110. Owner's Coverage
1111. Endorsements
1112. Closing Protection Letter
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 38.50; Mortgage $ 80.50;
1202. CilvlCountv TaxlStamps: Deed 880.00' Mortaaae
1203. State TaxlStamps: Deed 880.00; Mortaaae
1204.
1205.
1300, ADDITIONAl SETTLEMENT CHARGES
1301. Survey
1302. Pest Inspection
1303. Final Water
1304.
1305.
1400. TOTAL SETTLEMENT CHARGES IEnter on Lines 103, Section J and 502, Se~t1""-'O.
By slgolog page 1 ollhls stalemeot. the s;g""lones ackO"""edge ,""elpl 01 a completed copy 01 page 2 ollhls ""' page stalemeol /J ' ~~=-
\ u... <!L-..-.----
ApPlll8C9fan~ement Agency, LLC.
Settlem~Oent
to
to Appalachian Settlement Aoencv, LLC.
10 Aooalachian Settlement Aoencv, LLC.
to
to
to
to
Aooalachian Settlement Aoencv, LLC.
Aooalachian Settlement Aoencv, LLC.
to Annalachian Settlement Anencv LLC.
$ 70,400.00
$ 88,000.00
to Appalachian Settlement Agency, LLC.
10 Old Republic National Title Insurance Company
786.75
100130018.1
Releases $
to
to
to PA American Water Co.
Held in Escrow
Certified to be a true copy.
Page 2
PAID FROM PAID FROM
BORROWER'S SEllER'S
FUNDS AT FUNDS AT
SETTLEMENT SETTLEMENT
575.00
75.00
335.88
417.80
.391.09
J
786.75
150.00
35.00
119.00
880.00
880.00
4,085.27
( ASA..()50368 / ASA-oS036a I 27 )
49.18
87.75
40.00
10.00
25.00
10.00
50.00
50.00
.
-
. SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS I
INHERITANCE TAX RETURN l
RESIDENT DECEDENT
u. . .---." .-...
ESTATE OF I FILE NUMBER
SHIPE. LESTER K. 21-05-0513
-- --_.--...._._~.-- - ---- -- - ------------------
Include unreimbursed medical expenses.
----..-- ---..-- ----- ---- -------- - --- -...-----
ITEM DESCRIPTION AMOUNT
NUMBER
--
I Commercial Acceptance Co. 255.51
2 Hal S Fineburg, M.D. 44.20
3 Holy Spirit Hospital 20.21 I
4 Holy Spirit Hospital 2,443.54
5 Internists of Central P A 108.59
6 Keystone Urology, PC 123.16
7 ManorCare Camp Hill 30,503.50
8 Mobile X-Ray Imaging 86.06
9 Nephrology Assoc. of Central P A 170.51
10 William K. Daiber, DO. 6.96
11 Quantillll Imaging & Therapeutic 278.04
12 NCO, payoff credit card 5,899.75
13 Bureau of Accounts Management 46.35
14 Holy Spirit Hospital 1.042.77
15 Holy Spirit Hospital 2,374.57
... .--.-- -.- . _'_'-'0__-
TOTAL (Also enter on Line 10, Recapitulation) 43,403.72
SEP 29 2005 08:39 FR MANOR CARE-CAMP HILL 717 737 2189 TO 3673219
P.02/02
MANORCARE CAMP HILL 58~
1700 MARKET STREET
CAMP HILL, PA 17011
(717)-737-8551
PRIVATEl
BERNICE MORALES-NEIGHBORHOOD
SERVICES FOR LESTER SHIPE
134 SOUTH PRINCE ST BOX lSg3
LANCASTER, PA 176081593
ROOM 214 -C
SHIPE, LESTER K
1587
10/03/04 01/27/05 09/29/05
09/01/05
BALANCEl FORWARD
30,503.50
PAYMENT DUE UPON RECEIPT
30,503.!
RE.;'-1513 EX+ (9.{JO)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I
SCHEDULE J
BENEFICIARIES
I FILE NUMBER
I 21-05-0513
ESTATE OF
SI IIPE, LESTER K.
NUMBER ~~"=,,N~DDRESS OF PERSON,S) RECEIVING PROPERTY
I. ~ TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I Sheila Smith
c/o G. Bradley Snow, Esq.
29 Main Street
East Millinocket, ME 04430-0246
-1_ R:~~~~~~~:~
I Daughter
I
I
I AMOUNT OR SHARE
. OF ESTATE
-t--
Entire Residue
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
I BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
I
I
I TOT Al OF PART" _ ENTER TOTAL NON- TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-15oo COVER SHEET1
I