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HomeMy WebLinkAbout06-25-09 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~- INHERITANCE TAX RETURN PO BOX 280601 }" ~ 4 ~ ~ ~"~ ~ 7 . ~ ~ Harrisbur , PA 1712$-0601 RESIDENT DECEDENT ENl'ER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth a o 8 ~ a 5/ 5/ 3 5/ • ~ ©d ~ 02_, a ~ ~ 0 8 ©r l ~ .3.3s Decedents Last Name Suffix Decedents 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 O 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) ~ 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 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. LitigationP_roceeds 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 - "~'~IS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ,~ ~ c K ~,• sT u ~t~~ a ~~ 7 ,r_7 8s6 a ~ / y ' 15056051047 Firm Name (If Applicable) First line of address /sa © syE~~ fo ~~ R~ Second line of address , City or Post Office Correspondent's a-mail address ~} L..STii( C?-/7 ~ /~7/TOO . ~d I~ 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. SIGN RE F R LE FOR FILING RETURN DATE ~.~. ~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE State ZIP Code ~~ / 7o.SS REGISTER OF WILLS I~,~ ONLY ~~ - ~ ~' ~ ~ ~ - FILED ~~ . v~~ ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505651047 Side 1 15056051047 J J 15056052048 REV-1500 EX Decedent s Social Security Number Decedent's Name: Q ~ ~ fJ ~ ~ Y,~ RECAPITULATION 1. Real estate (Schedule A) . ................'.......................... .. " 1. ":~ - .. - ~ 4 Q 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~ . Q a 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. • ~ ~ ~ 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. d © Q 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. ? ! ~ ~ 6 sO„ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. Q O 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. Q ,, Q ~ 8. Total Gross Assets (total Lines 1-7) .................................... 8. ? ~ ~ ~ • B Q 9. Funeral Expenses & Administrative Costs (Schedule H) .................... . 9. ~ ' 6 © ©, O 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... . 10. Q ' ~ 11. Total Deductions (total Lines 9 & 10) .................................. . 11. ~ '~ O O „ ® p 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12. .~'~ ~ 8 , 0 ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... . 13. ~ ' ~ , © O * N 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... { . 14. f . 1 ~~ 4 ~ , D O TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 t x le 0 ~~ S ..~Q ~ at lineal rate X O ~ a 7 . . 16. , 17. Amount of Line 14 taxable at sibling rate X .12 . 17. 18. Amount of Line 14 taxable at collateral rate X .15 . 1 g_ - 19. TAX DUE ......................................................... ... 19.~,. *. O7 / ~.8 `~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052048 15056052048 O J REV-1500 EX Page 3 no~arlant'c (_mm~lpte Address: File Number uZ l • o g ~- (~ ~~ 7 DECEDENT'S NAME STREET ADDRESS - - -- _- -- --- - ---__- - -STATE - i -- --_ - --- - - - ZIP CITY C ~ I l ~ /~ C9/~!-~/ s E e Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) ~ ~! 8`~ 2. Credits/Payments ~' A. Spousal Poverty Credit - --_ _ __-- __-_--- _- - - -__ B. Prior Payments .~'~ -_ ____ -- C. Discount - ~ - -- - - - Total Credits (A + B + C) (2) Q , O O 3. InteresUPenalty if applicable S. D. Interest _ _~~~__ E. Penalty ~ ~~` ~ ~~~ - Total Interest/Penalty (D + E) (3) ~S .~~ 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. (4) ~ 0~ ~ , y a 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) .3 0~ .~ T a A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 3 °~ ~ ~ T °~ Make Check Payable L~o: REGISTER OF W-LLS, 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 :.......................................................................................... ^ r,~~~tt b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ Y~ 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 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}]. 