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Home My WebLink About08-18-09 (3)15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Bureau of Individual Taxes a v.~ Po6oxzaosot INHERITANCE TAX RETURN , Harrisburg, PA 17126-0601 _ RESIDENT DECEDENT ~ O MI a A MI 4~ '"° THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ ~ REGISTER OF WILLS 2, „, , a_ m FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return ~ O 2. Supplemental Return O 3. Remainder Return (date of prior to 12-13-82) O 4. Limited Estate ~ O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return death aRer 12-12-82) O 6. Decedent Died Testate - O 7. Decedent Maintained a Living Trust ® 8. Total Number of Safe Depc (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O it. Election to tax under Sec. ! between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TA%INFORMATION SHOULD BE DIRT Name Daytime Telephone Number t R S d' r 4fi* 't' t#} ~ ai R.yx $9AA~ a 9... a f i i 4 2'# 8029 $4~ 4fd ~n42 ~ ` ' k ~ ~ ~ ~ L Q~ ~N ~!~ "~ E ~N ~ ~ s7 7s~a ' i ? ! i ~ ~ ,_. _ . , a . . , ,. ,,: ... ..x. w. ,... a .. Firm Name (If Applicable) . . , ' REGISTE ~ E I R OF7 U5 >r.*q.x. ax :c a,rs4T.:t n.~a x-:.y...e ae ;,t 9... Y . 4 'sr»q q ..#a. . .n r:t:l.+ ~ T.~ First line of address r'!`>` ¢ ggp c t i e n 4 bb ' ' 4 ~ ` ~ ~ 4 a "' a y t. ~.' " .i 1 ~ LI ; ~ ' t;-~(,:l n-r, ~E R ' a ' ~(f~ t 0 P l ~ C~ Ea ~ ~C / a ' 1 ~ e, , . .,' ..t 4 n a µ x .ae _.f, ..,., ~l , 4a - _U Second line of address ;nom ,~ y p ttx> 1+ j i 4• t . 44wxia t •I t .V y S t n + I 9 n~~, t.. ' y. ~ :. DATE FILED Clt~ or Post Once State ZIP Code a + Correspondent's a-mail adtlress: DATE Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my Knowletlge and belief, it is true, correct and CAmplele. Declaration of preparer other than the personal representative is based on all information of which preparer has any kno ledge. SIGNATURE FOR SIGNATURE OF PREPARER OTHER THAN DATE Boxes 13(A) T0: n ~" _~ A., '~ r ~ l-7 '_J ADDRESS 15056051047 Side 1 15056051047 J 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) . ........... ....... ......... ........ . 2. Stocks and Bonds (Schedule B) ..... ......... ......... ........ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. , 4. Mortgages & Notes Receivable (Schedule D) ...... ......... ........ . 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... , 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Se crate Billin Re u sted 1 3 are.>~: i ! a Y':! ~ ~ aid z.. y: 2 « *e~rt;` r r +~_ 4 y xis FYMFS 4%y}y~v Gats F 5 7 9i y;,~31' 4 6 ty eG. 8. Total Gross Assets (total Lines 1-7) .................................... 8. r~ •. _ ' ~i, ,~ 9~ Funeral Expenses 8 Administrative Costs (Schedule H) .... . ................ 9 ' zd ~i~zaxariin°'+xt 10. Debts of Decedent, Mortgage Liabilities, 8 liens (Schedule I) ................ 10, f ~. 11. Total Deductions (total Lines 9 & 10) ................................... 11. ;-- ~. , 12. Net Value of Estate (Line 8 minus Line 11) ....... .......... ........ 12 ~ ' ~ , 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which •i>.$sx d> `°"'' ")# an election to tax has not been made (Schedule J) ........................ 13. ,. 4 ~ ~ ' 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ; <,.,.'... ' - - - ,...¢...a.r. ..: s : ~ 15. 16. 17. 18. 99. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~~ 1.5056052048 Side 2 15056052048 t npr :,i R3 ~. SF*>ti• O J REV-1500 EX Page 3 Decedent's Complete Address: File Number __ CL~P,~NG~_ KFN~~TE+_ LEBo _ _ _ _ STREET ADDRESS _ _ __(¢t3 CUPPER__CtRCLE __ - _ _ _ _ PrR - - -- -- _ __ - - _ - Pf+ _ _ - _ _ CITY /r ~~C ~ - -1 STATE 1, ZIP ' ~O` Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) ~~ (1) 2. Credits/Payments A. Spousal Poverty Credit __ _-_ B. Prior Payments C. Discount - Total Credits (A + g + C) (2) 3. InterestlPenalty if applicable D. Interest E. PenalTy --- __-- _- -- Total lnterestlPenalty(D+E) (3) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT - b PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE B 1. Did decedent make a transfer and: Yes N a. retain the use or income of the properly 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, benefts 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? .................................................................................................................. ...... ^ ~e IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 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 fw the use 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 spc [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 d filing a tax return are still applicable even if the surviving spouse Is [he 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 adoptive parent, or a stepQarent