HomeMy WebLinkAbout08-09-06
RIN-15oo EX + (6,00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Herman Cornelia H. Herman
DATE OF DEATH (MM-DD-Year)
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DATE OF BIRTH (MM-DD-Year)
09/30/2005 08/12/1928
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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IX] 1. Original Retum
D 4. Limited Estate
IX] 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2, Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrusl)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER
21 -0 5 0904
COuNTYCOOE -VEAR- - - NUM8ER- -
SOCIAL SECURITY NUMBER
2 04- 2 0 - 7 685
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Retum (date of death prior to 12-13-82)
o 5. Federal Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A} (Attach Sch 0)
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NAME
Jac ueline A. Kell Es.
FIRM NAME (If Applicable)
Jan L. Brown & Associates
TELEPHONE NUMBER
717-541-5550
COMPLETE MAILING ADDRESS
845 Sir Thomas Court
Suite 12
Harrisbur
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
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14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under See. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
X _(15)
345,037.05 X .045 (16)
X .12 (17)
X .15 (18)
(19)
20. [8]
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
PA 17109
120,000.00
235,047.72
OFFICIAL USE ONLY
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13,329.59
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11,992.24 !
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Q 380.369.55
(8)
32,659.16
2,673.34
(11 )
(12)
(13)
35,332.50
345,037.05
(14)
345,037.05
15,526.67
15,526.67
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ece en s ample e ress:
STREET ADDRESS
426 S. Pitt Street
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
15,526.67
15.000.00
789.45
Total Credits (A + 8 + C)
(2)
15,789.45
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. 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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 00
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............... .......... .... ...... .... .... ... ...... .......................... ................ lRJ 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 lRJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 00
262.78
0.00
0.00
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 IlIave examined this return, including accompanying sclledules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer lias any knowledge.
SIGNATURF~O. ".QSON RESPONSIBLE:~ FILING RETURN 1-IdJ".A<\.- DATE
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ADDRESS 329 W. Ridg Street
Carlisle PA 17013
SIGNATURE c:i PREPMER OTHEll THAN REPRESENTATIVE DATE
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ADDREQ 84 Sir Thomas Court, Suit 12
HarrisburQ. P A 17109
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)].
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'B\\led \\700
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olicable even if
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 I
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosUl
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 de
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)l.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, ex
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
individual who has at least one parent in common with the decedent, whether by blood or adoption.
:Ioptive parent,
ci" ~9116(a)(1)].
. _. 9102, as an
R~V-1502 E~ + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Herman Cornelia H Herman 21 05 0904
All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller. neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real DrODertv which Is iolntlv-owned with rlaht of survivors hiD must be disclosed on Schedule F.
SCHEDULE A
REAL ESTATE
ITEM
NUMBER
1.
DESCRIPTION
Real property located at 426 S. Pitt Street, Carlisle, PA 17013
see attached settlement sheet
VALUE AT DATE
OF DEATH
120,000.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
120.000.00
REV-1503 EX'+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Herman Cornelia H. Herman
FILE NUMBER
21 05
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
0904
ITEM
NUMBER
1.
DESCRIPTION
3000 shares of Sprint Nextel Corp common stock @ $23.78
VALUE AT DATE
OF DEATH
71,340.00
2.
Capital Income Builder Class C mutual fund: 458.286 shs @ $53.76
24,637.46
3.
Eaton Vance Tax-Managed Equity mutual fund: 1999.586 shs @ $12.13
24,254.98
4.
Eaton Vance Floating Rate Fund mutual fund: 3167.073 shs @ $9.89
31,322.35
5.
Income Fund of America Class C mutual fund: 4503.074 shs @ $18.49
83,261.84
6.
Eaton Vance Floating Rate Fund mutual fund: accrued dividend, paid on 10/3/05
104.69
7.
