HomeMy WebLinkAbout06-21-06
...J
15056051058
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Veal'
File Number
21 05
1029
Date of Bi rth
716-09-4403
11/14/2005
10/12/1909
Decedent's Last Name Suffix
Decedent's First Name
MI
R~h M~
George
D
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FIl.L IN APPROPRIATE OVALS BELOW
.. 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return ReqUired
4. Limited Estate
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
o
8. Total Number of Safe Deposit Boxes
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. All CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytirne Telephone Number
William C. Dissinger
Firm Name (If Applicable)
Dissinger and Dissinger
(717) 957-3474
REGISTER OF WILLS USE ONLY
First line of address
400 South State Road
Second line of address
City or Post Office
State
ZIP Code
DATE FILED
Marysville
PA
17053
Correspondent's e-mail address:mville@pa.net
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 prepareI' other than the personal representative is based on all information of which prepareI' has any knowledge.
DATE '
5/.J-<J/ a ~
I ,
II 15 Kemrer Dr., Marysville, PA 17053
TATIVE
~ '1 DATE
j -'J 0 -C(y
~'DRESS
400 South State Road, Marysville, PA 17053
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051058
15056051058
....J
---I
15056052059
REV-1500 EX
Decedent's Name:
George
D Roth
RECAPITULATION
1. Real estate (Schedule A).
2. Stocks and Bonds (Schedule B) . . .
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) Separate Billing Requested . .
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.
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)...
.....11.
12. Net Value of Estate (line 8 minus line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (line 12 minus line 13) .. . . . . .
...........14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X .O~ 15,108.80
15.
16. Amount of line 14 taxable
at lineal rate X.O 45
17. Amount of line 14 taxable
at sibling rate X .12
18. Amount of line 14 taxable
at collateral rate X .15
30,217.60
16.
17.
18.
19. TAX DUE. . . . .
19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059
Side 2
L
Decedent's Social Security Number
716-09-4403
1.
89,900.00
1,073.70
2.
0.00
0.00
899.10
6.
0.00
7.
0.00
8.
91,872.80
31,303.14
15,243.26
46,546.40
45,326.40
0.00
45,326.40
0.00
1,359.79
1,359.79
.
15056052059
---I
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21
05 1029
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
George D Roth 716-09-4403
STREET ADDRESS
5 Tod Circle
--
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
1,359.79
0.00
4,045.50
67.99
Total Credits ( A + B + C ) (2)
4,113.49
3 Interest/Penalty if applicable
D. Interest
E. Penalty
0.00
0.00
Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(SA)
(5B)
0_00
2,753_70
0.00
0_00
0.00
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.
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 [KJ
b. retain the right to designate who shall use the property transferred or its income; ............................................ D [KJ
c. retain a reversionary interest; or.......................................................................................................................... D [i]
d. receive the promise for life of either payments, benefits or care? ...................................................................... D [i]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? _.........._.................................................................................................. D [KJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [KJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...._............................................................_...................................................... D [KJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates 01 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 three (3) percent [72 P.S. 99116 (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 zero (0) percent
[72 P.S. 99'116 (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 zero (0) percent [72 P.S. 99116(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 four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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.
REV-1502 EX+ (6-9*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
FILE NUMBER
ESTATE: OF
George D. Roth
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
NUMBER
DESCRIPTION
602 Landsvale Street, Marysville, PA 17053 (settlement sheet attached)
VALUE AT DATE
OF DEATH
89,900.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
89,900.00
REV-15D:3 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
ESTATE: OF
George D. Roth
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
'1
DESCRIPTION
VALUE AT DATE
OF DEATH
21 Shares of MetLife, Inc.
1,073.70
TOTAL (Also enter on line 2, Recapitulation) $
1,073.70
(If more space is needed, insert additional sheets of the same size)
REV-15C8 EX+ (6-9S)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Geor~le D. Roth
FILE NUMBER
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.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1. Checking acct #419575 with First National Bank of Marysville (letter attached)
899.10
TOTAL (Also enter on line 5, Recapitulation) $
(It more space is needed, insert additional sheets of the same size)
899.10
REV-1511 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Geor~,e D. Roth
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Shalonis Funeral Home
Church of God
4,484.00
150.00
2.
B ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Carol Hoke II George A. Roth
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 121 Ridge Road II 15 Kemrer Drive
City Carlisle, PA 17013 II Marysville, PA 17053 State Zip
Year(s) Commission Paid: 2006
5,512.36
2.
Attorney Fees
4,072.06
3
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
0.00
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 256.00
5 Accountant's Fees 0.00
6. Tax Return Preparer's Fees 0.00
7 Sentinel 112.16
B Cumberland Law Journal 75.00
B. Costs of Real Estate Settlement 16,641.56
TOTAL (Also enter on line 9, Recapitulation) $
31,303.14
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Geor~~e D. Roth
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUME:ER DESCRIPTION OF DEATH
FILE NUMBER
Sara Todd Home 6,742.07
2. Union Plus 5,09031
3 DISCOVER 2,445.78
4 Sprint 32.12
5 United Water 31.13
6 PPL 72.55
7 C&C Buggies 750.00
8 Patriot News 8.40
9. MGM Pharmacy 23.00
10. Marysville Bank 14.00
11. Comcast 33.90
TOTAL (Also enter on line 10, Recapitulation) $
15,243.26
(If more space is needed, insert additional sheets of the same size)
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
BER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Carol Hoke, 121 Ridge Road, Carlisle, PA 17013 Daughter 1/3
George A. Roth, 15 Kemrer Drive, Marysville, PA 17053 Son 1/3
Rosella Roth Wife 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
I NON-TAXABLE DISTRiBUTIONS:
A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEiNG MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Geor~le D. Roth
NUM
I
2
3
SCHEDULE J
BENEFICIARIES
FILE NUMBER
(If more space is needed, insert additionai sheets of the same size)
A. Settlement Statement
U.S. Department of HOUSIIl);
ami Urban Development
01\1[3 No. 2502-0265
6. PIle Number
S. ~1or(gagc Ins. Case Number
D. Type of Loan
1. D FllA 2.Dl'mHA 3.lXJConv. Unins.
4. D V A 5. DConv. Ins.
GR05-1258REP
203005113557
7. Loan NumJcr
C. This form is furoishe{1 as a statement of aChJal settlement costs. Amounts paid to and by the settlement agent arc shown. Items marked
(p.o.c) were paid outside the closing; they are shown for informational purposes and arc not included in totals.
D. Name and Address 01 Borrower
Raymond R. Reed
Estate of George D. Roth
F. 0ame and Address (>I Lender
Decision One Hortgage llC
6060 J.A. Jones Dr. Suite 1000
charlotte. NC 28287
E. Name and Address of Seller
167 Ashford Dr
Enola, PA 17025
G. Properly Location
602 landsvale Street
Harysville. Pennsylvania 17053
Borough of Harysvi 11 e. Perry County
L SUMMAR YOP BoRRC'WER'S TRANSACTION:
100. GROSS AMOUNTDUEFROM>BORROWER
lO I. Contract sales price
102. Personal property
103. Settlement charges to borrower(line l400)
104. overnight
105. wire
Adjustments for items paid by seller in advance
106. City/town taxes to
l07. County taxes iI/30/200fu 12/31/2005
108. Assessments ll/30/200fu 06/30/2006
109. se\'ler/trash credit
110.
ll1.
Il2
89,900.00
890.32
25.00
25.00
51. 32
823.53
71.61
........
-
120. GROSS AMOUNT DUE FROM BORROWER 91,786.78
200. A1\IOlJNTS PAIDIlYOR INBEHALPOFBORROWER
20 I. Deposit or earnest mllley
202. Principal amollnt of ncw loan(s)
203. Existing loan(,') take'l subject to
204.
205.
206.
207. S,~ for Escrows
208. S.1I for 2nd fees
209. 2nd Hortgage Proceeds
Adjustments fo, items unpaid by scller
210. City/town taxcs to
211. County taxes to
212. Assessment..~ to
213.
214.
215.
216.
217.
218.
