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> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
UndOI penalties 01 perjury, I declalo thaI I Mvo examined this rehlfn, including ~C(lmpan~ino schedllle;j'~;menlS, i111d 10 thO besl of my ~nowladgo and belief, II IS !rIle. corrCl.~t and complote Dooljlrllhon of prepilflll (lltlo,
than theoorsonal reDresonlalivois basedonallinformatiQn.2i:!hlill~~nQ\ljltld(l(j
"J;I!1~TU /F PERtO~R~SPONSI~rE FOR FILING RETURN ADDRESS ~--
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EOFPRE~~~' HER THAN REPRESENTATIVE ADDRESS (J'"'~" I
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~ri~9... REV -1500
GOMM(lfI~"Y'VA"'A INHERITANCE TAX RETURN
Oi:PAfI fMFNI or llEVLNl!1
IIARR'S~~~h.~~~'\\11B oo~ RE.SID~~J. D~EI?_ENT
Q[:Cr:OENT'S NAMr, IlAST. rlll~>'. MjD MI()[)~' 1~1I11AII II~nd bl;jlJ ~Io(~ kl ~~tl'll;l\tl '/Ir<J!'!'!
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SOCIAlSH:UllIlttIU!.llltfl
1. 4-" 0 5 ~ 0 44 (0 __r;; ~ 1 qL~__~ 8~~J-'YI' :..?- /1 q ls::~____n~--
,II 'PrIlCARlE! SURVIVING SPOllSt ",W." !lAST fI"". AI<oM,,,"Ll'N"IA', SOCIA, :;'CU"'" ""Mill" !IllS RETURN MUSTOE flLFO 1M IIUpLICATE Wlnl HII
~/~_________....::...__=--____. _.___ REGISTER OF WILLS
[J;r'f, Original R,lum [J 1 supplemenlal R'lum [] 3 RemalnelOl Relurn '''',,' ,,".,,,, P'~ . '" ,,;,
o 4. Limited Eslale LJ 4a. Futuro Interest Compromise (llotlilo!dI1a(h~nllr 12.111\/1 [] 5 fedoml Eslate Tax ReIIH!l ROQuired
o 6. Der,edonlOicd Testate (Ma.:llcvpyo!WdlJ [1 7. Decedent Maintained a l.il/ing l'ru5t {M~hCOf1'fO! TMII '" 8 Toll'll Numh(lf 01 Sale DepOSit Boxes
o 9 litigation Proceeds Recei\'ed [""110 SlXJllSal Poverty Credit (dd!llOldfJ~ht>eM'"n D,)l.'H Mid '.1.9S) lJ 11, Eleelion to tax undtH Sec. 9113(,A,) (Ahi\f;h;~:hii)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATiOifSHOui.b BE DIRECTED TO,--
tiMlE _ CQMPI ElE MAiLING AOORf:SS -
_~f-.) tJ...~CO\..:r~ ___
fIRM~:;',ME {If''Ppl~:ablel
1, Real Estal' (Scrodllle A) (\)
2 Stocks and Bonds (Schedule Bl (2)
3. Closely Held Corporation,Partnership or Sole.Proplletorship (3)
4. Modgages & Nole. Receivable (Sch"Jul. D) (41
5, Cash. Bank Deposits & Misoollaneolls Personal Property 15)
Z (Schedul, EI
0 6. Jolnlly o.ned Property (Schedule FI (6)
5 7. Inter-Vivos Translers & Miscellaneous Non.probate Property (7)
;:) (Schedule G or LI
t: 6 Totll Gr... A..." (Iolal Unes 1-71
~
9 Funeral Expenses & Adrnlnlstralive Costs (Schedule H) (9)
~ 10. DeblS 01 Decedenl. Modgage L1abllllles. & L~n' (Schedule I) (10)
11 Totll Deduction. (Iolal Unes 9 & 10)
r.') C,
5 z. . C>C)
.j::~.
(6)
7.,. 5~<='), Dc:>
5'2..... CD
(111
(12)
(131
2. I S"?O) . () D
'2..4~-7.0<::>
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12 N.t Vllu.e! E.t.t. (Une 0 mieu. Une11)
13, CharItable and Governmental BeQuests/Sec 9113 Tlllsts for which an elAclion to tax has not been
made (Sch'dule JI
14 N.t Vllut Subject to T"IUne12 mlnu, Une 13)
15, Amo",1o!line 141a"bl'
at thfl spousal tax rate I I
See instructions on reI/elSe side lor applicable percentage
16, Amour)t of line 14 taxable
816% rate
17 ~.mounl olline 14 ta"ble
at 15% rate
D
(14)
-'2.,4-'2.7 ,0 D
x .0
(15)
x ,06
(161
(17)
(16)
x ,15
18, Tal Ou.
