HomeMy WebLinkAbout08-06-07
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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
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
_ 1. Original Retum
C)
2. Supplemental Return
C)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
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 Da ime Telephone Number
C)
C)
4. Limited Estate
8. Total Number of Safe Deposit Boxes
-
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
Correspondent's e-mail address:
Under 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,
it is rue rrect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
BLE FOR FILING RETURN
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
~
L
....J
15056052048
REV-1500 EX
Decedent's Name:
RECAPITULATION
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.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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L-.. 15056052048
Side 2
Decedent's Social Security Number
15.
16.
17.
18.
c::;)
15056052048
....J
REV-1500 EX Page 3
D~aedent's Complete Address:
DECEDENT'S NAME
File Number
I---------u
STREET ADDRESS
I---___~__________ u_ _
--- --- ----
I STATE
I ZIP
CITY
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
Total Credits ( A + 8 + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
_________________u_ 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)
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 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. ~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)]. 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)].
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. ~9116(1.2) [72 P.S. ~9116(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)]. 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-1502 EX+ (6-98)
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
TIfelUSA
A-
~ Vfi::-rL
ITEM
NUMBER
1.
DESCRIPTION
"3 ~ l ~ Cv:L>--V- ~ u-tvuf k-ll' I Pit- '(0 \ \
VALUE AT DATE
OF DEATH
\ '1- <1 I OOD
TOTAL (Also enter on line 1, Recapitulation) $ /2--9 I cJ() ()
(If more space is needed, insert additional sheets of the same size)
c
REV-1503 EX' (1-97)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
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
TOTAL (Also enter on line 2, Recapitulation) $
!If morA ~n~.e is needed. insert additional sheets of the same size)
I1EV-1504 EX+ (1-97)
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
-_.,~ '.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Corporation
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
State
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
Product/Service
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? 0 Yes o No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? 0 Yes o 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 stock of this company 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 Number of Shares
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?
If yes, provide a copy of the agreement.
Consideration $
Date
DYes 0 No
10. Was the decedent's stock sold?
DYes 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.
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.
. F1EV-t506 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
Date Business Commenced
Business Reporting Year
City
2. Federal Employer I.D. Number
3. Type of Business
State
Zip Code
ProducVService
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
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Percentage transferred/sold
Consideration $
Date
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.
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 returns (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/so If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
R,loV-~507 EX+ (1-97) '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
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.
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
_'~n.~ *
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
()) 351
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
NUMBER
1.
1.
fers(/VLci
AA ~..,.- 12; A- tJ\L.-
VALUE AT DATE
OF DEATH
DESCRIPTION
~
~/rff-~~ ~
ekt. ~ "-a yo z. ~ z.. "11"\
S;c1fl~ 0' S6a4U~~g-Z2-33
22eJ. '"V
4041.31
TOTAL (Also enter on line 5, Recapitulation) $ -t J..-. q 7. 31
(If more space is needed, insert additional sheets of the same size)
REV..1509 EX + f~.971
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNS, LVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
()03~(
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.
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY '10 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 DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointiy-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-15!O EX. (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
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 DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
NUMBER VALUE OF ASSET INTEREST IF APPLICABLE)
1. ~C>>-vl h 1,0 q ( 1-QO.2-')
M-{T too 9J ~O. '2- CJ
I
)
TOTAL (Also enter on line 7, Recapitulation) $ C{t'2...--~O. V>l
'.-
..
(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
FILE NUMBER
003S/
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES: \l
~(}QA~ fu,. Vt'\Q. V Th-.~oJ. ~
~ \ qa., rv\J)AJ(L t S\-. &"'f t~ l',fA 1"10 t ,
~~ l )y. () 0
...
~\~~~~V\ ~~~
\ 1(8 u-YU-olL ~ Ql:"i L~ \, fA- no \ \
u q ~--. eU
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
l~. v0
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
"C \Q O. "';U
5. Accountant's Fees
6.
Tax Return Preparer's Fees
cJU
I dO'
7.
