HomeMy WebLinkAbout10-17-07
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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 1iI II
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
~\ D '1
b1 ~L
Date of Birth
0711f 7'fr
o 7 -S (3 z..OC> 7
Decedent's last Name
Suffix
1 () J 3' I '! ~o
Decedent's First Name
MI
~t<o f(f,fHT
(! II,,(/Z' r~H
A1
(If Applicable) Enter Surviving Spouse's Infonnatlon 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 Retum
C)
C)
4. Limited Estate
c:::::>
3. Remainder Retum (date of death
prior to 12-13-82)
5. Federal Estate Tax Retum 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 CONADENTlAL 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:::::>
I/"N~t.l? J..
;>,ee>/J/;9tYT
71 T 1.cg S8PO
Firm Name (If Applicable)
REGISTER OF WILLS USE ONLY
First line of address
/635 (C.SVS/<E P^,/v€
.. .,~,-~
Second line of address
--.,.....
City or Post Office
State
ZIP Code
DATE FJU,D"
~$.CH'",~/c.s.Bv,J(/~ j?/f 17aS-O
Correspondent's e-mail address: t:J<:>AI ~ L U r r:: /'f F P # / ~. ~~M .: ::;.1 :::
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowl~nd 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.
SIGNATU PERSO~ ~SP~S~ LING RETURN ATE
~?-i C::) r CJc::) 7
ADDRESS L? -/2 .# -
/~8~ /r..zl/:?~~ O~y~ ~&::<<h'~/e:=5r.701't~, r;#/Tt}!70
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
--J
--.
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
.....I
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~
'ql vl 'P!Bl '^JO^I'6ulll~M IO:JO.O~d uosdWIS
REV-1500 EX Page 3
Decedent's Complete Address:
DECEOENrS
File Number
CITY
$zcto/ /) A-J/C.5
STr/1
ZIP
l,?oSa
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditsIPayment
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InterestlPenally if applicable
D. Interest
E. Penally
(1)
/~ 7'/4, /f;
p~z. ~o
Total Credits ( A + B + C )
(2)
?3z., 30
TotallnterestJPenally ( 0 + E ) (3)
4. If Line 2 is gI1l8ter than Line 1 + Line 3, enter the dlffetence. This is the OVERPAYMENT.
RUin oval on PIge 2, Une 20 to request . refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the dlffetence. This is the TAX DUE. (5)
/~/ 79/. a~
A. Enter the interest on the tax due.
(5A)
(58)
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 No
a. retain the use or income of the property transfened;.......................................................................................... 0 ~
b. retain the ~ht to designate who shal use the property transfened or its income; ............................................ 0 [E
C. retain a reversionary interest; or.......................................................................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 LA
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
3. =.~~~~;;.~;~.;;;;;.i;k.~~;.~~~.h~.;;~.;;?:::::::::::::: 8 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ J8I 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 tine (3) percent [72 P.S. f9116 (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. f9116 (a) (1.1) Oi)). 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 retum 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. f9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is toor and one-half (4.5) percent, except as noted in
72 P.S. f9116(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. f9116(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.
'01171 'a^OM 'AaJ~ IOO~ 'BUAlJM IO:JcqDJd uosdw\S
REV-1503 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
IeNIDUU .
STOCKS & BONDS
ESTATE OF
d#~"eL f7)/LI m ;::?~UJ/JAlr
AU pnlIlIrty joInt1y-ollflld wIIh fight of IUl'YIvorIhlp IIlUIt .. dllclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
5E-tE /1TTAcHEb
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional 8heeIs of tile same sizel