1. 000 . 00
71. 920.00
676.56
715.88
16.991.76
219.
.'::::::::::::,:.>.", .,-'-':.':;-'.,--',',:','.:;:,.", '-'. ,'., .
: ;'- '-;",:':::., :::::<;:<: "<::<::::::'::::':::::>::::;>' ::.::: ;:;' ':":' -:
220. TOT ALPA fDJ3Y ipORBOAAOWER'
300. CAsHATSETtLEMENTl:'ROMITO BORROWER
30 I. Gross amount due t rom borrower(1 ine 120)
302. Lcss amount paid by/for borrower(line 220) ,
............ ......i.) .(d......... ............. .....
303. Ct\SH((!] FROM)iOTO)
91. 304.20
. ......
91. 786. 78
91.304.20)
482.58
Ii: Settlemcnt .-\.gellt Great Road
Settlement Services, lLC
Place of Settlement
I. Settlemcnt Date
2157 Harket Street
Camp Hill PA 17011
11/30/2005
K. SUr-.lr-.lARY OF SELLER'S TRANSACTION:
400. GROSS AMOCNl DUE TO SELLER
40 I. Contract sales price
402. Personal proper;,:,
403.
404.
405.
..
89,900.00
Adjustmcrn for itcms paid by seller in advance
406. City/town taxes to
407. County t.lxes 1l/30/200fu 12/31/2005
408. Assessments 1l/30/200fn 06/30/2006
409. sewer/trdsh credit
4l0.
411.
412
51. 32
823.53
71. 61
420. GROSS AMOUNT DUE TO SELLER
500. REDUC'TIOI'S IN AMOUNT DUE TO SELLER
501. Excess deposit ,ee Instructions)
502. Settlement char,::es to seller(line 1400)
503. Existing loan(s taken subject to
504. Payoff of first mortgage loan
505. Payoff of second mortgage loan
506. PA Dept of Revenue inheritance tax
507. SA for escrONS
508. SA for 2nd fees
509.
90.[.46.46
12. 150 . 08
4.1J45.5C
576 . 5(
715.81
Adjustments for items unpaid by seller
510. City/town taxes to
511. County taxes to
5 \2. Assessments
to
5\3.
514.
515.
5l6.
517.
518.
519.
.. ..
520. TOTAL REDUCTION AM.OUNT DUE SELLER.
600. CASH AT SETrLEMENTTO/PROM SELLER
601. Gross amount due to seller(line 420)
602. Less reduction amount due seller(line 520) (
.. ....
603. CASHi[!J TO:lCO fROM) SELLER
17 . 588 . I
90.846.
17 . 588 .
72.258.
The information contained in Biocks E. G. H a;1d I and on line 401 or. ifline 40] is asterisked.
lines 403 and 404 is important (ax information and is being furnished to the Internal Revenue Service. If you are required 10 file a return, a negligence
penalty or other sanction \\'illbe imposed on YOll if this item is required to be reported and tile IRS determines that it has not been reported.
""" 1 C'CTTr P1I.1I;NT STATEMENT
Q Bra.insrorm Software 1-.540-G65-0S00
\V A It NING: It is a , rime tn knowil1):I)' make f"lse stalel11,~nts tn the United StatL.'
nn this or 01,1)' other ,imilar form. Penalties upon conviction can include a fine
;\nd imprisonment. I'or details see: Tille 18 U.S. Cude Section 1001 "'- 1010.
SETTLEMENT STATEMENT
PAGE 2
L SE1TLElvlENT CHARGES
700. TOTAL SALE:;/BROKER'S COMMISSION based on price $
Division of commission (line 700) liS follows:
70 I. $ 2.672.00 to Remax Realty Associ atcs
~-702. $ 2.722.00 10 ERA NRT
703. Commission p;,id at Settlement
704. Transaction Fee-Remax $125 (b); ERA NRT $125 (s)
SOO. ITEMS PAYI\DLE IN CONNECTION WITH LOAN
89.900.00 @ 6.0 ~f = S
5,394.00
PAID FROM
BORROWER'S
FUNDS AT
SUTLEr-.! [NT
PAID FJ\iJM
SELLER S
FUNDS ^ T
SElTLEI'-1 ENT
125.00
5.39'\.00
12:1.00
SO I. Loan Origination Fee
802. Luan Discount
;;03. Al'lHllisal Fee
-.-.-------
804. Credit Report
S05. Lemkr's Inspection Fee
S06. Mortgage Insurance Application Fee
S07. Ass\llllption F( e
S08. Decision 01 e Htg - underwriting
%
%
475.00 to
14.75 to
Apex Appr.li sa 1 ';
Accubanc
~
i
47';~
1".75
to
I
89~' .00
S09.