U.S. Savings Bond, Series EE, C142227968EE; issue date 10/1987; $100 denomination
see attached inventory report
126.40
TOTAL (Also enter on line 2. Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
235047.72
R.EV-1508 ~ + (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
21 05
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
DESCRIPTION
Financial Network Investment Corporation
Money Market Account: Ing Classic Money Fund
0904
VALUE AT DATE
OF DEATH
879.67
25.67
7,961.68
436.32
573.29
52.14
4.57
241 .95
531.38
150.00
437.64
20.52
596.00
1,360.95
57.81
Herman Cornelia H Herman
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
15.
16.
Cornerstone Federal Credit Union
Savings Account #9614
Cornerstone Federal Credit Union
Money Market Account #9614
Cornerstone Federal Credit Union
Savings Account #69
Cornerstone Federal Credit Union
Checking Account #69
The Sentinel--refund
Comcast Cable--refund
Household goods and furniture
PA Department of Revenue--refund
Cash on hand
Proceeds from sale of chair lift
HMA Physician Management--refund
Sprint Nextel--refund from overpayment on CIGNA health insurance
Reimbursement for school and county taxes
Real property located at 426 S. Pitt Street, Carlisle, PA
see attached settlement sheet
State Farm Insurance; refund
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
13.329.59
REV-1510 EK + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Herman. Cornelia H. Herman
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
21 05
0904
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INClUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER ATTACH A COP'\' OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPlICABLE)
1. Members 1 st Federal Credit Union 12,517.82 100. 3,000.00 9,517.82
Savings Account #49729-00
made joint wI daughter, Anna Gardner-Horst, 10/29/04
2. Members 1 st Federal Credit Union 2,474.42 100. 2,474.42
Checking Account #49729-11
made joint wI daughter, Anna Gardner-Horst, 10/29/04
TOTAL (Also enter on line 7 Recapitulation) $ 11.992.24
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+(12-99)
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Herman Cornelia H Herman
21
05
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
Ewing Brothers Funeral Home, Inc.
1.
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
1.
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attomey Fees Jan L. Brown & Associates
Family Exemption: (If decedenfs address is not the same as claimanfs. attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees Register of Wills, Cumberland County
5.
Accountanfs Fees Parks & Company--fiduciary tax prep
6.
Tax Retum Prepare(s Fees Greenawalt & Company, PC--2005 individual income tax prep
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Cumberland Law Journal--advertising
Central Penn Business Journal--advertising
Mackey's Flooring--new carpeting @ real property 426 S. Pitt St., Carlisle, PA 17013
Boggs Painting--painting @ real property 426 S. Pitt St., Carlisle, PA 17013
Gelco Carpet Cleaning--cleaned carpets @ 426 S. Pitt St., Carlisle, PA 17013
Pre-sale cleaning supplies and new fixtures for 426 S. Pitt St, Carlisle, PA
U-Haul rental for hauling of material @ 426 S. Pitt St., Carlisle, PA
UGI Utilities--maintenance for 426 S. Pitt St., Carlisle, PA
PPL Electric--maintenance for 426 S. Pitt St., Carlisle, PA
Sprint--maintenance for 426 S. Pitt St., Carlisle, PA
Borough of Carlisle--maintenance for 426 S. Pitt St., Carlisle, PA
Members 1 st FCU--estate check fee
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0904
AMOUNT
6,567.70
7,679.00
372.00
250.00
200.00
75.00
97.00
1,166.00
2,900.00
121.85
115.20
521 .02
1,112.06
148.62
42.16
148.91
23.50
32659.16
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Herman, Cornelia H. Herman
Decedent's Name
Page 1
21 05 0904
File Number
Schedule H - Funeral Expenses & Administrative Costs - 87.
ITEM
NUMBER
DESCRIPTION
AMOUNT
19.
20.
21.
22.
23.
24.
25.
26.
27.