of the child is zero (O) 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) Qerc 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 (/2 P.S. §9116(a)(1.3)]. A Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. THE RETURN. suNiving spouse is zero (0) percent sure of assets and natural parent, an except as noted in is defined, under REV-1502 EX+ (6-96) SCNEpYLE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or ae a tenant In ramman must be reported et faV market value. Fair market value is defined as the price at which p o exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the releva Real property which la Jolntly~owned with right of survivorship must be dlsdosed on Schedule F. perty would be fads. ITEM NUMBER DESCRIPTION VALUE' OF T DATE EATH 1. TOTAL (Also enter on line 1, Recapitulation) S (If more space is needed, insen additional sheets of the same size) REV-1503 EX+ (6-9a) SCNEpULE B COMMONWEALTH OF PENNSYLVANIA STOCKS St BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property )otntly-owned with right of survivorship must be tllselosed on Schedule F. ITEM VALU AT DATE NUMBER DESCRIPTION OF EATH 1. TOTAL (Also enter on line 2, Recapitulation) $ (g more space is needed, ireerl additlonal slleels of the same size) REV-1504 EX+(7-97) SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR IN RESIDENTEDECEDEN7RN SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting inormation) must be attached for each closely-held corporation/partnership interest of the decedent, t her than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALU ''.A T DATE NUMBER DESCRIPTION OF EATH 1. TOTAL (Also enter on line 3, Recapitulation) $ (It more space is nestled, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCHEDULE C-1 CLOSELY-HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on 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 Product/Service 4. x: #> } riy BIR Mkt tt 4 ui 3e ' 4 k .s-iR~ i~se tAYa f 1, 9ti i t t1 e *~} x+ •y5n#~ ~ i Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was 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 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 D 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 (Porto 1120) for the year of death and 4 precedi~g years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate a preisals 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. ^ No (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (e-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCETAX RETURN RESIDENT DECEDENT SCNEDYLE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER Name of Partnership 1 Date Business Commenced . Address Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number Type of Business 3 ProducUService . Decedent was a ^ General 4 ^ Limited partner. If decedent was a limited partner, provide initial investment $ . 5. 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 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 f death was prior to 12.31.82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration Attach a separate sheet for additional transfers andlor sales. Date 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 Ilquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distrtbutions 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 corporetions 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 C. If the partnership owned real estate, submit a Ilst showing the complete addresaJes and estimated fair market values. If real e: been secured, attach copies. D. Any other Information relating to the valuation of the decedent's partnership interest. ^ No years. isals have REV-1507 EX+ (1-97) SCHEDULE D MORTGAGES & NOTES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property )ointlyrowned with right of survivorship must be diaelosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF EATH 1. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) PEV-1508E%•11dn SCHEDULE E CDMMDNWEALTH OF PENNSYLVANIA CASHr BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DEC DENT ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property JoiMlyowned whh the ripM of survivorship must a die bsed on Schedule F. ITEM ALUE AT DATE NUMBER DESCRIPTION OF DEATH MbN~y MARKET A~cc~vMT' - pNC T3if-n!K ~7 /y, 3~ , TOTAL (Also enter on line 5, Recapitulation) S 7 /y 3s (If more space is needed, insert additional sheets o t e same size ~~,xarx.nan SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY•OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER k an risk was made Jo1M adtllin one year of the dscedak's deb of loth, k must be roporbd on Schsdub G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELA IONSHIP TO DECEDENT A. B. C. JOINTLY-0WNED PROPERTY: IETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name offinandel instiWam and bank eceounl number a similar idenlifyinB number. Atlach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed fajdntly-held real elate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL,(Also enter on line 8, Recapitulation) S (li more space IS needed, insert atltlitional sheets of the same size) REV-1511 EX+(10A6) SCNEpYLE N FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A OUNT A. FUNERAL EXPENSES: 1 ~6, y7. 