CHECK IIfRI If YOU ARE REQUESTING A RI fUND Of AN OVERPAYMENT
~
DATE
-~\5\~P,
OAT
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)?~~!~ent'a Complete Address: ~ ~
~'I""I^,I[lHl'," 'St-tb 1..':::>t- -:Jt((ff..~ -- -_.---~,-~ ~-.~___..u_______
___0 __ _ _ _ ~_ _ _ _ _ ~____._.. .. __~~_~........._~_~~. ._~.____-++
l,"'--'~~Rl~..j ~ ~. ~~--.---------- lsr'fr" '1-s..--lZiPi70~ ';l.
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Tax Payments and Crodlts:
1 Tax Duo (Pago \ l.inoll\)
2 CredllslPaymonl,
A Spousal PovNly Croctll .'_,___,_.____
B. Prior Pay",onls
C Dlscounl
(1)
TDlal Credits (A + B + C) (21
3.
Interost/Ponalty II applicablo
O.lnterest
E, Penalty
~
T otallnterest/Penalty ( 0 + E ) (3)
4, If line 215 grealer Ihan linn 1 + line 3, enter Ihe dlilerence. This Is the OVERPAVMENT.
Check bOK on paga 1 Line 19 to raquall a refund (4)
5, II line 1 + IIno 315 grealer Ihan line 2, onler the difference. This is Ihe TAX DUE, (5)
A. Enler Ihe Inleresl Dn Ihe lax due (5AI
8. Enler Ihe IDtal Df Line 5 + 5A This is the BALANCE DUE. (58) _ (:)
Make Check Payable to: REGISTER OF WILLS, AGENT
... ..... 1 I .4... . .
PL.EASE ANSWER THE FOl.LOWINO QUESTIONS
BV PLACING AN "X" IN THE APPROPRIATE BLOCKS
1, Old decedent maka a transfer end: Yes
a, retain the use or income of the property transferred; ....... .......... []
~. retain tha right to designate who shall use the property transferred pr its income; ..... ..... []
c, relaln a reversionary interest; or........................................... ........0
d, receive the promise for life of either payments, benefits or care? ............ ............................ 0
2, If death occurred on or before December 12, 1982, did decedent within two years
preceding death tranefer property without receiving adequate consideration? If death occurred
after Dacember 12, 1982. did decedent transfer property within one year of death without
receiving adequate consideration? ............. ................................................. ................... ...... [J
3, Old decedent own an "In trust for" or payable upon death bank account or security
at his or her death?.. .. .. ..... ..............0
4. Old decedent own an individual retirement account. annuity, or other non-probate property? ...0
b
No
~
BJ
KJ
g]
~
8
~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
~~..R!ftl~~i\*..tJtM&1M:ft;iF;J;l~:MVlytl~:~~'JJ!r,m~~;i1if;~NlliW'i11m~,(~~~W,fl~il\f;l~.~\~S;~N,._
72 P.S. ~9118 (a) (1.1) (I) provided for the reduction of Ihe tax rale imposed on Ihe net value of transfers to or for the use of the
surviving spouse from 6% to 3% for dates of death on or aHer July 1, 1994 and hefore January 1, 1995.
72 P,S. ~9116 (a) (1.1) (ii) provided for trle reduction of the rate imposod on the net value oftransfers 10 or for the use of the sUNlving
spouse from 3% to 0% fOI dales of death on or after ,January " 1995. The statute gQ@~J}Q\..Q.~erDPJ a transfer to a surviving spouse
from tax. and the statutory requirements for disclosure of assets and fiiing a lax return are still applicable even If the surviving spouse
is the only beneficiary.
FOR DATES OF DEATH ON OR AFTER JANUARY 1. 1995 - Please .answer the lollowing question by placing an "x" In the
appropriate space.
Old the decedent create a trust or similar arrangement which Is sol~ly for the sllNlvlng spouge's benefit for hl9 or her entire
lifetime? Yes [] No [J
If you answered yes to the above question, the lax on tile trust or ,imilar arrangement is postponed until the death of the second
spouse, at which time it will be fully taxable althe ratu(s) applicable 10 the remainder beneficlary(ies). Enter the veiue of the trust on
Schedule J, Part II, in order to remove It from tho calculation of the tax due in this estate. You may wish to file Schedule 0 In order to
make the election available under Section 9113. If the election is made, the trust or similar arrangemBnt Is taxed in the estate of the
first decedent spollse, the portion of the trust or similar arrangement which benefits the surviving spouse Is taxed at the zero tax rate,
and the remainder is t~xed et the rate(s) applicable to the remainder heneficiary(les). If YOll choose to make the election, you must
attach Scheduie 0 to a timely-filed tax return, along With Schedule(") K and/or M in order to show the apportionment of the trust or
similar arrangement between the surviving spou,e and the remainder tJeneficiary(les).