Loading...
HomeMy WebLinkAbout08-08-08 (2)15056041046 REV-1500 EX (05-04) OFFJClALUSE ONLY PA Department of Revenue Bureau of Individual Taxes ~ County Code Year File Number Dept. 280601 INHERITANCE TAX RETURN ~ Q ~. Harrisburg, PA 17128-0601 -~ RESIDENT DECEDENT Z ~ ~ ~ -~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth l k3 ~.~'~3$J ~s~3zav~ ~ 1 ~71'~(~2. Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Betow Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 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. 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 Daytime Telephone Number D~Nti~IS ~ C12~ i 7"y cx~~Yor2. ~1 ~ ~?32 ~~~a 1 Firm Name (If Applicable) First line of address I 1` ~ Iv Second line of address City or Post Office CNu~1~ Correspondent's a-mail address State L. REGIS{~~~ WILLS ll`SE ONL1r- ;, x _~; cp ~~ i-r~ 1 C.'~ .,_.., r_ _ _, =_, i ~: ~I -~ ---1 .. - rv ~ DATE FILED .~„2 ZIP Code I-- 17~~s Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and =_;tatements, 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. SIGNI~FJtB~ Opp! P~R~ ON R~SP9FjISIBL,E,FOR FILI~~~'URN~ (~ DAT~+E ~+ SIGNATURE OF PREPARER OTHER TH N REPRESENTAT DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ~~~~ Side 1 15056041046 15056041046 J 15056042047 REV-1500 EX De ced e nt's Soc iat S ecurity Number ~1- }y~} ~/ Decedent's Name: ~ ~ f_ ~.~ 1 ~ , . ~ 1"~~ : r... ~ 1 ... .. l _. t ~ ( w.: - l U 3 ( r ~} °~ _ ~ ~ ~ j 4 RECAPITULATION 1. Real estate (Schedule A) . ......................................... ... 1. V . 2 S B " . tocks and onds (Schedule B) ..................................... .. 2 . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. V . 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. v. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. ~ '~ 5 ~ ~ (~ . O W 6. Jointly Owned Property (Schedule F} O Separate Billing Requested ..... .. 6. V. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested...... .. 7. (,1, 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ~ ~ ~ ~ ~ ~ . ~ ~o 9. Funeral Expenses & Administrative Costs (Schedule H} ................... .. 9. lj (o ~ ~, 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. ,~ ~ y • to 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ~ ~ 7 5 , ~ 7 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ ( aJ (? ~~ ~ Q 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. a ~ (~ U S5 . ~.~ 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 .O~S . 15. • 16. Amount of Line 14 taxable p L_ at lineal rate X .0- 1 a~ ! ,7 ~, ~ ~ 16. t ,~ r~ ~ 2 ~ 17. Amount of Line 14 taxable ` ~ ' ~ ~ at sibling rate X .12 . 17. - • 18. Amount of Line 14 taxable r, at collateral rate X .15 • 18. v 19. TAX DUE ....................................................... ..19. ' ~ ' S:~ ~-~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O ~' 15056042D47 Side 2 15056042047 REV-1500 EX Page 3 Decedent's Complete Address; File Number STREETADDRE~,S ~ ~ ~~ CITY ~ ^ ~ !~ zIP 17C~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments -- C. Discount (a ~~ 3. Interest/Penalty if applicable D. Interest E. Penalty " c1) 1 ~,1s a ~ ~~ --~ Total Credits (A + B + C) (2) ~ ,~ ~ , ~Cf Total InterestiPenalty (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) ~ ~ . ~~~ . / A. Enter the interest on the tax due. (5A) CJ B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~ ~ ~~~_~ (~ 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, tlitl 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. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary tlesignation? ........................................................................................................................ ^ 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. §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 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 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-1502 EX+ (6-98) ' SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F to inure space is neeaea, msen aaamonal sheets of the same size) REV-1503 EX+ (6-98) SCHEDt1LE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All nronerty jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) f4EV-1504 E~C+ (1-97) -. ~ ~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER i° i -~ 1 L j 1° o~`T~ ~l~ ~ _ ~ n~ ~ Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. to more space is needed, insert additional sheets of the same size) atv-~sosEx. j~~sn SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RFSIf1FNT t1F(lFr1FNT ESTATE OF FILE NUMBER ~' (~ i ~ i ~' C ~ C~ t2b 17~ ~t~c~~ - ~ /~U 1. Name of Corporation 2. 3. 