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HomeMy WebLinkAbout08-25-09 (2)hr J REV-1500 EX (D6-D5> PA Depadment of Revenue Bureau of Individual Taxes PO BOX 280601 ' .. Harrichnrn pD 1N9A-nanl 15056051047 OFFICIAL USE ONLY Countv Cade Year File Number INHERITANCE TAX RETURN Date of Birth ppT ~~,~ ~abv Decedent's First Name MI y aaam„~ u ,~a. ~ ...a~.aa.aa-a, i Souse's Last Name SufFx Spouse s First Name MI , ~~~~ ~ s , eea~ ~a~~aa , a,za,a aaa, ~`° , S Ouse's Social Security Number ~~°~~ ~'g°"°> THIS RETURN MUST BE FILED IN DUPLICATE WITH THE &::> ,~, a,s'~.t«E!.>a.:<-t~e:~..a~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retrirn D • d. Limited Estate ~ 6. Decedent Died Testate ~- (Attach Copy of Will) O ~ 9. Litigalion Proceeds Receivetl O 2. Supplemental Return 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 1-1-95) O 3. Remainder Return (date of death prior to i2-13-82) O 5. Federal Estate Tax Return Required ~~ 8. Total Number of Safe Deposit Boxes O 11. Election to taz under Sec. 9113(A) (Attach Sch. O) CrORRESPONDENT -.THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD RE DIRECTED T0: Name .. .. .': . . as ,. a Da Ime Telephone Number e r ,p a .. .aaa ! e a a i ~ e g .asn s { ) { a j ~C J ~"~ a t~ I < r ' ~ ~ o~e eao~x+ Ixes $ a ; a mea ~ a a a~ a ~ ~s , +xa a ... .. aa . a s FIrm.Name {It Applicable) . ~ o~*+=.txs §n y ,=a »a>« t ,r " REGISTER OF S_USE ONLIa'=~s , C q• ' .. I i , r t - ~7 ~ _ ~ ~ t aa. a a0a+. i., i t„axfa. t»tao-d xn.M a J'+ .,m+t, exaaaa xa nai +a aaa •»aa ........a ax~ U First line of address ~ ~ .:?- ~+. c7 8 d Q : ~~ ~P~F~ ~ ~ ~ a,. s ; r „- U ;n N EE + ~~a,~°x a,. O efa ~a „x a„ ab l Second line of address _._; C - fgp ~.x z. rvau.tg imafan ' » xa {...q - ~xanx #+.a~qs I~..yxa+. pApBt 'a,. $$ I I ~~ a... a.+.y ':p...p 8 t _ ~ li .y:. 1~ d I I b R rt ~ 4 anf•x:... x~x„s i a a aaa , rapb+nabv OOOr t i a y I ~ i p a~ N I ~ ~ Oit~ Or PO St O fflCe - S tat e ZIP CO de DATE .ED N ^ ~ ' p ~ ~ ~ '~ } f ~ ~ y ~ °g ~ 4 a ~ ~ st' Y `~ ~ :~ ~db~ H;! 3 1 B ! ~ d ~ ~ $ C ° 6 a~ x , : ., . ,. ._. a a.a >a. :~ , a . a a a , as. .a „a e,e aa. . Correspondent's a-mail address: ~L. -g, ~ILy.~ ~ y~/~Q , Cm/'L( 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 [he personal representative is based on all in(onnation of which preparer has anv knowledge. ADDISdO SiSlE~FD,C~ R~ WtEC~,/.9nrics,~vrea PI~• i7o.rt SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 1505:6051047 -l ~ . `l 7 -~ r r ?J _i ,, ~ - L J r ~-; --l .T ~ :.') -ry1 J r OF MELVIN L. 3TUMBAUGH I, MELVIN L. STUMBAUGH, of Lower Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. FIRST The expenses of my last illness and funeral shall be paid from the property of my estate. It is my further desire that upon my death, my body will be cremated and any costs will be expended from my estate for this purpose. ECOND I give, devise and bequeath the rest, residue and remainder of my estate together with all insurance proceeds thereon of whatsoever nature and wheresoever situate in equal shares to my grandchildren, REBECCA L. STUMBAVGH, JOSHUA G. STUMBAUGH, and ABBEY L. STUMBAUGH, who survive me by thirty (30) days, per stirpes. It is further my desire that my personal representative, after consultation with any heir or heirs of mine who survive me, and in Page 1 of 5 r1(n11~1n(] r LAST WILL AND TESTAMENT OF MELVIN L. STUMBAUGH his own discretion, choose such articles from my tangible personal property (exclusive of cash, stock certificates, bonds, and all other tangible evidences. of intangible personal property) as he believes will be useful. to such heir or heirs or desirable for him or her or them to have, either from a sentimental point of view or otherwise, and to deliver such articles to such heir or heirs or among such heirs in equal or unequal shares as determined by the further exercise of his discretion, provided no other heir objects to the distribution. All tangible personal property not so distributed is to be sold, either publicly or privately, by my personal representative, adding the proceeds of such sale or .sales to my residuary estate and to be disposed of in equal shares among my surviving .heirs after payment of my estate debts, taking into account the tangible personal property otherwise provided to them. THIRD I nominate, constitute and appoint RICKY L. STUMBAUGH as personal representative of this my Last Will and Testament. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his duties in this or any other jurisdiction. Page 2 of 5 i LAST WILL AND TESTAMENT OF MELVIN L. STUMBAUGH IN WITNESS WHEREOF, I hereunto set m y hand to this my Last Will and Testament this ~~t~` day of / 1-h~ku~'~' 2002. WITNESS: ~~ ~ r '' MELVIN L. STUMBAUGH ~~- ~, Page 3 of 5 r LAST WILL AND TESTAMENT OF MELVIN L. STUMBAUGH ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND . I, MELVIN L. STVMBAVGH, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. ELVIN L. STUMBAUGH Sworn or affirmed and acknowledged before me by MELVIN L. STVMBAUGH, the Testator, this ~_ day of ~~~~~ , 2002. .---~ `r NOTARY~PUBLIC NOTARIAL SEAL HELEN E. FlASMUSSEN, Notary Publk Camp Hill 9orough, Cumberland Counly My L'ommisston Expires Aug. 2, 2W3 Page 4 of 5 ^ I r LAST WILL AND TESTAMENT OF MELVIN L. STUMBAUGH AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND wE, .~ifiGaHAnie_~ l~F~~b'~:~- and ~-r'ndt~ ~~. ~'la~jt.ICc~ , the witnesses whose names are attached to the foregoing document, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the .instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testator signed the Last Will and Testament as witnessed and that to the best of our knowledge the Testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. J ~- ~, ~~~ /S")worn or affirmed and subscri(bFed befLore me by ~~Q~~iCt,aut. /°Q./ and ~ rn1.~.2 Q. 1 ".C~~ -l= this ~ da Y of ~ 2002. i" ~ OTARY PUBLIC NOTARIAL SEAL Page 5 o f 5 HELEN E. RASMUSSEN, Notary Public Gamp Hill Borough, Cumberland County My Commission Expires Aug. 2, 2003 Pa. O.C. Rule 6.12 STATUS REPORT _ _ ___ _.. - ____ _ . REGISTER OF WILLS OF C~(~gnrD COUNTY, PENNSYLVA~I,4 - Name of Decedent ~ Q~Z V'/r~J •L., t,~wl U-ez~ Date of Death: `~ oZ ~ , a, O~ File Number: d D4 p ' ~~ S 9~P - Purseant to Pa. O.C. Rule 6.12, I report the fallowing with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete :.................... ~ Yes ~No 2. If the answeris No, state when the personal representative reasonably believes that the adrninistrationwlll be complete: ~yo r~~.r~-,6E`R. a6o 9 - 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a final account with the Court7....... Yes ®No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? ............:..........:........ ~'es ®No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts maybe filed with the Clerlc of the Orphans' Court and may be attached to this report. Omer/a -3 ~~ ~~ ~ S~ Signature of Perron Filing this ornt Capacity:Personal Representative Counsel Nmne of Person filing tl~is i m~m /Solo sf/Ert.7°fo~Q ~2~J . ,~da a:: IM lCc ~jy / CSId U' IQ~i~-_ /7L~~ Trfephone REV-1502 EX+ (6-96) SCMEp11LE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER wte~~rN L. sTuwt,~Avt~.l,! aoo9 - BosP~ All real property owned solely or as a tenant In common must be reported at lair 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. Reel property which Ia Jointly-owned with right of eurvlvorehlp must fx dlecloaed on Schedule F. ,. w~oAic.F Hon~>E - Nb ERo9~ ~s~~ - c_ec~b p~ o~ , o0 i,., w~ez•it-c~ Naw)e ®AkK-~n)~ ceT TOTAL (Also enter on line 1, Recapitulation) I $ gB00 ® O (If more space is needed, Insert additional sheets of the same size) I REV-1503 EX+ (6-96) B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER wt~ztt..~ ~. s~u-titaa ~~ aoo 9 - dd s9l~ All property )ointty-owned wkh right of aurvlvonhip must be dlaclosed on Schedule F. (If more space is needed. irwert addkiaW sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ~~EZ~'l/~ ~~- ~-~~~1 ~~ 07oa 3 - ao silo Frhadnla C.1 nr (;-2 linrludina all suooortina information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCNEpULE C-1 CLOSELY HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT 1. Name o1 Address State on Incorporation Date of Incorporation Ciry State, Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year_ 3. Type of Business Q. Product/Service ... ... s •ii } u }t ~ •i.~.r y tsi •ML..f #- eytk4i il x t q'y F ~V 5 t} $ Common _ ~ _. $ Preferred Provide all rights and restrictions pretafning to each class of stock. 