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Home My WebLink About02-13-09J 15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Depadment of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN^y ~ ' 'Q~` `~ ! r ~ "~ ~' Harrisburg, PA 17128-0601 04 ~ 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 (If pplicable) Enter Surviving Spouse's Information Below Spouses Last Name First Na m e Suffix S sesj M AI \ \ \ r µ Sp use s Social Secunry 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 WIII) (Attach Copy of Trust) O 9. Litigation Proceeds Receivetl 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 TO: Na a Daytime Telephone Number ~~' ~ ~~ ~~CC I~ C ~ (1 ~~~ S~1 S Firm Name (If Ap icable) REGISTER OF WILLS USE ONLY First line ^r address r 11 ^ C ~ ' ~ N c~ W ~ tJ~ ~, ~~Svt~w a .~ Second hne of address _, ~ -ci ~ ~ I'rl ~ , ~ ...: b~'PttLED C'`y City or POSt Office fate ZIP C d D r o e C. 7 ~.~ _ :_ ~r w ,,,:-, Correspondent's a-mail address: .C' Under penalties of perjury, I declare that I have examined this return, inclutling accompanying schedules and statements, and to the best of my knowledge and belief, it is true, coylpdFand complete. Declaration of preparer other than the personal representative is based on all information of which prepaFer has any/knowledge. OF PREPAREYi OTHER TF ADDRESS FOR FILING RETURN ! ~. ~~iUG ~~~~io?- J REPRESENTATIVE DATE PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J `~~;~„ f r. ~r .' ..,~ _., '~~ ® ,'.. , :~.~ 4 ~V v~ ~~ 7~' ~r '~ ,~ V 7 ~ ~ C'' ...C y. ~ ~ ~l' t~ ~O '{~ .~ V ~ ,.• ' '~ N~G ~ .~ .~ 3 ~ -- o `~ ~ t~ -~ p ~ .~ ~ ~~~ ~_ ~, ~~ ~~~~ ~: ~~r:. ,, ~..~ .~~. REV-1500 EX DecedenPS Name: Decedent's Social Security Number RECAPITULATION ~~--''''SS 1. Real estate (Schedule A). ... ..... ....... ...... .. .. t + ~} Y 2. Stocks and Bonds (Schedule B) ...... ...... ....... .... .. 2 ~ ~ 4 u C tyy ~~~--. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3 s lJ ~ 4. Mortgages 8 Notes Receivable (Schedule D) .................. ........ .. 4 " ~! \ x ~. K { a ikt. xa~ j~.:. 1 h d l E 5 4 ~ i ~ 5. e u e ) ..... Cash. Bank Deposits & Miscellaneous Personal Property (Sc .. ~ t + $~ : a 6. Jointly Owned Property (Schedule F) O Separate Billing Requested . ... S .. 6 .k 4 f ,h ~` ' ' ,.~, r i, .. '11q s + t 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property .fi ~ (Schedule G) O Separate Billing Requested...... .. 7 y' t % =%+4i Y ~. x i + ~' h~N s ~9 , + i 8. Total Gross Assets (total Lines 1-7 ) .................................. .. 8 .,....^ + y (`+~ a...S 3' 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...... _ . _ ..... 10 ? t. ', -. (:$vi2 ph 11. Total Deductions (total Lines 9 & 10) .... ......... .............. ...... 11 ~+ n t: c 12 Net Value of Estate (Line 8 minus line 17) ........................ ...... 12 ~ ., 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. ...... 13. Y 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 under Sec. 9116 i 16. Amount of Line 14 taxable ~ at lineal rate X .0 _ ~i /•! (~ 17. Amount of Line 14 taxable /r ~ at sibling rate X .12 ~ ~ ~-~ ~ ~ ~ • ~~ 18. Amount of Gne 14 tazable • \ at collateral rate X 15 - 17 a 18 ~' t ~' 19. TAX DUE ......................... .......... ..... ..... 19 ...,, ~" 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~ Side 2 L 15056052048 15056052048 1505605248 O REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME ~t~~Qe~. ~~MPS ~~(C';C STREET ADDRES~~ ~~ J~ ~ ~ Q~ New ~u ~~~~~r~ ~~- CITY STATE ZIF ~U ~?~ Tax Payments and Credits: 1. Tax Due (Page 2 Llne 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable D. Interest E. Penalty 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 fAX DUE. A. Enter the interest on the tax due. 6. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (i) O Total Credits (A+ g + C) (2) Total InterestlPenalty (D + E ) (~. (3) ~~ (~ (a) ) (5A) (SB) Make Check Payable to: REGISTER OF WILLS, AGENT ,,. , ~,tiza~~~~#€t~€itF§£tt{i=E~~~t~~a,fra~xr.s,ur:v . a ,. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income :...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ......................................_.............._...._. _._.. ^ (~ 2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration? ................................................................................................... ...... ^ 3. Did decedent own an "intrust 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 [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 (O) 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 dales 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 adaptive 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 far 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+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF ~ FIL NUMBER ~t~C~C~~ ~ ~~iMPS ~c.