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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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DATE OF DEATH (MM-DD-YEAR)
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DATE OF BIRTH (MM-DD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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o 1, Original Return
04. Limited Estate
o 6. Decedent Died Testate (Attach ropy 01 Will)
o 9. Litigation Proceeds Received
INHERITANCE TAX RETURN
RESIDENT DECEDENT
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-ll2)
o 7. Decedent Maintained a Living Trust (Allach copy 01 Trust)
o 10. Spousal Poverty Credit (dale 01 death between 12-31-91 and 1.1-95)
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OFFICIAL USE ONLY
F~ ~UMBER
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COUN1Y CODE YEAR
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NUMBER - --
SOCIAL SECURITY NUMBER
'100S-
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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o 3. Remainder Return (date 01 death prior to 12-13.a2)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
FIRM NAME (~Applicable)
TELEPHONE NUMBER
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14. Net Value Subject to Tax (Line 12 minus Line 13)
COMPLETE MAILING ADDRESS
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(1)
(2)
(3)
(4)
(5)
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(6)
(7)
(9)
(10)
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SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
OFFICIAL USE ONLY
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-VIVOS Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
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x.O _ (15)
x .0 ~-%6)
x .12
x .15
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(11)
(12)
(13)
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(14)
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(18)
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Decedenf's Complete Address:
STR ET~DDRESS (}t:)
CITY
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Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
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.
Check box on Page 1 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)
A. Enter the interest on the tax due.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
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
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
ADDRESS
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 3%
[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 0% [72 P.S. ~9116 (a) (1.1) (ii)].
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 0% [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 4.5%, 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 forthe use of the decedent's siblings is 12% [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.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESI NT DECEDENT
ESTATE OF ----r--:-
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
R. /V},/kr
FILE NUMBER
Indude 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. /<1 '1'" a,~S/~ 0-11 #~ 5ao. (JCJ
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TOTAL (Also enter on line 5, Recapitulation) $ 7&o-on
(If more space is needed, insert additional sheets of the same size)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
C];;hn R. 1V1,/k--
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (Ir decedenfs address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship or Claimant to Decedent
4. Probate Fees
5. Accountanfs Fees
6. Tax Return Preparer's Fees
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A. }~~.t-Q.\ - 4$ '2; I ClJS . ~~
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TOTAL (Also enter on line 9, Recapitulation) $ ~ 3.53. IJO
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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OFFICIAL USE ONLY
FII-E NUMBER
--~-O..L
COUNTY CODE YEAR
NUMBER
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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SOCIAL SECURITY NUMBER
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DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
11- . 36) 2c-D"D ) 2/ 3/ See..
(IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL)
o 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy 01 Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date 01 death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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o 3. Remainder Return (date of death pria to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AttachSch 0)
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FIRM NAME (II Applicable)
COMPLETE MAILING ADDRESS
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TELEPHONE NUMBER
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OFFICIAL USE ONLY
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(7)
(11)
(12)
(13)
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(6)
(9)
(10)
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9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
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)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
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x .0_ (15)
x .0 K~6)
x .12 (17)
x .15 (18)
(14)
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(19)
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16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS (}()
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
A. Enter the interest on the tax due.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
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;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
c. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
No
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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.
ADDRESS
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
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ADDRESS
DATE
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 3%
[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 0% [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 0% [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 4.5%, 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 12% [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.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESI ENT ECEDENT
ESTATE OF -
,.JoA#'\
R. (V},lkr
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
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. It; if b a,~S/~ 0-11 #~~.o-O
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TOTAL (Also enter on line 5, Recapitulation) $ "Z~.O"O
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~ohn R. /Yl,lJ-r.
FILE NUMBER
Debts of decedent must be reported on Schedule I.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attomey 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
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. m, ~<!e.n4.V'l ~ 't=:x.~.3eS -
A. J-l~rl-Q.\ - 4$ ;Z; I ~S . LI~
f>. .1.~+c-e - it ~~~Lf~
C. &\e. ~ v~h,~le. - Ii. LJ Ill. (J(J
C+rlIe. ~s.~ ~ I.:sWbMC<::,.. Q.cb ~ ~~, ~
TOTAL (Also enter on line 9, Recapitulation) $ S ~.IJO
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
Telephone
717 787-3930
JULY 11,2001
Dear Register of Wills:
Re: Estate of JOHN R. MILLER
File Number: 2101-0622
County: CUMBERLAND
Date of Death:08-30-2000
The subject decedent legally resided in YORK County as of the date of death.
Accordingly, you are authorized to cancel file number ~~~-~622. All matters concerning this
estate should be maintained under YORK County File er 6701-0785.
All original Inheritance Tax documents for the subject decedent should be forwarded to
the YORK County Register of Wills; however, you may wish to retain a copy, including
photocopies of all receipts for the collection of Inheritance Taxes in the subject estate which
have been issued by your office.
Please contact me at the telephone number above if you have any questions.
ft~IY, ///:/~/
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Jeffrey D. Hollenbush, Supervisor
Document Processing Unit
Inheritance Tax Division
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