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Home My WebLink About09-04-09 REV-1500 EX (OS-04) PA Department of Revenue Bureau of Individual Taxes Dept 280601 Harisburd. PA 17128-0601 15056041046 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth Suffix Decedent's First Name MI ~ ~ CFA R !'t i e Paz Suffix Spouse's First Name MI a .~~R I~.?-.Y ` THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Retum O 3. Remainder Retum (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal. Estate Tax Retum Required death after 12-12-82) ~ 6: Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Bozes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election [o tax untler Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTFAL TAX INFORMATION SHOULD BE DIRECTED T0: Number 1 X ~ -t ~~y '~ _';' fi r';'1 _„~ C„mt~yi~o~r POSI Office State ZIP Code ~ DATE ,'axe h .~ ~ ~b~,tHY. mmY,~n ~. ~1~~75~~a>(~~$mWgg~ Correspondent's a-mail address: Under penalties of perjury, I deGare [hat I have examined this return, including accompanying schedules and statements, and to the best of my knowledge antl belief, i[ is true, correct and complete. DeGara[ion of preparer other than [he personal representative is based on all information o/which preparer has any knowledge. SI T RE OR'ItfiRSON (j~9f~SI~FOR ~,IILING RETURN pA7E u _~~ A~ 1J 1 n j°" u -17 f O• Ai p~ I ir~~~er Cheek`~r~V'e-~'ler_41r~n,tcsb,.rna.`~~ 1~Dvr0 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE PLEASE USE ORIGINAL FORM ONLY Side 7 15056041046 15056041046 J REV-1500 EX Number RECAPITULATION ,~ x . ~, u v « a~ s ~t v ~ , ,~ ~ 1. Real estate (Schedule A) ...... ..................................... .. 1. 11 2. Stocks and Bonds (Schedule B) ..................................... .. 2.. 3. Closely Held Corporation, Partnership or Sole-Prppfietprship (Schedule. C). -.. .. 3. 4 Mortgages & Notes Receivable (Schedule D) ........................... .. 4. ~ ~~~ . 4M 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 6. Jointly Owned Property (Schedule F) .lam Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) l= Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ............... _ . ... 9. ~ ' r 10. 9 9 ( ) ............. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 10. ~ ... ~ '+ w 1t. Total Deductions (total Lines 9 & 10) .... ........ .......... ...... ... 11. ~ - 4 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~ ~ 0 0 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. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(l.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Q ~~ V 15056042047 Side 2 L 15056042047 15056042047 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STREET ADDRESS 0~5 ~_v~ -Cry-~~k d7 ~; v' e - r - - ~ - - - - -- --- - clrv _ - I I srAr~~ zIP) 7~6~ ech ~ cs r Tax Payments and 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Credits: (1) Total Credits (A + g + C) (2) 3. InteresVPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (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. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the taz due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) (5A) (58) Make Check Payable to: 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 transfened 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 property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in tmst 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? .................................................................................................................. ...... ^ rr~~t ip IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 1 t t€ t31tt~N t# 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)]. ~,~,~.,, ('AMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE B STOCKS & BONDS NILE NUMBER All propeAy JolMlycwnad whh ripM of sunNOlshlp must W disebsed on liehedub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 2, Recapitulation) I S more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpULE J BENEFICIARIES RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llat Truetee(a) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distdbutions, and transfers under Sec. 9116 (a) (12)] D D q Sr~~sZ o - P~ 11D60 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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)