SJO.
S II.
900.
901.
902.
903.
904.
905.
1000.
e--
1001.
1002.
1003.
1004.
1005.
1006.
j007.
1008. agqregate adjustment
1100. TITLE CHARGE,')< ><d-,
1101. Settlement or closing fee to
1102. Abstract or tille search to
1103. Tille examination to
1104. Title insurance binder to
1105. Document preparation to
1 106. Not.ary fees to
1107. Attorney's fees to
(includes above ilems Numbers:
J 108. Tille insurance
YSP to Nat'l City Htg d/b/a Accubanc $1078.80 PBL
ITEMS REQlllRED BYLENDERTO Be PAID IN ADV ANCE
Interest from 11/30/2005to 12/01/2005 @$
Mortgage Insurance Premium for months to
Hazud Insurance Premium for 1 years to
15.422800
/dav
15.42
)0." 73] .06
>
182.76
138.36
355.44
~
'^ 10.00
USAA
RESERVES DEPOSITED WITH LENDER
Hazard insurance 3 months @ $
Mortgage insurance months @ $
City property taxes months @ $
County properly taxes 3 months @ $
Annual assessments 3 months @ $
months @ $
months @ $
60.92 per month
per munth
per month
46.12 per month
118.48 per month
per month
per month
....
GRSS-domestic relations
GRSS- Ianni pac $116
GRSS
GRSS
GRSS
cash
GRSS
search
o IS. 00
to
GRSS (Stewart
... ' )
title Guaranty)
)
~ 815.75
(includes above items Numbers:
1109. Lender's coverage $ 71.920.00
IlIa. Owner's cover;:ge $ 71.920.00
1111.
1112. closing ser~ice letter
1113. Donald Palm~r - tax cert $10: school tax $1595.86
1200. GOVERNMENTRECORDINGANDTRANSFER CHARGES
1201. Recording fees: Deed $ 39.50 ;Mortgage $ 72.50
1202. City/count)' tax/stamps: Deed $ 899.00 :Mortgage $
1':03. State tax/stamp';: Deed $ 899.00 ;Mortgage $
Decision One
Reed
35.00
....
rCfi05.86
:Releases S
I
. X 112.00
~ 899.00
899.00
1:04.
1205.
!.IOO.
!.I 0 1.
1_\02.
1303.
1304.
1305.
1400.
ADDITIONAL SETTLEMENT CHARGES
Survey
Pest inspection
Harysville 80rough
H,3rysvill e I\orough
to
to Sudden Death
sewer 9/1-11/30 2 units @ $59.83
trash 12/1-2/28 2 units @ $16.67
40.00
- -
119.66
33.34
TOTAL SETILEMENT CHARGES. (enteron line 103. Section J and line 502, Section K)
890.32
12.150.08
CERTIFICATION
1 have carefully reviewed the HUD-I Settlement Statement and 10 the best of my knowledge and belief. it is a true and accurate statement of all receipts and
disbursements made on m)' account or by me in this transaction. I further certify that y,we received a copy ,~~he U ~ 1 Setllen:~nt Statement. '.
/R'''''Od R R~ if: ,t,t, of r;e';J Rot ' '.
~~ /C, /1 ~ elf ~ 1/.
UOrro\\'er~ ~e ers,' '. .
The HUD-l Settlement Statement which I have prepared is a trtle and accurate account of this transaction. 1 have caused ~r will cause the funds to be disbursed
in accordance with this statement.