73 R. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) _,._ ,__, Street Address _ Ciry State Zip _ _. Year(s) Commission Paid:._ _. - 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as Gaimant's, attach explanation) Claimant })ENNlS f~ I..FBO ~ 3, OO. ~ Street Address ~t 3 COPPER CtRC~E __ ___ p~ City CRRL(SLE State Lt'LZIp l7olS Relationship of Claimant to Decedent _, y~V _ __ __ _ ~ ~3• 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 9 '~~ , 73 (If more space is needed, insert additional sheets of the same size) REV-1512 EXi (12-03) '~ SCHEDULE I I DEBTS OF DECEDENT, ~ COMMONWEALTH OF PENNSYLVANIA ~ INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT , ESTATE OF FILE NU BER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical ezp nses. ITEM VAL E AT DATE NUMBER DESCRIPTION 0 DEATH 1. TOTAL (Also enter on line 10, Recapitulation) $ (Ii more space is needed, insert additional sheets of the same size) REV-151$ EX+ (9-00) SCHEDULE 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 Llat huatee(s) OF S TATE I TAXABLE DISTRIBUTIONS ]include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COV R SHEET It NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (It mare space is needed, Insen additional sheets of the same size) REV-1514 EX+(12-03) SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single fife, joint or successive life estate and term certain calculations. For dates of death ri or 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 ^ Life or ^ Term of Y ears ^ Life or ^ Term of ears ^ Life or ^ Term of ears ^ Life or ^ Term of ears ^ Life or ^ Term of ears 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 Ilfe estate (Line 1 multiplied by Llne 2) ............................. .........$ • it i I i.:., xt~'V/-MPS. }' iii ~~Iyrj]}]~~ ,i.. - • ~a~jy,p~.j g{IR ii,5y~ wi xt i t• y ^ Lila or ^ Term of ears ^ Life or ^ Term of ears ^ Life or ^ Term of ears ^ Life or ^ Term of ears 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 3112%, 6%, 10°l , or it variable rate and period payout is at end of period, calculation is: Line 4 x Llne 5 x Line B ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Llne 5 x Llne 6) + Llne 3 ................................................. .$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedu~es 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 thr ugh 18. (If more space is needed, insert additional sheets of the same size) REV-0644 EX + (3-04) INHERITANCE TAX I i SCNED~lLE L COMMONWEALTH OF PENNSYLVANIA ~ I IN RESIDENTEDECEDEN TN OR INVAS ON Of TRUST PRINCIPAL FILE NUMBER I I. ESTATE OF (Last Name) (First Name) (Middle Inltiaq This schedule is appropriate only for estates of decedents dying on or before December 12, 19 2. This schedule is to be used for all remainder returns when an election to prepay has been filed under the pro isions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to re rt the invasion of trust princip I . II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wilis on (Date) 8. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years i ncome or Annuitant(s) of election or annuity is ayable C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stacks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. CashlMisc. Personal Property ................$ 6. Totalfrom Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ............ . ..............$ 2. Unpaid Bequests ...........................$ 3. Value of UninGudable Assets .................$ 4. Totalfrom 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. Irnasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years ncome or Annuitant(s) corpus or annuity is p yable 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, Recaptulation) REV-16d5 E%+ (~.esl INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION ' INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER 1. Estate of (Last Nama) (First Nome( (Mid le Initiall II. Item No. Description V lus A. Real Estate (please describe) Total value of real estate S (include on Section II, Line C-1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds S (include on Section II, Line C-2 on Schedule L) 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 L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C-d on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Section