HomeMy WebLinkAbout01-24-07
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EV.I500 EX (6-00)
;;JFF;C~p..L USE ON'i~Y
COMMONWEAlTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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o 1. Original Return 2. Supplemental Return 0 3. Remai"~m (~deathprlQrbI2.1*J
o 4. Limited Estate 0 4a. Future Interest Compromise (date of dealh a!ler 12-12.a2) 0 5. Federal~Tax R~ Required
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o 6. Decedent Died Testate (Atlachalp)"of'Mft) 0 7. Decedent Maintained a Living Trust <-chalp)"ofTMt) 8. TotaINUIl'Iber.llf Safe ~t Boxes .-C.;
o 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (daleof__12-31-91 antll.1-95) 0 11. E1ectlon~ ~~ under ~ 9113("fi~SchO
THIS SECTION MUST'BE'~Q~~E):)iAtJ-~fI~~N@.~.~~'tP4(t.....
NAME 1 .:....::, r-+~\ _U~" i. COMPlETE MAILING ADDRESS ('", I . 'f,/t' It
FIRMNAME~"AppIieabl.) J..!A /11:.,'; } IL!,I OC/",'/(? (?;ovjv1fl,.Z.ItE"1' :;i:, JUIfl;-'
TELEPHONE NUMBER l 1 ....,..' r. i ~ ,.../'T t'J . ~ l ^' /....(3.;"("1 t> y fJ';!. I f"/~ '.1.:)1.-t;.3
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM.DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, ARST. AND MIDDlE INITIAL)
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or So\e-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Properly (Schedule F)
o Separate BiRing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property
(Schedule G or L)
8. Total GI'O$S Assets (total Lines 1-7)
g. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage LiabHilies, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Une 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an eIeclion to tax has not been
made (Schedule J)
(6)
(7)
(9)
(10)
14. Net Value Subject to Tax (Une 12 minus Line 13)
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SEE INSTRUCTIONS ON REVERSE SIDE fOR APPlICABlE RATES
15. Amount of Line 14 taxable allhe spousal tax
rale, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Une 14 taxable al sibling rate
0- ",,' {I c'2 tj' '7
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18. Amount of Line 14 taxable at collateral rate
19. Tax Due
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FILE NUMBER
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COUNTY CODE YEAR
0'12*,
_ _ _"'IL-....e..
NUMBER
SOCIAL SECURITY NUMBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH n
REGISTER OF W1LLS
SOCIAL SECURITY NUMBER .-:>
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I BUREAU OF COLLECTI(1I1Jf?
j AND TAXPAYEP ,..
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IJEPAi-;i 1.:::,\IT OF REVENue
~Af\RISBURG DISTRICT OFFIC~
(8)
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(11)
(12)
(13)
(14)
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x.O_ (15)
x.O_ (16)
x .12 (17) / 0 I J.-szl, .~5
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x .15 (18) tf. 7-12. t~
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Decedent's Complete Address:
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CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
Z. CredltSlPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
I STATE
I ZIP
(1)
Total Credits ( A + B + C ) (2)
3.
Inlerest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestIPenalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OYERPA YM~NT.
Check box on Page 1 Line 20 to request a refund
(3)
(4)
(5)
(5A)
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5. If Line 1 + Line 3 Is greater than Line 2. enter the difference. This is the TAX DUE.
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A. Enter the interest on the tax due.
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8. 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
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
C. retain a reversionary interes~ or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
P":' 1-10>5
DATE
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ADDRESS,.,
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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 dales of death on or after January 1. 1995, the tax rate imposed on the nel 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 exemot 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
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 paren'
or a stepparent of the child is 0% [12 P.S. ~9116(a)(11)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(11) [12 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is 12% [72 P.S. S9116(a)(1.3)). A sibling is defined, under Section 9102, as al
individual who has at \east one parent in coml1lO!\ with the decedent. whether by blood or adoption.
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COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~ p.,. '~.\l t';' ....""'0', t;.;:.,.- .l-\. ".1
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
.., , -.. ' '''c'' .." ~
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Include the proceeds of litigation and the date the proceeds were received by the esIate. All JHOP8flY joIntIy-owned MIll tile right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. OO.'f)-FJr}'f-:t~ h'iV't',ucr,f... , !>/ )J'/)-Y ~ q!.{.<;;.;7,::~~<./O (~ "+r~CJ.tb-r:J) It 11'-- a ;2'1 l?
T /<.-Vv'- ' ?,.,' ,. r;;>
TOTAL (Also enter on line 5, Recapitulation) $ ll? I j, '0"1. '1.?
