HomeMy WebLinkAbout08-24-07 (2)
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue .
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
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ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
County Code Year
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File NlJ mber
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Date of Birth
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Decedent's Last Name
Suffix
Decedent's First Name
MI
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<If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
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Spouse's Social Security Number
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
- 1 Onginal Return c::::; 2, Supplernental Return 3 Remainder Return (date of death
prior to 12-13-82)
4, Limited Estate {:=J 4a, Future Interest Compromise (date of 5, Federal Estate Tax Return Required
death after 12-12-82)
... 6, Decedent Died Testate c::::; 7, Decedent Maintained a Living Trust t 8, Total Number of Safe De~osit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9, Litigation Proceeds Received c..""::) 10, Spousal Poverty Credit (date of death 11, Election to tax under See:, 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 DIF:ECTED TO:
Name Daytime Telephone Number
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Firm Name (If Applicable)
First line of address
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H f A ~T H SIt 11! E
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Second line of address
City or Post Office
State
ZIP Code
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Correspondent s e-mail address:
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Under penalties of perjury, I declare that I have examined this return, ing accompanying schedules and statements, and to the best of my knowled,le and belief,
It IS true, correct and complete Declaration of preparer other than the persona,~,~:~ntatlve IS based on al Information of which preparer has any knowledge
SiGNATURE:Ot-~S~N~RESPONSIBL~~~RCIL'ING REYURN'-'~'~' =2,,^-"" ~-,~- '" , - ,,, , ,~, ", DATE' ,~",'-','
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ADDRESS / ' ,
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
f\DDRESS
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PLEASE USE ORIGINAL FORM ONLY
Side 1
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15056051047
15056051047
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1.50.560.52048
REV-1500 EX
Decedents Name:
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Decedent's Social Security Number
7 7
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C '{'15-
RECAPITULATION
Real estate (Schedule A).
2 Stocks and Bonds (Schedule B)
2.
I D c-,
C I..f 7'7 . 'U t
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
LI ,~I ( I. L 4
6. Jointly Owned Property (Schedule F) C-::J Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) C-:::..::J Separate Billing Requested.
6.
7.
8. Total Gross Assets (total Lines 1-7).
8.
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.... .
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) .
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J)
...12.
. . 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___
15.
16 Amount of Line 14 taxable r. ~ G
at lineal rate XO ___ ! L. 7 C
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
16
'-I 3 2~ 'j' . 7>
17.
18.
19.
-!.~'c'7' 7)
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
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1.50.560.52048
1.50.560.52048
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REV-15OC) EX Page 3
File Number
Decedent's Complete Address:
DECED.ENTS NAME, /..,0 .' j r
~) l ~ ).-1 '\i v () ~ I IV S r-- (
STREE~.A~Dr~SS JJ t ri " tt \ '-r 1-~ 'I" ( r<. c(
CITY '1
(,iff' 'I) ......, !.
f
Tax Payments and Credits:
1 Tax Due (Page 2 Line 19)
2 Credits/Payments
A Spousal Poverty Credit
8. Prior Payments
C. Discount
STATE J . I
;-'-1
ZIP . ~
//LI/
(1)
(J 0> ) (.
7 ;. L /
7.>
3 InterestlPenalty if applicable
D. Interest
E. Penalty
Total Credits ( A + 8 + C ) (2)
,
.,.
____u_____________._____ Total InteresUPenalty ( D + E )
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in avalon Page 2, Line 20 to request a refund.
(3)
(4)
(5)
(5A)
(58)
5
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(-1)
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A Enter the Interest on the tax due
8. Enter the total of Une 5 + 5A This IS the BALANCE DUE.
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Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Old decedent make a transfer and: Yes ~~
a. retam the use or income of the property transferred;. ............................................... c 'J
b retain the right to deSignate who shall use the property transferred or its income; .. [~~
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c. retain a reversionary Interest; _
d. receive the promise for life of either payments, benefits or care?............ ......... .............. .............. . [] l~g
2 If death occurred after December 12,1982, did decedent transfer property within one year of death
without receivmg adequate consideration? .. i:~~
3. Old decedent own an "in trust for" or payable upon death bank account or security at his or her death?.. r;J
4 Old decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . c~t
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 oj the surviving spouse
IS three (3) percent [72 PS ~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 PS ~9116 (a) (11) (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. 99116(a)(1 .2)).
The tax rate imposed on the net value 01 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 PS ~9116(12) [72 PS ~9116(a)(1)J.
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 PS ~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.