5. Was the decedent employed by the Corporation? ................................. Q 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 ^ 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. e • • • ~ ~ A. Detailed calculations used in the valuation of the decedents 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 addresses and estimated fair market value/s. If real estate appreisals 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 1s needed, Insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpULE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF FtLE NUMBER ~/~ 1. Name of artnerehip Date Business Commenced Address Business Reporting Year Giry State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. 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 12-31-62? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ 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 decedents partnership interest sok!? ....................................... ^ 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? ................... ^ Ves ^ No If yes, provide a breakdown of tlistdbutions received by the estate, including dates and amounts received. 13. Was the decedem 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. • •• • ~ rr A. Detailed celculations used in the valuation of the decedents 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 addrassles anti estimated fair market valuels. Ii real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of tne decedent's partnership interest. REV-1507 EX+ (1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT All properly fointly-ownetl with right of survivorship must be disclosed on Schedule F. (h more space is needed, insert additional sheets of the same size) FEK1508IX.pB]) CAMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY FILE O~ Indude the proceeds of IifigaGon and the date the proceeds were received by the estate. All properly Jointtyovmed whhthe right of survivonchip must tw dkelosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. ~,~,,~ _ ~doo.c~ ,N w~~ a~..e 'Z' C/{6'CKJ~+G ~C~ M-t.7` >3J9Nk /$00.00 3. Mlsc.~ccyntia~t ~5'~~N~~D 1?zti"~-APP4~nrc~s/dY,T. YDo.eo 'i~ a oa 3 /~oreD ~R us - eP~fckdo vt~.~asy~[~r Imo` yo oe , o0 w~ i ~~+as~ , ~ verv Y~iXl4S Jnr u Ph/oc,sT~Y TOTAL (Also enter on line 5, Recapitulation) I E ~ yOO. ~ more space REV~t50BTJt.ltbn SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DE EDENT Wts~LviN ~_ s~-Nwl3r~vt~.-h/ .. .. a?eo9-aosflo M an asset wu made JoIM whhln one year ottM dseederd's data of death, h must be reported on Sohsduk G. SURVIVING JOIPfT TENANT(S) NAME A. /1~0I'VE B. C. JOINTLY-0WNED PROPERTY: RELATIONSHIP TO DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include nano of financial lnstlWtlon and Bank acaurd numberasimlla identlryiig number. Adach deed forjointly~held real astaM. DATE OF DEATH VALUE OF ASSET %OF DECOS IMEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. (If more space TOTAL,(Also enter on line 6, Recapitulation) ~ S the same size) RE41510 E%. (1811 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN _~.^. W1 EL/rnl G • ~'rur~gc~p~A~N a eo 9 - do sPlQ This schedule must be completed and filed'rf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY ITEM NUMBER DESCRIPTION OF PROPERTY ixauoE rHE xoHEOG rxE rannsrERCE,n+EiR r~unoxsxiR ro oECeoExrsxorxE OnrE Or rwwsFl=R ACHPCOFY OFTRE OEEO FOR RE/d EBTAn:. rr A DATE OF DEATH V LUE FAS ET °.6 OF DECD'S INTEREST EXCLUSION irnrRicae~E TAXABLE VALUE 1. ' - ,~! / ~~/~+G TOTAL (Also enter on line 7, Recapitulation) I S more space is needed, insert REV-1511 EX+(10-06) scNEOU~E x COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF , l FILE NUMBER V-'it G~-l~`l/y G • ~'f'U Wt BA yl FN a?0 09 - 60 S'~ Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: ~ AMOUNT ,. N.w~ssczvuron~s FvuEIZq~ jjorvt~ /7y,Z,37 ~ crw~aynle~ !',Q B. I ADMINISTRATIVE COSTS 1. Personal Representatlve's Commissions ~ )~ ~+~ / Q ~ Q , Q O Name of Personal Representative(s) /S 1 C/C L. • v / LI ~'/r~AN ~.