4. Address City Federal Employer I.D. Number Type of Business Business Reporting Year STOCK TYPE Voting INon-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ^ Yes ^ No v If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMAT#ON MUST B;E' SUBMITTEp WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. State of Incorporation Date of Incorporation State Zip Code Total Number of Shareholders Product/Service REV-1b06 EX+ (9-00) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-Z PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address City 2. Federal Employer I.D. Number 3. Type of Business ProducUService Business Reporting Year State Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. ( PERCENT PERCENT ~ BALANCE OF PARTNER NAME OF INCOME OF OWNERSHIP CAPITAL ACCOUNT A. B. C. i). 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. ~ • •- ~ ^ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addressJes and estimated fair market value/s. if real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. F?EV-15p7 ~X+ (1-97) c, s SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER _ Y~ i-I (~ r ~' C . ~t/~b [ 7~ ~ bag' - ~D ~~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ~ ...-.- r -~ ~~ „~~v~ ~~~~~~ ~.u.,~~w~~ui oiiccw vi uic Jalllc JILG~ REV4508 Ek ; (1-97~ ' SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSfTS, & MISC. INHERITANCE 7AX RETURN PERSONAL PROPERTY xein~niT n~r~nGnt7 ESTATE OF FILE NUMBER I°l-4 l ~i W ~-. C~12~ ~ T~ ~Of~~-tSb~o~' 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 I VALUt A I UH I t NUMBER DESCRIPTION OF DEATH S~.e 1~~~~'~i~nh~ ~n ~ ~~h na ~v~'D CD IM'vvtd ng ~'QS~- p..~ ~ n ~ r ~ ~-e Chu 1~i ~'~ ~ 7p~s~ C~ ~ee~Ci ~e cvuvt~- ~ ll ~ S~aS ~ 2. U~ea~>>~~~ ~}~4v~~ ~-Se~cJY~r ~~ ~~ riot ~ ewe ~ n~e ~= u hol N~~~~r 'C~ c~1 kt~id~ ~'~ ~~~L ~ tine. sh i ~~o(-- ~-e~uv~d ~'czvt~~e.~ec~ ~C~~~ S ~e~ ~Uv~ - ~~~ u ~ v~ '1'11 n~~~ 1~~ ~~~ ~t ~ s~s.; s t ~e~ ~; v t +~ ~ ©ri, ~ ~ . c~~v~~ ~ay~Y ~uh~e~ ~ N~ ~. ~e~~~~ du~-e -~a ~r~-ya-~.~C~ ~~tnera.j ~• ~r~- joc~.`d, 1~u v,Frc,t1 Arrav~~n~-~~- w~ -1-h `~~ov,e.Y ~oYey ~U,n.QY~t~ ~d~~ ~~~ 1 I°~bc.,~r~ i 1~ g, ~.~y}iii '~..Ct"~'E's ~ ~'e~ t ~ ~ f ~'! i d ~~~''IY1 ~1~1 K ~~,~2 'C.~tr Jo51re Pi ~~e; ~i ti'!i~'a~' ~~ f7D5U s u~~a~~.l3an~' ~~ ~e~n Sri ~-e, ~'~~~, ~ /7~~-" ~1'$l, o~~. ~I 3~ ~ g7.ls' 3~ , 78' ~ i ~6 ~~ o~ ~'s~- ~9 ~~4~ ~t 53 ~. ~,3 X7,1 ~'~° ~ TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-509 EX ~ (1-47) ' SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER I~~l ~ i ~' ~ • C1.~20 I ~ ~ D0 ~ - c~ ~ ~ 5 If an asset was made joint within one year of the decedent's date of death, ft must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME B. C. JOINTLY-OWNED PROPERTY: RELATIONSHIP TO DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Atlach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET °/ OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) ~REV~1510 EX ~ (h971 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the' REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRRElATIONSHIPTODECEDENTANDTHE0ATE0FTRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION iFAPPUCAeLE TAXABLE VALUE 1. TOTAL (Also enter on line 7, Recapitulation) I $ ~'~ {If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) s~ ~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER aC~U b ~- dd Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. f , •;! lets b~r~ ~-~~ 1._ ~~l I {~` ,,N1 ~4Jt t...4/n ~ i3~ r ~~ ~~ ~ ~-~38Ye~r 1Fuv-era~ ~d~ ~ - i?r' e ~- d F`u ~ ~. i ~. ~ Y , i4v~~~xy~-~ ~w~ ~v~~s B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Adtlress City State _Zip 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 Atldress City State Zlp Relationship of Claimant to Decedent 4. Probate Fees v~• r U,/~r ~v1~ ~~ ~ 1 J 1 ~ a [~ ~1 1 ~S VT ~bo ~®~ 5. Accountant's Fees 6. Tax Return Preparer's Fees ~,~ j~ ~'i ~l M 1 f ~. !~ (~'1~ ~ ~ ~~ 7. TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCFIED~lLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER +P~ I L ~ ~P ~~ ~-t2a7 7-~ ~~C~~'~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE ITEM Of DEATH NUMBER DESCRIPTION ~ ~~~,~0 I-~~vh~ ~rstead ~ e~, ion' ~re - ~? r.~l ~-i~.I ~~~~i r~eC~ Q} (~1uYSi ~ ~o~n~e. V7YC~V1~1x1v ~" _ ~u~,ny, ~ g7 ~ • ~ ~'~ ~ I ~h ~ T'r r~Y1'he~~ - I~Y~e~r~' ` 6~S ~ J :3• ~ev~st ~h ~ ev~~~ ~ t~a~ ~Y ~n.~~-~~ ~~ j~e~~trr,1 -~'c~Y~uh~ icy vh~e~-~- I~er~si ovt ru ham( TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~! °y ~~~~ REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~-~~~ ~-: c~~~ i ~ y aoa~-oars 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. ~ ehh o s ~ Yc~y s-~1r1 Dn ~ ~I'Ji -~(, ~ ~~~~ ~'n~l~y ~P~ 1 `70~ ~~ Crt~~ G~ro~y 3D~ cVYEY ~'i n ~o~ ~ (i/~e, Scan ~ n e 7h ~ ~( 'Nav r i s ~ou~ ,~ 1 "'i t 10 3. ~.a~ ~r ~ ro~t~ ~ 31~ ~'1 atAh~t h ~ Soh . d ~ ~ 7h ~ r~. