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Home My WebLink About02-17-09 15056051047 REV-1500 EX 06 05 PA Department of Revenue ( - ) OFFICIAL USE ONLY Bureau of Individual Taxes PO BOX 280601 ~ County Code Year File Number INHERITANCE TAX RETURN Harrisburg, PA 17128-0801 _ RESIDENT DECEDENT -~ ~ ~ ~ ~' ~ 5 ,~ ENTER DECEDENT INFORMATION BE LOW Social Security Number Date of Death Date of Birth ~ ~~ ~~ ~?~° ~ ~,~ ~~ ~od~ v~67 ~ ~i 7 G Decedents Last Name Suffix Decedent's First Name MI ~-~~~~ i G~ l~ h ~' ~ reS i P (If Applicable) Enter Surviving Spouse 's Information Below Spouse's Last Name Suffix Spouse's First Name MI l~ ~ ~ i ~~~ ~ cti ~~ rI ~ Spouse's Social Security Number / LI / ~( ~ / ~ /( ( ' (Q 1 `~ 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 O 4. Limited Estate prior to 12-13-82) O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate (Attach Copy of Will) O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 1J~~ 1 ~ ~-~ i ~ e~~o~T o~.ti ~~h 7/ ~ _3~~ 5~7.~ Firm Name (If Applicable) First line of address ~ ~ S T ~% p1 i~-5 70 ~ l~ ~- ~ Second line of address City or Post Office ~ e ~ ~ ,~ r c Sb~ `9 ate ZIP Code ~> REGISTER~F~LLS USELY ° -`7 `T l - , r Y .I 8 C ~ ~_ ~~~ -_._ i _z:7 .,~ j -~, ; ._ ' ~^ _ _.,i __.,_. _ ---~ C"O DATE FILED C.) ';'-1 ,``~ -~ _,_~ ~i C ~~~5 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, t and compl t . Declarati n of preps er other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU OF E~RSON R PONSIB EIFrI It~2E~U1~1 DATE ~ a n ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE AUUKtSS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J J REV-1500 EX 15056052048 Decedent's Social Security Number Decedent's Name: ~ ~, ~' 1. Real estate (Schedule A) . ............................................ 1. 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) O Separate Billing Requested ....... 6. r " _ • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~~ ~ ~ ~ ~ ~ ~ ~ ' ` ~ ~ (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7)........... ~ • ......................... 8. ~, ~~ ~ ~ -, -, ~r" , _, 9. Funeral Expenses & Administrative Costs (Schedule H}........ L~ ............ 9. ~~ ~ ~ ~~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. • ~ ~ ~ ~~ c. c~, -, ~~ 11. Total Deductions (total Lines 9 & 10) ................................... 11. I ~i i i 7 5.~=~ c~ 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 13. Charitable and Governmental Bequests/Sec 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. 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~% 1E. Amount of Line 14 taxable 15. at Iinea( rate X .0 _ 17. Amount of Line 14 taxable 16. at sibling rate X .12 • 18. Amount of Line 14 taxable 17. at collateral rate X .15 • 18. 19. TAX DUE ................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052048 15056052048 REV-1500 EX Page3 Decedent's Complete Address: STREET ADDRESS a~ ~ STS m ,~s%Q ~ ~~ ><2 ~ CITY File Number (/~~~~ _ /SIC ~ 5~. STATE ~ ZIP 17c~ ~~,~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fiil in oval on Page 2, Line 20 to request a refund. Total Credits (A + B + C) (2} 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 APPROPR I S ATE BLOCK 1. Did decedent make a transfer and: a. retain the use or income of the property transferretl :................................................................................... 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 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 [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)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT t,lAlt Ur low~c~ FILE NUMBER ~~ -~; ~~~ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS ~~ _ FILE NUMBER Sc - All property jointly-owned with right of survivorship must be disclosed on Schedule F. ~ ~ ~~~~ ITEM NUMBER DESCRIPTION VALUE AT DATE 1. OF DEATH TOTAL (Also enter on line 2, Recapitulation) (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 SCNEDIJLE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF ~~ n ~~~~~ FILE NUMBE 'ly ~~ ~~ . Schedule C-1 or C-2 (including all supporting information ust 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) ,;, ~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~~`~5~ 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business 4. SCHEDULE C-1 CLOSELY HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER ti~ ~ ~J~C,~ ~~~ ~ ~ ~ S ~ Sta on Incorporation Date of Incorporation St e Zip e Total Number of Shareholders Business Reporting Year Product/Service A STOCK TYP OT UMBER OF Voting/No -Voting S OUTSTANDING PAR VALUE Common Preferred NUMBER OF SHARES VALUE OF THE OWNED BY THE DECEDENT DECEDENT'S STOCK Provide all rights and restrictions pretaining to each class of stock. 5. Was the d dent employed by the Corporation? ................................ . ^ Yes ^ No If yes, sition Annual Salary $ Time Devoted to Business 6. s 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 COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF ~ ~ ~~ ~~ ~ FILE NUMBER G2S~~ --CX-b~5 _ 1. Name of Partnership ~' Date Business Commenced Address B iness 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 li 5. was a limited partner, provide initial investment $ PARTNER NAME _ _ _ _ A. _ PERCENT OF INCOME PERCENT OF OWNERSHIP _ BALANCE OF CAPITAL ACCOUNT 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 ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. ~ ~ •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es 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. REV-1507 EX+ (1-97) _ ~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF ~C~~' ~ ~~~ I~~ ~ FILE NUMBEC~ ~~- 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-1508 EX * (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH ~. ~ ~ ~CC ~ ~j~~ - z ~ ~} ~- GCC~~ Z ~ ~ y TOTAL (Also enter on line 5, Recapitulation) I $ (If more space Is needed, insert additional sheets of the same size) REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (iCS~ ~~~~~~~C~ 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 ADDRESS A. ~~~~~ ~~~ld~~ ~~~g ~~~~n-~f~s~wr~ ,2~ ~~~r~cS~~~~ ~'a 17~ B. C JOINTLY-OWNED PROPERTY: RELATIONSHIP TO DECEDENT ~~~ LETTER DATE DESCRIPTION OFPROPERTY ITEM NUMBER FOR JOINT TENANT MADE JOINT Include name of financial institution and bank account number or similar identifying number. Attach deed forjointly-held real estate. DATE OF DEATH VALUE OFASSE7 % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDE ' NT S INTEREST 1. A. )~(~' Sin % ~S7 I'~~r~-E' ~~~~~~~~3~ ~ I ~~~ ~ `~~ ~J ~~~' SCHEDULE F JOINTLY-OWNED PROPERTY NU TOTAL (Also enter on line 6, Recapitulation) I S (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 (~~.5 ~ ~ SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ~, C2 FILE NUMBER c~c,F - ~~~5 ~- 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. DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIRREL4TIDNSHIPTODECEDENTANDTHEDATEOFTRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE JMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. Mini nr ~r .....ter ...______ TOTAL (Also enter on line 7, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT tJlHlt VF Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. P~~~p~ s~r~lces , ~e~u 11/,e-s C~S>f ~2~S~S~-~n %~'~~ ~e~ ~~dy?~ ~ ~~ s ~ ~~~ ~~~~ B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid State Zip 2~ Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant __ _ __ Street Address __ __ City State Zip Relationship of Claimant to Decedent - _ 4. Probate Fees 5 Accountant's Fees 6. Tax Return Preparer's Fees 7 FILE NUMBER AMOUNT 3~~ 5 ,~~~ 7_S ~ 7 `' /~ > ~. ly '~~ ~~ _ TOTAL (Also enter on line S Recapitulation) I $ ?,/ _~ ~ C 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 Report debts incurred by the decedent prior to death wh LE NUMBER -~~-~5 ~ remained unpaid as of the date of death. includinn uoraimhu~cnA ,sa~~~~ e,,.,....~,.,. ~1 J ~~~ ~~~~~~ ~Naoc ~~ iiGeueu, insen aaonionai sneers or me same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF _ , J FILE NUMBER ~ NUMBER `~ NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under 1. Sec. 9116 (a) (1.2)] C/~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. ~J 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 (' ~ ~ ~~~(, ~ ,1 ~~ FILE NUMBER ~~~ ~ JU ~~ ~ ~ ~~ I `-'~"j c~ 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 NAMES} 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 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 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) ^ 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 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 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) K:-~-,b~ tX.13-~4, INHERITANCE TAX SCHEDULE L COM NOHER TANCE TAX RETURNANIA REMAINDER PREPAYMENT ~ J ~~~~ RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF 'v~~ 0 ~~~~L~^ ~~~ (Last Name (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of Unincludable Assets .................$ 4. Total from Schedule L-2 ......................