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Home My WebLink About10-16-0815056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes ~,, County Code Year file Number Dept. 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 ~ RESIDENT DECEDENT Z ~ O S ~ ~ Z- ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 R~ i6 96~ Z" ~ff ~ !~ oS ~~ a3 ~ ~;~, Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) 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 O 1. Original Return ~ 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~-. ~ n ,:: , Firm Name (If Applicable) First line of address Second line of address City or Post Office Gtata 71P r'.nria ~ ~ ~., ~~ REGISTER flF Itf}S US NLY -;,. r- -_a i-r,~ = -~~; Q-~ ~ =-. "i7 f. - " -°°` . ,, --t ~ n1 7 ~ DATE FILED Correspondent's a-mail address: 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. SIGNATURE PERS R SP SIBLE FOR FI G RETURN LATE "" `` 8 ADDRESSr~.., / _ ~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATI DATE ADDRESS e PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 ~ REV-1500 EX 15056042047 RECAPITULATION 1. Real estate (Schedule A) . ...................................... . .... 1. ; Decedent's Social Security Number 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. 3 ,~ 7 "/ 5 6. Jointly Owned Property (Schedule F) O Separate Billing Requested , ... 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) .... 6. ' O Separate Billing Requested.... .... 7. 8. Total Gross Assets (total Lines 1-7) .... • .......... ................. ... 8. ' 9. Funeral Expenses & Administrative Costs (Schedule H) • .................. ... g. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 11. Total Deductions (total Lines 9 & 10) .. .............................. ... 11. 12. Net Value of Estate (Line 8 minus Line 11) ...... • ..................... 13. Charitable and Governmental BequestslSec 9113 Trusts for which ... 12 • an election to tax has not been made (Schedule J) ... .................. ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ... .................. ..14. ^5 7 7 q 5 3 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_ 16. Amount of Line 14 taxable • 15. at lineal rate X .0 -- ' 17. Amount of Line 14 taxable 16. • ~ at sibling rate X .12 3 3 " L ~ ~ ~ , 18. Amount of Line 14 taxable 17. at collateral rate X .15 • 18. 19. TAX DUE .................................................. 19 ~'0 5Jr^1{ ...... . . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042047 15056042047 O REV-1FEJ0 EX Page 3 Decedent's Complete Address: STREETADDRESS ` ~ ~ ~ ~~ r ~ ~ ~V 1Q R ~ S File Number CITY C ~ ~ ~ ~7'~L.~. ~~~i l ~~ ~~ STATE Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + g + C) (2) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.tal Interest/Penalty (D + E) (3) 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. (4) A. Enter the interest on the tax due. (5) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT ZIP PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and• a. retain the use or income of the property transferred : Yes No .................... . 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 on ....... ^ e 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 awn an Intlividuai Retir ....... ^ ...... ement Account, annuity, or other non-probate property which contains a beneficiary designation? ............... .................. .................. .... ................................................................ ^ 0 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 is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. use of the surviving spouse 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 [72 P.S. §9116 (a) (1.1) (ii)]. The statute doesdoes n~m~t a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of ass filing a tax return are still applicable even if the surviving spouse is the only beneficiary. (0) percent ets and 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 adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. parent, an 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, exce t as 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. p noted in 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)]. A siblin is defin Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 9 ed, under REV-1502 ~X+ (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. (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA 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-1504 EX+ (1-97) ~` COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER 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. (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCHEDULE C-1 ~. ~ CLOSELY HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VotinglNon-Voting SHARES OUTSTANDING pAR VALUE OWNED BY THE DECEDENT DECEDENT'S StOCK Common ~ Preferred ~ Provide all rights and restrictions pretaining 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 an stock in 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 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 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. (If more space is needed, insert additional sheets of the same size) 'REV-1506 EX+ (9-00) SCHEDULE C-Z PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME PERCENT PERCENT OF INCOME ~ OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 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 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 addresses 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. ^ No REV-1507 EX+ (1-97) .~ z SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE 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-1W8 E%+~1-9)) • SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~'LlZ~$~-7'E}- iY1, moRFZas FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~..+C~C~~~rclf/ //,7~~/~ ~ O x ~2.~p , ~~~~ ~ ~,'~O `~,~~. ~,s~„~o . Ja y~a ~ ao ~~ ~~ ~ ,~ lix ~"/~ ~ 3v 8 . ~z moo? /~ 'I~i~~~~ 6 ,~ ~° ~ ~° ~ ~'~ ~ ~~o, ~-~ ~~~~-~~s ~iNCo~" ms's s v~~'~ ~3 ~~ Ob.~ ,~~ ~~~ ~~ ~~8~ TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~ REV-1509 EX ~ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. 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+(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY 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 INCWDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENTANDTHEDATEOFTRANSFER. ATTACHACOPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IFAPPLICABLE 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) , SCI~IEDULE N 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. (If more space is needed, insert additional sheets of the same size) REV-1512 EX+(12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) ~TEV-15`131=X+ (9-00) ' ~ . ~ SCFIEDt~LE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT 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 1. Sec. 9116 (a) (1.2)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If mare space is needed, insert additional sheets of the same size) AEV-1544£X+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover SheE FILE NUMBER 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 ANNUITANT(S) DATE OF BIRTH • NEAREST AGE AT DATE DF DEATH TERM OF YEARS ANNUITY 1S 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) ^ Semi-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 3 1/2%, 6%, 10%, 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)