~C~~C ~~~ - 06 ~Ll ~ All real property owned solely or as a tenant in common must be report d at fair market value. Fair market value is defined as the price at which propeny would be In more space is neeaea, insen aamnonai sneers or me same srze) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~r~~~ c~MP ~~~~Ic ~c~ - ~c Li ~`" All property jointly-owned with rig of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~~~-~ TOTAL (Also enter on line 2, Recapitulation) I $ Qf more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) r ~` 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 attadhed for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions tar the s pporting information to be submitted for sole-proprietorships. (lf more space is needed, insert additional sheets of the same size) REV-1505 EX+(6-98) ~- SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF~ (C ~~ (~ 1 , Mpg ~ ~~ 1 ~ CUM~iBER V 6 l~ % \ ~ 1. Name of Corporation _ Address City _ __ 2. Federal Employer I.D. Number 3. Type of Business 4. ProducUService STOCK TYPE OTAL NUMBER OF ppR VALUE NU ER OF SHARES VALUE OF THE VatinglNOn-Voting SH ES OUTSTANDING OWN BV THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to )oath class of stock. 5. Was the decedent employed by the Corporation? :.....................:'~.......... ^ Yes ^ No If yes, Position Annual Salary $ rT-Tme Devoted to Business 6. Was the Corporation indebted to the decedent? ...................../.............. ^ Yes ^ No If yes, provide amount of indebtedness $ i~ 7. Was there life insurance payable to the corporation upon the death of If yes, Cash Surrender Value $ Owner of the policy `~~ 8. Did the decedent sell or transfer an stock in this company if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Transferee or Purchaser Attach a separate sheet for additional transfers and/or sale Date 9. Was there a written shareholder's agreement in effect at the t' a of the cedent'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 de dent's death? .... ............... ^ Yes ^ No If yes, provide a breakdown of distributions received by he estate, including d tes and amounts received. 12. Did the corporation have an interest in other If yes, report the necessary information on a A. Detailed calculations used in the valuation of the B. Complete copies of financial statements or Fed C. If the corporation owned real estate, submit a lis been secured, attach copies. o bons or partnerships? ... ^ Yes ^ No a ate sheet, including a Sch ule C-1 or C-2 for each interest. • ~ ~ cedent's stock. Corporate Income Tax returns (Form 120) for the year of death and 4 preceding years. wing the complete addresses and esti ted fair market value/s. If real estate appraisals have D. List of principal stockholders at the date of de h, number of shares held and their relationship toe 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. on Date of Incorpbration State Zip Code Total Number of Shareholders BusinessReporting Year year prior to death or within two years Number of Shares ie decedent? ..... ^ Yes ^ No Net proceeds payable $ (If more space is needed, insert additional sheets of the same size) REV-1506 EX+(9-00) SCHEDULE C-s PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE F ( ~ FILE MBER ~ " ~ 1. Name of Partnership Date Bu Hess Commenced Address Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limite partner. If decedent was a limited partner, provide initial investment $ 6. PA(iTNER NAME T .. PfsRE~°Fffl' 8~,`~I - Ot='.~! ME '. (7p f34YliLRSHIP ~APIY'Af. .. ~. . 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 ath 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 wit 'n one year prior to death or within two years if the date of death was prior to 12-31-82? r ^ Yes ^ No If yes, ^ Transfer ^ Sale ~ Percentage transferred/sold Transferee or Purchaser Con ~deration $ Date Attach a separate sheet for additional transfers and/or les. 10. Was there a written partnership agreement in effect If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .. . It yes, provide a copy of the agreement of sale, eta 12. Was the partnership dissolved or liquidated after thi If yes, provide a breakdown of distributions receive 13. Was the decedent related to any of the partners/ at th time of the dece Ht's death? ...... ^ Yes ^ No ................................... ^ Yes ^ No decedent's death? ................... ^ Yes O Nc by [he estate, including date and amounts received. ......................... ......... ^ Yes ^ Nc If yes, explain 14. Did the partnership have an interest in othe~orporations or partnerships? .......