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Home My WebLink About09-26-0815056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 2aosol INHERITANCE TAX RETURN ~ ( U~ ~? Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix Decedent's First Name MI 1y~2 T,~ ~. ~~~~,~~ ~~ (If Applicabte) Enter Surviving Spouse's Information Below 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 2. Supplemental Retum 3. Remainder Return (date of death prior to 12-13-82) _., 4. Limited Estate 4a. Future interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 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) « ~ REGISTBH-~F~/iIILLS USC~NLY -_ First line of address ! -'-' :rTl N ~ C3', .3f ~. ~`%t,~/~Lfa six ~~2 ~ - x Second line of address , ~~ ~ _~ AI ^~ ~. City or Post Office State ZIP Code BATE FILED O rJ-~z-~'-rS ~-'~= j~f}~' /70/.3 Correspondent's a-mail address: ~j ~jq ~r tt~ ~ p g , /y ~",.7" Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tru ,correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI T RE OF PERS PON FOR FILL G RETURN DATE ~' vim SIGNAT~~~ PREPARER/OITHER THAN~~ ES NTATIVE ,Q DATE ADDRESS j'G_ /~f - /~5~.' ~ t~~ // f/ c7 ! t '~~ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name' RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. ~_j ~ ~ ~ O 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. ~ ~ ~ ~• ` 6. Jointly Owned Property (Schedule F) '+ Separate Billing Requested ...... . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ' > Separate Billing Requested....... . 7. 8. Total Gross Assets (total Lines 1-7) ................................. . . . 8. f L ~ l~ G 9. Funeral Expenses & Administrative Costs (Schedule H) .................... . 9. Clr l ?~ // 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) ............... . 10. 11. Total Deductions (total Lines 9 & 10) .................................. . 11. ~ ~ 3 ~` 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12. f (~ C _~~~--~ 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. / ~ ~ 7 ~ ~ ', 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 at lineal rate X .0 ~[,~ 16. ~ ;2 2 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at coNateral rate X .15 18. 19. TAX DUE ........................................................ .19. ~ z._ Z 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENTS NAME ^ /~~// A ~- ,~j DECEDENTS SOCIAL SECURITY NUMBER /~ r / /~~N L,+ Cf~(/~~( STREET ADDRESS CITY ~' ~u- r L/' STATE ~~' ZIP ~~ a ~ 3 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) Total InteresUPenalty (D + E ) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (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 : ............................................ ^ [`f 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. §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 isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-'502 EX+ (6-98) SCNEDIJLE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~' /L i /z.~. ~~~2TiFC 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, Moth having reasonable knowledge of the relevant facts. tiT more space is neeaed, msert adoitional sheets of the same size) REV-Y503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANVA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /~' FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-7508 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER /`Ii/ ,2, r ~ ~~k~~N~ include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCI~IED~ILE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ~~ FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. /~/N r_S7" /yc. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State 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. Accountant's Fees 6. Tax Return Preparer's Fees 7, Zip Zip TOTAL (Also enter on line 9, Recapitulation), $ (If more space is needed, insert additional sheets of the same size) X200 / -3 ~- ,~ J~ l3~ o?ee RE'~1-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OP PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RES4DENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)j ~AV~>>sori ~• ~~ 4 ~/ J'I r ~ L ~izt-rs~.- ~ ~9 ~~`~ ~ 3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 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 8. GHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (lf more space is needed, insert additional sheets of the same size)