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REV.346 EX (B-92) _~~
PA DEPARTMENT OF REVENUE ~
ESTATE INFORMATION SHEET
FOR REGISTER'S OFFICE USE ONLY
County Code Year File Number
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DECEDENT INFORMATION:
Enter data as It will appear on all documents submitted to the department.
~~ ~~~
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Name (Last)
'\.
I
TYPE FILING: Enter check (v) mark to indicate the nature of the return to be filed with the department.
~ Probate Return
o Joint Assets Only
o Estate Tax Only
o Litigation Purposes (No Other Assets)
LETTERS GRANTED.' Enter check (v) mark to Indicate the nature of the proceedings at the Register of Wills
Office. (Attach additional sheets if explanation is necessary.)
o Testamentary
)lI Administration
o No Letters
o Other (Please Explain)
ATTORNEY/CORRESPONDENT
INFORMATION:
Enter all data concerning the attorney or other Individual to receive all
tax information and correspondence.
Name (Last) (First) (Middle) Isupreme Court 1.0. ,
Street Address
City State Zip Code ITelePhone Number
PERSONAL REPRESENTATIVE
INFORMATION:
Executorl Administrator
Enter all data concerning the personal representative(s) of the estate
authorized by the Register of Wills
Street Address
State
Zip Code
J/;;;l
1.-
Yl
(Middle)
^--
Name (Last)
(First)
City
~
Co-Executorl Administrator
Name (Last) (First) (Middle) I SocIal Security Number
I I
Street Address
City State Zip Code ITel.Phone Number
Co-Executorl Administrator
Name (Last) (Fi rst) (Middle) I Social Security Number
I I
Street Address
City State Zip Code reiePhone Number
IPfeparey - ~ k
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Department of Treasury -- Inte~al Revenue Service.:II....'::i;I,"::;;I':;;:~!;; : \
Form )L.'!;;::!'.:':::li:~I:;::" U_~ Individual Tax Return ..::JRS uSL~lt.Do not write or staple in this space.
For the year Jan. - De~....1J..LJ1_~_9LJ~1h.~r taxJllLQ~giJlD~____.__._.___._.___J.J.~L_~Ddin9.___~__"..._--l11._ : OMB. No. lS4S~_9.Q1~
: : Your social security no.
Use IRS L ~_l o:::/c! (...J,YE: Jr : .199--<-52>'1:249
label. A: :Spouse's social security no.
Otherwise B: :
print or E R ~ [) ~ t-t-2 Elcn< 170 E~ : : Note: Checking
type. L t'le~'\Ivi lIe P(~ .l7::?41 : Yes: No "Yes" won"t change
Presidential \ Do you want $3 to go to this fund? . . . . . . . , . . . .. .......... :__'~"-:____: tax or refund.
Election CaMPaiQn I If ioint return. does your spouse want $3 to gO to.this fund? . . . . . . . . . .: : :
1 i_li__:Single :For Privacy Act and Paoerwork Reduction Act Notice, see page 4.
Fi 1 i ng S.ta.tus: 2 :_____:Married filing joint return (even if only one had income).
3 :_____:Married filing separate. Spouse's SSN above & name >>
4 : :Head of household (with qualifying person). If qualifying person is a child but not your
:_____:dependent, name >>
5 : :Qualifyinq wido.(er) with deD. child (yr. SP. died))19 ). (See paQe 13)
6al_Lf__lVourself. If your parent (or someone else) can claim you as a dependent on\ No. of checks pn
_____ their tax return, don't check 6a. But check box on line 33b on pg 2. > 6a & 6b. , . .___~1_~
b: : Soouse. ..... . . . . . . . .. ............ /
c Dependents: (2)Ck' (3)If 1 or older (4) Dependent's : (S)Mos.
(1) Name (first.initial,last name) if <1 dependent's SSN Relationship ;in home
r) i ,,3. n L, El. n (j e r" .1 d '9 '.w () (;,.... 2 066 : (j i r" 1. .... -r t~ :i. (:~ i ., d ~l. :::;:~
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Check only
one box.
Exemptions
If more than six
dependents, see
page 14.
Income
Attach
Copy B of
forMs "-2
W-2G, and
1099-R here.
Attach check
or money
order on
top of any
Forms W-2
W-2G, or
1099-R.
Adj us.t-
ments
To
Income
_1~\Q1
H733
No. of your
children on 6c who:
*lived w/you. .____1_~
*didn't live
"ith you... ..._______
No. of other
dependents.. .._______
d If child didn't live with you but is claimed as dependent under a pre-1985 agreement.>>:__:
e Total number of exemptions claimed . . . , . .. . . . . . . . . . . . . . , . . . . .
1 Wages, tips, etc. Attach Form(s)W-2.
...:::. I.
E:, " t~~ ::;~= ~!~~ .4
8a Taxable interest income. Attach Schedule B if over $400.
b Tax-exempt interest income. DON'T include on line 8a
9 Dividend income, Attach Schedule B if over $400. . .
10 Taxable refunds,credits, or offsets of state & lotal inc. taxes (see page 17).
11 Alimony received . . . . . . . . . . . . . . . . . . . . . . . .
12 Business income or (loss). Attach Schedule C or C-El. . . . . ..
13 Capital gain or (loss). Attach Schedule D. . . . , . . , . . . .
14 Capital gain distributions not reported on line 13 (see page 17) .
15 Other gains or (losses). Attach Form 4791. .
16a Total IRA distributions. . . . :16a: ---1 b Taxable amount.
11a Total pensions and annui ties.: 11a: : b Taxable amount.
18 Rents, royalties, partnerships, estates, trusts, etc. Attach Schedule E
19 Farm income or (loss). Attach Schedule F
20 Unemployment compensation (see page 19). . . . . . . . .
21a Social security benefits .:21a:
22 Other income
2.1..
.: 8bl
..1. , ;522 ..
b Taxable amount.
23 Add amounts shown in far riQht column for lines 7 - .22~ This is your total
24a Your IRA deduction (see page 20) . . . , . , . . . . . .. :24a:
b Spouse's IRA deduction (see page 20)... . . . . . . . . . . :24b:
25 One-half of self-employment tax (see page 21) . . . . . . . :25 :
26 Self-employed health insurance deduction (see page 22) .. :26
27 Keogh retirement plan and self-employed SEP deduction :27
28 Penalty on early withdrawal of savings. . . . . . , . :28
29 Alimony paid. Recipient's SSN )) :29
incolle.
7 H 26~:;. ~
30 Add lines 24a throuqh 29. These are your total adjustments. . . .
31 Subtract line 30 from line 23. This is your adiusted Qross income.
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