~ ~\e. 1o..y
VIL~ +t
\l 00. 00
4ru
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
QJfq
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
AMOUNT
~ ~lVL; ~ -- IlA ~ T iS~/~
~S-5- :>7
TOTAL (Also enter on line 10, Recapitulation) $ 'iltf 3. :3 7
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee( s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
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 II - 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+ (12-0.
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
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% 0 10% 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 - 0 3 1/2% 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)
REV-1644 EX+ (3-84) INHERITANCE TAX
~tk
SCHEDULE ilL"
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions
of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
II. Remainder Prepayment:
A. Election to prepay filed with the Register of Wills on (Date)
(attach copy of election)
B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) of election or annuity is payable
C. Assets: Complete Schedule L.l
1. Real Estate S
2. Stocks and Bonds S
3. Closely Held Stock/Partnership S
4. Mortgages and Notes S
5. Cash/Misc. Personal Property S
6. Total from Schedule L-l S
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities S
2. Unpaid Bequests S
3. Value of Unincludable Assets S
4. Total from Schedule L-2 S
E. Total value of trust assets (Line C-6 minus Line D-4) S
..,,'
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F) S
(Also enter on Line 7, Recapitulation)
III. Invasion of Corpus:
A. Invasion of corpus (Month, Day, Year)
B. Name(s) of Life T enant(s) Date of Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
C. Corpus consumed S
D. Remainder factor (see Table I or Table II in Instruction Booklet) S
E. Taxable value of corpus consumed (Line C x Line D) S
(Also enter on Line 7, Recapitulation)
P.EV.16.o15 EX+ (7.85) INHERITANCE TAX
. '*'
SCHEDULE L-l
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Value
A. Real Estate (please describe)
Total value of real estate S
(include on Sedion II, line C-1 on Schedule L)
B. Stocks and Bonds (please list)
Total value of stocks and bonds S
(include on Sedion II, line C-2 on Schedule LI
C. Closely Held Stock/Partnership (attach Schedule C- 1 and/or C-2)
(please list)
Total value of Closely Held/Partnership S
(include on Sedion II, line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes S
(include on Sedion II, Line C-4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property S -,-
(include on Sed ion II, Line C-5 on Schedule L)
III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) S
(If more space is needed, attach additional 8Y2 x 11 sheets.)
REV-1646 EX + (3-84)
.
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION
-CREDITS-
FILE NUMBER
I. Estate of
(Last Name)
(First Name)
II. Item No.
Description
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule l- 1 (please list)
Total unpaid liabilities S
(include on Section II, Line 0- 1 on Schedule l)
B. Unpaid Bequests payable from assets reported on Schedule l-1 (please list)
Total unpaid bequests S
(include on Section II, Line 0-2 on Schedule l)
C. Value of assets reported on Schedule l-1 (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets S
(include on Section II, line 0-3 on Schedule l)
III.
TOTAL (Also enter on Section II, line 0-4 on Schedule L)
(If more space is needed, attach additional 8V2 x 11 sheets.)
(Middle Initial)
Amount
S
8EV:1647 j:X+ (9-0*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev-1500 Cover Sheet
ESTATE OF
FILE NUMBER
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
0 Unlimited right of withdrawal 0 Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) ..... .$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One o 6%, o 3%, o 0%......................$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One o 6%, o 4.5% .......................... .$
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ..... .$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) ..... .$
7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .$
(If more space is needed, insert additional sheets of the same size)
REV-1648 EX (11-99)
'*
'COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX DIVISION
SCHEDULE N
SPOUSAL POVERTY CREDIT
(AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94)
ESTATE OF
I FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) ............................................ 1.
2. Insurance Proceeds on Life of Decedent ................................................ 2.
3. Retirement Benefits ................................................................ 3.
4. Joint Assets with Spouse ............................................................ 4.
5. PA Lottery Winnings ............................................................... 5.
6b.
6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a.
6c.
6d.
6.
SUBTOTAL (Lines 6a, b, c, d)
6.
