HomeMy WebLinkAbout02-09-07
...J
15056051047
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 Year
File Number
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(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
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return
c:::>
2. Supplemental Return
c:::>
c:::>
4. Limited Estate
c:::>
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
c:::>
c:::> 4a. Future Interest Compromise (date of
death after 12-12-82)
c:::> 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
c:::> 10. Spousal Poverty Credit (date of death c:::> 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
c:::>
REGISTeiilOF WillS
",,0
=-i.' )
'\)
First line of address
D
11
I
I
\...0
Second line of address
- )
-T:1
City or Post Office
<; L-A
State
ZIP Code
bl
"DATE FilED .'-
--.J
Correspondent's e-mail address:
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.
SIGNA I~E, Ot..~;RSON ESPO)\~~~ILlNG RETURN DATE
f1.M'JII"~ I' l~ .:{ ~ I"~ 0 '7
ADDRESS B --r: r. 10
I J.- 00 R. V N I Y ODy N {/iL r ft I q a ~'5
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
6/6.cl.w{~
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
-.J
REV-15C - . ",a 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME
u_ .....___l}]f1 r?-Li tJ l- C L 0 if S 6_
STREET ADDRESS J. ..- - C fV (h ../. f) /
cX.')G (iC S- . ( ~
CITY
STATE n
rfJ-
ZIP I 7 tJ I 3
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
O,Ot)
(1)
Total Credits (A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( 0 + 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)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
A. Enter the interest on the tax due.
(/. DO
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 gJ
c. retain a reversionary interest; or........................................................................................................................ D ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... D [2g
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. D 1.&1
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... 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.
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 three (3) percent [72 PS. 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. ~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 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 PS. ~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 four and one-half (4.5) percent, except as noted in
72 P.S. 99116(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 twelve (12) percent [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.
REV-151l3 EX + (1-97)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF lV7iL f) I A I f) /1 .' .
I' f' Jf'--t-I 1'\1 "- L L-C LJ S 6
FILE NUMBER
;210S~ 0910
All property jointly-owned with right of sUNivorship must be disclosed on Schedule F.
ITEM
NUMBER
1,
-' .
:::> h e.rvJ \ Y'\ -
9 ~ Co~rn~
DESCRIPTION
Lu \ \ \. U~ N' ~ l a (Y\pC>-I'. '-{
S- ~n? ~ vV'\. (~- lLQ f-
\.../ C-...( v '>2-
VALUE AT DATE
OF DEATH
1t~ 4H Lfu
TOTAL (Also enter on line 2, Recapitulation) $ Y \ Y (0 q .40
(If more space is needed, insert additional sheets of the same size)
II)
.....
q
~
ID
.....
o
z
i
o
cD
~
9;
~
o
Ji
.....
)(
~
I/)
~
o
~
\I
i
...
....
&
c:
l,l:l
-a
~
...
~
l,l:l
CD
"0
i
...
i
o
...
CD
e
o
...
-
I/)
"0
8
o
...
0.
16
~
~.
,g
0..
0:
o
cP
..r
(f')
<<:t
~
..-
o
o
~
~$
otll
o(f)
OiS
~ ~
~ 0
c
~
~
to
e.
o
~"O
G'S
J!!
'1::
::>
ci
~
Q)
-g~
0<(
0.0.
N5 .
-g o~
tll"'z
22~'"
~3ffi:::
"'.~~~
~:2:~5
" ~\UO
tii a:;o.~
"'1ll'B:)
~ ~~-g
"0 ~(;'1
~ .\-,-,0
l
~
\
!II
Qi.
~
0..
(f)
~o
S<<:t
~$
8. <<:t_
e~
1
g
~
~
C)
g
o
c-.i
a>
1
~
~
~
9
~
~
to
<<:t
a>
..-
o
C\l
r-
.to
o .1
z&
g
'"
,....
c:
Q)
'0.
.~
~
50
-..:<t.O
~cP
.- <0
'tC\l
<1)1.0
Jaq
Q<<:t
-(f')
~
u..
tI)
"$
~
0..
o
o
d
l
~
~
~
l-
~
~
e
~
u..
..r
i
~
Q) us
! ~ ~i
~:;i~b'"
-g
tll
tii
$
l
~
tll
Z
tI)
\
'0.