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. ~ih ~« t~ LAST WILL AND TESTAMENT OF JOANNE L. STUMBAUGH AUGI~, of Lower Allen Township, Cumberland County, `r and making void any and all other Wills by me at any time heretofore made. I. I direct that my Executor, hereinafter named, shall pay all my just debts and funeral expenses as soon as conveniently may be done after my decease. II. All the rest, residue and remainder of my estate whether real, personal, or mixed and wheresoever situate, I hereby give, devise and bequeath unto my son, RICKY L. STUMBAUGH, of Silver Spring Township, Cumberland County, Pennsyl- vania. In the event that my said son does not survive me, then this gift to him shall be divested and I then give, devise and bequeath my entire estate, whether real, personal or mixed and wheresoever situate unto my Trustee, hereinafter named, for the benefit of my grandchildren, REBECCA STUMBAUGH, JOSHUt~ STUMBAUGH and ABBY STUMBAUGH of Silver Spring Township, Cumberland County, Pennsylvania, who are the children of my son, RICKY L. STUMBAUGH. I direct that my Trustee, hereinafter named, shall take custody of all Raj the assets bequeathed and devised in trust herein, and that it sha~.~have ~rthority .q ~_ ~.ZJ W~~E1 .,J p'.. ~~ n,~• I __v ~/ ~ ~` •~Z i ~....~ ~ J , .: ~~ other moneys and the net proceeds deriv ~ +~i~zvest ed from the sale of assets bequeathed and devised hereunder, collect the income theref rom, after paying all expenses incident to the management of the Trust, and it shall use and apply as much of the net income and principal as may be necessar ~" Y n the sole discretion of F .~ i t` ~~'~ _ ---`~e~~~~~.,:.:. ~~,r,-nom,.........., s~ u s ~. -'. - ~- '~'' ,tt,, .~.~,f-~~. : - :~~~ti~.. ~re~n~i,~ted ~~t~nue until Ghat chic ' d attains the age of twenty-one 2 which time a ( l) years at p yment shall be discontinued, When the youngest at twent tams the age of y-one (21) years, I give, devise and bequeath the assets and principal held in t balance of the net income, rust in equal shares unto my grandchildren, REBECCA STUMBAUGH, JOSHUA STUMBAUGH and AB]3EY STUMBAUGH III, I hereby appoint CCNB BANK, N.A, as Trustee o f the Trust created by this my Last Will. IV. I hereby nominate, constitute and appoint m s Y on, RICKY L. STUMBAUGH, as Executor of this my Last Will and Testament. If my said son should predecease not qualify, or ~"~ ~ - ~~won of Executor, then I hereby nominate constitute and appoint CCNB BANK N.A, as Executor. IN WITNESS WHEREOF, I, JOA~'VNE L. STUMBAUGH this my Last Will and Testamen ~ the Testatrix, have unto ~. t, set my hand ~ and seal this ,~~'` ~ C ,~~~~~~~~~c- , 1990 daY of (SEAL) f,. w'rr,~"F3a~i' thfs Treat, Page Two of Four Pages SIGNED, SEALED, PUBLISHED ands of us, who have hereunto subscribed our names as witnesses at her request, in the vresence of the ~ai~ Tr~4tatrix antl of own}, ntl,nr AC~IV V W L.CLIsI'1~1V 1 t]1VL tiC r 1LAY l i COMMONWEALTH OF PENNSYLVANIA ) i SS. COUNTY OF CUMBERLAND ) We , JOANNE L . STUMBAUGH, KATHLEEN E . LOYD and ,/~Cy ~~' ~ L / /fir ~ :~ ~-,c,:~ , t}ie Testatrix and witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, ,and that each of the witnesses in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no contraint or undue influence. a~";~~=--1 ~'~,~~c-~• ~~-i'~~ - ( SEAL ) tatrix `~" ~'' f ~~~~ ~~ w`~f'~: ~~ ,~ -~ . ~ ~'~'-~' ,..~~ _... ( SEAL ) fitness `~-°'7f~ {-~ti1_:' ( ~. "~ ,~ c=7!~'' ..~~,~iL. (SEAL mess Page Three of Four Pages above-named Testatrix, as and for her Last Will and Testament in the presence =:,. ~_. - ,~, ~; ; .:. _ - ~ ' ern to and ac~cnowle+dged before me by JO L ., ~ , ~~`~ ~., . _~ . . the Testatrix, and subscribed and sworn to before me by KATHLEEN E. LOYD and r 1 ~~- L'~~'~ ~. ~ • -~''~~ ~' ,1 -j ~` ~~ witnesses this ~ ,.~``~ ~` day of ,~~G"'-~'•~ ,,~`~l ,,~C~~' 1990. ;, j '.# ', ,: ~i f, ~' ~' f~ ~~ 1„ ±' Page Four of Four Pages. i_~.,,.. _.r - .~.~.._...~_~ ._...........~.,. ..._.. . REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDt~LE A REAL ESTATE 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. ose~ ....,.,e.~.. whirh is ininflv.nwnPd with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER d ~~~ ~~~~~ a ~ ~ - oyi~ All nronerty iointly-owned with right of survivorship must be disclosed on Schedule F. (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 SCI~IEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must 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. fir more space is neeueu, risen auwuunai sneers ui uie same sice~ REV-1505EX • (1-9~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER ~e,gNntE S,j,~,tw~ ~/~~IIG-~' ~/ - 0 9 - o ~// 7 1. Name of Corporation /l~ State of Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business ProductlService 4. STOCK TYPE Voting /Non-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 7 8. 5. Was the decedent employed by the Corporation? ^ Yes ^ No If yes, Position Annual Salary $ 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ Was there life insurance payable to the corporation upon the death of the decedent? ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy Did the decedent sell or transfer stock of 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. Time Devoted to Business ^ No ^ Yes ^ No REV-1505IX + (13~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER ~a'q,~~ E'- S~1,,~lr,•~,ggc~( a~ - off' - ~ ~/7 1. Name of Corporation ~/~ State of Incorporation --T Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business ProductlService 4. STOCK TYPE Voting INon-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ^ Yes ^ No If yes, Position Annual Salary $ 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ^ Yes If yes, Cash Surrender Value $ Net proceed;; payable $ Owner of the policy 8 Did the decedent sell or transfer stock of 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 addfional 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. Time Devoted to Business ^ No ^ Yes ^ No REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN o~cinGniT ncf~GnFNT SCI~IEDI~LE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER ~o,~Nnr ~ STu,w-~BA~ I~~ ~/ - o ~ ~ o y/ 7 1. Name of Partnership _~, Address , City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code Product/Service 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5 ~ 4 ~ s u ' f .~ ti__ w.t ,,~ n ..~ r f 4s ~ ~~ , f J ;'. , ti ' : s ~ ,: ~ ir ~ ..~. ` 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 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 addresses and estimated fair market values. ff real estate appraisals have been secured, attach copies. Date Business Commenced Business Reporting Year D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) SCFIEDI~LE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER 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) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RFRIf1FNT nF(:FnFNT __ ESTATE OF FILE NUMBER Include the proceeds of I'~igation 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 ,. sg~j,IN'G..S ~}cco ~nr?' w~fT ~~~- ~'/ 08. ~o ~~ss ~o ®a/o f TOTAL (Also enter on line 5, Recapitulation) I $ 7/ ~8 , 8 ~ (If more space is needed, insert additional sheets of the same size) REV-1509 ~c + (1-9n COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY ~o,¢ivNE' J%ulwt ~~ ~ ~ Han 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. N/9 B. C. RELATIONSHIP TO DECEDENT JOINTLY-OWNED PROPERTY: LETTER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT 1. A. DESCRIPTION OF PROPERTY °k OF DATE OF DEATH Include name of financial institution and bank account number or similar identifying number. Attach VALU OF SET INTEREST DECEDEN S NTEREST deed for iointiy-held real estate. FILE NUMBER a?/ - 0 9 -- TOTAL (Also enter on line 6, Recapitulation) a (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF 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, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. ~1 ~~ TOTAL (Also enter on line 7, Recapitulation) ~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCI~IEDI~LE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~~~ sTv- -~,~.~~ a ~ - a ~ - a yip Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,/53~. ys" ~ ~etY-~1~7'1 a~~ ,~v nl~~g ~ ~ vht1~ c~rYt~~~y B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) /~/ C~ ~ • ST.~t/1 /'~/~/x N ~~7 Street Address ~~OZO S/SFCC/ ~~~ ~ ~ ~ • City ~L~~/1~'/ G.S ~ V"12~T-- State ~. Zip ~7w V Year(s) Commission Paid: c?DO _ 2. ~ Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent s'a'/l~ N. ~' ©, p0 4. Probate Fees ~f ®~ ~ O 5. Accountant's Fees ~'~ O ~ O~ 6. Tax Return Preparer's Fees ,~~ ~ ~ p p 7. TOTAL (Also enter on line 9, Recapitulation) $ ~(p pp , 00 Zip (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 SCI~IEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ~m~¢n/nt ~' sT'~tn~I 13 ~ ~~ ~ d - - o /T ue.,,,~+ soh+~ ~nr~~r~p~ by tha dacedent 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) SCI~IEDIlLE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 ~ 1. Sec. 9116 (a) (1.2)] ~~ ck L . S'7'itJ11M ~ ~I Gil s' ~g ~ J ~ D O O Asa o sh~~~~A ~~ - IN~ ~9N, ~ s ~VIzG-~ P19 . ,,a s~ ~ ~ /~ `'~ s'S'O ~' . O O ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II 1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE Q ~ © ~ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ~ ' a ~ 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 SCI~IEDI~LE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shei ESTATE OF FILE NUMBER q /9/1P /V'E Sf U11N1 ~ ~~~ ~ - b / '" D ~ 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 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 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) REV-1644 