7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7.
8. Total Actual Liabilities .............................................................. 8.
9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9.
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Return for decedent and spouse.)
Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse .......... . 1a. 2a. 3a.
b. Decedent ......... . 1b. 2b. 3b.
c. Joint ............ . 1c. 2c. 3c.
d. Tax Exempt Income . . 1d. 2d. 3d.
e Other Income not
listed above ....... . 1e. 2e. 3e.
f. Total ............ . 1f. 21. 3f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(1 f)
+ (2f)
+ (3f)
(+ 3)
1.
Insert amount of taxable transfers to spouse or $100,000, whichever is less
1.
2.
3.
Multiply by credit percentage (see instructions) ........................................... 2.
This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................... 3.
4.
For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate ............................................................. 4.
Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . .. 5.
5.
.
tax purposes, whether or not passing under this will, together with
any interest or penalty imposed in connection with such tax, shall be
considered a part of the expense of the administration of my estate
and shall be paid from my residuary estate without apportionment or
right of reimbursement.
ITEM VI: I appoint my son, JOSEPH A. STOUFFER, Executor of this
my last will.
ITEM VII: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his or her
duties in any jurisdiction.
hand and seal this
~
I, THERESA A. STOUFFER, have hereunto set my
day of ,J01^"U ~ ,2006.
'-1' -! (J .
~,? .i~J9t. tz... ,.~~ IxjZ__
THERESA A. STOU~ER
IN WITNESS WHEREOF,
SIGNED, SEALED, PUBLISHED and DECLARED by THERESA A. STOUFFER,
the Testatrix above named, as and for her Last Will and Testament, and
in the presence of us, who at her request, in her presence and in the
ot er, have subscribed our names as witnesses.
Wit:~~ e
414 Bridae St., New Cumberland, PA
Address
414 Bridae St., New Cumberland, PA
Address
D~~", ') r.-F ?
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courtnouse Square
Carlisle, PA 17G13
Rece~pt Date:
Recelpt Time:
Receipt No.:
4/20/2006
13:24:10
1044095
STOUFFER THERESA A
Estate File No. :
Paid By Remarks:
2006-00351
JOSEPH STOUFFER
RSK
------------------------ Receipt Distribution ------------------------
Fee/Tax Description PaYment Amount Payee Name
TEST
210.00
15.00
20.00
10.00
5.00
----------------
$260.00
$260.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
CUMBERLAND COUNTY GENERAL FUN
,;OMMONWEAL TH OF PENNSYLVANIA
DEPf'RTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
STOUFFER JOSEPH A
523 WARREN STREET
LEMOYNE, PA 17043
_~~_u 'oid
ESTATE INFORMATION: SSN: 208-38-5912
FILE NUMBER: 2106-0351
DECEDENT NAME: STOUFFER THERESA A
DATE OF PAYMENT: 01/10/2007
POSTMARK DATE: 01/10/2007
COUNTY: CUMBERLAND
DA TE OF DEA TH: 04/08/2006
NO. CD 007676
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $9,000.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 2633
SEAL
INITIALS: CJ
RECEIVED BY:
TAXPAYER
$9,000.00
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
CUMBERLAND County, Pennsylvania
CERTIFICATE OF GRANT OF LETTERS
No. 2006-00351 PA No. 21-06-0351
Estate Of: THERESA A STOUFFER
(First, Middle, Last!
Late Of:
LOWER ALLEN TOWNSHIP
CUMBERLAND COUNTY
Deceased
Social Securi ty No: 208-38-5912
WHEREAS, on the 20th day of April 2006 an instrument dated
January 9th 2006 was admitted to probate as the last will of
THERESA A STOUFFER
(First, Middle, Last!
la te of LOWER ALLEN TOWNSHIP, CUMBERLAND County,
who died on the 8th day of April 2006 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
JOSEPH A STOUFFER
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 20th day of April 2006.
c.,~ "'~ ~.
eglster 0 I S \
~-\(~ ~~ ~~
~ . Deputy j
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