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qUESTiQ.!i.LCONUERNING PROPERTY TRANSFERS
1. Old de.. cedont, Wlt.hl.n two yenr~ of death, Ina.ka any tranufer 01 any mtt'rlal,port of hl9 ostato. WI.thout r.OCOIVlng
Valuable and adequato conslderallon? (Answer "Yes'l or "No" ,) . v
2, Old do.cOdont,. within two yoars of doath, transfor prollorty from.iI.lnlSell/ harSOIf.tQI)lrISOlf/herSOlf and another party
or parties (Including a spouse) In lolnt ownorshlp? (Answer "yes" or "No",) ~ .
S, II the answer to 9ne or two alxlve Is "Yos" and tho transfers ore claimed tobo nontaxablo, provide the following
Inlormatlon:
a. Age 01 decodent at tline of transfer. . . .
b,. Copy 01 death cerllflcato,
c. .Affldovlt by tho attending physlclah Indicating tho state 01 decedent's health otllme 01 tronsler,
d. Ail other Information sUPllOrllng nontnxablllty 01 transfer,
4. Old do..cOde.nt, In hls./hElr IIfellme,moke any translor olpropmty without recolvlng a valuable 01 adoquate conslderotlo~ Jf. .
therelor which was \0 take effect In possosslon or enjoyment at or after his/her doath? (Answer ".Yes"or IINo".) ..p."t..U-
OJ Wa.s thore any possibility thot the prope.rty transferred might rot~}odranSferor or his/her oslalo or bosubjocl
10 his/her poWer of disposition? (Answor "Yes" or "No" ,) . .. .
b, Whal was tile transferoe's ago. alllmo..ol decodenl's death?
. 6. DI~ decedent In his/her lifetime moko any transfer without receiving a valuable and adequate consideration Iherofor
under which lransferor expressly or Impliedly resorves for his/her life orany porlod which does In laot end belore his/her
doath: kJO
a, The possession or enloyment of or the right to Incon\o from the property transferred? (Answer "Ves" or "No" ,) -4'!
.; . .b, The rlghlto deslgnale .the perso'W\who. shall possess or onloy the property transferred or Income therefrom?
(Answer "Yes" or "No" ,) ---w-- '
6. II the answer to live b. above Is "vesY wns tho. right reserved In deco\lontnlone ( ) or decedent and others ( ),
7. Old.decedent In his/her II fetl 111. e m. akea translef, the conSlderall.on 10.f w~CM.1 as transferee's promise to pay Income.
to or lor the benefit or care of transferor? (Answer "Ves" or "No" ,j.~ .
8, Old decodent,. at any lime, Iransferproperly, the b81eflclal enloyment ot which was sublect .to change, because of
a reserved power to alter, amend, Of. \~ wot\.e e,l,.or Which could rovert.to..decedent under tefm~ 01 transler.orb.y oporallon 01
law? (A09wer"Yas'" or "No'!,) :::-E . .
9. If the answor to eight above Is '~Ves, ' was the power 10 alter, amend or revoke the Interest of the beneficiary reserved
In Ihe decedent alone ( lor decedent and others ( ).
U(:V.4'11'E~1 13.1101
OOMMONWPA~ TIi or PftNN~YW^NIA
OSPARTMINT OP ~SVIN~IR
TRANIrK" INlisnlTANOB TAX .
"lIlO"NT OSOltlllNT
RCIHiOULF. "0"
aSNEFICIARIDS
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IWale 01 " Louhll M.. G1mW_
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llBNBFICIARIBS AND ADDIlBSSBS RnATION8111P 8v". .. DATil OF INTIIRBlT Ol'.III1NBPICIARV
llBCRDRNT lllRTH
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The above beneflolarlel ere living et thll time exoopt for tho followlngl
NAME
DATIl 01' OIlATH .
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~ION8I;.QB COMPLETING 8011~DULE "E"
Schedule liE" must Includo all property, 1'001 and 110rsonol, ownod by tho docedont Jointly with enother
perty or pertle8 a8.jolnt tOl1onts with rloht of survivorship, Both tonolblo and Intonglble property aroto be
Included. List real 08tote 111'81.