~.... ^ Yes ^ No If yes, report the necessary information on separate sheet, including a Schedule C- or C-2 for each interest. A. Detailed calculations used in the valuation of'ihe decedent's partnership interest. \. B. Complete copies of financial statements or ederal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. It the partnership owned real estate, submit a list showing the complete addresses and estimated fair market values. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ p-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE (It more space Is needed, Insert addltlonal sheets of the same size) RE0.151B E%~ (191) SCHEDULE E coMMONweaLT"oEaENNSnvaNln CASH, BANK DEPOSITS, 8t MISC. I"HERIT"NCE Tax RETURN PERSONAL PROPERTY SIDENT DECEDENT ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by a estate. All property jointlyowned with the right of survivorship must be disclosed on Schedule F. ITEM VHLUCHI URIC NUMBER DESCRIPTION OF DEATH ~ ~ fl ~J TOTAL (Also enter on line 5, Recapitulation) ~ 5 (If more space is needed, insert additional sheets of the same size) REV4W9 E%~ (1b) SCHEDULE F coMMONwEAtTHDFPENNSYtvnwA JOINTLY•OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~~. FILE NUMBER If an asset was made joint within one year of the decedent's date of~de , `il must be reported an Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY-OWNED PROPERTY. `~, ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPE TV Include name OffinanCial inetitufien and bank account numbeilor similar identiJging number.Attach 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. 1 i TOTAL (Also enter on line 6, Recapitulation) I $ / more space is needed, insert additional sheets PEV-15W E%~ (t~9]~ SCHEDULE G INTER-VIVOS TRANSFERS 8 coMNOERTANCE~nzEaETUaNANIA MISC. NON-PROBATE PROPERTY RESIDENT DECED T ESTATE OF ~ LE NUMBER This schedule must be completed and filed if the answer to any of questions t tbrough 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY irvcwoE rNE rvamE Or rnE ranrvsEEaEE, rrvEiPaEUnarvsnivrooECEOErv*nrvo*rvE OnrE Or*au+sEEa. nnncPncocv ov rPE OEEOPOa PE.u ESrnrE. DATE OF DEATH VALUE OF ASSET %a OF DECD'S INTEREST EXCLUSION u'ACaicae~E TAXABLE VALUE 1. ~~ TOTAL (Also enter on line 7 (If more space is needed, insert additional sheets of the same size) March O5, 2008 Page 1 of 2 7412 -Neill Funeral Home, Inc. 3501 Derry Street Harrisburg, PA 171111817 (717)564-2633 Statement Date: Account Number: Director Name: March O5, 2008 741200200212 Stephen J Wilsbach Kelly Yurcic 1 Monterey St. Hershey, PA 17033 The following is a detailed bill for the professional services andlor merchandise arranged for: Michael J. Yurcic Date of Service: February 09, 2008 Funeral Dir & Staff Srvc Basic Professional Service Fee $2,330.00 Total Funeral Dir & Staff Srvc $2,330.00 Care & Prep of Remains Embalming $795.00 Total Care & Prep of Remains $795.00 Fadli0es & Related Srvc Chapel Memorial Service $595.00 Total Facilities 8 Related Srvc $595.00 Transportation Service Vehicle $395.00 Transferring Remains to Funeral Home $495.00 Total Transportation $890.00 Other Goods &Srvc Crematory $295.00 Total Other Goods &Srvc $295.00 Merchandise Herculited Grey Emb Doeskin Cskt -Full Couch $495.00 Total Merchandise $495.00 March 05, 2008 Statement Date: Account Number: Director Name: March 05, 2008 741200200212 Stephen J Wilsbach 7412 -Neill Funeral Home, Inc. 3501 Derry Street Harrisburg, PA 171111817 (717)564-2633 Kelly Yurcic 1 Monterey St. Hershey, PA 17033 The following is a detailed bill for the professional services and/or merchandise arranged for: Michael J. Yurcic Date of Service: February 09, 2008 Cash Advance Certified Copies Newspaper Notice Permit Total Cash Advance Total Service, Merchandise and Cash Advance Charges Cash Received Unpaid Balance Due $72.00 $198.72 $25.00 $295.72 $5,695.72 $(4,150.00) $1,545.72 Page 2 of 2 REV-1511 EX+(12-99)~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF(~ t,,C G P \ ~G ~P ~ \I ~'1 t r I C FILF~NUM~~ ~ r ,6 ~~ "~ Debts of decedent ust be reported on Schedule L c]C~ v NUMBER ut; A. FUNERAL EXPENSES: 1. Cc ~`~ 2,-,~ ~ ~ B. 1. 2. 3. 4, 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Street Address City Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the me as Claimant Street Address City - .