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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
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COUNlY CODE YEAR
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NUIJ8ER
SOCIAL SECURITY NUMBER
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DECEDENrSNAME (lAST, FIRST, AND MIDDLE INITIAL)
/-'AlE 1..0 e; ~E E
DATE OF DEATH (MM.DD.YEAR) DATE OF BIRTH (MM-DD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
NA-
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
(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. Original Retum
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WillS
SOCIAL SECURITY NUMBER
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date ofdaath after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (date of death be_n 12-31-91 and 1.1.95)
o 3. Remainder Retum (date of death prior III 12.13-82)
D 5. Federal Estate Tax Retum Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach ScI1 0)
COMPLETE MAILING ADDRESS ])'
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SEE INSTRUCOONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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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
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
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x .0 _ (15)
x .0 ~ (16)
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x .12 (17)
x .15 (18)
(19)
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Decedent's Complete Address:
STREET ADDRESS
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
If) l/t 7 't
Total Credits ( A + B + C ) (2)
3. InterestlPenalty 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)
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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.
(5)
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
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[B
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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
d. retain a reversionary interest; 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? ........................................................................................................................ [B/
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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.
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ADORES ' . A.It
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SIGNATURE OF PREPARER OTHERTHAN REPRESENTATIVE
ADDRESS
DATE
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 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) (iill.
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 retum 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 0% [72 P.S. ~9116(a)(1.2)).
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(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 decedenfs 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.
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Decedents Complete Address:
s
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. CrecfrtslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
/otlf I 7P
Total Credits ( A + B + C ) (2)
3. InterestlPenalty if applicable
D.lnterest
E. Penalty
TotaIlnteresWenaIty ( 0 + E ) (3)
4. If Une 2 is greater than Une 1 + Line 3, enter the dllference. This is the OVERPAYMENT.
Check box on "'1 Lint 20 to request a rtfund (4)
5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Una 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X. IN THE APPROPRIATE BLOCKS
1. Old decedent make a transfer and: Yes
a. retain the use or Income of the property transfer'red;.........;................................................................................ 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; 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. Old 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 Accoun~ 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.
Under penIIeI ollJlllurY. I decIII'Ilh8l1 '- tIXIII1ined lhls 1lIlum. including ~ lIChecIuIlIa end 1lIlImenII. end to the belt ol my ImowIecIge n bIliIf. 1111 trill. CllmIClIl1d compIIIB.
0edIIIlIan ol PI'I*W olhIr thin the l*IllI1II'epl_1lIlIve II bII8d on IIInIonnIlIon olwhlch prepnr his IIf'/ knowIIdge.
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
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ADDRESS
DATE
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on lha net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 59116 (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 0% (72 P.S. 59116 (a) (1.1) (i)).
The statute does not IlX8IIlDl a transfer to a surviving spouse from tax, IInd the statutory requirements for discIosura of assets and filing 8 tax return are stiR 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 paren~ 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 or for the use of the dececlent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 59116(1.2) [72 P.S. 19116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs slbIings is 12% [72 P.S. 59116(8)(1.3)). A sibling is defined, under Section 9102, as an
indMdual who has at least one parent in common with the decedent. whether by blood or adoption.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
NT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF r,- FILE NUMBER
LI Nt, .-/crre.-Y\c~ t: ~ I OCl
If an HIlt WIIIllIde joint wlhln one year of the decedInt'. .. of deIIh,lt mUlt be ..... on Schedule G.
00014
SURVMNG JOINT TENANT(S) NAME
RELATIONSHIP TO DECEDENT
ADDRESS
A. J-hrrLf Li 11~
B./l1 A e-r nvJ.1 \A,}o L il N GEe..
c.. F Vir, In, a.. Ifodc.b"l bt'€1j
~.b&\Jt.rk, J. G ~(f"
E L..J..Ch.t. r ft1 vf,.,}, '1 J it.
100 Fhnf5ton~.])Ltvc...
tV E W VIL.l..E PA 17;) '-/ I
.:L Jlq2~l wood ,4H,p,q
/Yk..c../1tA-rl ~s bu. ,;" J
~3J ~ LlndsA.Y U AA 17;;257
Sh Ipp.e..ris.bu'r~
Sw-Lt.n~ Caur t
1001 oriole. D,e,v-t-
Mt.d1OJt,cs bur''' PA no~S"
50 AI
.DAtJ6 riTE. R:.
))lWe~TE" ~
'VAOGl-\I"C e:
SON
JOINTLY -OWNED PROPERTY:
LETTER DATE DESCRI'TOI OF PROPERTY '4 OF DATE OF DEATH
ITEM FOR JOINT MADE Include ,... d llnlIICIII inIItulion 8IId bri ICCCllIIIIIUlDr or ~ IdenIIfytng 1UIlbIr. AIIIch DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT dB b jalnIIy-heId 1lIII... VALUE OF ASSET INTEREST llECEDENT'S INTEREST
1. A. JF751J t../q 4/ ~5. 3SC1. q? ~S, 35'. 'If
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15, ~q3.42- /5 ~q3. 4')."