I., . _ ~ ,~_ __ _ __ :_ ___..._.... :-__.... _.......:.:_...._1 ....h"..".... ,.s thft C"'<'UftoD ~i"70\
000001036
~ Prudential
'.e Financial
The Prudential Insurance Company 0' America
Prudenllal Annuity Servtcos
P.O. Box 13686
Philadelphia. PA 19176
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Check Statement
THE ESTATE OF MARY R DONAGHY
218 BAILEY ST
NEW CUMBERLAND PA 17070
Date: JANUARY O~ 2007
Owner: MARY R DONAGHY
Annuitant: MARY R DONAGHY
Contract #: 94518440
Product: Flexible Discovery Plus
Market Type: Non Qualified
Page 1 of
Thank you for your patience while we completed your request for death benefits from the contr(lct
listed above. Tile table below provides a breakdown of how we determined the net check amount;--~
Taxable amounts are reported to you and the Internal Revenue Service. The federal taxable arnount
of your payment is $ 88937.23. The state taxable amount is $ 88937.23. We have presented this
information based on our knowledge of tax law. You may wish to consult your tax adviser if you ha'
any tax questions. Because each situation is unique, neither the Company nor its representatives
can provide tax advice.
Financial Breakdown Information
GROSS FUND WITHDRAWL AMT
NET AMOUNT OF CHECK
113937.23
113937.23
(VPAS d055216) PLEASE DETACH CHECK - KEEP STATEMENT FOR RECORDS
"~'__"'__"""_~'._-~_.':;'.'.'_~':_;.".'...~~'-. "~{"";'"'''''-''''''''' . _'(.I.._..:I.I..."...........3[.......IIII...ll'..d:UII~'........r.l'~!f1l1f':_hll.":I"'~"r'.
. Prudentlal:.o ThePr_nllall__~afAmorlca ':,.,........<.", ',_. ,.~., ,...~. ..:~,~.. "" ".. ~
Financial Prudential Annuity $eovIces:': WachoYia Bank;.., o....-"'.N.A.. '. .
~~=p~:8~A,'i9'76 ' . ',' ~~Ion. ~~9lM)8.J '~;}..: \:;" ',J'
.' ~~. ..:,. '.," ":" -::"'.'.:' ,- . . ~
:~;~3.&'?;fd'~.._.8l4-..-..-,.~
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':\.,~~i~;i;~~~;.,c}J,~{0r t:3,~Ji
.... .,.... ," ....' ..' '. ..,:~c:on~ctNO.:94;184~O '..
~ay: "'.*. **. *.1C....*P.NE~'.,.H. U.. N.,D. R.E'Q\.T.H I RTEEN THOUSAND N I HE:-HUNDRED'.; . I JAN:04.2007:
,,1c.******,.n'c~#.~~.~,1q'(~TH I RTY-SEVEN AND 23/100 DOLLARS ..../
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6~~:Of:1 AUSTIN DOUGHERTY, EXECUTOR**************
EXECUTOR ESTATE OF THE ESTATE OF KARY R*
218 BAilEY ST
NEW CUMBERLAND PA 17070
I $~"lJ3937.2ll
Cent.
III ~ ? .01.?8 .1.0111 -:03 I. 1.00 [! l! 51: [!O 'jIr:JE~ 5008 21. 21.111
~(- 0& -o~~3
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
. .
REV.1513 EX.. (t.9il
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DEe DENT
ESTATE OF
!vt !t-f(.'( R- r 1)nf /.W-PrY
NUMBER
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1. Lr\4 ~~ s: '9~~'1
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5; ~1,;f^1 f)oa~t.."!r2j''''1
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fbU~ 1,..,l1'?':f{Vir%e "PR./ 1Jt1-#r.SGWi", 11.:, t'l~~
'1, !+rJ.,1...r-,.g; 'Po ~ tJ{4 1''1, . '
J.W 6A-'c..<fi Sr. I N';:'.J i!.l.Jl-tfJ f."'U..A,'JP, f'~ l'i c""lt:'
1. 1vlwt:.Y' OoV~')C?~ H.M2t$f3
ti't rP.,e/~ ~1)., /..(f1Jt;.fl,"<fifollE. (IF 1'1 f1'f1
cr, /:;-z...f'>Wl{;' 1/\, l'f~(,.o
";;2.(.> ,I'm- $1', tIc..) ~!:,';;,;:.tfN!> 1m /70?O
(6. G-Wli'NDot..Yp ~'H...,~...t+ea,:ry
1J-o$" e:H!--t-IE ~'/., HI+(;.J.J';:j't:...'~:J"'1f1 P;" i'?,~1
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1]')1 t't.1l1VJe!P ~1j(..'1 rtiit::C.Hp..J!'-5r;{)rJ~, {# 114S"$"
FILE NUMBER
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If"" J,;ci,. ":)
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r.?'31(1 clr--~IPVA
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· ~.:7 $'
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ENTER DOLlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE. ON REV 1500 COVER SHEE
II, NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
e. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. THr:::. 5,'M'!...f(;:':"'/ poa 17+8 ftlo{JO&-ffne'l<.l of 17+6 FA-!1H
tA--TH'vI.~- 7){~{!.ese C.?{: ~f~.;e(!: f; t$G--
~ 6. f)()r~ "3 [,,57 I H-A,:..!(r!15 i7;/j (J &-, f);': f7 u~.s-
I, pOl>. 0-0
TOTAL OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV 1500 COVER SHEET $
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