___ _._ Relationship of Claimant to Dece nt Probate Fees / Accountant's Fees Tax Return Preparer's Fees Tl1TAI (Alen enter nn lino 0 Flnranifi ilafinnl e State _ Zip /, attach explanation) State ____ Zip ~~~~ . ~~- I ~~ (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) SCHEDULE 1 commorfwEALTH of RENNSVLVnNin DEBTS OF DECEDENT, INHERIT^NCET^X RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF M t C~r ~' ~~ ~p \ ~ 2 ~r. t C ~C ~FI`E NCU~MB~ER~ ~~ Report debits incurred by the decedent prior to death which) remai ed unpaid as of the date of death, including unreimbursed medical expenses. ITEM ~~ ~e TOTAL (Also enter on line 10, Recapitulation) S VALUE AT DATE (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ~_. FILE NUMBER (~~~G P ~ ~ G~^-~P~ ~~-t ~ rl c ~~ ~ -- oo (fit ~` NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING OPERTY 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)] ( I ~~ l~ L~t=~.'vtPw ~C ,vQ ~~4 l1°L~ ~~--~~,G~.~~. ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET tI 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, insen additional sheets of the same size) REV-1514 EX+ (12-03) r' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~~ 1~ 0 \~P ~ ~~~~'~ ~ vl `~1 ~ ~ f CJ ~-C-~ER ~ r ~ ~~ SCNEDIJLE K LIFE ESTATE, ANNUITY & TERM CERTAIN 4 on REV-1500 Cover Sheet 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 obt fined 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 [he 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 81RTH j • 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 co Frequency of payout - ^ Weekly (52) ^ Quarterly (4) ^ Semi-annually (2) 3. Amount of payout per period ........... . 4. Aggregate annual payment, Line 2 multipliq~ 5. Annuity Factor (see instructions) , t Tespon~g (number) ^ ~i-weekly (26) ^ Mor~(hly (12) .4.tJ Annually (1) ^ Other (t ) by Line 3 ......... ...........:~.............. Interest table rate - ^ 3 1/2 % ^ 6% /^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions),f 7. Value of annuity - If using 31/2%, 6 % , 10%, or if variable rate and period payout is at end of period, calcu lion is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and periytl payout is at beginning of period, calculation is: (Line 4 x Line S 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-teaaEx.l3-oaf INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN = REMAINDER PREPAYMENT ~~ //~~ f FILE NUMBEI~~W L RESIDENT ol ceoENT OR INVASION OF TRUST PRINCIPAL I. ESTATE OF ' ~ ~ t ~ (Last Name) (First Name) (Middle Initial) This s hedule 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 inwme or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate ......................`:.........$ 2. Stocks and Bonds ..........................$ 3. Closely Held StocWPartnership ...............$ 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 Lire 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, ay, 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 L C. Corpus consumed ....V .......................................................$ 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) PEV.16d5 E%t p-85) INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION ~ ,If ~~ FILE NUMBE RESIDENT DECEDENT -ASSETS- I. Estate of ~ t c t I C G~ Last Namel (Firs) Name) (Middle Iniliall II. Item No. Description Value 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) G~~~ 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 list) ~~ 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 Cosh/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) $ . ~~ J (If more space is needed, attach additional 8'h x 11 sheets.) tEV~1646 E%+ (3-Bd) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA E TAX RETURN N REMAINDER PREPAYMENT ELECTION ~-~~ 1 ~ ~ ~ INHERITA C RESIDENT DECEDENT -CREDITS- FILE NUMBE ~_ ` I. r Estate of \ C f (C ae (Last Name( (First Nama( (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) ~~ I / 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) ~~~ I Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) 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: `~ 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'/x x 11 sheets.) ~~ REV-1647 EX+ (9-00) SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4a on Rev-1500 Cover Sheet `- ~~ ESTATE OF FILE NUMBER ~~ `~C~P~ Cr _ This Schedule is appropriate only for estates of decedents d ing after December 12, 7 82. This schedule is to be used for all future interests where the rate f tax which will be applic le 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 c~py to the tax return. ~ Will ^ Trust ^;/Other T. Ranefiriariec NAME OF BENEFICIARY ~' RELATIONSHIP i~ ~ DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. ~ ~ ~~t C 1tiJ t t //'' ~D- ~~ 2. i 3. ~, 4. 