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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV -1500 EX + (6-00)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Vesel A nes N.
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
09/29/2005 12/06/1922
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
X 1. Original Return
4. Limited Estate
X 6. Decedent Died Testate
FILE NUMBER
COUNTY CODE
OFFICIAL USE ONLY
2105 - 0911
YEAR
NUMBER
SOCIAL SECURITY NUMBER
184-16-3223
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
2. Supplemental Return
4a. Future Interest Compromise (date of death after 12-12-82)
7. Decedent Maintained a Living Trust 0
3. (date of death
. Remamder Return prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
[J 9. Litigation Proceeds Received 010. Spousal Poverty Credit 0 11. Election to tax under Sec. 9113(A)
(date of death between 12-31-91 and 1-1-95) (Attach Sch 0)
J'Hl$$eQJ'IQNMQ$m..eg;'QQM~~gTi;D;'.~~tl'QQaB.g$~QNPgNQg.~QQNEIPgN.mIA~ntAX'JN'FQB.MAitjQN.$HQQLb.pe..[jlfteQme[\.m'o.:
NAME COMPLETE MAILING ADDRESS
Patrick C. O'Donnell, Es uire
FIRM NAME (If Applicable)
Law Office of Patrick C. O'Donnell
TELEPHONE NUMBER
32 South Church Street
West Chester, PA 19382-3221
610 431-4141
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole-Proprietorship
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 (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 Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(1)
(2)
(3)
R
E
C
A
P
I
T
U
L
A
T
I
o
N
(4)
(5)
(6)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2)
16. Amount of Line 14 taxable at lineal rate 132,817.46
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
22,282.28
None
None
None
67,960.67
62,080.00
None
13,550.57
5,954.92
x
X
X
X
.0 0
.0 45
.12
.15
OFFICIAL USE ONLY
(8) 152,322.95
(11) 19,505.49
(12) 132,817.46
(13)
(14) 132,817.46
(15)
(16)
(17)
(18)
(19)
0.00
5,976.79
0.00
0.00
5,976.79
Copyright (c) 2000 form software only The Lackner Group, Inc.
<<
Form REV-1500 EX (Rev 6-001
Decedent's Complete Address:
STREET ADDRESS
229 Log Cabin Road
CITY I STATE 1 ZIP
Newville PA 17241
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
5,976.79
3,000.00
157.89
Total Credits ( A + B + C) (2)
3,157.89
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)
S. 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. (SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
2,818.90
0.00
2,818.90
iU[:[[~t~~~g~~~Wg~iy~i&I~~tt8W~~~II~U~~Y~:8~~i~9'1~t~8I~~[~~ "X" IN THE APPROPRIATE BLOCKS
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?
2. If death occurred after December 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? . . . . . . . . . . . . . . .
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation? . . . . . . . . . .
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Yes No
~~
D
D
D
ITJ
ITJ
ITJ
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief. it is true,
correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
Marie Vesely Pelliccio
5320 White Oak Road
-- --------------- -- ------ - -- - -- --- -- - - -- - - - - - - - - - - - --
Paradise, FA 17562
Law Office of Patrick C. O'Donnell
32 South Church Street
---------------------------------- - - --- - - - -- - - - - - - - --
West Chester, PA 19382-3221
DATE
(/?() O(
DATE
.~l2--(/O(
..:. 1:::.
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 filinl;:J a tax return are still applicable even if the surviving spouse is the only beneficiary.
For date,s 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 orlor the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116( 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.
CODvriQht (c) 2000 form software only The Lackner Group, Inc.
Form REV-1S00 EX (Rev. 6-00)
REV-1502 EX t (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Agnes N. Vesely SSU 184-16-3223 09/29/2005 2105-0911
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 property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
DESCRIPTION
NUMBER OF DEATH
1 2723 Cleveland Street 22,032.28
McKeesport, PA 15132
(See attached settlement statement)
SCHEDULE A
REAL ESTATE
2
Vacant Lot - Cleveland Street
250.00
TOTAL (Also enter on line 1, Recapitulation) $ 22,282.28
(If more space is needed, insert additional sheets of the same size)
Copyrig~lt (c) 1996 form software only CPSystems, Inc. Form REV-1502 EX (Rev 1-97)
REV-1508 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Agnes N. Vesely SS# 184-16-3223 09/29/2005 2105-0911
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
surviivorship must be disclosed on Schedule F.