Schedule B
Charlton M Prowant
Security Symbol # Shares Bid Ask NAV Value Total
Baker Huahes BHI 540 $80.74 $82.49 $81.62 $44,072.10
Boeina BA 16 $98.00 $98.47 $98.24 $1,571.76
CitiaroUD Inc C 200 $48.45 $48.60 $48.53 $9,705.00
DNP Select Income Fund DNP 505 $10.13 $10.90 $10.52 $5,310.08
lntermec Inc IN 200 $22.00 $30.00 $26.00 $5,200.00
Mirant COrD MIR 2 $37.70 $37.81 $37.76 $75.51
Mirant COrD MIR WSA 6 $19.00 $114.00
Public Service Entemrise Group PEG 100 $86.74 $88.56 $87.65 $8,765.00
Rockwell Automation ROK 200 $69.07 $70.89 $69.98 $13,996.00
Rockwell Collins COL 200 $67.14 $68.96 $68.05 $13,610.00
Southern ComDanv SO 200 $36.05 $36.75 $36.40 $7,280.00
TXU Core TXU 400 $65.54 $67.26 $66.40 $26,560.00
Mutual Funds At Ameritrade
Dodge & Cox Balanced Fund DODBX 356.267 $87.84 $87.84 $31,294.49
Gabelli Asset Fund GABAX 389.16 $51.93 $51.93 $20,209.08
Vanguard Fixed Income VFIIX 1246.532 $10.05 $10.05 $12,527.65
Vanguard Fixed Income VFSTX 4324.299 $10.55 $10.55 $45,621.35
Vanguard Fixed Income VSGBX 1166.468 $10.29 $10.29 $12,002.96
Vanguard Index Fund VTSMX 2112.218 $35.55 $35.55 $75,089.35
Mutual Funds At Vanauard
Vanguard Short Term COrD VFSTX 540.993 $10.54 $10.54 $5,702.07
Vanguard Total Stock Market Index VTSMX 402.329 $35.55 $35.55 $14,302.80
Vanguard Smail-CaD Growth Index VISGX 800.319 $20.08 $20.08 $16,070.41
Merril Lvnch
Preferred Plus TR SRS PIS 300 $24.73 $7,417.50
Morgan Stanlev CP TR III MWR 140 $22.72 $3,180.80
Total
$379,677.89
__a._ .
ESTATE OF
d#~,el" rr.JN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
,-;n r:'~ev ""'^'T
FILE NUMBER
COMMOHWEALTK OF PeNNSY\.VAltA
INHERITANCE TAX RETURN
Indude 1he pRlCIlldI ti IIIgaIlon IIld 1he dale ht pnx:eeda WllIlCllMld by ht lIllID. AI pnlIIIfty ~ .. till right of IUfYIIl'onhIp IlUIt be clIIcIoMd on ScIIIdcdI F.
N:R DESCRIPTION V~E~~TE
1. I'IA?FI2/rteI'70F ~A-IEY ;?lNRKEr f334.eJt:I
Sq.3Z.
;l.
",e~~t.l.. ~ YAJ"C:# ~~,<tJFY m~;eKE-r
B
S~t/c(Z € I~/!J ;J/PA/IC (j D
JOIAJr c;~~E,e.s/y'I'r::'
I~ r.::f'8, ~~
-:2-
831-1'. ()z-
4
/)~O~e y//lA,)
?~, Ot!)
5'
5" v iY! E ( (: If..) ~19 JltJI::"
/ ~ z "". ~.!7
TOTAL (AIlIoenleroo HileS, RecapiIuIaIion) $ 3 Z, 003. 'i'9
(If InOI'8 space is needed, insert addilionaI sheels of lhe same size)
_d.._ *
COMMOIMEALTH OF PENNSYlVANIA
rNHEmANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
FU NUMBER
This schedule l1IlSt be CllmIlIIIId and tiled If 1he answer" IllY of questions 11hlllUllh .. on 1he nMII18 side of 1he REV-1500 COVER SHEET Is yes.
DESCRIPTlCfl OF PROPERTY "OF
ITEM INCl.UDETHE.- OFTIE-r-. TlElRIEA_TO DECEIlBIr flllDTIE MTE OF_ DATE OF DEATH DECO'S EXClUSION TAXABLE VAlUE
NllMRFR A'!TN:I4AlXlPtOFTlEDEBl__EJfATE. V. - INTEREST
1. ;::iesr r;EL)E~I'I(, S-t1L
I~"" #~r O?~~(>eJ~ It;:, /~ ~5',1Jt 0
IR" I1ccr o9~4(J11999 2,22~. 9) 0
I If I? /lee..,.. 09(, 40/ Z 1:)00 ~ 2.t!:> 9'.. t/:s 0
TOTAL (Also enter on line 7, Recapitulation) $ ~
(If more space IS needed, Insert adlItionaI sheeIs cI the same size)
REV.1511 EX+ (10-06)*
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
IeN.DUU N
FUNERAl. EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
DebtI of deCecIInt must be reported on SctleduIe L
ITEM
NUMBER
A..
AMOUNT
DESCRIPTION
1.
FUNERAL EXPENSES:
()t. t> r~ CVIf,I Fl.~Iff!/.J:7
.5c.)S~OeHI'9A/,tI~ ~~~d - FVN"E/~Ht. ~"q:J/~'?~N~
c' ;.I/L/sr,.;J',v ~/P~ c'lV~,ee'H
fJ"'~r-H~~t:)~.F r~A.lF,~,~r ,,</.,r./.IsP
l'illf~~ I'C,."IiC,i L F F /C'l'V
B. ADMINISTRATIVE COSTS:
1. Personal Represenlative's Commissions
Name of Pl!fSOIlaI Representative(s) ______
Street Address
City
Year(s) Commission Paid: __________
Slate_Zip ___
/~?~CJ
/42'1- ~O
I
/~.,,()
~3'37: 7r
/ ~ . tf:)(;J
5S-00,ao
,
2. Attorney Fees
3. Family ElUlITlption: (If decedent's address is not \he same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State _Zip ___
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7.
