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Home My WebLink About12-28-07 , ...J 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 OFFICIAL USE ONLY County Code Year File Number 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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WillS FILL IN APPROPRIATE OVALS BELOW _ 1, Original Return .C) 2. Supplemental Return C) c;:) 4. Limited Estate C) 3, Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ~ C) 4a. Future Interest Compromise (date of death after 12-12-82) Q 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 Da time Tele hone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes -C:) -0 =zc ._ -'.., -. r~-l' 1 .,"):-:) .- f.~ c...:> Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, 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 representative is based on all information of which preparer has any knowledge. De e SIGNATURE OF PRE PARER OTHER THAN REP DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 ...J ~ --1 15056052048 REV-1500 EX - RECAPITULATION Decedent's Name: Decedent's Social Security Number J;<{ 13 O~:l ..2/.:0 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. S. 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). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. ? S'3 · / '1 16. . 17. . 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT - ),. L 'q.- <s:- '2- Side 2 15056052048 15056052048 --.J REV-1500 EX Page 3 File Number Decedent's 'Complete Address: ~;~~G:l ~:1-- -~ -B Q W~:L'_ - --- -- - --- - -- -- /~/__Lu__ - .... -----B-oFO-J'Y'.----_________ _ ___u_ ____ ___ __ __ __ __ -Ci~l+fFA.L-sJ1U-f'dT --- --- --------------- ------ Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) - -J<4-5: S~-- Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty --- --. --- --- 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) <j ~ I PC"j . / <-j t), .~S- /od..,bb 5. if Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (5A) (5B) A. Enter the interest on the tax due. 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 ~ ~ ~ 00 JXJ ~ 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. 99116 (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. 99116 (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. 99116(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. 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. 99116(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-l509 EX + (1-971 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT JWSer SCHEDULE F JOINTLY-OWNED PROPERTY If an a set was made joint within one year of the decedent's date of death, it must be reported on Schedule G. O{J C) b L- SURVIVING JOINT TENANT(S) NAME RELATIONSHIP TO DECEDENT ADDRESS A. n h RJ' L. Vet I e I 'S B. c. ).I? l.J C\' (1) ~-I U I€.. "gel. SkiPfe//1.Jsb4f'd I PeL- 17~S-1 Ifi~~ie(' 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 jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. Ie ,).-;).( ~ CJl"'f':)+C:W II,) bAN k 1030013J..b ~ I :~~. 'J..'I 5"</0 30lc '--{ , I :A.. TOTAL (Also enter on line 6, Recapitulation) $ j ofo </. ,:J. (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . * SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ('(VA ~e~ Ii RE t ,-Bo wse rz. Debts of decedent must be reported on Schedule I. FILE NUMBER :1!O') -<:JOUb~. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Q7S 1. Or eNl"V,j GrC\..lie,.. f "V <i:.v-J 'S~"y~" fV.,1 '~es 33Y ../0 C\:: 1'''' ~C) i bO r , i'1-eC)' 0 I'i 1Q S PI 0 t~ ~ {'s ()"1.2... DiP Fe ;.J e /v<!-e J-iV Vre fO-, ~qo/71 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name 01 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 no I 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _Zip Relationship 01 Claimant to Decedent 4. Probate Fees b (.{ 5. Accountant's Fees 6. Tax Return Preparer's Fees loV 7. TOTAL (Also enter on line 9, Recapitulation) $ / b.S:"'-' ~q (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT C:Y' FILE NUMBER )7- 00 O~;;... ITEM NUMBER 1. 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 1. DESCRIPTION lY\ e ~X I ~"- .,. " V N ~ (n'\ "1 eN I 4 YY\] 6IDO~ u.)c)R~ Pa. I D~r+ t...") P R € v.e ,'OJ u. -e. ..3,,).0__ (1::. g ? ,~? 31 I D ;).. TOTAL (Also enter on line 10, Recapitulation) $ Lj ~"\: DV (If more space is needed, insert additional sheets of the same size) REV-1513. EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT 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. I~o b t': .~-l B 0 ....;; OS E r'"' '1 D 'i:J. S- 'Jf" (' \,,! ~ (~ f'. '0. . ~' 'J-;; ').. :J- n. '\)' >Q ~ ( . 4. VV\ }J. ( rll d - 2. J i.... ~ ~+ r\ \ CL. )'.. ~ e I ) D f' ' "-lll S- lu. \\\ e c.\ Lc ~ k . A 'i' /::)'-D i q el\C12.v/l\) '2 3 ) 'V\ ?t ,~y V ~ I (! I? . 71 I e Rd', /) /7 l,.0Ci.I)v...... t VO- ,_ f/-.. . ij:J-> ? 'S h. ~Clf Iii' /v l:__IoL' r'J) rB. 17 {( . e ~ t" V' I .,:> c,,/r-, 0' u. f' F' -< ~'lJ <t 3 '3 .f:: (' '€ -< oc' r -{ K.? ' r _ I J Pc. J t.:.?--J-i' tre.~forlJ FILE NUMBER - () CJ (J b d;l.. RELATIONSHIP 0 DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE s(~ A) D4 '^ fj- "'- ... ~ (". OCt "'":]- \.. T t' (' br.:z. /1/( i <::. 0 ,,-' '1<; 'Iv )/y ~ 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)