Setliemcn'f;~eat
~-
November 30, 2005
Date
17053-0017
DUNCANNON OFFICE:
55 South Main Street
Phone: (717) 834-5161
Fax: (717) 834-5639
MAIN OFFICE:
101 Lincoln Street
Phone: (717) 957-2196
Fax: (717) 957-4578
RIDGEVIEW OFFICE:
500 S. State Road
Phone: (717) 957-2114
Fax: (717) 957-4678
JANUARY 17, 2006
DISSINGER & DISSINGeR
400 SOUTH STATE RD
MARYSVILLE PA 17053
RE: ESTATE OF GEORGE 0 ROTH
HERE IS THE INFORMATION YOU REQUESTED:
CHECKING 419575
GEORGE D ROTH
OPEN: 6-11-04
INT: N/A
000 BAL: $899.10
SO BOX 1000137
GEORGE 0 ROTH
ROSELLA ROTH
IF YOU REQUIRE ANY FURTHER INFORMATION, PLEASE CALL
SINCEREL Y,
&~~-~
BARBARA RECHER
CUSTOMER SERVICE
~
~
~.
LAST WILL AND TESTAM~NT
Ot
GEORGE D. ROTH
I, George D. Roth, of 5 Todd Circle, Carlisle, Cumberland
County, Pennsylvania, being of sound and disposing mind, memory and
understanding, do ~ake, publish and declare ~his to be my Last Will
and Testament, hereby revoking all Wills and Codicils heret.ofore
,ade by me.
ITElvI 1-.
I cirect. that all my debts and funer2.1 ex:;:;,enses,
including my cemetery lot and grave marker and 2.11 expenses of my
last illness, shall be paid from my residu2.ry est.ate as soon as
racticaole
after my death as part
of the expense or the
administration of my estate.
ITE~l II.
I devise and bequeath all of dl'! esc:.ate",_ e'Js>:~-
ature and where~!er situate equally to
my c~ildre~, ~eorge
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':", ,-,,' - ~ - ,
Sr. and C2.rol L. HOKS, and their issue per st~roles.
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I ap~cl~L my children, George Aa ~ot~r
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Hoke, or their survivors,
Co-Sxec::Jt<)rs :Jf
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In connection with their duties as such in any
they may be called upon to act.
jur13dictio~ I
in '"hich
IN V1JITNESS
liJHEREOE', I
have
hereunto set my hand to this my Las~
c:::f'
0- pages, to each of which
Will and Testament, which consists of
I have affixed my signature this :;.,ry
thousand five (2005).
day of
Ar/tv
I
t1,'lO
A~~'jf Jj.,~
George 0 Roth '
OMMONWEALTH OF PENNSYLVANIA
55
OUNTY Of I Pj~
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and ,\\1 f'\\\ r\. l<: c"\i,
the testator and
ct-- n !-i
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ftle, George
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D. Roth,
the
(!'i2-t.nesses
~
respectively, whose names are signed to the attached or foregoirg
instrGment, being first duly sworn, do hereby declare to [he
undersigned authority that tne testator signed and exec'...:ted tr;e
inst.rumert as his Last Will and t.hat he had signed willin~lYI and
that he executed it. as his free and voluntary act for che p~rposes
therein expressed, and that each of the witnesses, In the presence
a"d
, .
nearlng
of the
testator,
sig"ed the Will as witness and that to
the best of their knowledge the t.estator was at that time eighteen
years of age or older,
of
sound mind and under no constraint
" ~
.~-
undue influence.
ftli~~tf ~
4 C(~ >t~_~-
Ij\ilt~
Subscribed and sworn to and acknowledged
before me by George C. Roth, Testator
and subscribed and sworn to and acknowledged
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Derore [7'12 oy .,,-, \t),'.-\..l ~\ '~-.)~r"'" , 2:-'.Ci
, Ute." ,,\ \2.c\-\-<~ "" -, , '!'iitnesses t.his
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Ma:ysYiE-s Bem. POOy C;';~rf ',,~
~ ,}I.y Ct>..mrrJss.~ Expires Cd. 31, ZOOS,
.