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Home My WebLink About06-20-0815056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Dept. 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ D 7 ~ ~ d ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~. c~ ~ G :3 "L (~" C 1' b I I tom. 2. ~ ~ "~ ' .~. Z 5 I q Decedents Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below ~C~S~~ Spousse's Last Name Suffix pouse's First Name MI Spou ~>e's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL NN APPROPRIATE OVALS BELOW 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Oied Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name; Daytime Telephone Number Firm Name (If Applicable) \2 C:~ ~~ tZ, T ~ M I L L E 1~ First line of address Second line of address City or Post Office ~- ~c M n "y N '~ ~ U E ~~ ti State ZIP Code r•~ REGIST ~OF WILLS U~"~ONLY . ~.__, ~ ; c~. r ~~ -,~ ~ ~°, - rj ~ C.3 - =.~. _~ %'DATE FILED fV I"7C~4~ IS 3 1 Correspondent's a-mail address: `~ ' Q~/~ r ~I ~~\ ~t' ~C7~ , ~[ ~,~,~ 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 truce, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. \F PERSO(V~R`E~SIBLE FOR FILING RETURN DAT, U ~~ AD6RESS ~ ~ SIGN~~E,O~EPA~ OTH~tT~F~y~ENTATIVE 1~: ~ I(j ~C? K ADDRE~ ~~ ~ ~ ~v~ , ~c-~ lO I 6~ c -CC'1 ~ ~~~') ~ ~ ~ PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J J 15056042047 X REV-1500 E Social Security Number Decedent 's r \ , ~~ `l~ ~ ~ Y" ' t 1 2~ `"t ~ ~ Z - V s Name Decedent REC APITULATION 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. ~• 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ...... .. 5. Z~ -7 ~ ~ • , ~ 6. Jointly Owned Property (Schedule F) O 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) ................................ . .. 8. ~~~ ` ~.\~ 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. ~j~i ~ ~ . ~ S 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. ~ • , 11. Total Deductions (total Lines 9 ~ 10) ................................ ... 11. ~j ~~ ~~ Z • . 12. ........................... Net Value of Estate (Line 8 minus Line 11) ...12. Z 1 2. U ~- ~ • - 13. Charitable and Governmental Bequests/Sec 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. 2- U ~ ~ ~ • TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or - transfers under Sec. 9116 ~. 15. ~ . (a)(1.2) X .0_ 16. Amount of Line 14 taxable c at lineal rate X .0 ~ ~L ~ ~ ~ • Z ~ 16. t- ~2 ~3 • 17. Amount of Line 14 taxable ~' • 17 ~ • at sibling rate X .12 . 18 . Amount of Line 14 taxable ~ 18 at collateral rate X .15 . 19. TAX DUE .........................................................19. 20~. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 4 ~. ~ • ~ Z O Side 2 15056042047 15056042047 REV-1500 EX Page 3 File Number Decedent's Complete Address: STREET ADDRESS _ _ __ __ I~_ __ __ - __ - _ _ CITY STATE ~ ZIP ~ ~~r ~1c~~,1 ~ ~y, y ~z-i ti ~ ~ ~G+ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) {1) ~~„ }S .`~' L 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount - - Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable , r'-"~ D. Interest - __ E. Penalty Total InterestlPenalty (D + E) (3) ~--~~ r 4. !f 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~ ~ Z- A. Enter the interest on the tax due. (5A) tp B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~"(3 `~ '~, 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 No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ [~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ [~] 4. Ditl decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ 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. §9116 (a) (1.1j (i)j. 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. §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 zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate irriposed 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. §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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling 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-1508 EX. (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF 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 ~- ~ C. A-~ ~ ck ~ ~ ~ ?~ C~c~~..rv~-~ ~-c~ , 2Co"Z ~ ~ C ~+ (~ ~ Z~ , ~ ~4 \ , z~ .- ~~ -~ T' C~pc--=. i~ TOTAL (Also enter on line 5, Recapitulation) I $ Z 3 ~ \ y, ~ ~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) r COMfviONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ~, V {~~ ~? iT ~ ~. ~~ ~ ~ ~ ~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~D ' ~ CC~72 . ~~ B. 1 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: Attorney Fees 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 g, Tax Return Preparer's Fees 7 TOTAL (Also enter on line 9, Recapitulation) I $ 3~'7 z , (If more space is needed, insert additional sheets of the same size) REV-1513 E:X+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE aF FILE NUMBER ~_~ 91.1 V `1''"i 1 7rtYfi~ - c-r~t~ ~ ~ rh NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ~ ~~~ +' `~ ~ S ~~ ~~ ~1 c~ ~~ ~~N Me~N ~~ ate. ~~'` ~1 ~~~ P.CZt~, SL`c C , . ,~~~ ~~ i N`htiS~i ~ ~,v~~~TF'CL ~Z~ G~~ . ~~ ~~' ®~~ C~~sL~ , ' 2~ ~~~ ?~. ~~ ~~' ~ ~•nZ1~~~~ E~ ~~~~1Z ~~ ~~i~`~7 ~~LitiG SP~~~S ~ `I;. , . ~~ ~ ~ i T ~ SCt~ C ~~ VIcJ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 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)