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ _ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ __ (Also enter on Line 7, Recapitulation) REV-16d5 EX+ (7-85) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT 1. I Estate of II. Iltem No. A. Real Estate (please describe) on Total value of real estate (include on Section II, Line C-1 on Schedule B. Stocks and Bonds (please list) Total value of stocks and bonds (include on Section II, Line C-2 on Schedule 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 D. Mortgages and Notes (please list) Total value of Mortgages and Notes (include on Section II, Line C-4 on Schedule E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property (include on Section II, Line C-5 on Schedule III. ~ TOTAL (Also enter on Section II, Line C-6 on Schedule L) (If more space is needed, attach additional 8'/s x 1 1 sheets.) INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION -ASSETS- t-f? FILE NUMBER ~ ~~~~ ~~ Value S S S KtV-1646 tX+ ~3-841 INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION ~ ~ RESIDENT DECEDENT -CREDITS- , ~~ FILE NUMBER ~~_ I. Estate of ~~j / WIIJY~ ~~~r (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable fr assets reported on Schedule L-1 (please list) Total u aid lia` ilities $ (inclu on Se ion II, Line D-1 on Schedule L) B. Unpaid Bequests payabl from a ets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of a sets reported on Schedule L-1 (other than unpaid bequests listed under "B" abo e) that are not included for tax purposes or that do not form a part of the t st. Comp ation as follows: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1647 EX+ (9-00) ea COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT t51Alt OF SCHEDULE M FUTURE INTEREST COMPROMISE Eck Box 4a on Rev-1500 Cover Sheet FILE NUMBER This Schedule is appropriate only for estates ofd d t a er ecember 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. Will ^ Trust ^ Other I B f' ' ene Iciaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST RIRTHnnv 1. _......_,.. 2. -- 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. I Summary of Compromise Offer: 1. Amount of Future Interest ........................................................ . 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 3. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ ~ Total value of Future Interest (sum of Lines 2 thru 6 must a ual Line 1 q ) ......................$ (It more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) ~; COMMONWEALTH OF PENNSYLVANIA ESTATE OF I nis schedule must be completed and filed if checked the spousal poverty credit box on the cover sheet. 1 Taxable Assets total from line 8 (cover sheet) .................................... . ...... 1 . 2. Insurance Proceeds on Life of Decedent ................................................ ~~~~ J ~~~ 2. 3. Retirement Benefits ................................................................ ~ l (cJ`? 1v 3. 4. Joint Assets with Spouse ............................................................ ~ S ~ 4. 5. PA Lottery Winnings .................................. . ............................ 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. --{ 60. 6d. 6. SUBTOTAL(Lines6a,b,c,d) ................ ... ..................................... 6. 7. Total Gross Assets (Add lines 1 thru 6) ............ ..................................... ~ v, 8. Total Actual Liabilities .......... . .. ......................... . . ......... 8 L ~' G 9. Net Value of Estate (Subtract line 8 from line 7) ' . ...... If line 9 is greater than $200,000 -STOP. The estate is not ...... . eligible to claim the credit. If not, continue to Part IL 9 ~ ~ ~ ~ ~{ • • • ~ • ~ •. • Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse ........... 1a. 2a . 3a. b. Decedent .......... 1 b. 2b 3b. c. Joint ............. ic. 2c . 3c. d. Tax Exempt Income .. 1d. 2d e Other Income not 3d. fisted above ........ 1e. 2e . 3e. f. Total ........... 1 f. 2f 4. Average Joint Exemption Income Calculation . 3f. 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) _ 4b. Average Joint Exemption Income .................................................... . if line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .................... . 1. 2. Multiply by credit percentage (see instructions) .......................................... . 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . .............................. . 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover chaar 5. SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) ~ ~ I~~~t FILE NUMBER ~~~ REV-1649 EX+(i-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE 0 ELECTION UNDER SEC. 9113(A) ~~~ ~ U ~ ~~~ ~ 10 FILE NUMBER Do not complete this schedule unless the estate is making the elec ion to tax assets under Section 9113(A) of the Inheritance & EstatAct. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election a lies to the Trust marital, residual A, B, B -ass, Unified Credit, etc. . If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arran ement included as a taxable asset on Schedule 0. The denominator is e ual to the total value of the trust or similar arran ement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. PART B: Enter the Part A Total (Ir more space is needed, insert additional sheets of the same size)