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HomeMy WebLinkAbout08-19-09 REV-1500 EX (06-05) PA Depadment of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg. PA 17128-0fi01 ENTER DECEDENT INFORMATION BELOW Social Securit Number Date of Death Date of Birth ~ ~ 3 ~a ~ 0 ~ ~ ~Ta~ ~ ~ ~ ~ ~r ~ Decedent's Last Name Suffix , Decedent's First Name MI ~ ~ E L (If Applicable) Enter Surviving Spouse's Information Below , ,. Spouse's Last Name Suffix Spouse's First Name MI P E A ~ 8 R F o t~ .. ~ Souse's Social Securit Number ~~~ ~ O a THIS RETURN MUST BE FILED IN DUPLICATE WITH THE D REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received CORRESPONDENT- Firm Name (If Appli xeage roxo-sea xxe}em, (hx,.... ~t....,.r....> First line of address Second line of address O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-951 O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Bozes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Da ime Telephone Number ~ ~`z ~~~ ~ ~,~ a tF~ ar x e>r-la. aasra 2S::.. +aaxr r. w:. e> x_aawsv> ear+r1.n ta,R~ x .....; txe+i.e s#.. Cin~r or Post Office State ZIP Code REGISTER OF WILLS USE ONLY RECORDED OFFICE OF REGISTER OF WILLS 2009 AUGUST t9 CLERK OF ORPH.~INS' COURT CUbIDERL~IND CO., PA DATE FILED :4 3 ,.f gar#e aMYa s4{ 1 Correspondent's a-mail address: N 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, conect and complete. Declaration of preparer other than the personal representative is based on all in(onnation of which preparer has any knowledge SIGNATURE OF PE SON RESP ~ ISIBLE FOR FILI G RETURN DATE A.i~. - -d7lo-O~ ADDRESS a ~ a ,y r P/cut,ee.. S~ >q>er! ~ ~dupaens, ,~ ~7.za g SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 15056051047 OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT REV-1500 EX 15D56052048 Decedent's Social Security Number l i~ ~$ of 4i ~{3~4®i~.s 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 ... ec' 88 igau; ~j i 1 i of f..s a aet:q:f o anssa°ox Rt and~'~8 alst gO O, 2 Ant$ axiS;'tP fa. ^r -'%a +$~y $){t. x + 3 +; x'ad?gSafl~e s. ~`,:a + aia kaar ~~~ x~ O „ ~ i 4 ' +jeS&~aPaiEaa ,a4cta v ivs:x~f p*'~a-ax~.••iF f ~ ><~~~K +~i L6$~~~a i~ i 5 ;, 6 a eia$q aej:°t ~9 ~~.K ~&e ed i:pff daYAvx r. ~: ~.a (Schedule G) O Separate Billing Requested........ 7. ; a 8. Total Gross Assets (total Lines 1-7) .................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H).... _ ... ......... 9 y 4 ~6%Xia.'T56fid t atii 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .... ......... 10 if.>sa arsse~$a°tsno$a <;H«a#, F 11. Total Deductions (total Lines 9 & 10) .. ......... ......... ......... 11 _ ^<~am*Qyg ea ~ ~,.y~t 12. Net Value of Estate (line 8 minus line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 15. 16. 17. 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT /~~~~~ !-~ ~ ~~ _~ Side 2 L 15D56D52048 15056D52D48 O J REV-1500 EX Page 3 File Number ueceaent•s complete Aaaress: DECEDENT'S NAME _ _~J~.rd ~ ~ I t ~_ p~hna~e.. _ _ _ STREET AD RESS rye p~1~y , _- ___ /7 ___ CITY ~~ i"~.~-[!~µ:r~r'_ 1 ~ ~ ~~~_I _.". _. STAT~ _. ZIP.. _- -_ _~_. b ._ _. Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _-- __ _ _ _ _ _ _ _ -_ _ _ _ 8. Prior Payments C. Discount _.._ ___- _--- ---- TotalCredits(A+g+C) 3. InteresUPenalty if applicable D. Interest E. Penalty -- -__- _"- --"- --- Total lnteresUPenalty(D+E) 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. Ii Line 1 + Line 3 is greater than Line 2, enter the deference. This is the TAX DUE. A. Enter the interest on the tax due. (1) r'VV 12) . ~ ~ (8) ~~ (4) - ©~ (5) • OCR (SA) td~ B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB) Make Check Payable fo: REGISTER OF W-LLS, AGENT .a 43 i°°° a »tlo4abii~$a°a'~'#1)iiai{~Spy~a~~ 1Saa ° '~1¢'uB m ~ ° a m ~ '~• ; a ^a a°u'iat t~" t °1$i ~e '(*ng .i %o': ~,a.g~e1~,..°~ t~. . < , .~, t~t~1d$...a~~s~.3~=t~$~3ta~~F.~1°3~~i.~~l~~~~~s,~t{~~§t~]E..t.tfl..ltk]e..°S11tea1 > ~ t3 t t~~. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property trensferced or its income :...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "Intrust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .m~tt~~tttl~~t~t€t~~~;~t~~~~«a~tE~~~s~~~~$~fr~~4€#~~g~~§~t~~~~~ts~'s~~~~$#°~x~~3~~1~~~~~~1~€~?~a`it~?~e~~~~~ti~~t~fl~~~~ n~~~q$€mtt~~l~~tttt~t~€13€~~~{ 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 oS 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 race 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 tour and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [(2 P.S. §9116(a)(1)]. The tax rate im~sed 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. PEV-1508 E%:11.9]) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. ESTATE OF FILE NUMBER ~4.-Y~~I ~ pEAiNA~13f~I~E~ Include the proceeds of litigation and the date the proceeds were receNed by the estate. All propxty jointly-0vmed vATh the rlgM of survivorship must be disclosed on Schedule F. NUMBER DESCRIPTION OF DEATH ~. Ct~.t.-~.~a~~483g8a43i~/ ~~6 zi 3r ~o ((~ /Fe.e?~.. i5 ~ ~, s95~~i5, TOTAL (Also enter on line 5, Recapitulation) E l[~ . ~o~ Z , ~3 (If more space is needed, insert additional sheets of the same size)