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Home My WebLink About07-30-08 5056041046 REV-1500 EX (05-04) OFF~CtAt use DNIY PA Department df Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ' Dept. 280601 RESIDENT DECEDENT a ~ ~ ~ u ~ Harrisburg, PA 17128-0601 - ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death ~~r~~g ~~s'~ O~o~~U~ DecE~dent's Last Name Suffix KC'~.12 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix X~~~ Date of Birth o~a~~ ~~~ Decedent's First Name MI f ~ d m!7'~S Spouse's First Name MI o' f~ ~a Z / ~ ~ .f . Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ ~ a ~ ~ ~~ ~ REGISTER OF WILLS FILL. IN 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 Died 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 ~ Attach SchaOunder Sec. 9113(A) between 12-31-91 and 1-1-95) ( ) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Narne Daytime Telephone Number CA~o ~ r ~~ J K~~~2 7 ~ 7 ~~7 ~o~~ Firrn Name (If Applicable) First line of address ~~~ j ~~}-222 t~~C Second line of address City or Post Office Correspondent's a-mail address: ~C '~ ~ G R A ~1au_S~= 1~~I v State ZIP Code REGISTER OF WILLS USE ONLY ~a C"~ ° Ca _C7 t.._ ~ ~ ~~ . rte- i_" _ ~ ~ '' `._,.~ ~ C._ _ 3 =.=i ~E FILED '"'°' _- -.,-, ---i -' l 7 U I OG. a O 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, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG TURE OF PERSON F~SPONSIBLE F FILING RETURN DATE ~~ , _ ~, ' `lam- . ~~~ 7'- a? ~ - CJ ~ SIGNATURE REPRESENTATIVE 0 ~/ DATE ADDRESS - PLEASE USE ORIGINAL FORM ONLY 15056041046 Side 1 15056041046 t C1 J 15056042047 REV-1500 EX Decedent's Social Security Number z Decedent's Name: ! °i RECAPITULATION 1. 1. Real estate (Schedule A) . ........................................... . 2. 2. Stocks and Bonds (Schedule B) ....................................... 3. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)- ... 12. ................ Net Value of Estate (Line 8 minus Line 11) ........... . ..12. ~ • 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 . an election to tax has not been made (Schedule J) ...... . . ~ / ~ ~• [ 14 14. .......... Net Value Subject to Tax (Line 12 minus Line 13) ........... . . .. 1'AX 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 ~ Q ~ 16. at lineal rate X .0 17. Amount of Line 14 taxable 17 • at sibling rate X .12 18. Amount of Line 14 taxable ~ 18. at collateral rate X .15 U. () ........ 19 ... 19. TAX DUE .............................................. 4 /~ 3 ~ (/ 7 ~. 7 ~ ......... 4. Mortgages & Notes Receivable (Schedule D) ................ . . ... 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... 5. .. . 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property C Separate Billing Requested..... ... 7. (Schedule G) / ~ ~ ~ ~~ 8. Total GrossAssets(totalLines1-7)......•.~~~~~~~~~~~•~•~•~~~~~~~~ _ ~"'~ 8' // / // ~ (R (¢ CP ........ 9. Funeral Expenses & Administrative Costs (Schedule H)........ . .... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. ... . 7~ ~ ~.o 0 ........................ 1'I. Total Deductions (total Lines 9 & 10)..... .... 11. 7 ry ~a / O 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042047 1505604.2047 ~~~u„ . REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME -- - - __ STREETADDRESS ~C 3 --__ - - - ~~-`~ _• - CITY STATE ZIP Tax Paymei(its and Credits: 1. Tax Due (Page 2 Line 19) (1) " ~ - 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments _ _ __ _ __ C. Discount _. __ _ _ __ -_ __ _ __ _- - Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest _ _ _ _ _ _ _ _ E. Penalty Total InterestlPenalty D + E (3 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. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) - (S A. Enter the interest on the tax due. (5A) B. Enter the: total of Line 5 + 5A. This is the BALANCE DUE. (5B) - C9 -- Make Check Payable fo: 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? ....... ....... ^ ~C 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 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) (1.1) (i)]. 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. §91113 (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 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. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate immposed 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. REVd508 EX+(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY 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 DESCR/IaPTION // OF DEATH ~ . oS0 v Ei+e ~/ ~.~ ~ R ~tl' K - (. ~cl ls'c ~ /.c7 ~ f~ G c T, o~ 7'~ . y ~ ~3~~ 7.~~~,~ ~3Sia~ ~i~g ~~~ i2~5231.c.iz 6 /` f~ . U 5 C N aP.. VS G t~ ~ ins ~ YA ~ ~ G~ o ego _ a o TOTAL (Also enter on line 5, Recapitulation) , $ /Q ~ 3 7~. 2,6 (If more space is needed, insert additiona- sheets of the same size)