1. Oe80rlbo ell real proporty oslndloeted In the In8tructlons for Sohodule "A." Desorlbe 1111 personal property
oslndloated In the Instruotlon8 for Sohedule "B." Includo tho nome, oddl'ess and relatlon8hlp to tho
decedent of tho co,ownsrl81 and tha date the Joint ownership WIIS o8tabllshed,
2. Indloate th'o total market value of tho jointly owned proporty,
3, Indloete the pal'cllntago of tho deoedent'slnterest,
4. Indloate the market value of the deoodent's Interest.
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INVENTORY 011 ,REAL AND PltRSONAL ESTATE
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laId of ..~,9.'1...r..,hl+,.,~..'f.mm,~".~.\3.................lnlho Counl)' olaaM~ State. oll'enl\a., dec.a~d,
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JlIllflllllfU of the real anll peraqnal ealale whl~h were 01 lhe ahove,named
.......;..,.................,",......~~rt....I.;rk:l.\...~<.?~,.. decenaed, .Taken and 'appralaed
Ihe ,.....".......... da)' 01 .......""."".".........111. (Pate of dealh .....?I.!fl.~.1....,.....)
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Ouh $6,738.00
6;138 .00
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COMMONWBALTH OP PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF ElUIMINATION
OFflOIAL NOTIOE Of
INHERITANOB TAX
AaSBSSMENT
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ESTATH
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COUNTY fiLE NO: "",' /
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FILE NO.
COUNTY
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DA T& OF DeATH
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Appr~l"d V~luo of &81010:
Roal E"olo
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pertonal Propbtly
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LOll: Approve,d Charll~bla Exomptlonl
Cloar V~I~o of EII~le Subjeot '0 Ta.
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Amount Ta.eblb @ '6% Ralo
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TOTAL PENNSYl.VANIA INHERITANCE TAX DUE . /"J/ 'I ;;;.
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Amoun' Ta~abla <lP 0% Rale
. . . . . · A flvo poroanl dlaooun' totaling ·
Will ba granled If. tho Inherltanoo Ta. 10 paid by
Lell Credits:
DATE OF PAYMHNT
'l.?-FI
AMOUNT PAID ~
DISCOUNT
INTEREST
TAX CREDIT
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Ih18rell aooruGt . at the rate of II~ (B)petoont par annum
on Ihe unpaid balanca of Inherltanco Too from
'to date of paymenl. In'etelt dllo If paid by . 10 ;'J' .'
BALANce OP PENN8YLVANIA INHHRITANCB TAX DUE . .7.( .c.. . ;"i L...
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80. Inlo,msUon on Rsvs,.. Sld:'Ulled by:' A~~: ~~s~:~"r\:;;llh ,)I~ I " .,./
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O~NERAL 1~l:lee'TANge TAX ltllF9ElM~T~
Un8lltllfl,ed lIa\)llltles Inourred by the dec~dent prior to hls(hur doeth ura deductlbla agaln8t hI8/~ar taxable aeleta,
In addition to dobU InQurrad,by the deQedent or estato, other Itel11S aro olalmable Including the cost of adlT\lnlstratlon,
attornay foes, fiduciary feel, funoml and purlal expenso.lnoludlngthc c08t of a burlallot,tolT\bstono or groVOlT\orkor,
All dobl8 beln\! qlalmad against an as tate ara sublecttCl tho approval of the, Raglstar of Wills with whom tho
Inheritance Tax ReHlm Is fllad. Evldenco 10 support Iho deoedent'sor Iheesloto's liability for Ihe debls being olalmed
should be ettaohed to Ihl~ 80hedule,
A family exampllon of $2,000 may pa olalmed by a spouse of a decedent Who dleddomlolled In Pennsylvenle, .
If there Is no spousa, Or If the spouse hP8 forfeited his/her rlghls, Iheneny ohlld of the decedent who 18 a IT\ember of
tha same household Oen olalmlho exemption, In the avent ther8,Is no luoh spouse or child, the exemption oenbe
olalmed by a parenlllr parents who are members of the same household as the deoedent. The family eXelT\ptlllnls
a,lIowable only a9alns\8sse18 which pe88PY a will or by tho PennsylVania Intestato Laws,
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INSTRUCTIONS FOR COMPLETING SCHEDUl.1! "F"
'1, .If the family exemption Is being olalmed, Indicate tho olelmant's neme' eddress and his/her relationship to the
deoedent, Entor "family exemption" In the remarks oolumn and tho amount olalmed In the emount oolumn,
2, A8slgn oonseoutlY8 numbers to eeoh Item Ileled.
3, Enter the date on whloh each debt wes Inourred end/or paid,
4. Enter the mimes of eaoh peyee.
6, Provide a brlof explanation In the rell\ark8 cohlmn for eeoh debt olalll\ed,
e, Enter the amount of eaoh debt being olalmad,
7, The form must \)e 81gned by therarson who has 08sumed the responsibility for paying the debts,