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HomeMy WebLinkAbout03-02-09J REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 15056051047 OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN :~ g RESIDENT DECEDENT `~~~ ~ ~~.~_ _.__ ~, ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death I9q I'~,~`~.,~~' o~l~ado Decedent's Last Name Suffix ~; o R ~ ~`: (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Date of Birth o ~ I..~ 1,1~a Decedent's First Name MI .~ .,. p ~ ~ "'l ~ ~ = ~ ~ k..~.,..m,, Spouse's First Name MI _ .~ _ ~. 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) ® 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust d 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 T0: a ime e e hone um Name yt p er -,. ,._,.,y,.~,,.,,.-. ~ -_ ~ , Firm Name (If Applicable) ~ C;~` REGISTER OFI~ ~ E O ' C. First line of address t~ ~~ ~ C ~~# ~~ Second line of address ~~ ~ " _ _ . , ~...._ fV _ - City or Post Office ~k~`~~g~~cS,~~R~ Correspondent's a-mail address: State ZIP Code DATE FILED Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and comple e. DeGar 'on of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG URE OF P S SP SIBLE FOR FILING RET N DATE SIGNATURE OF PREPARER OTHER THAN DATE ADDRESS T~~~i~1~Tf~ ~~ N~~Na~/ n»,k5av.~~- P14 / ~~~ 9 15056051047 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 J 15056052048 ' REV-1500 EX y,/ ,~ / / /~y~ Def cedent/'~s% Social Security Number~`'vy, Decedent's Name: { ~f=/'~ ,~ /v` (.~~/(~/"j ~~ t -~ ~ ! 1 ~~~ ~~~~~ ~ ! ' RECAPITULATION 1 Real estate (Schedule A) .-w. - , . -... D Q . ........................................... .. L a.,,S 2. Stocks and Bonds (Schedule B) ..................................... .. 2. d ~ ' f .~: " 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... 3. ~ ~ .ti ~? t:, s ~ .-u.- ~ ,..~;~. } 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. ~ . ,~ r rte ~ .~, - a ~~ 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ...... .. 5. ~ . ~ ~ ;' ~ (7 ~ Q ; 8 6. Jointly Owned Property (Schedule F) O Separate Biliing Requested ..... .. 6. „ .,x~ x :~~ ~ 1 ~ ~ ~ ~ ~ ^~ ~ ~~,. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Pro ert y ~` (Schedule G) O Se crate Billin Re nested...... P 9 q .. 7. s ` - ~ ~ ~ C ~ Q ~ ~,, 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ~ - f ,°' ~ ~ ~ ~ ~~ ~ ~ ~ Q ~, 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ................... .. 9. ~ ~ ~~, e, , 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. d_. ~;~, ~, 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ' ~ ~ s~ C ,~ ~' 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ` ~ e ~ o 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~ ~ - an election to tax has not been made (Schedule J) ...................... .. 13. fi ~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. , ~ 1 ~ ~ ~4'l.'.~~~ ~~ ~,~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 - - -~ ; ~~ - ~~- 15. ~ €~ ~ 16. Amount of Line 14 taxable m at lineal rate X .0 _ ~ ~1 G' ~ ~ . ~ ~' 16. ~ ~ . ~ " = ~ . 17. Amount of Line 14 taxable - ~''-"~ f - at sibling rate X .12 17. t ~ ~ ~ ~ `~ ' 18. Amount of Line 14 taxable ~ ' ~"' '; at collateral rate X .15 1 g ~ . 19. TAX DUE ....................................................... .. 19. ~ ,.!t .,.~,,,.