Larry E. Foote--appraisal of property @ 426 S. Pitt St., Carlisle, PA
advertising of property @ 426 S. Pitt St., Carlisle, PA
Postage to insure mailing of US Savings Bond; FedEx charge
Borough of Carlisle--2005 real estate taxes for 426 S. Pitt St., Carlisle, PA
Register of Wills--filing fee for Family Settlement Agreement
Settlement charges; 426 S. Pitt St., Carlisle, PA
Register of Wills--filing fee for Inheritance Tax Return and Inventory
OK Electric; electrical repairs for 426 S. Pitt St., Carlisle, PA
Additional death certificates
275.00
68.88
22.93
497.45
20.00
9,622.64
30.00
485.24
97.00
SUBTOTAL SCHEDULE H-B7
11,119.14
REV-1512 EX + (6-98)
.
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Herman. Cornelia H. Herman
FILE NUMBER
21 05
Include un reimbursed medical expenses.
0904
VALUE AT DATE
OF DEATH
ITEM
NUMBER DESCRIPTION
1. Masland Associates Inc.--outstanding medical bills
2. Lancaster HMA Physical Management Central PA--outstanding medical bill
3. Moffitt Heart & Vascular Group--outstanding medical bills
4. Discover Platinum Card--outstanding debt
Account#6011002060375698
5. Apria Pharmacy Network--outstanding medical bills
6. Carlisle Regional Medical Center--outstanding medical bills
7. Law Offices of Duncan & Hartman--outstanding legal fees
8. Members 1 st Checking Account: ck #1316 cleared after death
9. Members 1 st Checking Account: ck #1317 cleared after death
10. Members 1st Checking Account ck #1318 cleared after death
11. Members 1st Checking Account ck #1319 cleared after death
12. Carlisle Neurocare--outstanding medical bill
13. Holy Spirit Hospital--outstanding medical bill
114.75
20.52
107.27
30.89
39.67
36.20
750.00
540.00
100.00
490.25
63.99
10.05
369.75
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2.673.34
flB,-1513 EX' '_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
Herman Sornpli~ H" ?1 Ofi O!:}O4
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Timothy Herman son 1/3 of residue
329 W. Ridge Street
Carlisle, PA 17013
2. Anna Gardner-Horst daughter 1/3 of residue
52 Shell bark Court
Carlisle, PA 17013
3. Michael Herman son 1/3 of residue
47 Prospect Court
Coral Gables, FL 33133
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 BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
LAST WILL
&
TESTAMENT OF
CORNELIA H. HERMAN, of 426 S. Pitt Street, Carlisle, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make,
publish and declare this as and for my Last Will and Testament, hereby revoking any and all
other wills and codicils heretofore made by me.
FIRST. I direct that all my just debts and funeral expenses be paid from my estate as
soon after my death as practically and conveniently may be done. :.-)
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SECOND. I direct that my remains be interred within my family's burial plot iri~ fCQCorcf~:~
with my expressed wishes. : __ ,>)
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THIRD. I authorize my personal representative to expend funds from my estate~lin suCh
amounts as my personal representative shall consider necessary and desirable for .t~e'I)Urchas.~;
erection and inscription of a suitable marker for my grave. ".::-
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FOURTH. I give, devise and bequeath any and all tangible personal property owned by
me at the time of my death unto my husband, STEPHEN HERMAN, JR., provided he survives
me by thirty (30) days. In the event he fails to survive me by thirty (30) days, I give, devise
and bequeath all said tangible personal property unto my children, Timothy Herman, Michael
Herman and Anna Mae Herman, in equal shares, per stirpes.
~'.lJ:I.l'H. I give, devise and bequeath any and all real estate owned by me at the time of
my death, unto my husband, STEPHEN HERMAN, JR., provided he survives me by thirty
days. In the event he fails to survive me by thirty (30) days, I give, devise and bequeath all said
real estate unto my children, Timothy Herman, Michael Herman and Anna Mae Herman, in
equal shares, per stirpes.
(
SIXTH. I give, devise and bequeath all the rest, residue and remainder of my estate
unto my husband, STEPHEN HERMAN, JR., provided he survives me by thirty (30) days. In
the event he fails to survive me by thirty (30) days, I give, devise and bequeath all the rest,
residue and remainder of my estate unto my children, Timothy Herman, Michael Herman and
Anna Mae Herman, in equal shares, per stirpes.
