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HomeMy WebLinkAbout12-05-08 (2)15056041046 REV-1500 EX (05-04) r;FF:,C,At USE onlLV _ ____ PA Department of Revenue File Number County Code Year Bureau of Individual Taxes INHERITANCE TAX RETURN ~ Dept. 280601 /'~ T ~~~ ~ ~ ~ ~ Harrisburg, PA 17128-0601 RESIDENT DECEDEN -~~~^~N-~~~~- ~ _ll. _. an~~~~~y~- _ _ _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Narne Suffix Decedent's First Name MI 1 ~~' ~, ~ ~ . ~3 f,, c T r 7 ~ t- r~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Fi rst Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUpLiCATE WITH THE REGISTER OF 1MILLS FILL IN APPROPRIATE OVALS BELOW i~9 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate C~ 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Gied Testate 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of WiII) (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 TA;K INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number t) ~ c N t~ ~ ~ L_. l' .r fU' ,'V ~ r.,~ it l 7 ~~ ~ 0 . Firm Name (If Applicable) ; __.____.~_ _~ ~7 t~i7 rai v R= GIST'- s us f ~^ ~ / ~ ~ -_ _ n ~ :; ~ ~ 1 ;~-<- First line of address ~ ~` ~ ~` ~ ' ~ ' ;.._wif 3 - " Second line of address r t -p "'f •• r--; r `>~ City or Post Office State ZIP Code ~ ~t" /~ ,+ 6. Correspondent's a-mail address:./}~~,Ytc~..~~~-o- ',rte } 1:1~`)'rt.[''.2~1~. 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 cx>mplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ~,w ._._ ..._ ._. ... ~..., __..... a _ _. .., ~~, SIGNATURE E SON RESPONSIB FO INS g~TURN ~ DAT ADDRESS o.~_ ~ ~ ~~ ~..~. G~%ii~n ,~i~..w~~07iJ_. .._. __..__ w~~._ ..___ _ .... ~ .. SIGNATURE OF PREPARER OTHER THAN R PRESENTATIVE ~ DATE ADDRESS -TV34.~M_~... PLEASE USE ORIGINAL FORM ONLY _-~..~ ...,._. .e .._.,... „ .,~ _....a_. . ~__.n..,_~ Side 1 15056041046 15056041046 '1 J 15D56042047 REV-1500 EX c-C Dtcedent's Soci/al Security Number Decedent's Name: ~ ~ ~`'~ I ~~ ~ r - ~ RECAPITULATION ~ ~ ~ ~ 1. Real estate (Schedule A) ............................................ . 1. • ~~ ^ ~~ ~ l "++ 2. Stocks and Bonds (Schedule B} ...................................... . 2. - ' l ~ • ~' ~~ 3. Closely Held Corporation, Partnership qr Sole-Proprietorship (Schedule C) .... . 3. . ~ • ~} ~~ 4. Mort a es & Notes Receivable Schedule D ................... 9 9 ( )......... . 4. E h d l 5 C. ~ `f c~. ~ ~`7 5. ) ....... e u e Cash, Bank Deposits & Miscellaneous Personal Property (Sc . . 6. ~F~ Jointly Owned Property (Schedule F) Separate Billing Requested ...... . 6. , ~~• ~I 7. Inter-Vivos Tr<~nsfers & Miscellaneous Non-Probate Property ' Separate Billing Requested....... (Schedule G) •- ~ . 7. • 8. Total Gross Assets (total Lines 1-7) ..................... ...... .... .~_ __......... __.._ ., ,. .. . 8. 7 /~ c,~-- , ~' ( ~ ~ . ~' ,,`'~ _ . __ 9. _ .. _ u. _.. . Funeral Expenses & Administrative Costs (Schedule H) .................... . 9. _~ ~~ ~j ~ ~ 1 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... . 10. ~'• ~` ~' 11. Total Deductions (total Lines 9 ~ 10) ................................. .. 11. ~ ~ ~ j 9 12 1 ~7 / s ~~ J ~~ i ~'' 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. . (~ • / c 13. Charitable and Governmental BequestslSec 9113 Trusts for which ~`~} ^' ~ C ' an election to tax has not been made (Schedule J) ...................... .. 13. ~-%• ' - 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. / (} / ~? . ~~ ~~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers und~ar Sec. 9116 (a)(1.2) X .0__ 15. 16. Amount of Line 14 t a e p~- ~'"~ J O ~" ~, 16 ~ ~ ~` ~ . ~ at lineal rate X .0 . c • ~ 17. Amount of Line 14 taxable at sibling rate X .12 17. • 18. Amount of Line 14 taxable at collateral rite X .15 18. • 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042047 7,5056042047 ~ ~ ,~ ~ • ~- 5 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENTS Ni3[AE /i ~~.)' ~~i - yr~~ /~ ~~^ L G V~ f~ 1 G, ~ 1 C~~-J J STREETADDRESS ~i - 1 9 STATE__ __.__ _ _ ZIP ___ CITY ~ n .,~ ., J.~IT ~'1~~~~~~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditstPayments A. Spousal Poverty Credit ___ _ ___ __- _._ B. Prior Payments ~~ // - _ _. tv ~_ _ - --- C. Discount (1) g~, ~~ Total Credits (A + B + C } (2) 3. Interest/Penalty if applicable D. Interest _ __ _ - - E. Penalty - - __ Total Interest/Penalty (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) ~. D.D~ (4) ©~ (~ c5) Ski ~ (5A) c~~D ~ {5B) g~ 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 N o a. retain the use or income of the property transferred :............................................................................ ^ r ~ yi u 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 occun•ed 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'? ....... ....... ^ 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 172 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) p2 P.S. §91161;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+ (6-9BJ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt1LE A REAL ESTATE ESTATE OF FILE NUMBER Aft real property owned solely or as a tenant to 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. pr more space +s neeaea, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCMEDI~LE B COMMONWEALTH OF I~ENNSYLVANIA 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 TAA; RETURN RESIDENT DECEDENT SCNEDt~LE 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 corporatioNpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole:-oroorietorshios. ~« nrv~c aNatie ~5 7~C6ge0, insen aaamona~ sneers of the same size) nEV.,sos~c.~,a~ SCHEDULE C-1 CotrtMONUVEALTH of PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN ~+TA/+V 1\ICAS\r1AT1A\I ~CI9As ESTATE OF FIi.E NUMBER 1. Name of Corporation 2. 3. 4. Address City Federal Employer l.D. Number Type of Business State Z•ip Code ProductlService State of Incorporation Datc; of Incorporation Total Number of Shareholders Business Reporting Year STOCK TYPE Voting INan-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 tf yes, Position Annual Salary $ Timr; Devoted to Business 6. Was the Corporation indebted to the decedent? ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there 1'Ife 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 iwo years'rf the date of death was prior to 12-31-82? ^ Yes ^ No ff yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date _ Attach a separate sheet for additional transfers andlor sales. 9. Was there a written shareholders 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 solo? ^ Yes ^ No ff yes, provide a copy of the agreement of sale, etc. 11. Was the corporation diss<~ved 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 ff yes, report the necessary information on a separate sheet, including a Schedule G1 or G2 for each interest. THE FOLLOWING INFORMATION MUST SE StJBM{TTED WITH THt$ SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of finandal 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 addresses and estimated fair market values. tt real estate appraisals have been secured, attach copies. D. List of princlpal 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. REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA}: RETURN RESIDENT DECEDENT SCHEDULE C-Z PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER ~ Name of Partnership Date Business Commenced Address 11 Business F~eporting Year City State _ Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initi~~l investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedents 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 ~Nithin two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/:~old 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 decedents death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedents 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 decedents 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 decedents partnership interest. B. Complete copies of 1`inancial 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 valuels. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedents partnership interest. REV-1507 EX+ (t-97) COMMONWEALTH OE= PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE 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-1508IX+11-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER >~~-~~ ~-. Foss ~ ~ - o ~ --10~ l Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointlyowned with the right of survivorship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, ~5'~~Cr~F~~/NG- ~~T. ~R~~-New ~~% ~0 8' f l~ ~P'~41-r~ FUn~ee2 ~ ~x~E'-fuses l8'?~. ZS- 88~/- g~ TOTAL (Also enter on line 5, Recapitulation) I $ ~~~ 7 ~~, ~- (If more space is needed, insert additional sheets of the same size) REV-1503 EX ~ (1-97~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~iE~ULE F ESTATE OF FINE NUMBER ff an asset was made jointwithin-one year of the decedents date of death, it must be reported on Schedule G. SURVNING JOINT TENANT(S) NAME .ADDRESS RELATIONSHIP TO DECEDENT A. B. C, s!~+ JOINTLY-0WNED PROPERTY; ~~~ ,~//~- REM NUMBER LETTER FOR JOINT TENANT DATE MADE JDINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number a similar identi(yin9 numUer. Attach deed ~ jp~yy.}~ ~ egg, DATE Of DEATH VALUE OF ASSET 9b OF DEC05 INTEREST DATE Of DEATH VALUE OF DECEDENT'S INTEREST 1. A. ~, / / /V rr I ( - t. TOTAL (Also enter on line 6, Recapitulaticn) ~ ~ ,-- Q .~..- (If more space is needed, insert additional sheets of the same size} REV-rs~o Ex ~ tt-sn COMMONWEALTH OF PENNSYLVANIA INHERITANCf TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE: NUMBER ,~ E T ~0 5S - x.21-- 4 ~` ` / d '7 This schedule must be completed and filedrf the answer to any of questions 1 through 4 on the reverse side of the REV-950o COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY tNClUOETHENAA(EOFTHETRANSFEREE,THEIRRELAR~1SNfP700ECEDEMT/WDTHEDATEOFTRANSFER nTrncHncoPr of THE OEEO FOR REAL ESUTE. DATE OF DEATH VALUE OF ASSET °~ OF DECD'S INTEREST EXCLUSION IFAPRICABLE TAXABLE VALUE ~. TOTAL (Also enteron line 7, Recapitulation) + 3 ^ ~ .....