~f O 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052048 15056052048 O REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME .1 RL~JN~ _~_, __~-0~2~ STREt i nuuitESS 3 3 ~ w~ s~~y_ ~~, CITY v. Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Penalty if applicable `D._ Intere t E. Penalty File Number 'Z ~ Q ~' ~. Q Z q~r ~~~ __ a~HfE ~ I_ZIF 74~~ 1 ~ / 7d (1) 3 G,C~D r.~~ __ Total Credits (A + B + C) (2) ~~ , aD_ Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) ~0 ~ (~ D (4) (5) (5A) (5B) ~~ ~o~ i ~ Make Check Payable to: REGISTER OF WILLS, AGENT ~. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedeht 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 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)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCFIEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. ~n IIIVIC S~1dGC IS IICCUCU, II WCII AUWUUIIQI 511CC1A' UI IIIC Sd1I1C SILO REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ll~~N~~ CYol~ ~ Z I o 8' - c~ -z 9 b All property jointly-owned with right of survivorship must be disclosed on Schedule F. pr more space a neeaeo, insert aaartional sneers of the same size) ( REV-1508 EX • (1-97) SCHEDULE E p ~+ COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, Cr MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMI3NK ~Rz~N~~' C~-~1~~ z j d ~ - a -Z ~ ~ 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. j~~r C~~l~ C~~~~~I%~' ~i~v ra) s~91-~5 ~'a2/~' ~' 7p©, o© TOTAL (Also enter on line 5, Recapitulation) I S ~~~~ (If more space is needed, insert additional sheets of the same size) REV4509 EX+i1-9~ SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER I ~klvi~ ~, m4~, ~ ~ 0 8' -- o z 9~ If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME a. p opt 1 NlGIC 5, ~~- ~,~ ~' a. y"~fFJV~yTk~ f~~IvND/V ~. JOINTLY-OWNED PROPERTY: ADDRESS RELATIONSHIP TO DECEDENT lle ~~ tip, ~,~a~v,~~ R>b. S o.~/ ~I~t~~Hf1i~ I CS,b'!1/elr~ P~ 17vy~ ~1~~ 5 ~ c~~'~,, YR~ ~ `70 / 9 ITEM UMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET °k OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST JDY~S TOTAL (Also enter on line 6, Recapitulation) I S ~ / ~~ ~~ (If more space is needed, insert additional sheets of the same size) J REV-1510 E%• (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE. THEIRRELATIONSHIPTODECEDENTANDTHEDATEOFTRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET '% OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ,. pR u u ~'~ ~'~~4~- ~~ ~~ ~~f e., A ~ ~ ~~ ~, ~g~ U a ICD% 3 7 ~ ~~',bJ ~N~V~~~fy ~~'~~x~sL~ ,~ts~y~~~'1~~.v5) ~~~rR~~~ ~ ~~5~,1~~y P ~ ~ ~- c sc~ f ~~~~~tr-t~~ TOTAL (Also enter on line 7, Recapitulation) 13 3 "7 ~ 3~ ~fJ ~1 t~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) F' ~, • ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER I Rte lV~ C~~/~/~ `z P o B' " O Z 9~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ ~ s r~RK s`r ~'~ A t,~S p~ ~ ~ 7d ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number{s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. ~ Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) ,. Claimant Street Address ' City State Zip Relationship of Claimant to Decedent 4. Probate Fees ~ i~~ ~~~~ ~I~JV fJ ~-~ - ~~4~~s/ F~~/L ©f, ~~~"'t+'S (~~~ Q I/ 5. Accountant's Fees 6. Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) I $ Q i ~ ! 3~ ~O (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12.03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ll~riyL' C ~R~ ~z ~ o ~ -. e z. 9 ~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~arc~i~ J9ll~ti:~v rk'J°, ~ Ca;rn Bk~~~~~U ~~viu ry ~~yicG'' c~ ~~-~.~.~ l 7,1 ~ ~~ rMA,vy 7~owk..R.S -Rt'NY ,~3~. 4~ 9 TOTAL (Also enter on line 10, Recapitulation) S (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER l R ~ N~~' C~c~R~ -Z ~ o ~ - o Z 9 ~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP 70 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)j dl ~l'~jl~ 1. ~ ~ 1~l J ~~ ICS' S, C-C~~ R •5 ~ ~~ i~i~c~~N1e5 ~~~C~, ~~- ~~~~5 ~, ~ ~~~k rye ~~~~w~~ P~~~`N~~'~ ~~,/~ ~~ CRR~DL. ~~, . ~ ll~L~ 5 ~ ~QRG-~ ~'~ f `Tb~ ~ 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 IIVHICH 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, insert additional sheets of the same size) LHJk=^lVL"LL-~ANI/^ 1 C 0~ TR1rN~ M. Gc)RA r ~ ~ , LAW OFFICES ANTHONY B. PANAWAY WILKES•BAI7BE, pA. T, TRi:Nir R4. GURA, a~ the Tawn~sh~.p a!~ PLd.~n.a, Luzenne Caun~y, Penn.3y.~vantia, be~.ng a~ ~saund and d-i.~sna~s.i.ng m~.nd, memany and unden~s.~and.Lng, da mahe, ~ub.2~:.ah and •deekane ~h~.b ~a be my La~s~ W~:2.2 and Te~~amen~, heneby nevaFz~.ng a.e..~ Wti.E:2~s and Cad.c;e~..2.~ hene~a~ane made by me, T'T~D.~ T: T g~:ve, dev~:~e and bequeath a.2.~ ag my eb~a~e, nea.2, ~en.aona2 and mtixed, a~ wha~~saeven h.~.nd and u-hene~aeven ~ti~ua~e, ~a my hug band, S~an.2ey ~. Gann.. llaweven, ~.n the even ~ha~ meJ liu~sband ~shaukd pnedeeea~se me, ~h,en and ~,n ~ha~ even, I d~.nee~ ~ha~ my ed~a~e be dtid~a~sed a~ ab ~a~2ow~a: (A) 7 d~:nee~ my rrxeeu~an~, hene.i.na~~en named, ~a d e.E:.2 a.~.E' ag my nea.F? e.~~a~e ass aaon a~ may be eanven~.en.2y dane a~.ten my death and T d~,nee~ ~ha~ the ~naeeeds o~ aa~,d .~a.2e an da.2eb a~ my neat ed~a~e be equ.l'.1'y d~,v~.ded between my daugh~en, Jeane~~e and m y .a an, Vam.%ni,c~, ~ hane and ~ hane a.E'~.Ize. I B) A.~.2 a ~ the ne.a~, ned~.due and nema~,nden a g my e.a~a~e, I g~.ve, dev.Lde and bequeath ~.n equa.2 dhane.a ~a my daugh.ten, Jeane.t~e, and my .pan, T7am.~n~.eh, ahane and ~shane a.2~.lze. T~T~'M 'T I : T heneby nam~,na~e, ea n~s~~,~u~e and ap}~a~.n my hub band, S~an.~ey 7) . Gana, ass b a.2e ~xeeu~on a ~ ~h.~d my Lae w.t22 and Tea~amen~. Haweven, .tn .the event ~ha.t my hu.aband .shau.E;d ~nedeeea.ae me, then and .gin ~ha~ even, "i nam~.na~e, eanb~~,~u~e and appa~.n~ my daugh~en, Jeane~~e, and my ~aan, Vom~.n-i.eFz, a.d l:xecu~anb a {~ ~h~..a my La~~ G1.L.2.2 and Te.~~amen.t. 1 ~un~hen d~.nec~ ~ha~ na ~~,duc~.any ac.t.ing heneunden .aha.E;,E be nequ~.ned ~a b.L.Ere a band an pads any .aecun,L~y ~,n any ~un~,.bd.i,c~~.an ~.n wh.ich .aa~.d ~~.duc.Lan y ~ laa.E:.2 act . TN tUITN~SS WH~R~OF, I, TR~N~ M. GORA, the Teb~a~n~.x, have ~a ~11~..a my La~~ W.i.2.~ and Ted~amen~, .ae~ my hand and .bea.~ ~h~.~ 23nd day o~y Ju.~y, i97G. ~ ~~~ (SEAL) S~.gned, ~sea.2ed, pub.~~,~shed and dec.2aned by the above I named Tnene M. Gana, a~ and Uan hen La~,~ tV~..22 and Te~xamen~, ~.n the pne~s ence. o b ups , wha have heneun~a d ubd cn~.bed aun name.a a~ hen neque.3~ as w~.~ne.a.ae.a ~hene~a, ~.n the pne~ence o~ the ~ ~a~.d Te.a~a~n.i:x and a{~ each o~hen. I %c: ens ~ nedd .ti ned~ ned - ~[ :~-~ R