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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FilED IN DUPLICATE
WITH REGISTER OF WillS)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
P.O. BOX 8327
HARRISBURG, PA 17105
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
'M.\c.>\~SL.EK \-\.~Le.N
SOCIAL SECURITY NUMBER DATE OF DEATH
~A- ''''0 t.3
FILE NUMBER
dll-18 - 'f3d--
DECEDENT'S ADDRESS
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<; .M. l. "T~.
County ~V"N'\~ ~rL...J. ~M"'"" It ~ (e ,
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1 - If. ~ 78
01. Original Return
04. Life Estate
@'i Supplemental Return
o 4a. Future Interest Compromise
o 3. Remainder Return
o 5. Federal Estate Tax
Return Required
_ 8. Total Number of safe deposit boxes
06. Decedent died testate 0 7. Decedent maintained a living trust
(Attach copy of Will) (Attach copy of trust)
ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME ADDRESS L.j
c;eo,~E \-. 'uooG.LtrS I ~( )..l) W. tG~ ST
TELEPHONE NUMBER p.O. B ~ ~c. /
*'Il"'1 - 1-4- ~ - "<<10 CITY ~,L..l~ L..C
STATE ~ ZIP rlb/~
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1. Real Estate (Schedule A) ( 1)
2. Stocks and Bonds (Schedule B) ( 2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Mortgages and Notes Receivable (Schedule D) ( 4)
5. Cash~ Bank Deposits & Miscellaneous Personal Property( 5) 3/. ?7 s: () ()
(Scnedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G) (Schedule L)
8. Total Gross Assets (total lines 1-7)
9. Funeral Expenses, Administrative Costs, Miscellaneous ( 9)
Expenses (Schedule H)
10. Debts, Mortgage Liabilities, Liens 'fSchedule I) (10)
11. Total Deductions (total lines 9 & 10)
12. Net Value of Estate (line 8 minus line 11)
13. Charitable and Governmental Bequests (Schedule J)
14. Net Value subject to tax (line 12 minus line 13)
15. Amount of line 14 taxable at 6% rate
(include values from Schedule K or Schedule M)
16. Amount of line 14 taxable at 15% rate
(include values from Schedule K or Schedule M)
17. Principal tax due (add tax from line 15 plus tax from line 16)
x .15 =
(17) _ / I (, S/'? . 7 S-
( 6)
(7)
3 L 87S:00
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( 8)
(11) ()
(12) ~2.-.~ J "..l.~.-S-r-
(13) 0
(14)-11h:)'.S-~
X .06= ~ ~.E'1-.7~
(15) o<.a LL)' .~S--
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(16)
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Amount Paid
Discount
Interest
18. Total Prior payments:
+
(18)
(19)
(20) ~.t,.- 8' 9. 7 S-
(20A)
(20B) I (, f'1. 7~
19. If line 18 is greater than line 17, enter the difference on line 19. This is the OVERPAYMENT.
A. OCheck here if you are requesting a refund of your overpayment.
20. If line 17 is greater than line 18, enter the difference on line 20. This is the BALANCE DUE.
A. Enter the interest on the balance due on line 20A.
B. Enter the total of line 20 and 20A on line 20B.
Make Check Payable to: Register of Wills, Agent
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REV-IS08 E:t+ (7-83)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCH EDU LE liE"
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
ESTATE OF II
Il-Ef'/ t( ISIMLEK
(All property Jointly-owned with the Right of Survivorship must be disclosed on Schedule "F")
ITEM
NUMBER
FILE NUMBER
2/~ 7? -~3c:l--
DESCRIPTION
VALUE AT
DATE OF DEATH
1.
b;~~o~~~
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3/.875.00
TOTAL (Also enter on line 5, Recapitulation)
$ 31 f7S-:oo
(If more space Is needed insert additional sheets of same size)
REV-1511 EiX+ (7-83)
SCHEDULE "H"
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF , \... .-"
!::l ~~ N M \ S , 't ~ 2-E \c....
FILE NUMBER
21'" 78 - Lf3;t...
AMOUNT
ITEM
NUMBER
A.
1.
B.
1.
2.
3.
4.
C.
1.
DESCRIPTION
Funeral Expenses:
Administrative Costs:
Personal Representative Commissions
Social Security Number of Personal Representative:
Year Commissions paid
3 7 /~. IfJ
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Attorney Fees
Family Exemption
Claimant
Address of Claimant at decedent's death
Relationship
Probate Fees
Miscellaneous Expenses:
/oTfJt. [xflnSlS t7n ORIj'f}I{! N.- fvP-^ ~
j-21:J. 'IS-. /oTAL IfSfrrs of 1he lrrlf-TC
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oF-" f';XpRI\SeS 0 f-
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed insert additional sheets of same size)
$ 3 1/:J.. · 'IS-
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