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SCHEDULE 8
STOCKS & BONDS
~
CJMMOI,WEAL TI- OF PENNSYLVANIA
INHLRI~AfICE TAX ":ETURN
RESIDE~T DECEJeNT
EST ATE OF ~
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v. .. /f J
t( J{ I M"kt
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
?~;H: (,i~'1("e~ tf 11:1FC /ffl!l;Vvl'lF~ r:.vJivc,'41 C,IfoiA.'.d
VALUE A T DATE
OF DEATH
)$ 1.8'72 . C;[
I
r..._
/'(1' 55 Z 5l^"i('( (, t f C/!. I AX j814J((vcl f1tJ.4.\!(\:U\ Fu,vl
fJ /I "Ly-g Y[i
~:
I 7:; S 72-( <) ['\4 rt ~ Cl (111 It\. 6 xj1vj FS T)j+) ~Jl.{rv
~ 27 (<;02-Y
L! ~
? n < 1? s , I \M e 7 t f /)Jj A \ /J",.;~"V 4 "~1fA".,11
,ti LJ~ ::>(? )i../
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tj C;"7 'f t:; 7
d,A ,1 \ J 1/ C S LV xfA. ~^~'" L-:",;U 1).(A'N
'11 '( 77(
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TOTAL (Also enter on Ihe 2, Recapitulation) S / L 17' 7 7 I . Z 2
(If more space is needed, insert additional sheets of the same size)
Rug OB 07 08:10a
p.3
RE' 15(181:'\ '1..~I:
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH 0; PENNSYLVANIA
INIIERITA'<CE TAX R::TURN
RESIDENT DECED;:~l
ESTATE OF c) {/ f ,), vt 13(" i '.: L t
. . .' h I J IV F.-
FILE NUMBER
ITEM
NUMBER
Include the proceeds of litigation and the date the proceeds were recei~ed by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
DESCRIPTION
VA..UE AT DATE
OF DEA TH
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. " " 'I ,I\! 4 (" t.' f ,"I) L C
S (("fr, f. '-:' S
S I'I...!
Ct1
LV
TOTAL (Also enter on line 5, Recapitulation) $ "lJ [J ( Y . tv l/
(II more space IS needed, Insert additional sneets of the same size)
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REV.ISll E>:- 1',2-99) .
1f~,\~~:9~
...l:.<~~~.I~"."
COM~~O',iNEALTH OF PENNSYLVMJlA
INHE=iITAhCE TAX RETURN
RESIDEI'JT DECEDE~n
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF L
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__. _"> L~j 1\~_Jt_ l~ l IiV ~ I " (.
FilE NUMBER
ITEM
NUMBER
i'..
,- - -
Debts of decedent must be reported on Schedule I.
DESCRIPTION
F}:!;N~tA(L,~~:~~rE~: C:t"( ..f' ('/.-,,11(. f"lrl<'"
-,'. 'vv C1-H~Llfl , ,
[,fUrlIO'I "jUt - cfc ~f C:4tl'\~/.( ({/LleT1"tS
t:" < Ie' '2 ( /1, t ,Ii c ,~, i I - r l' ~ I /1 fl I ' t
V 7 L ': I ~T VI t 'C (e ,11 (' .1 ,r! r ~
("',"'/' r'" I,;'"vcf, - Cie J C4fj,dc C(/lre,11r,,'rS
/>.rll,,,/,,..Ji SV('; , Ii/;-,/I (A i/' il-// i- , , / II.
- '. ., ",I,"/I.!ir/'I ,.,llt
t VH/,o lt1t>"cL~.\I,1 J (,- 'fLip, II (Af~/ N. 1/ hYl/o(~-+1 //<. f~1 ~
B ADM'NISTRAT:VE COSTS
AMOUNT
2
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1. Personal Representa:ive's Commissions
'lJame of Perso.~al Representative(sj
Socia' SecJnty Number(s)iEIN Number of Personal Representative(s)
S'ree: Address
City
_ State __ Zip
Year(s) Commission Paid:
2. Allorney Fees
3.
Family Exemption: (if decedenl's addr!3ss 's not the same as cia mant's, attach explanation)
Clama,,! I)CNAIA . J tflN.>k( J;/
~v' .1 JJ i- /,71
Street Address) (, Ie tr e,'t r ~ .:, f ( .[1 (' l\c{
City __(;.~~ 'f. J/
Relatio~ship 01 Claimant to Decedent
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S/') ,~ L ,~ t
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State ~ Zip
/ ?[ II
4. Probate Fees
5
Accountant's Fees
P U,[
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) S I~' /~' 2..
(If more space is needed, insert additional sheets 01 the same size)
Rug 08 07 08:11a
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:iE\'-1.512 EX-t i~2.('J;
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SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
CU.1MCN.'.'EAL TH :y PENf:SYLVANIA
fl.,ERITANCE TAX RETURN
RE, IDEI.. T JECEDEfl1
ESTb,TE OF >1 Sri/v' ~/ d~. ':v>kt
FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses
!Tf!'v' j VALUE AT DATE
NUI',1BER ' DESCRIPTION OF OEATH
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f 1FT. I.
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6S
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TOTAL (Also enter on line 10. Recapitulation)
I!I more space is needed, insei addi1ional sheets of the same size)
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Rl,Jg 0-8 07 08:11<3
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REVI513 EX+ (90C) r:.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETU8N
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
,) L'r (,/.J;\
V IS t, Ivskt
FILE NUMBER
NUMBER
I
\lAME: AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABI.E JISTRIBUTIONS [include outright spousal distributions, and transfers under
SGc. 9116 (a) (1.2)J
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'Itlt )f;,,!'~r~~t;;,vr ~A CIM~ /f,Jf J~ I (t!t
RELATIONSHIP TO DECEDENT
Do Nor ListTrusree(s)
AMOUNT OR SHARE
OF E~jTATE
1.
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EI\ TeR DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
fJ NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BE~NG MADE
1/
1,
B, CHMIITABLE ,4ND GOVERNMEI\!TAL DISTRIBUTIONS
TOTAL OF 'AFIT " - ENTER TOTAL NON- TAXABLE DISTRIBUTIONS ON UNE 13 OF REV 1500 COVER SHEE~t--
(If more space is needGd, irsert addilional sheets of the same size)