~. _,. Street Address /.s~0 .4 ~p~~Q _~~-, Ciry~N/ CS s lll~L~ State~Zip JOSS Year(s) Commission Paid: oZ d O' 2. Attorney Fees ~'~ m , O O 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip __-_ Relationship of Claimant to Decedent 4. Probate Fees 6. Accountant's Fees ~SQ/~(gL R`v Ie{~~~~%~E'• '~.O© 6. Tax Retum Preparer's Fees P~;pyJ /~(~ 1e1~~'S e'1M)-/grf 1IE /QO. O'Q ~. a/©c.oFlcq~ wt~l~/9c. 6/I~}~9/?p cc.c~gnr ~P / f o7• // ''~rutKo~l2ouP, eatw~~p dlu, ~A. /7®i/„ 8. 'D o vrt Est 1 c c cu9iv t~ P ,/n~ A ccp9r~3 a v~'J- !o ®o r o0 "ptswNNr~OE PRoPa~Ty sac..N7~or=ai ~rtcN, P/. I>o q. ~i {lam IQ~1¢11~s// O~}/In~77N~ FCC 'Bqo© "PgIwJ w t 0 F pRo PNQ~7'`{ •so cu7•lcw S, ccc ' ` ~"'~~H9N~cSlbtlRl,.~ ~~- /7oSS TOTAL (Also enter on line 9, Recapitulation) $ ~4 3 9 ! 8 (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 SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIEN5 ESTATE OF FILE NUMBER rn,EZVin1 c.. s~i~~g;a Ohl ac~o9 - ®m s9lo Repoli debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (fi more space is needed, insert additional sheets of the same size) REV-1513 E7(+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF e . S EC.-V)' ~C. S Wl blG. q~00 ooS7Co RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE [ TAXABLE DISTRIBUTIONS [include outright spousal distdbuticns, and transfers under Sec. 9116 (a) (1.2)] 1e ' ,. I~F~B~'cc'~ ~- .T7'Idr-~~Igul~h~ - ~KAA9u~E /sao sy~o~le]p Rig A Vu'ECI1//9N 1 GS~ U'R-~~ ~q • /70.5 e}. ~SMN~ ~" Sr,1wf6ANa/~ ~ /1918 s`/~A.u.s~vf~y .AR. 6~gNOSt,~N .3 fRabA~cKS~NRa~ d~• as yo7 3. AsaeY ~~ sJ~gw)69N6.n1 isao s//Ek~Pi*oR4~ Ipp • ,~RA.~dD9~aN ~3 Iti1~LR,~1AN 1 cJ IgIP1QL4-~ 1~~' I ~OSS ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 1S, AS APPROPRIATE, O N REV-1500 COVER SHEET tI NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE A/• 1. ~J B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. XJ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ Q . ~ O (If more space is needed, insert addRional sheets of the same size) '~ ~~ . ~ ,. '. ~, REV-1514 E7(+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY 8t TERM CERTAIN heck Box 4 on REV-1500 Cover Shea ESTATE OF FILE NUMBER ri~ttZ/yN L- szu~wtBA~1~l~ ~too9 - oos9l~ This schedule is to be used for all single INe, 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 5-1-69 to 4-30-99, 1~ 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 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 Ilfe estate (Line 1 multiplied by Line 2) ......................................$ ^ Life or ^ Tenn 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 6. Adjustment Factor (see instructions) ......... . ^ Variable Rate 7. Value of annuity - If using 31l2°! , 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) ~i Rev.tsa4 Ex.(y°'I INHERRANCE TAX SCMEDtlLE L COMMONWEALTH OF PENNSYLVANIA IN EC RN E REMAINDER PREPAYMENT q q R o2Op / ' Q t:~S/ FILE UM EDENT RESIDENT D OR INVASION OF TRUST PRINCIPAL N BE ESTATE OFrfltl~G 77 M~1 EZ//nI L (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedent dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an eledion to prepay has been filed under the provisions of Section 714 of the Inheritnee and Estte Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Eledion to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of eledion or annuity is payable 0. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. CashMlisc. Persona{ Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of Unindudeble Assets .................$ 4. Total from Sdteduie L-2 ......................................................$ E. Total Value of trust assets (Line C-8 minus tine D-4) ................... . .............$ F. Remainder fador (see Table 1 or Table II in lnstrudion Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) IIL 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 orAnnuitaM(s) corpus or annuity Is payable consumed C. Corpus consumed ............................................................