EX + (3-04) INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN RES DAENTEDECEDENTRN OR INVASION OF TRUST PRINCIPAL FILE NUMBER d/•- Cy ~ - !J y/ T I. ESTATE OF /V'/v` ~. (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 ( ate) 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-1645 EX+ (7-85) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION ~/-~dg - pj/~7 -ASSETS- FILE NUMBER I . Estate of ~TU1 W1 ~~/'9~N~ '~ ~ (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) ®~ B ~ Total value of real estate (include on Section II, Line C-1 on Schedule L) $ ~ 0 ~ • B. Stocks and Bonds (please list) ~ . O C Total value of stocks and bonds (include on Section II, Line C-2 on Schedule L) $ ~ 16 ~ C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) ~, , O O Total value of Closely Held/Partnership (include on Section II, Line C-3 on Schedule L) $ m . ~ O D. Mortgages and Notes (please list) ~ ~ C ~j Total value of Mortgages and Notes (include on Section I I, Line C-4 on Schedule L) $ ~ • ~ ~ E. Cash and Miscellaneous Personal Property (please list) ~~~s1aa6~L- s~(vl nsa-s A c co u rvT, rvt~-T BAN k- -~ o.z I e oo BQo p8 p Yo ~ ? / ©~ • O ~ Total value of Cash/Misc. Pers. Property (include on Section I I, Line C-5 on Schedule L) $ d ~• ~ C III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ p 8.00 (If more space is needed, attach additional 8'/s x 1 1 sheets.) REV-1646 EX+ (3-84) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN _CREDITS- FILE NUMBER a~~ O p o y~? RESIDENT DECEDENT I. ~ Estate of (Last Name) rv~E (First Na ~, • (Middle Initial) Amount ~.oo II. Item No. Description A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) 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) Total unpaid bequests I $ (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: ~. 8 ~ ~.0© ~~ ~© A~pO Total unincludable assets S (include on Section II, Line D-3 on Schedule L) ~ ` ~ ~ III. TOTAL (Also enter on Section I I, Line D-4 on Schedule L) $ ~ ~ (If more space is needed, attach additional 8'/s x 11 sheets.) F(EV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER dAn1N`~' ~Tu- r`'~~~ v1~. o? - cs S - a y/7 This Schedule is appropriate only for estates of decedents dying after December 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 T I Reanpfir_iaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AG E TO NEAREST BIRTHDAY 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. 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% ......................$ ~alcr~ Innli,riP as Hart of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$_ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 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-1648 EX (11-99) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 1?J31/94) wHFRITONr;F TAX DIVISION ESTATE OF ~ FILE NUMBER This schedule must be completed and filed if you 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 ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ..................................... ,....................... 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. ' 6. SUBTOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) .............................................:... 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ............................................ 9. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: Spouse ........... a 1. 1a. TAX YEAH: 1J . Decedent .......... b 1 b. . Joint ............ c 1 c. . d. Tax Exempt Income .. 1d. e Other Income not listed above ........ 1 e. f. Total 1 f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) 3c. 3d. 3e. 3f. YEAR: (= 3) 4b. Average Joint Exemption Income ..................................................... _ If line 4(b) is greater than $4Q,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 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 sheet....... 5• 2. TAX YEAR: 2a. 3b. 2c. 2d. 2e. 2f. REV-1649 ~X + (t-97) SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN (SPOUSAL DISTRIBUTION nr P~nrA~T r1Cl~CIICAIT ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance 8~ Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies 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 arrangement included as a taxable asset on Schedule 0 The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION VALUE Part A Total ~ ~ PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 DESCRIPTION Part B Total I (If more space is needed, insert additional sheets of the same size) election to tax is being made. S~ "due L}S - ~`~' ~t r, ~ ~; .c:~ ~-~x~