ITEM
NUMBEH
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
DESCRIPTION
Dollar Bank Checking Account (1661890050)
Dollar Bank C.D. (60662313534)
Sky Bank Checking Account (6261738)
Sky Bank C.D. (990000011958)
Merck & Company dividend
St. Paul Travelers dividend
H.J. Heinz Company dividend
MetLife Insurance Reimbursement
St. Paul Travelers dividend
Del Monte Foods (4 shares @ $10.5196/share)
Visteon Corporation (42.946 shares @ $7.83/share)
Merck & Company (300 shares @ $27.94/share - $8.00)
St. Paul Travelers (6 shares @ $44.9601/share)
Citibank (126 shares @ $44.841 share - $30.12)
Ford Motor Company (573.401 shares @ $8.020/sh - $83.88)
Visteon Corporation
Cordia Commons refund (assisted living)
Blue Cross/Blue Shield Refund
Ford Motor Company
H.J. Heinz Company (10 shares @ $34.76/share - $15.00)
Medco Health Sol. (36 shares @ $57.54/share - $81.09)
Unisys Corp. (132 shares @ $6.06/share - $81.04)
National City Bank (#12336529)
Verizon refund
Westmoreland Municipal Authority refund
VALUE AT DATE
OF DEATH
4,448.97
6,521. 08
14,120.04
11,959.92
114.00
1. 38
3.00
1,629.05
37.37
32.08
321. 27
8,374.00
259.16
5,619.85
4,514.80
38.70
2,233.00
171.12
57.34
322.60
1,990.35
718.81
4,361.24
5.93
105.61
TOTAL (Also enter on fine 5, Recapitulation) $ 67,960.67
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV -1509 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Agnes N. Vesely
SCHEDULE F
JOINTLY-OWNED PROPERTY
SSlft 184 -16 - 3223
09/29/2005
FILE NUMBER
2105 - 0911
If an clsset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
Marie V. Pe11iccio
5320 White Oak Road
Paradise, PA 17562
Daughter
B.
Sarah V. Roaderme1
1109 Georgetown Road
Christiana, PA 17509
Daughter
c.
Christine V. Shaffer
229 Log Cabin Road
Newville, PA 17241
Daughter
JOINTLY -OWNED PROPERTY:
I LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH
I
ITEM FOR JOINT MADE Include name of financial institution and bank DATE OF DEATH DECO'S VALUE OF
account number or similar identifying number.
NUMBER TENANT JOINT Attach deed for jointly- held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1 A 07/01/85 EE Savings Bonds 31,040.00 50.00% 15,520.00
2 B 07/01/85 EE Savings Bonds 31,040.00 50.00% 15,520.00
3 C 07/01/85 EE Savings Bonds 31,040.00 50.00% 15,520.00
4 D 07/01/85 EE Savings Bonds 31,040.00 50.00% 15,520.00
TOTAL (Also enter on line 6, Recapitulation) $ 62,080.00
(If more space is needed insert additional sheets of the same size)
Copyrig~lt (c) 1996 form software only CPSystems, Inc.
Form REV-1509 EX (Rev 1-97',
REV-1511 EX. +(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Agnes N. Vesely
SS# 184-16-3223
FILE NUMBER
2105-0911
09/29/2005
Debts of decedent must be reported on Schedule I.
ITEM
NUMBEH
A.
B.
4.
S.
6.
7.
a.
b.
c.
d.
e.
DESCRIPTION
AMOUNT
1
2
FUNERAL EXPENSES:
Willig Funeral Horne
Tombstone
7,635.00
1,221. 80
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees Law Office of Patrick C. O'Donnell
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4,000.00
City
Relationship of Claimant to Decedent
State
Zip
Probate Fees
Register of Wills
245.00
Accountant's Fees
Tax Return Pre parer's Fees
Other Administrative Costs
Advertising in The Sentinel
Advertising in the Cumberland Law Journal
Executor travel and expenses related to opening
estate and arrainging sale of real estate in
McKeesport
Marie Pelliccio (reimbursement for postage for
express mail of stock sales and related)
Postage (to post master)
100.73
75.00
243.51
/. Y . 'i j
TOTAL (Also enter on line 9, Recapitulation) $ 13,550.57
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1S11 EX (Rev. 1-97)
REV-1512 E>: + (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Agnes N. Vesely
Indude unreimbursed medical expenses.
