HomeMy WebLinkAbout05-19-82
PEV-:I.SOO EX + (9-81)
~ BUREAU OF EXAMINATION
PENNSYLVANIA DEPARTMENT OF REVENUE
P.O. BOX 8327
HARRISBURG, PA 17105
edent's Name (Last, First, and Middle I nitiall
, r'\ re.
Social Security Date of Death
0'& -I If- -'i
INHERITANCE TAX RETURN
RESIDENT DECEDENT
File Number
~/-7K-Di5f
Decedent's Address
CHECK
2. Supplemental Return 0
~'ll, PA
1. Original Return D
3. Remainder Return D
APPRO-
PRIATE
BLOCKS
4. Life Estate D
6. Decedent died testate D
(Attach copy of Will)
5. Federal Estate Tax D
Return Required.
7. Decedent maintained a living D 8. Number of safe deposit D
trust (Attach copy of trust! boxes inventoried
All correspondence and confidential tax information should be directed to:
CORRE-
SPONDENT Name Address
Telephone No.
City
Recapitulation
1. Real Estate (Schedule Al ( 1)
2. Stocks and Bonds (Schedule B) ( 2)
3. Closely Held Stock/Partnership Interest (Schedule C) ( 3)
4. Mortgages and Notes (Schedule D) ( 4)
5. Cash & Miscellaneous Personal Property (Schedule E) ( 5)
RECAPIT- 6. Jointlv Owned Property (Schedule F) ( 6)
ULATION 7. Transfers (Schedule G) ( 7)
8. Total Gross Assets (total lines 1-7)
AND 9. Funeral Expenses Administrative Costs/Miscellaneous
Expenses (Schedule H) ( 9)
TAX 10. Debts/Mortgages/Liens (Schedule I) ~ fP' (10)
11. Total Deductions (total lines 9 & 10)
12. Net Value of Estate (line 8 minus line 11)
CALCU- 13. Charitable Bequests (Schedule J)
LATION 14. Net Value subject to tax Wne 12 minus line 13)
State
Zip
( 8)
(11) cQ. '3 ig. 5'7
(12)
(13)
(14)
Computation of Tax
15. Amount of line 14 taxable at 6% rate (15)
!include values from Schedule K)
16. Amount of line 14 taxable at 15% rate (16)
!include values from Schedule K)
17. Principal tax due (add tax from line 15 plus tax from line 16)
18. Total Prior payments:
(a) Amount Paid
(b) Plus Discount
(c) Minus Interest (18)
19. Balance Due (line 17 minus line 18)
Make Check Payable to: Register of Wills, Agent
* * * PLEASE RECHECK MATH * * *
x.06=
x.15=
(17)
(19)
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, corre and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has
any knowledge. ..,j II i / i c:L--
ADDRESS ' , DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
ADDRESS
DATE
R E V"455 (8-78)
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DEDUCTIONS ALLOWED IN
OFF ICE OF THE
STATEMENT OF DEBTS
AND DEDUCTIONS
THE SUM OF
$
"r' REGIST R OF 11LLS~'
/ i ') ,
OF<=, "''-'l It' ,Y'l/ COUNTY
AND AGENT OF THE COMMONW AL TH
DA T! APPROVED
./ i ('
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REGISTER OF WILLS, AG ENT
I I
DATE NO. OF NAME OF PAYEE REMARKS AMOUNT
VOUCHER
J! [(4 ,,/ 1I /7'15
A
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ESTA TE OF /I/,/;:(/< "I' J f(;c~(//-YI:~TE OF {;/2?~/ ~ / / J';> c / L
DATE OF F~ING APPRAISEMENT ;;tc/r/ {.., /f1l?t.TE OF DEATH At t:j /1 /7 --7 ;'":/
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COU~
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MY KNOWL DGE AND BELIEF, THE FORGOING IS A JUST AND T~/Sl
EXPENSES OF ADMINISTRATION SUBMITTED TO THE ESTATE OF ~
DECEASED, AS DEDUCTIONS FOR INHERITANCE TAX PURPOSES.
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