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HomeMy WebLinkAbout10-14-09 (3)r 15056051047 -'' REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN Po Box 2ttosol z~ o q o 0 7 8 y Harrisburg, PA 17128.0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth S 7 ~~ 6 ,~ 8 2 6 O S. d % 2 v o 9' 1~! S' 7 9 3 2 Decedent's Last Name Suffix Decedent's First Name MI T' R 1 M 'M ~ IZ S A V E fZ 1 R ~ S (If Applicable) Enter Surviving Spouse's Inionnation Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILE D IN DUPLICATE WRH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum 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) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiil) (Attach Capy of Trust) O 9. litigation Proceeds Received O 10. Spousal Poverty Credit (date o>f death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - TNIS SECTION MUST t4E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 8E DIRECTED T0: Name Daytime Telephone Number Y I G K y R'NN '1 f:1 M h~%'~ 7/'7 (~Z~' Zyy~v Firm Name (If Applicable) REGISTER OF SE ONLY`a , , tl First line of address : ~``-rl . r ~ ~ ~ _ ~ ~. - Second line of address l . ~-t , ~ - ~'C1 :;~ ~ ,.~y e DATE~LED N City or Post Office Stat ZIP Code 1M C G ' ~ ~ A ~ N 1 ~ t.. , j ~ v ~ ~ b ~ ~ f}'~ ~ ~ 7 , v' ar ~ t O ` G ~ ~' ;_ Correspondent's a-mail address: Under penalties of pery'ury, l declare that I have examMed this return, including accompanying schedules and statements, and to the best of riy knoNAedge and belief, it is true, correct and canplate. Dad~atiorr of preparer other than the personal reproaentative is based on all information of which preparer has arty lowwledge. SON 3PONSIBLE FOR FILING RETURN SIGN TU O DATE ~ ADDRESS 6oc~ t ~ 11 R~a~ /Nro~ rt W r ~ 0 /7~n - a c, ew -N D ~ru 4 ~.~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PEASE UsE ORIGINAL FORM ONLY Side 1 L 15056051047 25056051047 15056052048 REV-1500 EX Decedent's Social Security Number ' S 7 7 ~ ~! 3 S 2 Decedent s Name: RECAPITULATFON 1. Real estate (Schedule A) .......................................... ... L 2 y; ~ o / ~~ 6 + 0"O 2 ~ ~,/`yz. 2. .................................... Stocks and Bonds (Schedule B) . ... I I 3. Closely Held Corporation, Partnership or Sole-Proprietorship (schedule C) .. ... 3. ~ • 4. Mortgages 8 Notes Receivable (Schedule D) .......................... ... 4. i • 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. / ' ~ ~ ! v 9 • "77 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. ~ 9 9 ~ ~ 6 7 ~' 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property 7 2 7 i r~ ~ ~' Z ~ ! '7 (Schedule G) O Separate Bd6ng Requested..... ... . - 8. .......... Total Gross Assets (total Lines 1-7) ....................... ... e. S3~ 7,'z~ 3 0 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. Z ~ ~ ~+ ~ • ? b 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............. ... 10. ' I y~ ~ 9 • V 7 l Li 9 8 10 1 L Z ~j II ~" ~ ~ ~ 3 11. ) ................................ nes Total Deductions (tota ... . 12. Net Value of Estate (Line 8 minus line 11) ........................... ... 12. s D ~ ~,' ~ 9 ;a ~/ 7 13. Charitable and Governmental BequestslSec 9113 Trusts for which I I !` an election to tax has not been made (Schedule J) ..................... ... 13. ": 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. .f ~ y Ii 7 :3 / ~ Y 7 TAX COMPUTATION - 3EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabe at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) X .0_ a 15. ' 16. Amount of Line 14 taxable at lineal rate x .0 ~' `,$" o ' ~ , Y 3 y Y 7 16. ' I Z 2 I I ~ ~ 7 ~, 7 7 17. Amount of Line 14 taxable i I is at sibling rate X .12 y 17. 18. Amount of Line 14 taxable I I at collateral rate X .15 + 18. , ~ ; 19. TAX OUE ................................................... i 20. FILL !N THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 L 15056052048 15056052048 REV-1500 EX Page 3 Decedent's Complete Address: B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. FNe Number S R yr Rr~ S, 1 R i~-r~rut- -- STR1trADDRESS ~VV CAi7f" W ~r~i/r~.__ ~"i ~_I 2~ CITY c/f~fNi c1Q~ s STATE ZIP pR r7~ ~- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) Z Z ~ 6 cj~ 7'7 2. Credits/Payments A. Spousal Poverty Credit ____ __ ....__ __ B. Prior Payments __ L l,_ ~ (, y_ 7 __ _. C. Discount f r__ 1.3'{. 9 7 _ ._ __._ Total Credits (A+ B + C) (2) ~, Z. 6 9 `7. ? 7 3. Interest/Penalty if applicable D. Interest _ _. __ E. Penalty __ __...... ___._ _ __ _____ Total InterestlPenalty (D + E) (3) O 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 2Q to request a nfund. (4) d 5. If Line 1 + Line 3 is greater than Line 2, enter the d'dference. This is the TAX DUE. A. Enter the interest on the tax due. ~T (5A) O (5B) p 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 :.......................................................................................... ^ Q~ b. reta~ the right to designate who shah use the propeAy transferred or its income : ............................................ ^ 'Q~ c. retax~ a reversionary irt~resi; ~ .......................................................................................................................... ^ d. receive the promise for rrfe of eithher payments, benefits or care? ...................................................................... ^ 2. If death occurred a1~r December 12,1982, did decedent transfer properly within one year of death without receiving adequate oonsideration? .............................................................................................................. ^ d 3. Did decedent own an ~n trust ibr or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent aWm an kidividua! Retirement Account, annuity, or other non-probate property which ,..,/' contains a benefia~y designatbn? ........................................................................................................................ LJ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PjIRT OF THE RETURN. j, ,~ For dates of death on or after July 1,1994 and before J~uary 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)J. 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 survnlirg spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statuth does not exempt a transfer th a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even 'rf the survivng spouse is the only beneficiary. For dates of death on or after Juty 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger ai death to or for the use of a natural parent, an adoptive parent, or a stepparent of the chikf is zero (0) percent (72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers b 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 th or for the use of the decedent's siblirxJs is twelve (12) percent ]72 P.S. §9116(a)41.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent th common with the decedent, whether by blood or adoption. (5) O REV-1502 EX+ (i1-08) ~ ; pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER S~v,~ aiR s. T tZi.~,M ec Z /- vq - oo ~ B Y All real property owned solely or as a tenant in common must be reported at fair 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. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 7n S ~9P/J ~s~r,: ~1q~ ~ /-~q.i;~~•h.~.~ I''"~N'l'";~°~ ~`~6~g D6. Gu C Hv,~;.J ~A~:.. wc-~kw~ ~12LT~%cf ~ u~ t /N/''~~r} tNA-~ 1 VA~vJta Ui~r I~sr,~r~~ u~lv~ i~. s41 h s'.s9. ry6~ 9u6.v~ rZo% ono .oo ~,.a.0 vP~N ~ ~/~ Z , Gov E'~t w• r-li- ~,rG Mfr // ~ ~ Cr~~-Ey . Q.. ~ C1,~/r/~ P~ ~ CvM or l„twt.V TOTAL (Also enter on Line 1, Recapitulation.) ~ ~ Zy ?~ 9U 6 if more space is needed, insert additional sheets of the same size. REV-1503 EX+ (698) COMMONWEP.LTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER All Droperty lointlyowned with right of survivorship must be disclosed on Schedule F. (fl' more space is needed, insert additional sheets of the same size) REV-1506 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER SA /r<R.~ ,~ S, ~-r~ ~,~r~,-~ .2vt-. Z /- o g- vo 78 y include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDt~LE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER Spa ~~ A t. -~ n-t ti-~,~ .t. z ~- ~q - U~ 7 ~ If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. V; ~kY /-}^,,~ 1 r : MM tsv GW Z'A/"~ L./1NO ~- ~ !/ ~ ~.~~.~ rn~~-~ANTcJ~~-'~ P4 f7~n- B. C JOINTLY-OWNED PROPERTY: REM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY+IELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET X qF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ,. A. !99`I /V1/lf.+.. ~~eN h f/t~i!~~ d.M~~ ~,°o,t3f.9? su ~9~ 067. 9 14«.-'f ~ sy~~c'SC~i3-I~ `Jnly TOTAL (Also enter on line 6, Recapitulation) I !S ~/~~ O6 7. 9~ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VNOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER .sue /le' R( ~C} S . T'R 1 MM t/L 2~ ^ v! J- 00 78 Y This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME Of THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY of THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF PL~ASLE) TAXABLE VALUE 1. ^Prv~~~~ Nr~~ :-1-~ - PATcQ fi. e=i '~ S ybz. yj- i /Jo ~ S ybz.SrJ =Ri4 z/, b~S9.6~ -~ G~: I r[ /12'r /9~1s 6 ~c N r~ c i M i ~7 TOTAL (Also enter on line 7 Recapitulation) S I Z7~ / ZJ . ~ y (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 SCNEDt~LE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ,s,gVt/trA. S, Tn~/+yYir1~[ Z/-v9- OU7D"f Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: /S^~ $ 7 ~, . ~/ O 3, c1v /. ~ o Y Y• v o y, lrt•~r B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2. 3. Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant /i aKa ~.~ ~R-f,MM o~- 3 rp o , ~ Street Address (O f~J t$. (~ .N d INr- 1-11/E~ l~w.fl City M t~(~nrM't~ ASV rt State ~ Zip (7_ O~ Relationship of Claimant to Decedent ~ A~ f ~- ~"' 4. Probate Fees ,3~0~• V'' 5. Accountant's Fees 6. Tax Reium Preparer's Fees 7. ~[ ~- !~ itirr~/i «~ .~.fU. u~ 9. .~//~~Ga-y v41.~ ~~.~~ ~f9 /. `~7 // ~~ ~ctca-~i ~ ~. Z Do , vJ . /ac .~~ ~- ~ ~ U~~ , w J TOTAL (Also enter on line 9, Recapitulation) $ 2~r $6/, 7 b (If more space is needed, insert additional sheets of the same size) i___: REV-1512 EX+ (12-08) =~ij Pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER SAvdi1-iA 1, '7~2r~+e~ ~°.t. Z/- D~j_ pu7c~'Y Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) ~~ ; pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAx RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER f/~I/17'IL~R' S, T~2.h~iNCriL Z/- Urj~ v- 7~y RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under 1. ~ P T Sec. 9116 (a) (1.2).] V i G~~ ~l'i/ 1 r ~ NMa~ Y /1tiJ~ ~ l ~(SO i /Y~ / LOJ ~ . W.~n ~NL hF~ // ~~ I' ~~~1 ~pJ/j / d: l OVA ,f~0/lJ 11170 i L~ ~. ~ ~, ~.~ ~y ~ . Y ~ %/1 M/rO+~ ~cV y 4. ~a,.• , (L~ ~~~~G T ~. s, ~ ~G /r. r ~ A , L2M~yN~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON TAXABLE OISTRIBUT[ONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. N~n~-~ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. N~~" TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 Of REV-1500 COVER SHEET. I~ If more space is needed, insert additional sheets of the same size.