ITEM
NUMBEli
1
2
3
4
5
6
7
8
9
10
11
12
FILE NUMBER
2105-0911
SSff 184-16-3223
09/29/2005
DESCRIPTION
AMOUNT
3,331.80
85.30
1,381.39
52.55
71.27
6S.4U
1+71.00
400.00
3.2]
11.I+J
l"i.V,
66.23
John Haughey, Plumber
City of McKeesport
Equitable Gas
Verizon
Duquesne Light
Westmorland Hospital
MetLife (Homeowners insurance)
Maintenance Affiliates (clean out of home)
John Weinstein, Tax Collector
City of McKeesport (real estate taxes)
McKeesport Sewage
Allegheny County Recorder of Deeds
TOTAL (Also enter on line 10, Recapitulation) $ 5,954.92
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-1513 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIAR IES
ESTATE OF
Agnes N Vesely
09/29/2005
SSij 184-16-3223
NUMBER
I.
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions):
Marie V. Pe11iccio
5320 White Oak Road
Paradise, PA 17562
Sarah V. Roadarme1
1109 Georgetown Road
Christiana, PA 17509
Christine V. Shaffer
229 Log Cabin Road
Newville, PA 17241
David D. Vesely
112 Irene Drive
Irwin, PA 15642
2
3
4
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Daughter
Daughter
Daughter
Son
FILE NUMBER
2105-0911
AMOUNT OR SHARE
OF ESTATE
() . ? ')
0.25
0.25
0.25
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON- TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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)
Copyright (c) 1996 form software only CPSystems, Inc.
0.00
Form REV-1513 EX (Rev. 1-97)
A.
Settlement Statement
U.S. Department of Housing
Urban Development
and
OMS No. 2502-0265 (Pa~e 1)
n. Type of LuulI
-;---1 Ff[;\- 2. I F~;-n COllY UIlJllS
't VA 5. r-;- Cony. 1m. ,
2060 J 57
3041246
I 8. r-,.'lorlgage Ins. CJSC #
I
6. File Number
7. Loan Number
C. i'\OTE: TillS fOtm IS [urni~llcu.lo glVe yml aslUlcmcnt afilClUl1l sculcmcnt costs. Amaunls paid to and by the settlement agl.:nt arc Sllown.
closIng; they arc SllO\~l1l\1::rc for mfonml1lOnal purposes and arc nOIIl\C1Ullcd in the totals.
C;N;fllC am] Address ofBorron--cr -. IE. Namr..:. Address. and Taxpayer identificallon # ofSdlcr
SlJcrry ;Y'kslarik ITlle EstiJtc of Agnes N. Vesely
11CI115 marKcu "(p.D.C.)" were Pilid outside the
J'-lUJ Versailks AVCflW':
rvkKl:c':>port, Pa 15132
,
I
;5320 White Oak Road
[Paradise, Pa 17562
f. Name and Addn.:ss or Lemler
Public Savings Bank
2300 Computer Avenue .sullc 1-142
Willow Grove, Pa 1905l0
(j, Property Locallon
2723 Cleveland Street McKeesport, Pa 15132
.J. SUMMARY OF BOIUWWER'S TRANSACTION
100 GROSS AMOUNT DUE F1WM nOlUWWER:
H. Settlcment Agent Name, Address and Ta.'(j)ilycr idenlificatlon Number
Laurence A. NClsh
Foster Plaza I, 415l-Ioliday Drive
Pittsburgh, PA 15220
Plote of Selllemellt 1. Settlement Date
Pittsburgh. PA 15220 3/3/2006
K. SUMMARY OF SELLER'S TRANSACTION
40() GROSS AMOUNT DUE TO SELLER
101 COnm.lCl sales price 30.000.00 401 Comfacl sales pnce , .-
I 30.000.00
10' Pl.:rsona.! property 402 Personil! property i
..-------,------ -
1 ')3 ScttJcIIlcnt chargcs to burrower (Linc 1400) 3,G52.27 403 !
l(H 404 -r~-----
-_._------,.._-_._--~ -
lO5 405
Adjustmcnts for items pOliti by scller In auvance Adjustments for items paid by seller In advance