'g
0:
li
UJ
it
'0
UJ
a:
a:
o
u..
,;,
~u
~~
-,3
9
t:,~
g....
.,~
Jo'o'-
e(;
~'i
s'g.
.aU
e,
e~
~o
~..-
.ge
%0
"Olb
~o
g~
.~~
~~
o~
tjO
..'rh...~
~g
.g~
Otn
es
~t:,
~ft
bb~
~'
.9:-
~
<I)
o
liS
><
~
.~
~
g .
.... "$ ~
~...iJ;
., ~,g
.so'"
.saS.B
.~...~
,s:l8~
~",S
se...~.
.,So
.~,.E!':g.
(: "0 ';:
~~~
~..~~
r.I'J..u2
6. .....!
.gO%
uu;.-.....Jo;O.
.s.%,
~:d...~
ot::....
t::o~
%.eo
...... . ..,,,,,"
...
.~ ... g--d
~ ~...~..~
~ ~~.g
...... .~p":;;:J
~ ~g.p'~
e:::lOOx
,.E!~P'.. ~ ~
....s:od;"~ ~
g g~ e e
~~eSs
&~o.e.e
'g.~;e ~
't::V) ,~
%,0 'S a
6. 0 l5':::I 0
~.B ~S%
o ~ S'~ ';
~. ~ ~..'.IO....O
1M ~ ~u ....
. ~ .S"$ g
00-" '" ... ...
~g~....~
"0..... ~.. 0 ~ ..0
~-%g~~
'~g ~z.~
..~.....d";?
Pl:s'1..9 .,
~1
~<Q
~ ~ .~,s
,go ..b
V)~ .....S
l t.. ...\U"...-g
...;. ~o~,g
,.. ~:g ~.s
o "".~ ...-
~~~....~
.~...1l
"""i'.,:::.4>. ;::
.l:>S"
..o~
"''e~
t.-l:l
~~g
...._l.,)
,nod
.-:~~
,...s:o ~
cio~
g
00 ..D
9.S .9
"'~~ 'g
~ .s. (\) p..
.g'O.a e
o"'"t:,
~~o ~
~~e ~
l:l bb
s.s 9 ~
go~ 0
.rJ:l..,....4 ::liJ..t
g""~ ci
g~e .8
p"~e ~
~\'i~ ~
'ae~. l:l
''0 ~.t d .5.
~ ~g'B "0
e~~ ~
g~~l:l -0
~z::..dp.;. ~ ~
g ~ g~ S~.
,S9~~ ~~
~..-. <<) ql..1-o".
~.s; ~i
.~e ~.... ~.v; s
~~~g~iJ;
.>I..., 00'" S
eg.,e,Oi:l
Ct:l :>-..s ~~ 0
E
o
~tDl
3<>>
~<>>
.g~
c::-d
~t::
00
~p..
.~~
o~.
U'....
'-'~
!::.1
tn~
:::>...
u~
.sS
g
"
~'i
..a......
;>:>..6
~3
o
iP:
g~
',;:;.8
......
@~
..;s
l:lc::
....,
~;:a
e~
;p.t:
'a~
Il-'V)
.6e
......0
~..~
>li:::>
e
..
:I:
.c
~
~
...
o
o %.g
.s .t;:.,
Q-o",g
... 1-"'d l-
li~~
pa"",e
"t::~OO
~o.s~
g.~.a.s
~.~..g~
00,3 '::;. ~
.S \2"
:>- . ~~
~ ~g:a.
.S l:l -0 ;::
g8j'~
.~ ~rA_ e
Cd (I$....-l t--
~~p~
SS,;,'%
6.0~0
o ".,.<=:
.t;:~,%""
i~ ~;1
g%~~
....6,.- t::.
~o;::o
~ tj.t ';,
",~"$~
~'l~,.E!
~--~- ~~ ~
c--iO-~~--~
~~ g ~ ~
Ct:l-ooe ~
~,~.."" '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF /Vl.ftl-uf rJ P-
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
CC()Us.c
FILE NUft\BER
o<'lo5-Qcnb
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.
