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Home My WebLink About06-26-08 15056051047 REV-1500 Ex (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Coun Code Year h` File Number Po Box zsosot INHERITANCE TAX RETURN c~ p~ ~ ~ D ~~ " O _ Harrisburg, PA 17128-0601 RESIDENT DECEDENT U ~j Cw ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~?06 12 ~7~i3Z 120 ~200-~ oc~ t~ ~~2.~ Decedent's Last Name Suffix Decedent's First Name MI t~ ~~ R c. 1 V~ o ~. ~~ v (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Socal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL iN APPROPRIATE OVALS BELOW N 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) C~ 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) C~ 6. Decedent Died Testate O 7, Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiil) (Attach Copy of Trust) C~ 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 T0: Name paytime Telephone Number V A -~ ~. R Y A ~ 1~~ d R Z ~ N ~ 1 ~? 2 '~ g~ `~ ~ S Firm Name (If Applicable) REGISTER OF WILLS USE ONLY I First line of address .~ ;,,~ ~ Sd"1 S N~.DO~ES~.X ~oA9 =~_~ :~~ Second line of address - -' ~= _C> _ - ;~,' -r., ' V City or Post Office State ZIP Code DarE F1€t7` ~ ` -" ~ C~ Correspondent's e-mail address: N ~ }~ ~ Under penalties of perjury, 1 declare that 1 have examined this return, including accompanying schedules and statements, and to the best of my krawledge and belief, it is true, conHCt and complete. Declaration of preparer other than the personal representative is based on ell information of which preparer has any knowledge. :il,~G,yy~~TURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDR~S C~ d~ ~ ` { ~~~L.'~SEI~ RO A~ C~ \t~ L1+ T't1 `~ V ~S ~ \~ ` \ _ 31 AT RF. O`+FpGt$PARER OTHER THAN REPRESENTATIVE OATS PLEASE U$E ORIGINAL FORM ONLY ,T. .., Side 1 15056051D47 15056U51U47 15056052048 REV-1500 EX {~` 1 - Decedent's Social ^S~ecu-ri-t7y Number Decedent's Name: y~„Q Lli,. ~ ~. ~ ~/ R~ ~ O ~ ' 4 1 q 3 ~, RECAPITULATION 1. Real estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2. Q . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C} .. ... 3. O 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. Q . 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 4 ~ Q ~ . ~{' Q 6. Jointly Owned Property (Schedule F} O Separate Billing Requested .... ... 6. ~ ~} Q `~ . ` 7. Inter-Vvos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. ('~ ~ 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ S ~ ~"~ . S S 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. q 2 ~ Q ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. O ~ 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 1 ~ t{ 3 ~ ~ l 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. O ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Met Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. O ~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal Tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ . 15. • 16. Amount of line 14 taxable of lineal rate X .0- . 1g. • 17. Amount of Line 14 taxable at sibling rate X .12 . 17. 18. Amount of Line 14 taxable at collaferal rate X .15 1 g, 19. TAX DUE ...................................................... ...19. O . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q Side 2 15056052048 15056052048 J REV-1500 EX Page 3 Decedent's Complete Address: FIIe Number DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER y TO ~~ `~__ D u3c.s -__12~~. STREET ADDRESS - ---_-- --- T~toR~3wA~ KOM~ -- - 't~ f~tNV~r 4~!~'~ c~ R4I~~_ __ _ _~ CRY STATE - ~ ZIP CRS s ~.E P ~ \~ 0 ~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CredilslPayments A. Spousal Poverty Credit B. Prior Payments C. Disa>unt 3, fnteresU'Penalry if applicable D. Inten:st E. Penalty (1) ~ Total Credits (A + B + C) (2) 0 Total Interest/Penalty (D + E } (3} Q 4. If 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, ff Line 11 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE (5) ~ A. Enter the interest on the tax due. (5A) Q B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) O Make Check Payable to: REGISTER OF Wl!!S, 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, ff death oaxrned after December 12,1982, did decedent transfer properly 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. Did 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 R 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 p2 P.S. §9116 (a) (1.1) (~]. 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 ~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 ~ zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax raise imposed 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. §9'116(1.2) p2 P.S. §9116(a)(1)]. The tax rata 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 91102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1509 EX+ (8-98) COAAMONVVEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F 101NTLY-OWNED PROPERTY ESTATE ~OF FILE NUMBER ~ :~.o t,~~ V Dv~ ca~ M an asset was made joint within one year of the dacede~'s date of death, it must be reported on Schedule G. SURVIVING J01NT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Va.~er,i~ ~ . K~rzu.,~ e. ~,~.de~~,Q ~ ~ W ~.~-~ C. .I[11NTI Y.,nWNED PROPERTY: sd~ S. M~d~~Qs~x Roan ~;aa~~~a~, aL~ Cac~ a\~ , (~ ~~ 013 G,wr~hkc~ a~~h~er ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION ANp BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % of DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~. A. SI2g~(9q MI;`t Qo,.1,r, ~hec`<~~ 0.cc~. 1.'~O~1,lS 104 +`1~a7.tS ~«~ +~ 3 ~ ~ d ~\ --~-~ ~ 5 TOTAL (Also enter on line 6, Recapitulation)' ; ~ 1{'Q') ,1 s (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-08) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~ ~a ~.e T ~ , pv Rc~ Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ 2..~' ~ ' ~~ ,. v ~'t~r ~u~n~.cw~ ~omc ~ ~hc . ~v~n~~al 84 get .~~ Grc~.-` hlosk~(~ ~ ~ ~r ~ . ~ ~ ~a~~1 ~i2~.~`t B. 1 ADMINISTRATIVE COSTS: Personal Representadve's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent 4. ~ Probate Fees 5. I Accountant's Fees 6. ~ Tax Return Preparer's Fees 7 State Zip Zip TOTAL (Also enter on line 9, Recapitulation) I s ~ 2,t{Q , (If more space is needed, insert additional sheets of the same size)