lOG City/town Trsxcs to 406 City/town liJ..'\cs [0 I
107 County Ta.\:c5 to 407 County Taxes tu !
108 i\ssCSStllCnL'i to 408 AsSC5smenl) to
109 School Ta.\. 3/3/200G [0 G/3 012006 IS3.28 409 SClloal Ta.\. 3/3/2006 to 6/3012006 183.28
110 G~lrbag,c Fcc 410 Garbage Fcc
III 411
412 -- -~~
112
12() Gross Amount Due From.Borrower 33,835.55 420 Gross Amonnt Due To Seller 30,183.28
20()
201
:202
203
Amoonts Paid By Or On Behalf Of Borrower
I?Cp05!t or earnest money
I'nI1CiPQJ amount of new IOiln(:;)
EXlstmg (oan(s) taken subject to
250.00
30.000.00
250.00
6.054.00
3% Seller A..~Slst
900.00
S()O
501
502
503
504
505
506
507
508
509
Adjustments for items unpaid uy scller
Reductiolls ill Amount Due Seller
Excess depOSIt (see instructions)
Settlement charges to Seller (Lml.: 1400)
E:'\Is1mg Jonn(s) luke" subject to
Payofftlrst mortgage kl<lIl
Payoff second mortgage loan
3% Sellers AsSIst
I
I
l-----
I
I
I
900.00
20,1
205
20(l
207
208
109
Adjustments for items unpaid by seller
.- I
210 City/town Tnxcs 111/200G 10 ]i:lI2006 34.33 510 City/lown taxes 1/l1200G to 3/3/200G 3'1.33
211 Coullty 1'<1'\:c5 I/J12006 to 31312006 12.67 511 County Ta'\cs 111/2006 [0 313/2006 I 12.67
712 t\ssc'.:islm:nts . to 512 Asscssments to I
.---~-- I -----
213 School Tax to 513 SCllool Ta\: 10
------- I .. -_.,-~
21,1 514
215 515 i
216 516
. I '-,.~---_.-
217 517
218 518
219 519 I
220 Totull'aid by/For Borrower 31,197.00 520 Tot'll Reduction Amount Due Seller i 7,251.00
JOO Cash At Settlement To/From Borrower GOO Cash At Settlement To/From Seller
]01 Cirass amount due from borrower (Linc 120"1 33,835.55 601 Gross amount due sellcr (Lme 420) I 30,183.28
302 Less ;.Imolll1l paid bylfor uorrower (Line 220) 31.197.00 602 Less rcductlOn 10 amount due seller (Lme 520) 7.25100
-- ---. I
303 CASH FROM BORROWER $2,638.55 603 CASH TO SELLER $22,932.28
ll:~\,l; c~crully f~YlC\\'cd the HUD.j Settlement SI:\tcml;o( ill1d 10 the hest arlllY Imowlcdgc una bchl;'f. illS ~ true ami ::u;cur(lle SLat~.mcntornll rCCCIU~~lItl dh1.lUrscmcnls made on my tlccounl orbv me In lllb lTiUlsactlOR. I further
"'''f~;''tll~''m''''d'''mp['''d''PY'f''~5t'''d2QfU;i'HUD'IS''t''m''''s''lemo"l. i/ ") /t{;8.JT ;=tJ.tf:.. cES;/~ OF
_ 1~)j.y"v~d\Q ':)9D~~ 1'" 3~()(;, '-C! &; c A,LJl.I_!"ft.~1
SbCfl)' lvJcswfjk I Borrower Seller 7
,11 ~ BQrrowcr~-
II
SE1TLCMB T 'WENT CERTlFICATlON
l'li~ liUD.l sCll:('i~~1 sJIJmcnythi~ill b~vc prcp.ozrcd i~ ~ !rue and a~;:;urJIC JCCUUllt (jfthis transaction. I
Il::we ;;,;;,lllo.:d the ~umf~ lo Fe diSbj d 1l1" {;;{Jrd,mc;c Iwlll/IIIS S!JICI11W!
! U ~, 313/2006
Settlemcnt Agent Date
WAIL"-ilNG, j; 13<1 J:nml!-IO knowmgly m;lKC fJhc st;\Il:lIIcr1~ 10 thl: Unilcu Stales un this ur ,lilY {l\11<::( sHllil:tr
fe-nil. l'cnallic:i upon conviction l;;mllll;lude a fille :lud impruonmcnl. For dCIJ-ils ~ce: Tille 18 U.S. Code
5',-C!I(1!l IOClI iU\dSedlon 1010
Seller
IIU1)-13/91
rU:SPA. HB 4305.2
I L. SETTLEMENT CHARGES
700 TOTAL SALESIBROKER'S COMMISSION bnsed on price S 130,00000 PAlO fROM
Divlsmn of COrIlnllSSJOn (line 7UU) <IS follows' BORROWER'S PAJD FIlOM
SELLER'S FUNDS
701 S2,000,00 10 Coldwell Banker FUNDS AT AT SETTLEMEN'I
702 S 1.75(1.00 IQ Coldwell Bankel S2,000.S250 hund moneY'~ S1750,00 SETTLEMENT
7UJ Comr1llssJOn naid ilt Settlement 3,750,00
;0,1 Broker Fee payablt.: to Coldwell Bunker 200,00 100.00
SOO ITEIHS I'AYABLE IN CONNECTION WITH LOAN
;\U! Lo;m OflgmatHJfl Fel.:
t{02 Lonn Discount
803 I\pprillsal fcc to Umled i\pr;raLs.]l POCS300.00
'0.1 Credit Rcnort Fc~ to Public Savlllg.sB<lllk 50.00
X05 Flout! C~rt Fcc to Public Savmgs Bank 2300
'106 Prnccsstng Fcc to
807 t'vlortgtlgc Broker Fe\.: to O'Neill Fm.mCI;ll 1,350,00
XliX Proccssmg: Fcc 10 Puhlic Savmgs B3nk 600,00
809 Tax Ccrtjfic;JIJon 10 Public :Sav1l1gs I3anl~ 90.00
X 10
~ II
<)OU ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
90[ Interest hom 03/03/0G 10 03/01/06 al $6,370000 per day .13.74
9U2 Mortgage Insurance PrcmwnJ
~1I3 Hazard Insurance PrCl11lUm
911.1
905
,
I 1000 RESERVES DEPOSITED WITH LbNDLR
[001 Hazard Insurance 2 {/lQnths at $29.00 per month 5S,00
11102 i'vlorlgagc lnsurilllcc mOlllhs <It per manUl
[0113 County RCfl( Eslaw Ta.,,,~s 2 f1lonUls ilt $G.32 per monlh 1?6'[ ..