SEVENTH. I direct that any and all Inheritance, Estate and Transfer taxes imposed
upon my estate passing under my ",rill or otherwise, shall be paid out of the principal of my
residufuy estate.
EIGHTH. I hereby nominate, constitute and appoint my husband, STEPHEN
HERIviAN, JR., as Executor of this my Last Will and Testament. In the event of renunciation,
death, resignation or inability to act for any reason whatsoever of STEPHEN HERMAN, JR.,
I nominate, constitute and appoint Timothy Herman, as Executor of this my Last Will and
Testament. I hereby relieve my Executor from the necessity of posting security in connection
with his duties, as such, in any jurisdiction in which he may be called upon to act insofar as I
am able by law to do so. In addition to the powers conferred by law, I authorize my Executor,
in his absolute discretion, to retain in the form received, and to sell either at public or private
sale any real or personal property owned by me at the time of my death.
NINTH. I have made, or may from time to time make, a written memorandum
expressing my desire to give certain items of personal property to specific persons. I urge my
Executor and beneficiaries to respect these wishes. Such a memorandum, if made, shall be
stored in conjunction with this Will.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will
and Testament, consisting of two typewritten pages this 2(~y of October, 2000. .
-,'
Signed, sealed, published and declared by the above named Testatrix Cornelia H. Herman
as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight
and presence and in the sight and presence of each other, have hereunto subscribed our names
as witnesses.
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COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
I, Cornelia H. Herman, Testatrix 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; that I signed it willingly; and that I signed it as
my free and voluntary act for the purposes therein expressed. I
4~/$-
CORNELIA H. HERMAN
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Sworn or affirmed to and
acknowledged before me, b~
Cornelia H. Herman this..)-$' day
of October, 2000.
NOTARIAL SEAL .
Cynthia L Darr, Nota~t~u~l~erland
South Middleton Twp., C?untyA 14 2004
My Commission expIres ug. .
I
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
We,'l.D \\ \ lQ\'Y\. \A. ~{An ((k~ and SJep~ {j...ero"-C!i N I Se the
witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Cornelia H. Herman, sign
and execute the instrument as her Last Will; that she signed willingly and that she executed as
her free and voluntary act for the purposes therein expressed; that each of us in the hearing and
sight of the Testatrix signed the will as witnesses; and that to the best of our knowledge, the
Testatrix was at that time eighteen (18) or more years of age, of sound mind and under no
constraint or undue influence. ,'. . A 2lJ'.. L/1" ,I .'
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Sworn or affirmed to and
.subscribed before.....me by I
(U,'/ I ( ce f1,-L fJ Uun (Q 1'" and
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, I ~tt/..Lt+'l. V ' WItnesses,
his &ay of ~ctober, 2 ~ .
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NOTARIAL SEAL
Cyr.th:a L. Dair, ~Jotar; PubHc
South Middleton Twp., County of Cumberland
My Commission Expires Aug. 14, 2004
......... IV...... ,...,UU/Ie'1 ncll.VUUU'" l4..JIJ
A. Settlement Statement
U.S. Department of Housing and Urban Development
R Tun.. nf Ln:m ",,,, A r val No. 2'\n7.n7l'i'\ (pxnir..~ Q/1nJ?nOfil
1. OFHA 2. OFmHA J. Deonv. Unins. I 6. File Number I 7. Loan Number \ 8. Mortgage Insurance Case Number
4 nVA ~ nrnnv In. S 100-469 0605306787
C. Nole: This form is furnished to give you a Ilstement of Belval ..Itktmenl CO..S. Amount. paid to end by the ..W.men. agent are shown I TilleExpress Selllemenl Systei
lIem. martl;ed "(p.o. c.}" WBre paid Qutslde ,he dosing: 'hey are lhown here tor information purpose..nd.... not lnduded In Ih.lot.I..
