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Home My WebLink About04-30-09J REV-1500 EX (06-05) PA Department of Revenue Bureau of individual Taxes PO BOX 280601 15056051047 INHERITANCE TAX RETURN Social Security Number r,....._ v~wDate of Death ~, , Decedent's Last Name Suffix (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix BICIIW- .~°. - r:. - ~ ~' - - C'S~. ` ~ Spouse's Social Security Number ~r, >.~.-y.~.- OFFN~AL USE-ONLY County Code Year File Number Date of Birth ~~~ v~y Decedent's First Name MI L _~ Spouse's First Name MI ICI W ~~ II ~` THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~.-.~. _ _~.. ~. ,~,. ~ REGISTER OF WILLS FILL I N APPROPRIATE OVALS BEL04V 1. Original Return O 2. Supplemental Retum O 3. Remainder Return (date of death O 4. Limited Estate O 4a. Future Interest Compromise (date of prior to 12-13-82) 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 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 TO: Name Daytime Telephone Number tv ,. ~ ~ {,~ Firm Name (If Applicable) l./" I V ' ~ ~ • , ner, REGISTE ~` US NLY ~ m W ~} ~ ~{ ~x } 'r ' 77 p ' .~f ~, First line of address ¢~~ C ~ ``. 1 :2 ~3'~ 5~1 V A L L ~. ~- (n~O:d p~ p~~/ ~;~ o°T' ~ - `> Second line of address ~~ ,~ } W -, r ~ ff1 i s ~ City or Post Office l State ~' ZIP Code DATE FILED - ... ,~~ _ <~. w Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI E OF PERSON~ESPO~IBLE FOR.EILING RETURN DATE siw.- 1. ~ . i28S ~ V~4tt~ywooJ Die/ ~~ , W ~O B R-~,D G~, ~/~4 Z2 t ~' Z SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 J 15056052048 REV-1500 EX Decedent s Name Decedent's Social Security Number ~ ~ ~ ~ ~ ~ ~.`~ RECAPITULATION 1 (~~~1% 1. • ..... Real estate (Schedule A) ...................................... . . . kr ~ - r;c~ ~~ 2. Stocks and Bonds (Schedule B) ....................................... 2. ,~ ':~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. a"A•~ a~.-:..~ ~,. 4. ..... Mortgages S Notes Receivable (Schedule D) 4• "O'~~ ~~ ~ ~ ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... . 5. , { 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... . 6. ~ b 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested....... . 7. ~ ~~ 7 ,, 8 4 ~ ~ a ~ ~ • 8. ) ................................... Total Gross Assets (total Lines 1- . . 9. ::~ Funeral Expenses & Administrative Costs (Schedule H) ............... `~ ...... 9. .. • ~ a 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......... ...... 10. • 11 ~ ~ ~ ~ ~ ~ 11. Total Deductions (total Lines 9 & 10) ............................. . ...... • ;._ . . 12 2 2 ! ~ ~ • ~3 12. Net Value of Estate (Line 8 minus Line 11) ........................ . ...... 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 ~. d ~' D .................. an election to tax has not been made (Schedule J) . ...... 14 ~ Z / / ~ 6 / • ~~ 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. . ...... 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_ . 15. 16. Amount of Line 14 taxable ~t L at lineal rate X .0'~ ~a / v ~ • $ 3 16. 17. Amount of Line 14 taxable 17 at sibling rate X .12 " . 18. Amount of Line 14 taxable ' 18 at collateral rate X .15 . 19. TAX DUE ...................................................... ... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT •. ~ o z ~ *r~ Z O Side 2 15056052048 15056052048 REV-1500 EX Page 3 Decedent's Complete Address: File Number O ^ DECEDENTS NAME `` // STREET ADDRESS - N1~O~V02 C~4Q~ ~9as ~ . T,~i~o~ 2~ CITY M~ c~6d,N I cs v~(, _ STAT ZIP j 7 aSv Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. fnterest/Penalty if applicable D. Interest ~~/y SS E. Penalty Total Credits (A + B + C ) (1) ~F`~,o~.~12 (2) Total InterestlPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII 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. (4) (5) (5A) (56) ~ j, ~ 3 x.2,7 Make Check Payable fo: 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 o 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 oax~rred 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? .................................................................................................................. ,~,/ ...... ^ Ill, IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .. ~ . _ ~ ;~'.,.~,~~,. _ ,t,_r;,~. For dates of death on or after Jul 1~, 1994 and before Janua ~ 1, 1995 _ ~ I .. < ; n~,; ~ i1,~~ ~~~ z~ ,; ~ ~' { ,<, ~ , Y ry ,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)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE E ~,~TMOFrr~w,~, CASH, BANK DEPOSITS, & MISC. """"`~ T""'~" PERSONAL PROPERTY ESTATE OF A ' ~~~i-/t'GG C . n^D Y FlLE NUMBER D,~i~2S Inckbe the proceeds d ingalion and the dale the proaeedsGwere n3ceived by the estate. AM goperly joint~ownsd wMh die riDht d nrvironihip mwt be dNebeed on ScMdWe F. ITEM VALUE AT DATE NUMBER DESCR{PTION OF DEATH ,. ea s ~,v o , 83 No Pf~2.SaN~ t PQ.oP~,~~'l TOTAL (Also en{er on line 5, Recapitulation) ~ S (If more space is needed, insert addiiti~anal sheets ~ ~e same size) REV-1611 EX+ (12-99) . T COMMONWEALTH OF PENNSYWANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scN~ou~ N FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS C'.L~~~NG fC ~ . CDC ~ ..~......~o~.. b?.~~$ Debts of decedent must be reported on Sclleduk I. .ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: /N ~ S ••~ ~ ~ ~V N~ ~ ~ ~M ~ ~ ~ ? ~2 O O i. 1 ~ 0 3 MA2~r ST2 ~?' ean~P ~~~-~-~ P~41~aj~ s. 1. 2. 3. 4. 5. 6. 7. (K more space a needed. insert additional sheets of the same size) ADMINISTRATIVE COSTS: Personal Represerdative's Commissions Name of Personal RepreeeMative(s) SociM Secrufty Numtrer(s~IEIN Number of Personal Representatives SVeet Address Cih/ State ~ Year(s) Commission Paid: Attorney Fees Fammilyy Exempdan: (H decedent's address is not the same as daanant's, attach explanation) C Street Address ~ ~ Relsdonship of ClaYnent to DecederN Probate Fees Acxoluttant's Fees Tax Realm Preperer's Fees TOTAL (Also erner on lute 9, Recapitulation) I ; 3, ~2, a~j S~ ~~~- ~ ~ ~~ ~c~- 20 ~ ~ ~2~3~