;). AB Ii '15l) tift t.J-;;. I
.3, ~8C.bE it- 15"'01100 )0, 03 '-/. ~D 10, 0 3t/. ~o
5 ~1". ~9
J.J lAec.bE -tt 1'itJ'I9 J/-{) 5, lD 74. '?>'1 I
1M !kC1Jw'l:, fro"7t 1 S- oL(q
{Y1embers 1st
TOTAL (Also enter on line 6,Recapitulation) $ 5(P I 3 (P d.. 3 q
(If more space is needed, insert additional sheets d the same size)
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REV.1510 EX. (1-97)
.
SCHEDULE G
INTER.VlVOS TRANSFERS &
MISC. NON.PROBA TE ~ROPERTY
COMUONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SI NT DE DENT
ESTATE OF F r
I ()'( lnc. e.. r=
L( rJE
FILE NUMBER
ala, - CKXJI 'f
This schedule must be compIeIed and filed If the answer to any ofquestlons 1lhrough 4 on the reverse side of the REV.1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY . %OF
ITEM IHQ.UlJE THE NAIIE OF THE ~ THEIR AB.A'IlONSIIP TO DECBlENT AND THE DIllE OF lRAN8FER. ~~TE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NIIMR~R AlTACIl A fX1I'Y OF THE DEED FOIl REAL mAlE. . v. U~ rv: ASSET INTER~ST
1. 1iIfA- CR.EF To: 17 07.?;~ /701.3'i
C)-II L bREN :
Lu..-l:hu- M u r p~ JR.
(Y} fI(TINA f<. w L (I N6 f.f.
f. V,RGI/.ltA H()t:..k.ENBE f:-~,/
rtARft'/ E. L"J E
~ eve te.L '{ J. G~IGE.~
TOTAL (Also enter on line 7. Recapitulation) $ I 7D7. 38
(If more space is needed, insert additional sheets of the SflT1e size)
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REV-1!i11 EX+ (12-99) .
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULI H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
i.sl NE
Flo-rlj\(~ E
D8bIa of decedent must be reported on Schedule I.
FILE NUMBER
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ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
A-u-o- 1Ykmur-ltd 1-4~
'it~n &t:ht-ra.n (J)(JrCh
(Y), /hn 7;;4 c..c.Jr) I I~STlJt:..
~mJw..lU\d &. HrmOt' GLJafd
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representatlve(s)
Social Security Number(s)JEIN Number of Personal Represenlatlve(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's addreas is not the same as claimant's, attach explanation)
ClaImant
Street Addreas
City
Relationship of Claimant to Decedent
State _ Zip
4.
Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
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AMOUNT
J,!}, Cj , (JO
~Oo.06
J d(). () 0
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COMMONWEAlTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
REI NT NT
ESTATE OF
L,NE
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABiliTIES & LIENS
F/oY~ce E.
FILE NUMBER
d / at; l)!Jo/tj
Include un reimbursed medical expenses.
ITEM
NUMBER
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3.
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DESCRIPTION
'v\1L~ Shcrrc. 6n~'ft:n c'f /'1die4l SUllie ~S
13, b. Wtll fY10tl , ~o.
S h I p~!.bu.rq U.eal:fh ()O:.( ~
~A.(.llsk. Jhr~
Pui k.u-"" f\~SDCi.at8 A
~bu-sbu.( Ir-na.~. SSDC..
1> 11lm" nd pfucl..tnCl-"1 "x:rl11C.f' $
fYlob,lu.. l X rOAj .eh:.)
And tr riA.- ((A tHOl.l)G 'I tlssoc. Pc..
~,^n\bet'a...'\d Va.,U..e~ E. M.S ~
~ Medical CJ,nIL, PC
Re1tdb tl1eCUci.n~ Asso<!. ~ Pc
f..lJ f\.k ph ("0 J ~ d4 H-s 5 0 C :r: N ~
VdsulOf ~SSOC PC . -
I-anCllitu f/117A PII'/S fr/6 /Vl r (leN, PeN
1711 II- e.,U i= -. 0 f/.e-..r j)O. '1 m-e n I- n~ed cd
I -hJ k ~ bAcJ:::..
Ifpu Asset- (fJ()n{):qe.merJ- !
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TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
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.3~~ 55
rql11.q3
q fa. DO
/ 4. ~ 'l
3.{,,~
.3qq G,o
.Jfq. 09
J ~ O?J
) 48. 6a
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J!' .:;.1
8(l.O~
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79.1/
;? 3 ;l.oK
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57.f7
~t)q. 7l/
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