10lH City gCi.ll Eslate Ta""cs I months Ul S17.12 fler month 17,12
1005 Sellool Real Estelle T.L'\CS 9 months. ilt S4G.35 per month 421.65
[OOG
1007 J-\ggrcgatc Accounting Adjslltmcnt -245.13
1100 TITLE CHARGES
1101 Sc!llcmenl or CJosmg Fcc to Laurcncc t\ NCIsh
110' Abstract or title SCLlrch to
1103 TItle Exrunll1al1on to
1j(J.l Title Insurance Bmder to
1105 Document Prcparalloll to Laurence A. NCISh POC S150.00
1106 Noiary Fees 10
1107 Attorney's Fees to LLlUfcm:c A, Ncish 125,00
(incluues abovc fine numbers
110S Title Insur;:mcc to Laurence;\, NC1Sh .120,00
(inCludes <Ibovc line numbers' Rl,:ls::iul: .
110') Lender's Coverage 530.000.00
1110 Owrw:(~s Cover;:lgl: S30,000OO
1111 Endor:icmcms
1112 Other Endarsclm:nls 8.1, 100,300 150.00
1113 Closmg Protcctlon Letter to Ticor 35,00
1200 GOVlCRNEiVlNT RECORDING AND TRANSFER CHARGES
1201 Recording Fecs: Deed: S45,00 Monguge S35.00 Otlier: 130.00
1202 City Transfer Taxes ( 2 Percent of 30,000.00 ) 600.00
1203 St,lle Transfer T,L'\<..'S ( 1 Percellt of 30.000,00 I 300,00
1204
1205
130(J ADDITIONAL SETTLEMENT CHARGES
1301 Survf;Y to
1302 Pest Inspectlon to QU31ity Pest Services 525.00
13G:l Tax Ccriiiicallons/"No-Licll" Lellers rCllnbursclm:lll to Laurence A. Nelsh 45.00
130,1 Couf\t.:r & Win: Fcc to Laurence A Nets!l 72,50
1305 200() County Ta.\:.l.':s to AllcgJlcny County Trl:<lsllrc[ 75.84
[306 2006 .tvlutllclpal Tax~s to the City of i\.'lcKccsport 205.39
1307 AON I-lollle Warranty 409.00
UOS ESllOl;1(cd Fina! Water &: Sewag.e to Tl/(~ City of N1cKccsport 200,00
1400 TOTAL SETTLlCMlCNT CHARGlCS (elltored on lines 103 nlld 502) $3.652.27 $6,0)4.00
I have carefuly reviewed the HUD-1 Settlement Statement and to the best of my knowledge and betler. n is a true and accurate stalemenf of all receipts <Jnd
disbursements on my <:lccaunt or by me In this transaction. 1 further certify that I receIved a copy of the HUO-1 SeUlement Statement.
Cb!~ -
l: .f --. ,)
. I / 11\.Jl~<lA.-,/\
Sherry Mesdrik
t1~
" ;-Ob
)
t Q
1\
roo the best offJ1~ Yf ,wle e the r-tUO-1 Settlement S!atemen! '.vhich I have prepared is a true and accurate account of the fundS which were received and have
been or will be th!?tJiblJte y the underSigned as part of the settlement of this transacllon.
I ~ ".
Laurence Ai. NC1Sh