II, Line C-5 on Schedule L) Ili. TOTAL (Also enter on Section II, Line C-b on Schedule L) $ (If more space is needed, attach additional 8'/s x 11 sheets.) REV.1646 EX+ (3-84) INHERITANCE TAX ' SCHEDULE L-2 , COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -CREDITS- FILE NUMBER I. Esftafe of (last Namel (First Nome) (Middle n itial) II. Item No. Description Amo o f A. Unpaid Liabilities Claimed against Original Estate, and payable From assets ~i reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L B. Unpoid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (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: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL Also enter on Section II, Line D-d on Schedule L) $ (IF more space is needed, attach additional 8%z x 11 sheets.) REV-1647 EX+ (9-00) SCEIEDIifLE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA ~. INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER This Schedule Is epproprlete onty for estates oT decedeMs dying after December 72, 1982. I This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest Jests in possession and enjoyment cannot be established with certainty. I Indicate below the type of instrument which created the future interest and attach a copy to the tax return. I~ ^ Will _ ^ Trust ^ Other I. Beneficiaries ~ NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH A NEARE E TO T 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 withdraw I within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the survivi g spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: 1V. 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 pan 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 Gheck 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) ......................$ ill mnm ¢n°CO i¢ ,1GG(I¢d IOROM °1~fII}I/IOAI SIfAP}S M rI1P RAf11P. CIJ81 ~_ REV-tsaa EX (11-99) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01!92 TO 12131!94) i INHERITAN E TAX DIVI ION 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. a 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6d. 6. SUBTOTAL (Lines 6a, b. c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilitles .............................................................. 8. 9. Net Value of Estate (Subtract line S from line 7) ........................................... 9. 1/line 9 is greater than $2tN1,000 -STOP. The estate is not eligible to claim the credit. I/not, continue to Part II. Income: a. Spouse ........... b. Decedent .......... c. Joint ............. tl. Tax Exempt Income . . e Other Income not listed above ....... . 4. Average Joint Exemption Income Calculation 4a. Adtl Joint Exemption Income from above: + (3t) 4b. Average Joint Exemption Income ..................................................... _ 1. {nsert amount of taxable transfers to spouse or $700,000, whichever is less ..................... t 2. Multiply by credit percentage (see instructions) ........................................... p. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure 1n 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 Yo 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....... 6. REV-649 EX.(1.9p COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 0 ELECTION UNDER SEC. 9113(A) Do not complete this schedule unless the estate is making the eledfon to tax assets under Section 9713(At of the Inheritance & Estate ax Ad If the election applies to more than one trust or similar arrangement, a separate form must be filed for each tmst. This election applies to the Trust (madtal residual A B By-pass Unifi~d Credit etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: i a. The trust or similar arrangement is listed on Schedule 0, and I L. TFe oli i ni 16e In M n mild nl i nlnmA i uNnln nd n .. C..6..A. A.. /1 ~ then the transferor's erso V y y, yV ., V V ~ ,V yV I .. ,V y V ~ ro„ 4j ~~~ aJ,c~ ~„ .,~, ~cVU~G v~ p nal representative may specifically identify the tmst (all or a fractional portion or percentage) W be inducted in the election to h 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 c 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 frad the amount of the trust or similar anan ement included as a taxable asset on Schedule 0. The denominator is a ual to the total value of the trust or simil r e such trust or hedule 0, the n is equal to arran ement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to h survivin s ouse under a Section 9113 A trust or similar arran ement e decedenPs OESCRIFTION VALUE Part A Total $ PART B: Enter the descri lion and value of all interests included in Part A for which the Section 9113 A election to tax is bet made. DESCRIPTION VALUE Part B Total (If more space is needed, insert additional sheets of the same size)