- (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) } .:.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ~E=7'7'~. .loss ~ 1- ~-g--- /~ 7 l Debts of decedent must be reported on Schedule I. ITEM A. 1 FUNERAL EXPENSES: 1 'RE ~ ~ ~ ~uN~E~' ~4L ~jC/0 USES ~~ _ B. 1 2. 3. 4. 5. 6. 7. VJ V (/i gLJ ADMINISTRATIVE COSTS: Personal Representative's Commissions /~ ~ j Nan1e of Personal Representative(s) / ~ Social Security Number(s)lEIN Number of Personal Representative(s) Street Address City State Zip _ Year(s) Commission Paid: Attorney Fees ~ ~' Family Exemption: (If decedent's add ss is not the same as claimant's, attach explanation) Claimant Street Address Ciiy State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Zip TOTAL (Also enter on line 9, Recapitulation) I $ ~ 8 ~/~ ~~ ~~ (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TEJ( RETURN RESIDENT DECEDENT SCNEDVLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Q E.T-~-ic ~-. ~o ss __ ~1-- ~~ -- !D 7l ao~,~,~t ~phts inrurred h~ 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) REV-1513 EX+ (9-00) -, ~ SCNEDVLE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECE=DENT ESTATE OF FILE Nk1MBER ~ ~-rT~- i~. ~ 5S a 1-- D B`-- 1D 7! NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TC~ 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. ~E~1/N'!F ~. ~B~fC_ ~}~~~'~=~ ~ 8'9,15 .5-00 ~~ ~ X ~ ve. l UecvCju »~ ~3E,~t.,~xiD ~i¢/7070 7~e~L'L~rnE~7"S ~/A~u E o ~ ~sr~-TE ~ r87~: ~s' r~~NUSTAX es P,~ ~ - ~~: Sys" ~ ~ ~9a.~o 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 BEIPIG 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 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shee ESTATE OF FILE NIJMBER ~`1" `l'am /~. ~ S S al - 0 8 -' /l1 '7l 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;I OF LIFE TENANT(S) GATE OF BIRTH • NEAREST AGE Alf 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 fife 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 ANNURANT(S) 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) ^Seml-annually (2) ^ AnnuaNy (i) ^ Other ( ) _ 3. Amount of payout pear period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ....................... . .......... . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 112% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31 /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 rates 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 tihe estate assets on Schedules A through G of this tax return. Thee resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and i5 through 18. (If more space is needed, insert additional sheets of the same size) ?EV-16d5 EX+ (7-85) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION _ _f~'~l -ASSETS- FILE NUMBER ~ ~ ~ ~ 55 ~ - ' Estate of (Last Name) (First Nome) (Middle Initial) 11. Item No. Description Value A. Real Estate (please describe) ~/ I / ~+ ~~ Total value of real estate (include on Section II, line C-1 on Schedule L) S B. Stocks and Bonds (please list) / V f~ ~ ~~ Total value of stocks and bonds {include on Section II, Line C-2 on Schedule L) $ C. Closely Heid Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) A ~ ~] ~j Total value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) N ~ /~~ ~ " ~~ Total value of Mortgages and Notes $ (include on Section I1, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property (include on Section tl, Line C-5 on Schedule L) $ ill. TOTAL (Also enter on Section 11, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/4 x 11 sheets.) REV-t644 Ex • (3.04> I. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~'~' I~ Na-~) _ (Frtst Name) (Middle In~lal) 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 invasthn of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) 8. Name(s) of Life Tenant(s) Date of Birth Age on date or Annuitant{s) of election C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Ciosey Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ _ 'I 5. Cash/Misc. Personal Properly ................$ _ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of IJrbndudable Assets ........ . . . ......$ 4. Total from Schedule L-2 .......................................................$ Tenn of years income or annuity is payable 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) )11I, (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitants} corpus or arxruity Is payable consumed INVASION OF CORPUS: A. Irnaswn of carpus _ C. Corpus consumed . . . . ........................................................$ D. Remainder factor {see Table I or Table It in fnstrudion Booklet) ........................ . E_ Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recapitulation} INHERITANCE TAX scNEOUt~ ~ REMAINDER PREPAYMENT FIDE NUMBER l~l " Q~" /D l 1 OR INVASION OF TRUST PRINCIPAL REV-164b EX+ (3-84) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT "'BAR-"-* gyn.---~~~ _. ,. ,~a /gyp ~~r~ ,F~,.. ~~~ ! * ~,~.., ~ a u FILE NUMBER ~/~ "`~ , ` D~/ s ~~~~ 1. Estate of / l~s " ' (Lost Name} (First Name) (Middle Initial) 11. Item No. Dg~r.,~:s,,., Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) N J~. n~lA Total unpaid liabilities $ (include on Section ll, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-t (please list) N !7` / ~ ~~ Total unpaid bequests $ (include on Section !), Line D-2 on Schedule Lei C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: N ~-- ~/'~ Total unincludable assets S (include on Section li, Line D-3 on Schedule L;- 111. TOTAL (Also enter on Section il, Line D-4 on Schedule L} $ (If more space is needed, attach additional 8'h x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX I~ETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE ck Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NIIMBER ~ ~. r r~ ~-. ~oss _ _ ~ l ~- D8`--1 ~ ~ l 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 vuhen 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. ^ Wilt ^ Trust ^ Other I. Bene iciaries AGE TO NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to e:Kercise 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; i. Amount of 1suture 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 Lirte i 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. Value of Line 1 taxable at lineal rate Check One ^ 6%. ^ 4.5% ...........................$ (also inclucte as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also inclucte as part of total shown on line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also inclucte 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) ~~v-teas Ex („-ss) COMffONWEALTN OF PEf SCHEDULE N SPOUSAL POVERTY CREDiT (AVAfLABLE FOR DATES OF DEATH 01I01I92 TO 1?J31/94) ESTATE OF FlLE NUMBER .~ 7TE- ~: /~o ss mil- ~8' -- l 0 7 f This schedule must be completed and fBed 'rf you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ................................. . .......... 1 2. Insurance Prok~eds on Life of Decedent ................................................ 2. 3. Retirement8enefds ................................................................ 3. 4. Joint Assets with Spa~se ............................................................. 4. 5. PA Lottery Winnings ....:.......................................................... 5. 6a. Other Nontaxable Assets: t.ist (Attach schedule H necessary).. 6a. _ 6b. tic. 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 fine 8 from Line 7j ........................................... 9. H Hrte 9 is greater than S20D.000 -STOP. The estate is not eYg~fe ro r~aarr the t~edit H not: cautinka: ro Pan ti. Income: a. Spouse .......... b. Decedent .......... 1 c. Joint ............ 1 d. Tax Exempt Income .. 1 e Other Income not listed above ........ 1 f. Total ............. ~ 1 f. ~ 4. Average Joint Exemption lnoome Cakxilation 4a. Add Joint Exemption lnoome from above: (1 f1 + {2f) + (~ (+ 3) 4b. Average Jont Exemption InrArrte ..................................................... _ K ~ dlht is nma-Mr than 3dn IlM _ _C'rY1P Tho eetnee :~ .ard = .~=:_ ~.. ,.b~... ~-.s ...,s.c~ -s ..,,s .......:...._ 1. Insert amount of taxable transfers to spouse or $100,000, uvhidtever is less .................... . 2. Mttttiply by credit percentage (see iristructiwrs) .......................................... . 3. This is the amount of the Resitteni Spousal Poverty Credit. Inclurte this figure in the k~lculation of total credits on line 18 of the cover sheet . .............................. . 4. For Nonresidents, enter the ratio of the dacedenYs gross estate in PA to the value of the decederrYs gross estate ............................................................ 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credif .include this frgure in the calcutatiort of total credits on line 18 of the cover sheet ..... . + Part • 1. III. t ®~ 2. 3. 4. 5. " ttEV-sas ex. ~~-s~} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 0 ELECTION UNDER SEC. 9113(A) ESTATE OF /~ FILE NUMBER Do not complete this schedule uniess the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to mon: 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 sirriilar 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 (ail 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 inclwied 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 vaiue of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's (If more space is needed, insert additional sheets of the same size) PART B: Enter the description and vaiue of all interests included in Part A for which the Section 99 ~ 3 ~A~election to tax is being made.