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Home My WebLink About05-30-07 -.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 OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 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 c::) 1. Original Return 4. Limited Estate c::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ~ 2. Supplemental Return c::) 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 Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes c::) c::) REGISTER p~ WILLS USE ~L Y ( _-:: C) --.,J () (,') c::: Correspondent's e-mail address: Under penalties of pe~ury, 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. SIG T E OF PERSON RESPONSI E FOR fiLING RETURN ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 -.J )yA ~ REV-1500 EX Decedent's Name: RECAPITULATION 15056052048 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . " 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) c::::) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c::::) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 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).. . . . . . . . . .. . . . . . .. . ... . .. ... .... . . 11. 12. Net Value of Estate (Line 8 minus Line 11) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. Decedent's Social Security Number 15. 16. 17. 18. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15[]56[]52[]48 Side 2 c:::> lS[]56[]52048 --.J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME ___iY~ L _1- t ~__ T~__BJ:-~~J~_-----_-_-_ ________ u___________ ~T~EETj~RJ8 Cf-(?) 1ft AIYl_ J:),eU)~ _________~-------~----------- ___C~{}lt_~----------------.- CITY CA In P J+ ILL --------, ! STA~A I ZIP 170 J I Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) It 3:2.0 J cr 7 Total Credits ( A + 8 + C ) (2) 3. Interest/Penalty 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. 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) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) ~ 3 ~(). q 7 A. Enter the interest on the tax due. 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;.......................................................................................... 0 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 0 c. retain a reversionary interest; or.......................................................................................................................... 0 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ~ 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 P.S. 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. 99116 (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 P.S. 99116(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. 99116(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. 99116(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., 503 ~+ 16'98* Ct>MMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF AI~ J.L/ e X. AJ..&;SI.Afl FILE NUMBER ITEM All property JoI~-owned with right of . c9. / 0 & -00 c::t1 NUMBER survivorship must be disclosed on Schedule F. - 1. " DESCRIPTION' -Stocks (5h.a..re ",,'t5 50 Y cr , 0 ()d (:) C(J CP/2-ILD&VYI A 1- n"vM!CIAt- ;rmc. L.cIYl PU rgASJ-f/1f8 5/-IfJ&Mt.f::ee ~C5 -~ -9/C099 Am7 of ~4re iflj I.f ~3~G ~J ~G3, 11 ;VlT AJrlT dfS~t.-l ~.~ D 1 'b 'fOf? zb 4-A't T~ 0/ 54 t-C.- stoc/($ C?fk3rrll/f5~es) 7 Ljqj '1 I.f J ~ ,me 1-~ol\l m ~ Ll--oAJ :t:/lJUE.S ,oR. SBt<!l7(c.es 9ROSS A-mt ofl 94~ $~ 7J. Lj.fi IV~T Am-r. of S\~ ~) 70Cj3/ . IJtr~ of -S4l-g O;)./~!07 SCHEDULE B STOCKS & BONDS cJ, TOTAL (Also enter on lin 2 R . (If more space is needed . . . e , ecapltulation) $ , Insert additional sheets of the sa . me size) VALUE AT DATE OF DEATH ~ O1Jt-Y J-8MJJ8J:J Q~ -of, s .rtt5 (jA;VuA12V z(}or vJ~ OtUh V ~~/lJ CD 0)- -r1l/5 IAJ 'dANU A-/2 P ~ oa: $:1) 7JL/.S1 Please Note: Your Sale Proceeds Check is Attached ~ Mellon Mellon Investor Services A Mellon Financial Companylill ~~~ Login to Investor ServiceDirect@ at www.melloninvestor.com/isd ----------------------------..-----------------------.-----------ii-.u---.-----------------------------------------------..-----.-------- INVESTOR 10 1251561to206 SHARESlUNITS SOLD 49.7414 GROSS PROCEEDS $2.724.59 NATIONWIDE FINANCIAl SERVICES. INC. CUSIP ACCOUNT KEY 001 75063861210 BOWER-MARYAOOOO PRICE PER SHARE ($) 54.7751003 CHECK NUMBER 6243362 TRADING FEES PAID BY SHARES SOLD CHECK DATE 0212112007 CHECK AMOUNT $2.709.59 SERVICE FEES PAID BY TAX WITHHELD $O.Q<L_ COMPANY $0.00 SHAREHOLDER $5.97 COMPANY $0.00 SHAREHOLDER $15.00 NET PROCEEDS $2.1---- ~"., Please Note: Your Sale Proceeds Check is Attached @ Mellon Menon Investor Services A Me/Ion Financio/ CompanyDl ! ! . . i I . a . ~ - ~ iii !!! 5~w~iWw_ffl.*jf#iW!fg4tf,*,ifiW"'*%%@j\'gW%1fg<<~P~~~~~;;&-~B Login to r~ Investo.. ServiceDirect@ at www.melloninvestor.com/isd 'IM~~~~J~]~j~~~!~iI~~rt!mWJl~~: INVESTOR ID 125156190206 SHARESlUNITS SOLD 49.7414 GROSS PROCEEDS $2,724.59 NATIONWIDE FINANCIAL SERVICES, INC. CUSIP ACCOUNT KEY 001 750 63861210 BOWER--MARYAOOOO PRICE PER SHARE {$) 54.7751003 CHECK NUMBER 6243362 TRADiNG FEES PAID BY SHARES SOLD CHECK DATE 0212112007 CHECK AMOUNT $2,709.59 SERVICE FEES PAID BY ~ PLEASE DETACH BELOW CHECK NUMBER: 624336: , ~.,. ~..,,,,:,,,,,,..-,,.~_,,......,,,...,... .... ,"', .":"'.... .., or .-.,.~ ,_'" .~':~'.~.., ..:.. .~_u~<!t<._.. - ... "'".'l':'.,..!t..~. .. ;:'--,'.""i,~;.:-,,);;',,~'''':;-7~ - - -'.-.-~.,."7,...-...-.- -._- ,...........n- ....~. .., .'!:"U~"':'.q~..~....~.',~ ''!',...~ ,___ ~....... .~.,,!!, ~.- "':'..'" ... ... ..._.. ..- .. ...- ... .. .. ... ... .. ... ... ... - .. - -. ~. -. - - -. -.. - -..-.- - - - - - - - - - .. .. .. - .. ~ .. .. - .. .. .,'" -.- $2,709.59 $0.00 SHARES HELD BY PLAN 0.??oo COMPANY $0.00 SHAREHOlDER $5.97 COMPANY $0.00 SHAREHOlDER $15.00 TAX WITHHELD NET PROCEEDS .~ -_.-~.- -1. 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