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Home My WebLink About08-14-09T t 15056051047 REV- ^ 5OO EX (06-05) OFFICIAL USE ONLY PA Department of Revenue "° Bureau of Individual Taxes County Code Year PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 °~ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~g~ a~ ~ ~~ ~ m~ 1 ~ ~--~~~ os~~ t q~~ Decedent's Last Name Suffix Decedents Fir st Name ~ ~ 1 j ~~ ~~S C ~.~~ ~i o--t t~ MI MI ~' 1. Ongrnal Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 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. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) bet~.veen 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL 7AX INFORMATION SHOULD BE DIRECTED T0: N`am~e Daytime Telephone Number File Number (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Firm Name (If Applicable) First line of address ~D ~ rU ~~~ ~'7' Second line of address City or Post Office State ZIP Code L / 7 ,:~ ~~ w Correspondent's e-mail address: la~N ~~~ / ~ ~ ~= ~~f--~~~ j ~ ~~ ~ 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. SIGNATU E OF PERSON RESPONSI LE FO FILING RETURN DATE ,cam-~~.,:x . ~ ~~c~-~ __~-~o ~- 8 9 ADDRESS ~6 r, SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ ~ DATE ADDRESS 15056051047 PLEASE USE ORIGINAL FORM ONLY Side 1 REGISTERCF WILLS USE+~k~LY c~ .'Zn ~ r ` ~" ~' s- - n ~ 'L3 ~ ' = - ~ ` r CfrILED - .. , 15056051047 J ~,l `" U J REV-1500 EX ~ ~ ~: Decedent's Name: 15056052048 RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ ~ `L~.~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. ' 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~, ~ 2~• 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. " ~ ~ ~ ~~ 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I ~ /~ C ~ h l 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. a 33 I ! I ~ 03 / ` 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~~ Q Q 13. Charitable and Governmental BequestslSec 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. ~. O TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ ~ 1g 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~ ~~ ~ ~~ ~,~~a~ ~`q, ~~ Side 2 15056052048 15056052048 Decedent's Social Security Number O REV-1500 EX Page 3 1'lwwwrlw r~4~c f nmr~ln4o A~'IfIPPCC_ File Number vca.cuc..a .~ vv...p...........~.. ___- DECEDE T'S NA E ~'f/J / ~~ STREET ADDRESS )~~~~~- ~ .. ~ 1 ~ ~ ~ ~~~~ ~~' CITY `~:~G~ STATE f ZIP 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 + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^ Q' Q` d. receive the promise for life of either payments, benefits or care? ................................................................ ...... If death occurred after December 12, 1982, did decedent transfer property within one year of death 2 . without receiving adequate consideration? ....................................................................................................... ? ....... ^ ^ ~` ~' ....... 3. Ditl 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? ................................................................................................................. ....... ^ LJ 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 for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (1-97) SCHEDULE E ~+ ~, COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ,~ ~ ~ A FILE NUMBER -D03~ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned wkh the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 5, Recapitulation) $ ~ ~~~A -~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ` ^~ C/~w1~ ~ / B. ADMINISTRATIVE COSTS: ~~ ~ ~• a ~ ~- J` ~~ -'"- '~`"f"`~'"""" - '" 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip __ Year(s) Commission Paid: 2. Attorney Fees 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 ~7`3 . Q 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) I $ 7~/ ,~~ (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, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRJIPTION /,? /~~ OF DEATH G ~i ~~~~ ~~~v`~ ~~~ ~ . ~~ TOTAL (Also enter on line 10, Recapitulation) $ ~ ~~~ G ~ ~„Q Qf more space is needed, insert additional sheets of the same size)