5. II. For decedents dying on or after July 1, 1994, if a rvlving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appro riate block d attach a copy of the document in which the surviving spouse exercises such withdrawal right. ~ ^ Unlimited right of withdral(val ~ ^ Limited right of withdrawal _ III. Explanation of Compromise otter: IV. Summary of Compromise Offer: ' 1. Amount of Future Interest .......... ........................ ............ ..........$ 2. Value of Line 1 exempt from tax as a ount passing to charities, etc. (also include as part of total shown o Line 13 of Cover Sheet) ... .. $ 3. Value of Line 1 passing to spouse a appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ...................... (also include as part of total show on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal r to Check One ^ 6%, ^ 4. % .......................... .$ (also include as part of total sh wn 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-1646 EX (11-99) SCHEDULE N 'r ` SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12131194) ESTATE OF FILE NUMBER This schedule must be completed and tiled if you ch cked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ..................................... :...... t 2. Insurance Proceeds on Life of Decedent ....................................... ~........ 2. .............................................. `:......... 3. 3. Retirement Benefits ...... 4. Joint Assets with Spouse ................................................ 1~........... 4. 5. PA Lottery Winnings ..................................................: ............ 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. ~, 6c. 6. SUBTOTAL (Lines 6a. b. c. d) ..............,......................:................... 7. Total Gross Assets (Add lines 1 thru 6) ........\ ........................................ 7. 8. Total Actual Liabilities ..................... `.`. ... ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 8. 9. Net Value of Estate (Subtract line 6 from line 7) .... ~~ . ...............:....................... 9. It line 9 is greater than $200,000 -STOP. The estate is nd( eligible to claim the credit. If not continue to Part II. Income: 11. TAX YEAR: 19 a. Spouse ........... ta. ea. b. Decedent .......... 1b. b. c. Joint ............. tc. 2c. ~ d. Tax Exempt Income .. 1d. ' 2d. e Other Income not Ilsted above ........ te. / 2e 1 f. Total ............. 1 f. i r 2f. ~ ` 4. Average Joint Exemption Income Calculation ~ 4a. Add Joint Exemption Income from above: (1 f) + (2f) I + (3Q 3d. 3f. 4b. Average Joint Exemption Income .......... ........... ................. __ ~. ~.__ au .,...._ ...... ....... enn nnn _ erno rr,e ear to i~ ~.,f d(nlnl< to rlnim t credit 1l nnt. continue to Part 1I1. 1. Insert amount of taxable transfers to spouse or $r 00,000, whichever is less 2. Multiply by credit percentage (see instructions) 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 . .............................. . 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 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...... . • 1. 2. 3. 4. 5. .. RELL160.9 E%~!19i) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 0 ELECTION UNDER SEC. 9113(A) ESTATE OF [ FILE UMBER i , s ~. ,C p4i\ G ~ P ~ ~nt- - ~~J l`f S Do not complete this schedule unless the estate is making the election to t assets under ection 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate i rm must be filed for each trust. This electron 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 Q 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 ir~luded 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 orsimilar property is inclu~d 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 arrangeme t 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 thg total value of the trust orsimilar arrangement. A: Enter the description and value of all interests, both taxable and non-taxable, nn snnuse under a Section 9113 (A) trust or similar atrangement. of location, which pass to the decedent's PART B: Enter the description and value of all interests included ira Part A for which the Section 9113 (A) election to tax Fs being made. more space is needed, insert additional sheets of the same size)