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Home My WebLink About06-01-07 -' 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 INHERITANCE TAX RETURN ... RESIDENT DECEDENT r;-( i () 4;j File Number : . ,./ <,,') OS ,) '-~ Date of Birth 1,/3 tf2- 'f7 76 OSt920(}c:;, c10Z' ((is Decedent's Last Name Suffix Decedent's First Name MI S L 0 .., A fYI t? S L eJ.L..A y (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) 4. Limited Estate C) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required C) 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) J)~1-6 f!.~5 Firm Name (If Applicable) illfl I fi1 It rT II el),l S .7 f-7 5 ~;;:.f 23.710 ~F;"'....' --' RE~~TER OF ~LL,LS UsJ:.,?NLY ..,-.", ".-"'-<1 First line of address .3 ,s~ cJ 0 e&AiIG~F(6L-D j(orrP ",", " .- i Second line of address .d ----1 City or Post Office State ZIP Code U1 DATE ~L'ED ... , t..~ . 1 '-~ /-1 IT I? 1(' S13 () RG fA / 7 / CJ f Correspondent's e-mail address: Under penalties of pe~ury, I declare that I have examined this retum, 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 r~~sentative is based on all information of which preparer has any knowledge. SIG TURE OF PER '~E~~:~,~~~~:~_~""""co"~"~~rco~_","~~_~~~__~~AZv '7_ AD ~;:~ /' 1~~~J.7-,:) ~ C:il - /1 .~~~~~d~(~':~L+Lt2~c_~.."-~~-~."~~~-~~--'"'.DATE =~~~_~""~~~'c. =,.~-=,-,,-,,=,-.",",","",,,",,,,,,-~~=-=,.,....--.,..,.,,,,-_=<>_.,.,,._=,,-,,==~,,,,,=~==-..,,.=......,,,-,,~"',,",,,,,,,=~~'"-_"".~,",,"'='_'= c.,.,-..~~~~,-,-..".."~,=,=,-,-",-,",_.,-""",-""~,=-=..,.,.="-~=,",,,,,,,,,,",,,,,="=-~.......,-,-~....-=.-,-"-==,="',='~"'==-=-'",,,,,""'-=-"'" ADDRESS >.-"=.--======_....-__~==,~,.".~'"..-..=....~"""'"'=.e....,."",~~.-~.,~.,,''''=..''=''''~==-=~=..~==.=_.,._....-,..-:::.=~,.,.,..=.-r="-...==...~~"....,"t,=-':",.c-"."-"'.=-.O:,..,c,c.-='=""'"="-",,,,,,,",,,,,',~=-,,=.~....-.,,,...,=----=:...~c:.'.~'~=~""'='.''''''-'''''''. ,.~; :(, ,", PLEASE; USE? ORIGINAL FORM ONLyr: '"J ,!., __"'''', . ....' ,,~. ~ ,,- l' c:._ '. ._ ",.. -' . ....' ",: ;~- ',,-. .,J Side 1 L 15056051047 15056051047 .-.J ~j --I 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION '1. Real estate (Schedule A). . . . . . 2. Stocks and Bonds (Schedule B) . . . . 2. 0.00 O. GO 0.00 0.06 . . . . . . . . . .. 1. 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. '2-/0.C'c) 6. Jointly Owned Property (Schedule F) <::) Separate Billing Requested . . . . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) <=l Separate Billing Requested. . . . 6. D.O() Q.U() 7. 8. Total Gross Assets (total Lines 1-7). 8. 2iO.oc1 1 z..(,o. 00 0.00 77-&0.00 (7 c ~ 0 · 00) 0.00 0.00 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 . 15. . 16. . 17. . 18. . 19. TAX DUE. . . . . . . 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c::? Side 2 L 15056052048 15056052048 -.J REV-1500 EX Page 3 Decedent's Comp..:te Address: DECEDENT'S NN~:: ~J'~ srS!JO I(E !fihiO.d STREET ADDRESS j) C7 I-/) " rop'-/~u hi.iI{CI, ^~. File Number CITY r?A--/n r #, L-L ST~E }/1--- l ZIP I /70~ Tax Payments and Credits: 1, Tax Due (Page 2 Line 19) 2, Credits/Payments A, Spousal Poverty Credit 8, Prior Payments C, Discount (1) o Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable 0, Interest E, Penalty () Totallnterest/Pena!ty ( 0 + E ) 4, If Line 2 is greater than Un8 1 + Line 3, enter the difference, This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 8, Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) Ci (4) 0 (5) n (5A) 0 (58) 0 5, If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE. 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 ~ 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 g 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? ..........................."""....."""".."".,,,....,,..,,........,,...,,,,,.,,...,,...."....".....""...". 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. S9116 (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. S9116 (a) (1.1) (ii)]. The statute does not exempt 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 twenly-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. s9116(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. S9116(1.2) [72 P.S. s9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is twe!ve (12) percent [72 P,S s9116(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 adoptioil. . Co hl h~j. -t'1J tA c1, . ib, I'~ fe.t2- f OJ; / /s I Cou,tfit""$€ S't{,;- CA-t<./-ISLe; ;?t. /11 "3 ,a; j.uLI1/J. ,eose 3/v+-~ #z/()(,.65'.3 2--' E 0ck'S-e4 fJ~e ~AJd "'/s-;- ~ -9,'jI'~ ~€e A5 (o-v ~ti~+-eJ. I 4 ~!vc .,./ 1"\ i~\ 'II .;-~, "- .. ~ ).:J . ~ ; " , ..."..).;..._....0:... ....... -""',_.........~',.-.....:.;,.;~,..._ Mrs. Delores Matthews 3506 Centerfield Rd. . RRISBURG. PJ\171 Harrisburg; PA 171 09:~ 1 3~ MAY' 2007 PM 4 L a~~{ilIDU.J7' Re(i';}eJe o~ [;Jilts :-'I .e'lvR-f -J../o ose SQUlllJee 9S : II !j~ 1- (!](~~l.5tef I~, 17 /d3 \ J'lUJ/'\ "':\.../:.,J.,..;I IIHHllUHlI IIIUill1 iilllll! IIIi I! lilill It li,llllllulllll;