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 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) REV-1514 ~X+ (12-03) y. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover SheE ESTATE OF FILE NUMBER ~ I-~] L, ~ C . C. ^f ~ y ~tac~g ~ bD ~D s This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANTS} DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 3112%, 6°I°, 10°I°, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ................................................. .$ -~ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) ,REV-tsaaEr-Is-oal INHERITANCE TAX SCHEDULE L COM MONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT / ~~~11 C Q~ RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER r ~t~V ~t.~ I. ESTATE OF C12~ ~~ ~ ~.., C~. (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Reai Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ..... . .........$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of Unincludable Assets .................$ 4. Total from Schedule L-2 .......................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ ~~ (Also enter on Line 7, Recapitulation) ?EV-16d5 EX+ l7-$5) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION -ASSETS- FILE NUMBER ~~~^~~(.~ Estnte of ~ ~~ j Z--~ I 1.. (last Name) (First Name) (Middle Initial) 11. Item No. Description Vplue A. Real Estate (please describe) Total value of real estate (include on Section II, Line C-1 on Schedule L) $ B. Stocks and Bonds (please list) Total value of stocks and bonds (include on Section II, Line C-2 on Schedule L) $ C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership (include on Section II, Line C-3 on Schedule L) $ D. Mortgages and Notes (please fist) Total value of Mortgages and Notes (include on Section II, Line C-4 on Schedule L) $ E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property (include on Section II, Line C-5 on Schedule L) $ III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.) REY-1646 EX+ (3-84) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-2 REMAINDER PREPAYMENT ELECTION (FILE NUMBER 2~~~~ -CREDITS- I. Estate of ~ b ~ ~.- (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Volue of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for rax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ (If more space is needed, attach additional 8'/z x 1 1 a~heets.) REV-1647'EX+ (9-00). -.~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Box 4a on Rev-1500 Cover ESTATE OF FILE NUMBER LPN r ~ 1 ~' C. ~12bTi y a©a~- ~ ~o~ This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intemds to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: N. Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Vaiue of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) REV-1.648 EX (11-99)' SCHEDULE N ~' SPOUSAL POVERTY CREDIT COMM(3NWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01101/92 TO 12131/94) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ............................................ 1 . 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. if line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. a. Spouse ........... 1 a. 2a. 3a. b. Decedent .......... 1 b. 2b. 3b. c. Joint ............. 1 c. 2c. 3c. d. Tax Exempt Income .. 1d. 2d. 3d. e Other Income not listed above ........ 1e. 2e. 3e. f. Total ............. 1 f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) 4b. Average Joint Exemption Income ..................................................... _ If line 4(b) is Greater than $40.000 -STOP. The estate is not eliaible to claim the credit. if not. continue to Part 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... I 1 2. Multiply by credit percentage (see instructions) ........................................... ~ 2 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . ............................... 3 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate 4• ............................................................. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet....... 5. ~~// nFV-spa ex . i, s» r SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN (SPOUSAL DISTRIBUTIONS) orclnGNr nGrFnGNr ESTATE OF FILE NUMBER I)o not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement, The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator Is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. nFC!".RIPTI(1N VALUE Part A Total ~ $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. --~~ (If more space is needed, insert additional sheets of the same size)