P 1'9'J??/ ~ 'I EX' En? r??7I:J,v
TOTAL (Also enter on tine 9. Recapitulation) $ 1.3; ~'si". 7S-
(If more space is needed, insert additional sheet$ of the same size)
REV-1512EX+(12.Q3) '*
COMMONWEALTH OF PENNSYlVANIA
INHeRITANCE TAX RElURN
RESl)ENT DECEDENT
leNIDULI I
DEBTS OF DECEDENT,
MORTGAGE UABlUTlES, & lENS
ESTATE OF ;:::?, FILE NUMBER
~lIl9lt?l n:;N /l'J 'leow /?/'./T ~AiI::&' /4F 2
Report debts Incurred by the decedtnt prior to dHth which ,.lIlIIned unPlld II of the dill of deltll, including un,.lmburMd medlcll IX,*,,".
VALUE AT DATE
OF DEATH
ITEM
NUMBER
~
5.
DESCRIPTION
1.
;tP/I I?E~r Or K!Et/EAJl/6 ~ /;f/Ct?;,'/C
)
TJ?;< . /,/?/O O?/,,//~.,.
fl/l j)~f1r IJr I&-V€A.JulE, Z~~ /p~~nIE
(/9X. t?/?/D ?/ze/()7
;;/1 P E f?r g),c: 4 (/€AJv<E I ;z.J:)d r / ;It.Jr:::o".,€
r..4K, ~/// 9/,,/t?7
a54,~()
z.~. / ~
3S4-f 00
15t:::J~,oc
7/. 84
1::2 5"~ . 0 0
) z , ~CJ
~I tj-. 00
/~. 00
=>. CJ~
II t:(/Q//3$K'~/) C.fJv~rY /ff~/:;Te#~ CJFUI/Cl!;" ~37,oo
3
-4
1/5 r,e~N.s (,)~r/ ~t. /ItKC;;,/E THk .
j?1910 9111~7
,r;/?' k .
us r~~~u~~ 2!06f; /~~~~F
(//911.) 1~/8Io7
(/ 5 r~E"'s (/ t?r" Z~C 7 //tIt::dn? E r"'x.
;//9/0 9/1 It) 7
~A/P~t.c fI~"~".-1 - f?;/r!7,v2. 5:2."&v/ce
fllt,P 9/'/(} "7
,.
1
t
/lOt?I17()AlP~ I/EF171-r c!~',(';-'TI /-/(-/~ TF.5
r
'.
SHO,.er ez~rIFIC/9nS;
/D
,()t? rd/Cr Sr If'vl C z.
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is 1lIIlded. insert additional sheets of the same size)
REV-1512 EX+ (12-03) *' IeNEDUU I
COMMONWEALTH OF PENNSYlVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORI'GAGE UABIUTIES, & UENS
RESDENT DECEDENT
ESTATE OF .At} JA.? ...::?..?~ /~ I .M:3 A ._ L? FILE NUMBER
dh";P~croAJ" r /tv~""f..'" r~Ye 2 &>r 2
Report dtbIs Incurnd by the dIcIdInt prior to dHth wItIch remained unpaid _ of the date of dHth, IncIudIllfI unrelmburHclllllldlcll exptnIH.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
/t2
~ / A/ C' /t'1'~ h/ /f"/f /;7-/C//(? / /il L S
5~.s; Oe>
TOTAL (Also enter on line 10, Recapitulation) $ ~.3 4b. '17
(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
SCHIDUU J
BENEFICIARIES
ESTATE OF
FILE NUllBER
R8.ATIONSHIP TO DECEDENT
NUMBER NAME AND ADDRESS OF PEASON(S) RECEIVING PROPERTY Do Not LIII'IhIIIiII(I)
I TAXABlE DISTRIBUTIONS [lncIude outrighIlIpOUIII cIIIJibutions, and transfers lIlder
Sec. 9116 (a) (1.2)J
1.
f) &;;V At... p '- f? Ie () tv /'9 A/T
::5 0 ^-J
AMOUNT OR SHARE
OF ESTATE
/00 %,
ENTER DOllAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
D NON- TAXABLE DISTRIBUTIONS:
A. SPOUSAl DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
,.
B. CHARITABlE AND GOVERNMENTAL DISTRIBUTIONS
,.
TOrAL OF PART n - ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S
(II more space is needed, in8erI addllional sheets of the same size)