$ D. Remainder fador (see Table I or Table II in Instrudion Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recapitulation) 0.EV-16d5 E%+ h.e5( INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA IN E RN REMAINDER PREPAYMENT ELECTION g Q ~Q~ ~~05 RESIDENT DECEDENT -ASSETS- FILE NUMBER ° + + I. Estate of ~ Z.r~ (Last Name) (First Nome( (Middln Initial) 11. Item No. Description Value 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 $ (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 HeIdlPartnership $ (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-4 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) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ ~ . ®© (If more space is needed, aMOCh additional 8Ya x 11 sheets.) tEV~1646 EX• Is.eq INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION oZcop OOSP r RESIDENT DECEDENT -CREDITS- FILE NUMBER I. ,s , Estate of U1 ~ ~ ~ / ~/ ~+ ' (Last Nemel (First Name) IMiddle Initial) 11. Item No. Description AmounT 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 $ (include on Section II, Line D-2 on Schedule L) C. Yalue 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-4 on Schedule L) $ ~ r 0 (If more space is needed, attach additional 8%z x 11 sheets.) REV-1647 EX+ (9-00) SCNED~lLE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER Wil2U_/N L 5'T7'atvf~~9~A~/~ d0o9 - ao~9t'a This Schedule Is appropriate only }or estates of decedents dying attar 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 i I Flanafirlarias NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE 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 Compromlae 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 Une 1 passing to spouse at appropdate 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 Check One ^ 6%, ^ 4.5°I° ...........................$ (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 Linos 2 thru 6 must equal Line 1) ......................$ ®+ (If more space is needed, insert additional sheets of the same size) REV-,69aEX,,,-99) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 1?/31/94) INHER TANCE TAX DIVI ION ESTATE OF FILE NUMBER WItZ./fN, L s'Ltam'2,Avl6.l-~ o1ao9, a© 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) ............................................ t 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joim Assets with SPouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6d. 6. SUBTOTAL (Lines 6a, b. c, d) ........................................................ L 7. Total Gross Assets (Add lines 1 thru 6) ............................................... 7. 8. Total Actual Liabilities .............................................................. o. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. I/line 9 is greater than $200,000 -STOP. The estate is not eligible to Gaim the credit. I/not, continue to Part II. Income: a. Spouse ........... b. Decedent .......... c. Joint ............. d. Tax Exempt Income . . e Other Income not listed above ....... . 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) _ + (3f) 4b. Average Joint Exemption Income ..................................................... _ 1. Insen amount of taxable transfers to spouse or $100,000, whichever is less .................... . 2. Multply by credit percentage (see instructions) .......................................... . 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 . .............................. . 4. For Nonresidents, enter the ratlo of the decedent's gross estate in PA to the value of the decedent's grass estate ............................................................ . 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...... . 2f. Part • 1. III. . ~ 2. 3. 4. 5. 0 aEV.,e~s er.~isp . SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATE OF ~ ~ FILE NUMBER Do not complete this schedule unless the estate Is making the election to fax assets under Section 9113tH) of the Inheritance & 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 BV-Doss Unified Credit etc ) If a trust or similar artangement 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 surviving spouse under a Section 9113 (A) trust or similar arranoement. PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. (If more space is needed, insert additional sheets of the same _ r w o H 4: o ~ /~ N VI J~• H W-• OOJ~ •2 M ¢SM1NO Y ~o •a s o N a (76 0 O C¢1 ¢ M 0 T~~ r 44~ N aly O ` 'i F G ,. <:., ~ ~ < ~ i fV ~ " . ~ l .~ J. c , - in [i-'. ~ U i~ ' r 1 . e, C7 =j [.a- ~ C~ r.: a 0 i~ Y C N d i~Q~ c ~ s s ~ v Q 7 V ^`~ ^ L\ \/ ~ ~ ~ ~ ~\ 7rT~ +• N O v a ro a~ ^\ J