DESCRIPTION
VALUE AT DATE
OF DEATH
Ch~cf(lnb !JC(QUflf
(V1+- T %lfrJr:-
fIef * f) ~ 70 6 I 7 /5 /
i1 ~~ 9. 9 ~
TOTAL (Also enter on line 5, Recapitulation) $ K(g Cf . q S-
(If more space is needed, insert additional sheets of the same size)
ACCOUNT NO.
m1 M&fBank.
26760171S1
CLASSIC CHECKING
OCT.lS-NOV.16,200S
1 OF 1
00 0 0433S" N" 017
23714
MARLIN R CLOUSE
250 CACTUS HILL RD
CARLISLE PA 17013-9616
NORTH "IDDLETON
ACTIVITY
DEPOSITS~INTEREST
& OTHER ADDITIONS
CHECKS & OTHER
SUBTRACTIONS
lO-lS-OS BEGINNING BALANCE
11-01-0S "ASS "UTUAL PENSION CK
$869.9S
892.S4
ENDING BALANCE Y\~t-
5~~ (YlQ-A+
IT'S EASIER TO BANK AND INVEST IN ONE PLACE. WE'RE THAT PLACE. VISIT US AT
WWW."ANDTBANK.CO".
$892.S4
INVEST"ENTS: * ARE NOT FDIC-INSURED * HAVE NO BANK GUARANTEE * "AY LOSE VALUE
BROKERAGE SERVICES ARE OFFERED BY "&T SECURITIES, INC. ("E"BER NASD/SIPC), NOT
BY "&T BANK.
L008A (1103) - 84
ACCOUNT NO.
STATEI1ENT PERIOD PAGE
.
NOV.17-DEC.16,2005 1 OF 1
rm
2676017151
CLASSIC CHECKING
00 0 04335M NM 017
60269
MARLIN R CLOUSE
250 CACTUS HILL RD
CARLISLE PA 17013-9616
NORTH MIDDLETON
OTHER
SUBTRACTIONS
NO. AMOUNT
1 22.59
ENDING
BALANCE
0.00
ACTIVITV
DEPOSlTS, INTEREST CHECKS. & OTHER
& OTHER ADDITIONS SUBTRACTIONS
11-17-05 BEGINNING BALANCE
11-21-05 MASS MUTUAL RECLAIM
22.59
$892.54
869.95
ENDING BALANCE
$869.95
IMPRESSED BY THE SERVICE YOU RECEIVED AT M&T? IF YOU'D LIKE TO NOMINATE AN M&T
BANK EMPLOYEE FOR EXCEPTIONAL CUSTOMER SERVICE, PLEASE COMPLETE OUR H&T SERVICE
EXCELLENCE FORM AT WWW.HANDTBANK.COM/EXCELLENCE. WE APPRECIATE YOUR FEEDBACK!
L008A (1/03)
REV-1511 EX+ (12-99) ~
_~...; 'J .~.... ~&..
~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATMi+-rLu n
R- L WU~ t:;
FILE NUMBEB,
0( l as-09iG
Debts of decedent must be reported on Schedule L
ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
FUiK?rO- I
(-tomE - f/9Ff(rl ft.rJ Ro TH
(!culr.J{e PA-
opm (,1 (q- Cumber /6-1}d UulZey
rne~7\OIi o...{
-fu fllf ~ l -foro ((J {.(r1S ~o"B
B'VK !+€iL( ~CtJI2-{ SN--I 0vJ \' C 1-\
ft'A ~~
1.
6rO-.v ~
fYllse
B. ADMINISTRATIVE COSTS:
1. 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. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4.
Probate Fees
CJA\bulG-nO
C 00rJTt(
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
mise
- (\'\W ~, Nb;.ek .
~x..p.
AMOUNT
It to 1 Lf g I 5""0
I
6. II Ol./fi~ ()o
t) ? otr> . 0<-1
t
~<1
() c)
it
~/.,",l
TOTAL (Also enter on line 9, Recapitulation) $ <6' l ~ \ \ S-
(If more space is needed, insert additional sheets of the same size)
1'-1'-00
. !'-ON
!II~ I'- ~
. 1'I'l0~
,'-'>
OOeD
: ~'.' III LIJ <(
,fa....Q.
.".\10 ~
~or"g
,~~ ~
~ · ill
. or" ~
'N,IO 0
fit
1'01'-
.:::l~N
1- l'- ~
- ..- 00