WA~NING: n l~ . aim" Ie:' kno'Nfngly make 'BI.e slalements to ~f~~~?1 5;8t81 on this or ."y other .imn.r form. Penalti.. upon ,,,. 1~'1~ K<:(
D. NAME OF BORROWER: Richard J. faulkner and Nancy A. Faulkner
AOORESS'
E. NAME OF SELLER: The Estate ofComelia H. Herman
AnnD""".
F. NAME OF LENDER: USAA federal Savings Bank
An,"oo,,"". I 0750 McDermott Freew"v ~an Antonio TX 78288
G. PROPERTY ADDRESS: 426 South Pitt Street, Carlisle, PA 170J3
r.arlisle Borom'h
H. SElTLEMENT AGENT: P A Real Estate Settlement Services, LLC
PLACE OF SflTLEMENT' 354 Alexander SDriuS! Road Ste Carlisle P A 17013
I "~~. r..r.~ nATE. 07/10/2006
.I. OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
1nn r-R I ''''T DUE Aon ,..,n,.,.... A Un' ...... 0111= Tn "1"1 1 1"0
1n1 ."..~ 120.000.00 An. , nri~... 120 000.00
1n., An~ n. ._. n__
1n. . 'v"",,,,-,,,,,, lIin" 140m 4 473.43 AM
104 AnA
.n~ An"
; for j'..m<l n"irl hv . I. . ilAm!: n:lirl bv !:Aller in :Irlvanr'.A
1nR 411A
.n7 07/10/061012/31/06 238.50 An? 07/10/061012/31/06 238.50
'08 07/10/061006/30/07 1.122.45 AnA 07/10/061n 06/30/07 1 122.45
10<1 4na
f1n A.n
11' 411
11? 4'?
1'0 ,..,~,..,~~ ..", "'T DUE FROM 125 934.39 4?n '"""''''''<> UE Tn <::1=1 1 1"0 121 360.95
200. AU"" ,....... PAl RFHAI I" nF !inn OI:M"rT'n....<: IN AMnl 'NT nllF Tn <::1"1 1 FR
?n, 5.000.00 .""
7n7 96.000.00 ~M C!dU,,"_ftn" 9 622.64
?O~ j 110 ~n,>
71\4 ~n4
Defense Activites Federal ered
~n~ "....... i 350.00 ~n~
USAA Federal Savinas Bank
?nR "'''I 200.00 ~"'"
7n7 ~n7
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.,na ~na
,fnr ~. j.... _II II r
?n ~.n
71t ~11
"p ~1?
213 ~1'
714 "'..
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"0 TnTAI pAIn nvn:no 101. 550.00 !;?n "''''''A' AMOIINT nllF .<;1"1 I FR 9 622.64
300. r.A!;H AT "'CTTI cuc"", FROM nR Tn RORR( lINER Rnn rAC:1-I AT . TO OR I:onu <:1=1 I 1=1
.n1 "',nn ~_n"n' .!,~ 1m.., borrower IIine 12m 125 834.38 An. ~ 121 360.95
.07 I d.. . hnrr<tW<>r IIine 2201 101 550.00 An? ,,,mnllnt r 9 622.64
:In:l 24 284.38 ..n,> rA"''''' Tn <::"" I "'" 111.738.31
SUBSTITUTE FORM 1099 SELLER STATEMENT: The Informalion contained herein Islmponent lex information IInd III being furnished 10 the Inlemal Revenue Service. If you ere required 10 file a relurn.
a negligence penally or other sanction wUl be imposed on you if this item IS required to be reported and the IRS determines that it has not been reported. The Contract Sales Pnce described on
line 401 above ccnstilutes the Gross Proceeds of this transaction.
You life required by law to prottide the seWament agent (Fed. fax 10 No: ) with your corred taxpayer ldentlticatlcm number. If you do nol provide your correct laxpayar tdenti1icaliorl
number, rau may be subject \0 civil or criminal penalties imposed by law. Under penallles or perjury, I certify that \he number shown on this statement is my eorred laxpayer identificalion number.
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