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Home My WebLink About06-15-07 -.J 15056051047 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes PO BOX 280601 Harrisbur , PA 17128-0601 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth ~ Suffix [IJ] MI [j (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix [IJ] Spouse's First Name MI o THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW .. 1. Original Return 1:) t::) 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) t::) <::) 4a. Future Interest Compromise (date of death after 12-12-82) <::) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) <::) 10. Spousal Poverty Credit (date of death <::) 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) REGI~ OF WILLS tm}: ONLY ~:.o.O >: =t; ~= CJl -0 jO-..) Correspondent's e-mail address: penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowled e. SIGNAT RE OF eERSON SP SIBLE F~ FILING RETURN E ".l\)Ce... ~ \\ . ~ -, ~ \7 DATE (; € J11(~".-v s"..- E is J, ,. ~ 4..- f". 17.5- Z z..... PLEASE SE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 ....J ~ 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 GrossAssets (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. Decedent's Social Security Number 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 Subjectto 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!:t.S" 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c::> L 15056052048 Side 2 15056052048 -...J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME _--DennIS STREET ADDRESS I./~~ N . G- F'I?Y1 ~~OV~~ S+re~1- -- I STATj? ~ I ZIP /7' /.:3 ~. CITY ~(;L,..II s/~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C ) (2) o 3. Interest/Penalty if applicable D. Interest E. Penalty o 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) / f/ "3 7. 0 9 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) J C; '3 7. 07 A. Enter the interest on the tax due. (5A) (5B) 'f37.0? B. Enter the total of Line 5 + 5A. This is the BALANCE 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 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 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 No I a A- ~ ~ 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. ~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 zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)J. 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 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. ~9116(a)(1.2)J. 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. ~9116(a)(1.3)J. 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-150,2 EX+ (6-9. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER (?~N~/.r FiNN All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH N{)#"~ TOTAL (Also enter on line 1, Recapitulation) $ - 0 - (If more space is needed, insert additional sheets of the same size) _a."", *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Ue'("\ n I S- F"tnl'] FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NON& TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) -c.:> - REV-1504 EX+ (1-97* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH J.I / Ir TOTAL (Also enter on line 3, Recapitulation) $ D (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER VeV'\ ~ l S E htln 1 . Name of Corporation Address f\C{ ft~ State_ Zip Code State on Incorporation Date of Incorporation Total Number of Shareholders City 2. Federal Employer I.D. Number 3. Type of Business Business Reporting Year 4. Product/Service Common $ $ Preferred Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. 0 Yes 0 No If yes, Position Annual Salary $ lime Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years jf the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....D Yes 0 No If yes, provide a copy of the agreement. Number of Shares Consideration $ Date 10. Was the decedent's stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1 . Name of Partnership Address '1)eNNl>" Ii. FII"It! ~. Date Business Commenced Business Reporting Year State Zip Code City 2. Federal Employer 1.0. Number 3. Type of Business Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. c. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. 0 Yes. 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferrecl/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additional transfers ancl/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement. Date 11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax retums (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 E~+ (1-97) . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Ve..f1 f\ ( ~ &. - J-, IV N FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. NONe:- TOTAL (Also enter on line 4, Recapitulation) $ "0 {If more space is needed, insert additional sheets of the same size) REV.1509 EX. (1-97) '* SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNS) LVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ve Yl Il ( SO ;E. rllY 1'1 FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ~oll~~n F'N/'I I" ,~ et2nk"'I/"/~ /?caP! N~u.J VI 11t!.r;,. 17.2."/ / :p~(,4.j h -I~",.. B. c. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 199 :> H"lA.~e 1(21 JJ 110.. w"oue.r )(" ~ ~o 33000 eO-/" Itsll! PA 170' 3 /, " 000 . TOT AL,(Also enter on line 6. Recapitulation) $ 33000 - (If more space is needed, insert additional sheets of the same size) -,..~.""'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF j)enn,S HII{N SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE OATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A CDPV OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPUCABLE \ NUMBER 1. Nol(.-L -V - TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV.l508 EX + (1-87) '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ve."ntJ:'" E ;:; N IV FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. P,A/N $'11 lid n t et ~Ta.-+e.. 64.r'1 (-c- ;!. ~ ",3 tt. S-~ flet!ou"T ~ 9/s-()~o 8-1 YO TOTAL (Also enter on line 5, Recapitulation) $ ~ ~ ~ ..J ~.. 6"6,-- (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF 1k.,., ('\ l S' E. FILE NUMBER NN.# Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: A v... 4.. -r fill. tN\.O N .. L ,., 0 I'VI e K1I'~~"" 1( /#,11 ~ fOfrt'~ J.OIt 9' 99.5'0 1 fro OD ;?dc;J B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 100. (:) D 5. Accountant's Fees y , S t 11 AleN41 ,J,l. S ~ It. j.",,, l. j1,~po" At... (pf tI ffltl'l'S jIlr i.- 1>e" T IIN#l/Ol.A.',Ct.I1Ylllc_T" ~'"1.(Jp,r'r 300. cJD if-rl.f 6. Tax Return Preparer's Fees 7. ~DD()- d,;J TOTAL (Also enter on line 9, Recapitulation) $ 3 if 99- 3 ~ (If more space IS needed, Insert additional sheets of the same size) REV-1512 EX+ (~2-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ITEM NUMBER 1. Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE OF DEATH P4 DESCRIPTION B "" 11 Ie.- rtI () I' f~ a..( ~ :L ~ 'I c. /. S 2...,{ so!,. 11230,7' 9'2./, 'I' 3 /2'3.'''' f.- :t . SC{ :1 9. ,.~ / 7,,}.oo '11./3. SO? 1:1.. f..{- 2.._" '7'7 S-rp,.T~ 2, \J Y $" (, 7 8- 'I {.La-I ppCI- --re/~f~Ne.. -- E.."" 8.4-9 60r-o~r ~ ~ f tLtd.Jc F~,l.,~.... L 'T4Ke.r r:>elli(~t FINal s-fArt... ft\ c I, to.."l. e {ud~ r 1+~IlIL~ ljc.-- 't- ~tI"'''' TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13/21. ()O REv-I51' EX+ (l>{)():W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER ""De 'fill, S E:. r,nrJ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. j)A.wl'l #~ rre-"- 19~" H~_I(Jck. oS" t'ol/(,_b,~ OH 113~1 7 :t t.lluN FiN'" ~O" ~c..,.,k,.'v, /I-e RD Nl-vJI/,tle fA 172&/ f J ~N/~~. F,,,n '3 f<~e~g"ll---r J>K:. :p~(l "U fA 1'1 SI 7 if S hlL-"" N 1=", ~ n 4 33 S- P,.I(.,' e A-v <- C ha.-.b,r-..s bu~ PA lJ~o I oS Te,..r-~"c.e ,:, t)t) ~ 'I'C/I 917L.. AUt 50",""" Ic.~", ,. IJIJ- 980 3 ( (, e ,7..; 4# F. "fl s" ;l ~ R,,y II 0 1t;l.J Ave fiG. I-e,-s-/ow I't An> ~17'1o RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE 41 S"'"Oc>'" ~ h,/e/ Oa.~~ kle" ~o to ;\0% Dcu.c.,h.-k" SO~ D ~o 1"0 SOl") <#- ~O~ >aN do lah ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed. insert additional sheets of the same size) REV-1514 EX. (12-03. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER Der\()(~ E.. ht1n This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ................................................. Interest table rate - 0 3 1/2% 06% 010% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . . Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 031/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size)