HomeMy WebLinkAbout06-04-0915056041046
REV-1500 EX (05-04) C~ICtAt t7Sf ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes " ~- INHERITANCE TAX RETURN
Dept. 280601 '
Harnsburg, PA 17128-0601 RESIDENT DECEDENT ~ 1 ~ ~ U
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
Decedent's Last Name Suffix Decedent's First Name MI
~, ~ '~ ~ ~ -
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security 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)
® 6. Decedent Died Testate O 7~ Attach Co alof Tru ~ a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) ( PY )
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11 ~ Attach SchaxOunder Sec. 9113(A)
between 12-31-91 and 1-1-95) ( )
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
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Firm Name (If Applicable)
First line of address
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Se/cond line of address
State ZIP Code
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Clty or Post Office ~ a ~
I, ~ ~ 7 i _ ~, I'V t
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Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, ana to cne oesi vi niy nii~wicuyc a~ ~~ ~~~~~~,
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.
SIGNATURE O SON RESP~tVjBi~L~ OR FI ING RETURN DATE
F' _ ~ 2 -l''Ca
ADDRESS ~~ ~ tJ~C`~1Cy1~1~C1~C ~ .. 1J1~~ ~4?i~Lr ~,,~ ~ ~ ~j2j~1
SIGNATURE OF PREPARER OTHER THAN REPRESS IVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
15056041046
Side 1
15056041046 J
15056042047
REV-1500 EX
Decedent's Social Security Number
'~-
Decedent's Name: ~ '
RECAPITULATION
1. Real estate (Schedule A) . ............................................ 1. .
2. Stocks and Bonds (Schedule B) ....................................... 2. ~ ~ ~ ~ 9 Z 7
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. 3 ~ qQ '~1 ~ U
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~ Z I 8 `{ . ~~
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) .................................... 8. 1 ~ `1 ~ 7 ~ I
9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. ~ ~. ~~
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 3 (.~ ~ . ~: 3
11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ~ ~ ~ ~ ~
12.
Net Value of Estate (Line 8 minus Line 11) ............................
.. 12. t
~ ~
~' ~ ~ gj
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13.
14.
Net Value Subject to Tax (line 12 minus Line 13) ......................
.. 14.
I ~ ~ 1 (~~
~? 1 ~~ . / c_.~
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 1 ~` `
at lineal rate X .0 ~ 4 ~ ~ U I y ~ ~
16.
~ /~ t~
l~ '.~ I ~ ~ I
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
~ ~
15056042047
Side 2
15056042047
REV-1500 EX Page 3
Decedent's Complete Address: File Number
DECEDENT'S NAME
STREET ADDRESS M \ ~~ _ ~ "5~~~~'
`~ ~ ~- .x-71 c~~~~~? c~ _ _~- ~ -
CITY _ - -
L.- ~. W < <j J C~ ? h~ ~-+ - - _ _ _ STATE -
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
ZIP
~~3~
Total Credits (A + g + C) (2)
D. Interest c`~3r~ S -,OO b ~ (~ ~{
E. Penalty
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.tal Interest/Penalty (D + E )
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.
(~
(4)
(5) ____ ___~ C~7C ~ ~ ~ 7
(5B) ~ ~ ~JU Uzi
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
Yes 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? ........................................................................................................................ ^ ~Y.
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 n_ of 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 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)
SCNEDIJLE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
. - ~1
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 reas~nahla k~~Wip~~o of fho .o~~.,.,... ~..,....
~~~ ~~~..~.. ~Na~~ .o ~iocucu, ~~~~G~~ auuiuunai sneers or me same size)
REV-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
_ti ,`;,
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
1. ~
~ ~2~U~~V~ '"`~ ~~~c._ ~1-1~2ac~'L ~{U~755~I
VALUE AT DATE
OF DEATH
3, ~ ~~ c{ , ~'"7
TOTAL (Also enter on line 2, Recapitulation) $ ~ ` g(~
(If more space is needed, inseR additional sheets of the same size)
REV-7508 EX * (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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 wkh the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER VALUE AT DATE
DESCRIPTION OF DEATH
1. ~, i
1
., ,-,
TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~ ~ ~ a~
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX * (1-97)
ii ySCHE~U~E F
COMMONWEALTH OF PENNSYLVANIA ~~i~~~~ i "sJ7'~i~lE~ ~~`l~i~~~ 8 I
I
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~ FILE NUMBER
J~~ - )
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 I .ADDRESS I RELATIONSHIP TO DECEDENT
A. I`~~ :,
-`~~-
B.
C
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER 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 % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTERESI
,, -, _
/ 4
i
_a ~ -
~11
.... I-~~ I
_ ...,1 _. ~ ~ ._ ~? -~
,- ~ 2 _
~_~ LI~`i :~ ~ _
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!~>1 ~ -~~--~. _
_
i
i
I - }- _
- - -~~_'
I
I
I
i
M
-_~
TOTAL (Also enter on Gne 5, Recapitulaticn) I $ .,..__-
(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
ESTATE OF FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. -.
~~-' .__ .
'A\ 4
B.
1
2.
3.
4.
5.
6.
7.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City
Year(s) Commission Paitl:
State
Zip
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant - - -~~f-1y\l~ L - `~~t~,~C~ --°-~i __
Street Address ~~iT J~C1~~{;~2~, KC.!
-_ - _-
` __ ~..3
City ~~W1 SQL \~~ ~ State ~ Zip ~ ~~ ~7 C~
Relationship of Claimant to Decedent t~jy\~
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
': ~\
~~ ~vn
.~ ..~ ~;:
~ ~ ~?
TOTAL (Also enter on line 9, Recapitulation) $ ~;{,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
SCNEDI~LE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
E
J
SCNEDI~L
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
~
Ar tl
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)J
1.
Z
~~2._ jtc~c~pnc,~~z ,, ~~~-
Lew\5~ ~~. ; P~ ~ ~ 3'~c~
1
.~A~V~L~ G'N ~~ ~~~~~ ~tZ.
J IZ
~ 8~ ~~+J~~c2 ~. c Cc~,~nno f.~S
~~ 1~3~~~
~- 342.- ~~~~~~
f
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
9
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rr~ry Q
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